Any transition serious enough to alter your definition of self, will require not just small adjustments in your way of living and thinking, but a full-on metamorphosis.
-Martha Beck, 0 Magazine, "Growing Wings," January 2004.
Following most surgical procedures, once you are in the recovery room/PACU it is fair to say that "the hard part is over." But with the AGB that is not the case. While the surgical procedure itself may be over, the operation simply marks the beginning of the real work of changing a lifetime of habits, behaviors, and thoughts that lead to your obesity. Nevertheless, getting past the operation is truly a milestone in your weight-loss journey.
Immediately after Surgery
The first hour or so after surgery is spent in the PACU, where you will be carefully monitored as the effects of the anesthesia drugs gradually wear off. You may not even remember being in the PACU. I have had many patients tell me that the first thing they recall is waking up in their hospital room. This is despite the fact that I spoke with them and they spoke with me a few minutes after their operation. Most anesthesia medications cause a drug-induced amnesia, which is not necessarily a bad thing.
It is almost comical at times to hear a patient ask a question about the operation and appear to hear and understand the answer, only to repeat the same question within a few seconds. Sometimes patients will repeat the same question over and over, with the exact same words and the same vocal tones. The next day they never recall having had any conversation and will once again ask the same question. But this time, only once.
For those who are awake and alert in the PACU, the two most common complaints are pain and nausea. Both of these can often be prevented by giving appropriate medications in advance. If they occur despite these efforts, additional medications are readily available.
Pain following laparoscopic surgery is generally not a major problem. The small incisions are not typically the source of major pain. The exception may be the site where the injection port is placed.
Because the port is sutured to the muscle layer, it may cause an occasional sharp pain in the area, especially with moving, deep breathing, or coughing. But these are important activities after surgery, so if the pain is bad enough that it is restricting movement, pain medication will be given.
Not surprisingly, operations performed directly on or around the stomach are often followed by nausea once the patient is awake. Likewise, retching or vomiting after this type of surgery is not a good thing. It is possible it might do some serious damage, so it is very important to get nausea under control. The best way to deal with this problem is to give appropriate antinausea medications beforehand. For those patients who develop postoperative nausea, we have a wide variety of medications available. Fortunately this type of nausea is usually gone by the next day.
This figure shows the relative locations of the incisions and the location of the band, tubing, and port after the laparoscopic placement of the AGB.
The Hospital Stay
Each patient remains in the PACU for an hour or so, or until they are awake and alert. They are then taken to a hospital room where they will stay until being discharged, usually the following morning. For the first few hours the nursing staff will be in and out of the room every hour or so checking blood pressures, making sure the IV is working properly, making sure the compression devices on your legs are working properly, and asking you about pain and nausea. Eventually, these visits become less frequent, allowing you some uninterrupted time to rest.
Many bariatric surgeons perform the AGB procedure on an outpatient basis, allowing patients to go home just a few hours after their operation. In many cases that practice is quite safe, but my own preference is to keep my patients in a hospital setting overnight. My rationale is that if patients are going to have problems after surgery, they are most likely to occur within that first 24-hour period. This includes serious issues such as heart attack, internal bleeding, or signs of stomach perforation. Granted, those may not be all that likely following an AGB operation, but morbidly obese patients are at higher risk for developing a variety of problems than patients of normal weight.
There is another reason I believe keeping patients in the hospital overnight is generally a good idea. Family members may or may not be comfortable providing even the basic care needs of someone following surgery. This can be a frightening job if you are not sure exactly what you should be looking for and what to do in the event you suspect a problem. Nurses are specifically trained not only to recognize potential problems but also to provide a calming environment. Patient and family alike can experience considerable anxiety when dealing with postoperative pain and nausea in the absence of professional help. Even just getting in and out of bed to go to the bathroom creates questions about what to do. All of these issues are much easier for everyone the next day than they are just six or eight hours immediately after surgery.
In addition to taking your vital signs and asking how you are doing, the nurse will also be encouraging you to breathe deeply and cough. This is extremely important because after surgery you will tend to take shallow breaths only, which can lead to retained secretions in your lungs, and eventually even cause pneumonia. To help improve lung function you will be encouraged to get out of bed and even take a walk in the hallway. Walking also improves the circulation in your legs and helps reduce the risk of blood clots.
