Weight Loss Surgery with the Adjustable Gastric Band

Introduction
How We Got Here

Robert W. Sewell, M.D.’s Story: Master® Laparoscopic Surgeon

I have to admit, I didn’t exactly embrace “the band” when I first heard about it. It sounded like just another gimmick procedure, and I had a legitimate surgical practice and a decent reputation I’d spent 23 years building.

To provide some context for my involvement in the adjustable gastric band (AGB) phenomenon, it is important to understand that as a general surgeon, I spend most of my time operating within the abdomen. As you might imagine, performing abdominal operations on an extremely obese patient is much more difficult than operating on a thin patient. Dealing with the unyielding nature of fat stored in and around the abdomen often made me feel as if I’d done an hour or more of isometric exercises. For that reason, and for many years, I would say to anyone who would listen, “I hate fat!” At the same time I was always quick to add that, if I had the medical “Midas touch” to cure one disease, it would not be heart disease, diabetes, or even cancer; it would be obesity. My rationale was that if obesity were eliminated, many of those other illnesses would become far less common and easier to treat. Besides, my job as a surgeon would be easier.

In December of 1989, I witnessed my first laparoscopic gallbladder operation, and my perspective on abdominal surgery changed forever. It became clear to me that virtually any surgical operation could be done using a laparo-scopic approach, which makes use of a small camera to look into the cavity, allowing intra-abdominal procedures to be performed without the need for large incisions. Since that day I have vigorously pursued these minimally invasive techniques, and today my entire practice is limited to such procedures.

While the benefits of the minimally invasive approach for the patient were obvious, a side benefit for me also became apparent. Carbon dioxide gas used to inflate the abdomen during laparoscopic surgery holds the abdominal wall up, and does it without physical effort from me or my assistants. All of a sudden operating on obese patients was more or less the same as operating on anybody else—no more “fighting the fat” just to get access to the inside of the abdomen.

Over the past 15 years, laparoscopic surgery has provided me with countless opportunities to be involved in a truly revolutionary process that is changing the entire field of general surgery. I have not only performed these new procedures but have been actively involved in training many of my colleagues in these innovative techniques. I’ve had the privilege of lecturing on this topic and supervising various laboratory sessions around the world. My motto was, If it’s new ground-breaking technology, I want to be involved, both in performing and teaching the procedures—except for bariatric surgery.

The surgical treatment of obesity was a very sore subject in most surgical circles during the 1970s, when I was in training. The procedures I was aware of were fraught with serious complications and were considered fringe medicine by the vast majority of surgeons. I avoided surgical treatment for obesity like the plague. Actually, I was taught very little about obesity, except that it was more a personal lifestyle choice than an actual illness. I was taught to believe that obese people needed a psychiatrist, not a surgeon. So when I was approached about doing laparoscopic gastric bypass in the mid-1990s, I replied without hesitation, “No way. I am not getting involved in that.”

In 2000, when I was first approached about the laparoscopic adjustable gastric band, I didn’t exactly embrace it, either. It sounded like just another weight-loss gimmick, designed to take advantage of people desperately seeking a surgical solution to a psychological problem. I had a legitimate surgical practice and a good reputation, and I didn’t want to jeopardize any of it by doing a procedure sure to be labeled as illegitimate by my peers. That all changed when I was approached by an oral surgeon colleague about advising a close personal friend of his. He told me that David, a prominent local businessman, wanted the band procedure and was looking for an experienced laparoscopic surgeon. I agreed to talk to David by phone and was actually planning to talk him out of the foolish idea.

During our discussion, David made a very compelling argument for getting a band. He had been overweight his entire adult life and had tried every diet I had ever heard of and several others I wasn’t familiar with. I finally conceded he might be a candidate for the band, but then I told him that I didn’t do the oper-xii ation; however, a close friend and colleague of mine in Miami was doing the band operation. Needless to say, David was eager to make the contact.

