POD#5

Post op day 5 is almost in the bag...my sleeve and I are getting to know each other. I stuck to my full liquids as directed and got in more fluids by sticking to herbal tea. The warm tea goes down easier, even if it takes an hour to drink half a cup. I spent some time feeling hungry, and some time feeling very full. And I had several hours feeling just fine, although the head hunger still toyed with me.

I had my first regurgitation episode. Forgive me for going into this a bit. First, I heard about this with the band all the time. This is really what the band is most famous for. This afternoon I was hungry and got out some pudding. I ate a bite, put it aside for a while until I felt like another bite, etc. I did this for a while, and then I ate a little when I felt full already. After a few minutes it just slowly came back...not forcefully, just slowly. That was my limit. About 1 ounce. I put everything away and was thankful to know what happens when I don't pay attention.

This never happened to me with the band! I can see how if it happens when you've done something wrong, it can be a good thing...and if it happens all the time, especially when you are making "good" food choices, it would be an absolute no-go.

Tonight I decided to make the split pea soup I was saving the hambone from Christmas dinner for. I've never made split pea soup before, and my mom always made it vegetarian. She is a good cook, but there really is no substitute for ham in split pea soup. I googled some recipes and found that most of them were almost identical. I made it and it is awesome.

Why did I cook just 5 days after VSG surgery? Well, it's soup, for one thing. I can have soup, puréed and thinned. For another, most of the stuff on the menu suggestion for the full liquid diet is "fat-free, sugar-free" which means, if you follow that entirely, that you are eating entirely processed foods. I can deal with some of that for the short term, but I really wanted some of my diet to be real food with actual nutritional value. Especially since I have eaten a sum total of 5 ounces of liquid "food" today, it meant something to have some food that was real. I use SF jello, but regular pudding. I opt to leave sweetener out of tea entirely rather than use Splenda because that stuff just isn't any better for you than sugar. I hope that one day my tastes might change enough that I don't need sweetener in almost anything, but I'm not really holding out hope for that.

I puréed some of the soup, put it aside for me (my family gets the glorious chunky version) and spooned out 2 oz for dinner. I slowly ate 1 oz and put the rest back. Then I realized I probably should have had a little less. Then I remembered that I still had to take my evening pills. Lesson learned, I should probably do that part first. Now I'm sitting up with heartburn.

I am learning. It won't always be this unforgiving, for better or worse. But I'm doing fine, and excited that this seems to work way better that the band already.

The bloats

Ugh, I hate the bloated feeling! But, I'm not in pain or nauseated, so I can suck it up. Definitely a low-energy day today though. I've been having a private Lost marathon (NO spoilers! LOL).

I'm trying to decide if I should take more time off from work. I'm currently scheduled to return on Monday. I just don't know about my energy level yet.

-16

I just reviewed my posts from my first week post-lap band surgery.  I've lost about twice as much weight as I had by post op day 4 then, despite starting out slightly heavier then.  I don't know what that means, but it makes me happy.  I am down 16 lbs today.

I've been resting a lot, going for a long walk once a day, otherwise not doing all that much.  My belly is a lot less sore than a few days ago.  I haven't taken anything for pain since leaving the hospital (unless you count the 1/4 cup of coffee to treat the caffeine headache).  The hardest thing is not being able to pick my daughter up, which really upsets her.  My husband is around to do the things that require picking her up.

I'm glad I have been through this once before with the band.  This part of the post-op process is easier than it was when I was banded.  I'm still hungry intermittently, but not as much as with the band.  It's easier for me to stick with the prescribed diet as a result.

I'm having just as much trouble with getting fluids down as I did back then, though.  I am just not one to drink so much water.  But I'm going to drink more tea and see if I can get more that way.  I ordered some new teas from Tea Forte--they are a little pricey, but I love their tea so much.

Post op Day 2

I got home yesterday evening.  So far I am feeling bloated and sore, and hungry.  Otherwise, not too bad.  I slept from about 8pm to 6 this morning, got up a couple times to the bathroom which is very unlike me.  I guess I got a lot of IV fluids during surgery, because what I got post op doesn't account for all this urine output.

