tasherie

SO...I am a little over 18 months post-op and now ttc. I think that I might be..you know..pregnant...BUT my symptoms are kind of wacky and confused. Ever since surgery and losing the weight my PMS has been a little out of control. I kind of get pregnancy symptoms every month now with my time of the month..and it sucks because it really fakes you out sometimes. Lately though, I have felt 'kind of' nauseous, and I say 'kind of' just because with my new tummy I don't feel nausea like I used to. When I do feel it its kind of a back of my mind type of feeling..like a ghost of what it used to be. I honestly don't even feel like it is even possible for me to throw up anymore. Usually if I ever feel sick to my stomach it always ends up being my intestines issue (if you catch my drift lol) Anyone else go through this with the 'kind of' nausea? Or am I just a unique case?

LOL mine is too..but I am happy. That is all that matters, right? (or at least in MY mind). I have the comforting thought that I will want to try to lose that last bit and go for it..but my motivation just isn't there. As long as I am not gaining I am going to wait until I am ready.

I agree. It is hard but it is necessary...at least until you can eat your protein. I HATED Protein Drinks of any kind..as soon as I could eat it..I never drank those horrible things again.

refried beans with cheese, any kind of soup, half a scrambled egg and that is about it.but I never really ate much. I just never felt like it...now a days I eat way more..just remember to take it slow and do what your body wants. I personally think drinking is way more important at that time and taking your vits.

I haven't posted in a while but I was a low bmi'er..sort of. My bmi was around 39..and I technically only had about 90 pounds to lose. I am now almost 9 months out. I am sitting right at about 185 so that is about 75 pounds gone. I lost fairly quickly in the beginning but it has def slowed WAY down but I am just about at goal and the weight my body feels comfortable at. I should also say that I do not watch what I eat...I just focus on protein first and variety and I do well, but I am pretty sure if I went back to a very low carb diet I would lose the rest..I am just happy where I am *shrug

