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I'm also revising from the band, which I had for 5 1/2 years. I lost 60 lbs. but am now having trouble with reflux, nausea, etc. Apparently my esophagus looks like "ground beef." So the band needs to come out but I'm having trouble deciding between the sleeve and the bypass. How did you make that decision, Vicki and Johnny?

Well that sounds good! Your surgeon sounds great. Yes, its true band to sleeve revisions risk for leaks does increase by about 2-3%. I was very lucky in my revision that my only complication was some pretty bad nausea (vomited as well but only once) and my pain was pretty bad. Tiffykins did experience a leak with her revision from band to sleeve. But today, she is BETTER than OK!! Really I haven't heard many other revision stories here that were note worthy. It is my hope that everything will turn out fine, which I'm sure everything will. Like you said, even though the complication risk is elevated, it's still single digits. Its very normal though to feel a little worry while going through this. I was NOT immune to that! But, I was so ready to do it!!!

I'm just full of advice today LOL. If it were me, and it pretty much is, I'd opt for revision to RNY. It's what I'm doing and my Doctor agrees. Apparently, according to him, you're more likely to slip if you've slipped in the past. Even with a whole new band. I can't afford to pay for any future surgeries should I lose my insurance so I'm going for the more "permanent" wls.

Anybody that revised from band to rny feel like or thought that you would have the somewhat the same kind of restriction? I asked surgeon about this at follow up and he said it wouldn't be the same. I'm 5 weeks out and eating regular foods now but I feel like I'm eating way too much at times. I'm measuring everything and trying to keep everything to a minimum. In my manual from Nut some stuff have 2 T servings of this or that and I can eat more than that. Today I wanted to eat every hour. I'm tolerating everything so far. I haven't had any stuck episodes on anything so far except last Friday I ate something that I shouldn't have and way too much of it too fast because I let myself get very hungry. I had some nachos with chilli. I dumped and I believe i got some stuck also. Just wondering.

Hi I have had 3 stages of excess skin removal I had arms, breasts and bra line back lift (stage one) Hip to hip tummy, vertical chest wall(stage 2) Tummy revised to Fleur de Lis and full medial thigh lift I had an awesome surgeon in Sydney named Dr Kevin Ho Happy to share pics if your interested Sarah

I am 4 months and 3 weeks post op revision from Sleeve to bypass. I just feel like I am struggling and in a rut with losing. I have lost 54.2 (39.2 since surgery) which I am happy with, but my weight loss has really slowed down big time. I don't know if i am stalling or if my weight loss is done. I only lost 4.2 lbs last month and only 1.6 lbs so far this month. The last 2 weeks i have gained and lost same 2 lbs over and over. I am trying not to get frustrated and down about it, but i am down about it. I know we aren't supposed to compare ourselves to other.....BUT i see others with similar starting STATS as me and they are breezing right past me with their weight lost. I hope i am just losing slowly, or maybe stalling, and i will continue to tick away to my goal, my body just does not seem to want to cooperate. I do great with my eating during the day but i struggle with night snacking/grazing which i am working on, I know this is an issue for me that i need to control. My cravings and head hunger seem to be strong in the evening. i am just worried because my weight loss "honeymoon" is ticking by and i am so discouraged that my body is stuck at this weight and i won't meet my goal. I guess Just needed to vent some today. This too shall pass.... I Hope!

I had the band for 4 years and severe reflex also indegestion. The doctor told me I should revise to sleeve I have 50 pounds to lose. Today was my surgery date and I went in very worried that if I did the sleeve I would have more acid reflex and its unreversable procedure. This morning I backed out and removed my band only. I refused to do the sleeve last minute. I don't know if I did the right thing but I was afraid of getting worse. Now I am hoping I can get back to normal from constant sore throat from the acid and dry mouth also white tongue all caused by my band.

Anyone have their band out and have time in between the revision? I had my band out on Thursday and they haven't set an exact date for my bypass yet, but it will be sometime within the next 2 months. I made a tuna melt for lunch today. My first bite in and it got stuck!!! I mean, sliming, gagging, painful, stuck! It eventually went through, but I can't believe that the scar tissue from only having a band for 2 years could cause that much of an imprint on my belly that food is still getting stuck. Anyone else have this happen??

