Weight-Loss Surgery with the Adjustable Gastric Band

The Health Benefits of the AGB and Weight Loss

Formulate and stamp indelibly on your mind a mental picture of yourself as succeeding. Hold this picture tenaciously. Never permit it to fade. Your mind will seek to develop the picture.... Do not build up obstacles in your imagination.

-Dr. Norman Vincent Peale

In the last chapter, we looked at adjustments and the eating strategies that will make you successful with the band. In this chapter, we look at the payoff for that success. What can you realistically expect in terms of improvement to your health? It is true that some band patients experience the disappearance of high blood pressure, sleep apnea, and other debilitating illnesses. They can potentially experience the permanent remission of other illnesses such as diabetes. But just how is that possible? And how do health improvements with the AGB compare with those of other weight-loss surgical options? Let's take a look.

Factors That Influence 
the Improvement of Your Health

Patients seek out bariatric surgery for a variety of reasons, but in my experience it is health concerns that provide the compelling reason why obese individuals may be wise to consider weight-loss surgery. The objective should be improved health, not weight loss just for the sake of weight loss. At the same time, most patients are justifiably concerned about the health risks that naturally accompany procedures such as the gastric bypass. This is why many choose the AGB as a lower-risk alternative. But the question that must be asked is, What about the results?

Improved health following any bariatric operation depends on a number of factors. One of the most obvious is the amount of weight lost. The rapidity of the weight loss also can play a role, and faster is not necessarily better. There is no question that weight loss following gastric bypass is typically faster and more dramatic than it is after the AGB. Those patients who undergo gastric bypass may have a quicker improvement in some of their health problems than patients undergoing AGB, but at the same time they are somewhat more likely to have other problems related to malnutrition.

Following a gastric bypass, patients may lose as much as 5 pounds per week or more. They tend to lose the majority of their weight during the first six months and then begin to taper off. During this time it is very important to follow a diet with plenty of protein to avoid hair loss and maintain muscle mass. They must also take vitamin B12 regularly to avoid anemia, since iron cannot be utilized by the body to make red blood cells without vitamin B 12.

AGB patients tend to lose the majority of their weight over a year or two at a slower and steadier rate, usually about a pound to a pound and a half per week. They too need to be on a high-protein diet, but they typically have less trouble maintaining adequate nutrition. Since the stomach is not bypassed, they don't require B12 supplements. When we look at the results over three to five years, the two procedures actually offer quite similar weight-loss outcomes.

With weight loss, both gastric bypass and AGB patients can experience significant improvement in a variety of medical ailments including diabetes, high blood pressure, sleep apnea, reflux, and various back and joint pains. However, weight loss is not a cure-all! Some patients continue to suffer from one or more of these conditions despite losing significant amounts of weight. In other words, there is more to being healthy than just controlling your weight. But, more often than not, for morbidly obese people virtually all health problems become easier to manage once they have lost weight.

Improvement in Diabetes

Diabetes is a complex metabolic illness, characterized by problems processing the simple sugar glucose. Many people still refer to it as "sugar diabetes." The actual medical term is diabetes mellitus, which differentiates this disease from another illness, diabetes insipidus, a disorder involving excess water loss through the kidneys. In general, when people, including physicians, use the term "diabetes," they are referring to diabetes mellitus.

To further complicate matters there are two forms of diabetes mellitus, Type 1 and Type 2. In both types the fundamental problem involves levels of glucose in the bloodstream that are significantly higher than they should be.

Type 1 diabetes has historically been called juvenile onset diabetes, or hereditary diabetes, because it commonly occurs in younger patients and tends to run in families. In recent years the name has been changed to Type 1 diabetes, because not all patients are young, nor do they have a family history of the disease. This form of diabetes is influenced to some extent by obesity, and obese patients with Type 1 disease are encouraged to lose weight. But most people with Type 1 diabetes are not morbidly obese. Type 1 patients virtually all require insulin, either by injection or by intravenous pump.

Type 2 diabetes is the more common variety (90-95 percent), and is the one most closely associated with obesity. This form of diabetes, Type 2, will be the subject of the remainder of this discussion.

Glucose is the number one source of energy for the cells of our body, but for the cells to use glucose the sugar molecule must first be absorbed into the cell. Insulin, a chemical produced by specialized cells in the pancreas, facilitates that process.