This is my appeal letter that was sent out February 15, 2012 after initial denial for Sleeve Gastrectomy. I was denied because my BMI is not over 50. If this can help you in any way feel free to pull from my references or my letter. February 14, 2012 Carefirst BlueCross BlueShield C/o Member Services 10455 Mill Run Circle Owings Mills, MD 21117-5559 Case ID: Member Name: Member Number: [000] Re: Grievance with the Plan following ‘Adverse Decision’ for primary service code 43775 – Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (IE, Sleeve Gastrectomy) To whom it may concern: In accordance with the Internal Grievance Process of Carefirst BlueChoice Inc. (hereafter the “Plan”), I received a written notice of an Adverse Decision regarding the above identified health care services based on a review of the request for benefits. It was determined that the health service requested was not medically necessary, appropriate, or efficient. I am writing this letter to request redetermination of approval based on research provided. I will also show that I meet the Plan standard for treatment of morbid obesity, that it IS medically necessary, appropriate, and efficient; Sleeve Gastrectomy is a covered and appropriate stand-alone procedure to treat obesity, current body of evidence iterates the need for the procedure and other forms of treatment for obesity are not for me. According to the Center of Disease Control (CDC), research has shown that as weight increases to levels of “overweight” and “obesity”, the risks for the following conditions increase (3): - Coronary heart disease - Type 2 diabetes - Cancers (endometrial, breast, colon) - Hypertension - Dyslipidemia (for example, high total cholesterol or high levels of triglycerides) - Stroke - Liver and Gallbladder disease - Sleep Apnea and respiratory problems - Osteoarthritis (a degradation of cartilage and its underlying bone within a joint) - Gynecological problems (abnormal menses, infertility) At a current weight of 248 (247.8 rounded to the nearest whole number), and height of 66 inches, my BMI is 40.0. This puts me at MORBIDLY OBESE and at HIGH-RISK. As written in your medical policy “Patients with morbid obesity generally have at least a body mass index (BMI) of 40 (35 with certain co-morbid conditions).”(1) Sleeve gastrectomy is also listed in your medical policy as a proposed laparoscopic procedure to treat morbid obesity. Your policy deems it APPROPRIATE and EFFICIENT by listing it as a proposed procedure to treat morbid obesity. My medical doctor and surgeon have deemed weight loss surgery as MEDICALLY NECESSARY for treatment of my morbid obesity. The National Institute of Health Consensus Conference on obesity surgery recommends that surgery be considered for individuals who meet the following criteria: - Individuals with a BMI of 40 kg/m(2) or greater - Individuals with a BMI of 35 kg/m(2) or greater who also have serious medical conditions that would improve with weight loss.(6) As previously stated, at a BMI of 40 I meet these criteria. Also, you reference a position paper by the American Society for Metabolic and Bariatric Surgery (ASMBS) from June of 2007. Your update reads as: - “Sleeve Gastrectomy, Update 2008, January: - Sleeve gastrectomy has been proposed both as a stand-alone gastric restrictive procedure, and as a first stage operation for the extremely morbidly obese patients, e.g. those with body mass index (BMI) exceeding 50, or for those with serious comorbid conditions that would increase risk for morbidity and mortality with the initial use of a malabsorptive procedure such as gastric bypass with Roux-en-Y anastamosis or duodenal switch. Bariatric specialists believe that with the initial weight loss and improvement of comorbid conditions following the sleeve gastrectomy, the malabsorptive procedure can be performed at a later time if necessary with greater safety. In June of 2007, the American Society for Metabolic and Bariatric Surgery (ASMBS) published a position statement on sleeve gastrectomy as a bariatric procedure. The paper states that sleeve gastrectomy may be an option for carefully selected patients, particularly those who are at high risk or super-obese, and that the concept of staging bariatric surgery may have value as a risk reduction strategy in high-risk patients. The paper also suggests that surgeons performing sleeve gastrectomy inform their patients regarding the lack of published evidence for sustained weight loss and provide information regarding alternative procedures with published long-term (>5years) data confirming sustained weight loss and comorbity resolution.”(1) The update as states for this procedure was last done in 2008. As most medical professionals know policy and opinions change as more research is done and more studies published. The ASMBS recently released an updated position statement on Sleeve Gastrectomy (October 28, 2011) which supports the growing body of evidence that sleeve gastrectomy has value as a stand-alone procedure for the effective treatment of morbid obesity, and falls somewhere between the lap-band and the gastric bypass in results. Your update is NON-CURRENT. The ASMBS is the largest organization for bariatric surgeons in the world. It is a non-profit organization in whom you reference substantially in your own medical policy. I have included a copy of their current and updated position statement, along with tables displaying randomized trials evaluating sleeve gastrectomy and long-term follow-up after sleeve gastrectomy. I will also provide excerpts that support my argument that sleeve gastrectomy is an appropriate, effective, and efficient way to treat my morbid obesity. In the summary and recommendation portion of the position statement it says: “substantial comparative and long-term data are now published in the peer reviewed literature demonstrating durable weight loss, improved medical comorbities, long-term patient satisfaction, and improved quality of life after Sleeve Gastrectomy. The ASMBS therefore recognizes Sleeve Gastrectomy as an acceptable option as a primary bariatric procedure and as a first stage procedure in high risk patients as part of a planned staged approach. Based on the current published literature, Sleeve Gastrectomy has a risk/benefit profile that lies between the laparoscopic adjustable band and the laparoscopic Roux-en-Y gastric bypass.” (9) The position statement also supports my argument that the number of 50 (BMI) in your guidelines is arbitrary. In the studies referenced, patients had a BMI of >35 with comorbities or 40> without. There were no studies done that were referenced where all patients had a BMI of 50 or greater as a stand-alone procedure (Shown in the tables provided). There were those kind of patients INCLUDED, which shows some success, but not exclusive. In fact, Mercy Health Partners published a study in August 2011 proposing that laparoscopic sleeve gastrectomy is a safe and effective bariatric procedure for the lower BMI (35.0-43.0 kg/m2) population. The study was a nonrandomized retrospective analysis of 204 patients from a single surgeon operated between July 2006 and April 2010. The study was comprised of 155 women and 49 men with a mean age of 45 