So it been some time since I posted. I was sleeved in 2012. I was blessed with being the 5% with complications such as GERD and now I have a hiatal hernia. I was told the a RNY is no only option. I desperately tried to find an alternate solution to no avail. I would like to know a few things. 1) for those who have fed bc/bs., how long did it take to get a revision to RYN approval. 2) have you had any complications since the revision. 3) any regrets? I just idea of losing the with you have gained because of all the crackers they manage the GERD is appealing but I am scared out of my mind. A little depressed. Feeling like a failure.

Hello, I had the sleeve in Nov of 2016. I did great with that for about 8 months, then I started to get horrible acid reflux, etc, which eventually led to not being able to swallow any solid food due to pain in my throat and chest. Hospital stays, ER trips, gastro doctor trips, surgeon trips, endoscopies, barium swallow, and basically living off of pureeds for almost 5 months. Finally had my revision to bypass on May 29th. I did my revision strictly for the GERD probs, I was already at my goal weight. I also had a hiatal hernia that was repaired at the time of the revision to bypass. It's just over a month later and I'm doing good, overall. The main thing is that ALL of the acid reflux/swallowing/pain/ETC is gone! No more problems with GERD. What a huge relief. The recovery hasn't been so bad. My bruising is just now going away, but the pain lingers a little. The largest incision from the surgery was the most painful, but I was getting up out of bed by myself one day after my surgery. In fact, I was sent home 24 hours after surgery. Don't get me wrong, it was pretty painful and rough for awhile, but it was SO worth it! Don't feel like a failure, you're doing great! The revision may be just what you need to get you to the place where you want to be. Wish you the best.

I'm 1 week post op sleeve to bypass revision

I'm 7 months out and down 65 pounds. It seems about normal for revision patients to lose slower. We know what we can "get away with" and we already had that initial shock to our system. Be patient, track what you're eating and see if there is a way you can cut out the excess calories or add a work out. You'll get there!! I promise.

Thanks everyone for the nice and supportive comments! Just a note on the pain, I was a revision and the doctor did say that causes more pain that a straight VSG. If you think about it, they did have to cut a plastic device off of my stomach, plus fix a hernia. Anyway, once you get the medicine, you will be fine. I hope I didn't scare anyone. When I said I was screaming, I should have said I was screaming "Give me medicine! I can't take it!" LOL Well, I am home now and doing great. I am so happy to have the surgery behind me so that I can work on the next part- losing weight!

Hello all! I just got back from an appt. with my surgeon. He seems very happy with my progress. He said I didn't need to loose anymore weight and I looked "terrific!" He asked if I wanted to loose any more. I told him that I thought 5-10 more pounds. My original goal was 150 pounds, but that was based on my high school years. Now, my body is shaped different and I think I might be too slim at that weight. Now my Goal weight is 165. I am now officially 10 pounds away from my new goal weight! I am VERY excited and hopeful. I justed wanted to share with the MOST supportive group ever!!!!!!!!!!1 Thanks, Shawn

I am almost 3 years out from my sleeve surgery and down 130 lbs. My starting weight was 405 lbs. I consider my VSG to be a success, however, I have been gaining and losing the same 5-10 lbs for about a year. I am considering going back across the border to Mx for a revision. I would love to know what VSG to MGB patients have experienced. Especially if you chose Medical Tourism. Also - with the revision, how do they alter an already altered stomach?

When I started my wls journey years ago, I went with the Lap Band, for a few reasons, but I feared Bypass because I thought it was too invasive and too permanent. Fast forward 7 years and I developed GERD and had my Band removed. Now I'm revising to Bypass due to GERD complications. After recently doing research on the Bypass for revision, I watched a YouTube video, and realized that my fear of Bypass was due to Lap Band marketing. So what I will say is, if you start out with Sleeve and have to be revised due to complications or other reasons, you might be "forced" into Bypass the same way I was. Now, no one knows what path their weight loss surgery journey takes us, but it's a theoretical "what if." I never thought I would end up with Bypass. But now I have no other options as far as weight loss and fixing GERD goes. And I've realized I probably could've made a better choice than Lap Band 9 years ago. When you actually research Bypass thoroughly, you'll find that although your disgestive tract is rerouted, it's reversible just like the Lap Band. Sleeve is revisable but not reversible. This video is quite informative and at around the 15 minute mark it discusses the marketing tactic that Lap Band used against Bypass. Best wishes on your journey!