Patients who have diabetes don't process glucose normally. A simple way to understand diabetes is to think of it as either not enough insulin, or to think that the insulin present is simply not effective because the cells have become resistant to its effects. In either case, more glucose remains in the bloodstream because less is taken up by the cells. Obviously, this process is much more complicated, but for purposes of our discussion, it will do.

The association between obesity and diabetes is well known, but the precise mechanism by which obesity seems to "cause" diabetes is not completely understood. What we do know in general is that fatty tissue tends to be more resistant to insulin than other tissue types, so the transport of glucose into fat cells is impaired. With increasing weight gain this difference becomes exaggerated, and the patient's blood sugar increases. If you are diagnosed with diabetes or even pre-diabetes, one of the first things your doctor will tell you is that you need to lose weight. So once again we get back to the issue of voluntary weight loss. Pre-diabetes is simply defined as having higher than normal blood glucose levels, but not high enough to meet the criteria required for the condition to be called diabetes.

The diagnosis of Type 2 diabetes signals the start of a race to control this serious disease before it has time to cause any of the well-recognized pathologic effects. These include diabetic retinopathy, the leading cause of blindness, and diabetic nephropathy, the leading cause of kidney failure. Also high on the list of problems associated with diabetes are coronary artery disease and cerebral vascular disease, with heart attack and stroke being the leading causes of death among patients with diabetes. The effects of peripheral vascular disease, including potential limb loss, are known to be greatly accelerated by diabetes. Diabetes also interferes with nerve function, causing what is called diabetic neuropathy. This is the underlying cause of disabling diabetic foot ulcers. It is also well recognized that people with diabetes don't fight infection well, and typically they don't heal injuries or surgical wounds as well as those without diabetes. The bottom line is this: you need to get your diabetes under control, because there are a lot of bad things that are likely to happen if you don't.

Obviously, diabetes is a huge problem and has been on the rise in the United States for several decades. Not surprisingly, this increase parallels the rise in obesity in our society. According to governmental statistics from 2005, nearly 21 million Americans have diabetes, with nearly one-third of those currently undiagnosed. Perhaps even more alarming is the fact that nearly 10 percent of Americans over the age of 20 now have diabetes, with the highest prevalence being among American Indians and Alaskan Natives at about 18 percent each, as well as the Hispanic and black populations at about 14 percent. In 2002, the medical cost associated with treating diabetes in the United States was estimated at $92 million, making it one of the most costly of all diseases.

While these statistics are frightening, the good news is that most obese patients who are able to lose weight successfully will experience a significant improvement in their diabetes. But, as you know, losing weight can be an extremely difficult task. Many patients who have diabetes require medication to lower their blood sugar, and an unfortunate side effect of artificially lowering blood sugar is often an increased appetite. This creates a vicious circle in which obesity leads to the need for medication, and medications lower blood sugar, which in turn increases appetite. Increased appetite results in excessive eating, driving glucose levels higher and causing weight gain, leading to the need for even more medication. Eventually the diabetes can become impossible to control with diet and oral medications alone, so patients end up being placed on insulin.

One of the major objectives of any bariatric operation in a patient with diabetes is to break the cycle of excess weight, medication, hunger, and further weight gain. In some cases following weight-loss surgery patients are able to eliminate their medications, and diabetes often ceases to be a problem. This is particularly true for patients who have had diabetes for less than five years, and for those who are not taking insulin. For those who have had diabetes for many years, especially if they have been on insulin injections for several years, it is less likely that they will ever be completely cured of their diabetes. But, even under these circumstances it is quite common for patients to experience a significant reduction in their insulin dosage.

A variety of reports in the medical literature have documented diabetes improvement following gastric bypass surgery, with some demonstrating total resolution in 75 percent of patients and either resolution or significant improvement in more than 90 percent. The results reported following the AGB are not quite as spectacular. They are more in the 50 to 60 percent range for total resolution, and 80 to 90 percent resolution or significant improvement in diabetes. Sometimes the facts are difficult to separate from the hype that can accompany what should be a nonbiased scientific study. Regardless, there is clear and unquestioned evidence that shows that when patients lose weight they more often than not experience a significant improvement in their diabetes.

What is interesting is how fast this improvement in diabetes can occur following surgical procedures that restrict your ability to eat, such as the AGB. Improvement is generally seen long before major weight loss has occurred. For many years diabetes educators have preached to their patients to follow a diet of fewer than 1,800 calories to lower blood sugar. Following the AGB procedure, that is precisely what happens. Patients simply can't eat they way they used to, making it difficult to take in as many calories, so their blood sugar goes down.