Definitely hungry, but I am reading that initially stomach acid doesn't catch up with the small new stomach, so an antacid might help.  I will try that today and see if it makes a difference.  I am on "stage 2", full liquids diet. I can have blended soup, pudding, Carnation Instant Breakfast, that sort of thing...and as much water as possible.

The scale was down 10 lbs from Saturday...I don't see how that is possible, even with all the fluid I'm losing.  I don't feel 10 lbs lighter.

My daughter and husband are still asleep, so I have this quiet morning to myself--fireplace going, a little bit of coffee to take my caffeine withdrawal headache away.

Done

The lap band is gone and I am sleeved. I had surgery yesterday morning. It took about 3 hours. They found that my band was completely loose and the buckle was unclasped. Apparently that is an unusual finding. Also, my original surgeon did not tack my stomach around the band as is common now, so it might have moved more, especially when I was pregnant. Basically, I didn't really have a band for an unknown period of time. My surgeon considered just resecuring it, but I'm glad he didn't. I am done with fills and band stuff.

I had great OR staff, people with lots of experience, and one of my favorite anesthesiologists. (Dr D asked me if I had a request for someone specific, but I really trusted my whole department so I didn't request anyone.). I went in at 7:30 and got to recovery about 1115. I was quite nauseous, and a little painful. I threw up a few times, which was memorable because I never threw up once when I had the band, even with morning sickness. After some phenergan and fentanyl, I was brought to my room pretty sleepy. I mostly slept the rest of the day, but continued to have a lot of nausea, especially when I drank water. After trying all the antiemetics, I called the anesthesiologist on call, who happened to be my boss, the chair of the department. Our department has several MDs and CRNAs who are trained to administer acupuncture for nausea, so he came up and gave this to me, two tiny wire tacks taped inside each wrist. Finally, the nausea improved, more than I expected. I still have two of them on now.

I still am not able to take more than water or jello, everything else makes me nauseated. I took one shot of dilaudid when PT came to work with me yesterday, but didn't need it after that. I've just been taking Tylenol and Toradol. My pain has been minimal, which was my experience with the lap band as well.

I'm being discharged today, so I can be a lot more comfortable at home. Yay!

Finally!

Insurance company relented...they reversed their denial!  Interestingly, my employer is switching insurance providers on Jan 1, which I didn't know until very recently.  I think that might have been part of why they did not follow their own revision policy...they didn't have a lot of time to wait me out.  But, they reversed, and just in time. My surgery is one week from today.  It's hard to wrap my brain around.  It's hard not to feel like this won't help.  I think I have really gotten accustomed to the disappointment from the band, and it's hard to think that I might be successful long-term this time.

I've ordered my B-12 vitamins, and I'm preparing for the whole surgery thing again.  This time I am doing it as a mom of a toddler.  I've never spent a night away from her before!  I don't know how that's going to go.  And she likes to be picked up, won't be able to do that for a while either.

I've started talking with my regular counselor about my food issues.  It felt really good to do that.  I hope that I can work through some of that stuff that holds me back and keeps me holding onto this weight.  I guess the biggest difference for me this time versus the band surgery is that now I know the surgery is not the biggest part of this.  I don't believe I can eat as little as I need to to lose weight without this surgery.  But a much bigger part is going to be dealing with the emotional issues around food, which are extensive and very difficult to bring into the light.  If I can't be successful in dealing with the emotional issues around eating, no weight loss is going to be lasting.

Wish me luck! :)

A Date

There still is no answer to the second appeal to Aetna.  But I did see my surgeon today, and we set a date for December 29 for my surgery.  That gives Aetna plenty of time, and me plenty of time to accrue benefit hours and prepare for surgery (and time off).  This time through is much different than the first time I had surgery.  I know the surgeon professionally, and he knows I know what I'm dealing with, so our appointment was short and on-point.  He addressed some specific issues, I asked a couple of specific questions, and we talked turkey.  He is kind enough to come in on a Saturday to do my surgery, so I don't have to be on the main OR schedule that hundreds of my coworkers and colleagues will see.  He asked if I had a particular anesthesiologist that I prefer, and I told him no, that any of the anesthesiologists I work with will be just fine.  I had my labs drawn and an EKG, and that was about it.

