April 22, 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> Hey all, I am ready.

<Chrissy> what protein shakes do you recommend

<Dr. Simpson> Morton's, Ruths Chris, Outback. Steaks, not shakes.

<SUZY-Q> IS IT NOR MAL FOR A PERSON 3 YEARS OUT TO HAVE PROBLEM ABSORBING IRON?

<Dr. Simpson> Food gives you the best source of protein. Yes, iron absorption is a major issue with patients, and it can occur at anytime, and needs to be monitored if it does occur. So if you have it -- take iron supplements. If you are a female still having periods then two iron pills a day but do not take them with calcium.

<Sandy> Hey i am almost 7 months out i would like to know how much i should be able to eat now

<Dr. Simpson> It depends -- you can eat as much as you like and that is dependent upon what you eat. If you eat soft foods, carbohydrates that are highly processed then you will end up eating a lot. A bagel is 550 calories, doesn't last you long, and you can eat a few of them or you can eat meat and vegetables, and eat fewer but that is the idea. Eat less, feel full, lose weight.

<Kimberly> Hello Dr. Simpson. I am 2.5 yr post op and down about 100 lbs. I still have another 60-80 to lose and my surgeon has found that my pouch is enlarged. He mentioned a non surgical way to reduce the size of the pouch/stoma, but did not go into detail. Do you know about this proceudre and what it entails (hospital stay, meds, etc) Thank you.

<Dr. Simpson> The pouch and the stoma are two different things. The stoma is the opening between the stomach and the small bowel. It can be reduced with sclerotherapy -- where a gastroenterologist injects it with material that will cause it to scar down. It is an outpatient procedure, and requires one or two applications, if the pouch is enlarged the way to reduce it is with surgery. The final way is to simply have a lap band placed over it, and that will take care of it. In the last Obesity Help magazine I outlined revisions in an article. Get a copy today.

<SUZY-Q> DR. SIMPSON I HAVE GAINED 30 LBS. I NNED TO LOOSE 50 TO BE AT GOAL ANY SUGGESTIONS?

<Dr. Simpson> Eat less and move more. We wrote a workbook called "Getting to Goal and Staying There: Lessons learned from successful patients." That book will work you through the process to get to goal for those last stubborn pounds and have delicious recipes that you can use as well as menu plans, and the whole process of what makes a successful patient no matter what surgery you have had. It is available at www.obesitydr.com, good luck.

<Sandy> CAN YOU STRETCH YOUR STOMACH AS BIG AS IT WAS BEFORE SURGERY?

<Dr. Simpson> No.

<Bonnie> For a RNY patient 5.5 years out, can you give an idea of where the pouch is located (if standing in front a of person)? Would any of the connections be in the belly button area?

<Dr. Simpson> It is below the xiphoid bone -- the sternum or breast bone, not connected to the belly button.

<Sandy Spera> What determines whether surgery can be done lap or open?

<Dr. Simpson> The surgeon.

<Jerry> why does the ds have a better lost rate, 85% body weight compared to the lapband and Rny?

<Dr. Simpson> Early weight loss the DS outstrips all weight loss operations, and works quite well but the key to maintaining weight loss and long term is not the first year, it is making the lifestyle changes necessary to maintain it and in the long run, if you do not make those changes you will regain weight. One reason some prefer the lap band is that it works more as a tool forcing you to make changes and if you do you see the results -- which is why they have equal weight loss after several years. The bottom line is chose your operation by what works for you, what you can afford, and what makes sense, or what your surgeon does. They are all tools, and they will all work if you make the changes. If you can eat whatever you want and still lose weight in the first year, you are on a path to regain weight.

<Bonnie> Are there benefits to stopping vitamin supplements for a specific time prior to having the annual blood work drawn? Is it something to consider if previous labs have been within safe ranges?

<Dr. Simpson> We stop the supplements because some of them will interfere with the tests and because it will give us an idea about if your diet is such that you are getting enough vitamins and minerals in it.

<SUZY-Q> I HAVE TAKEN IRON BY IV FOR 6 WEEKS AND IRON IS STILL 52 FERRATIN 72 HOW BAD IS THIS?

<Dr. Simpson> You have an iron deficiency that is needing major treatment. It is not something to fool around with you will need to continue to take iron for the rest of your life, and be very serious about it.

<cateyes"N"GA> could you please tell me what the H-pylori test indicates ?

<Dr. Simpson> It indicates if you have the bacteria which causes an ulcer. Ulcers are formed, in the stomach by a bacteria, and the test tells you if you have those. They are also formed by mother-in-laws, however, antibiotics get rid of the bugs, but it is much harder to get rid of a mother in law. T they are fast riding on those brooms.

<Anna> why is losing weight before surgery important?

<Dr. Simpson> Some feels it shows commitment -- but there is nothing to indicate it will show long term compliance besides if you lose it before surgery you will never have to gain it back.

