<**MODERATOR**> WELCOME DR. SIMPSON! NICE TO HAVE YOU BACK WITH US THIS WEEK!

<Dr. Simpson> It is nice to be here,

<Dr. Simpson> always good to see a lot of friends and some new faces, let us see what they have to ask.

<**MODERATOR**> LS YOU HAVE THE FIRST QUESTION PLEASE:)

<LS> Hi Dr. Simpson- I am 6 months post now and I have not had any gas or discomforts for about 2 months now. I just started a new anti- depressant Lexapro and yesterday (my first day on it) I had a very strange discomfort- Like I took a mild poison- sick but not that severe. Gas and a bad taste in my mouth. The psychiatrist said it would taper off. He is aware that I had DS. Do you think that it is safe to be on anti depressants that upset my stomach a little? Also I just switched vitamins a few weeks ago to a more expensive brand. I was taking Centrum- which I understand has synthetic vitamins and minerals and that I don't get much out of it. Supposedly it is like the difference between wearing acrylic and silk. What is your oppinion on this?

<Dr. Simpson> Hey LS. Lexapro is a new antidepressant, and it is something that does cause some GI upset. It is safe to be on it....

<Dr. Simpson> in terms of the vitamins-- I like silk, but whichever you choose should work. The Lexapro should get better. Good luck. Keep walking

<LS> Thanks Doctor

<**MODERATOR**> LORA YOU HAVE THE NEXT QUESTION PLEASE:)

<Lora> How do I get my insurance company to approve WLS?

<Dr. Simpson> The first question you have to ask is whether your insurance company has a policy exclusion to...

<Dr. Simpson> weight loss surgery. If they have that exclusion it is very difficult, if not impossible, to get around that fact....

<Dr. Simpson> otherwise, you have to find out what your insurance company requires. Some insurance companies...

<Dr. Simpson> require that you see your primary care doctor and be on a physician supervised weight loss program...

<Dr. Simpson> most, however, follow the age old NIH criteria, which are not that old....

<Dr. Simpson> Trisha-- you have to wait your turn, ....

<Lora> When I first contacted my insurance company the said the surgery was approved then in mid stream they changed it saying I needed to prove I had a metabolic condition

<Dr. Simpson> well, Lora, I don't know what a metabolic condition is, and I am a doctor, so that is a new one...

<Dr. Simpson> I would suggest you put together, as best you can, a diet history, of every diet you have been on...

<Dr. Simpson> every program, and have that ready to submit to the insurance company. If you have a BMI over 40 it should be just fine. Good luck.

<**MODERATOR**> CANDACE YOU HAVE THE NEXT QUESTION PLEASE:)

<Candace> Postop 1 year how many protein grams and calories should I get in a day? I still need to lose 57 pounds. Also do you think the proteinx pills will work?

<Dr. Simpson> Proteinx pills work fine, but I think you should be able to simply eat protein, and not rely on pills, shakes, or other formulations...

<Dr. Simpson> in terms of protein grams, we recommend anywhere from 40 grams per day for a proximal bypass, to 80 grams and up for a distal bypass, or a duodenal switch....

<Dr. Simpson> in terms of calories-- don't even worry about those, they will take care of them self. The big thing is to limit...

<Dr. Simpson> the number of carbohydrates to around 60 grams or less to maintain, 40 to lose slowly.

<Candace> 200cm RYN bypass

<Dr. Simpson> So, eat well, protein based, and you should do fine. No supplements needed.

<Dr. Simpson> good luck. And walk.

<Dr. Simpson> walk some more

<**MODERATOR**> CAROL-65# YOU HAVE THE NEXT QUESTION:)

<Carol -65#> Hi Doc, I had my surgery 11/13/02. I am PO 2.5 months. I had open rny and a hernia repair around the navel area that was done by reopening my C-section scar (up and down scar). How soon before I can do any type of stomach exercises and what type should I start with? I have lost 65# so far and starting to see the sagging skin already. Thanks!

<Dr. Simpson> Skin does sag sometimes, and I think in terms of exercise you are far enough out that it would be ok to begin some light exercise...

<Dr. Simpson> generally we recommend light weights with rapid repeats, as opposed to being a body builder...

