Success is the ability to go from one failure to another with no loss of enthusiasm.
-Sir Winston Churchill
As we saw in the last chapter, while the successes accompanying the AGB in terms of the reduction or disappearance of chronic health problems is pretty impressive, any surgical procedure carries with it potential problems or complications. Although the incidence of these problems is generally outweighed by the benefits of the AGB, they must be recognized as real possibilities. That is the subject of this chapter.
Introduction
We have all seen actors dressed in surgical attire, playing the roles of surgeons, assistants, anesthesiologists, and nurses in dramatic operating room scenes. While some of what is presented is fairly accurate, much of what you see and hear is designed more for entertainment than anything else. Some of the newer health documentaries are a bit more realistic, and they often show an entire operation from start to finish. Even so, these procedures and the patients are often selected in advance for demonstration purposes, and you aren't likely to witness any major problems or complications.
Surgical complications and poor outcomes can and sometimes do occur. Within the surgical community a common statement is "The only surgeon who has never experienced a complication is one who has never done surgery." That is not to say that problems are inevitable for every patient, or even the majority of patients. Modern, minimally invasive surgery and anesthesia are generally much safer than a generation ago, but even so there are still risks, which are to a large degree dependant on individual patient factors. Obese patients with diabetes, high blood pressure, or cardiac problems are clearly at higher risk, but then again those are the very problems that lead to the need for bariatric surgery.
While it is important for patients to be aware of the potential risks of surgery, it is impossible to cover every risk and every situation with every patient. What you will find in the remainder of this chapter is just a brief explanation of some of the risks most commonly associated with the AGB. These problems can arise during surgery, postoperatively, and even long after the procedure.
Intraoperative Complications
When most people think of surgical risks, they immediately think of things such as uncontrolled bleeding or a heart attack, or something similarly catastrophic. But most intraoperative problems are less spectacular and are managed by the surgeon without incident. The key to minimizing problems during surgery is to recognize them before they become true complications.
Laparoscopic surgery has many well-recognized benefits, such as less pain, quicker recovery, and smaller scars, but it also has some limitations. Specifically, it can be more difficulty to identify certain unexpected injuries because the surgeon must rely solely on what he or she can see on the video monitor. Even so, experienced laparoscopic surgeons are able to identify and manage intraoperative problems with virtually the same capability as during open surgery.
There are some injuries that are unique to laparoscopic operations. When the surgeon inserts the laparoscopic canulas there is a chance of injury to blood vessels within the wall of the abdomen or one or more organs inside the abdomen. Injury to small blood vessels is typically not a major problem, but it may result in significant bruising around the site of the incision. Injuries of the intestine are uncommon, but they are a bit more likely in patients who have had previous abdominal surgery. Internal scarring, called adhesions, may cause the intestine to be stuck to the inside of the abdominal cavity. That not only increases the risk of injury to the intestine but also can make it more difficult to see such an injury. Such an injury could lead to a serious infection, but it may not become apparent for several days.
Electrocautery is a technique commonly used to control bleeding during surgery. During laparoscopic surgery there is a somewhat greater risk of unseen electrical injury to internal organs when electrocautery is used. These are par ticularly difficult injuries to identify because they can happen well away from the area the surgeon is looking at, and the damage may be virtually invisible. Once again, the effect of such an injury may not show up for several days. In the last several years, the mechanism behind electrocautery injuries has become better understood, and the incidence of such injuries has decreased.
When performing the AGB procedure the surgeon is required to perform a dissection around the area of the upper stomach and lower esophagus. During this process it is possible to injure either of those structures. The presence of an unrecognized hole in either the stomach or the esophagus is likely to become an extremely serious problem. If the injury occurs on the back side it can be nearly impossible to detect. Within about 24 hours the patient will generally develop a rapid heart rate, with fever and abdominal or chest pain. Should such signs occur after surgery, one or more tests can be used to identify whether the esophagus or stomach has actually sustained a perforation. If an injury is confirmed, the sooner it can be surgically repaired the better. The longer it remains untreated, the higher the risk of developing a life-threatening infection.
In addition to the esophagus and stomach, there are other organs and structures in the same general area that can be injured during surgery. The spleen is particularly at risk because it is very near the upper part of the stomach and is fairly easily damaged and can potentially cause major bleeding. Also, there are many major blood vessels in the same region. Fortunately, injuries of this nature are extremely rare during AGB surgery. But if major bleeding should occur, the surgeon very likely would need to open the abdomen to gain control of it.