years (range 19-70 years), a mean preoperative weight of 126.6 kg, and a body mass index (BMI) of 45.7 kg/m(2). Coming to the conclusion that Laparoscopic Sleeve Gastrectomy (LSG) yields excellent outcomes with low complication rates for morbidly obese patients and advocate LSG as a safe and effective stand-alone procedure, especially with the lower BMI population. (5) There is NO evidence showing reason that Sleeve gastrectomy should be restricted as a stand-alone procedure for patients with a BMI of 50 or greater. There is no evidence showing that this procedure would NOT help me, but to the contrary showing that it would. There are no studies analyzing patients with a BMI of 50 or greater exclusively. Patients with a BMI of 40 or greater (35 or greater with comorbities) are analyzed along with these patients showing SUCCESS. This should mean that with my BMI of 40, I would have success with the Sleeve gastrectomy in bringing me to my surgeon’s goal of 60% EWL and with commitment and work, bring me to my personal goal of a normal BMI. I have tried to lose weight all kinds of ways (Diet pills, medically supervised diets and exercise, South beach diet, Atkins diet, 1000 calorie diet, Low Carb/high fiber diet). I go to the gym and workout whether I lose weight or not. I have even bought fitness games to do in my free time at home to burn calories and stay active. I FAIL to lose weight despite my efforts. I take in too many calories despite my efforts, and have a sedentary job where I work long hours. Surgery is necessary due to my ever growing weight. I recognize that I am severely overweight with a weight of 248 and 66 inches tall. My surgeon have clearly explained to me that this level of obesity has been shown to be unhealthy and that many scientific studies show that persons of this level of obesity are at increased risks of respiratory disease, high blood pressure, heart disease, high cholesterol, stroke, diabetes, arthritis, clotting problems, cancer and death. Most of these risks already run in my family and put me at even further risk. I DO NOT WANT TO DIE. I believe with a Sleeve Gastrectomy providing me restriction, and my current gym schedule and commitment to be more active, I can lose a significant amount of my excess weight and become a normal, active, healthy person. By your own medical policy guidelines, I easily meet your requirements for surgery as an option to help battle my morbid obesity. The evidence and research provided and referenced shows that Sleeve gastrectomy is recommended as a stand-alone procedure, and can help me with a BMI of 40. Sleeve Gastrectomy should be provided as an option for those of us who are morbidly obese, but cannot have gastric bypass, and are not comfortable with a foreign mass being placed inside their body. I cannot have gastric bypass because with my diagnosis of osteoarthritis, I will probably have to take some form of N-SAID all my life for pain. With the gastric bypass my new ‘pouch’ would not be able to handle them, and I would be at risk for ulcers. I am a 27 year old single female, who at some point in the future would love to have children (multiple if possible). With the malabsorptive qualities of the bypass, I would have a high risk pregnancy. I do not wish to put me or my future children at risk. Gastric bypass also leaves you with what essentially is called a ‘remnant stomach’, a non-functioning portion of stomach that if ulcers or cancer comes about CANNOT be endoscopied. I am not comfortable with this procedure. I prefer the Sleeve gastrectomy because my system is NOT being rerouted. What I eat, as little as it could be, will be absorbed. Nutrients and minerals my body needs can be absorbed with no problem. Vitamin deficiency after gastric bypass surgery is a known complication, according to the University of Alabama, Department of Gastrointestinal Surgery in Birmingham, Alabama. (4) Compared to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass has higher nutrient deficiencies in a prospective study done by Department of Surgery, St. Claraspital, Kleinriehenstrasse 30, Basel, Switzerland. (2) In summary, I meet the policy requirements for bariatric surgery for treatment of my morbid obesity. I meet NIH requirements for bariatric surgery for treatment of my morbid obesity. Surgery has been deemed medically necessary by my medical doctor, and surgeon. The ASMBS position paper Carefirst references in the plan is non-current, and with the research provided and CURRENT position statement recognizes Sleeve Gastrectomy as a stand- alone procedure. There is no evidence that Sleeve Gastrectomy as a stand-alone procedure should be reserved for patients over 50 BMI. There is no evidence showing problems performing sleeve gastrectomy for patients with a BMI of 40 or greater. On the contrary, there is evidence and studies referenced in this letter showing the benefits of performing sleeve gastrectomy as a stand-alone procedure for patients with a BMI of 40 or greater; or 35 or greater with comorbities that would improve with weight loss. Gastric bypass is NOT a viable option for me, with my need to take n-saids for pain. I hope you take my research and references into consideration. I know that this is not an emotional decision, but I hope that you can understand why I would fight for a procedure I have researched and read about extensively enough to be comfortable with. I do not take surgery lightly, but I believe that this surgery will save both the insurer and I great cost down the road. Bibliography included if further review of references are needed. Thoughtfully, Me Works Cited "Carefirst Medical Policy 7.01.036." Carefirst BlueCross BlueShield. N.p., n.d. Web. 27 Jan. 2012. <notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/4dd2d4d2d0b090>. "Fewer nutrient deficiencies after laparoscopic sle... [Obes Surg. 2010] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 27 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/20101473>. "Healthy Weight: Effects of Overweight | DNPAO | CDC." Centers for Disease Control and Prevention. N.p., n.d. Web. 14 Feb. 2012. <http://www.cdc.gov/healthyweight/effects/index.html>. "Incidence of vitamin deficiency after laparoscopic R... [Am Surg. 2006] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 27 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/17216818>. "Laparoscopic sleeve gastrectomy is a safe and effe... [Obes Surg. 2011] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 14 Feb. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/21128003>. "Medscape: Medscape Access." Medscape: Medscape Access. N.p., n.d. Web. 14 Feb. 2012. <http://www.medscape.com/viewarticle/734500_print>. "Results of laparoscopic sleeve gastrectomy: a prospe... [surgery. 2009] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 25 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/19081482>. "Third International Summit: Curr... [surg Obes Relat Dis. 2011 Nov-Dec] - PubMed - NCBI." National Center for Biotechnology Information. N.p., n.d. Web. 25 Jan. 2012. <http://www.ncbi.nlm.nih.gov/pubmed/21945699>. nonegiven. "Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure." ASMBS 3 (2011): 17. Print. MLA formatting by BibMe.org.