<Carol -65#> what about stomach exercises?

<Dr. Simpson> of course, those of us who are body builders like to think our fine firm abdomens are truly an inspiration....

<Dr. Simpson> (for those who don't know me, I have a rippled abdomen--- one ripple--)

<Carol -65#> lol

<Dr. Simpson> but it is an allergy I have to work. Anyway-- light workouts and plenty of walking.

<Carol -65#> thanks

<Dr. Simpson> drink lots of water-- and pass the cake.

<**MODERATOR**> LANA LEIGH YOU HAVE THE NEXT QUESTION PLEASE:)

<lana leigh> What makes a dr. choose distal rather than proximal?

<Dr. Simpson> It depends on the particular surgeon, there is no magic here....

<Dr. Simpson> I do duodenal switch as my primary operation, which is a distal bypass, however when I did RNY....

<Dr. Simpson> a distal was reserved for certain patients who had a high proportion of their diet from fats,...

<Dr. Simpson> so, no magic, but a lot of religion--- of course, mine is best.

<lana Leigh> i would like proximal better absorption.....NO?

<Dr. Simpson> absorption is your friend and your enemy. You want to absorb just the right amount-- not too much otherwise you end up as a patient of mine.

<**MODERATOR**> TERRI 4 WKS YOU HAVE THE NEXT QUESTION:)

<Terri 4 weeks post o> I am 4 weeks post op, some days I am hungry all day long, is this usual???

<Dr. Simpson> It is normal to be hungry, and it does happen to some people for a variety of reasons. Suggestions have to do with where you are in your current diet plan from your surgeon....

<Dr. Simpson> for example, if you are eating solids then we would suggest that you eat more protein based foods...

<Terri 4 weeks post o> yes eating solids

<Dr. Simpson> tuna, turkey, and so forth. They tend to stay with you. Also, don't eat and drink at the same time,

<Terri 4 weeks post o> I shall do that, thankyou

<Dr. Simpson> as drinking will force the food out of your pouch and into your gut where it will absorb and you will be hungry.

<Dr. Simpson> Good luck.

<**MODERATOR**> GAYZELLE YOU HAVE THE NEXT QUESTION PLEASE:)

<Gayzelle> Are staples always used in the roux-en-y procedure and are there any histories of causing problems like cancer and if so is the cancer hard to detect in the unused portion of the stomach. What's the difference between a proximal and distal bypass

<Dr. Simpson> Some surgeons sew the guts together with suture, some use staples, and there is no evidence that staples cause cancer...

<Gayzelle> what about long-term side effects

<Dr. Simpson> it is hard to detect cancer in the unused portion of the stomach, but stomach cancer is rare in America...

<Dr. Simpson> in terms of long term side effects-- we really don't seem to see too many, and we have a lot of these operations done in the United States...

<Dr. Simpson> proximal is about 15 per cent bypassed, distal is about 60 per cent bypassed. Good luck.

<**MODERATOR**> MISSY WV YOU HAVE THE NEXT QUESTION:)

<Missy*WV>2 months po> Hi Dr. I am 2 months post, I had lap RNY and I have hit a plateau already. I haven't lost anything in 2 or 3 weeks now. I feel like I'm drinking enough water and am taking all my vitamins. Also, it seems like everything I eat makes me nauseaus. I don't throw up, but very sick to my stomach. Any advice?

<Dr. Simpson> No, you do what the surgeon wants to do, don't change it. In terms of plateaus....

<Dr. Simpson> I suggest that you measure your neck, thighs, waste, etc. and you will probably see that you are losing inches, not pounds....

<Dr. Simpson> just like most gain inches before they gain pounds...

<Missy*WV>2 months po> ok, thank you.

<Dr. Simpson> to get off the plateau is simple== first, some have to plateau in order to rebuild critical muscles and such...

<Dr. Simpson> second, you should begin to walk-- and not just a saunter, but spend 45 minutes a day walking...

<Dr. Simpson> and walk fast, very fast. Walk like a cop going to Krispy Kreme. Good luck.

