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I had lap band revision (reposition of the band) with hernia repair, and the recovery was a little tougher than the original lap band surgery because of the scar tissue on my stomach. Basically weaker than last time, but felt better both times by day 8. good luck!

Hey everyone! Just wanted to see if anyone else has found out they're band intolerant? I've been having really bad bouts of constantly vomiting for awhile, and it has gotten to the point I'm vomiting up white mucus and blood clots. I went to my doctor's office that did the surgery, and they checked the band to see if it slipped, and it hadn't. So then 2 weeks later I had an upper endo by the same doctor. The procedure he said only took 4 minutes, and the band hadn't eroded. So it hasn't slipped, or eroded, however, I have all the symptoms that would make you think so. I can't hold down majority of solids now, and liquids are questionable. My band is completely unfilled at this point. I am working on trying to get an appointment with a gastroenterologist to get their opinion on it. I am really starting to think my body has just rejected it. I have stomach inflammation, and they biopsied a bacteria but didn't tell me what it was. All I got was,"maybe it's your gallbladder, you should get that checked out." I told them to do it when I was in the hospital after the endoscopy just to get it out of the way, but they wouldn't. My band physically hurts, and I don't know what really to do. My symptoms are just getting worse...and revision may be my only option to fix it, but I don't have the money for self-pay and my insurance won't cover bariatric surgery. But if anyone else has had intolerance, it would be nice to get your input. Thank you

I got the lap band done 3-29 this year and I'm over disappointed/frustrated with my weight loss so far. I'm down 20 lbs but I'm also up and down 2 lbs constantly. I feel like I have to fight for every single ounce. All foods are high protein and almost no carb or sugars. If I ate more than 1000 calories a day it's very rare. I keep a food log everyday. I don't think I should have to struggle for every single lb with weight loss surgery! I'm considering talking to my Dr about having a revision to the sleeve. My concerns with the sleeve.....I have 2 relatives that had it done and they've started gaining weight back. Am I giving up on the band too soon?? Is the sleeve any better?? Advice please!!

Oh pm me if you want to. I was widowed suddenly at the age of 35. That was a long time ago . That definitely led to my obesity. I started throwing up in my sleep with the band. I had to have the band completely unfilled and keep it that way. Restriction was always changing. I was worried the band was damaging my stomach. I knew people who were not able to revise to sleeve because the band damaged their stomach. Is that what you were asking me?

Yes, I have experienced that pain and I ended up having a port that would bonk against my rib area and cause pain that got worse and worse. I would call your surgeon, be very adament that you need to be seen, they need to determine what is going and then fix it! I ended up having a port revision with a low profile port that was smaller and thinner. My surgeon was very responsive to my needs. Good luck to you and do not take no for an answer!!!

To make a long story short. I had lapband in 2008, lost 90 lbs within a year and now have gained back 30 lbs. The band is no longer working for me. If I get a fill, I have problems, no fill= I eat more. I checked with my insurance, they cover WLS but only 50% after my deductible has been met, which it has. I've had my consult and he order my EDG, motility study and gallbladder ultrasound. Everything came back good for sleeve revision versus RNY. My insurance will not require me to go through the 6 month diet history and psych eval, etc because I am seeking revision. The problem is getting through to my advocate. I did not go to seminar again and for some reason, getting through to my coordinator/advocate has been an issue. I have let two messages but no return phone call. The good thing is I have an appointment scheduled with the nutritionist (scheduled prior to finding about no diet history needed). The nutritionist is in the same office as the advocate, so hopefully I can get some questions answered and tell her what the insurance company said. The only thing is I have a real good medical necessity letter. I will just pray they give me a good one and I am approved. I meet the requirements (BMI over 35 with 1 problem- joint issues plus I now have an auto-immune disease which was diagnosed last year. From what I've read, the lapband does not work well for that type of disease. It's just depressing to think about getting back up to 278 and my highest ever was 321. Currently, I weigh 221 which is depressing enough. I can not wear any of my clothes and it has been rough. I never thought I would be need my size 18 and 20s again but I do and I do not have them. I gave them all away making a vow to myself not to ever get that size again. But the lapband only worked for me for a few years. It would be nice to have surgery by June... We shall see. If I do not get a return call from my coordinator before my appointment with the nutritionist, I will get my questions answered then,