We all expect Aetna to approve my request now since my BMI is now back over 40.  But this process has been quite frustrating.  They have very clear criteria for approval for revision surgery, and I met every requirement, but they denied me (twice) on different criteria.  I'm sure a letter from an attorney would change it, but that's ridiculous.

Meanwhile, I am thinking a lot about how my approach will have to change this time.  When I had my lap band surgery, I had a good mindset at the start.  I followed the rules, exercised as I was supposed to, and was patient about weight loss, which took longer than many people but was still within the expected time frame.  It did take about 18 months to lose 70 lbs, and the last 9 months I was running 10-15 miles per week.  This time, my exercise capability is a bit more limited--I'm not in grad school anymore, but I have a toddler and two jobs.  I'll have to figure out a way to make the exercise work.

Getting my brain in shape is more important, though.  There are some cliches in the world of WLS that hide a lot of truth within them.  One is that the surgery is on your stomach, not your brain.  Another is that the surgery is just a "tool".  A lot of people talk very non-chalantly about "emotional eating".  The truth is that appetite and hunger are controlled by multiple redundant mechanisms.  I believe one of the big reasons that the lap band failed is that it only addresses one of those mechanisms: it relies on a small sub-stomach (pouch) to register fullness by stretching that small pouch.  But the entire stomach is still there, producing ghrelin.  So there is no hormonal change to one's hunger.  Plus, all the mental and emotional reasons that we eat are not addressed.  That is why it is possible to eat small amounts of food constantly, or foods that easily pass through the pouch, and gain weight, even if one has good "restriction".  And if you think you can outsmart your brain in its attempt to keep you from starving, you have a much better brain than I do.

What I have learned in the past 5 years since having lap band surgery is that we humans are very well adapted to under-nutrition, but poorly adapted to over-nutrition.  Put us in conditions with very few available calories and our bodies work quite valiantly to keep us from starving.  But most of us in the US live in an environment with lots of available calories.  Rich or poor, there is calorie-rich food available all around for any budget.  In this environment, it takes a lot of resources, including money and plain-old "willpower", to resist this American norm:  work a lot of hours, live an otherwise sedentary life, eat cheap prepared foods (and drinks) with more calories than we expend.  Add in too much stress, too little sleep and too much stuff to do, and the obesity "epidemic" is no mystery.

My family is a great example of adaptation.  Before my father's generation, there were not a lot of overweight people on his side of the family.  His family have been farmers for many generations, and our body type is stocky and solid.  When my predecessors worked as farmers and ate the food they produced on their farms, they were solid and healthy and lived into their 90s almost without exception.  But starting with my dad's generation, there is a lot of obesity.  We aren't working the family farm anymore.  (My uncle is, but he is my uncle by marriage--married to my aunt. And he is very lean.)   Most of us do not do a lot of physical labor.  We don't produce our own food, or cook as much as the prior generations did.  And more often than not, we are fat.  My dad is the first person in my family that I know of to develop diabetes.  He also has hypertension and has had a heart attack.  He recently lost 100 lbs, and hopefully can keep it off.  (He has lost hundreds of pounds in his adult life, and always puts them back on.)  He wants to live to 100, but until this year it didn't look like he would make it to 70, which is in 2 years.

So, I hope to get more of a handle on the psychological reasons that I overeat.  One part is simply pursuing a less stressful, happier life.  Another part is working with someone experienced in these eating issues.  The last part is prioritizing my exercise so I am doing something active every day.  This all actually sounds enormously difficult to me.

One month to go!