<**MODERATOR**> PATRISH YOU HAVE THE NEXT QUESTION

<patrish(-25# in 6wks> i had a lap RNY 6 weeks ago (150 cm bypassed - is that distal)? and have lost 25 lbs (slow loser, and hungry alot too, altho i follow surgeon's diet of solids).Aside from a barium test, how can you tell if the stoma has stretched?

<Dr. Simpson> You have a proximal bypass, or a bit more than proximal. Endoscopy is the best way to see if that is done, where they stick a scope down your gullet and you see what it looks like...

<Dr. Simpson> otherwise, I think that you should have good high protein food, keep away from drinking and eating at the same time...

<Dr. Simpson> and walk with our friend up there. Good luck.

<patrish(-25# in 6wks> would i have had some pain if it had stretched?

<Dr. Simpson> no pain.

<patrish(-25# in 6wks> ty!

<**MODERATOR**> JIM HOCKENHULL YOU HAVE THE NEXT QUESTION

<Jim Hockenhull> Good Afternoon, Dr. Simpson. How much can I expect my skin to draw up after the DS?

<Dr. Simpson> Skin is dependent on the individual, and is nothing we can quantitiate....

<Dr. Simpson(Phoenix)> some people have a lot of excess skin, and some people bounce back faster than gumby....

<Dr. Simpson> it is a bit genetic, and a bit a few other things. The best way to avoid a lot of excess skin is to have a cannibal as a neighbor...

<Dr. Simpson> the other way is to exercise a bit, and that will help increase skin tone. Good luck.

<Jim Hockenhull> Gee Thanks

<Dr. Simpson> For you Jim, I have a special friend for you to meet--- he has quite an appetite.

<Dr. Simpson> teeth are a bit filed.

<Jim Hockenhull> Thank you but no Dr. S LOL

<**MODERATOR**> MATT YOU HAVE THE NEXT QUESTION

<matt> I am a smoker... I am worried that I may have breathing trouble... my surgery is in 1 week...should i take a bronchial dialator pill (Bronkaid...primatene)...and is it standard to have a heparin shot? should I be concerned if i haven't seen a lot about my surgeon on the internet?

<Dr. Simpson> if he says he wants you over for dinner-- well, nevermind.

<Dr. Simpson> well the internet is not the best source of information about a surgeon, it is a good source, but not the best source...

<Dr. Simpson> of course, I have a lot of stuff here, so it is good for me....

<Dr. Simpson> in terms of smoking, I think you should simply stop. It is a good chance to, and it will do better for you...

<Dr. Simpson> otherwise, when you have the surgery, you will go through that coughing phase while you are post op, and that is no fun...

<Dr. Simpson> so stop before surgery, so you go through that phlegm phase before you have a cut on your belly....

<matt> i will...thank you...

<Dr. Simpson> your surgeon is someone you have to have trust in. Anyone can put anything on the internet-- hey, I look good on the internet...

<Dr. Simpson> in person, of course, I am one mean fellow- but I have filed teeth and invite my patients over for dinner- oops, wrong board.

<matt> i don't... thanks for the info...

**MODERATOR**> CAROL-65# YOU HAVE THE NEXT QUESTION:)

<Carol in MI (postie)> No question, just listening

<Carol -65#> I seem to have a lot of intolerances to food at this point, like i said 2.5 mos PO. How long does this normally last, and can you tell me why our taste buds seem to change so drastically? I feel like I do throw up a bit more than I should

<Dr. Simpson> taste buds don't change but some things do over time.....

<Dr. Simpson> in terms of those things, however, it is something that a lot suffer with, but it is something that gets better with time....

<Carol -65#> things i liked before, i hate now, they taste funny

<Dr. Simpson> put a slice of lemon in your mouth, and as long as you can, then drink some decaffeinated tea....

<Dr. Simpson> that will reset your taste buds.

<Carol -65#> what about the vomiting?

<Dr. Simpson> vomiting is something which happens when you overfill your stomach, so that is something that you have to do.

<Carol -65#> i hardly eat anything

<Carol -65#> maybe two to three ounces at a time

<Carol -65#> it only happens with certain foods

<Dr. Simpson(Phoenix)> some foods are hard to tolerate after surgery, but they do get better with time, and usually at three months or so...

<Dr. Simpson> especially red meat, or fried food.

