January 28, 2005

<Moderator> Welcome to tonight's chat with Dr. Simpson. Chat starts at 4pm PST/7pm EST. Please type out your questions and hit enter. We will see them and present them to Dr Simpson at the time of chat in the order we receive them. Thank you!

<Moderator> Welcome Dr. Simpson. Just let me know when you are ready to begin and we will get started.

<Dr. Simpson> From the warmth of Phoenix Arizona, where it is a balmy 72 degrees, we bring you the chat. Ready, willing, and able. Let's go.

<shelli> How do you decide how much of the small intestine to bypass?

<Dr. Simpson> We flip a coin. There is no formula for the amount of intestine to bypass. Some insurance companies have criteria where they will not allow a malabsorptive procedure. That is they will not allow you to bypass more than 100 cm of small bowel. The malabsorptive part of the surgery is not, nor should anyone think, is the most important. Part of weight loss surgery -- the malabsorptive part -- is short lived, and after a while the small bowel will get use to and absorb better, plus, small bowel, no matter how much is bypassed will not malabsorb simple sugars or carbohydrates --- you can see some good drawings of this in my book -- available at www.obesitydr.com.

<liz> I had a jejunal bypass in 1975. In 1982 it was reversed and a stomach stapling was done. I am 61 years old, and wonder what my prospects are for an updated surgery. I currently weigh 220 lbs.

<Dr. Simpson> Revisions are always harder than the original surgery, and 220 lbs is not a lot of weigh for a person, so you might be done. It is far better to use the tool that you have to lose the weight. We just came out with a new book, called "Getting to Goal and Staying There: Lessons Learned From Successful Patients." This is a workbook for patients who have had wls at anytime which will allow you to get to goal and to stay there. It goes through a lot of information.

<shelli> IS it okay to do the atkins diet prior to surgery?

<Dr. Simpson> The Atkins diet is not a great diet -- and I like steak. However, the Atkins diet is something that can jump start weight loss, but I don't like patients on diets. Instead, I like it when patients learn about nutrition and balance their diet prior to surgery, that is all the more important.

<Kimber> Dr. Simpson, I am 5 yrs post op and starting to put on some weight. Is it common to start gaining weight this far out? Have I ruined my tool?

<Dr. Simpson> I doubt that you have ruined your tool, Kimber. Instead I would probably say that you have made some bad choices, and you can use your tool and make some better choices. We looked at successful patients -- that is those patients who made it to goal and stayed at that weight at least four years and we found that there were a number of things that these individuals did to get there and when we applied these tasks to our patients, it worked --- so these are things and principles that anyone can do, so I doubt you have ruined your tool. I think you simply have to work it more ---- and that information is available so, you still can get it done. Good luck.

<Marshmellow> question: im 5 mons PO and i gained 3 lbs....... i was 427 lbs and lost 87 do u think its water weight?

<Dr. Simpson> It is not water weight, it is not water weight at all . I think you need to work on what you are doing. A lot of weight loss patents enjoy the honeymoon phase of weight loss surgery where they can lose weight almost by the hour but without some minor changes in lifestyle, such as starting exercise and if you do not make wise food choices, you will start to regain weight. So start a walking program, make some better food choices, and work that tool.

<Jacklyn> I am very interested in learning more about the lap band. I feel that this is the best procedure for me. Can you tell me if this surgery will allow me to lose the same amt of weight as the rny? I am about 150 lbs over weight. Thank you.

<Dr. Simpson> With the lap band you can lose every bit as much weight as the RNY. The newer data shows clearly and convincingly that the lap band is as good a tool, it is slower in the beginning, but it lasts and patients lose weight for over three years. The complications are related to port site problems, or device issues, which are relatively minor.

<Scott> I have a nut case evaluation next week. I was once on Lithium, will this prevent me from having surgery if I tell them? Why do they make us have a evaluation anyways?