Immediately after surgery I place all my patients with diabetes on a low-calorie liquid diet, and we monitor their blood glucose level every six hours. Typically the levels are much lower than the patient had expected. They almost always express concern over the fact that they haven't taken their diabetes medication, even though I've explained that it is all right to be off their medication. They won't need to take medication unless or until their blood sugar starts to go back up. I have them monitor their sugars closely once they go home, and most are surprised at how well controlled they continue to be on the postoperative diet. Obviously, that is not the case with every patient, especially those who are on insulin, but even patients on insulin will almost always have to adjust their dosage down.

Longer-term the results following AGB in patients with diabetes are extremely promising, but they depend on a continuing commitment to a change in lifestyle. In addition to weight loss, getting exercise and following a sensible diet are vital components of diabetes management.

Whitney's Story

I was diagnosed with Type 2 diabetes a year before I got the band. I was 326 pounds and I'm 5 feet, 10 inches. Every woman in my family had diabetes, so I got really scared. I'm a full-time nurse and I've seen a lot of what diabetes can do to someone, so I decided that my eyes, my feet, and my kidneys were not worth that extra Twinkie®.

It was my endocrinologist who found the diabetes. I gained 50 pounds in a year and was concerned about how I had gained so quickly. I was planning my wedding, was a full-time nurse, and was going to graduate school, so it wasn't like I was idle. The weight wouldn't come off no matter what I did, and the endocrinologist said I needed to do something quickly to lose the weight. I found Dr. Sewell, went to one of his seminars, talked to him, and got to know his staff. I battled insurance companies a lot. Even though mine said the band was a covered benefit, they refused to pay for it. I had 300 pages of documentation on failed weight-loss attempts, knee surgery, and the diabetes. I finally decided that my health was too important to continue to wait, so I decided to pay for my own band.

I'm a labor and delivery nurse, and I've seen some train wrecks with pregnant bypass patients. I was terrified of that for myself. I thought the adjustability of the band was a cool option as well.

I was on the pre-op diet for the last two weeks of my school semester. I really committed to the diet, and as a result, my need for the diabetes medication diminished. The endocrinologist took me off the medication, and I have never needed it again.

I was banded in August of 2003, and in a year I'd lost 94 pounds. By then I was married and found out I was pregnant. Dr. Sewell is very conservative when it comes to the management of pregnant women, and he took all the fluid out of my band. I had a high-risk pregnancy with lots of complications. My daughter was born premature, but she's happy and healthy. A week after I delivered in March of 2005, he put 1.0cc back in, but he didn't reinflate the band back to my previous level until I was done breast feeding.

While I'm so happy with my healthy baby, I haven't gotten back to where I was before the fill was taken out. Right now I'm down 65 pounds from my pre-op weight. I still yo-yo. I find having a band is a lot of headwork. I had never been thin my whole life, so when people started paying attention to me, I thought, "Was I that much of a mutant before?" It's great to be appreciated, but it's also nice to know there are other things people value you for.

I hate exercise. I don't do it. And I have bad knees and suffered a bad ankle sprain this year. Plus I'm so tired. My baby is now 19 months, and I think that's part of it.

It's weird being a band patient and having a kid. I think I may overcompensate, like making sure we don't celebrate with food, that we don't comfort ourselves with food when we're sad and all that. Looking at my family history, everything good happened around a big table of food. My dad is from a big Southern family, and everything was made from scratch, never processed or out of a box.

Currently, I'm struggling with my band. There is stress in my GI system, and Dr. Sewell and I are trying to rule out GERD. I am frustrated. I want the control the band gave me back again. I had an upper GI and still we can't figure out what's wrong. Dr. Sewell doesn't know exactly what the deal is. I'm his challenge. Even so, I don't regret getting the band, but I think I'd change the way I managed my pregnancy. Instead of taking all the fill out, I'd have just some taken out. I equate my problems with when it was deflated during my pregnancy.

I've really tried to stay focused spiritually and believe that the problems I'm having now are something God is putting me through to teach me something. I work with a lot of people, and I often ended up telling them about the band usually just through casual conversation. I give them good and reliable information, and that's pretty powerful. I can't tell you how many people have come back to me to let me know they or a family member got a band. But I tell them about my struggles, too.

Has my band journey been easy for me? No. Do I wish I'd had a totally uneventful, uncomplicated course? Yes. But I'd do it again.