Postoperative Complications
Postoperative chest pain, especially when accompanied by shortness of breath, could be a sign of a serious heart problem. The stress of anesthesia on the heart can be significant, especially for those patients with prior cardiac disease. That is one of many reasons why I feel that observation in the hospital for the first night is a good idea.
Following general anesthesia there are a number of respiratory problems that can occur. The most common respiratory complication is what is known as atelectasis. This occurs whenever you don't breathe deeply enough to fill your lungs completely. Small airways in the lower areas of the lungs tend to collapse, trapping mucus and bacteria in those tiny areas. This problem can generally be prevented if the patient will breathe deeply and cough regularly. If not, atelectasis can actually progress into pneumonia. Respiratory complications are more likely in patients who smoke or have pre-existing pulmonary conditions such as asthma, emphysema, and chronic obstructive pulmonary disease.
One of the most feared of postoperative complications is pulmonary embolus. This occurs when a blood clot develops in the veins of the legs or pelvis and breaks away, moving quickly through the heart and into the arteries of the lungs. If the clot is small it may result in only some transient shortness of breath and minor chest discomfort. But if the clot is large it can block one of the major arteries in the lungs. That not only blocks blood from passing through the lungs where it should be picking up oxygen and leaving off carbon dioxide but also puts tremendous stress on the heart. Pulmonary embolus can occur days, weeks, or even months after surgery, and it can be the cause of sudden death. Most blood clots begin while the patient is completely inactive while on the operating table or during the first few hours after surgery.
Normally the frequent contraction of the muscles in your leg acts like a pump, literally forcing blood through the veins. As long as blood is on the move it is unlikely to clot. During the total inactivity of anesthesia, as well as the limited muscular movements of the initial postoperative period, blood has a tendency to pool in the large veins of your legs and pelvis. If the pooled blood clots inside those veins, it may remain there until it dissolves, or become permanently affixed to the wall of the vein. The clotting of this pooled blood is known as deep vein thrombosis (DVT). But if the clot breaks free, it becomes a pulmonary embolus.
The best way to manage DVT and pulmonary embolus is to prevent the clot from forming in the first place. That is particularly true in bariatric surgery. As a group, obese patients are at greater risk than most normal-weight people for developing DVT during surgery. To help reduce the risk, patients are given heparin, a blood thinner, prior to surgery and usually for 12 to 24 hours afterward. This makes blood less prone to clotting inside the veins. At the same time, the patients' legs are wrapped with specially designed leggings called sequential compression devices (SCDs). These devices squeeze the legs periodically during the operation and in the postoperative period, simulating the pumping action of active leg muscles. The combination of heparin and SCDs reduces the risk of DVT substantially. In addition, the sooner the patient is up and around, the sooner blood flow will return to normal.
Problems following an Adjustment (Fill)
Most patients have an uneventful surgery and recovery I have had a couple of patients who decided they could eat solid food earlier than was recommended, which caused them chest discomfort and some spitting up of the food they just ate. But most patients follow our recommendations carefully and have few if any problems-that is, until they have their first adjustment. Even then, the majority of patients are able to modify their eating behavior to deal with the restriction imposed by the band.
There are those, however, who really struggle with changing their eating habits. For patients who have trouble with solid foods after adjustment to the band, the result is unpleasant. While that is not in itself a complication of the AGB, if it is allowed to continue it can lead to other problems.
Every time you regurgitate food or fluids there is a risk that some of it will go into your trachea, or windpipe. This is called aspiration, and it can lead to episodes of severe coughing and even pneumonia. Patients are particularly prone to aspiration if they try to eat while lying down or if they lie down shortly after eating. While the problem can occasionally be due to the band's being excessively tight, most of the time it is simply because the patient is eating too fast, taking bites that are too large, not chewing adequately, or not stopping when they first feel the sensation of fullness. If the problem reaches the point of causing pneumonia, the solution is to take the fluid out of the band and leave it out for a few weeks. The process of gradually inflating the band can then be slowly started over.
Some patients are so enthusiastic about losing weight that they want the band tighter and tighter. When the restriction gets to a certain point, the only thing that will go down is liquids. Eventually it may be difficult even to get liquids through, and the patient will quickly become dehydrated. This is a potentially serious situation. Our bodies can go for extended periods without food, but only a few days without water. Whenever a patient tells me they can't keep anything down, including water, the band is too tight. The solution to this problem is to remove enough fluid from the band to allow liquids to pass through easily. The patient should be able to eat solid foods as well, provided they are "small bites, chewed well, and eaten slowly." (Sounds like a broken record, doesn't it?)
