Life shrinks or expands in proportion to one's courage.
-Anais Nin, The Diary of Anais Nin
Patients always point to the day of their surgery with great expectation. It is, in fact, a major event, one that marks a life transition. But, before going to the operating room, there are a few details that should be addressed to help ensure your safety. In this chapter those details are examined, along with why they are important. Having a clear idea of what to expect can allay some fears and create an atmosphere of appropriate anticipation.
Pre-op Testing
Many patients have already had a thorough medical evaluation by their primary physician prior to being referred for weight-loss surgery. This is particularly true for patients with known medical problems such as diabetes, hypertension, and heart disease. But, for patients who have not seen their personal physician recently, some routine lab tests to determine their current health status may be necessary. Likewise, if questions or concerns arise about specific medical issues during the assessment process, specific tests may be required before proceeding with AGB surgery. In some instances, the results of these tests can actually determine whether the AGB is even a reasonable weight-loss option.
Since the operation requires general anesthesia, meaning you will be completely asleep and under the care of the anesthesiologist, the status of your cardiac and pulmonary functions is obviously important. For most patients this is relatively easy to determine through a medical history and examination. However, for those with a history of significant medical problems, it may be necessary to perform a more extensive evaluation of specific organs.
If there is a history of chronic respiratory problems, an evaluation of pulmonary function may be recommended. Patients with poor lung function, especially those who require oxygen even at rest, have a higher than usual risk during anesthesia. Armed with this information the anesthesiologist may request that a pulmonologist, or lung specialist, be called in prior to surgery to optimize the patient's breathing.
In the same way, patients with a history of heart problems may require a cardiology assessment to determine the relative risk of a cardiac complication during or after surgery. This may include an electrocardiogram, or in some cases a cardiac stress test, to see how the heart is likely to respond to the pressures of surgery.
Patients with diabetes should have their blood sugar under reasonable control before surgery, especially immediately prior to the procedure and immediately afterward. Blood glucose levels can change significantly as a result of many factors, including the preoperative diet, the absence of any food on the day of the procedure, intravenous fluids and medications, as well as the stress of surgery Testing the blood glucose frequently during these times is relatively easy to do and provides important information for maintaining a safe operative course.
For patients with a history of liver or kidney disease, a comprehensive set of blood tests will provide a better picture of the functional status of those vital organs. If there is significant compromise of either organ system, it may not be advisable to proceed with surgery without consulting with an expert. For problems with kidney function that specialist would be a nephrologist, and for abnormal liver function the expert would be a gastroenterologist or hepatologist. Depending on the extent of the problem, as well as whether it is recent in onset or more chronic in nature, surgery to place the AGB may or may not be a reasonable choice.
One of the more common comorbidities that accompany obesity is sleep apnea. In some cases this may be the major reason why the patient is seeking weight-loss surgery. Many patients complain of severe snoring, problems sleeping, or chronic fatigue. These issues are often related to sleep apnea, but most patients with these symptoms have not undergone a formal sleep study. Those who have are usually on some form of airway support at night such as CPAP or BiPAP. Some have even undergone one or more surgical procedures to improve their airways.
While a sleep study can demonstrate the presence of sleep apnea, the question is whether confirming the diagnosis in this manner is going to change the procedure. The definitive treatment for sleep apnea is weight loss, which is obviously the objective of the AGB surgery. Sleep studies are often costly, and whether the outcome of the test is positive or negative isn't likely to change the planned procedure. The main reason for getting a sleep study prior to surgery is often to document the condition in an effort to satisfy insurance criteria for the surgery. If documenting sleep apnea is necessary, whatever the reason, there is no better test than an overnight sleep study. The test is best performed in a sleep laboratory equipped with extensive monitoring equipment. It can also be done in your own home, but the ability to monitor is generally more limited.