Improvement in Hypertension 
(The Silent Killer)

"Hypertension" is the medical term for what most people call high blood pressure. To grasp the importance of this common condition requires a basic understanding of the cardiovascular system, starting with your heart. The heart is the engine that drives the body. It pumps blood through the lungs where red blood cells pick up oxygen. It then pumps this oxygen-loaded blood out to all areas of the body through a system of vessels, called arteries. As oxygen is delivered to all the tissues, carbon dioxide is picked up and carried back to the heart through a vast network of veins. The blood is immediately sent back through the lungs, where the carbon dioxide is exchanged for oxygen, completing the circuit.

Your heart beats on average about 70 times per minute over your entire life, maintaining the constant flow of oxygen and nutrients to every part of your body. This system requires no thought on your part and continues uninterrupted for 80, 90, or even 100 years or more, making it one of the most amazing aspects of life.

Obviously, there are a number of things that can influence how well this system works, and one of the most important factors is the pressure of the blood within the arteries. If your blood pressure is too low, blood may not get to certain areas, such as the brain. A transient episode of low blood pressure can cause you to faint. If the blood pressure remains low for a prolonged period, it causes shock and even death if vital organs don't get enough oxygen. By contrast, if your blood pressure is too high it may cause few if any immediate symptoms. Sometimes patients will report a headache or a pounding sensation, but most of the time high blood pressure is a silent problem, and over time it can be a silent killer.

Blood pressure is measured in millimeters of mercury and is generally recorded as two numbers, such as 120 over 80. The first number is called the systolic pressure, the peak pressure that exists when the heart is actively contracting to push blood through the arteries. The second number is called the diastolic pressure, the minimum pressure that remains within the arteries during that period between heartbeats.

The heart works best when the blood pressure is maintained within the normal range. When the pressure is higher than normal, the heart is required to push against considerably more resistance. Over time this can create pump problems as the heart muscle enlarges to compensate. An enlarged heart is less efficient and can eventually lead to heart failure.

Hypertension also causes damage to the arteries themselves. The wall of the arteries will compensate to this increased pressure by a thickening of the wall and narrowing of the channel, a process known as arteriosclerosis, or peripheral vascular disease. It used to be called "hardening of the arteries," which is actually a pretty good description of what these vessels become-hard. Each and every artery in the body can be affected, but some are more susceptible than others, including the arteries to the heart (coronary artery disease) and the brain (cerebral vascular disease). When enough narrowing occurs in these arteries, it can lead to heart attack and stroke.

Other factors certainly play a role in the development of arteriosclerosis, including diabetes, and when combined with hypertension the result is predictably bad. One of the most frightening statistics is that nearly three out of four adults with diabetes also have high blood pressure.

The bottom line is that high blood pressure is a silent killer. But it doesn't have to be. Most of the time hypertension can be controlled through weight loss, reducing salt intake, and increasing physical exercise. (Sound familiar?) When those efforts are not successful, it becomes necessary to add one or more medications to lower the blood pressure artificially.

Obesity is a well-recognized and often major factor in the development of hypertension. Volumes have been written about this association, but there is no consensus on exactly how the two are related. Many researchers believe that el evated blood pressure in obese patients is related to the kidneys retaining too much sodium. In simple terms this means that obese people tend to retain salt and retain water, which leads to an increased blood pressure. Certainly it is far more complicated than that, but there appears to be a direct correlation between obesity and hypertension in many patients.

It naturally follows then that losing weight should result in lowering of the blood pressure, and that is what we generally see. As is the case with diabetes, there are many articles in the medical literature documenting this fact. Losing weight with the AGB results in resolution of hypertension in about half of patients, meaning that they are able to get off medication entirely. Nearly three out of four are either resolved or are more easily controlled once they have lost weight.

Like the improvement in diabetes, the reduction in blood pressure often doesn't take very long. The restricted diet after surgery also tends to restrict both salt and water intake, so we watch the blood pressure closely in the hospital after surgery, then have the patient monitor it closely at home.

I distinctly recall one patient who returned to see me in the office one week after undergoing an AGB procedure. When he came in he looked terrible. He was unsteady on his feet and could barely stand. We took him into the exam room and checked his blood pressure. It was 80 over 40! That's low! Obviously my first thoughts included some delayed operative complication such as bleeding or infection. His abdomen was soft, and he denied having any pain. When I asked him if he was taking his blood pressure medication, he informed me, "Oh yes! My doctor told me years ago that I would have to take that for the rest of my life." I explained to him that it was the medication that was causing the problem, and that he should stop taking it. I wanted to admit him to the hospital, but he was insistent on going home. I convinced him to come back two days later, which he did, and by that time his blood pressure was normal at 120 over 80 and he felt fine.