Anyone have experience with this insurance for band to sleeve revision? Health Net HMO originally covered my band in 2007 after 2 appeals but I'm more hopeful with the PPO I'm getting starting Jan 1

well I do know what u are going through. I been there and it sounds like u r too tight if u cant do solid foods.... also it depends on ur doctor some of them want u to be tight or at ur gren spot where u can only eat one bite of foodand be full.....I personally could nt handle tht hurting discomfortable feeling and I would constantly throw up so much until it caused my band to slip..... u have to do whats best for u and ur body n please kp in mind tht all of our bodies are different andthe band reacts differently....eventually my band slipped 3xs and I had to have surgery agin to revise my slip band and now I hv gained 20lbs bk so Im trying to get it off again.... Im so frustrated because Im at a stand still I dnt want to be to tight where I cant eat solid food n have to throw up.....just try and chew ur food very slow and if u can only do one bite then do it..... If it hurts I advise u to let them take some out so tht u can b comfortable.... best wishes. and kit

Please go to www.wlsforum.com You have to register or you can't see all the boards. You won't get lost in the confusion there. There are many revisions over there, and they will treat you well. Post on the band board if you like and they will direct you from there. Tell them I sent ya. Good luck!

Here is the medical policy. The link was open one day so I copied it Does anyone understand D.....preprinted, check off forms are not acceptable. Does that mean my WW Book for the weekly weigh ins? E-Mail Us Medical_Policy@Horizon-bcbsnj.com Horizon BCBSNJ Uniform Medical Policy Manual Section: Surgery Policy Number: 022 Effective Date: 06/10/2008 Original Policy Date: 06/22/2001 Last Review Date: 11/25/2008 Date Published to Web: 08/11/2008 Subject: Surgery for Morbid Obesity Description: _______________________________________________________________________________________ IMPORTANT NOTE: The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member. Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment. __________________________________________________________________________________________________________________________ As indicated by its name, morbid obesity is defined as an increase in weight over optimal weight, which 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 life style changes. Although this strategy may be effective in some patients, frequently the weight loss is not durable with only 5%-10% 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/m2, or greater than 35 kg/m2 in conjunction with severe comorbidities such as cardiopulmonary complications or severe diabetes. Super obesity has been described as a BMI greater than 50 kg/m2. Surgery for morbid obesity, termed bariatric surgery, falls into three general categories; (1) gastric restrictive procedures that create a small gastric pouch, resulting in weight loss by producing early satiety and thus decreasing dietary intake; (2) malabsorptive procedures, which produce weight loss due to malabsorption by altering the normal transit of ingested food through the intestinal tract; and (3) combination of both restrictive and malabsorptive components. 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. The following summarizes the different bariatric procedures. 1. Vertical Banded Gastroplasty 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. 2. Adjustable Gastric Banding This is the most commonly performed restrictive procedure. 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, the Lap-Band Adjustable Gastric Banding System made by BioEnterics Corporation is an approved device by the U.S. Food and Drug Administration (FDA) for marketing in the United States. Another FDA-approved device is the REALIZE Adjustable Gastric Band For Morbid Obesity which is manufactured by Ethicon-Endo-Surgery, Inc. [Please refer to specific benefit coverage under the Federal Employees Health Benefits Program (FEHBP).] 3. Gastric Bypass with Short-Limb (150 cm or less) Roux-en-Y Anastomosis The original gastric bypass surgeries were based on the observation that post-gastrectomy patients tended to lose weight. The current procedure involves division of the stomach into a smaller upper (called the pouch) and larger lower sections in association with a Roux-en-Y procedure (i.e., a gastrojejunal and a jejujejunal anastomoses). 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. 4. 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. 5. Sleeve Gastrectomy A sleeve gastrectomy has been proposed to be an alternative approach that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of HIS to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through the stomach into the intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this procedure as the first in a 2-stage procedure for very high-risk patients including those who are “super” obese (BMI>50). Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus, reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion. 6. Endoscopic Gastric Reduction or Transoral Endoluminal Gastroplasty The EndoGastric Solutions StomaphyX endoluminal fastener and delivery system was approved by the FDA on March 3, 2007 through the 510(k) marketing clearance as substantially equivalent to its predicate device, the Bard EndoCinch Suturing System. It is specifically indicated for use in endoluminal trans-oral tissue approximation and ligation of the GI Tract. The device uses vacuum to invaginate tissue through a port into a chamber and fasten it using H shaped polypropylene fasteners. It has been investigated as a possible minimally-invasive endoscopic procedure for patients who gain weight after bariatric surgery (e.g., due to a dilated gastrojejunal anastomoses after a Roux-en-Y procedure). 