A significant number of morbidly obese patients also suffer from sleep apnea. That is even more likely when you are under the influence of sedating medications. If you are one of those who require a positive pressure breathing machine to sleep, bring it with you to the hospital and use it as you normally would to sleep. Don't assume that the hospital will provide you with your CPAP or BiPAP treatment.
You will be connected to a monitoring device called a pulse oximeter, which is placed on your finger to measure the amount of oxygen in your blood. If your blood oxygen level is lower than normal, the nurse will place a small plastic tube in your nose or a mask over your face to supply you with more oxygen to breathe. You may also be hooked up to a heart monitor, particularly if you have a history of cardiac problems or an irregular heart beat.
If you have diabetes your blood sugars can fluctuate dramatically following surgery. The combination of not eating, receiving IV fluids, and the stress of surgery makes it difficult to predict exactly what your blood sugar will do. One thing is certain: your usual dosage of insulin or oral medication is not likely to be appropriate during this time. Instead, the nurse will check your blood glucose level every few hours so that the right amount of medication can be given.
To avoid getting dehydrated, you will remain on IV fluid until you are fully awake and able to take fluid by mouth. The continuous flow of fluids into your body will catch up with you, and eventually you will need to get up to the bathroom. Don't try to manage all the monitors and tubes by yourself. The nurse will need to help you for at least the first time or two.
Problems urinating are not common following obesity surgery, but occasionally patients are unable to urinate. This may be because of the effects of sedation or a pre-existing condition. If your bladder becomes distended and you can't void on your own, the nurse will need to insert a small tube, called a catheter, up into your bladder. Urinary difficulties of this kind are most often temporary, but if you continue to have trouble emptying your bladder it may be necessary to put in a catheter that remains in for an extended time. Fortunately, that is pretty rare following AGB surgery.
Between the IV, the blood pressure cuff, the compression devices on your legs, oxygen tubing, the oxygen monitor, the heart monitor, and the breathing machine you may feel like an astronaut, ready for take-off, or Gulliver trapped in the land of the Lilliputians. Just remind yourself that all this "stuff" is actually designed to help you get through your surgery safely.
Once you are awake, the nurse will offer you some ice chips or clear liquids to sip on. This will be the first time you will be swallowing anything after your band has been placed, so take it slow. Make sure you are sitting up, and take only small sips. If you try to swallow liquids while you are lying down flat, or nearly flat, the liquids may not want to go down. Even when sitting up you may get the feeling that there is something slowing down the passage of fluid into your stomach. That's the band.
Occasionally, patients describe some pain in their chest, back, or throat when they first start taking liquids, especially if the liquids are extremely hot or cold. This pain is due to a spasm in the lower esophagus that occurs as the esophagus is attempting to push the fluids past the resistance created by the band. The best way to avoid this problem is to drink very slowly and avoid hot or cold liquids. Carbonated drinks may also cause esophageal spasm, but the main problem they create is a feeling of being bloated. Once the gas gets below the band it can be very difficult to belch it back up, so it is best just to avoid sodas and sparkling water.
Checklist: Post-op Tips for Taking in Fluids
✓ Take small sips.
✓ Avoid hot or very cold liquids.
✓ Sit up when you swallow.
✓ Avoid carbonated drinks such as sodas or sparkling water.
Following surgery you will have some pain from the small incisions in your abdomen. Some patients describe their pain as severe, but most people describe it more as soreness rather than a real pain. Typically, they say it feels like they have just done a hundred sit-ups. To manage this postoperative pain, the nurse will give you medication either through the IV, as an injection, or as a liquid pain medication that is taken by mouth. The advantage of IV drugs is quick action, but they also tend to wear off more quickly. When drugs such as morphine or Demerol are given by injection into the muscle, they are a little slower to begin working, but they will generally last several hours. Oral medications are even slower to begin working, but are easier to take than a shot.