This all sounds too good to be true, right? A surgical procedure that "cures" high blood pressure? Well, the fact is that even if your blood pressure falls to normal after AGB surgery, hypertension can return unless-are you ready for this? you get regular exercise and eat a sensible diet. This is not rocket science!

Improvement in Sleep Apnea 
(The Thief in the Night)

Many obese patients report that they are tired all the time. It is easy to pass off this chronic fatigue as the direct result of carrying around all those extra pounds, and that certainly plays a part. But obesity can frequently lead to fatigue by interfering with sleep. A condition known as sleep apnea is quite common among obese patients, and it is often the "thief in the night" that robs you of a good night's sleep.

There are several stages of sleep, but the one that offers the most rest is called REM sleep, or Rapid Eye Movement sleep. During this deepest phase of sleep the body relaxes completely, and during this time we not only regenerate our body physically but we also recharge our psyche-we dream. Many morbidly obese individuals never reach this phase of sleep because as they begin to relax their airway becomes obstructed and they literally stop breathing, which causes them to wake up. Typically patients are not even aware of these episodes, because they immediately fall back to sleep. This can happen over and over, all night long. In the morning they "wake-up" still exhausted and remain tired throughout the day. They may be so tired that they even fall asleep at times during the day.

The medical term for this situation is Pickwickian syndrome, named for the character Joe in Charles Dickens's first popular novel, The Pickwick Papers. Joe was a very obese young man who was described as eating large quantities of food, then suddenly falling asleep anywhere, anytime. Patients who are so extremely obese that they can't walk or even get out of bed are at risk of dying from what amounts to a respiratory arrest as carbon dioxide builds up in their blood.

Snoring is closely related to sleep apnea and is also very common among obese patients; just ask their spouses! As you fall asleep and begin to relax the tissues in the throat and nasal passages tend to collapse in on your airway The rhythmic movement of air through these partially blocked passages can create enough noise to keep the entire household awake!

Many remedies have been used to treat sleep apnea and snoring, including even surgical removal of the loose tissues in the back of the throat. But for those with proven sleep apnea, the most effective treatment is often a breathing assist device called a CPAP machine (Continuous Positive Airway Pressure) or a BiPAP machine (Bilevel Positive Airway Pressure). The patient wears a tight-fitting mask over the face that provides a small amount of positive pressure inside the upper airway. This pressure holds the passages open, allowing air to move in and out more easily.

Once you get used to wearing the mask these devices can provide major relief from the problem of sleep apnea and snoring. The results are often so dramatic that patients tell me they will not travel anywhere without their machine. One patient said that he will not go camping with his family unless they go somewhere with electricity for his CPAP machine. Obviously there is nothing like a good night's sleep.

While these machines can provide obese patients relief from sleep apnea, it is also possible to get dramatic results following weight-loss surgery. Typically, improvement comes after losing only 20 or 30 pounds. Patients tell me that they are not only sleeping better but also dreaming again, many for the first time in years. However, the most common statement I hear after weight-loss surgery is "I have so much more energy!"

Undoubtedly, some of this renewed energy is a direct result of not having to carry around so much excess weight, but most patients experience this phenomenon long before it should be expected based on their lighter load alone. Because they are finally getting some rest at night, they are waking up more refreshed and able to function through the day without that sense of chronic fatigue.

In a 2001 study of morbidly obese patients by Dr. Dixon and his colleagues from Australia, 59 percent of men and 45 percent of women suffered from various sleep disturbances prior to having AGB surgery. The group lost an average of 48 percent of their excess body weight during the first year after surgery. Snoring had been a major problem for 82 percent of these patients before surgery, but 12 months later only 14 percent reported that they still had a snoring problem. The incidence of sleep apnea decreased from 33 percent to only 2 percent. Daytime sleepiness fell from 39 percent to 4 percent, and only 2 percent of patients reported poor sleep quality, compared with 39 percent before the surgery. It would be interesting to see the results of a study of the sleeping patterns of their spouses, whose nights are no longer spent nudging their partner and urging them to "roll-over!"