So I am 5 years 4 months post op and I got down to my goal weight and then about 2 years ago I started getting my cravings back and started giving into them and started putting the weight back on, I have since gained about 55 lbs back and I am very discouraged, and feel awful. I had a great surgeon that did my surgery, and since my surgery he has left and moved across the country and I trusted him and felt good with him, so after he left I started seeing another doctor in the practice he was in and do not like him, don't feel comfortable with him and so since about a year after my surgery I haven't been back? He didn't seem interested in knowing how I was doing or my progress so I didn't go back, and just kept doing it on my own, but now I am this far and gained weight and I am not happy with myself and I am back to where I was prior to surgery, except I can't eat as much, and as many things. I have made steps in seeing another doctor that a friend of mine referred me to, she goes to this other doctor and she loves her, and so I am going to meet with her and see how I feel. I am nervous that I have stretched out my stomach and I don't know what they can do for that? I am so disappointed in myself, cause I did so good for 3 years and kept it off, and I felt so good, and now these past 2 have just been down hill? Does anyone know if you stretch out your pouch do they do or will they do a revision? Also does that help with the cravings?

It sounds like you're on the right track with finding a new good doctor that you like and can trust. A revision might be the answer. Check the forums here and many people have had them and have had success with that. Hang in there.

i was in the same boat as you. but my bmi is also VERY high and my surgeon continuously suggested bypass or sleeve. i tried to convince myself otherwise every other day! ive seen my friend go through the journey of the lapband and just reading about it puts it into perspective. lets put it this way theres a reason why "band to sleeve revision' is a sub topic under forums. it happens too often too many times. im scared of having that port under my skin and with a 2 year old, going to school and working full time fills and unfills are just not something id like to add to my schedule. id rather heal up and be done and im also scared of my intenstines being rearranged which is why im with the sleeve (and a million other reasons) i would read up and youtube as much as you can about it. i personally have made up my mind good luck to youuuu!

My PS wanted me to try to lose more weight, but I was stuck for years as far as weight went. I was having reflux at that time and within the past two years after the tummy tuck, it got worse , I think due to all of the muscles being tightened, it put more pressure on my stomach, so I had to have the band removed. Now, I'm 8 months out of band removal and haven't gained any weight... yet. But I feel like it's only a matter of time, so I'm probably going to revise to RNY. At least when I do get to goal, I can finally do all of the plastics that I was planning to do right when Covid hit. But I understand about your age and the risks involved, and it will be a relief to get the excess skin removed. Best of luck to you!

I had revision from band to sleeve this past November. I Love the sleeve so much better.... I lost about 100 pounds when I was banded in 2005 and slowly I gained it back. I take responsibility for that. However, I was vomiting at almost every meal and turned to foods that were sliders. in 2011 I went to a different clinic as I felt my current dr. was not listening to me about how much I was vomiting and the reflux. I would literally wake up choking at night because Water or whatever I drank prior to going to bed was coming up on me. My poor partner thought I was dying. Anyway, when the new dr. ordered an upper GI it showed the band was waaayyy tooooo tight and he opted to empty it and then refilled it a few months later. Even with the tiniest fill, I was vomiting and having nighttime reflux. I ended up getting sleeved this past November. My surgery was rough and I had some complications from having such bad scar tissue. An overnight hospital stay ended up being 4 days. Dr. said I had an infection on the lining of my stomach where the band was. After a couple of weeks I felt so much better. Also during the past year I was diagnosed with Fibro as I had such wide spread chronic pain..... After about a month after being sleeved, I noticed I wasn't in pain anymore. Dr. felt that having the infection could have caused some of the inflammation in my body. Super glad to be rid of that damned band.

Hello Stars in your eyes, I recently went through the revision on 1/30/2014 so i am 21 days into this and unlike you I didn't lose all my weight with the band. I only lost about 40 lbs and was so tired of food getting stuck and feeling every meal was a challenge. So I had the revision and had a lot of scar tissue around my band which needed to be removed before he could remove the band and do the revision. I have lost a total of 23 lbs so far and feeling great! I wish this procedure was done 1st and foremost! The feeling of full is very quick and different than the band. I am still on mush foods but love being able to have the foods i can had until I start regular foods next week. You won't be disappointed. Of course I don't know what it feels like having regular meats, chicken, breads, etc till next phase but so far doing really great. Oh and by the way the dumping syndrome does happen with Sleeve patients. (I tried orange juice, and wish I hadn't)!!!