I can tell you I felt the same exact way (except for the back pain) at one week out. I am almost 4 1/2 months out and it gets better!! Day by day, week by week things will get better. Then one day you will feel totally normal, or at least what normal is now. I did horrible with my fluids the first month and a half..I had to find what was right for me. Gatorade that was kind of half frozen in the bottle (grape was my fav) from the freezer was the easiest for me. i still cant drink anything too much like water..just doesnt feel good. I also was horrible at my Protein because I hate Protein shakes. It wasn't until about week 11 that I got on track with that because I could eat my protein.

Thank you! You won't reget it!

I haven't really been on here as much as I used to mostly because I get so busy living my life now and being happy. Its the first time in my life I can see the light at the end of the tunnel. Its not really about the weight loss that makes me so happy but the not having to worry about it as much anymore. I have 60 more pounds to lose to make it to my goal. My surgeon says I am ahead of schedule with weight loss. Sometimes protein is still a b***h LOL but I refuse to drink a shake (Ugh!) So I eat every bit of it that I can. I have finally just in the last two weeks worked out my fluid schedule to where I am getting 64 oz. Im not gonna lie..I don't always make the best choices but my main focus is my protein and I have been doing really well. I get sick of stuff very quickly so sometimes its a challenge to come up with different ways to eat. It really is a chore now. I get hungry from time to time..no where near what it used to be. I am satisfied with very little, and am a VERY cheap date LOL I have tried everything except raw veggies and fruits, but in two more weeks I should have the go ahead for those. I have no pain. Sometimes I overeat and get a sickly feeling that makes me miserable..lol but I learn from it and take my time. I do exercise but only 2 days a week. I try to be as active as possible in my free time so I hope that makes up for it. The great thing about losing inches and pounds is that you become more willing to do new things because you have the energy and the mobility and boost in confidence. If anyone has any questions I am more than willing to IM. I hope everyone is doing well!

In a jam I eat the grilled snack wraps all the time..I get mine with no lettuce. I have lost 42 pounds in 10 weeks so I have not been doing too bad. Do I eat all of the tortilla? NO..i peel most of it away but the chicken is really good

I was told I could have a salad at 6 weeks..but I was scared. Had one for the first time on sunday and I don't know what I was so afraid of. It was delicious, went down well and I could eat quite a bit

Yea we are. I didn't really expect to lose so fast because I was a lower bmi (41)..but its just coming off. Thank you so much btw!

Lissa already answered this for you, but I wanted to thank you for your congratulations lol