<Carol -65#> ok, thaks

<Carol -65#> I have had nothing fried

<Carol -65#> or red meat yet

<Carol -65#> still on soft foods

<Carol -65#> but thank you

<Carol -65#> i will be patient

<Dr. Simpson> well, once you get off of soft foods you will have a little more time for things that are better.

<Dr. Simpson> Be patient, it will get better I promise, in 20 years you will be fine.

<Carol -65#> lol

<Dr. Simpson> now, back to the other conversation-- where was I?

<Dr. Simpson> oh, I am still here.

<Dr. Simpson> did I answer something, or was I in the middle?

<Dr. Simpson> what is my name anyway.

<**MODERATOR**> APRIL YOU HAVE THE NEXT QUESTION:)

<April> Good evening Dr. Thanks for being here. Why do they say its best to transect and does that elleviate leaks or does it relate? That is my worry more than anything!

<Dr. Simpson> transsection does not have something to with leaks....

<Dr. Simpson> oh April-- ok, transection, very good point. ...

<Dr. Simpson> that has proven to not be the case.

<Dr. Simpson> well in terms of transection there is no evidence that transection leads to more leaks.

<Dr. Simpson> in fact, transection seems a bit protective, so more bariatric surgeons are transecting stomachs...

<Dr. Simpson> since I do the DS, I remove a bit of stomach, but that is another story.

<Dr. Simpson> So-- transection is a good way to go.

<April> Thanks Dr.

<**MODERATOR**> CANDACE YOU HAVE THE NEXT QUESTION

<Candace> Is 200cm RNY proximal or distal? Is it true they bypass the part that digests sugar? (I don't dump.)

<Dr. Simpson> you can never avoid the part which absorbs sugar....so that is something that isn't a problem. 200 cm is proximal.

<Dr. Simpson> or mid way, not distal.

<Candace> I thought so I just read it on the net and was ready to turn to chocolate :) Thanks. Where does distal start?

<Dr. Simpson> Distal is about 400 cm

<Candace> Darn I wish I knew that before surgery

<Dr. Simpson> as long as it works for you, it will be fine.

<Candace> I lose only a pound a week

<Dr. Simpson> You will lose more-- a pound a week is doing well.

<Candace> thanks

<**MODERATOR**> GAYZELLE YOU HAVE THE NEXT QUESTION PLEASE:)

<Gayzelle> i had a previous knee surgery and it causes me pain to walk (i'm sure a lot of it is weight related). what about water aerobics or water walking in place of the walking? Does transsection mean removing of part of the stomach?

<Dr. Simpson> No, transection does not mean moving the stomach. Water aerobics are just fine.

<Gayzelle> what does transection mean?

<Dr. Simpson> transection means we separate the stomach into two parts, as opposed to putting a stapler across the stomach.

<**MODERATOR**> TERRIE YOU HAVE THE NEXT QUESTION PLEASE:)

<terrie> Why do some people have no appetite months after surgery and others are hungry from the start? If it is the vargis nerve cut than can I ask to have mine cut during surgery?

<Dr. Simpson> the vagus nerve does not have any part in bariatric surgery, and it is something that we don't do, and has nothing to do with appetite....

<terrie> what abut the hunger?

<Dr. Simpson> hunger is subjective...

<terrie> is it motivation, how much you are to lose?

<Dr. Simpson> some patients have it, and some do not......

<Gayzelle> thank you

<Dr. Simpson> your motivation is something that is individual.

<terrie> thank you

<Dr. Simpson> good luck.

<terrie> I want to lose weight befoe surgery, is it ok to try and lose as much as I can

<Dr. Simpson> yes, it is ok to lose as much weight as you want before surgery, and take some good vitamins along with it, eat lots of protein, and take plenty of walks.

<**MODERATOR**> MISSY WV YOU HAVE THE NEXT QUESTION:)

<Missy*WV>2 months po> Dr, in regards to the earlier question about the stretched stoma early out, I was wondering how easy is that to do?

<Dr. Simpson> the stoma is fairly difficult to stretch, most instead tend to stretch their pouch as opposed to their stomach...

<Missy*WV>2 months po> is that pretty easy to do early out after surgery?