<Dr. Simpson> The evaluation is a misnomer and it is not a "screening" process at all, at least that is never the way most surgeons look at them. Most patients have had some depression and have been on some medicines, and I have operated on patients with major mental illness. The purpose is to begin a relationship with a therapist who you can see afterwards as you lose weight because issues come up, sometimes depression, sometimes relationship issues, sometimes friends change, and you need a professional to help you, plus you will find that you might have issues with food, and need other strategies to deal with them and this is a good person. So do not fear the evaluation with the psychiatrist, instead, think of it as a beginning of a process. Good luck. Oh, don't tell them about the voices.

<Honda> I am three years post op and want to have children. My problem is that I have a testosterone level of about 95, but have not been clinically diagnosed with PCOS. My periods are always on time. I thought losing weight would help with this. Have you had any patients that have had similar symptoms and went on to have a successful pregnancy?

<Dr. Simpson> I have had a lot of patients who become pregnant, often when they don't want to. My suggestion is to do it in the back seat of a Chevy on prom night, that is the most fertile time.

<efunk77> what is the average cost in the US for the lap band procedure?

<Dr. Simpson> It varies from about 14.5 thousand to 24 thousand, depending on where you are and so forth.

<tammy 23week> how come the doctors do not give u a more general idea of what food u are 2 eat and when

<Dr. Simpson> I don't know -- that is probably why we wrote our first book: "Weight Loss Surgery: A Lighter Look at a Heavy Subject," so that you would have a guide for the first while after weight loss surgery. And it has a bit of humor in it, too.

<efunk77> what are the disadvantages to having the lap band surgery done in Mexico?

<Dr. Simpson> If something happens, then you do not have the same type of care after surgery as you would have in the United States. Let me give you an example: If you have a heart attack, then in the US you would be rushed to a cath lab where your heart vessel would be opened, and in Mexico, you would spend hours trying to get back to the United States and every hour you spend is lost heart muscle. It is not the surgery that is different. The surgeons there, at least some that I know, are great surgeons. Weight loss surgery is more than the procedure, it is the aftercare. And while you might pay a few thousand more at home, it is worth the aftercare, and the other insurance of having a medical system that can handle you.

<Debby> If I go on a 650-800 dr. approved diet without surgery will my stomach shrink?

<Dr. Simpson> Stomachs don't shrink, that just does not happen. It may not be used to food, but it doesn't shrink.

<tammy 23week> i am 3 weeks out of surgery and i am havin a hard time with it i feel i did not have enough information and now i feel like i am goin crazy , having a hard time not having food is this normal and will it get better

<Dr. Simpson> I think the more information that you have the better that you will do. There are a lot of good sources of information, and there are many places. These chat rooms are one. There are many issues with weight loss surgery, one of which is food issues, so get online, chat with your peers -- read some books about the subject, and get educated. It is better to get educated before surgery than after surgery, but get educated.

<Debby> Should I have a heart test done before I have the surgery?

<Dr. Simpson> If your doctor wants you to get it, then get it and yes, before surgery is the time to.

<Dolly> Hi Dr Simpson - loved your book, love your sense of humor :) i am 10 months post op, down 133 lbs, and 37 from goal, and am in a wheelchair, but can walk a little bit, but only about 3000 steps a day. Do you have any suggestions on how to get the last 37 off, do I go back to basics? Thank you in advance Dolly

<Dr. Simpson> Thank you for those kind words, and it sounds like you are on the right track. I think if you can begin to increase your steps. That would be a good first step, the basics always work. And those last 30 lbs are the toughest. In fact, we are writing a book called "Losing the Last 30 lbs" which should be out soon. Well, this summer, but it is the basics that are important here. Making good choices, increasing exercise, and so forth.

<Kimberly Feller> I've lost 150 lbs and have thigh/leg skin that hangs down over the front of my knees. My Kaiser plastic surgeon can't figure out how to remidy the problem. Any suggestions?