Although each of these preoperative tests can help offer you peace of mind, they are by no means a guarantee against serious complications. Even someone with no history of any previous medical problems could still have complications during surgery. The question is invariably raised as to whether every patient should undergo an extensive battery of tests prior to having any type of surgery. However, currently there is no evidence to suggest that such an approach would significantly change the outcome for most patients. The most important factors in reducing the risks of surgery are an experienced surgeon and anesthesiologist, along with an operating team that is familiar with the procedure and attentive to the details of your care.
The Pre-op Diet
Some doctors are willing to proceed directly to surgery once a patient is determined to be an appropriate candidate for the AGB. While it is generally possible to perform the procedure safely, this approach risks encountering situations that can make the operation far more difficult than it needs to be. Patients who are morbidly obese almost always have significant stores of a fatty material called glycogen in their liver. The livers of obese patients are often quite large and heavy, making it difficult to expose and perform the necessary dissection around the upper part of the stomach. The pre-op diet is designed to shrink the liver so that it's smaller and lighter, to make band surgery safer.
Preoperative Liver-Shrinking Diet
Provided by the MASTER CENTER® for Minimally Invasive Sungeiy- Texas, LLP
Three Week Nutrition Plan'
Goal: To decrease the size of the liver prior to AGB surgery.
Breakfast: High-protein drink supplement-2 scoops (300 calories and 48 grams of protein)
See "Recipes for Protein Shakes" on pages 144-145
Lunch: High-protein drink supplement-2 scoops
(300 calories and 48 grams of protein)
See "Recipes for Protein Shakes" on pages 144-145
Dinner: Broiled, baked, or grilled chicken, fish, or turkey (4 oz. cooked-28 grams of protein)
Low-calorie vegetables (2 cups), such as green beans, carrots, broccoli, celery, spinach, beets, tomatoes, cauliflower, brussels sprouts, turnip greens, asparagus, zucchini squash, yellow squash, cabbage, cucumbers, radishes, eggplant, or okra (boiled).
Salad: Lettuce and tomato; fat-free salad dressing
Fresh fruit -I cup
(400 calories)
Snack: (200 calories)
See Protein snack list on page 146
The size of the fatty liver can be significantly decreased by placing the patient on a pre-op diet designed to use up the glycogen stored in the liver, effectively shrinking it and making it easier to move out of the way during surgery. In my practice, our dietitian places each patient on a low-fat, low-carbohydrate diet for three weeks before surgery. The diet consists of a protein shake for two meals each day. The third meal consists of broiled or grilled fish, chicken, or turkey accompanied by vegetables without added fat such as butter or margarine.
Virtually everyone can stay on this diet for three weeks as long as they understand what we are trying to accomplish. Typically patients lose 8 to 10 pounds during this time, which provides them with a great positive head start to their program.
The Tests for Rational Beliefs
G. Dick Miller, Psychologist
As I've already mentioned, challenging your current beliefs is the way to change your thinking. After you have written down what you're thinking about food and what you are eating, you can use these five tests to see if what you are telling yourself is rational. There is nothing new about these principles. If you examine your thinking with these rules, and replace erroneous beliefs with ones that line up with these principles, you'll find yourself on the way to making the changes you want to see in your weight.
The first test is a simple one: Is it literally true? In other words, Could I defend this statement to someone impartial? I am often called as an expert witness in court, and my daughter is an attorney. At times I tell her I am concerned about a certain case, that I'm not sure I am as prepared as I should be. She says, "Just get up there, tell them the facts, and shut up." That is a rule to use talking to myself, not just to a jury.
The second test: Is it good for my physical health? Many people will consistently rationalize thinking and the resulting actions that are inconsistent with their physical health. Often we are talking about the chemicals we put in our body. Our grandparents didn't have to make this decision. They grew what they ate, the quantity was limited, and there weren't preservatives, junk food, or stores on wheels. I hear statements like "So everybody drinks," or "What is one cookie going to matter?"
What we find out when we examine those thoughts is that everyone doesn't have bad habits when it comes to food. Now I'll grant you that more of us have bad habits because of the culture we live in. But our choices do catch up with us. Really, everyone doesn't do it, and do you want to be one of those who does?
