April 01 , 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!

<Tamika> I wanted to know how to do the "codes" in my packet. CPT like do I have to list them all, b/c I found a place online that lists them, but not sure which to put

<Dr. Simpson> Your surgeon will do the codes, they submit for insurance.

<susan> Why would anyone choose the DS over other procedures? Thank you

<Dr. Simpson> DS is a very good surgery, with great results, and has a lot of advantages to it. It is a technically more difficult procedure to perform, which is why there are not many weight loss surgeons who do it as their primary operation but it works quite well, and patients who have it are pretty happy with it.

<vikki> last week i asked about lap band mortality rate and i can't seem to find that data. Is it common for people to die under general anesthesia?

<Dr. Simpson> Lap band mortality ate is the lowest of all the weight loss operations. It is estimated only, because there have been so few. In the first 15,000 there were three deaths, when you compare that with RNY. For 15,000 operations you would expect to have anywhere from 75 to 200 deaths, so it is quite safe.

<lou> HAVING A LAP BAND HOW SOON CAN I GO INTO THE POOL AFTER OPERATION

<Dr. Simpson> That is up to the surgeon. Most of us allow you in three weeks

<Laurie C> I know someone who had gastric bypass RNY and gained his weight back. what are the things that people do to make the surgery unsuccessful?

<Dr. Simpson> We wrote an entire book called "Getting to Goal and Staying There: Lessons learned from successful patients." To help you get there and to stay there. There are a number of common things for patients who make it to goal and stay there. You can regain your weight after any weight loss surgery if you do the following: eat the same things you ate before surgery, do not exercise, drink alcohol, graze, eat foods that are filled with processed carbohydrates. Essentially, with any weight loss surgery you have to change your lifestyle, if you do not. You cannot expect that you will lose to your goal and stay there.

<violet> what qualifies someone for WLS?

<Dr. Simpson> That depends on the insurance company but most of us, it is a bmi of 40, or a bmi of 35 wth co morbidities.

<jerry> how many calories should you eat a day, one year post-op?

<Dr. Simpson> That depends on what you want to do. If you want to lose weight then you have to eat fewer than your basal metabolic rate (BMR). If you want to gain, then eat more. The best defense against gaining weight is to eat small portions. Three meals a day, do not skip meals, and avoid highly processed foods and eat plenty of vegetables and protein first.

<ben> what type of vitamins should you take after surgery and is this forever?

<Dr. Simpson> Vitamins are forever, and the type of vitamin that you take depends on the operation that you have. If you have a distal RNY or a DS, then you need vitamins that have extra. A,D, and some K -- and you will need to have those monitored. There are a lot of vitamin companies out there -- good to investigate them and make that determination.

<Laurie C> Is the lap band technique as successful on someone with 150 lbs to lose?

<Dr. Simpson> Yes, it is. It is quite successful to lose that amount of weight.

<Cheryl G.> Hello Dr. Simpson! Have you ever started a Lap RNY and then had to go to an Open RNY? If so, what was the cause of having to do so?

<Dr. Simpson> That can happen, and has happened, and the reason for that are many - including scar tissue, problems with the instruments,and internal anatomy.

<Jan in MN> what is the difference in the lapband and lap rny?

<Dr. Simpson> The lap band is an adjustable ring placed around the top part of the stomach. The RNY is where the stomach is cut in two -- and the small portion the upper, is attached to the small bowel. Two different operations and we have a whole book "Weight Loss Surgery: A lighter look at a heavy subject." Written with diagrams about those operations.

<carol> what do you recommend is the most important thing when finding a surgeon?

<Dr. Simpson> Someone who you feel comfortable with.

<Renee Ramsey> Will I still have trouble with "emotional" eating?

<Dr. Simpson> Yes.

<Cheryl G.> Dr. Simpson, can wls "cure" a "fatty liver" condition?

<Dr. Simpson> Fatty liver is a complicated entity, and the recommended treatment for it is weight loss but it also means you have to not eat highly processed carbohydrates, such as white bread, simple sugars, candy, pasta, and rice. Send ice cream to me.

<helen> I know the national average for deaths is said to be 1 in 200, is each surgeon different?

<Dr. Simpson> It is a statistic, and that is all it is. You can have e a run of 600 patients without a death and then have three in a row. You can have a run of a thousand patients without a death butt, it is a statistic, and in some places it is as low as one in fifty.

<anne> If one is having the DS done in two stages laproscopically is there a chance that scarring from the first op will effect the second procedure. I have read that if one has internal scarring one can't have lap surgery? thanks

<Dr. Simpson> You can have them both done laparoscopically.