Welcome to the site...there are a lot of people on here who has had the revision surgery...sorry for your complications but you are almost their...Good luck on your journey

Yes, Gail10, it's daunting. If I get any answers that may help you, I'll post them here. Meanwhile, don't let them give you too much of a fill. Throwing up is not good for your gastro-intestinal tract, aside from being very uncomfortable. Just follow the food and drink instructions to the word. That is all in your best interest and you'll be doing all you can do that is within your control. We cannot control the adhesions or scar tissue, or inflammation that the band may cause in some people. Just so you know, a woman who had her band placed on the same day and by the same surgeon as I did in 2011 got her band revised to the sleeve last July, with no problems whatsoever and in a single surgery. Each of our bodies are different.

It is common to feel apprehension or fear prior to any surgery. There are several different forms of surgery, so you may want to ask about each type. Also many of us have health issues. These can lead to defining the best type of surgery appropriate for our particular issues. I had GERD and RNY gastric bypass is better for this condition than the sleeve because the sleeve will only make this condition worse. You might want to discuss the rate of revision for each type of surgery. If I was going under the knife for this surgery, I did not want to repeat the experience.

My revision was on the 7th so far so good. Down 12lbs.

Thanks, @NancyNYC! BTW, Dr. Fielding did my lap-band surgery years ago! I ended up having to revise to a VSG, but not b/c Dr. Fielding wasn't an amazing surgeon.

I got my lapband remove 3 days ago. I will be having my revision surgery in about 2months. My doctor wants me to get the sleeve and at the beginning I was up to it, but asked some friends that had the gastric bypass and are doing great and had lost a lot of weight. Now I'm so confused. Don't really know which one to have. I haven't had either surgery, so I'm no expert, but based on my research: (1) The sleeve is not malabsorptive, whereas the bypass is. This means you'll run less risk of bone problems, Vitamin deficiencies, and probably not have to be on diligent consumption of Vitamins and supplements. (2) The sleeve seems to have a lower complication rate than the bypass and be simpler. (3) The bypass has a slightly higher average of weight loss. However, from what I've seen, the optimal candidate for the bypass is someone who is morbidly obese (by obese standards), and has let their weight spiral up to 500 or so, where they are having difficulty even ambulating and need a drastic intervention. My advice? Get the sleeve.

Hi Stefanie, I'm in toronto too. I'm going to Montreal for a revision (self-pay). I looked into both. Like others have said. Bypass is the proven gold standard, so should not be something to be too concerned about. I'm the opposite of you. I've been told they may not be able to do a bypass because of scar tissue and my have to do a sleeve. I won't know until I have woken up which I got. Sent from my iPad using the BariatricPal App

I know many people state that the RNY is to invasive for them but...even tho they reroute our pouch etc think about the Sleeve they are removing your stomach like 85 to 90%. Thar is pretty invasive if you ask me. Also if you have GERD the Sleeve tends to make it worse. I do know some have to be revised to the RNY. Also I see that your weight is 245 right, my STATS are: Highest weight 249#'s Surgery weight 232 Current weight 125#'s. I went below my goal weight because of Strictures ( kind of like scar tissue) I got down to 117#'s and both my PCP and my Suregon were worried that I was losing muscle instead of the fat. I managed to gain 8#'s and it is amazing how healthy I feel!! I did get to my goal weight in 6 months and have managed to maintain at 125#'s. Just check out your options. It also depends on your diet if you love carbs sugar etc the RNY gives you restriction and the malobsorbsion too. Which means you don't absorb as many calories. Like I said do your research because noone can decide which is best for you.