The third test: Is the way I am thinking right now consistent with my short- and long-term goals? I think it becomes clear when I have people write their homework assignments dialoging their inner conversation. It's clear that we sell ourselves out for our short-term goals at the expense of our long-term goals. If you ask someone if they want good health when they're older, they will say yes. But with the help from Madison Avenue and our history of irrational thinking, we're not making choices that work for both our short-term and long-term goals. I often find myself thinking, "I'm a good guy. I deserve that cake or drink I want." But if I look at my longterm goals, I see that it's more important to lose weight, to live longer, to be here for my grandchildren. It is a smart decision to take both sets of goals into account, because if I act exclusively in terms of my short-term goals, I can set myself up to suffer long term.
The fourth test is: Does it prevent significant conflict with others? This doesn't apply as much with food, because abusing food, unlike alcohol or drugs, does not usually put me in conflict with others. But think about how able you'll be to participate with your friends and grandkids if you continue to gain weight. And what about conflict with yourself? Each person knows what they've done. Even if the food disappears and no one saw you eat it, you know. How do you feel about that?
The fifth and final test is this: Does it help me feel the way I want to feel? I can ask myself, "Will what I'm putting in my mouth make me feel better?" It might, short term, if it's sugar or alcohol. But what about the resulting crash later? Is this really the best choice for feeling the way you want to feel?
Checklist: The Five Tests for Rational Beliefs
Write down your thoughts, then check them against this list.
1. Is it literally true?
2. Is it good for my physical health?
3. Is the way I'm thinking now consistent with my short- and long-term goals?
4. Does it prevent significant conflict with others?
5. Does it help me feel the way I want to feel?
These five tests for rational thinking are the basis of acting responsibly. Realistically, you may be able to act contrary to your belief systems for a while, but if you don't change the way you think, sooner or later your behavior is going to line up with your thinking. As you can probably see, personal honesty is the key here. If you look at your thinking, evaluate it, challenge it with these guidelines, practice the new way of thinking, and tolerate feeling uncomfortable during the transition period, you can and will succeed. But if you decide you're being forced to do something you don't want to do, if you make changing your thinking into a "have to" task instead of a "want to," then your chances at success diminish. We'll look at the "have to" mentality next.
Just before Surgery
Before surgery I have patients come into the office for a last preoperative visit. That is when we see just how well they have done on the preoperative diet. We go over the sequence of events that are going to happen on the day of surgery, and make sure that any last-minute questions are answered. I give each patient prescriptions and encourage them to get them filled prior to the day of their surgery. That way they won't be running around trying to find a pharmacy on their way home from the hospital. The prescriptions include a medication for pain (usually a liquid rather than a pill), as well as antinausea medication.
Our patients are also advised to prepare for their homecoming by stocking up on the foods they are going to need after surgery. The dietitian gives each patient a postoperative diet to follow for the first few weeks after the band is placed, but they really need to stock up only on the food they will need for the first few days. This includes things like sugar-free liquids, Jell-O, low-calorie puddings, and a liquid protein supplement.
Hospitals can be somewhat intimidating places, so to be better prepared, I recommend a preoperative visit to the hospital a few days before the procedure. The nursing staff will show you around and provide specific instructions as to where you should go and what time you should arrive on the day of your surgery. Any preoperative blood tests may also be drawn at that time. You'll also be told not to eat or drink anything past a certain hour (usually midnight) before your operation. This helps ensure that your stomach is empty at the time of surgery.
A meeting with the anesthesiologist is a very important part of your preoperative preparation. He or she will need to be familiar with your medical history prior to putting you to sleep. They will be particularly interested in knowing if you've ever had any problems with anesthesia before, or if you have family members who have had problems with anesthesia. Be sure and share that information.