<Laurie C> I am a mother of twin 9 month old girls.and ended up with post parnum cardiomyopathy my infraction score went from 27 back to 60. is Rny extra riskey for me?

<Dr. Simpson> If the cardiomyopathy has resolved, you should be fine. So there might be some risk, but the excess weight will have a larger long term impact on your heart. We would recommend a cardiologist work you up prior to surgery to insure that there everything possibly done for a safe operation.

<jack> Do you do surgery for people over 600lbs?

<Dr. Simpson> Sometimes, although generally we have those. Individuals placed on a strict diet pre operatively to get them below 500 lbs. Sometimes that involves placing them in a rehabilitation unit but we do get patients on the table who weigh that much.

<laura> Dr. Simpson, I just love you! Your books are awesome. Do you have any new books coming out soon?

<Dr. Simpson> We do have a few books coming out, although they are still in the writing stage. Have a few things at home to do first but we have a few more to come.

<Beth in VA> How long have you been doing bariatric surgery?

<Dr. Simpson> Since 1991

<Laurie C> what is the best surgury to have as some with hypo thyroidism, borderline diabetic, Post parnum cardiomyopathyinfraction score 60

<Dr. Simpson> The operation that your surgeon does as a matter of routine. The thyroid is not an issue in surgery, nor is diabetes. The heart could be an issue, but probably not.

<Winter> can surgery be done on someone with congestive heart failure?

<Dr. Simpson> No, they have to be out of heart failure at the time of surgery and they have to be maximized for their heart performance and the cardiologist is of great help to maximize the ability of us to do the operation.

<monica> Hi, I'm 6wks postop and have stopped losing weight .I havent lost weight in 2wks is this normal and if so why does this happen and what can i do in times in when i stop losing weight for long periods of wks? RIGHT now i'm drinking 12oz. of protein drinks spread out through out the day giving me 60 g of protein. and 2tbs. of puree food 45 oz of liquids.o

<Dr. Simpson> A plateau is not just two weeks. The definition, of course, is in the book but instead of protein drinks, consider real food and eat simply three meals a day, with enough protein to get in the amount your body needs. All of which is outlined in the appendix of our first book "Weight Loss Surgery: A lighter look at a heavy subject" available at www.obesitydr.com. Forget puree -- go to solids, three meals a day, and if you snack, plan a low calorie snack, and high in protein but the best thing is to start an exercise program -- like walk, walk walk walk walk then walk some more.

<Blessed one> long term what problems are we possibly looking at with WLS?

<Dr. Simpson> If you look at it long-term you could die of obesity related problems. Oh sorry...if you do not take your vitamins, and eat poorly, you could suffer from protein-calorie malnutrition. Essentially you have to take care of yourself, and if you do not, then bad things can happen to you. You need to watch your calcium intake, make certain your bone density is watched and you must buy every book that I write.

<Cheryl G.> Dr. Simpson, there has been a lot of controversy over what form or Calcium post-op RNY, wls patients should take. What say you on this issue? Citrate or Carbonate?

<Dr. Simpson> There isn't a controversy except for those who don't know the data. The data about calcium is very clear; first of all you are talking about the anion that the calcium is affiliated with citrate vs carbonate. The first issue is that if you absorb it or not, and pills are not as well absorbed as either liquids or a chewable. The second is that the data, which was done with radio labeled calcium --- shows that there is little difference when taken with food -- in fact, the difference is not statistically significant. Citrate is absorbed better in a non-acidic environment. However the pouch does produce acid. So, there is no controversy, simply there is a lot of individuals who take for gospel myths which are not well founded. Those individuals take their viewpoint as gospel. Here is the simple truth: take whatever calcium you feel comfortable, and make certain that it is absorbed out of your stomach -- pills are not too well, lozenges (bariatric advantage) or chewable (Tums, Viactive) are liquids are you need to take the calcium with the meals, not on an empty stomach but, no doubt this simple, scientific, well researched approach offends those who think they read something on the Internet and take it as gospel. More about calcium in our free newsletter out next week.

<rachel> how long do we need to wait to drive after surgery?

<Dr. Simpson> I had surgery for my knee in 1987 and my ex-wife says that I shouldn't drive yet. Drive when you are off of narcotic pain medication, and feel your reaction time is back to normal so you can step on the brakes quickly should you need to for lap band, probably a week, RNY two to three, and so forth.

<Sue G> Will insurance pay for skin removal after WLS??

