Friday May 27th, 2011 - More Fat Means Less Life

Research from The National Institutes of Health published in the New England Journal of Medicine, reports that your risk of premature death increases 31% with every five-point increase in the body-mass index (BMI).

In real terms this means that...

• A BMI of 25.0 to 29.9 increased death risk by 13%
• A BMI of 30.0 to 34.9 increased death risk by 44%
• A BMI of 35.0 to 39.9 increased death risk by 88%
• A BMI of 40.0 to 49.9 increased death risk by 251%

To calculate your BMI go to http://www.nhlbisupport.com/bmi/

The following conditions significantly increase your risk:

• Fatty liver 
• High blood pressure (hypertension)
• High LDL cholesterol ("bad" cholesterol)
• Low HDL cholesterol ("good" cholesterol)
• High triglycerides
• High blood glucose (sugar) Diabetes
• Family history of premature heart disease
• Physical inactivity
• Cigarette smoking

And, of course, cirrhosis of the liver can be lethal. Actually, it is. So I need a transplant asap.

Thursday May 26th 2011 - Perhaps I am in denial

I try not to think about it. I generally feel okay especially after Dr Goldstein gave me some oxycodone. The pain from my spleen is somewhat mitigated to a level of tolerance. Sometimes you don't realize how much pain you have until its taken away.

So, I have stage four cirrhosis. My liver is basically an irreparable mass of scar tissue. If I understand the grading system, then grade one (0 to 3) then I have some blockage in my liver, but not completely blocked. I believe that grade three is liver failure. The minor blockage would explain why my spleen is enlarged and it could even explain my chronically low platelets. If I sit and think about the dying organ and visualize the damaged liver sitting right here. Right under my skin. Right under my right ribcage. I can touch the spot. When I touch the skin over my spleen, it actually feels bruised.

But, I feel fine. I went to lunch with my friend, went shopping, and wrote on the book and I felt fine. Other than being fat, I feel healthy so it is disquieting to think that my liver is so close to failure. To look at me, you couldn't tell that I was sick. I'm not all crumpled up or pale or yellow. I look fine. So it is weird.

Even though I read my pathology report, it still seems very abstract. I asked my fourteen year old if he was freaked out and he said, "Not really. I mean we've been through the medical scares and hospitalizations so many times I just don't think about it. Besides, you seem fine."

Jokingly, he asked me if I had a bucket list. To which I responded no. I've always thought that if someone was critical then they should go see the world or go to strip clubs or rob banks. I don't know. Live like there is no tomorrow because there isn't, but now that I am sort of there, I really just want to live everyday with my family and friends. If I died next week I wouldn't have any regrets. I've lived a nice life. I've traveled the world and I have experienced far more than the average Joe. I've been rich; I've been poor. I have no desire to jump out of planes or bridges with a bungee cord. No; if this is it, then I want to spend it with my family.

Of course I'm not going anywhere soon. I just meant hypothetically. I plan on doing whatever it takes to stay alive and well. I'll have the Realize Band surgery and get thin so I don't wreck the next liver. I hope I get the liver of a playboy bunny. Owe, that might be yucky. All joking aside, I can't possibly be dying because I feel too alive. And I'm happy today. It was a good day and I think its going to be a nice weekend. I hope I get to see Hangover II.

I have to stay healthy because I have way too much to do in the next few years and I want to see my boys marry and give my little beautiful granddaughters. Grandson's will be cool too, but I've always wanted a little girl to spoil.

Was this post too weird? Probably. I'm a bit... I don't know. I'm a bit something. I don't want to die, but I'm really not afraid of it. I just don't want to leave my family behind. And I promised my mother-in-law that I would go back to church. I never really left, but I'll go. I don't think you could be on too many prayer chains and I do believe in prayer. Gotta go cook dinner. Lemon skinless chicken and my favorite salad with dehydrated cherry's, blue cheese chunks, spinach, a tangy sweet dressing and almonds. Yumm. Plus I picked up a fresh loaf of whole wheat bread. Oddly enough, my appetite has gone down. Maybe it was the hypnotherapy??? 