Ideally this should be a face-to-face discussion, but the fact is that anesthesiologists don't generally have regular office hours. Instead, they try to see patients at the hospital between cases. Unfortunately, they are frequently busy giving anesthesia to other patients during the time when preoperative patients are visiting the hospital. So if you don't have the opportunity to meet the anesthesiologist, you can make arrangements to have a personal contact by phone a day or two before your surgery. You will also get a chance to meet and visit with your anesthesiologist just prior to the operation.
As part of the routine preoperative procedure, you'll be asked to sign several documents. These may include a general Consent to Treat form that simply says you agree to allow the staff of the hospital to provide medical care as directed by your physicians. There will also be a specific consent form for the operation, which details the specific procedure along with the more commonly recognized risks associated with that operation.
This consent form generally has a subsection that details your consent to receive blood or blood products if needed during the procedure. You can refuse blood transfusions and in most cases you'll still be able to have the surgery, but you should be aware that for this type of procedure, blood is given only in extreme life-or-death situations. Another form you'll be asked to sign is the consent for anesthesia. Many hospitals combine the operation consent and the anesthesia consent into a single document. It is very important that you read these forms and understand them. If you have questions, ask.
Robin's Story
I'm a nurse and while at my heaviest, I worked in a practice that handled diabetic patients. I was 266 at 5 feet, 4 inches and had Type 2 diabetes, high blood pressure, and severe rheumatoid arthritis. The doctor I worked for said that if I didn't get the weight off in five years, I'd be in a wheelchair. We had a patient come in for a follow-up who was heavy but had lost a lot of weight. I asked her how she did it, and she said she had a band.
My husband of 30 years thought I could lose the weight on my own, and he didn't want me to do the surgery. I found a band doctor, did the pre-op tests, then took out a second mortgage to get the band. Turns out my husband had issues at the beginning that I might find someone else if I lost weight. But when he went to the band doctor's seminar, he asked a lot of questions and was comfortable with the answers. So he got on board and now he's very supportive.
I got banded in February, and by the end of May I'd lost only 14 pounds. But I was taking Prednisone, a steroid that helps reduce inflammation to treat the arthritis. I knew the drug might affect my weight loss, but at that point I was starting to think I'd just thrown away thousands of dollars for nothing. When I got off the Prednisone, my weight started to drop.
Now, two and a half years out, my diabetes is under control, I'm decreasing the arthritis medication, and I feel great. I was taking two shots of insulin a day, and my blood sugar was over 300. And it was a cascade effect, because the Prednisone made my blood sugar problems worse. The lowest I got was to 189, but now I stay somewhere around 200 pounds. I dropped from a size 26 to a 14 and a half, I ride bikes, hike with my husband, and I feel so much better. I used to come home from work feeling exhausted. I feel I went from a nonproductive life to a productive one.
I've had some problems. At one point, I had my port flip. It turned completely upside down and had to be sewn back in. I've also had esophageal problems. My food sticks in my throat and holds there several seconds. They put me on a medication to help with the spasming. Mostly they blame the esophageal problems on the band. On fluoroscopy, you can see the fluid stop for several seconds, then drop down and go right through the band. I drink hot water in the morning before I take my pills to help. Cold things make the spasming worse. I heat my food, dry food bothers me, and I can't eat salads. I have to concentrate when I eat because if I phase out of what I'm doing and swallow too soon, I have problems. It's like I'm starting all over again with the band.
I've been cold since I lost weight, and I wasn't before. I use flannel sheets year round, wear warm pajamas when I didn't before, and I find myself snuggling in my quilts. Even in 100-degree weather I put on a sweater.
Also, my hair fell out about month four. It was thin and fine already, so I thought I was going to go bald. Now it's back to where it was, but for a while there I thought it wouldn't come back. And I'd like to get a tummy tuck or maybe a lower body lift because I do have that apron from the hanging stomach skin.
A friend and I decided to open our own clinic to do fills for patients banded in Mexico and to help diabetics patients. The band end is such a positive thing. We see people who are happy about losing weight, and it's so great. The diabetics whine a lot and are unhappy. We had a lady come in who had her leg amputated last year and her blood sugar was 300. I said to her, "I'll bet I know what you did. You had three donuts this morning." She said, "They should have a cure for this, and I should be able to eat whatever I want."