Postoperative nausea is also fairly common, and medication will be available to help control it. Generally the nausea will subside within a few hours, once the effects of the anesthesia wear off, but it is important to get the nausea under control and avoid vomiting. Antinausea medications are usually given either through the IV or as a rectal suppository. It doesn't make much sense to give someone who is nauseated any medication by mouth, since they are likely to bring it back up before it has a chance to take effect.
Some surgeons routinely require their patients to have a stomach X-ray the day after the band has been placed. This involves swallowing some liquid contrast material to see exactly where the band is in relation to the stomach and esophagus, and to make sure that there is no leakage. Others, and I include myself in this category, order this type of X-ray only in cases in which the operation was particularly difficult, or if the patient is having some problems swallowing.
Before you can go home from the hospital you will need to be able to take adequate fluids by mouth. On rare occasions, the band can create a complete blockage of the stomach. This may be due to excessive swelling of the stomach wall, or the band may have been too tight to begin with. Generally the passage through the band will open up over a two- or three-day period, but until it does you will need to remain in the hospital on IV fluids. It is extremely uncommon to have to take a patient back to surgery to remove or reposition the band, but that might be necessary if the obstruction persists.
Lorrie's Story
I heard about the band from a girlfriend in Las Vegas who asked me if I'd be interested in doing it with her. We called around to find the lowest price and discovered we could have it done for less in Mexico. When we went through the process to get the band, I just barely qualified. I'm 5 feet, 5 inches, and I started at 215.6 pounds. During the qualification process, my girlfriend backed out.
I've always been on the chubby side. But I could lose until I started menopause and quit smoking. After that, I could starve myself and not be able to lose the weight. Every year my aunt went on a water-only fast for 30 days early in the year. And I did that with her for a couple of years and lost 20 pounds in a month. I found that after the first week, you go through a period of headaches and being sick; then, after a week, you have all the energy in the world. But I'd gain the weight back. A friend of mine who is in the medical profession told me that when you get too overweight, your body is just not going to be able to lose. That's why you need something to help you.
I deal poker for a living and travel a lot. I figured if I had the surgery at the end of October, that'd give me the whole month of November to recuperate. I did the pre-op diet and had a talk with some of the doctor's staff before the surgery.
The easiest part of this process was doing the surgery. They kept me one night in the hospital, and the next night I went to a hotel. I went shopping, did a lot of walking, and none of it bothered me at all. Then I came home and sat around for a week and a half and didn't do anything strenuous at all. Just rested.
Just before I went back to work I had a massage by my regular massage therapist. The first week of working I had a lot of pain, and I wonder if it was because of the massage. On the table (when I'm dealing) I do a lot of stretching and moving. My port, my stomach, my back all hurt. I called the doctor's office, and they didn't think the massage was a problem. I took a lot of pain medication, and after about a week, the pain went away.
However, a friend of mine who had weight-loss surgery marvels at how fast I was up and around. He was almost 500 pounds, had the gastric bypass, and lost 240 pounds altogether. But he was laid up for months.
I just had my first fill at six weeks in Tijuana with the surgeon who did the band. Seven hours prior to the fill they asked me not to eat anything, just have water. And now I've been on yogurt, very liquid soups, Slimfast°, and water since the fill. I tried to eat an egg, and it wouldn't go down. They did tell me to go back to the post-op diet, meaning start back on liquids then to soft foods and then back to regular foods, since they expected I'd be a little swollen after the fill.
Since I travel a lot, wherever I go they have food and there's always room service. I think had I been home more, I probably could have gotten a good band diet going. But I really didn't have any idea what to eat. At times, I do feel kind of panicky. I tried a milkshake and could only get about a fourth of it down. It's uncomfortable to adjust to a fill.
I obviously have a fascination with food. But now people invite me out to dinner, and I don't always care to go. It used to be my whole social life was about where to eat. Now I'm planning what I'll do about Christmas dinner. I find I have more time, and I'm working more to keep myself busy. Early on, I had a couple of days where I didn't know what I should eat when I was in a casino. I went to the seafood buffet in Reno and it seemed like a waste, because I knew I was going to eat only four bites. I realize now my old pattern when I used to travel was I'd stop for breakfast, then get some Cheetos® to snack on in my car on the road. In fact, my car would be filled with food. Now all I get when I stop is water.