7. Biliopancreatic Bypass Procedure (also known as the Scopinaro procedure) The 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. 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. B. A 200-cm long "alimentary tract" consists of 200 cm of ileum connecting the stomach to a common distal segment. C. A 300- to 400-cm "biliary tract," which connects the duodenum, jejunum, and remaining ileum to the common distal segment. D. 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. E. Because of the high incidence of cholelithiasis associated with the procedure, patients typically undergo an associated cholecystectomy. There are many potential metabolic complications 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. 8. Biliopancreatic Bypass with Duodenal Switch The duodenal switch procedure is essentially a variant of the biliopancreatic bypass described above. 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 segment. 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. 9. Long Limb Gastric Bypass (i.e., >150 cm) Recently, variations of gastric bypass procedures have been described, consisting primarily of long limb Roux-en-Y procedures. 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. The stomach may be bypassed in a variety of ways, i.e., either by resection/division 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 degree of malabsorption, depending on the location of the anastomoses. Policy: [iNFORMATIONAL NOTE: When significant weight loss is achieved such as is typically the case after bariatric procedures for morbid obesity, it is not uncommon for the patients to be left with a significant amount of redundant skin (e.g., in the abdomen, breasts, thighs and arms). Procedures to remove the redundant skin are typically considered to be cosmetic. The eligibility of procedures and/or services related to, or resulting from, a prior surgical procedure for morbid obesity is determined by the patient’s specific contract benefits. When the patient’s contract does not specifically exclude such procedures and/or services, they are subject to review for medical necessity. Medical policies pertaining to the covered person’s condition should be consulted, as applicable (e.g., Policy #025 on Abdominoplasty, Policy #028 on Reduction Mammaplasty, and Policy #001 on Cosmetic Procedures including excision of excessive skin and subcutaneous tissue and suction assisted lipectomy, under the Surgery Section). The approval of a bariatric procedure for medical necessity should not be interpreted to be an automatic approval for procedures that address the sequelae of significant weight loss, nor should it create the expectation that such procedures will be approved.] I. Contract exclusions and/or limitations for surgery for morbid obesity (bariatric surgery) will determine the available benefit. [iNFORMATIONAL NOTE: Some contracts specifically exclude surgery for morbid obesity (bariatric surgery). Please refer to the group’s or individual member’s contract benefit language to determine benefit availability.] II. If it is NOT specifically excluded by the member's contract, surgery for morbid obesity (bariatric surgery) is considered medically necessary when all of the following lettered criteria are met: A. The surgical procedure is one of the following types: Laparoscopic adjustable gastric banding; [iNFORMATIONAL NOTE: Please refer to specific benefit coverage for adjustable gastric banding under the Federal Employees Health Benefits Program (FEHBP).] Vertical-banded gastroplasty; Gastric bypass with short-limb (i.e., 150 cm or less) or long-limb (i.e., greater than 150 cm) Roux-en-Y anastomosis; Biliopancreatic diversion and duodenal switch. [iNFORMATIONAL NOTE: According to the Consensus Conference Panel Statement presented at the Georgetown University Conference Center, Washington, DC, May 2004, "Standard of care for bariatric surgery includes use of laparoscopic and open techniques.] B. The member is at least 18 years of age and/or has reached full skeletal growth. Bariatric surgery is considered NOT medically necessary for members under 18 years of age unless the member has already achieved full skeletal growth and has a life threatening co-morbidity (i.e., pseudotumor cerebri, severe sleep apnea, uncontrollable hypertension, incapacitating musculoskeletal disease, etc.). [iNFORMATIONAL NOTE: According to published medical literature, bone age can be objectively assessed with radiographs of the hand and wrist.] C. The member has morbid obesity. Morbid obesity is defined as either: 1. A body mass index (BMI) greater than 40 kg/m2; or 2. A BMI between 35 kg/m2 and 40 kg/m2 with one or more of the following life-threatening, obesity-related co-morbidities which is (are) being treated or managed, and is (are) generally expected to be improved, curtailed, or reversed by obesity surgical management: coronary artery disease obesity-related cardiomyopathy congestive heart failure obstructive sleep apnea Pickwickian syndrome insulin resistance or frank diabetes mellitus clinically significant asthma chronic venous insufficiency of the lower extremities gastroesophageal reflux disease (GERD) pain and limitation of motion in any weight-bearing joint or the spine hypertension pseudotumor cerebri polycystic ovarian syndrome metabolic syndrome hyperlipidemia (hypercholesterolemia and/or hypertriglyceridemia) non-alcoholic fatty liver (NASH) osteoarthritis depression. [iNFORMATIONAL NOTE: 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] D. Within the 12 months prior to the time of surgery, the member must meet all of the following requirements: 1. Documentation of successful completion of at least 6 consecutive months of supervised conservative weight loss program, diet programs/plans (e.g., Weight Watchers, Jenny Craig), or the Horizon Obesity Disease Management Program. Successful completion means formal documentation or photocopies/print-outs of progress notes of at least monthly follow-up by the supervising physician, other health care provider, or program coordinator including the patient’s weight and progress relative to the goals set at the start of the program. (NOTE: Pre-printed check-off forms and summary letters are NOT acceptable documentation for this requirement.) [iNFORMATIONAL NOTE: Programs supervised by a registered dietitian may not be a covered service under a member's contract.] 