<Dr. Simpson> There are a lot of plastic surgeons who know how to take care of weight loss surgery patients and those would be the ones to talk to. It does mean you will have to pay for it but you live in your body all the time, so it is the best investment you can make.

<**Kristine> Hello Dr. Simpson - I have Blue Shield of Calfornia as my insurance and have been told I need to see a nutritionist for six months prior to surgery. In your practice, for those patients' insurance that requires the nutritionist wait, I have heard conflicting reports - is it a 6 month wait or losing 10 percent of current body weight? Thanks so much!

<Dr. Simpson> The surgeon should be able to tell you the requirements. Most require a six month supervised diet by a physician, with visits to a nutritionist. So, start with seeing your primary care doctor and get that underweigh. Good luck.

<Debby> Would it be better to bypass the least amount possible?

<Dr. Simpson> It is better to let the surgeon figure out what they want. They have a certain way they do things that works for them and as much as you might like to have them do whatever, they really do have the experience and skill to do that. The more you bypass, the more that you will have malabsorption, not only of fat, but also of vitamins, and calcium and some of that is good. But if the majority of your weight has come from processed foods and carbohydrates, but not fat, then more bypass does you no good whatsoever.

<tammy 23week> has there ever been a doctor, who has had this surgery himself and does the same type of surgery

<Dr. Simpson> Lots of them: Lee Grossbard in Florida had the lap band... In next month's issue of ObesityHelp Magazine you will read about Butch Rosser who had the RNY. There are a lot of surgeons who have done that.

<JEANNIE> I HAD OPEN RNY ON 4-04 I WAS 276 BEFORE AND NOW I AM 190 I HAVE STOPPED LOSING ALL TOGETHER. SINCE NOV. I CAN EAT EVERYTHING AND IT SEEMS SOMETIMES THAT MY POUCH IS REALLY BIGGER THAN EVERYONE ELSES. COULD THIS BE TRUE?

<Dr. Simpson> It could be. We do expect pouch stretch which happens for a number of reasons, but the main one is overeating. You need to apply the principles that go with weight loss. Weight loss doesn't just happen because of surgery - it happens because you eat less, and if you want it to continue you need to eat the right things. I have a normal size stomach, and I am losing weight -- although it might be that undiagnosed tumor inside of me. Still, you have a tool, you can work it, you can learn how to reuse that tool. We do have a free email newsletter -- which you can sign up for on the website www.obesitydr.com and read the old ones. We spend a lot of time going through these issues.

<Pamela> I am 15 months s/p rny surgery. I have lost 137# and am down to 153#. My surgery has been uncomplicated, and I am healthy. I take MVI, 4 tums, lecithin, vit E, and coenzyme Q 10. Recently one of the endrocrinologists where I work stated in passing that he was seeing patients in the office 10y post op with osteoporosis. He stated that he was recommending that they take 50,000 u Vit D. What is your feeling on this? Thanks, Pamela

<Dr. Simpson> If you have a deficiency of vitamin D then you need more -- otherwise, it does no good and possibly harm to take it. We have seen minimal issues with osteoporosis after surgery, and I have seen many more than your endocrinologist has, so get your vitamin levels checked, and see if you need that.

<Joanne> the 1st 2 weeks after lap band surgery requires liquid diet, is it okay to make homemade chicken soup and just put the carrots onions and celery in the blender and blend it all together. it would make a liquid still.

<Dr. Simpson> You could do that -- I suppose. The idea of the liquid diet is to keep your stomach from being irritated by the band.

<Debby> I have also heard that you can have the extra skin removed for free by the burn unit, has anyone hear of this? I'd like to donate some :>

<Dr. Simpson> It does not work.

<Shannon> I had a horrible time recently. Because of the malabsorption issue, I was not absorbing my medication. I spent two weeks in the hospital until the doctor could get my levels straightened out. Why aren't we warned that this can be a serious side effect?