Waiting game

I have been denied by Aetna twice so far.  Both times they have denied my surgery in spite of the fact that the reasons they state are not in the revision policy at all.  However, in the interim I have gained even more weight--not trying to!--and now I meet the BMI requirement they cite.  Yay me. I'm not entirely sure they will not find another reason to deny surgery, but in theory this should be happening.

I feel a lot of sadness about this.  I feel a little betrayed that the lap band has not worked out the way it was billed to work.  I had wanted to avoid "drastic" measures in choosing this route, but it's kind of pointless if the least invasive option just doesn't work.  Or maybe it's me, and not the band at all, which makes me wonder if a revision to a sleeve will help.  What has to change for me to stop this cycle?

Obviously, my eating has to change.  Oh, if it were as simple as just knowing what one needs to do.  I am really astounded at how little I must eat to even maintain my weight, much less actually lose weight.  It is incredibly difficult to eat 1000 calories a day without some sort of help of some kind.  Especially when you still haven't learned a good enough stress management technique to replace emotional eating.  I've learned a lot of techniques, but none are quite as effective.  And I have more stress than ever now.

My next post should likely contain some sort of answer to the Aetna question.  As for all the other questions, I am still waiting for the answers.

Revision

I'm glad I didn't call this "Gwen's Lap Band Journey" or something like that.  The lap band will soon be history.  I am learning that these days, the lap band is much less favored since the most recent long term studies are showing what I have experienced...only 30 to 50% of excess body weight lost at best.  Many have a lot of reflux or other complications, but I have not.  I just am not losing weight with it.  So, the paperwork has been submitted for revision, it appears that Aetna is likely to approve it since I meet their requirements, and once that has happened I will schedule surgery (on a Saturday, since I am having surgery at my place of employment--I don't like everyone knowing my business.)  I am taking as little time off as possible.  In fact, I plan to be back at work within the week.  I took a lot of time off for my lap band and it really wasn't necessary.  I have no benefit time now, due to issues with my family, and I can't afford to not work.  My job isn't sedentary, but I think I can get my circulating nurses to push the stretchers for me for a week, and beyond that I don't really have much physical work to stress about.

What remains is to decide exactly what the revision should be.  Both of the surgeons I have met with have suggested the vertical sleeve gastrectomy, a popular revision choice from a lap band.  The surgeon who will perform my revision is someone I work with fairly often and I have a lot of confidence in his skill, plus he's a good person.  Dr. D is sure he could perform the lap band to VSG in a single surgery, but if I choose a RNY it might have to be 2.  My thoughts have been that my metabolism just isn't strong enough for a mostly restrictive procedure.  (VSG is considered to have a very small bit of malabsorption involved due to the loss of gastric secretions.)  On the other hand, I know a lot of people with RNY, and it seems most of them have regained significant weight.  Still, the long term studies are still showing 50-70% excess weight lost at 5 years post op.  50% for me would put me at my pre-pregnancy weight--higher than I want to land at, but not terrible.  70% would put me at my lowest lap band weight, which would be fantastic.  So my question is, am I able to be one of the 50-70% people?

My current thinking is this:  if he gets in and sees that he can do RNY in a single operation, do that.  If he's going to have to come back for a second procedure but he thinks he can do the VSG at that time, do that.  The VSG is easily revised to RNY or DS if needed later.  So if I am going to need 2 operations anyway, it makes sense to do the sleeve and hope that's all I'm going to need.  I really, really don't want another surgery if possible.  I have a lot of stuff to do and laying on an operating table isn't on that list.  I'm supposed to be at the head of the bed with the machine, on the other side of the drape.

It's on my mind a lot.  I'm back on the Obesity Help site for the first time in several years.  Things have changed around there, although it seems the drama between the different types of WLS is still there.  And apparently the lap band folks who haven't been revised are kind of defensive about the band.  Whatever.  I don't have time for weird internet forum madness, I just want to make an informed decision about my own surgery.

Meanwhile, Lucy has just turned 2!  She had a rough day today--partly being sick, and I think partly just being 2, and some family stress taking a toll on her as well.  But usually she is happy and fun.