2. Documentation of participation in an organized multidisciplinary surgical preparatory regimen in order to improve surgical outcomes, reduce the potential for surgical complications, and establish the member's ability to comply with post-operative medical care and dietary restrictions. The regimen should provide guidance on diet, physical activity, and behavioral and social support prior to and after the surgery. Documentation should include physician's initial assessment of the member, and the physician's assessment of the member's progress at the completion of the multidisciplinary surgical preparatory regimen. 3.Documentation of pre-operative psychological evaluation provided by a licensed mental health care professional familiar with the implications of weight reduction surgery. (Please note that psychological testing is NOT included in this requirement.) [iNFORMATIONAL NOTE: 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 addition, patients must adhere to a balanced diet, including proper micronutrient supplementation, to avoid metabolic complications. (Micronutrients are defined as Vitamins, minerals, and trace elements.) The high potential for metabolic complications requires life-long follow-up. Therefore, patient selection is a critical process, often requiring psychiatric evaluation and a multidisciplinary team approach.] III. The following procedures are considered investigational: Mini-gastric bypass Sleeve gastrectomy (either as a sole procedure or as one step in a staged procedure); Endoscopic Gastric Reduction (also known as transoral endoluminal gastroplasty). [iNFORMATIONAL NOTE: There is limited data published in the medical literature to evaluate outcomes of sleeve gastrectomy as a stand-alone procedure and to compare its efficacy with other procedures. Furthermore, the published data on outcomes following completion of both stages of a 2-stage operation are limited to case reports and case series with very small number of patients. According to the ECRI Health Technology Assessment Information Service Custom Hotline Response on Laparoscopic Sleeve Gastrectomy for Morbid Obesity (last updated 01/22/2007), “None of the studies reported weight loss at three years or more after the operation, which we consider the most important outcome measure for these studies to report. Earlier follow-up periods may not provide data indicative of the eventual results of the surgery and do not provide sufficient time to assess the possible long-term complications of this surgery”.] IV. Repeat bariatric surgery or any subsequent modification should be handled on an individual case basis and reviewed by the medical director. Supporting documentation should at least include a clear explanation of the clinical circumstances as to why the procedure failed, the member’s BMI, and the results of any diagnostic tests or studies performed. Since members are expected to be compliant with the postoperative requirements, members who have failed bariatric surgery because of noncompliance and wish to be considered for revision surgery must be actively reintegrated into an established multidisciplinary bariatric program. These patients must demonstrate compliance to the bariatric surgeon through enrollment in a multidisciplinary bariatric program including psychological intervention nutritional counseling, and support group attendance. A distinction between clinical failure and technical failure must be established. A. A clinical failure is defined as weight regain, inspite of an intact, functional operation. In these instances, reintegration into a multidisciplinary bariatric program and psychological re-evaluation are required. If the member is able to demonstrate the probability of complying with the postoperative requirements (e.g., diet , physical activity, etc.), repeat bariatric surgery or any subsequent modification of the original bariatric surgery may be considered medically necessary. Otherwise, any further surgical intervention is considered not medically necessary. B. A technical failure is defined as a breakdown of the operation itself (i.e., staple line disruption, fistula formation, dilatation of the pouch, marginal ulceration, band slippage, anastomotic dilatation, etc.). In these instances, psychological re-assessment of the patient is not mandatory. [iNFORMATIONAL NOTE: Band adjustment is a regular part of follow-up for adjustable gastric banding. All adjustments done within 90 days from band implantation are considered part of the global surgical service. Any subsequent adjustment beyond this period is eligible for separate reimbursement if the band implantation was deemed medically necessary.] ________________________________________________________________________________________ Horizon BCBSNJ Medical Policy Development Process: This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations. ___________________________________________________________________________________________________________________________ Index: Surgery for Morbid Obesity Adjustable Gastric Banding Banding, Gastric Bariatric Surgery Biliopancreatic Bypass Procedure Biliopancreatic Diversion Bypass, Biliopancreatic Bypass, Gastric Duodenal Switch, Biliopancreatic Bypass with Endoluminal Gastroplasty, Transoral Endoscopic Gastric Reduction Gastrectomy, Sleeve Gastric Banding Gastric Bypass Gastric Reduction, Endoscopic Gastric Restrictive Surgery Gastroplasty Lap-Band Adjustable Gastric Banding System Laparoscopic Adjustable Gastric Banding Laparoscopic Gastric Bypass Laparoscopic Mini-Gastric Bypass Laparoscopic Sleeve Gastrectomy Long Limb Gastric Bypass Malabsorptive Procedures Morbid Obesity, Surgery for Mini-Gastric Bypass Obesity, Morbid, Surgery for Scopinaro Procedure Sleeve Gastrectomy Transoral Endoluminal Gastroplasty Vertical Banded Procedures References: 1. Blue Cross and Blue Shield Association. Medical Policy Reference Manual: Surgery for Morbid Obesity. 