Improvement in the Painful Load

For most people it is hard even to imagine lifting 100 pounds, yet morbidly obese people do that, and often more, without even thinking about it. They have adapted to carrying around far more weight than would seem possible, in large part because the weight has been added over a period of time. Their muscles have gradually enlarged to lift the load, but what about the bones and joints of their skeleton?

Our skeleton is designed to support our own normal weight, with built-in capacity that allows us to lift and strain against considerably more weight over short periods. The problem with obesity is that we can't put that extra weight aside and let our body rest. The bones and joints are subjected to near maximum stress continuously. Over time the wear and tear on the back, hips, knees, ankles, and feet are predictable.

Back Pain

The spine is the central support for the entire skeleton, and it also provides protection for the spinal cord. The nerves that go to every part of the body exit the column of bones, called vertebrae, through small openings, called foremen. The vertebra are stacked one on top of the other, extending from the end of the torso to the base of the skull. There are 8 cervical (neck), 12 thoracic (chest), 5 lumbar (lower back), and 5 sacral (pelvic) vertebrae. With the exception of the sacral vertebra, which are fused into one solid plate of bone forming the back of the pelvis, each vertebra is separated from the one above and the one below by a firm but spongy cushion called an intervertebral disc.

The bony parts of the spine can withstand tremendous pressure without breaking, in part because the discs compress like a shock absorber. When subjected to extreme pressure, however, a disc can rupture, putting pressure directly on the spinal cord or on one of the nerves. Depending on which disc it is and the severity of the disruption, the result can be neck pain, back pain, leg pain, or even numbness or weakness in one arm or leg. Morbid obesity increases the risk of this type of spine injury because excess weight creates excess pressure on each disc.

Chronic back pain is quite common among obese patients, but most of them don't have ruptured discs. Their pain is due to the constant strain on the muscles and tendons that support the spine.

Most obese patients with chronic back pain report improvement after losing only 15 to 20 pounds. If the pain is due to a ruptured disc or arthritis in the spine, losing weight may or may not lead to any improvement. These problems may require additional treatment, including even surgery. But if you ask any back surgeon, they will tell you that the results following a spinal operation of any kind are better after the patient has lost weight.

Foot, Ankle, Knee, and Hip Pain

Perhaps no other part of the body takes more punishment than your feet. They must bear every ounce of your weight as they literally "pound the pavement." Ankle joints are likewise subjected to compression with each step. The knee joints are extremely active, and the surfaces of the bones are protected by only thin wedges of cartilage. The hip joint is also subjected to tremendous stress. Given the mechanics of walking, is it any wonder that these areas of the body are the sites of frequent aches and pains? Add 100 pounds or more to the equation and you have a recipe for major problems.

Researchers have shown that during walking, each pound you weigh results in 4 pounds of pressure on your knee joints. That may not sound like much until you do the math. If you are 100 pounds overweight and take only 3,000 steps per day (less than 2 miles), the total pressure on your knees is a whopping 1.2 million pounds. That's per day! The result of this crushing load can accelerate arthritis, cartilage deterioration, and disabling pain. In other words, being obese wears out your joints far faster than normal. In sporting terms, it puts you on the sidelines.

Our bodies were designed to be mobile, and one of the most devastating effects of morbid obesity is immobility. I have had several patients who were using a cane, a walker, a wheelchair, or a scooter to help them get into my office for their initial evaluation. The irony is that everyone tells you to exercise to lose weight. Once you reach a certain point, however, and it is different for everyone, you are unable to exercise. It is simply too painful.

One solution is to have that painful hip or knee replaced. When you go to the orthopedic surgeon, the first thing you are told is, "You need to lose some weight before we can do your surgery." Doesn't anybody understand? The fact is that having a knee or hip replacement without losing weight makes it unlikely for the surgery to be successful. In fact, many of my patients are actually referred to me by their orthopedic surgeon for AGB surgery to improve the likelihood of a successful joint replacement. Occasionally, patients are able to delay or even avoid these operations by losing most of the weight that caused the joint pain to begin with. For those who go on to joint replacement, the speed and ease of their recovery, as well as their ultimate rehabilitation, are directly proportional to the amount of weight they have lost.

One of the most emotional events that I have had the privilege of witnessing in the past several years involved a morbidly obese woman who had been confined to a wheelchair for more than two years because of severe hip pain. She surprised us all about three months after her AGB surgery when she walked, with a cane, into the office. She had lost less than 30 pounds, but that was enough to allow her to regain an element of personal mobility.