Sometimes I have that attitude as a band patient. I think I just want a french fry. I'm certainly not working at 100 percent. I know to get this last 30 pounds off I need to change my eating habits and increase my exercise.
It's interesting to work in a fill practice and see where the doctors put their ports. Mine is in the right lower abdomen and rubs against my clothes sometimes. Some put them on the left-hand side below the ribs in the waist area on the abdominal muscle. That can be a hard place to get to when patients are pretty fluffy, and we only use a 2-inch needle. We sometimes have these patients lift their head and their leg up. Some docs put them on the sternum between the breasts. Others put it right underneath the left breast on the lining of the ribs. A lot of women complain that their bras rub it at first, but it's really easy to access.
Part of our goal in our fill business is to help people pre-op make the best decision. We tell people they want to know what they're getting into. You don't want to jump into a decision. Some doctors don't have you do the liver-shrinking pre-op diet, and they have to lift the liver out of the way. One patient we had didn't do the pre-op diet, and his liver was so huge they had to open him up 6 inches and the doctor had to use his hand to hold the liver out of the way.
I'd like to see the pre-op liver-shrinking diet be a requirement for every band patient. It's my opinion that if you can't do the liver-shrinking diet, you're not going to make it as a bandster, because this is a lifestyle change.
We have a support group for band patients and bring in guest speakers. We had a chiropractor who talked about getting your center of balance back. He said that obese people walk back; they tip back to keep their balance. So when you lose weight, your body is out of balance. An exercise ball helps, and so does standing on one foot and closing your eyes, then doing the same thing on the other foot. He said that he removed the chairs from his classroom and introduced the exercise balls, and his students started experiencing better balance. I remember when I lost 50 pounds, my tail bone hurt when I sat, and I had to sit on a pillow for about four months. And I noticed the weight loss changed my balance.
What I've noticed is you have to take the parts of the program that work for you and let the rest go. There are times when I can't eat solid food. I know I should eat an egg for breakfast, but even the oatmeal sticks. So occasionally I do a protein shake for breakfast. Not everyone can even eat breakfast, but most people can eat lunch. I find for lunch I use a George Foreman grill a lot, and the meat is really moist.
I believe a lot of my weight issues have to do with what happened to me as a child. I lost my parents and had to live with my abusive brother-in-law. My siblings and I became his servants. I was the babysitter, housekeeper, and was abused all the time. I've had to work through issues around that.
With a lot of band patients, I see them get angry at society when they get thinner. I hear them say, "Why do people treat me well now when they didn't when I was fat? I'm the same person." I believe it works better if we let go of what people think. That's what I've done.
I have a son who is 23 years old and was 413 pounds at 6 feet, 4.5 inches. He was getting more and more depressed about his weight. So we took him to Mexico for a band. He's lost 100 pounds in a year with no fill at all. My husband is very supportive of him as well.
As for the changes in me, I think people listen to me more now that I'm not as heavy. It's hard to tell someone they need to watch their eating when you're heavy yourself. I was not a role model. When I decided to tell people I'd had the surgery, I had doctors all over the area sending patients to talk to me about the band. As a consequence of both my weight loss and my willingness to help others, I think I'm more respected.
The Day of Surgery
All the anticipation has led up to the day of surgery. This is typically a very exciting day for most patients. You should arrive at least an hour if not two hours prior to your scheduled procedure for a couple of reasons. First, you need some time to relax and get comfortable. If you are rushed or overly anxious, your blood pressure and your heart rate can go up, potentially complicating your anesthesia. Surgery is too important for you to be rushed. Besides, on the day of surgery, what else do you have to do that is more important? Having said that, I'm reminded of a lady several years ago who showed up five minutes before her scheduled surgery. When I asked her why she was late, she informed me that she had a standing appointment to have her hair done on that particular day, and nothing else was more important. I guess it's harder to get a hair appointment than it is to schedule surgery. I will say her hair did look nice!