<Dr. Simpson> Well, you are, although I wasn't there when you were getting consented for surgery. In my book we go over that a lot. The first book, not the second book.

<Nancy S> I had a RNY bypass 1 month ago. I did not feel any physical hunger at first, but now am feeling what feels like hunger pains - in the vicinity of my remnant stomach. I have heard that some people have acid production in the remnant that they feel is hunger. Is this true and is there a remedy for it?

<Dr. Simpson> Well, to decrease acid you can take prevacid or zantac, which will decrease acid in the stomach, lower and upper, and you do not have hunger in that lower stomach, if your pouch is filled and you keep solid food, not mushy stuff in it, then you will do fine. Hunger pains happen, it is ok.

<Mary> As as self-paying patient, how can I expect my experience to differ from that of someone who is covered by insurance? For example, I will have to go directly to a surgeon and ask for evaluation without a referral from a PCP. What can I do to be prepared?

<Dr. Simpson> To be prepared, several things: Have your medical history ready, have a typed out list of any medications you take, along with the dosage of those medicaitons and a list of your allergies to medicine, latex, or iodine. In addition, have a list of the diets you have been on.

<brett> is laproscopic surgury more difficult becuase of previous tissue damage from operations like gall bladder and hysterectomy

<Dr. Simpson> Any prior surger makes other surgeries a bit more difficult. But we can successfully do lap surgery after previous surgeries. There is more to prepare for your surgical visit-- it is all -- you know where.

<Debby> I'm new to this where do I go to find all of your "GREAT Books"?

<Dr. Simpson> Is this my sister, or mom? Well, the books are found at www.obesitydr.com -- and are available through most bookstores. I do get a dollar and sixty seven cents royalty -- so I am making a lot of money here. Seriously, they were written for two separate purposes. The first book was written to explain the surgeries, how they work, the history of weight loss surgery, why we get fat, and how to get the surgery done, and how to take care of yourself afterwards. The second book was written for patients who have had the surgery and want to exercise their tool to get to their goal weight and stay there. It is a workbook -- which we use for our patients. Our next book is called Losing the Last 30 lbs, which I am still writing.

<Rhonda> I am considering WLS - how does one decide which surgery to have when there are so many choices. Does the insurance company decide or the surgeon? Do I have input? for example if I wanted to have RNY as opposed to VBG how is that decided? Thanks in advance.

<Dr. Simpson> Some surgeons only do one type of surgery. Some insurance companies only cover one type of surgery and a good surgeon always listens to the patient before making a decision, but it is his/her decision. It isn't like ordering a suit, but the better informed you are about the surgeries, the better for you. If a surgeon only does one type of surgery, and that is what you want, then you have a great match but do not talk a surgeon into doing something they don't normally do. You do not want to be their "first" at something unless you are their first patient who lost in record time without any nausea and vomiting.

<KIMBERLEE> Hello Dr. Simpson, I can drink up to 6-8 ounces of water and I am filled to the top and have to wait until it passes through, so am I right to assume that my pouch is ok, I can eat and sometimes it seems like alot, and there are days when it seems I am just hungry all day. I had a baby almost 2 yrs ago and since then it seems I can eat anything except spaghetti, but I worry, because,I was losing weight throughout the pregnancy and now have gained about 50 lbs, I started

<Dr. Simpson> If you are hungry all the time it might be because your stoma is too open, although it doesn't sound like that. You might need to make better choices with your food, you might need to eat things that keep you full for a while -- like beef, vegetables, elk, and I hear zebra (just kidding about zebra - don't know anything about them except they have polka dots) but eating food that sustains you, and keeps you full for a while is the key to sustained weight loss. Eating mushy foods, soft carbohydrates is not a good thing. Eating less, eating three meals a day, and controlling snacking is a major key. Good luck.

<Dori> I am about to convert from VBG to GB in a few short weeks. I'm very excited. However I forgot to ask my surgeon one important question. I am a wine lover (an amateur to some, but I can tell a good vintage from mediocre!). My question is, will I ever be able to enjoy a glass of wine after the bypass conversion?