5:2006: Policy #7.01.47 (and its associated references). 2. ECRI. Health Technology Trends. FDA clears stomach band for obesity. Vol.13 No.7. July 2001. 3. Weiner R, Bockhorn H, Rosenthal R, et al. A prospective randomized trial of different laparoscopic gastric banding techniques for morbid obesity. Surg Endosc. 2001 Jan;15(1):63-68. 4. Cadiere G, Himpens J, Vertruyen M, et al. Laparoscopic Gastroplasty (Adjustable Gastric Banding). Semin Laparosc Surg. 2000 Mar;7(1):55-65. 5. Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity. Surgical outcomes in 335 cases. Surg Endosc. 1999 Jun;13(6):550-554. 6. Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obes Surg. 1999 Oct;9(5):446-452. 7. Belachew M, Legrand M, Vincent V, et al. Laparoscopic Adjustable Gastric Banding. World J Surg. 1998 Sep;22:955-963. 8. Improvement of physical functioning of morbidly obese patients who have undergone a Lap-Band operation: one-year study. Obes Surg. 1999 Aug;9(4):399-402. 9. Furbetta F, Gambinotti G, Robortella EM. 28-month experience with the lap-band technique; results and critical points of the method. Obes Surg. 1999 Feb;9(1):56-58. 10. DeMaria EJ, Sugerman HJ, Meador JG, et al. High Failure Rate After Laparoscopic Adjustable Silicone Gastric Banding for Treatment of Morbid Obesity. Annals of Surgery. 2001 Jun;233(6):809-818. 11. National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Int Med 1991;115:956-61. 12. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990;107:20-27. 13. Willbanks OL. Long term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987;101:606-10. 14. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-35. 15. Kolanowski J. Gastroplasty for morbid obesity: The internist’s view. Int J Obesity 1995;19(suppl):S61-S65. 16. Melissas J, Christodoulakis M, Spyridakis et al. Disorders with clinically severe obesity: Significant improvement after surgical weight loss. Sout Med J 1998;91:1143-48. 17. Griffen WO, Printen KJ eds. Gastric bypass in surgical management of surgical obesity. New York, NY. Marcel Dekker, Inc, 1987:27-45. 18. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995;222:339-52. 19. Flickinger EG, Sinar DR, Swanson M. Gastric bypass. Gastroenterol Clin North Am 1987;16:283-92. 20. Cowan GSM, Buffington CK. Significant changes in blood pressure, glucose and lipids with gastric bypass surgery. World J Surg 1998;22:987-92. 21. Sugarman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweet eaters. Ann Surg 1987;205:618-24. 22. Fobi MA, Fleming AW. Vertical banded gastroplasty vs. gastric bypass in the treatment of obesity. J Natl Med Assoc 1988;78:1091-98. 23. Doherty C, Maher JW, Heitshusen DS. Prospective investigation of complications, reoperations and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity. J Gastrointest Surg 1998;2:102-08. 24. Doherty C, Maher JW, Heitshusen DS. An interval report on prospective investigations of adjustable silicone gastric banding devices for the treatment of severe obesity. Eur J Gastroenterol Hepatol 1999;11:115-19. 25. Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4 year follow up study. Obesity Surg 1999;9:183-87. 26. Suter M, Giusti V, Heraief E, et al. Eary results of laparoscopic gastric banding compared with open vertical banded gastroplasty. Obesity Surg 1999;9:374-80. 27. Scopinaro N, Gianetta E, Adami GF. Biliopancreatic diversion for treatment of morbid obesity: Experience in 180 consecutive cases. Obesity Surg 1999;9:161-65. 28. Nanni G, Balduzzi GF, Capuluongo R, et al. Biliopancreatic diversion: Clinical experience. Obesity Surg 1997;7:26-29. 29. Murr MM, Balsiger BM, Kennedy FP, et al. Malabsorptive procedures for severe obesity; Comparison of pancreaticobiliary bypass and very long limb Roux-en-Y gastric bypass. J Gastrointest Surg 1999;3:607-12. 30. Grimm IS, Schindler W, Halusza O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1992;87:775-79. 31. Langdon DE, Leffingwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993;88:321. 32. Sugarman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997;1:517-25. 33. Marceau P, Hould FD, Simrad S, et al. Biliopancreatic diversion with duodenal switch. Word J Surg 1998;22:947-54. 34. Hess DS, Hess DW. Biliopancreatic bypass with a duodenal switch. Obes Surg 1998;8:267. 35. Baltasar A, Del Rio J, Excriva C, et al. Preliminary results of the duodenal switch. Obesity Surg 1997;7:500-04. 36. Mason EE, Doherty C, Maher JW, et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1997;16:495-502. 37. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987;16:317-336. 38. Angrisani L, Furbetta F, Doldi SB et al. Lap Band adjustable gastric banding system. Surg Endosc 2002 Dec 4;[epub ahead of print]. 39. Vertruyen M. Experience with Lap-band System up to 7 years. Obes Surg 2002 Aug;12(4):569-72. 40. Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002 Aug;12(4):564-8. 41. Rubensteing RB. Laparoscopic adjustable gastric banding at a U.S. center with up to 3-year follow-up. Obes Surg