By this time, my interest had been piqued. I realized that I didn’t really know enough about the procedure to offer David any sound advice. I knew the band requires frequent follow-up visits and adjustments. And I was worried about the fact that, after surgery, David would be half a continent away from his surgeon. So I told David I was willing to provide his follow-up visits and his adjustments myself. I suggested that I’d be willing to go with him to Miami to watch his surgery in preparation for the follow-up work. It would also give me a chance to catch up with my friend, and get his insights on the band. It would also give me a chance to see for myself exactly how the procedure was done, so I could speak more intelligently about it in the future.

David made a quick trip to Miami to meet the surgeon, and he took his college- age daughter along. As it turned out, they were both candidates for the procedure, and both were scheduled to have the band operation less than a month later. When the time came for the trip to Miami, I was shocked to find that David had made arrangements for me and my nurse to fly from Dallas to Miami at his expense. First class, no less!

Both surgeries were performed the same day and were completed uneventfully. My colleague in Miami was very enthusiastic about the band. He and his partners had been part of the FDA trials during the previous two years, and they had done about 200 bands with very few complications and promising results. But, he admitted to me, he was doing far more gastric bypass operations, simply because insurance was not covering the band. I found that interesting, but not surprising.

When I saw David and his daughter back in my office about a week after their operations, they were both feeling well and offered no complaints. In fact they could barely contain their enthusiasm, based on the fact that they were already losing weight. After several adjustments and witnessing the clear evidence that the band was working for both father and daughter, I decided to get the required training to do the band myself. All of a sudden I became directly involved in exactly the type of practice I had vowed never to pursue. However, after seeing the excitement of those two people and remembering my career-long wish for the “Midas touch,” I was convinced this was the right choice.

Through the training process and discussions with other surgeons, it was very clear that there was far more to an adjustable gastric band practice than just doing the surgery. Since that time, my practice has undergone a significant change. I still do all the same laparoscopic operations I did before, but about half of my patients now are adjustable gastric band patients. But the biggest change in my practice has been the development of a comprehensive weight management program in support of the band procedure.

Suffice it to say, caring for band patients has required a major reorganization in my approach to the practice of surgery. Traditionally, surgeons are more or less like firefighters—we’re called in at times of crisis to extinguish a problem and then return to the firehouse. Except in very complicated cases, patients don’t usually follow up with their surgeon more than a few times before being sent back to their primary doctor. As a result, most surgeons (and most patients) have a “fix-it and move on” attitude. That just doesn’t apply to obesity or the adjustable gastric band.

Obesity is a chronic disease, and treatment with the band requires regular monitoring, periodic adjustments, and nearly continuous patient support in order to be successful. To accomplish this required me to make major modifications in my schedule, office personnel, and, most important, my practice philosophy. But, I have to say the results have greatly exceeded my expectations. Seeing the excitement in the eyes of patients who are finally achieving successful weight loss is far more rewarding than I ever imagined. As a result I undertook the task of writing this book along with one of my patients, who is a professional writer, in an effort to help shed some light on the problem of obesity and how the laparoscopic adjustable gastric band can be used to treat it successfully.

In the words of Hippocrates, “Extreme remedies are very appropriate for extreme diseases.”

Linda Rohrbough’s Story AGB Patient and Award-Winning Author

When Dr. Sewell told me, “It’s not your fault,” I didn’t believe him. Not because I didn’t want to. I did. But lots of stuff went through my mind, and most of it had to do with my past failures and what I’d been programmed to believe.

I was not overweight until I got married. I remember when I was 16, I worked with a middle-aged, new mother on a church project. Every time I saw her, she just kept getting bigger and bigger. I thought with disgust, “Why can’t she just stop eating?”

Two years later, several events occurred in my life. I was in a horseback riding accident and suffered a skull fracture that put me in the hospital for a week. Then I went through my high school graduation ceremony. And I got married two days later (an event my beloved and I had planned for four years—we met when I was 14 and he was 15). I started gaining weight in the hospital and barely fit into the wedding dress I’d bought months earlier. (And I’d tried that dress on every week except the one when I was in the hospital.)