So I'm playing the game that I hate. It's "up a lb, down a lb" which is followed by "up a half lb., down a half lb" in my life. Does anyone else experience this? I think I'm cursed. I swear all I see is people losing more weight and I compare myself. Then I think "hello stop your whining you durn cry baby." lol... just being honest. Here's the deal tho... I'm 10 weeks out and after receiving one of two hospital bills for my complications (I had aspriation pneumonia and a leak/abscess after my surgery, then revised surgery)... I'm just really wondering if this was worth it. Don't get me wrong, I know it was but.... if I knew then, what I knew now of my experience... would I still do it? In all undue honesty, yes, probably so. I've been fat since I was about 6 months old. Seriously, I have pix, I should scan them and post them. Not that anyone reads my posts Ok rambling, I just feel lonely in this journey and I'm a bit lost. I don't have a NUT, right now I can't afford one, my new insurance plan doesn't go into affect until June 1.... maybe I'm stuck in pity party central mode tonight, my apologies. Writing is supposed to help, heck how I used to cope isn't an option anymore (hello carbs and sweets, remember those days?). I just wish I could let the worry over all of this go. It's made me feel more anxious than ever and I was craving a big ol' cookie today, so I indulged... too much but it's logged into myfitnesspal dag nab it! But how do I cope with this? IDK... I went to the gym and that's helped some. Otherwise, I type in a journal here (which reads like a bunch of mess that no one reads, damn pity party again grrr). Who else can I talk to about this? Honestly there are very few here that I've spoken to and surely my biatching rambling session is running the rest off. Sigh.... Well SHOULD anyone read this, and IF you do pray, even if you don't know me... please say a prayer for me. I'm being super hard on myself, worrying too much and looking at a few things that are stressing me out seriously (money being the top worry). I'm attempting to fight the demons that got me in this mess with weight as it is, I don't really need more items to push me into failure - I'm struggling enough playing the up/down game enough as is, aren't I? I don't want to be "undone" after having gone through all of this..... Signed, Not the super sleever poster child of positivity ... my apologies.... Pity party is officially over on 5/19, I swear!

My surgery is scheduled for Oct 13th. I had my upper endoscopy on Tuesday. Surgeon came by afterwards and said he found a hiatal hernia as well during the scope. He's already planning on repairing a large umbilical hernia, then the sleeve and now the hiatal hernia as well. I guess I'm getting my money's worth. I've had two open abdominal surgeries in the past. Both were outpatient. Both sucked outright. I'm glad that this is being done with a hospital stay and obviously glad that it's laparoscopic. FWIW.....I'd been saying all along that I wanted a bypass. The first surgeon I was working with said it was doable, but I needed to be aggressive on my weight loss leading up to the surgery (at the time I thought I had ~8 months). I switched over to another program that my insurance company mandated (a Center of Excellence certified program) and had a new surgeon. Long story short is that I dropped the insurance and chose to self fund to speed things up. My new surgeon was very clear in that he though the sleeve would be better for me. He felt that I'd benefit more from it right now....less complications with the elevated BMI, bone-on-bone knee situation, back issues....ability to use NSAIDs and reap their benefit. I was going to have hernia repair this Fall anyway......decided to go this direction at his advice. I'll work his plan hard and do what I can to get my results. Down the road.....were there ever a need......I can use my insurance and have my sleeve revised to a bypass. I am not proceeding as if this is a safety net.....but it is nice to know that there are options in the future. I do not have diabetes, nor is there any family history of it. This combined with the reasons above as well as some other issues made the sleeve vs bypass decision easier for me. Everyone has unique circumstances.

Hi there, I just had a total unfill today. I was having a lot of pain and vomitting. I just moved to the area I am in and did not have a lap band doc so I went to my PCP. He was concerned because as he palpated my upper abdomen I had pain so he ordered a CT scan. The scan showed a hernia and a slipped band; that was yesterday. The PCP contaced a lap band doc in town and got me into see her this morning. She did an unfill and then a swallow study. she was able to see the slippage right then and showed me. i have to have a revision. I hope you have luck and I hope the unfill works for you. Were you having the same symptoms in November? If not, it may be a good idea to do another swallow study? Take care. Angie

For me the first 6 weeks after both my VSG (12/2019) and revision (8/2020) the focus was on protein/water and slowly reintroducing foods. After 6 weeks my calorie goals were 6-900 calories a day and a minimum of 60g of protein. Now that I’m at goal it’s 1000-1200 a day and a minimum of 90g of protein.