Hi all, Does anyone have experience with having their gallbladder removed at the same time of initial surgery or revision? How did it go and how are you feeling now? Recovery? Found out today I have gallstones so hoping they can remove it at the same time so I don't have to go under twice. Thanks!

Not rude at all. The doc that did my band is now 9000 for the sleeve. I am going to an associate of his for 5500. They both are HIGHLY recommended. Took me months to decide to go back. I feel comfortable with it. I'm nervous because it Is a revision but I feel safe. Make sense lol??!!

So, I'm now 1 week post "port revision" and feeling wonderful. The incision site had a bruise the size of my hand, which concerned me quite a bit, but after the bruising reached its max, it quickly started turning to yellow. Now it just itches like crazy! I had to take off the steri strips at 1 week because they were itching and irritating my skin, but the incision looks good. I stepped on the scale this morning and was shocked to see that the 5lbs that I had gained, were GONE! YAY!!!! My first fill gave me 6.5 cc in my band (holds 14cc) and I do feel a slight restriction, especially if I dont chew well enough or if its something starchy. In the mornings the band is tighter and I have been sticking to a protein shake for breakfast. By lunch time, I'm STARVING!!! Last night was my neighbors birthday and he invited me to go to dinner with them. So, I ordered a 6oz steak, baked sweet potato, and applesauce. I ate about 2/3 of the sweet potato, most of the applesauce (it was about 1/4 cup), and 1/2 of my steak. This was the first time having steak since I got my band so I was very cautious. I cut the steak into small pieces and chewed really well. I did not have any issues with it getting stuck. I know I ate more than the standard with the band, but I have only had 1 fill so far. I go in on March 5th for my next fill and I hope to have more restriction at that point. I feel great, seeing those 5lbs gone is a great motivator for me. Tonight I am going to my first ever Zumba class with a co-worker. I have NO rythem, so this should be interesting, but Ive heard its so much fun, I cant wait to get out there and shake my bootay, even if I do look like a fool while doing it. haha