After the wedding, my husband and I starved, literally. But we were too proud to let anyone know how much we struggled financially. I thought it was an aftereffect from the horseback riding accident that I didn’t feel well enough to hang on to the job I had doing credit card processing on the swing shift; so I turned in my notice. My husband was working 14-hour days doing roofing. We were both miserable. To say I got plump would be an understatement.

I went to my family doctor. He asked me what I had for breakfast. When I said a piece of cake, he glared, got his nurse, and asked her to give me a diet plan—loudly enough for everyone in the waiting room to hear. I was so humiliated I didn’t know what to say. But I stopped talking about it.

I was hungry all the time. I sat in our apartment in a bathrobe with the curtains drawn and cried. After a while, I got sick of that and decided to get a job. I remember walking into K-Mart; nothing fit but a size 18, when I used to wear a size 12. I sobbed uncontrollably in the dressing room for about 30 minutes, then went out and made my purchase.

I talked a local fabric store manager into hiring me and made model garments to have clothes to wear. I tried fasting and exercise, separately and in combination. I rode a bike. I worked two jobs at one point. Nothing helped.

I turned up pregnant a year later. Now that we were getting another life involved, my spouse and I packed what we could into our ’66 Chevy II and went off to Kansas State University. We picked Kansas because out-of-state tuition there was cheaper than in-state tuition in Colorado.

It was at K-State that I found a diet program called “Stucky Points for Weight Control.” With the help of the university dietitian, I lost 75 pounds in eight months. I was going to be their poster child. But I couldn’t maintain. I ballooned up again, only the result was that I weighed more in a year and a half than before I’d started the diet. Even though my grade point average was 3.9, I felt like a failure.

And that was the story. Diet, weigh more, diet, weigh more. I experienced failure after failure, which only made the situation worse. I did not have the courage to talk to a doctor again for help. I watched people who did Weight Watchers® and Jenny Craig® lose weight then gain it back—plus, I couldn’t afford a program like that. So I learned to shop the sales at Lane Bryant. A friend in college who was also overweight and I had a running joke about our “uniform.” We each had two pairs of pants and two blouses and one pair of shoes that fit. We did a load of laundry every day so our “uniform” would be clean for the next day.

I remember the day a doctor said I was morbidly obese. I sensed the heat climbing my cheeks, and I found the floor tile pattern extremely interesting. I was careful not to let anyone see how upset I felt.

When my husband graduated college, we moved to Amarillo, Texas, and life was even more miserable for me. I went to college again, on grants and scholarships I’d earned, had two kids now, and was bigger than ever before. I noticed people I hardly knew would find a need to tell me how to lose weight, assuming I didn’t know I had a problem. I had trouble fitting into booths in restaurants, struggled with seat belts, and was tired all the time.

I started writing about computers when my husband got a job in Los Angeles. Computer user groups asked me to write “how-to” articles about things I’d learned for their newsletters, and soon I was writing articles for national computer magazines. Before long I was working for an international computer news network.

It was in LA that I found the worst weight prejudice I’ve ever experienced. People, especially men, would yell obscenities at me about my weight when I was out walking. I still walked, but I felt a lot of fear. And I stopped trying to lose weight. I made the decision that I needed to accept the way I was—since I felt there wasn’t anything I could do.

And I decided to enjoy food. As I got more successful writing, I worked on skills to help people look past my weight. I learned to make jokes, like “Fat people are jolly.” On an airplane, I’d ask the stewardess for a seat belt extender and add, “And can you bring it so everyone can see you do it?” Airplanes were especially bad. The people who work for the airlines would often sigh and roll their eyes when they saw me coming. I figured it was because I weighed as much as two people and I was only paying for one. Often another passenger, whoever got stuck sitting next to me, was going to suffer as well. I’d drolly say to the wide-eyed, fear-filled face of the other passenger, as I shoe-horned myself into the seat, “Lucky you, getting to sit next to me.” They’d usually chuckle.

