DrHekier

To reply to the original topic of the thread: Most doctors in the US will place a Band for BMI >35. Recently Dr. Paul O'Brien reported results of a trial for Lap Bands for BMI from 30 - 35, and there are now some US Lap Band surgeons who will perform a Band for BMI > 30. Maybe 'Fee' , who posted that he/she was from Australia could let us know what the criteria are over there. But I understood the original question to be what about someone at a more or less normal weight now who has weight issues in the past.

I'm not on Obesityhelp.com; they wanted something on the order of $1000 for a doctor to be included. (Don't get any ideas LBT moderators! ) I figure on this board I can learn a few things from the many people that post here, as well as clear up misconceptions or misunderstandings.

What is strange about those is that they are actually ICD-9 codes. ICD-9 codes are diagnosis codes (International Classification of Diseases- 9th edition). In order to justify an intervention (such as surgery) you need to provide the diagnosis code. CPT (Common Procedural Terminology) Codes are generally codes for an intervention. What is strange with those set of codes is that those series of codes are ICD-9 codes for operations; and CPT codes are usually used for operations. For example for many insurnace companies we use :43659Unlisted laparoscopy procedure, stomach I'll have my biller look into it. I'm particularly interested because my wife and I performed several Lap Bands for Medicare that they subsequently refused to pay for( :cross-eye ). Maybe if we use some of those codes they will pay for them. (I'll owe you lunch Sandybells!)

That's a radical thought and quite thought provoking. Can you expand on your question please. Do you mean a person who has a history of obesity, and has lost the weight?

Firstly, the quote above is Dr. O'Brien's so he deserves the credit. Secondly, I personally think that the Lap Band requires a greater commitment and interaction from the patient than other WLS options. You have to work with your diet to find what works and what doesn't; you have to get a sweet spot on fills with your health care provider; you have to seperate liquids from solids, and on and on and on. I think if you are going the Lap Band route you are as committed, if not more, than people that go another route for weight loss.

(I should be posting anonymously, because some doctors might be offended, but I hope not.) In my personal opinion, there are a number of bariatric surgeons in the US who fit in the category as 'bait and switch.' They have you come to a seminar about the Lap Band, get you interested in their program, but then try to sell another surgery to you. Let's take a look (perhaps a cynical look) at the disadvantages of the Lap Band: 1) After the Lap Band, the surgeon may have to see the patient every 6 weeks for the first year. For the gastric bypass or VBG, you are often seen only once or twice posoperatively and then never again. Much easier for the surgeon if you never have to follow up with them. 2) Weight loss is more gradual with the Lap Band, (although after 2 - 3 years several studies indicate equivalent weight loss when compared with the gastric bypass) and as a result more patience and long term follow up is required with the Lap Band. (see #1) 3) The Laparoscopic gastric bypass is a surgical tour-de-force with a fairly high degree of complexity. In all honestly after a few dozen Lap Bands, it's a fairly straight forward procedure. I believe there is some intellectual snobbery against Lap Band surgeons, since it is a procedure more accessible to more surgeons outside of major centers, where many, but not all, bypass surgeons are. Ironically, since the risks are so much lower with Lap Band when compared with the bypass, I feel that some bariatric surgeons look down on the Band as a 'less elite' procedure. Who is cooler and more macho, the guy shot out of a cannon through a ring of fire across the street, or the one that uses a crosswalk when the light is green to cross the street? The guy shot out of a cannon might be cooler, but guess what, both guys cross the street, and one with much less risk. I know I would never perform any obesity surgery other than the Lap Band, given the options available now. I remember reading articles and interviews with Dr. Paul O'Brien. As many of you know he is (or used to be) the #1 Lap Band surgeon in the world, having put in nearly 3000 bands last I heard. He used to do all types of obesity surgery but has switched to an essentially Lap Band exclusive practice. He would always be presented different patient scenarios and what his choice for surgery would be, and it was almost always a Lap Band. As he told me over dinner at one of the courses; 'why would you choose to mutiliate the GI tract [his explanation of a gastric bypass], when you can perform a safe, reversible procedure for the same results.?' I agree. Thus endeth the sermon.

That may sound like a sensible thing to do, but would add a layer of complexity to an already complex and not necessarily sensible system.

A BMI of 30 is the level considered "obese" and per the National Institutes of Health (NIH) places an individual at high risk for Type 2 diabetes, hypertension, and coronary artery disease. Additionally per the NIH it increases the risk of stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers. However, most if not all insurance companies follow the guidelines set forth by the NIH in a consensus statement in 1991. In that statement they set forth that potential candidates for surgery have a BMI over 40, or over 35 with comorbidities. At the time of this consensus statement in 1991, the two main bariatric surgical procedures were open Roux en Y gastric bypass, and the open vertical banded gastroplasty (VBG). Those open procedures certainly have more side effects than the Lap Band. Also there was certainly less literature and scientific study available with results from bariatric surgery in 1991 than there is today. I would not be surprised if in a few years, as the scientific community is made more aware of the benefits of the Lap Band, when compared to other bariatric surgical procedures which have higher risk, we will see the "bar" for surgical intervention drop from BMI of 35 to BMI of 30 from the NIH.