I consider the band a diet. It's the best diet I've ever been on, and it's going to work. It was so depressing before, when I'd diet, diet, diet-follow all the rules, get on the scale, and nothing. But with this, I do what they tell me and I get on the scale and I see results. I'm now down to 190 pounds, which is a loss of 25.4 pounds.
I love the band. I think it's the best thing anyone can do for themselves. I am encouraging my friends to do it.
Going Home
The vast majority of my patients are discharged from the hospital the morning after their band operation, but I don't allow them to drive themselves. The lingering effects of pain medications can alter judgment and reaction times for several days. You'll need to have someone drive you home, and it is probably wise to have someone stay with you for a day or two, until you are getting around comfortably and able to take care of yourself completely.
During those first few days at home you will probably take some of your pain medication that was prescribed by your surgeon. As long as you are taking pain medication it is potentially dangerous to be driving a car or operating heavy equipment or power tools. If you are otherwise feeling well, about 24 hours after your last prescription pain medication, it should be all right to drive yourself short distances.
Guidelines for Recuperating at Home
• Don't drive yourself home from the hospital.
• It's best to have someone stay with you for a couple of days after surgery.
• Driving is usually safe 24 hours after you've taken your last prescription pain medication and you're feeling well. The same goes for operating heavy machinery or power tools.
• Skin incisions need 48 hours to heal enough that water won't damage them. So wait two days to shower.
• Take it easy. Rest. Give yourself time to regain your strength.
• Don't remove the butterfly strips over your incisions. Let them fall off on their own, usually in a week to 10 days.
• Do walk, working up gradually to longer distances.
The first few days at home should be spent resting and recuperating from surgery. The physical stress of an operation is obvious, but having surgery can also be mentally and even emotionally draining. Give yourself some time to gain your strength before plowing back into your busy routine. It will pay major dividends in the long run and may even convince you that it's all right to slow down the pace of your life. After all, lifestyle change is precisely what you are trying to accomplish with the band, right?
One of the most common questions asked after surgery is "When can I take a shower?" I suggest to my patients that they wait until the second day after their operation. After about 48 hours the skin incisions are healed enough that water running across them will not be a problem. This means showers only for the first week. Soaking in a tub should be avoided for the first week, and longer if there is any persistent drainage from the small incision sites.
I typically close the incisions with a type of suture that is designed to dissolve, and all the sutures are under the skin. To help support these sutures, we place small sterile tapes or "butterfly" strips across each incision. Additional dressings are placed over the incisions, and these can be removed about the time you take your first shower. But leave the sterile tapes on until they begin to fall off by themselves, usually about a week to 10 days later.
While getting enough rest is important, you shouldn't just lie in bed all the time. That is a recipe for problems, including blood clots and pneumonia. You should be up and moving around frequently. If the weather is nice, get outside and walk around the neighborhood. The fresh air will do you good. Start out slowly, and gradually work your way up to walking greater distances. The sooner you get started walking, the sooner you'll gain your strength back.
My Words Give Me Back My Power
G. Dick Miller, Psychologist
Does it really matter what we call something? What words we use? If I say, "I need something to eat," and you say, "It would be in my best interest to have something to eat," aren't we saying essentially the same thing? My contention is we're not.
The words we use can and do make a difference. Here's why. Certain words imply I have no rational choice. If I'm saying, "I should," or "I need," or "I have to," I'm sending the message to myself and others that I have given up my right to choose. My message is that someone or something outside of me is forcing me to do something I don't want to do. And if I don't want to do it, eventually, I'll find a way not to. In other words, I can create malcontent and rebellion in myself that will eventually lead to my making harmful choices by simply using language that gives away my power.
If I say, "I can," "I want to," or "It would be in my best interest to," I give myself back my power both in my own eyes and with others. Then I choose. No one is making me. And if I have decided, I'm not going to be expending my time and energy finding a way out. I allow myself the freedom of choice and give myself back my power.