Problems with the Port
At the time of surgery, the injection port can be placed in a variety of locations. I prefer to put it along the left side of the patient's abdomen, close to one of the small incision sites used to place a laparoscopic canula. The port is sutured to the surface of the abdominal muscle layer to keep it from moving.
Despite this fixation process, it is possible over time for the sutures holding the port to break. If that happens, the port can actually flip over, which makes it impossible to access it with a needle in the usual way. Occasionally it may be possible to manually flip the port over, but that may require fluoroscopy (X-ray) to visualize it. More often than not, if the port flips over it is necessary to return to the operating room and surgically reposition and secure the port to the muscle.
The reason why some ports flip over is not well understood. It may be due to excessive tension on the sutures, or extreme stretching of the muscles that it is attached to. This happens relatively infrequently, though, and usually is fairly easy to resolve. I did have one patient whose port flipped and following the resuturing procedure he developed an infection around the port. In his case, a new port placed in a new location was ultimately required to resolve the infection.
It is also possible for the port to leak some of the saline after an adjustment. This is not likely if the proper needle is used, since the silicone core of the port typically seals itself completely when the needle is removed. A leak can occur even if the proper, noncoring needle is used or if any part of the port other than the silicone core is punctured. The port housing is hard plastic and cannot be damaged by a needle. But the stem of the port can be penetrated by the needle, and that part of the port will not seal itself, resulting in a slow leak.
One of the symptoms of a leak is that the restriction seems to decrease rather dramatically over just a few days. When the port is again accessed there is less fluid in it than anticipated. A leaking port needs to be replaced. This requires an outpatient surgical procedure, but it does not require the surgeon to re-enter the abdomen or replace the band.
On rare occasions, the tubing between the band and the port can become the site of fluid leaking out of the system. If this occurs, it may be that the connection between the two parts of the system simply came loose. To fix this requires a repeat laparoscopic operation to find the two separated ends and reconnect them. Again, the band would not need to be replaced.
If the balloon portion of the band that controls the size of the stomach opening leaks, the band becomes ineffective and must be replaced. The most likely explanations for a band leak are either an unrecognized tear or puncture of the balloon during placement or material fatigue, which can occur over time. Fortunately, this is a very unusual situation. To prevent faulty bands from being placed, each band is tested by the surgeon prior to insertion to help ensure that it doesn't leak.
Delayed Problems with the Band
The most common significant complication encountered with the AGB is slippage. This is a man-made device being placed around a God-made structure, and it doesn't always stay precisely where it was originally placed. Despite the fact that the stomach is sutured over the band, it is still possible for the band to slip. It is possible for the band to move upward onto the esophagus. But what typically happens, if the band is going to slip, is that it slips downward.
The term "slipped band" is often used to describe one of two situations that are similar but not really the same. A true "slip" occurs when the sutures holding the stomach over the band break or pull through and fail. This slip is most often caused by excessive overeating with progressive stretching of the upper pouch. If the band slips down on the stomach, the pouch will continue to stretch, allowing the patient to eat more, which further compounds the problem.
With a slipped band the most common complaint is heartburn. When the band is positioned properly, the amount of acid produced by the small stomach pouch above the band is negligible. As the band slides down, not only is the stomach pouch larger but the amount of acid produced above the band also increases. The band serves to block the flow of everything, including the stomach acid, so it refluxes up into the esophagus, causing heartburn. This particular symptom can generally be improved by using an acid-reducing medication, but ultimately the slipped band will need to be addressed.
If the surgeon suspects a slipped band, the first thing he or she is likely to do is order an upper GI X-ray to document the nature of the problem. The patient swallows some liquid barium contrast, allowing the anatomy of the esophagus, stomach, and band to be defined. The presence of a larger than normal upper stomach pouch is clear evidence that the band has slipped. If the slip seems relatively small, it may be managed by simply removing the fluid from the band and then slowly reinflating it. This may or may not work as a long-term solution, but it is usually worth trying because the other option is another operation.
