January 2 , 2004

<**MODERATOR**> HELLO DR. SIMPSON AND WELCOME!

<Dr. Simpson> Hello. Ok I am ready, willing, able, and here I am.

<kathleen g.> Dr. Simpson: Happy New Year. You are my favorite Friday night date. Welcome back... I have read that we can survive on water and vitamins for six months. If this is true, would a prolonged period of clear liquids avoid the chance of developing strictures? Thank you.

<Dr. Simpson> It would not avoid developing strictures at all -- in fact, probably an earlier use of solid foods would avoid strictures, as solids help keep things dilated. However, that is all a lot of speculation -- and if I am your favorite Friday night....then you have great taste.

<Sherry> I just had my initial surgical consultation and I am having an open RNY with 75 cm bypassed. My stats are 5' 6" and 297# Both the doctor and I agree my goal weight should be 150#. With only 75 cm bypassed, won't this make me a "slow loser"?

<Dr. Simpson> Well, I don't know what you mean a slow loser? Does that mean you intend to eat candy, cake, ice cream...Not start a walking program, not measure your food...It is the RESTRICTION-- not the amount bypassed that is the critical factor in weight loss. Therefore, don't focus on what is bypassed, instead it is the restriction...But if you want to be a slow loser, I have a lot of things that can help you lose weight slower, such as skipping meals, eating at fast food restaurants, having meals of low glycemic index carbohydrates. I have a lot of ways to lose weight slowly. Or you can just go for it and get it off quickly.

<kathleen g.> Dr. Simpson: How can we avoid ulcers post-op? Thanks a lot.

<Dr. Simpson> Ulcers from the jejunal gastricanastomosis occur when there is a bit of ischemia at the site, such as when the blood supply isn't that good, and there is nothing you can do about that. Otherwise, to avoid ulcers for the rest of the stomach-- don't kiss someone who has the bug-- helicobactor pylori ---so if you have a new boyfriend or girlfriend (who am I to judge) then I suggest you have them tested first---Here honey -- spit in this bag. Good luck.

<Stevie H> Would you perform surgery on a 23 year old female with a BMI of 39.9 and No Co-Morbidities?

<Dr. Simpson> The patient has obesity, and does fit the criteria because we round up when we qualify people. If it is good enough for the IRS it is good enough for me.

<Janet> It seems that we are hearing about more complications and deaths from the surgery in recent weeks. What do you attribute that to? Is the surgery becoming more risky because inexperienced doctors are now doing the surgery? Or is it because more procedures are being performed?

<Dr. Simpson> It isn't inexperience of physicians that relates to death of patients-- but certainly there are more people who are having the surgery. Three years ago there were 20,000 surgeries performed, last year over 100,000 surgeries performed....and the press is better -- plus there are a few other things, such as the reimbursement to hospitals has decreased, so they are quick to pull out of the programs because if they are not getting good reimbursement then any excuse. Deaths happen and they will continue to happen. And there will be more press, good and bad.

<Jackie_10 wks postop> Dr. Simpson, I'm 10 weeks post op and I've lost 42 pounds (I'm a revision from Dr. Molina banding). My dietician says I should be eating no more than 200 calories per day. I think this is crazy and I can't live off of that. Both she and my doctor say that my weight loss is too slow. What is your opinion?

<Dr. Simpson> You can live off that if you have some weight to lose, if you don't have weight to lose then you cannot live off that. But setting a calorie limit is not helpful. Instead, I think they should provide you with some menu plans and recipes, things that you can use--which means you will have to buy my book when it comes out.

<FreeBird> I am about eight months post op. Started hair loss around 4 months and it continues. My surgeon told me to all some zinc to my diet, but didn't tell me how much and I forgot to ask. So how much should I add and do you have any other suggestions?

<Dr. Simpson> Superglue, unless you have a zinc deficiency, which you can see in the laboratory values. It is silly to add something. The work up of hair loss is something that you do with the laboratory values to see how a person is doing. It is not something you throw the sink at, and hope that one of the proteins, vitamins, minerals will make it come back. But it will come back richer and fuller than before--- just avoid a few things, like hair club for men. Avoid perms hair colors and other toxic waste things that people put in their hair. Good luck.