I seem to recall Dr. C Everett Coop testifying before Congress when he was the Surgeon General, that nicotine was more addictive than heroin. My mother in law quit smoking with the help of Zyban. That and the fact that she had a CXR with a funny spot that scared the s*** out of her. I can't tell you about the number of patients I've seen with several complications of smoking that still can't quit. People on supplemental oxygen secondary to emphysema, still smoking; people with amputations secondary to vascular disease worsened by smoking, yet they still smoke threatening the other limb, etc... Don't be discouraged if you can't quit the first time. Keep at it. In the long run the health benefits are worth it! Maybe you can use your Lap Band surgeon's support group to also discuss and encourage your tobacco cessation. Good luck!

Unfortunately we have found that several insurance plans will only cover the Roux en Y gastric bypass and not the Lap Band. Makes no sense to me. Let's see, one operation has a 10 - 100 times higher incidence of death, a longer hospital stay, is more expensive, and results in a permanent re-routing of the GI tract that can lead to nutritional deficiencies and other problems requiring surgery in the future. Let's cover that one! Some routes to fight your insurance company include: appeals, you or your surgeon speaking with the medical director at the insurance company, law firms specializing in obeisty discrimination e.g. www.obesitylaw.com, your state's insurance commision. Good luck!

You should be able to call your insurance company to find out if the Lap Band is covered. We generally do that for all of our patients so that before they show up for an appointment they know whether or not the insurance company will even potentially pay for it or not. Some insurance companies still don't seem to understand what the Lap Band is, and only know about the gastric bypass, so it may be easier to ask them about an exclusion for morbid obesity surgical procedures first, then ask about Lap Band specifically.

In our practice we have learned (the hard way) that even within the same insurance company, individual employers can add exclusions to policies. It's frustrating for our office to hear an exasperated patient tell us "but my friend has the same insurance I have and she got them to pay for the Band." Even with the same carrier, your individual employer can add an exclusion to the plan to exclude WLS. You would think a medical school would not do that but both hospitals in our town exclude treatment for obesity surgery.

Before you consider any form of weight loss surgery make sure your medical issues are optimized. For example, the thyroid gland is sort of the 'thermostat' of your body, and if you are significantly hypothyroid (have low thyroid function) and are not having adequate replacement through medication, your metabolism may be slowed to a a point that it is a factor in your obesity. If you do go on to consider and are a candidate for the Lap Band, with regards to patient financing call the surgeon near you that you would likely have perform the procedure and his/her office should have options available for you. Good luck, and lets count on the day when all insurance plans cover the Lap Band and stop obesity discrimination. As my partner (who happens to be my wife) says, "your insurance company would never tell you 'You got breast cancer and didn't have a mammogram in 3 years, too bad, we're not paying for surgery. You laid out in the sun as a teenager and now have skin cancer, too bad we're naot paying for surgery." Don't want to get on a soap box, but obesity may be the only disease that insurance companies do not have to provide service for. Sigh.....

The "full = not hungry" quote is right on and deserves to be a sticky! That's one of the main points we try to emphasize to our patients when they ask "how much should I eat?" I can't speak for patients who have had other procedures such as the gastric bypass or the VBG (because we don't do those) but for the Banded patients it's important to change your mindset towards food. We are genetically programmed to eat until we are full, and it takes a lot of work to change your attitude towards food and eat until you are not hungry. It's a completely different approach, but essential for weight loss success for Lap Band patients.

One of my patients last week asked about gallbladder removal during her upcoming Lap Band so I offer some thoughts: Many people who have not had weight loss surgery end up with stones in their gallbladder, but not all of those stones are symptomatic and cause pain. Since rapid weight loss or weight gain can cause the formation of gallstones it is an area of interest to bariatric physicians and patients. There is a debate among physicians as to whether or not to perform a gallbladder removal at the time of weight-loss surgery. I recall that it was a topic of discussion at the American Society of Bariatric Surgery meeting I attended a couple of years ago, and there was no consensus as to whether or not remove the gallbladder. Some laparoscopic gastric bypass surgeons commented that the placement of the instruments for the bypass is not ideal for removal of the gallbladder, and hence that makes the surgery more difficult or makes it necessary to place more ports for instruments into the patient. I am not aware of many Lap Band surgeons that remove the gallbladder at the time of surgery for the following reasons: 1) By removing the gallbladder you introduce the possibility of having bacteria enter the bloodstream or abdominal cavity, since the bile in the gallbladder can harbor bacteria. You would prefer not to do this in the presence of a foreign body, the Lap Band. 2) The port placement for the Lap Band may not be ideal for removing the gallbladder and more ports may need to be added. 3) It is felt by some that the more gradual weight loss seen with the Lap Band compared to gastric bypass makes the likelihood of developing gallstones lower. 4) While generally a safe surgery, gallbladder removal (cholecystectomy) does entail its own specific risks that are unique to that surgery, therefore adding a cholecystectomy to the Lap Band, theoretically adds to the risk of surgery. To answer Amy's original question about the recovery from the surgery: The laparoscopic cholecystectomy is generally well tolerated and most patients return to regular activity within a few days. I remember a patient who was a high school football couch and went to run practice the afternoon after his cholecystectomy. As with any surgery, everyone has a unique recovery based upon how their body responds to the surgery. Good luck!