<Missy*WV>2 months po> the pouch?

<Dr. Simpson> so, I would suggest you have endoscopy or a swallow to see how it looks.

<Dr. Simpson> It isn't easy to stretch the stoma, it is easy to overtime increase the size of the pouch

<Dr. Simpson> so don't do that. Good luck.

<Missy*WV>2 months po> but not at first?

<Dr. Simpson> not easy to do at first. Hard to do. Some people simply are more hungry.

<**MODERATOR**> DEE IN GA YOU HAVE THE NEXT QUESTION:)

<DEE in GA> Do you think it is better to transect the small and large stomach or to just put staple lines between the two?(with the RNY) Also, how many staple lines do you use?also, what are the chances of staple line breakdown?

<Dr. Simpson> Hi Dee-- good to see you.

<Dr. Simpson> staple line breakdown is about 1.5 per cent open and 3 per cent with laparoscopy...

<DEE in GA> Is transection better?

<Dr. Simpson> yes it is better.

<DEE in GA> Ok, thanks

<**MODERATOR**> QUINTON YOU HAVE THE NEXT QUESTION:)

<quintin> what is a stoma?

<Dr. Simpson> a stoma is the opening between the stomach and the small intestine.

<Dr. Simpson> some call it the anastomosis

<quintin> thanks

<Dr. Simpson> which is where we sew things together.

<Dr. Simpson> the stoma size is ok

<Dr. Simpson> or rather the stoma size is made small, about half an inch. Good luck.

<Dr. Simpson> The question about the construction of the upper and lower pouch are interesting. In the early years we had a stapler which we ran across the stomach to divide it...

<Dr. Simpson> what happened is that sometimes that staple line broke down, so the upper pouch drained into the lower pouch.

<**MODERATOR**> BABYDOLL YOU HAVE THE NEXT QUESTION:)

<Dr. Simpson> Hi babydoll

<babydoll: 3 wks post> Doctor... what is a pinrose drain and why would a surgeon use it? I had Lap RNY

<Dr. Simpson> Penrose drain is a drain which is placed in the abdomen in case there is a leak, then it will leak out of the drain instead of into the abdomen...

<Dr. Simpson> some surgeons use them, some do not, it is a matter of personal preference. I don't use drains, although sometimes they are very helpful.

<babydoll: 3 wks post> I've had to clean it for 3 weeks now is that normal?

<Dr. Simpson> well, it is probably time for that drain to come out. Check with your surgeon-- they do need to come out after a while...

<Dr. Simpson> it is ok to clean them, they get dirty.

<babydoll: 3 wks post> It's been awful and groww.. the drain came out in the hospital

<babydoll: 3 wks post> the hole that is...

<babydoll: 3 wks post> oops gross

<Dr. Simpson> Oh-- the hole will close up over time, just keep it clean and a bandaid over it.

<babydoll: 3 wks post> Thank you

<**MODERATOR**> TURTLDOV93 YOU HAVE THE NEXT QUESTION PLEASE:)

<turtldov93> hello dr. i was wondering after having gastric bypass surgery do you have to cut your tylenols in half sence your stomack is smaller, so you dont overdose and if you get the flu and your pouch is smalleryou throw everything up do you go straight into the er for fluids or just treat it the same as before surgery?

<Dr. Simpson> hopefully you won't need to go to the ER for fluids, and with the RNY it is actually easier to get fluids in you than with the stomach...

<Dr. Simpson> with the stomach in tact you have a pylorus which is closed, and when you have the flu it stays closed, and if you try to put something on your stomach it will toss it back...

<Dr. Simpson> as in tag, your toilet is it. However, with the RNY you have open access to your small bowel, and you can put in a lot of fluid, so in a way it is

<Dr. Simpson> easier to remain hydrated with a RNY. IN terms of Tylenol, you can get Tylenol in a liquid form, and that isn't bad to have around the house...

<Dr. Simpson> ultimately you can take all pills with the RNY. Good luck, and get a flu shot.

<turtldov93> lol thank you very much many blessings toyou

<**MODERATOR**> CANDACE YOU HAVE THE NEXT QUESTION PLEASE:)

<Candace> what is the opening to the stomach called? I have never vomited or had to change my chewing?