@@B-52 was that aimed at me? If so, I totally agree. All we can do is share our experiences. The first thing to try if the band seems tight is always, try to eat more carefully and slowly. But I will always continue to say that whatever the reason for getting stuck regularly, it is dangerous. If eating more slowly solves the issue, great, but if it doesn't or if the individuals simply cannot remember to take extra care, they are too tight. Being tight is my personal paranoia. When I was banded in 2006, everyone was very enthusiastic about the band but gradually over the years, more and more of those banded around the same time as me started to develop problems, obviously I have lost touch with many, but at a guesstimate, only around 30% are still happily banded. Of my actual online friends, the ones with whom I am still in regular contact, only two are still banded. Many have revised to other Wls, several have permanent damage to the oesophagus or the diaphragm. For some being tight was the cause of the problem, for others it was the symptom. But whichever it was, it was important to get it checked. So I will continue to say, being tight is dangerous. Ask your doctor. Don't leave it. Don't wish for it. I will continue to say, in line with all the latest research, the band should not physically stop you eating.

I have had my Band sicne 2007 my weightloss was wonderful and then in mid 2008 it just stopped, no matter what I do it does not go down it goes up. I have been filled and un filled as we call it here. I have suffered three different times from a dilated esophagus, my band gets very tight weeks after the fill, I vomit so hard that I sob afterwards. I have developed all over again GERD, night reflux and a bit of a cough. I have re gained 20 pounds and all I get from my Dr. is well maybe this is where your supposed to be with your weight, well no I don't think so. I requested a revision with the same Surgeon last year and I was refused twice by my health plan due to new guiodelines and such. I exercise daily and walk and yes I even still watch my diet and no matter what I am regaining and not losing. My question is can the lap band become defective after so many adjustments in the port and a few times the nurse could not find the right area in the port and I would get stuck several times. would a new Lap Band help resolve these issues I don't know and the last time I seen the Dr. he was in such a hurry that he rushed me through the appointment due to his office being over booked. I eat very little due to the pain with swallowing and the vomiting. I contacted the Dr. on Thursday and well no one even gets bak withme. Maybe I need a different Bariatric Dr. This surgery is supposed to help the patient not make them get worse.