I guess if you sit and think about dying then you would just go crazy and who wants to live like that. Unless I am truly  

Wednesday May 25th, 2011 - Stage four cirrhosis of the liver

I have mentioned many times that I have been told that I have nonalcoholic steatohepatitis (NASH), but the only way to tell if it has progressed to a critical stage is to do a liver biopsy. They have biopsied every organ and bone in my body hunting for cancer. My leukemic symptoms include chronically low platelets, swelling, and an enlarged spleen. Coincidentally those are the same symptoms for advanced liver disease. Now I don't know whether I have leukemia or not, but I do know for sure that I have stage 4 grade one cirrhosis of the liver. There is no stage 5. This is it. Ironically my late father was an alcoholic and he died at 50 with a healthy liver.

While there is no cure for stage four and it is not repairable except by transplant, I am going to continue my trek towards the gastric realize band procedure. If I am to extend my life, then I must lose all of my excess body fat immediately. At the very least it will make me healthier for a transplant. I received the bad news on Monday evening. I tried to schedule a follow up and I don't think the scheduler understood the critical nature of the follow up so she made an appointment without talking to me for June 21. Like I'm going to wait that long. Hellz no!

The dietary changes dictated by the bariatric surgery include many of the same elements as a liver friendly diet. But, I will still have to add more to that. For one thing, I have to call all of my providers to double check the safety of my current meds and I can never ever take Tylenol or even sip a drink of wine, beer, or any alcoholic beverage. I can never take Vicodin. I'm supposed to lay off red meat, processed foods, and other stuff I have yet to learn about. I am going to go to a new nutritionist as soon as possible. 

The following is the technical definition of NASH and cirrhosis: 

Nonalcoholic steatohepatitis or NASH is a common, often “silent” liver disease. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The major feature in NASH is fat in the liver, along with inflammation and damage. Most people with NASH feel well and are not aware that they have a liver problem. Nevertheless, NASH can be severe and can lead to cirrhosis, in which the liver is permanently damaged and scarred and no longer able to work properly.

Cirrhosis is a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, eventually preventing the liver from functioning properly. The scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, hormones, drugs, and naturally produced toxins. It also slows the production of proteins and other substances made by the liver.

According to the National Institutes of Health, cirrhosis is the 12th leading cause of death by disease.

Other than fatigue and pain in my spleen, I don't have any of the severe visible symptoms, but I will eventually. I hope that I can get on a transplant list now before I reach critical. Obviously, my family is upset, but I don't think they understand the seriousness of the situation. For now, it's life as usual. 

Sunday May 22, 2011 - Financing the Realize Band procedure

I still don't have a concrete number for the surgery. It has a lot to do with deductibles, co-pays, insurance allowances, and the various piecemeal bills like the anesthesiologist. My insurance pays $7500 and I swear I was told last time that the hospital wanted $4,000 in an account in case they need it. I don't know right now because the only finance person with the hospital that specializes in this kind of surgery is on vacation.

Much of the cost depends on your insurance and its agreed fee structure with the providers, but this was the best general answer:

"The price of lap band surgery will depend upon many factors.   Lap Band prices and how to finance it is something that everyone considering the procedure needs to sit down and think about before the surgery.

The price of surgery is complex because you need to include not merely the price of the surgery itself but the associated costs which will vary widely according to where your surgery is carried out and by whom. Costs must include such things as pre-surgical tests, fees for your surgeon and hospital charges, anesthesia fees and much more. Additionally, there will be various post-surgery charges for services like follow-up medical visits, psychological support and nutritional counseling.

If the surgery is done in the US, then you could expect to pay anywhere between $17,000 and $30,000 for your surgery and post-operative care providing you do not encounter any complications. While significant complications are uncommon they do arise every now and again and the cost can then rise considerably."

Now I've managed to bring together as much as $9000, but I still want to be prepared for a surgery loan so I paid down all my credit cards to less than 10% of the available credit and had my friend's wife work on getting some of the dead wood off of my credit report. I'm very anxious about the cost of the surgery and I suppose I'll stay that way until the hospital lady gets back from vacation. I hope its this week.