Not Friends

My band and I are not friends.  I've finally concluded that.  Perhaps if I can get back to some reasonable level of restriction again, this will work for me.  But I haven't really had much benefit from my band since immediately post-partum (and the baby will be 2 next month).  I have been seeing the PAs at my surgeon's office.  My surgeon is down to just one surgeon, herself, and she has 2 PAs and the bariatric endocrinologist.  The PAs are both pretty new to practice, and do not look like they have ever struggled with weight.  I'm older than both of them, and I'm not even 40 yet.  Anyway, I have been in about 6 times since Sept 2010, and have had fills ranging from small to infinitesimal.  They give me very little information about how much is in my band or how much they are giving me--I think they don't want patients to fixate on the amount that is in the band.  But I'm pretty fed up.

Here's the thing that I would tell anyone else interested in a lap band.  You will need to see a surgeon who specializes in bands for as long as you have your band.  That sounds simple when you are looking into surgery.  Why would that be a problem?  But the chances are very slim that you will always live in the same place and have the same insurance.  Even if you have the same employer for the rest of your life, they change their insurance plans all the time.  You may start out with your aftercare covered, but later on that changes.  And if you find yourself without your fills covered, you are looking at anywhere from $150 to $300 or more per visit to adjust the band.  If you have complications during a time that you don't have insurance coverage (you may, in fact, never have insurance coverage, like a lot of people with this surgery), you may have to pay out of pocket for surgery to revise the band, replace the port, or remove it altogether.  There isn't a good way to predict what will happen in the future or how you will be paying for it.  These days you can't even predict whether you will have a job or a home, much less insurance coverage for bariatric procedures.

The band requires a lot of adjusting, and this takes time, and money.  I feel like every fill I have gotten since I delivered my daughter has done absolutely nothing.  I still get hungry after 2 hours.  I can still eat anything, and a lot of it.  I'm still gaining.  I'm not going back to the bariatric endocrinologist, because I don't think he has much to help me with.  The last time I saw him, he broke it down like this:  I can eat 1100 calories a day if I want to lose 0.5-1 pound per week.  AND I need to eat at least 75g protein per day.  If you take the general rule of thumb that surgeons use, a good quality protein source should have 10 calories per gram of protein.  (Of course, protein itself has 4cal/gram, but no one eats food that consists SOLELY of protein.)  So that would mean I get 750 calories of high protein food per day, and about 350 calories leftover for the rest of the day for fruits and veggies (they actually don't want me eating fruit at all, which I don't think is that healthy or sustainable).  I'm not willing to stop drinking coffee or to stop putting cream in it, so that is a few calories right there.  Basically, I don't find this plan sustainable.  He might be right, that this is what my body will require because of my specific metabolism.  He may also be right that I should be concentrating on weight training, not running at all, and taking L-carnatine supplements.  But basically this plan seems extremely bleak, and definitely not possible without a lot more restriction.  So, I'm going nowhere here.

The last problem is one I have alluded to, that my insurance doesn't like me going to my surgeon.  They pay at the out-of-network rate, but only with a lot of complaining, even though they are only asked to pay for the equivalent of an office visit.  I'm lucky they pay at all.  They want me to see the bariatric people at my employer, even though they don't actually do bands at all.  They have a nurse practitioner that manages their band patients, but they don't place them.  Still, I've decided to go this route, because I'm tired of the hassle with Aetna, I don't feel like I am really getting what I need at my surgeon's office, and because I am strongly considering revision surgery anyway, and that is where I would be able to do it.  So next week I go see the nurse practitioner for a fill, hopefully a decent one, before she goes on maternity leave.

Would I do this again?  No, I don't think I would go with something that requires such constant attention as the band.  It has just been too difficult between changes in employers, insurance, and providers, to get the consistent care I need, and frankly it's too hard to get to the office so often with a small child at home and a full-time career.  I still don't think I want a Roux-en-Y.  I'm not sure what the best solution is for me.  I just know that my body needs a frighteningly low amount of fuel per day to keep me at a healthy weight, and I can't do that on my own.