Airwayman.. here is the policy that my bcbs goes by.... Sorry for its length. and here is the linkhttp://67.32.116.245/Internet/cmpd/cmp/mdclplcy.nsf/DispContent/F326B0F4EB49705E8525717700528079?opendocument CAM 70147 Surgery for Morbid Obesity Category:Surgery Last Reviewed:November 2006Department(s):Medical Affairs Next Review:November 2007Original Date:July 1996 Description: Morbid obesity is defined as an increase in weight over optimal weight that results in significant complications and a shortened life span. For example, morbid obesity has a significant impact on cardiac risk factors, incidence of diabetes, obstructive sleep apnea and various types of cancers (for men: colon, rectum and prostate; for women: breast, uterus and ovaries). The first treatment of morbid obesity is obviously dietary and lifestyle changes. Although this strategy may be effective in some patients, frequently the weight loss is not durable, with only five to ten percent of patients maintaining the weight loss for more than a few years. When conservative measures fail, some patients may consider surgical approaches. A 1991 National Institutes of Health (NIH) Consensus Conference defined surgical candidates as those patients with a body mass index (BMI)* of greater than 40 kg/m-2, or greater than 35 kg/m-2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Super obesity has been described as a BMI greater than 50 kg/m-2. Surgery for morbid obesity, termed bariatric surgery, falls into two general categories: Gastric restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake. Malabsorptive procedures, which produce weight loss due to malabsorption without necessarily requiring dietary modification. The following summarizes the different restrictive and malabsorptive procedures. Gastric Restrictive Procedures: Vertical-Banded Gastroplasty Vertical-banded gastroplasty is probably the most common kind of gastric restrictive procedure performed in this country. The stomach is segmented along its vertical axis. To create a durable reinforced and rate-limiting stoma at the distal end of the pouch a plug of stomach is removed and a propylene collar is placed through this hole and then stapled to itself. Because the normal flow of food is preserved, metabolic complications are rare. Complications include esophageal reflux, dilation or obstruction of the stoma, with the latter two requiring reoperation. Dilation of the stoma is a common reason for weight regain. Vertical-banded gastroplasty may be performed using an open or laparoscopic approach. Adjustable Gastric Banding – (gastric restrictive procedure without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty) Adjustable gastric banding involves placing a gastric band around the exterior of the stomach. The band is attached to a reservoir that is implanted subcutaneously in the rectus sheath. Injecting the reservoir with saline will alter the diameter of the gastric band; therefore, the rate-limiting stoma in the stomach can be progressively narrowed to induce greater weight loss, or expanded if complications develop. Because the stomach is not entered, the surgery and any revisions, if necessary, are relatively simple. Complications include slippage of the external band or band erosion through the gastric wall. Adjustable gastric banding has been widely used in Europe. Currently, one such device is approved by the U.S. Food and Drug Administration (FDA) for marketing in the United States, Lap-Band (BioEnterics, Carpentiera, Ca.). The labeled indications for this device are as follows: "The Lap-Band system is indicated for use in weight reduction for severely obese patients with a body mass index (BMI) of at least 40 and a maximum BMI of less than 50 with one or more severe co-morbid conditions, or those who are 100 lbs. or more over their estimated ideal weight. It is indicated for use only in severely obese adult patients who have failed more conservative weight-reduction alternatives, such as supervised diet, exercise and behavior modification programs. Patients who elect to have this surgery must make the commitment to accept significant changes in their eating habits for the rest of their lives." OpenGastric Bypass – (gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [less than 100 cm] Roux-en-Y gastroenterostomy) The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves a horizontal or vertical partition of the stomach in association with a Roux-en-Y procedure (i.e., a gastrojejunal anastomosis). Thus, the flow of food bypasses the duodenum and proximal small bowel. The procedure may also be associated with an unpleasant "dumping syndrome," in which a large osmotic load delivered directly to the jejunum from the stomach produces abdominal pain and/or vomiting. The dumping syndrome may further reduce intake, particularly in "sweets eaters." Operative complications include leakage and marginal ulceration at the anastomotic site. Because the normal flow of food is disrupted, there are more metabolic complications compared to other gastric restrictive procedures, including Iron