Gastric herniation is another condition that is commonly lumped under the title of "slipped band," because the symptoms are similar. However, this problem doesn't actually involve any movement of the band. In a gastric herniation, a portion of the stomach from below the band pushes its way up through the band opening. This is a potentially more serious problem, because the portion of the stomach that is herniated through the band can have its blood supply choked off. That causes rather severe pain and if left untreated can even result in the death of that portion of the stomach, with catastrophic results.
The management of suspected gastric herniation includes first removal of all fluid from the band to minimize the tightness around the herniated part of the stomach. An upper GI X-ray is used to document the problem, but occasionally the barium contrast never makes it up into the herniated part of the stomach, so it may not show up on the X-ray. An endoscopy can be performed to look inside the stomach, but it may or may not provide additional information. Ultimately, if a gastric herniation is confirmed, or even strongly suspected, the patient will need to have a laparoscopic operation to fix the problem.
The actual operative management of either a slipped band or gastric herniation is dictated to some degree by what the surgeon finds at the time of surgery. In both cases the options may include resuturing the stomach over the band, repositioning the band, or totally removing the band and potentially performing a totally different bariatric procedure. If the band is simply removed, without any restriction the patient is very likely to regain most, if not all, of their weight back.
Virginia's Story
(Left) Virginia, pre-op, 242 pounds.
(Right) Virginia, two years post-op, 154 pounds.
Like most people, I tried all the diets. I weighed 242 pounds at 5 feet, 1 inch. I carried most of my weight from the waist down, but my face was puffy and my arms were big. I finally came to the conclusion that there was nothing left to try but surgery. I had a heart condition, Type 2 diabetes, my joints hurt, and I'd had breast cancer. In fact, I had a couple of other serious problems that had to be treated surgically, and I think they were all related to obesity, including the cancer.
In October of 2003, I got a band with Dr. Sewell. He'd done my mastectomy to treat the breast cancer, so when I started looking into the band and heard he was doing it, I didn't hesitate. Now, two years out, I've lost 88 pounds and weigh 154. The least I've ever weighed was 149.
I stopped taking my diabetes medication soon after the band surgery, and now I'm in remission. I also used to wheeze all the time, like I had asthma. My lung doctor said the breathing problems were due to my heart, which was weak due to chemotherapy. But, again, shortly after the band surgery, the wheezing stopped. To tell you the truth, I didn't expect to have the kind of results I had.
In the first six months, I lost 70 pounds. And it was very effortless. I found the more weight I lost, the more motivated I got. I was losing so fast, mentally I was feeling better and better. Exercise is extremely important even if it's not vigorous. I have walked from the beginning, every other day for a little over a mile. There's a high when you're first losing. But as the weight loss tapered off, little by little, I became more complacent. I forgot I was a fat person, and now I think of myself as a normal person.
I noticed I wasn't hungry at all for seven months after I got the band. Then I had kidney problems, and one had to be removed. The kidney surgeon said he had a hard time working around the port when he was trying to remove my kidney. But after I had my kidney out, I had a tremendous appetite. So I got another fill, and I think it was too tight.
I knew something was wrong when I had so much indigestion. I thought I had ulcers. I suffered all through the summer, slept sitting up, and finally came in for an X-ray, and it showed the band was slipped. Dr. Sewell put less fill in my band, and that's been better. I'm going to have to get the slip taken care of, and I'm scheduled for Dr. Sewell to go back in to reposition the band. I just haven't done it yet.
Anyway, I am sure I brought this on myself. I overate, then had too much retching. I know if the band is too tight or if I'm overeating, the throwing up can cause the band to slip.
For me, I know I have a disease that I have to manage the rest of my life. I can't say I'm not going to have diabetes tomorrow. That doesn't work. Even if it's in remission, like mine is now, I have to be aware and monitor my condition. It's that way with obesity, too.
I have a tendency to get discouraged until I look back at what I looked like before. I feel pretty good when I see those pictures. But after the kidney surgery when my band slipped, I gained a few pounds and I got really frustrated with myself. I started thinking deja vu, here we go again, just like in the old diet days. But this is different. I've put on a few pounds, but I haven't gained all of it back plus 20 pounds, the way I used to. I'd like to be 125 to 135 pounds, but the reality is I'm going to learn to live with the 150s. And when I look at the old pictures, I'm happy with that.