I had a doctor tell me during a routine medical exam, “You know, you’re extremely overweight.”

I put my hands on my cheeks. “Oh no! What am I going to tell my family? What will my friends think?” The doctor just shook her head and left the room.

I had a friend say at least I kept myself clean. Another friend asked how I put up with the invasive things people said to me about my weight. I told her I was learning to accept myself.

At one point, I memorized all the Bible verses about obesity, thinking that might help. But they seemed contradictory. “The righteous will be made fat.” And from Proverbs, “The drunkard and the glutton will come to poverty and drowsiness will clothe a man with rags.”

When I started writing books, I became even more successful. I won three national awards for my writing. I thought my success might help my self-esteem, which in turn would help me lose weight. That didn’t happen.

At the peak of my computer book writing, in 1998, I was in a car accident and suffered a broken back. I only thought I had been in pain before then. In the hospital, I was fitted with a body brace that the technician turned upside down because he said it wouldn’t fit me right side up. I needed a heavy-duty wheelchair, and an oversized recliner became my bed. I was heavily medicated for a long time, learning to deal with constant agony. Over a period of two years I retrained myself to walk using a treadmill.

I heard the same thing over and over from the medical advisors I consulted during the course of my treatment: “This would be a lot easier if you could lose weight.” I didn’t say much, but I’d think, “It would be a lot easier if I could fly, too.” But I realized I needed to do something, so I started attending programs and seminars to teach me how to improve my self-esteem.

It wasn’t too long after I could get around again that I met someone from Overeaters Anonymous who’d lost more than 100 pounds. So I started going to OA meetings. I listened and envied the bulimics and the ones who’d figured out how to conquer their bodies. At this time we lived in Dallas, and my husband had excellent medical insurance. My beloved is overweight, too, but I was bigger; he told me he was struggling with embarrassment over my appearance.

On a routine visit to my doctor for a checkup, the nurse weighing me took the scale to the max, where it clunked. It only went to 350 pounds. She shrugged and said, “Oh well,” before she led me off to a treatment room. I knew that meant I wasn’t close to 350. I was probably a good deal over.

I took a risk and talked to the doctor about my weight. He said I needed a lifestyle change. I told him I was walking, and he said, “People who are practically dead can walk. Just visit an old folk’s home and watch them roam up and down the halls.” He told me to drink more water, suggesting that I work my way up to 100 ounces a day.

The lifestyle change idea stuck in my head. I started watching thin people and noticed that many of them carried a bottle of water. Over a period of two years, I dropped soft drinks and worked up to drinking 100 ounces of water a day. And during that time, I got down to 335 pounds. Clearly, this wasn’t anything to write home about. While the scale was going in a better direction, it wasn’t enough.

I started checking into weight loss surgery. My husband’s office moved, and so we relocated to the other side of DFW, north of Ft. Worth. I looked for a new doctor. By this time I was on medication for high blood pressure. I was also taking a number of vitamin supplements I’d discovered through research or friends, with the goal of feeling better. I found a new doctor, and she became very proactive in my care. She put me in touch with a physical therapist who started helping me deal with the pain in my back and knees. He prescribed or-thotics for my shoes, along with exercises. He treated me about three days a week to help me beat the pain, and it was working.

As we became friends, I confided I’d given up on losing weight. He told me about some surgical options, some of which I’d already checked out. But he knew about a new product, the adjustable gastric band. He explained to me how it worked and told me he’d worked with gastric bypass patients and AGB, or “band,” patients. Of the two, he said the band people didn’t seem to have problems, and they kept the weight off. I told him that surgery scared me. I don’t think I’ll ever forget what he said. He was on a stool, working on my leg, and he stopped, placed his hand on my knee, looked me in the eye, and said, “Linda, if I were in your position, I’d do it.”