<Dr. Simpson> Often not, but some companies will.

<sarah> what percentage of weight does the average person lose from the RNY?

<Dr. Simpson> There is no "average" person who has the RNY, everyone is special. You can lose as much as you like, or you can lose very little. That is more up to the patient than the operation. Eat right, exercise, and take your vitamins.

<jessica> do you plan on attend any obesityhelp events other than your state this year?

<Dr. Simpson> I will be at the National Event in May in New Jersey

<ginger> do you except people who self pay?

<Dr. Simpson> Of course.

<belinda> Also I'm hooked on lemons i've been eating at least i lemon (the juice that is with salt) for the last 5days? will this harm my new pouch?

<Dr. Simpson> Might make it easier to pucker up. It won't hurt the pouch.

<mark> what is the medical reason that we dump?

<Dr. Simpson> It has to do with osmolar gradients between the small bowel and the blood supply. Simple carbohydrates break down into more osmotic particles and the fluid will rush into the small bowel to equalize the osmotic gradient and resulting in feeling faint, diarrhea, or boating. How is that for chemistry? Makes you wish you took it in college.

<Mari C.> What is the difference between distal and proximal RNY? Advantages / disadvantages??

<Dr. Simpson> Distal RNY will not absorb fat as well, advantages are for those who eat a lot of fat in their diet. Disadvantages are that you will also not absorb vitamin A,D, E, and K as well, nor calcium, and you will have more loose stools and after a few years the small bowel will accommodate to that and absorb fat better.

<amber> how come we can't drink with meals? is that only in the beginning?

<Dr. Simpson> Send the red wine to me -- Dr. Simpson, Phoenix Arizona. I prefer the expensive red wines because if you drink a lot of fluid you could force food out of the pouch and will be hungry again, which defeats the purpose.

<hope> what makes you so passionate to help the obese?

<Dr. Simpson> The passion of Ter...a new movie at theaters near you. Oh sorry -- it is fun to see people's lives change, and see fat melt away, which we don't see in regular surgery and we get to see them for a long time, which is both good and bad.

<mary> why is water so much more important after surgery, as before we could go with out 64oz, even through they recommend it?

<Dr. Simpson> You could not go without that before surgery, you simply were not aware of what you were drinking or how much, cause if you had not had that much to drink you would shrivel up, like dried out road kill. So because you cannot eat and drink at the same time, we emphasize drinking a lot of fluid between meals, and getting that amount of water in.

<Mari C.> Why are open RNY's done when Lap has shorter recovery time ? does this mean the surgeon is less experienced?

<Dr. Simpson> Not at all, most of the early RNY operations were done open --- mine were laparoscopic surgery has evolved greatly in the last few years to allow that to occur but older surgeons don't feel as comfortable with the laparoscope, and do a great job open.

<Lori> Is being at 53.1 BMI too much for laporsotic RNY

<Dr. Simpson> No

<Tamika> will most ins cover lap band?

<Dr. Simpson> Sometimes

<julie> What is your opinion on the effectiveness of Lap Band surgery over the other types.

<Dr. Simpson> It is just as effective, and safer.

<Tamika> after having wls are you allowed to chew sugar-free gum for nausea?

<Dr. Simpson> I don't recommend sugar free gum for nausea, instead find out why you have nausea and treat that. My jaw gets tired chewing gum, so I avoid it.

<Mary> I need your advice to tell my 6 and 3 year-olds about why mommy is having an operation.

<Dr. Simpson> Because mommy wants to see their children, and dance at their wedding and possibly have four more kids.

<Cheryl G.> I have high blood pressure which is hard to control even with being on several meds for the condition. Would this prevent me from having wls?

<Dr. Simpson> Not at all, although the anesthesiologist might want to get your hypertension under control. Prior to having the operation.

<MCP> Hi Dr. Simpson, Im 5'5 and weigh 200 pounds, I am extremely depressed and hate to leave my house because of the way I look, I know I do not weigh enough to get surgery, but Ive tried a TON of diets to no avail... your suggestions please..

<Dr. Simpson> If you are depressed then you need to see a professional about your depression because if you get over your depression , then get out of the house and onto the road and walk, and bike, and exercise, and then eat less, and move more. That is my best advice. See someone, not a surgeon.

<Andrea> Will my hormaones be out of whack after I have the GB

<Dr. Simpson> Hard to say. Every month I deal with an entire office full of women whose hormones are out of whack, which is why I close my office door and try not to disturb them and notice the chocolate disappears quickly. I try to do a lot of operations during that time. They all cycle together. It is a danger zone, and I have considered asking for hazardous duty pay.