Thursday May 19, 2011 - Almost there...

Opps. I didn't report on the nutrition appointment or the support group. Last Monday, the 9th, I met with the nutritionist. She gave me the run down on what to eat and when to eat it. Surprisingly, it's more about texture and protein than it is about calories.

The basic philosophy is that you need well chewed food that won't get stuck in the new small lap band pouch. In addition, you don't want to eat greasy or buttery or finely milled foods like cream of wheat because they will just slide right through the new opening and defeat the whole purpose. Keeping good high protein foods in the pouch for as long of a time as possible means that you can't lubricate the stomach with liquids for 15 minutes before eating and you don't want to wash it down with liquids for at least an hour after eating. Absolutely no liquids during the meal.

Things I will have to avoid: bread, steak, and salad. No matter how much you chew them, they will reconstitute in the stomach and cause you to throw up or necessitate an ER visit. I'll go through the ABC's of staged eating in another post.

The support group was awesome. There isn't too many places where you can feel comfortable being over weight. Most of the participants already had the surgery and they looked pretty healthy and happy, but they are more than compassionate towards other obese people. Actually, I think most of them are still fat in the head. They haven't gotten used to being normal sized yet. Very nice welcoming people. We broke up into smaller groups depending on the type of surgery you had. I was with the realize band group. They were all women.

There was a 65 year old woman that had the surgery in December 2010. She has already lost 65 pounds and she hasn't even stuck to the liquids rule. Initially, her daughter had to push her to her first support group in January 2011 in a wheel chair because her knees are in such bad shape. Last month she walked in with a cane. At this meeting she walked gingerly without a cane. It was magical.

The other women were in different stages of post op and they shared their eating tips to make it all bearable. They had all lost an amazing amount of weight and their various obese conditions had decreased if not disappeared completely.

TODAY: Today I had my annual physical which is the last missing pre-qualifier for insurance approval for the surgery. My platelets were back down to 90,000 units and I was lower on Vitamin D than last year and I have been taking 2000 u.. somethings a day. He thought is had to do with the absorptive comparison between the gel caps and tablets so I'll switch vitamins and take 4-5,000 units. He still called me diabetic, but my numbers are way too low for that diagnosis, but I left it alone because it will be just one more reason for the insurance to approve the procedure. I don't think I am going to have much of a problem there anyway.

Next step: Insurance approval will take several weeks and then several more weeks until I have the surgery. I'm still thinking I will have the surgery in August. With God's help I have been able to catch up on all my bills and paid down my credit cards and fixed my car and ect... and I have $3500 USD coming in from Paris and another $2800 from the sale of two of the four burial plots I had for sale. I am also waiting for a smaller check of $750 giving me a total bariatric war chest of $7,050. If I am able to sell two more plots than I will have just over $10,000. I have yet to receive an estimated cost but I am sure I have more than I will need. I will probably put some away for plastic surgery to remove flappy skin when I have lost the weight. See? It will all work out. I am sooo excited. I have several overseas trips to make in 2012 and I hope to be thin enough to sit comfortably in coach. YEAAAA!

Monday May 9th 2011 - One step closer

This morning I went to my cardiologist and passed the exam with flying colors. Dr. Levene will write the bariatric endorsement and send it to Dr. Tillquist. Tonight I am going to the mandatory lap-band nutrition class. It costs $100 cash (Instructor preference). It lasts one and a half hours. Afterwards there is a support group that I will hang out for. I like hearing people's stories. Maybe I should take notes and include them here.

Tomorrow morning I get my blood draw for next week's physical. So I have the nutrition class, pulmonary, cardiologist, psychological eval, sleep apnea, and even a bonus gastrointestinal liver biopsy (GI not required for bariatric surgery). Throw in 12 months of medical notes from my primary care physician and my physical and I will have jumped through all of the hoops. After the surgeons office receives all of the documents, then they will give me a firm price including my insurance contribution. I may call the office and get a new estimate. I'm sticking with $4,000 for my contribution. I hope the final price is lower. 