Options If the Band Slips
While the problem of a "slipped band" can be managed successfully by repositioning and resuturing the same band, there is certainly some risk of having the same problem reoccur later on. Many surgeons ascribe to the old adage "Once burned, twice shy!" and recommend converting patients with slipped or herniated bands to a gastric bypass. Certainly this option should be discussed with the patient prior to any reoperation.
Another option that has shown merit in these cases is the removal of the band combined with a gastric sleeve resection. Unlike the gastric bypass, the gastric sleeve avoids the need to rearrange the small intestine. It is also solely a restrictive procedure much like the AGB, but without the band. However, a large portion of the stomach is removed under the theory that it produces hormones that lead the patient to feelings of hunger, so decreasing the stomach's overall size is likely to aid the patient in losing weight. This surgery avoids malabsorption problems because the digestive system is left intact.
One downside of the sleeve is that it can become stretched over time, leading to the ability to eat larger volumes again. Once it becomes stretched it cannot be adjusted or tightened like the band. Some patients relate that once they have had a problem with the band, they are less confident having a foreign object in their body, and the gastric sleeve provides a good alternative. The important thing to remember is there is no such thing as a perfect bariatric operation. No procedure comes with a guarantee. Any operation can fail, especially if the patient is unwilling to make the changes required in the way they eat.
Band Erosion
Perhaps the most serious complication related directly to the band is erosion. Over time the pressure of the band on the stomach wall can literally wear a hole in the wall of the stomach, allowing the stomach contents to leak out. If an ulcer develops in the lining of the stomach next to the band, it could potentially penetrate all the way through the wall of the stomach, creating a connection between the inside of the stomach and the band.
Generally band erosions occur months or even years after the band surgery and considerable scar tissue has already developed, which contains the stomach fluid to that area immediately around the band. However, the fluid is contaminated with bacteria, which cause an infection around the band. Patients with erosions usually complain of symptoms of fever, back pain, and even difficulty eating. But some patients have few if any symptoms from the erosion of their band, and may be totally unaware of the problem. Eventually the infection will make its way along the band tubing, and the patient will experience pain, redness, and swelling around their port. This is a "red flag" that strongly suggests an erosion has occurred.
An upper GI X-ray or an endoscopic examination will usually confirm the presence of an eroded band. If the band has truly eroded, there is no option except to remove the band. No matter how many antibiotics are administered, the infection will not resolve until the foreign object has been removed. It is not usually an option simply to repair the erosion and place another band. That is asking for trouble. It may be reasonable to perform either a gastric bypass or a gastric sleeve at the same time, depending on how inflamed the stomach is and whether the surgeon feels it is safe to perform any additional procedure.
Checklist: Signs/Symptoms to Watch For and Notify Your Surgeon About
✓ Swelling, pain, or redness in one or both legs
✓ Chest pain or shortness of breath
✓ Inability to keep down fluids
✓ Persistent heartburn
✓ Persistent vomiting or retching
✓ Pain, redness, or swelling at the injection port site
The exact reason why erosions occur is not known. Some surgeons have speculated that it is related to operative trauma to the outermost layer of stomach wall that occurred during surgery. Others suggest that it could be the result of ulcerations in the stomach lining at the site of the band caused by the pressure of the band or even anti-inflammatory medications that are known to cause ulcers. Either way, the risk of erosion is something that every potential AGB patient needs to be aware of. Fortunately, they occur in less than 1 percent of AGB patients.
Tracey's Story
I decided quickly, in just six days, to get a band back in 2003. It had to be removed a year ago, but I'm working on getting another band as soon as I can. Here's what happened.
I started at 357 pounds and I'm 5 feet, 1 inch tall, so my BMI was 67.5. I checked into the bypass, and at the time my insurance wouldn't cover it or a band. Since the band is so much less than a bypass, and it was even cheaper in Mexico, I decided to go down to Tijuana and get it done.
The first year I lost 96 pounds. Then my weight loss slowed way down.
First off I will say that my decision was very quick and I was not well informed. The worst thing for me was I did not have a local band doctor. I went back to Tijuana for my first fill, but I didn't keep up with the band in terms of getting regular fills, so I didn't continue to lose weight. I did finally find two band doctors in Oregon, where I live, who would do fills. But I didn't like one of them because I felt he wasn't very friendly and he was impatient, so I went with the other doctor.
I was going to get another fill, but then I found out I was pregnant. This was my fourth child and my fourth C-section. My obstetrician said he'd like me to have the fluid taken out of the band during the pregnancy, but I said as long as the baby is growing and isn't in any distress, I couldn't see any reason to remove the fluid. So we left the fill I had, and my baby is fine. And the C-section went without a hitch, too. The problems came afterward.