<kathleen g.> Dr. Simpson: My surgeon has indicated that he keeps his patients in the hospital at least 4 days post-op to fully observe any immediate complications. On the MO boards I have read that some surgeons send their patients home the day after surgery. Why is there such a discrepancy? Is it safe to go home so early? Thanks.

<Dr. Simpson> Everyone has a different style, and it depends on the surgery that you are having, as well as the things that happen during surgery. Keeping someone in four days is still fairly conservative. For lap band, most of us send them home the next day. For DS it takes four days. And RNY is up in the air depending on how you feel about it.

<Connie Farmer> Please compare risk factors and long term success rates for someone who is 400+ pounds compared to someone who is 100 pounds overweight.

<Dr. Simpson> The risk factors are increased risk of leaks, pulmonary embolism, and increased risk of all factors with those who are 400 pounds overweight. In terms of the 100 pounds overweight, same risks but less. Success depends on the patient and a bit of the surgery. At 100 pounds overweight you need a bit of help, not a lot-- and with some work you can succeed with almost any surgery. With the 400 pounds overweight there is a lot more needed, and probably you will also need a distal bypass surgery, such as a duodenal switch. But anything can happen to anybody, and anyone can do well or poorly.

<Annie> Hi..I had a VBG in 1993 with only temporary good result, I have a big incisional hernia as a rsult and must have it repaired...I am having a RNY done at the time of the hernia repair...any adaptation complications likely?

<Dr. Simpson> Probably not, but it sounds like you will need that and that you will do a good job once it gets done.

<kathleen g.> Dr. Simpson: I want to be prepared to come home to a fully stocked shelf of post-op necessities. I have heard that taste and likes change so dramatically post-op, that many people have wasted big $$ by having to throw out much of the food, supplements and protein items they stocked up on. Some go so far as to think that their taste buds have been surgically altered as well. Thanks.

<Dr. Simpson> Yes, we surgically alter the taste buds during surgery. We make it so that you won't like the taste of not paying your surgeon,...I think that protein supplements and bars and such taste like sawdust and don't think that one should get those before surgery because they may not be needed, and that if you do need them, then see how you like them after surgery and what you like after surgery, everyone likes different things. In terms of stocking the shelves--bottled water, crystal light-- get rid of a lot of the bad stuff, get some shrimp, and be certain to have a few other things ready for the post op.

<Natasha> I do noy have the type of insurance that will pay for the proceedure, and I am wondering what the costs will be if I have to pay for it out of pocket?

<Dr. Simpson> It depends on where you go. For example: in our city the price ranges from around 14,000 for a lap band to 20,000 for a duodenal switch and some charge more for that. It all depends. Those prices are all inclusive. Some are less, and some are more. But it is a great investment.

<kathleen g.> Dr. Simpson: Because I have had joint replacement, does that indicate mega dosing antibiotics immediately prior to WLS? Thank you.

<Dr. Simpson> Nope, no antibiotics are needed for the joint, although we use antibiotics for the wls anyway. I would get some WD 40 to lubricate them post op so you can walk a lot, though.

<Sue> What can be done for the post-op patient who has chronic diarrhea?

<Dr. Simpson> You have to work up the diarrhea and find out why they have it. There are a number of reasons to have diarrhea, and those include infection, or sometimes ... it includes dumping, or undigested fats. So diarrhea needs to be worked up to determine its cause, and then it can be worked with from there. Cork works well.

<Phatlexuspreop 55> Happy New Year Dr.! I have still not gotten by gallbladder out yet. how long can a person go with with gallstone. Is it life threatening

<Dr. Simpson> Many people carry around gallstones for years without a problem, and they only thing is you hear them rattling as they walk.

<Joel> I notice RNY post-op diet is stricter than most - liquids for a long time. Makes me wonder if my surgeon's postop diet is too liberal. What are your thoughts?

<Dr. Simpson> I think all of us have different ideas for surgery and post op diets, and they should read my book to find out the best post op diet. But that book will be out in about eight weeks, and you can buy it right here at obesityhelp.com. But all surgeons have different reasons for why they have it. Some like it for six weeks thinking it is easier than having solids. Some worry about overstuffing and getting leaks, so there are a lot of reasons. Liquids do go down quickly, and you can lose weight with that. But go with your surgeon's ideas, he/she is the one who has the reasons for their ideas.

<judy> Travel: When is the safest time to start extensive overseas travel after the procedure?