Should, can't, never, always, right, wrong-these are all absolute words that are not in our best interests to use. Use of them is very dishonest and manipulative. We use these words because we don't honestly believe we can attack a problem and solve it. We don't believe we can have an honest approach. We want a trick, a gimmick, because we don't trust that we can do, or will do, what's in our best interests.
So, yes, the terminology does matter. It matters a lot. For example, with head hunger, I can create a negative situation for myself if I'm not personally honest. If I call anxiety or stress "hunger," then it makes sense for me to treat it with food.
But if I can learn to identify my uncomfortable feeling, be honest with myself, and choose to call it what it is, anxiety or stress, then I have a whole range of choices. All of the options for treating anxiety become available to me once I correctly name my discomfort. And this change in my thinking allows me to make a better decision for myself.
What I call things has a domino effect in my thinking. I can make the domino effect work for me if I work to change my language around my choices.
Medication Needs
Obviously, your need to take pain and nausea medication should decrease rapidly as the incisions heal. Occasionally, I'll have a patient tell me that they are still taking prescription pain medications a week or more after surgery, but that is unusual. If you still feel the need to be taking pain killers after the first week it could signal that there is a problem, and you should make your surgeon aware of the situation. However, recognize that sometimes people just like the way their medications make them feel, and continue to use "pain" as the reason for taking dose after dose of these powerful medications. Addiction to narcotic pain relievers is a real risk for some people, especially if they have a prior his tory of similar behavior. So if your surgeon refuses to refill your pain medication prescription, it is probably in your best interest.
Checklist: Taking Medication Post-op
✓ Pain medication can become addictive. So your surgeon may not want to refill your postoperative pain medication after a certain point.
✓ For your regular medication, you will need to crush pills or open capsules and mix medication with juice or water. Before doing this, check with your prescribing physician and MAKE SURE THIS IS SAFE.
✓ There may be liquid alternatives for your medications available, so ask.
✓ If you are taking medication to lower your blood pressure, monitor your blood pressure carefully. Sometimes blood pressure drops dramatically post-op with band patients, and your regular doctor may need to adjust your medication downward or eliminate it altogether. Be especially aware of feeling weak or dizzy, as that may be a sign your blood pressure is getting too low.
✓ If you have diabetes, monitor your blood sugar levels carefully. Often band patients need to adjust insulin or other diabetes medications downward, so be sure to check your blood sugar before giving yourself shots or taking your medication.
Other medications you were taking before the operation will generally need to be resumed afterward. This can present a problem if the pills are large. Any pill or capsule could potentially get stuck in the narrowed area of the stomach created by the band. If possible you should crush your pills or open the capsules and mix the medication with juice or water to allow it to go down easily. But before you do that, you should contact the physician who prescribed the medication to make sure it is safe to do so. Your pharmacist will also be able to advise you as to whether it is safe to alter your pills in this way, or whether a liquid alternative is available.
For those patients with diabetes or high blood pressure, it is more important than ever to monitor blood sugar levels and blood pressure regularly. The dramatic change in your diet can greatly affect these measurements, which can then necessitate changes in your medication dosage. This is particularly true for patients with diabetes. For those who routinely use insulin, you can easily overdose if you resume your usual dosage without checking your blood glucose level frequently. Remember, you are not eating anywhere near the same number of calories that you did before, and your blood sugar will naturally be lower.
Blood pressure is often similarly influenced during the postoperative period. Many patients need to reduce their blood pressure medications long before a significant amount of weight has been lost. It's important to check your pressure frequently, especially if you begin to feel weak or dizzy. If your pressure becomes lower than anticipated, you should contact your physician and let him or her adjust your medicines.
Returning to Normal Activity
After surgery you will also need to return gradually to your normal physical activities and start getting some exercise. This needs to begin soon after you get home, with walking, but you should limit any lifting to a maximum of 10 pounds for the first 10 days. After that the limit can be raised to 20 pounds for the next 20 days. So, after about a month you should be able to lift any amount you were able to lift prior to the surgery
A number of patients participate in water aerobics and are eager to get back to that activity, which is great. However, waiting a week or so will allow the incisions time to heal enough to make it safe to be in the pool.