<Candace> I am a RNY postop

<Dr. Simpson> Candace it is good not to vomit, but a lot of people do have vomiting-- I hate vomiting, and do everything I can to avoid that...

<Dr. Simpson> the opening from the stomach to the intestines is called the stoma, or sometimes the anastomosis....

<Dr. Simpson> from the esophagus to the stomach is the lower esophageal sphincter...

<Dr. Simpson> and in terms of chewing-- always good to chew, but some people chew so much I wonder how they can tolerate it in their mouth that long...

<Dr. Simpson> good luck.

<Candace> I agree except have been able to eat to much from day one and wondered if that could be the problem

<**MODERATOR**> CAM YOU HAVE THE NEXT QUESTION:)

<cam> Why is a portion of the small intestine removed during gastric bypass

<Dr. Simpson> There is no portion of the small intestine removed during gastric bypass, none. Unless it is a very small amount when we put the pieces together...

<Dr. Simpson> so, we keep all the guts, we don't give them to the pathologist.

<Dr. Simpson> Chitlins\

<cam> Is the gall bladder removed?

<babydoll: 3 wks post> eww

<Dr. Simpson> Sometimes the gallbladder is removed, it really depends on the surgeon and what they do,

<Dr. Simpson> I remove it all the time, because it is simple to do at the time of surgery, some do not, and it is a matter of personal preference...about a quarter of people with Weight loss surgery will develop gallstones after surgery, so it is pretty simple to remove it at the time of the surgery...

<Dr. Simpson> sometimes it is a bit more difficult, but I think it is so easy, just get rid of the sucker and that is one problem they won't have...

<Cathy> I am at 400 lbs and having a rny on March 5..Is it true the more you weigh the faster you lose?

<Dr. Simpson> of course, I also like to wear belts with my suspenders.

<Dr. Simpson> Yes, Cathy, it is true.

<**MODERATOR**> SHARON YOU HAVE THE NEXT QUESTION:)

<sharon> Why are surgeons unwilling to operate on a high BMI and pulminary hypertension

<Dr. Simpson> because the leading cause of death in pulmonary hypertension is sudden death, and weight loss surgery is not what they need, rather they probably need a lung transplant, although they are not eligible for it until they lose weight...

<Dr. Simpson> it is a very risky surgery to operate on someone with pulmonary hypertension, and some won't do it at all.

<sharon> isn't pulm hyper common to all obese people

<Dr. Simpson> there is no evidence that weight loss will help pulmonary hypertension-- in fact, every thing says that it will have no effect on it at all. So many will avoid it.

<Dr. Simpson> it is not common, fortunately.

<Dr. Simpson> a little bit of it is common, a lot is not.

<*MODERATOR**> JANE YOU HAVE THE NEXT QUESTION PLEASE:)

<Jane> is the rny reversible, if not why?

<**MODERATOR**> CANDACE YOU HAVE THE LAST QUESTION FOR TONIGHT:)

<Candace> Would an endoscopy..

<Candace> tell the size and

<Candace> of the anstomosis and sphinchtere

<Candace> and stomach?

<Dr. Simpson> endscopy can tell the size of your pouch and your stomach, and your stoma. yes. IN terms of reversible, you can always put something together, but you cannot put it back the way it came.

<Dr. Simpson> so, if you have weight loss surgery, do not think that it is something you will put back, because it is something you need for life.

<Candace> the opening to the stomach too?

<Dr. Simpson> Yes, Candace, everything.

<Dr. Simpson> Thank you all.

<Candace> thank you!

<Dr. Simpson> have a good weekend everyone.

<**MODERATOR**> THANK YOU DR. SIMPSON AND THANK YOU TO OUR MEMBERS!

<Allison-Mississippi> (Warning: Wear Depends when chatting with Dr. Simpson)

<Dr. Simpson> 30 grams carbs per day is plenty.

<Dr. Simpson> thanks, Allison-

<Dr. Simpson> good night all

<Tammy> THANK YOU DR. SIMPSON! THANK YOU MEMBERS! You can visit Dr. Simpson at: www.arizonabariatriccenter.com

<Dr. Simpson> or www.doctorsimpson.com