<Dr. Simpson> I like my patients to eat steak before they leave the hospital. Travel when you feel as if you have the energy to enjoy the trip. Give it at least four months if you are planning on carrying your luggage or sometimes longer. However, for a small fee as well as room and board I will carry your luggage overseas.

<kathleen g.> Dr. Simpson: How does one go about ordering an autographed copy of your new book? Looking forward to reading your wit and wisdom. Thank you much.

<Dr. Simpson> Well, that is a nice question, but it is not quite ready yet, and when it is you will see it advertised here, or on my website...Although my website is having some technical difficulties these days because the web people are a bit slow in making changes. I guess they wanted time off for Christmas -- bah humbug...The book is going through the final draft before being submitted for the first printing, and when it does come out you will hear me yell so loud that it will be from here to the east coast.

<returningtohealth> WHY ARE SO MANY MORE OPEN RNY's DONE THAN LAP RNY's? I WOULD THINK THAT THE RISK OF COMPLICATIONS IS MUCH LESS WITH THE LAP VS. THE OPEN BUT FROM THE RESEARCH I'VE DONE HERE IN OKLAHOMA, THE RATIO OF OPEN TO LAP IS ABOUT 15 TO 1.

<Dr. Simpson> Lap takes some extra training which not all surgeons have, and since they do not, a lot more open are done than lap. Complications are probably about the same for both, and even out, but lap is the way things are going. Eventually the lap will be the way for all surgeons. But in Oklahoma they are worried about tornadoes so get in the cellar and get a longer scar.

<Sue> A local bariatric surgeon tells his patients that a person having WLS is twice as likely to die as a patient having open heart surgery. Do you agree? If you do, is it due to the general health of the population having the surgery?

<Dr. Simpson> Hmmm, that is an interesting concept, but it is probably not risk stratified according to various individuals. A person who has wls does not have a greater chance of dying than heart surgery-- for example, in the United States of the 14,000 lap bands placed, there have been two deaths, which is much less and safer than heart surgery. I would not do well with heart surgery. They would have to put one in first.

<Mickey Craig> After WLS, what causes an odor that some people need to take an internal deodorant pill for? Is there a change in bowel/breath odor?

<Dr. Simpson> Undigested food which goes to the colon is eaten by bacteria, and when it is it can cause an odor.... or a malodor, for which we often have people get some Devrom, which will deodorize things a bit, the other trick is to change the bacteria in the colon, which sometimes is done with an antibiotic known as Flagyl, and some use some lactobacillus yogurt formulas. Often this changes with time, and gets better. This does not happen with proximal bypass, VBG, or lap band.

<Gwendolyn D> I had my surgery on Oct 30 2003 I have lost 32 lbs since then. If I eat meat all the time do I need the protein also. At this point I am maybe consuming 700 calories.

<Dr. Simpson> Well it depends on what type of surgery that you had and it also depends on your size and how much protein you might need. If your concern is that you are wanting to lose more weight then I would suggest that you increase your activity level by walking a lot, and starting a walking program. If it is that you are worried that you need more protein then have them test your prealbumin level to see how you are doing. 700 calories is not that much, and you will lose weight with that. Walk, walk more, then walk again. When you are done walking-- start another walk.

<Joel> What are you seeing in RNY patients who have been post op for many years? Maintaining loss? Nutritional deficiencies? Are they satisfied?

<Dr. Simpson> I have seen RNY patients out a number of years, many of them are my patients. The deficiencies that I commonly see are things like B12, or iron-- rarely others. Satisfied -- yes, if they have lost and maintained their loss, otherwise, no. In terms of maintaining loss -- those who fall back do so with the following: they skip meals, they eat out at fast food restaurants, and they drink more alcohol. Do those things and you can find that you will not lose weight not matter which surgery you have.

<Joel> I hear much debate whether it's ok to get protein from shakes vs. food - what do you think?

<Dr. Simpson> There is no doubt that you have better bioabsorption from food than from most shakes. Some shakes have better bioavailability than food, but we don't like our patients to get use to drinking things. This is about food, not about shakes, this is about living with a normal diet, not about drinking fortified moss in order to get nutrients. So, eat some good food, find out what is in the good food, and you will like it all better than if you drink some petrified roadkill. Just my opinion.