Yvonne, You are absolutely correct. I have looked it up and yes there is an 11cm Band not for use in the U.S. Until just now I wasn't aware of it. I'm surprised why Dr. O'Brien, the Australian surgeon, doesn't refer to it in his paper we cited above, as he is the most prolific Lap Band surgeon in the world. In his paper he refers to the 9.75, 10, and VG sizes. Perhaps the 11cm band isn't used in Australia either. (On the internet I found Inamed's info card for the 11cm band and it has a brief paragraph in French, German, Spanish, and Italian, but not Australian.) So Yvonne is right, there is a separate 11cm Band, not used in the USA, that has a maximum fill volume of 9cc. Regards, Ron Hekier PS Sorry about the disclaimer Princess, but it was recommended to me by another physician. Sigh...the world we live in... PPS I am aware that Australians speak a form of English.

Ruthie, I wouldn't be stressed out unless you were at a maximum of 10cc filled and weren't receiving the results you wanted. See our thread on another topic: http://www.lapbandtalk.com/showthread.php?t=9192 About half way down find my message with a link to a paper by Dr. O'Brien. On page three of that paper there is a graph showing the size of the stomach opening with the 3 bands (9.75/10/11 or VG) at different fill volumes. What you will see is that at higher fill volumes, the VG band has an opening just about as small as the other bands at their higher fill volumes. I'm hopeful you will do just fine with your VG. Remember this is a journey for the rest of your life, and don''t get stressed out over one particular place in time.

The 11 cm band is the VG also known as Vanguard. My info says 10cc is the maximum but I wouldn't dwell on it. I think for most people the maximum fill volume is not an issue as you won't need to get near the maximum to have good results.

Nickie, From the information I have from Inamed, for a 9.75 cm band the maximum fill volume is considered to be 4cc. Perhaps you can stretch it a bit to 5cc, but per the Inamed material that I have, for the 9.75 and 10.0 cm Lap band, 4cc is considered the maximum. The inner balloon is rather sturdy, and I think it would be hard to 'pop' the balloon if you got a fill a bit past 4 cc. I would suspect with a 9.75 cm band you would not need to get a fill past 4cc. In fact I wonder if there is anyone on this board who has a 9.75 Lap Band and has been filled to 4cc and is not receiving good results? From a thread on this board in 2004, I found the following link. http://www.gisurgery.net/OverviewObesityBariatricSurgery.pdf It is a link to a paper by Dr. Paul O'Brien, an Australian surgeon who has probably placed more Lap Bands than anyone in the world. (Around 2500 when I attended a training course with him nearly two years ago.) I draw your attention to figure 3 on page 3 of the article. Notice the comparison of area within the band (i.e. stoma size) for the 3 Lap Bands depending on the amount of saline added, and that for the 9.75 and 10 cm bands the graph stops at 4cc. This graph in Dr. O'Brien's paper is an extrapolation of a bar graph I have seen from Inamed, the manufacturer of the Lap Band.

There are two issues here: 1) Band size 2) Fill volume There are three sizes of Inamed Lap Bands. As I understand it, the size refers to the inner diameter of the band. The 3 band sizes as per Inamed are 9.75 cm, 10.0 cm, and the VG (the Vanguard, which I believe is 11cm, but all the reps call it VG, no-one calls it the '11') Fill volume: The 9.75 and 10 cm bands can hold a maximum of about 4cc of saline. The VG holds a max of about 10 cc of saline. In medical circles I've always heard the Lap Band referred to by its size. For example, today in the OR we used "two 10's and one 9.75."

Thanks everyone. I didn't want to seem pushy and didn't know if I would be welcome to post here. I certainly don't want to intrude, but I would be happy to impart what I hope to be impartial, scientific, knowledge. Thanks for the kind words!

Spydr, Hi, my name is Dr. Ron Hekier. My wife and I are general surgeons that perform the Lap Band surgery. I think it is virtually impossible for the event described to you to occur. The Lap Band is made of an inert, smooth material, that generally does not have anything stick to it. Also, during the procedure, a small portion of the stomach is brought over the band to prevent slippage. This results in most of the Band not being exposed to other organs in the abdominal cavity. Besides, I have never heard of a case where an internal adhesion has ripped with sudden movement and caused bleeding. With the VBG (vertical banded gastroplasty or 'stomach stapling) the mesh around the top of the stomach can form adhesions to and stick to the liver. But even in those cases, you don't get bleeding from sudden movement. My $0.02. Regards,