<Angie> Do you prefer the lapriscopic or open surgery?

<Dr. Simpson> I prefer whichever operation your surgeon is comfortable with.

<laurie C> someone I know had a duadinal switch she said she had it because you never gain the weight back. is that better than RNY? how is it different?

<Dr. Simpson> You can gain weight back with any operation, including the duodenal switch and I do a lot of duodenal switch operations, and patients can gain it back if they don not change their lifestyle. The other myth is that you can eat anything you want with the DS -- which is simply not true, we call those patients failures.

<Donna in Raleigh> why is carbonation considered 'bad' for the pouch

<Dr. Simpson> Because the carbonation will force food out of your pouch and you will be hungry early and eat more. We have a nice section about carbonation in my latest workbook: Getting to Goal and Staying There: Lessons learned from successful patients.

<dee> does the shape of your body determine how you loose the weight

<Dr. Simpson> It determines where you lose the weight.

<JD> Not sure how to ask this, but with this permanent type procedure, what stops you from continuing to lose once you get where you need to be, in other words losing too much?

<Dr. Simpson> When your BMR equalizes, then you stop losing weight (see the workbook).

<Andrea> I am having Lap-GB on a Wed and planning to be able to work from home on the following Monday. Is that an unreasonable expectation?

<Dr. Simpson> Yes. Give yourself a break, Andrea. You are having MAJOR surgery. You have ONE good chance to recover, don't blow it.

<Jackieh41> I am a 46 year old woman, had gastric bypass with the vertical banding in 1993. Kept my weight off for ten years, then after a divorce gained it back, would the gastric banding be a good procedure for me?

<Dr. Simpson> We first have to discover why you gained the weight back. If it was because you ate the wrong things, then you need to relearn. If there was a technical problem with the operation then that can be changed. Just wrote an entire article about this in the latest Obesityhelp Magazine available from this website called "doctor, do I need a revision."

<laurie C> Why are smokers asked to stop smoking prior to surgery?

<Dr. Simpson> Why not -- because smoking makes more morbidity and mortality and if you are going to change lifestyle, then change them all.

<Randi> I am having surgery June 14. I am wondering about losing so much weight so fast. I remember the Carpenter woman was anorexic for a very long time and then when she gained 10 pounds she had a heartattack because her heart could not handle it. Could the same happen to overweight people if they lose weight too fast?

<Dr. Simpson> She had anorexia nervosa, and had a disorder from vomiting and having a low potassium. That should not happen to you. The Carpenter woman was a tragedy. Great singer, but had a problem. There is very little help for that psychological issue. It has the highest mortality of any of the psychological issues but that is not something that is caused by weight loss surgery, that is a psychological issue and in their realm of treatment.

<JD> If you have had previous Abdominal surgery can you still have the lap done?

<Dr. Simpson> Yes

<Brittany Mc Alister> should ALL patients that have Lap Band take a antiacid pill everyday??

<Dr. Simpson> No

<Tamika> what are the chances of leaks when having the lap band?

<Dr. Simpson> Very very very very very very small since we don't cut bowel and reconnect it. The only way it happens is if you poke a hole in it, which can happen, but is rare. Very.

<NANIE> dO YOU feel age of 65 is too old for lap band?

<Dr. Simpson> No

<Melissa> How will my birth control be affected post op?

<Dr. Simpson> Well, sometimes the pill is not absorbed as well. So depending on the operation, we recommend mechanical forms of birth control. I advise that you refrain from sexual activity for 17 years.

<Moderator> Last question goes to....

<jim> I'm having difficulty getting my insurance company to cover laparoscopic R-Y surgery, but they will pay for the open technique. Have you run into that before and what would be your suggestion at getting them to cover the lap proceedure? Thanks

<Dr. Simpson> They are simply being silly, and there may or may not be anything you can do. Remember, most insurance companies are NOT there for your health. There are some exceptions -- but that is clearly not one of them.

<Moderator> Dr. Terry Simpson, Arizona Bariatric Center. Website: http://www.drsimpson.com/. Phone: 602-234-8995. Fax: 602-230-8344. Books available at www.obesitydr.com.

<Dr. Simpson> Thank you all for wasting a perfectly good friday evening with me. Buy the books.

<Moderator> Thank you very much, Dr. Simpson. We enjoy your chats every week. We all thank you and have a great weekend. Thank you all, have a great weekend. Good nite everyone :-)