<David Langdon PA> I have Barretts Esophogus will that be of any concern post op

<Dr. Simpson> You will still have it after surgery, and you will still need to have it surveyed after surgery. That is not something that will go away, and is something that you will always need to watch and consider. But it is a risk factor for cancer of the esophagus. It does not mean you will get it. Just keep an eye one it-- although it is hard to swallow those eyes.

<Mickey Craig> My surgeon said I might have to be trached if i could not use a CPAP after surgery, I dont feel comfortable using a CPAP as I dont use one now and I do have sleep apnea. Why would he suggest this to me as the only other alternative to performing the surgery on me without the CPAP?

<Dr. Simpson> You would be an idiot to not use CPAP if you need it-- simple as that, you could die, you could have a big problem. If your apnea is bad, and you combine that with the post operative narcotics, then you will and can stop breathing and not start, which isn't good for our statistics, so don't be an idiot -- if they prescribe that for you, then do it. If you don't want to do what doctors tell you to do, then perhaps weight loss surgery wouldn't be a good thing for you. A trach is a viable alternative-- but don't do that-- use the da... machine. Preaching is over.

<David Langdon PA> Is there a chance the celulitis will go away in my legs post op?

<Dr. Simpson> Cellulitis is a bacterial infection of the skin. The tendency for cellulitis diminishes after weight loss surgery. But if you have an infection, then you have an infection. So the edema in the legs will go down, and I think you will like the results. Good luck.

<Mickey Craig> Hi Dr. Simpson, I am terrified of getting a blood clot after surgery. How can I help prevent this from happening?

<Dr. Simpson> You can walk, and walk from recovery room to your room, and every hour on the hour walk around the nurses station a lot. Walk and keep walking, and don't stop walking until you are home. So, I think the best thing you can do is walk, then walk again, and walk some more. If you want to get a blood clot then stay in bed.

<natasha> is the surgery any more invasive than a cesarean section? or are the physical limitations much different? how much time off of work can we expect to have?

<Dr. Simpson> In a C section we go inside of you and remove an alien which will live with you for the next 18 years and cost you about a million bucks. Then just when you think they are off on their own they get a divorce and move back in with you. You will be physically limited all your life by your kids, and your work will always be affected. Compared to that, weight loss surgery is a breeze.

<toots> what is the general time frame for major complications post-op to be out of the woods.

<Dr. Simpson> Soon as you see the light at the end of the forest. Six weeks.

<David Langdon PA> If people have the same surgery like RNY why do people tolerate different foods differently

<Dr. Simpson> Same reason that I like to eat cow brains and now I find they are cheaper by the dozen, especially since I can get them out of Yakama, Washington so inexpensively. Food intolerance is dependent on genetics.... and depends on how much is bypassed. Some have problems with gluten, some have problems with lactose, some have problems with beef, some do not like to eat elk anymore, and some have problems when they go back to being a cannibal. All depends on a number of things, but often after a year, you stabilize a bit.

<toots> why does the food we eat now taste so different?

<Dr. Simpson> When you were under anesthesia we altered the taste buds so that things don't taste the same... seriously, this happens after any major surgery, and is not something unique to weight loss surgery. It does occur, and we recommend that you increase the amount of salsa, pickles, and vinegar to spice up the food a bit.

<Linda> i had the rny in aug and was told no way can my pouch stretch ... is this fact or fiction ?

<Dr. Simpson> You can overstuff any pouch at anytime and get it to stretch. There is no way that a pouch cannot stretch, no matter how small it is made. Pouches simply stretch, and we expect them to, and we anticipate them to.... and we prepare them to. So measure twice, eat once -- don't stretch it.

<Jackie_10 wks postop> Everything that I've ever been taught about calories and weight loss is that if you eat too few calories... your body won't lose???

<Dr. Simpson> That is the silliest thing I have ever heard...Not the silliest, but the closest. You need to have calories, and you lose weight with calories being less. Surgery works by eating fewer calories, or malabsorbing a smaller portion of them. But there are always silly things that people say. Increase activity also-- that will help you lose.

<toots> why do post op have plateaus and how long do they last generaly?

<Dr. Simpson> A plateau -- which is nicely described in this month's issue of the obesityhelp.com magazine--- is defined as four weeks of not losing weight and not changing any measurements, that is you are not losing inches. So, I think that you need to think about that first. Plateaus happen in a normal manner, but once your calorie use decreases and your calorie intake increases, you will have a plateau.