Two weeks after my C-section, in April 2005, my port got hot and swollen. On top of that, the band doc I was seeing left his practice. So I went to my primary care physician. She lanced the port area and drained the fluid built up there. The port site never healed. Looking back, I probably should have gone earlier to the other band doctor, the one I didn't like. But I waited and worked with my primary care physician.
From May 2005 to nearly December of 2005, I made regular visits to my primary care physician about the port site and took antibiotics. I wasn't in pain. I didn't have a fever. And I didn't notice any problems eating, like being able to eat less or being able to eat more. The port site stayed warm to the touch and a little swollen. I talked to my insurance about covering the replacement of the port. They said they would cover taking the port out to clean the infected area, but they wouldn't pay for a new port or to put it in.
Finally, in November, my primary care physician said that in her opinion there was something wrong with the port and I should find a band doctor. I felt my only choice was to go to that band doctor I didn't like. He was much friendlier the second time I saw him. Turns out the first time, he was having a really bad day.
He did an endoscopy and found the band had eroded through 60 percent of my esophagus. In other words, I had a band erosion. The only thing he could do was take out the band. Since it was life threatening, the insurance covered the removal surgery. It took from January to May for the port site to finally heal.
The scary thing about this for me is I didn't have a bunch of symptoms that indicated to me something more was wrong, other than what seemed to me to be a minor infection at my port site. I've met other band patients since, and within three or four months there were five of us that erodedand we all had bands placed within a few months of each other. For me it had been two years, and I was fine until I had my C-section. Had I not gotten pregnant, I don't think I'd have had a problem, but I don't really know. The most fluid I had in my band was 1.5ccs in a 4cc band.
I've been without the band for a year. I had lost down to 248 before I had the erosion. I now weigh between 268 and 270. I'm hoping to get another band soon.
I wouldn't go back to Mexico. Prices in the U.S. for a band have come down to close to what it costs to go to Mexico anyway, when I include travel costs. Since I'm a self-pay patient, I cannot afford a gastric bypass. That is many times what a band costs.
I have an appointment to see about putting another band on. The concern now is that there could be too much scar tissue.
I will say I learned by having the band. I think a good psychologist could probably help me as well. I work at home, so I have access to food 24/7, and without the band I'm hungry all the time. With the band I wasn't hungry. I had moments when I wished I'd never got it. But now that I don't have the band, I wish I had it back. My hope is I'll be able to get another one, even though it will be funded out of my pocket again this second time around.
Band Intolerance
On numerous occasions I have had patients ask, "Can I have the band removed after I lose all my excess weight?" The answer is, "Only if you want to gain it back." For this reason virtually all patients have the AGB for life. Over time they learn to eat differently and don't really pay much attention to the band. In fact, most patients fear ever being without their band.
However, very rarely a patient will find they just can't tolerate the band. Despite having gone through the exhaustive assessments and counseling before surgery, once the band is in place they simply cannot tolerate the feeling of restriction. My approach to these patients is to work closely with them to achieve eating behavior changes before giving up on the band. More often than not the problem can be resolved. But when the patient becomes insistent, the solution may be removal of the band. While this is not truly a complication, it does represent a failure, and is obviously something we try to avoid through a careful pre-op selection process.
Handling a Crisis
G. Dick Miller, Psychologist
You feel you are in crisis. Something happens. You didn't expect it. You may feel fear or discomfort. Now is the time to use your new skills for rational thinking.
First question to ask yourself: Is it really a crisis? Another way to ask this question is: How big a problem is it? Do I have a chicken bone stuck in my throat? Or am I embarrassed because I'm getting up for the third time to go to the bathroom when I'm out at lunch with business colleagues? Which is a crisis? I can also ask myself, Would I call 911 for this? Or is it just inconvenient? If it's really a crisis, then it would be in my best interest to call in professional help quickly.
Some of us were raised or trained to "awfulize," "horriblize" and "cata- strophize" things that go wrong in our lives. While it's understandable if we were raised that way, it doesn't help. We can't solve one crisis after another. If we elevate the inconvenient things in our lives into crisis after crisis, we simply wear ourselves out.