Second, it is possible that if another procedure scheduled ahead of yours cancels, or takes less time than anticipated, the time of your procedure could be moved up. You want to be ready to go in case that happens.
Once you arrive at the hospital you'll be asked to change into a hospital gown, and the nurse will start an IV to begin giving you some fluids. You will also receive some IV antibiotics and a small injection of an anticoagulant, or blood thinner, called heparin. The antibiotic is given to help prevent infection, while the anticoagulant helps prevent blood clots.
While you are under anesthesia, blood will have a tendency to pool in the larger veins in your legs and pelvis. That is particularly true in patients who are extremely overweight. Blood that remains stagnant, even inside your own veins, will tend to clot, a condition known as venous thrombosis. If a clot forms it can block the flow of blood and lead to pain and swelling of the legs, ankles, and feet. More important, if this clotted blood breaks away from the wall of the vein, it will quickly travel back to the heart and be pumped up into the lungs. That is called a pulmonary embolus and is potentially a life-threatening situation, depending on the size and number of clots.
Pulmonary embolus is one of the most serious complications that can occur as a result of any bariatric operation, and the best treatment is prevention. So in addition to receiving heparin you will also be asked to put on a pair of elastic stockings to help keep the blood in your legs moving. As an added precaution, before the operation your legs will be wrapped with inflatable leggings called sequential compression devices, or SCDs, that will periodically massage your legs to promote normal circulation. You will need to continue to wear these stockings and SCDs until such time as you are up and about normally.
During your discussion with the anesthesiologist and the nursing staff, you will be asked many of the same questions that you've answered in the surgeon's office. While it may seem ridiculous to have to repeat the same information over and over again, this built-in redundancy is actually designed to help protect you from potential medical errors. There have been several highly publicized cases in which a patient got the wrong operation or received medications that were harmful, and everyone is acutely aware of these risks.
All the people who are involved in your care are charged with being on the lookout for potential problems, such as drug allergies, medication errors, and even getting you mixed up with another patient. While repeatedly being asked the same questions may make it seem like the staff and doctors are not communicating, the fact is that the more times you are asked about these things the safer you are. In fact, as a final step in that safety process, once you are in the operating room, but before the procedure is started, all the members of the surgical team stop what they are doing and have a "time-out." Everyone must agree on the identity of the patient, the procedure to be performed, and any drug allergies or other unusual circumstances about the case before proceeding.
Cynthia's Story
Cynthia, seven and a half years post-op at 145, shown with a photo of herself, pre-op, at 340.
I was one of the early band patients in the United States. I was banded on March 29, 1999, as part of the second round of FDA trials for the LAPBAND®. I live a day's drive from New Orleans, where they were doing the band surgeries as part of the trials. My starting weight was 340 pounds at 5 feet, 2 inches tall. I now vary between 140 and 145, and I'm an inch shorter, at 5 feet, 1 inch. I think there was padding in my feet, and so I lost some height.
I went back to New Orleans every couple of months, as part of the protocol. And I got a fill about every other time I went back. At first, I didn't want anyone to know I had a band because I was embarrassed. But I got over that pretty fast. Now I tell people that those who've gotten a band are doing something proactive with their lives.
I've had a good experience being banded, but my first band did slip. The circumstances behind the slip were I got engaged in 2005 to a man who had five children. I'd always been single, so it was a stressful time for me. Before the wedding, I was struggling. I'd had similar trouble after my father died. The pattern was that whenever I got nervous or upset, my band slipped over my esophagus instead of under my esophagus. So once or twice a year my doctor would take out the fluid, wait a couple of weeks, and put the fluid back in.