Hi all! I am officially 6 weeks tomorrow! Yay! So I thought I would pass on some advice to those of you that pre-sleeve or just newly sleeved (newer than mine lol). 1.) Take it slow after surgery. Don't push yourself because you WILL pay for it in PAIN. At 6 weeks I am just now getting back to my normal energy level. 2.)Relax!! I know that we want this to work so bad and so fast that we freak out when something goes awry. You are going to have stalls..BUT if you stay on plan (Protein first blah blah blah) you WILL lose the weight. Some lose faster than others and every body is different. Just try to have a little patience and don't tie yourself to a scale. Inches still come off in a stall! 3.) If you feel something isn't right. Call your nurse or doctor and ask. There is no harm in asking and I am sure they have heard anything you can throw at them. 4.) Don't beat yourself up! There is going to be a day that you are going to eat something that you aren't suppose to. My personal opinion (yours may be different) is that I did not do this to myself to be on a diet for the rest of my life. I stay on plan but I do treat myself to a bite or two of something I like sometimes. I have still lost weight. Not fast, or slow but somewhere in the middle...And YES I can eat a little more than most (My surgeon used a 40 sized bougie) but NOT so much that my loss has been different. I can still only eat about a 10th of what I used to at any given meal. When you feel yourself freaking out..take a step back and look at everything you have gained (ie..smaller clothing size, ease of movement)...and all that you have lost (ie inches and pounds). 5.) Keep up on your Vitamins. In the beginning there is absolutely NO WAY to eat the amount and variety of food to get the recommended amount of vitamins/minerals your body needs. You WILL feel it, and not in a good way if you don't. 6.) Keep up on your water/fluid. You WILL feel it, and not in a good way if you don't. 7.) Get active! Sitting around bored will not help with head hunger! Do other things! Get a hobby! LOL I am sure there is more that I could add, but I am leaving work and wanna go HOME! *whiney face lol and I am running out of time. Feel free to add what you would think is important to know. 33 pounds down and even though I am mad at myself that I had to do this and get here to lose weight it is the BEST thing I have ever done for myself. I can only see good things ahead. Good luck!

Your welcome. A lot of people are too hard on themselves after this surgery because I guess they feel pressure to 'succeed'. Sometimes you just have to look at the big picture. Try your best..that is all you can do.

LOL yes I know! Everybody says I look like I am shrinking but I haven't really gotten it through my head that I am the lightest I have been in 2 years!! LOL All of my old 'smaller' clothes are fitting and all of my 'bigger' clothes are too big! I am now in a size 14! yay!

What she said!

Your welcome! lol If you have any questions just IM me.

Don't stress yourself out about it. I can eat like that too. I can eat 2 whole hard boiled eggs at one time! lol I still lose weight, not slow or fast but moderately, and I am not even working out yet. I walk, but nothing other than that. (I get the go ahead for exercise this thursday). As long as you are following plan and doing what your suppose to do you will lose weight! Your gonna drive yourself crazy over-thinking everything lol

I third that. Just focus on your liquids for the first couple weeks. The most important thing is to stay hydrated. Dehydration can be AWFUL lol..seriously..don't stress yourself out about it. Things will get easier as you progress.

HI!! I am right around 5 1/2 weeks (surgery March 8). Doing very well. I feel very 'normal'. From my highest weight of 257 right before my pre-op diet I am down around 32 pounds. I feel so much better. The weight comes off at about 3-4 pounds a week now. I did have a stall the 2nd and 3rd week, but now I am back to losing pretty steadily. I eat pretty much what I want. I don't really have much room to go off of plan because I don't drink protein shakes. So I try to eat as much of my protein as I can. I don't have room for carbs and I am slowly but surely working on that 64 oz. goal of fluids per day, but not quite there yet. I take my vitamins everyday, and I have to say I am doing fairly well. Just enjoying life!

I can't stand protein shakes or drinks either! LOL As soon as I could start eating semi-solid and solid foods I try as hard as I can to eat all of my required protein. Sometimes that involves a protein bar. The atkins protein bars seem to sit with me the best. I can only usually get half of one done at a time, I kinda split it between snacks. (morning snack, and afternoon snack). The rest I get in with eggs, roast beef hash, shrimp (my sleeve loves shrimp), tilapia,tuna, canned chicken, chicken wings..etc. So to answer your question..I would say as soon as you can eat semi-solid or solid foods, but always ask your NUT or surgeon first. Me personally, I tried them at 3 1/2 - 4 weeks post op.

I have learned from lurking in some plastic surgery forums that massage of your incision scars can help reduce the 'raised' appearance sometimes. So I have been doing this with scar cream after the shower, with gentle pressure in small circular motions. Sooo you can HEAR the scar tissue breaking up underneath and its similar to how bubble wrap sounds!! Can you say the wierdest feeling since drain removal??? LOL

I just use Vitamin E capsules

My confession: I eat what i want, and don't count my calories. I usually go for protein first because that is what I crave but I have eaten pretty much everything that I have craved. Yes, I still lose weight. I don't mind that its slow. I can't get in much, and I try to enjoy every meal.