deficiency anemia, Vitamin B-12 deficiency and hypocalcemia, all of which can be corrected by oral supplementation. Another concern is the ability to evaluate the "blind" bypassed portion of the stomach. Gastric bypass may be performed with either an open or laparoscopic technique. Laparoscopic Gastric Bypass (laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy [roux limb 150 cm or less]) Essentially described the same procedure as above (see No. 3 above), but performed laparoscopically. Mini-Gastric Bypass Recently, a variant of the gastric bypass, called the mini-gastric bypass, has been popularized. Using a laparoscopic approach, the stomach is segmented, similar to a traditional gastric bypass, but instead of creating a Roux-en-Y anastomosis, the jejunum is anastomosed directly to the stomach, similar to a Billroth II procedure. This unique aspect of this procedure is not based on its laparoscopic approach but rather the type of anastomosis used. Malabsorptive Procedures: There are multiple variants of malabsorptive procedures, which differ in the lengths of the alimentary limb, the biliopancreatic limb and the common limb, where the alimentary and biliopancreatic limbs are anastomosed. The degree of malabsorption is related to the length of the alimentary and common limbs. For example, a shorter alimentary limb (i.e., the greater the amount of intestine that is excluded from the nutrient flow) will be associated with malabsorption of a variety of nutrients, while a short common limb (i.e., the biliopancreatic juices are allowed to mix with nutrients for only a short segment) will primarily limit absorption of fat. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure) gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption Biliopancreatic bypass (BPB) procedure, developed and used extensively in Italy, was designed to address some of the drawbacks of the original intestinal bypass procedures that have been abandoned due to unacceptable metabolic complications. Many of the complications were thought to be related to bacterial overgrowth and toxin production in the blind, bypassed segment. In contrast, BPB consists of a subtotal gastrectomy and diversion of the biliopancreatic juices into the distal ileum by a long Roux-en-Y procedure. The procedure consists of the following components: A distal gastrectomy functions to induce a temporary early satiety and/or the dumping syndrome in the early postoperative period, both of which limit food intake. A 200-cm long "alimentary tract" consists of 200 cm of ileum connecting the stomach to a common distal segment. A 300- to 400-cm "biliary tract," which connects the duodenum, jejunum and remaining ileum to the common distal segment. A 50- to 100-cm "common tract," where food from the alimentary tract mixes with biliopancreatic juices from the biliary tract. Food digestion and absorption, particularly of fats and starches, are therefore limited to this small segment of bowel, i.e., creating a selective malabsorption. The length of the common segment will influence the degree of malabsorption. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. Many potential metabolic complications are related to biliopancreatic bypass, including most prominently iron deficiency anemia, Protein malnutrition, hypocalcemia and bone demineralization. Protein malnutrition may require treatment with total parenteral nutrition. In addition, there have been several case reports of liver failure resulting in death or liver transplant. Biliopancreatic Bypass with Duodenal Switch (Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileosteomy [50 to 100 cm common channel] to limit absorption [biliopancreatic diversion with duodenal switch]) Specifically identifies the duodenal switch procedure introduced in 2005. The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described here. However, instead of performing a distal gastrectomy, a "sleeve" gastrectomy is performed along the vertical axis of the stomach, preserving the pylorus and initial segment of the duodenum, which is then anastomosed to a segment of the ileum, similar to the above procedure, to create the alimentary limb. Preservation of the pyloric sphincter is designed to be more physiologic. The sleeve gastrectomy decreases the volume of the stomach and also decreases the parietal cell mass, with the intent of decreasing the incidence of ulcers at the duodenoileal anastomosis. However, the basic principle of the procedure is similar to that of the biliopancreatic bypass (i.e., producing selective malabsorption by limiting the food digestion and absorption to a short common ileal segment). Long Limb Gastric Bypass (i.e., > 150 cm) (Gastric restrictive procedure with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption) Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures, which vary in the length of the alimentary and common limbs. For example, the stomach may be divided with a long segment of the jejunum (instead of ileum) anastomosed to the proximal gastric stump, creating the alimentary limb. The remaining pancreaticobiliary limb, consisting of stomach remnant, duodenum and length of proximal jejunum is then anastomosed to the ileum, creating a common limb of variable length in which the ingested food mixes with the pancreaticobiliary juices. While the long alimentary limb permits absorption of most nutrients, the short common limb primarily limits absorption of fats. The stomach may be bypassed in a variety of ways (i.e., either by resection or stapling along the horizontal or vertical axis). Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the anastomoses. Note that CPT code for gastric bypass explicitly describes a short limb (<150 cm) Roux-en-Y gastroenterostomy, and thus would not apply to long limb gastric bypass. Laparoscopic Malabsorptive procedure (Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption) Introduced in 2005 to specifically describe a laparoscopic malabsorptive procedure. Vertical Sleeve Gastrectomy is a procedure that induces weight loss by restricting food intake. Approximately 60 percent of the stomach is removed and takes the shape of a tube or "sleeve". Policy: Gastric Restrictive Procedures Open gastric bypass using a Roux-en-Y anastomosis or vertical-banded gastroplasty with an alimentary or "Roux" limb of 150 cm or less may be considered MEDICALLY NECESSARY in the following: Treatment of morbid obesity that has not responded to conservative measures. BMI (Body Mass Index) exceeding 40. BMI greater than 35 in conjunction with severe co-morbidities (CAD, Type 2 Diabetes, medically refractory hypertension, etc.). Laparoscopic gastric bypass using a Roux-en-Y anastomosis, or vertical-banded gastroplasty, is considered MEDICALLY NECESSARY in the following: Treatment of morbid obesity that has not responded to conservative measures. At increased risk of adverse consequences of a RYGB due to the presence of any of the following: Hepatic cirrhosis with elevated liver function tests. Inflammatory bowel disease (Crohn’s disease or ulcertative colitis). Radiation enteritis. Demonstrated abdominal surgery, multiple minor surgeries, or major trauma. Poorly controlled system disease. Laparoscopic Adjustable Gastric Banding (Lap-Band) is considered MEDICALLY NECESSARY in the following: Treatment of morbid obesity that has not responded to conservative measures. At increased risk of adverse consequences of a RYGB due to the presence of any of the following: Hepatic cirrhosis with elevated liver function tests. Inflammatory bowel disease (Crohn’s disease or ulcertative colitis). Radiation enteritis. Demonstrated abdominal surgery, multiple minor surgeries or major trauma. Poorly controlled system disease. Above minimum BMI requirement and, in addition, have a maximum BMI of less than 50. Gastric banding, consisting of an external band placed around the stomach, is considered INVESTIGATIONAL as a treatment of morbid obesity. Gastric bypass using a Billroth II type of anastomosis, popularized as the mini-gastric bypass, is considered INVESTIGATIONAL as a treatment of morbid obesity. Malabsorptive Procedures Biliopancreatic bypass (i.e., the Scopinaro procedure), biliopancreatic bypass with duodenal switch, or long limb gastric bypass procedures (i.e., >150 cm) is considered INVESTIGATIONAL as a treatment of morbid obesity. Vertical Sleeve Gastrectomy is considered INVESTIGATIONAL. Policy Guidelines: Patient Selection Criteria: Morbid obesity is defined as a body mass index (BMI) greater than 40kg/m-2 or a BMI greater than 35 kg/m-2 with associated complications including, but not limited to diabetes, hypertension or obstructive sleep apnea. *BMI is calculated by dividing a patient’s weight (in kilograms) by height (in meters) squared. To convert pounds to kilograms, multiply pounds by 0.45 To convert inches to meters, multiply inches by .0254 It should be noted that all bariatric surgeries require a high degree of patient compliance. For gastric restrictive procedures the weight loss is primarily due to reduced caloric intake, and thus the patient must be committed to eating small meals, reinforced by early satiety. For example, gastric restrictive surgery will not be successful in patients who consume high volumes of calorie rich liquids. In patients undergoing biliopancreatic bypass, reduced intake may not be as much of an issue, but patients must adhere to a balanced diet to avoid metabolic complications. In addition, the high potential for metabolic complications requires life-long follow-up. Therefore patient selection is a critical process, requiring psychiatric evaluation and a multidisciplinary team approach. Given these factors, bariatric surgery should be approached very cautiously in adolescents. References: National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med 1991;115(12):956-61. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990; 107(1):20-7. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987; 16(2):317-38. Kolanowski J. Gastroplasty for morbid obesity: the internist’s view. Int J Obes Metab Disord 1995; 19(suppl 3):S61-5. 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