May 7th 2011 - Transvenous liver biopsy

On Thursday I had my liver biopsy. A Transvenous liver biopsy is used when a person’s blood clots slowly or if he or she is obese or when excess fluid is present in the abdomen, a condition called ascites. I have all of the above.

During the procedure, patients lie on their back on an x-ray table and a local anesthetic is applied to one side of the neck. If needed, an IV tube is used to give sedatives and pain medication. 

A small incision is made in the neck and a specially designed hollow tube called a sheath is inserted into the jugular vein. The doctor threads the sheath down the jugular vein, along the side of the heart, and into one of the hepatic veins, which are located in the liver. To see the veins, the doctor injects liquid contrast material into the sheath. The contrast material lights up when x rayed, highlighting the blood vessels and showing the location of the sheath.

The doctor threads a biopsy needle through the sheath and into the liver and a liver sample is quickly withdrawn. Several samples may be collected, requiring multiple needle insertions. The sheath is carefully withdrawn and the incision is closed with a bandage. They took six biopsies from me and a series of pressure test (I really don't know what the pressure tests were all about.).

Step by step: I went into the "surgical prep" room about an hour before the procedure. The nurse setup my IV and gathered virtually every fact about my life-time medical history. At precisely 1:30pm they took me to an operating room with the biggest x-ray machine I have ever seen. It was like a 10 foot diameter swiveling arm thing. There was also a bank of 40" flat screens. I thought I would be able to watch, but they put an open ended pup tent on my head so that they operating area remained sterile. 

The anesthesiologist gave me some pain medication and 10cc's of some sedative through my IV. The surgeon gave me local around the insertion spot on my neck and then they began. 

I felt a lot of pressure on my neck and then an odd kind of pressure in my torso as the lead was fed down to my liver. I had an odd bend in my vein and it hurt when they tried to work through it. My blood pressure went through the roof and I lost count of how many painkiller shots they were putting into my IV. Ultimately, they took the six biopsies. I think I was in there for about an hour or so.

Then I went to post op where I had a ham sandwich waiting for me. They kept me for an hour for observation and then I was released. As the painkillers died off the mother of all headaches arrived and stayed through the rest of the day and well into the next day. I took my sleeping meds and tried to ride it out.  


On Friday I still felt horrible and my spleen hurt a lot, but this morning I feel much better. I still have some mild pain in my spleen, but I'm not too worried about it. I'll probably find out the results by Wednesday.


If it is just a fatty liver, I will need to lose weight. Duh. And if it is further along I will need to lose weight. Duh. If it is to the point of cirrhosis, then I may be in trouble.  

Wednesday May 4th, 2011 - Ten Commandments of Weight Loss Surgery

Quick update. (I swear I did this yesterday) Anyway, yesterday I had my psych evaluation with my psychiatrist and today I had my pulmonary testing. It's basically blow in the tube kind of thing. Piece of cake. Tomorrow I have the liver biopsy and I am nervous about them cutting my jugular vein.


Here are the commandments:

Ten Commandments of Weight Loss Surgery

1. THOU SHALL NOT DRINK with thy meals. This means never!  This is cheating...cheating yourself.  It washes the food out of your pouch and allows you to eat more.  This will slow and eventually stop your weight loss. PLUS you will not be getting all the benefits of the wise choices you have filled your little pouchy with.
2. THOU SHALL EAT SLOWLY, very slowly. This is not a rule for the first few months post op.  This rule is for the rest of your life. If you eat too quickly, you will surely stretch your pouch. Eat too quickly and you will learn the hard way...the nausea is stifling.  And CHEW CHEW CHEW!! And when you think you are done, CHEW SOME MORE.  Or your food will keep coming back to visit you.
3. THOU SHALL TAKE THY VITAMINS. This surgery is a great tool for weight loss. But, as with all benefits, there are costs...and malnutrition is one of the potential prices of this surgery. Take a multivitamin supplement every day for the rest of your life and it is one you may never have to pay.   You will also need to have your blood checked periodically for B-12 levels.
4. THOU SHALL EAT ADEQUATE PROTEIN. 
5. THOU SHALL EXERCISE. Just do SOMETHING.  Even if it means starting off simply...take the stairs instead of the escalator or elevator.  Park at the furthest spot in the parking lot.  Carry your shopping basket instead of pushing the cart (on small shopping days of course...LOL). 
6. THOU SHALL DRINK at least 64 ounces of water, everyday. It seems that some people have problems doing this. Use a water bottle and carry it with you everywhere.  Sip all day long.  Or refill a gallon jug and drain it every day.  Do it in 2 pitchers.  Do it with 2-32oz sport water bottles. Please note however, that if you are drinking coffee or tea with caffeine, you will have to compensate for the diuretic effects of the caffeine.  Caffeine robs your body of water, therefore, you will not only be unable to count the coffee or tea, but you will have to drink an extra cups of fluid for every cup of regular coffee or caffeinated tea that you drink to compensate for the diuretic effects of the caffeine.
7. THOU SHALL EAT WELL BALANCED MEALS. A  doctor said it best: Protein first and foremost, then green/yellow vegetables,  then fruit, then starches. 
8. THOU SHALL NOT EAT SUGAR, in ANY form....no candy!!! Treat yourself with some fresh fruit!!  
9. THOU SHALL NOT modify these commandments to suit thy needs.  It will not work.  You will only defeat yourself physically. 
10. THOU SHALL LOVE THYSELF and be happy with the body God gave you. God did not intend for all of us to be supermodels, and this surgery will NOT make you one. Happiness comes from within. Be happy with who and what you are. Or you will defeat yourself mentally.   Then the battle will be lost before it is ever even begun.                                                                              

Monday May 2, 2011 - Details from my first consultation

First, I started my vegetarian with seafood diet yesterday and found myself in a huge rush for lunch and accidentally ate a ham and cheese bagel. Seriously, I was half way through it when it dawned on me. I am possibly the stupidest smart guy on the planet. Nonetheless, yesterday's cuisine was very healthy, however, I did eat too much tabbouleh and falafel. The blackened grilled yellow fin tuna was awesome. Tonight I am grilling portabella mushrooms and organic hamburger for the boys. I need to define my one through five scale again. I suppose five being the best should represent a healthy day with smaller portions following the pre-surgery guidelines for the bariatric surgery plus the gym. Four being a good day less exercise. Three being healthy, but with servings that were too larger. Two should be deviating from healthy. Perhaps not so healthy and too much sugar. One, being the worst, would be any day that I have fast food or over-eat at a full service restaurant. I would give yesterday a three, but I didn't make it to the gym. Instead I took a Sunday afternoon nap.

My primary mission right no is to get all of the preliminary appointments and endorsement letters collected. I have a check list from the consultation meeting last week. All of the following must send in an endorsement letter.

1. Psychological endorsement- Purpose: to evaluate your emotional state and your capacity to understand the dangers and life changes resulting from bariatric surgery. Must be done by a psychologist or psychologist. In my case it is my bipolar doc, Cathy Collins, since she also conducts a therapy session each time we meet. She knows me best. I see her tomorrow, the 3rd of May. (Sample letter below).
2. Pulmonary test - Purpose: to evaluate your ability to breath and exert energy. My appointment was setup through the bariatric surgeons office. I have to go down to take one hour of tests Wednesday the 4th. 
3. Primary Care Physician - Purpose: to evaluate your health in regards to being able to handle the surgery and the post surgery change in life style. I am using my annual physical as an opportunity to get Dr. Goldstein's endorsement. My blood draw is on the 10th and my exam is on the 19th. (Sample letter below)
4. Cardiologist - Purpose: to evaluate the health of your heart. Must make an appointment with Dr. Levene.
5. Gastrointestinal doctor - Purpose: evaluate the health of my liver and NASH. While not named on list, but, just to be on the safe side, I will include an endorsement from Dr. Springer). I am waiting for my liver biopsy.
6. I must also attend a mandatory nutrition class given by Swedish hospital. It's focus is on lap-band patients. I should call as soon as I finish this post.

That's it for the required endorsements. Hopefully I'll get this done this month. Next big hurtle: $$$$ but I'm working on it.