<Dr. Simpson> Sure, but you will absorb all the calories from wine -- so be moderate and enjoy a nice Caymus Special Select.

<ChiChi> Dr. Simpson, would you still recommend a DS for patients who have a kidney disease in which they spill protein in their urine?

<Dr. Simpson> Well, kidney disease and proteinuria is something that a DS surgeon would have to look at. There are a lot of reasons for that, and with surgery you do malabsorb protein. I have had plenty of patients with renal impairement that I did duodenal switches on and they did just fine.

<Janice Emory> When you have the surgery, do you have to have tucks done too????

<Dr. Simpson> No

<daisy> i'm having surgery in 10 days how can i prepare?

<Dr. Simpson> Start walking, start taking your vitamins, learn about good nutrition and good luck -- soon you will be on the other side.

<Marla K.> I just underwent Roux en Y gastric bypass surgery two days ago. I had a bout with nausea and vomited up some blood. I was worried that the vomiting could push the pouch and make an ulcer or hernia. Should I be concerned????

<Dr. Simpson> Vomiting blood is not normal -- get to the emergency room ASAP and call your surgeon. Do not wait for this chat to end You can read the transcript of this chat on my website www.drsimpson.com. Good luck.

<Dawn> I am going to have the lap band surgery in 2 weeks and I am on an Insulin pump. I know I can not wear it in the surgery but should I bring my machine with me to put on after the surgery?

<Dr. Simpson> No, they can regulate you with shots while you are there, and you will only be there for a short period of time.

<Sally> why do you have to have a sleep apnea test

<Dr. Simpson> Because if you have it, then it is important to diagnose it and to treat it.

<Lisa Smith> After Gastric Bypass Surgery and you go home, is it difficult to get around by yourself? I have a 3 year old and no one to help after surgery?

<Dr. Simpson> It isn't difficult to get around, but if your son is over 20 lbs you might not want to pick him/her up because you could get a hernia. So, you may need some help. It is easy to get around. I have my patients walk all over the place. I want you walking miles and miles and miles.

<Sherrie> I had lap band on 1/13, I was then very ill after surgery due to Delayed Gastric Emptying, is this normal and will this happen again?

<Dr. Simpson> Some folks have that, but not too many and if your stomach is doing fine now, then it will probably be ok.

<Kate in IL> Dr Simpson, I have 15 to go, my plasic surgeon said he will remove 10 lbs of fat from my stomach area, the last 5 have me scared. I have never been at goal in my life

<Dr. Simpson> Get used to it, get there, stay there, and work the tool. You will do just fine. I am proud of you.

<Sally> which type of surgery do you do Dr. Simpson

<Dr. Simpson> Lots of them. For the first part of my bariatric career I did RNY bypass and did a lot of them the first ten years, then I did a lot of duodenal switch operations and now I do a lot of revisions, and a lot of lap bands. Someday I hope to do a lot of golf.

<Moderator> Last question goes to...

<daisy> Where can I buy zebra meat?

<Dr. Simpson> There is a restaurant in Kenya, called The Treehouse restaurant. It is actually in a treehouse. In that restaurant they serve many wild meats including Zebra, some lion, and other types which you cannot get here in the states. Zebra does not taste like chicken. It is a sweet meat and it has a low fat content, and is quite lean. So if you are in Africa, it might be a good source of protein. Otherwise, cats are quite good on the barbeque.

<Moderator> Dr. Terry Simpson, Arizona Bariatric Center. Website: http://www.drsimpson.com/. Phone: 602-234-8995. Fax: 602-230-8344. Thank you very much Dr. Simpson. We enjoy your chats every week. We all thank you and have a great weekend.

<Dr. Simpson> Books available at www.obesitydr.com. Thanks everyone. Good luck to the pre ops and for the post ops: Walk walk walk! Goodnight.