<angel> do you think there are more problems because dr's are not doing enough pre-op testing?

<Dr. Simpson> No, I don't think it is pre op testing, instead I think that there are more problems because we are doing more surgeries and we have more press. So we will read more horror stories about weight loss surgery, and this year we will do even more surgeries. Most doctors do the same pre op testing. But more press, more surgery.

<Gwendolyn D> I had my surgery oct 30 2003 I have only lost 32 lbs eating chicken breast is that enough protein for a day?

<Dr. Simpson> I don't know how much chicken breast you are eating, and that is what we have to know.. Not what you are eating. Chicken breast is a good source of protein, as is turkey, as is fish, but it depends on how much you are eating, and that is the key, not what, how much. So, if you are getting enough protein in with chicken, then that is probably ok. It isn't the chicken that is keeping you from losing more weight...It is the fries.

<kimberly> I have tried to get help losing weight from weight watchers to pill poppin, and and I have medicaid is there anyone whom might fund for me to have surgery?

<Dr. Simpson> Save your money, you can always find someone who will do the surgery for cash. Or go out of country for the surgery. The surgery cost less than most cars. And you live with your body, you don't live in the car.... it is more important than a new car. And you are always in your skin-- you just need less of the underlying fatty tissue.

<StephiAZ> Happy New Year Doc! With being almost 17 months post op and wanting to lose another 15 pounds, how much can I reasonable lose in a months time? Is it unreasonable for me to be at my goal by March?

<Dr. Simpson> Stephi you must have a hot date...Well, you have seen how much you can lose in a month, because you have lost a lot in any given month. It depends on how much you want to invest in walking -- and since you want us all to go out for a walk soon, I think you will do just fine. I think you can lose that fifteen pounds fairly easily -- start walking, riding, and so forth. You will do just fine (Steph is one of my patients).

<vam170> my pcp thinks it is ok for me to have wls even though i have crohn's disease. ive had it for 10 yrs, recent tests show it has not worsened. what type of wls would you suggest?

<Dr. Simpson> Not a distal bypass, probably a lapband although the manufacturer would say that this is not wise, but that would be the type I would recommend with Crohn's disease.

<Donalea (Indiana)> Dr. Simpson, Can you explain how digestion occurs after the WLS.

<Dr. Simpson> Yes. Oh, you want to know...In most of the surgeries which involve a bypass you simply separate the components of digestion, but they still work, just not as efficiently as they did before.

<kim1971> I went to the Dr the other day to get a fill in my band and the Dr. said he has some concerns that he was only able to pull out a half of cc and he put in a whole cc.. so this time he put in a whole cc so do I have to worry that i may have a leak??

<Dr. Simpson> I don't know if you have to worry about a leak with that or not, sometimes those things just happen, and are related to the device and not to the leak. It is easy to check for a leak, and can be done in x ray, but I think that you should have your next fill in x ray and see how it looks at that way.

<BayouMan> Dr. Simpson, how long do you have your patients wait until they try ground beef?

<Dr. Simpson> These days the only beef I allow my patients to have is Yakama beef from Holsteen cows imported from Canada. It depends-- if it is a DS, then they try in the hospital, if it is a lap band then they wait for a few weeks...If it is a RNY, then six weeks, and if it is a VBG then six weeks...Otherwise, get a chicken.

<**MODERATOR**> THIS IS OUR LAST QUESTION FOR TONIGHT :)

<Nammie> I've been wondering for a long time if i realy need this surgery and if it is considered to be safe, i am 5'6" tall and weigh 280lbs, would it be safe for me?

<Dr. Simpson> It will only be safe for you if you commit to walking and walking some more, and drinking water, and eating protein. Surgery is safe, effective, and works quite well. So go for it, and good luck.

<Dr. Simpson> Thank you all for another Friday evening, I will now retire to an evening of debauchery---oh, guess I cannot do that instead, I think I will watch TV.

<**MODERATOR**> THANK YOU SO MUCH DR. SIMPSON! IT HAS BEEN A PLEASURE!

<Dr. Simpson> Goodnight everyone.

<**MODERATOR**> TO LEARN MORE ABOUT DR. SIMPSON, PLEASE VISIT HIS WEBSITE AT http://www.drsimpson.com.