When I got engaged, it got worse. I was productive burping and throwing up. My meals just wouldn't stay down. I knew that something wasn't right. They did tests, found out my band had slipped, and my doctor took out all the fluid. I picked up 25 pounds-bam-just like that. My doctor said, Why don't we replace the band now, instead of waiting until two weeks before the wedding? In both cases, my insurance paid for the bands. I remember being one of the few during the FDA trials that did have insurance to cover the band.
At first I had the band that holds 4ccs of fluid and got it replaced with a much bigger 9cc band. I'm one of the few people who've had both bands. What I notice about the difference between the larger and smaller bands is it took longer to get to the sweet spot with the larger band, meaning that I had to have more adjustments to find the fill amount that was perfect for me. Another difference between the two is I now have more warning about being full with the big band. I can be chewing a bite and know I can have one more bite and that'll be all I can eat. With the smaller band, I got no warning. I'd have a bite ready and realize I couldn't swallow it-that I was full. I find it's nice to have a little more warning about when I'll be full.
I always say you don't know what you don't know. Back when I got banded there was so much less information. So I decided to do something about that. I've been very active in the banding community, doing seminars with doctors and even at one point opened my own business for banding care that I later sold to a band doctor.
In working with band patients, one thing I noticed is sometimes they can be like Veruca Salt, the girl from the movie Charlie and the Chocolate Factory, who wanted everything "NOW!" The weight loss is slow, and it's slow for a reason. The best part of this is it works, and the weight won't ever come back. I did all the diets, and the weight always came back. I kept waiting, with the band, for the other shoe to drop, and it never did. I advise people to go ahead, shop for a doctor and start the process with the doctor you like the best while you're still deciding whether or not to do it. Because once you decide, you'll want it done yesterday.
As for advice for band patients, I'd say do your homework and know what you're getting into. The patients who think they're just going to wake up one day and have lost 100 pounds are the ones who have a hard time. There is a process, and there are rules to follow. Banding is a surgery in which patients keep coming back, and both doctors and patients have to make peace with that. One of the things a band patient would be wise to find out is, Are they ever going to see their doctor again after the surgery? Is there a dietitian available? How about a psychologist?
The biggest change came when I'd lost about 60 pounds. It was interesting to me that I could be as huge as I was, take up so much space, and still be invisible. But once people started to notice me, I found it daunting. My life changed so much, I asked to see my band doctor for a talk. He told me my symptoms were from pure stress. I remember thinking I was going crazy. He put me on antidepressants, and I stayed on them until I got to my goal weight. At that point, my doctor told me to go talk to my therapist, and she gave me the tools to deal with people starting to notice me. I found, working with band patients, that a lot of people start self-sabotaging if they're not ready for the changes that occur.
I found myself and a lot of other people spent our time being fun and happy to make up for being overweight. It was amazing to me to see the transformation in people who've lost weight. They were people who had to work so hard at being cute and fun. I'm amazed when I think about how much I had to worry about hygiene and about dressing, how I had to go to specialty shops for clothes, and I knew I didn't look appealing. So I had to be the best friend, the fun person, and I worked hard at not being depressed because of the weight. As I lost the weight, I noticed I didn't have to be the fun one and go the extra mile. I found working with band patients, it was really neat to watch people become who they really are.
The band is a whole life change. Take me, for example. I'm married now, and I don't have the same job. I had ajob in the travel industry where I was a human doormat. As I got thinner, I decided to stop being that person. For example, I stopped accepting calls from clients in the middle of the night. I didn't lose any clients, but it was an adjustment for me and my coworkers when I started to say no. I found out saying no is okay. But it was a stressful process and one that took some adjustment.
I do think that having the band and the boost in self-esteem it gave me was a big part of attracting my husband. I met him through a band patient. I had some people ask me if I told him I was banded, but I made sure he knew. Some people who lose weight are like kids in a candy store with dating. I wasn't that way. I decided that if I knew someone well enough to take my clothes off with them, then I knew them well enough to tell them about my band.
I've had lots of plastic surgery. At one point they called me the plastic surgery poster child. My stomach hung down to my knees, and my insurance paid for the tummy tuck. I've also had a breast reduction, my arms done, thighs, my back around my bra area, and a couple of revisions. I also got a low-profile port because the other port stuck out.