The big question is always "What about work?" If you have a desk job, or one that does not include much physical activity, you may be able to return to work within just a few days. For patients with more physically demanding jobs, it is usually necessary to stay off work for a couple of weeks. But this can vary, depending on the patient's general health, how rapidly they are recovering, the type of work they do, and other individual circumstances. The decision is ultimately up to the surgeon.
As you know by now, the whole idea of placing a band around your stomach is to restrict your food intake. The problem is that the degree of restriction changes over time following placement of the band. Initially the stomach is bunched up inside the band, creating a relatively small opening for food to pass through. That is why initially only liquids will pass through the band.
However, over the next few weeks the wall of the stomach gradually stretches out, remodeling itself around the band, creating a larger opening so food can pass through.
Recommended Postoperative Dieu
Days 1-2 Clear liquids (32-64 ounces per day).
Day 2 Add protein drink (40-70 grams per day).
Days 3-4 Add full liquids, V-8 juice, thin cream soups, and yogurt.
Days 5-6 Add applesauce, pudding, smoothies, and banana.
Days 7-8 Add mashed potatoes, cream of wheat, and (baby food-style) well-cooked vegetables, vegetable soup, and legumes (beans) that have been well cooked (no grits, rice, pasta, or peanut butter).
Days 9-10 Add baked potato, oatmeal, soft boiled and scrambled eggs, cottage cheese, and canned pears (try adding low-fat cheese to eggs and potatoes).
Days 11-12 Slowly add fresh fruits; chew well and eat slowly; continue protein supplement drink, 64 oz. per day.
Days 13-15 SLOWLY add baked fish, tuna (with fat-free mayonnaise), toast or crackers, small amounts of rice, pasta, vegetables (except asparagus, celery, and corn), and whole-grain cereal (granola bars, protein bars).
Days 16-28 You're ready to try baked turkey and chicken and salads. Try one new food at a time, in small (1-2 oz.) servings, and chew, chew, chew.
Days 29-56 You can move on to ground beef, then gradually add roast beef, ham, and sausage. Steak should be last, and beef may always be problem. Bread may also be a problem no matter how well you chew it.
As the opening enlarges, fluids and even solid food will begin to pass through more easily. That doesn't mean that two weeks following surgery you will be able to eat a steak dinner. Some patients have more restriction than others post-op, but for most, they are pretty restricted in the beginning and there's a gradual change to less restriction. So to accommodate this changing level of restriction, we place patients on a progressive diet for the first few weeks. It starts with liquids, and then various solid foods are added as the opening enlarges. I've included the table (page 126) we give postoperative patients that gives our specific instructions for reintroducing foods.
Different programs will likely have different recommendations as to what you can and cannot eat in the postoperative period. Some may be fairly regimented like ours, while other may be much less specific. The important thing for you to realize is that the apparent tightness of the band will decrease significantly during the first few weeks, allowing you to eat more. Eventually, if you don't have the band tightened, filled, adjusted, or whatever they call the process in your doctor's practice, the band simply will not work.
This detailed guide for introducing foods is given to each of my postoperative band patients. It is provided courtesy of the MASTER CENTER® for Minimally Invasive Surgery-Texas, LLP.
And now that you're starting your new life with the AGB, here are the golden rules for success. It will take a certain amount of experimentation to learn to follow these golden rules. I'll cover them in more detail later, but let me introduce them to you here. (There is also a list of 10 rules distributed by a band manufacturer on page 131.)
Checklist: Dr. Sewell's Golden Rules forAGB Patients
✓ Eat until you are comfortable, NOT FULL!
✓ Choose protein first you need 50 to 70 grams of protein per day.
✓ Eat slowly and chew your food well.
✓ Don't drink 15 minutes before or during meals and for two hours after eating.
✓ Liquids will not satisfy your hunger, so you need to eat something.
✓ Exercise daily.
Conclusion
So far we've covered what to expect physically before and after surgery, but we haven't really addressed one of the most important aspects of the AGB process: adjusting the band. Following surgery, most patients begin to experience weight loss, but as they adapt to the band and the postoperative swelling subsides, their weight loss slows significantly. The most unique feature of the AGB is its adjustability This is the topic of the next chapter.