Jack's Story

(Left) Jack, pre-op, 430 pounds.

(Right) Jack, 10 months post-op, 220 pounds.

I guess we all have that epiphany moment or that thing that pushes us over the edge. I was 6 feet, 2 inches and weighed 430 pounds. Once every month or two when I'd fly, there would be a stewardess or a flight attendant who would dig a seat belt extender out of the cabinet and give it to me. But once when I was trying to wedge myself into the seat, the attendant said, "Next time you may have to buy two tickets."

I had a lot of problems. I was having trouble with my knees and had a handicapped tag for my car. My doctor told me that if I didn't do something about my weight I'd be diabetic. I had sleep apnea, my blood pressure was poor, and my cholesterol was terrible. But nothing motivated me like what the flight attendant said. That was one of those little things that went all over me.

The next day I started my "quest," as you might call it. I looked into several options for a surgical solution, including the band and gastric bypass. I decided to go the band route, found Dr. Sewell, and went to one of his seminars. The night of the seminar I made an appointment, and two weeks later I started the whole process.

When Dr. Sewell put me on the pre-op diet we'd hoped for 8 to 10 pounds weight loss, and I lost 16. My surgery was in May of 2005, and that went well, too. I remember waking up in recovery and there was a little more pain than I'd anticipated, but I'd never had abdominal surgery before. I had the surgery on a Thursday and went back to work at the forensic laboratory on Monday.

I've had a lot of lifestyle changes, most of which were self-choices, such as that I decided not to do red meat at all. It's not a have-to thing, just a healthy choice I made. I stay away from pasta and potatoes. I drank a lot of carbonated stuff before, and that was a tough change for me. So now, if I want a Diet Coke® I open it up, let it go flat, and drink it the next day. The no drinking thing at a meal was a real big change for me, too. There were a lot of minor changes, but once I made up my mind to do it, then I just did it. I consider it a very minor trade-off for the benefits.

Right now, 16 months out, I've lost 210 pounds. I was in a size 52, and now I'm in a 38 pant. Every time I have to change my size down, I wait until the very last possible moment, because clothes are expensive.

My regular doctor is pretty amazed at where I am now health-wise. He was skeptical and not very supportive when I told him what I wanted to do. He's been very supportive now, though. The need for all the medications I was taking is gone, and he's definitely a believer. He says I should be the poster child for the band.

In the first six to eight months I didn't change my physical activity level a lot. After the pounds came off, I'm a lot more active now than I ever was. I started biking and I play soccer. I've added activity a little bit here and there. I have to pay to park and I now am in a lot farther away, where I save myself 40 bucks a month. I always park at the back of the parking lot now and walk, when before I parked in the handicapped spot.

I've revised my weight-loss goals downward three times. And I think I'll do it again and lose another 10 pounds to give myself a cushion. I'm still amazed every time I look in the mirror. And I'm still thankful. I experience good physical health, and I feel better about myself than I have in years. Everyone notices a change. The band has been a perfect choice for me.

Improvement in Gastroesophageal 
Reflux Disease (GERD)

If you watch television for more than a few minutes, you are bound to see an advertisement for one of a number of medications purporting to eliminate heartburn. That is because heartburn is extremely common, and the sale of these drugs is in the billions of dollars each year. Heartburn, also known as acid reflux, is caused by stomach acid backing up into the esophagus. More often than not this is due to failure of a valve at the lower end of the esophagus that should prevent stomach contents from going up the esophagus.

In some patients, simple heartburn progresses to what is called gastroesophageal reflux disease, or GERD. The chronic reflux of stomach contents up into your esophagus and the back of your throat can lead to a variety of other symptoms, including regurgitation of food, chest pain, asthma, laryngitis, bronchitis, pneumonia, sinus infections, and even dental problems. It can also damage the esophagus by forming ulcers, strictures, and even a premalignant condition known as Barrett's esophagus.

When properly placed, the AGB is actually quite effective in the management of GERD. It acts as another barrier to the movement of stomach contents up into the esophagus. Most patients are able to stop taking their heartburn medications immediately following surgery, but that is not always the case. In fact, if the band is placed too low, or if it slips down on the stomach, it can actually make symptoms of reflux worse. This is one of the complications of the AGB and will be covered in more detail in the next chapter.