So if it's not a crisis, then it'll help my thinking and my well-being not to turn it into a catastrophe. I can call it what it is and then I can deal with it. By calling it what it is, I can decide what category it falls into. Here are five categories that problems can fall into: physical, social, emotional, financial, and spiritual.
Most people easily recognize the first four of these five categories. For example, going to the bathroom three times at a lunch is a physical problem and can also be categorized as a social problem. What I'm calling spiritual problems are those affecting my spirit or my core. I had a man in my band support group who didn't feel restriction with his band. In the beginning, he was upbeat and enthusiastic about his possibilities anyway. But as time went on, he got fills but felt no restriction. He saw other band patients lose weight when he didn't. And he got discouraged.
He started to identify with members of the group who had negative things to say about the band and what they couldn't eat. He started missing support group and then pretty soon stopped coming altogether. His problem was a spiritual one. He dropped out as his spirit, his motivation, and his belief in himself suffered. While spiritual problems tend to be underrated or even ignored, they are real problems.
Once you've defined which categories the problem fits into, that is the time to seek help. And the best place to find help for these problems is in your band support group. So many people try to solve problems on their own instead of taking the categorized problem to a group of people who can understand their situation and provide insight. There's no reason to go it alone, and it's usually not very successful.
In our example of leaving the table during a business lunch multiple times to go to the bathroom and throw up, a support group might suggest that you order something that goes down easily if you're going to talk, such as a bowl of soup. Or ask you to look at your bite sizes. Or you may find your band is too tight or too loose and you need an adjustment. (If the band is too loose, you can eat bigger bites sometimes but probably haven't learned to take small bites consistently.)
If you're not in a band support group, find one. You'll find the help and comfort you receive there will take you through a lot of problems before you're tempted to call them a crisis. And it'll help your spirit.
Checklist: Steps for Handling a Crisis
✓ Look at your thinking.
✓ Is it really a crisis? (Would I call 911?) Or have I awfulized, horriblized, and catastrophized it?
✓ If it's a crisis, call the appropriate professional for help.
✓ If it's not a crisis, what category does it fall into: physical, social, emotional, financial, or spiritual? (Problems can fit into more than one category.)
✓ Now that you have your problem defined, seek help. Band support groups are a great place for this.
Poor Weight-loss Results
So what about those patients who simply fail to lose weight? These are not complications; they are simply patients who haven't achieved expectations. The issue of expectations is one that deserves some discussion here. From the surgeon's perspective, a good result is usually measured by improvement in obesity-related health problems. From a statistical standpoint most studies suggest that a good result is defined as the patient losing at least half of their excess body weight. But from the patient's perspective, a good result can be defined as almost anything. I have had patients who are excited just to have lost 20 pounds and kept it off for six months. Others who have lost 100 pounds or more still feel as though they have failed because they have 20 more to go to reach their initial goal.
As the famous saying goes, "Beauty is in the eye of the beholder." Results are determined by perspective. I learned some time back not to argue with a patient who seems satisfied with their results. However, there are many patients who are less than satisfied with their results. The reasons for dissatisfaction and poor results range from "I'm not losing fast enough" to "I expected to lose more" to "I thought it would be easier than this," or, my favorite, "No one told me I couldn't eat the things I like."
The most unfortunate thing that usually happens when patients perceive poor results is the return of feelings of self-doubt and poor self-image. Often these patients stop coming in for follow-up because they sense that their situation is hopeless. At the very time when they need help the most, they may give up on the program and sometimes on themselves.
I have had patients who stopped coming to see the dietitian, support group meetings, and our behavior modification programs for six months or a year at a time. When they finally come back to give it another try, it is amazing to see that their weight is almost exactly what it was the last time they were in the office. In other words, whatever weight they had lost previously had remained off. Once they get back into the program they typically start losing again, provided they have committed to changing their lifestyle.
For some patients the AGB just doesn't seem to work. I had one 340-pound man who had his band for about two years and lost a total of only 20 pounds. His excuse was that he was too busy. He didn't have time to exercise. He didn't have time to come in for adjustments or dietary counseling. He certainly didn't have time for a support group of behavior modification sessions. In other words, he didn't have time to be successful. Eventually he went to another surgeon who removed the band and performed a gastric bypass. The last I heard he was losing weight as expected with the bypass, which is great. I can only hope that he will find a way to alter his lifestyle to ensure he keeps the weight off.
In the next chapter we will look at those critical lifestyle changes and the common hurdles and adjustments band patients face on their journey.