I've had the band for seven and a half years. I lost 210 pounds originally and have gained back 10 overall. I'm healthy, and I'm within a healthy weight category. But if you go by the weight charts, I should be at 120. However, I got down to 127 at one point and was so gaunt that people were asking me if I was okay. I think because I carried around so much weight before, I tend to be more compact and denser than the average person, almost like a former weight lifter.
The best part of the band is that it's reversible. I remember initially, I thought, "I'll get the band removed after I've lost all the weight." Two weeks after my surgery, I completely changed my mind, and now I say, "They'll take it off over my dead body."
Anesthesia
When everything is ready, you will be rolled into the operating room on a stretcher. You may or may not remember this particular event because the anesthesiologist will likely give you some medication that not only relaxes you but also has an amnesic effect. You will still be awake and able to cooperate with the staff; you just won't be able to recall much of the experience afterward.
Once you're in the operating room, a number of electronic devices will be connected to you to monitor your heart rate and the level of oxygen in your blood. You will be given some oxygen to breathe through a plastic mask that is placed over your mouth and nose. This is to ensure that your blood is fully saturated with oxygen before the anesthesiologist puts you to sleep.
To enable the surgeon to perform the operation, you must not only be asleep and unable to feel anything but you must also be totally relaxed. To accomplish this the anesthesiologist gives three different types of medications: (1) a narcotic-type drug that dulls the pain sensing areas in your brain, (2) an anesthes- tic drug that causes you to go to sleep and to stay asleep, and (3) a muscle relaxant that paralyzes your muscles. These drugs are given through the IV you had inserted when you first arrived in the holding area.
The most difficult part of the anesthetic is what is called the induction process, and the most critical part of induction is placing the airway tube, called an endotracheal tube, through your vocal cords and into the windpipe, or trachea, to maintain breathing. A significant number of morbidly obese people are classified as difficult intubations, and in these cases the anesthesiologist must be prepared to use any of a number of techniques to establish and maintain the patient's airway. The sequence and dosages of the various anesthesia medications is critically important in this process, especially the paralyzing drugs. Once the paralyzing drugs have been given, you will not be able to breathe on your own, and the anesthesiologist will have to do the work of breathing for you.
I've been asked many times why it is necessary for the patient to be paralyzed. The answer is really quite simple. Even when you are completely asleep, your muscles still move involuntarily in response to any stimulation. Laparoscopic operations require the abdominal cavity to be inflated with gas. Without paralyzing the muscles, that would simply not be possible. The muscles would respond by contracting down against the inflation process, and the surgeon would have no space inside the abdomen in which to work.
In recent years there has been a considerable amount written and a lot more said about what patients actually experience during operations, including their being able to remember hearing conversations and even experiencing pain. There is no doubt that such things can occur, but they are quite rare. Most surgical patients have no recollection of anything that goes on during their operation. For those who do have some recall, it is usually in the form of being able to hear people talking around them. That is because hearing is generally the last sense that is blocked by anesthetic drugs.
You are probably wondering why they don't just give enough anesthesia to make sure that such things can't occur. Well, most of the time that is precisely what the anesthesiologist does, but all of these medications wear off over time, and not every patient's body processes these powerful drugs exactly the same. The anesthesiologist must balance the effects of the medications with the needs of the patient, and at the same time avoid overdosing. The ideal situation is for the full effect of the drugs to be immediate, and then be completely gone at precisely the same time the surgeon finishes the operation. But not everyone responds exactly the same to each drug given. If more medication is given than what you need, you could be asleep considerably longer than necessary.
Once the operation is over you will be taken from the operating room to the recovery room. Interestingly, like many other things in medicine, its name has changed. It is more accurately called the post-anesthesia care unit, or PACU. Your arrival in the PACU signals the beginning of your postoperative recovery, which will be covered in the next chapter.