Like all the medical problems discussed here, obesity is a major contributing factor in the development of GERD. In this instance it's because of the extra pressure on the abdomen, which can literally push stomach contents up into the esophagus. So, when treating patients for GERD, the first thing the gastroenterologist is going to say is, "Lose weight."

Am I a Fraud?

G. Dick Miller, Psychologist

When I work with band patients, I find they often feel like frauds. But it takes some time to get them to be honest enough to reveal this. Let me tell you how I usually get this information.

One of the questions each new group asks is, "How much do I tell about having a band?" People want to know if they should tell their coworkers, their family, their friends. And I ask, "Why are you not telling?"

Various answers come up. One is that I don't want pressure to perform, and if people know I have a band they'll have expectations. Another is that it's no one's business. Yet another is that I don't want to fail.

As we discuss this, it always comes up that members of the group view not telling as dishonest. But it depends on who you're not telling and why. If you opt not to tell people you work with, that's not any more dishonest than if you had hemorrhoid surgery and you didn't tell, or gas last night and you kept it to yourself. It's not dishonest to accept a compliment and not spill your entire life story.

But what I hear when people get really honest is that they feel like a phony if they don't tell. When they're losing weight and changing, they start hearing things like, "You look marvelous," and how well they are doing. And they think it's a cheat, like they're tricking people. In other words, they feel like a fraud.

Most of them felt that way going in. They decided from the beginning that the band is a fraud, a cheat, a way to do weight loss without doing the work. But they decided they'll trade the money for the band rather than being fat. Since they've paid so much money for it, they expect the band to do all the work. The surprise comes when they find out there's work on their end. And when they find out that they have to do work, too, then they feel cheated. One thing I hear a lot is, "I paid all this money, this thing should just work and I shouldn't have to do anything."

As I've said before, the band is simply a library card. All it does is get you into the place where you can do the necessary and required change. But when the patient changes, because they thought it was a fraud going in, often they won't give themselves credit. They say things like, "It was too easy," or they discount their own part in this for some other reason.

But it's not a fraud. You and your doctor made a decision for your health. Look at it this way. If a heart patient has bypass surgery and starts thinking better, working out, and changes their eating habits, they accept the compliment when someone tells them they look great. They don't feel guilty, like a fraud, like they tricked someone. But because we're talking weight loss and you got help, that doesn't mean you're a fraud any more than the heart patient.

What I see is a lot of shame, because we have a history. People say to themselves, "I've attempted many things to control myself in regard to food and weight. I've cheated with my food and now I've cheated with the band. So I am not going to give or allow myself full credit for making a rational decision about the band."

That's rotten self-talk, and it won't work for you. Give yourself credit, tell the people you feel comfortable with telling and graciously accept the compliments. This isn't a trick and it isn't a cheat. You can allow yourself full credit because you searched until you found a tool that worked for your weight loss, you did the inside work on yourself to make use of the tool, and now you're enjoying the results. Let that in.

Obesity Is Misunderstood

The pattern here should be obvious by now. No matter which physician you see, primary care or specialist, from cardiologist to spine surgeon, from pulmonologist to endocrinologist, invariably the first thing you're told is, "You need to lose weight." Unfortunately, they don't usually tell you how you are supposed to do that.

This may sound a bit harsh, but most physicians simply say, "Diet and get more exercise." Don't they realize that number one, you know that, and number two, you've tried that? Why is it that most physicians are so hesitant to recommend bariatric surgery, despite the fact that it is the only treatment with proven long-term results? I think in large part it is because the problem of obesity remains so misunderstood, plus the "cause" is easily passed back to the patient. It's your fault. It's a behavioral issue. It's a social issue. It's not a disease. It also seems that whenever the subject of weight-loss surgery is brought up in medical circles, the discussion is usually more about the risks of surgery than it is about the benefits.

The explosion of interest in bariatric surgery over the last decade is in no small part the result of patients taking a more active role in their own health. I have had patients come to my office with reams of printed information off the Internet. Some of it is applicable to their situation and some isn't, but the fact is that they are attempting to make an informed decision about health issues they recognize as important. This is a far cry from the days of my youth, when the mantra was, "Whatever the doctor orders."

Today's patients are better informed about their options and anticipated results, and that is a good thing. But before we get carried away and assign all decision-making over to the patient, it is important to remember that healthcare is still a service provided by highly trained individuals. Unfortunately, even in the most skilled hands complications or unforeseen events can, and sometimes do, occur. And that is the subject of the next chapter.



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