<Linda Williamson> I am 3 weeks post of RNY. I was having trouble getting enough protein intake. I increased drinking "Boost" to 3 bottles a day, however, I have now gained 4 pounds. Will this reverse?

<Dr. Simpson> You need only so much protein, and there are better sources of protein than Boost. You need to monitor you calories, and increase your activity. Food is the best source of protein, not Boost. t will reverse if you eat right.

<LindaR> I am about to have Lap RNY and wondered does everyone wake up with a NG tube?

<Dr. Simpson> No.

<Chunk> Doc, I am having issues with Gout. When I only eat protein and veggies I aggravate my Gout alot. If I eat more carbs I rarely ever get Gout. However when I eat carbs I rarely ever lose weight. I am 13 months out and have only lost 100 pounds. I still weigh 350 and feel like i'm in a catch 22. Any suggestions?

<Dr. Simpson> First of all, protein has every bit as much calories as carbohydrates and I would have a hard time believing that you are eating spinach and gaining weight. Eating bread, pasta, white sugar, and the like will inhibit weight loss, but you don't need to eat those. You can eat some good carbohydrates --- such as legumes, green or yellow vegetables and you only need so much protein to maintain body functions and you do not need the fat associated with that. So reevaluate what you eat, and consider that you might need a more carb based diet but you do not need PROCESSED foods -- do you know what I call processed foods, PRE CHEWED -- because some machine has broken them down so your digestive system doesn't have to do work. So dump the red meat, eat more fish, eat less fat, and eat more vegetables and your gout will be much less of a problem.

<Stacie P> Hi, I had RNY last Friday. I've been a bit anxious lately about the connections holding up for the rest of my life. I'm 31 now. What's the long-term outlook on the surgery?

<Dr. Simpson> They will hold up just fine. Relax.

<Julie> Hello, I am 7 weeks Post op and I am not loosing weight like everyone else. what can I do to have the weight come off faster

<Dr. Simpson> You cannot compare yourself to everyone else ---- you lose weight based upon how many calories you burn and how many calories that you eat. You can burn more calories by increasing your exercise, and you can not eat as many calories by making better choices in the foods that you consume. T then you can watch the weight come off. Your body is perfect at recording this.

<Jes> I've heard in some of the earlier surgeries the intestine would stretch out to accomidate the new stomach, does this still happen?

<Dr. Simpson> The small bowel has a great capacity to absorb better as time goes on. The most radical malabsorptive procedure left only 18 inches of small bowel but after a few years those individuals gained weight again because the small bowel grew. Today, the longest malabsorptive bypass procedure leaves you 40 inches of small bowel, so it will take not too much time for the small bowel to be able to absorb fats better, which is why the "restrictive" component of the operation is so important. Eating less, feeling full with less, it is the best and safest form of weight loss surgery.

<Lisa> why does it seem people have to get revisions on the lapband to the RNY? Was it the surgery or the person that failed?

<Dr. Simpson> We have the opposite in my practice, people who had the RNY that are getting a lap band, or people who had a DS that are getting a lap band. The RNY is better known by some surgeons, and they convert folks back to it. The lap band requires a lot of work on the surgeons part, and the patients part to make it work, not all are willing for that.

<prissy> can you drink alcohol after RN-Y surgery?

<Dr. Simpson> Sure. I might have a martini later. The problem is that you will absorb all the alcohol and all of the calories in the alcohol. So you can drink, but you can gain weight from it.

<farah> when we lost rapidly do we lose muscle? how do we build this up again and stop muscle weakness?

<Dr. Simpson> You can lose muscle mass if you starve yourself, that certainly can happen. If you lose too fast that can occur and what I mean by TOO FAST -- is if you starve yourself. Best to not lose muscle mass, best to lose fat and burn fat, so that is why it is important to take an adequate amount of protein and the amount of protein is specific. In my first book "Weight Loss Surgery: A lighter look at a heavy subject" we have the amount of protein which is needed for each individual based on the operation they have, it is in the appendix of that book.

<lisa> DR Simpson- today I was told that BCBS of Az would not cover my lap band procedure but would cover a DS? Is it worth trying to appeal that, or should I give in, and have the DS done. I am so bummed!!

<Dr. Simpson> It is always worth an appeal, and they change their policy all the time. That they don't cover it today does not mean they will not cover it tomorrow.

<wendee> In your experience if your patient was 5' 8" 467 lbs BMI 71 and female, would you feel 100% that you could perform lap RNY?

<Dr. Simpson> Every surgeon has a different criteria. One of my favorite surgeons has probably more experience with laparoscopic RNY than anyone and will not perform it if the BMI is over a certain point, which has changed over the years, but everyone is different, so you have to check with your surgeon.

<Marc Phillips> I am interested in knowing about head hunger VS real hunger... and how does the surgery help with either of these.

<Dr. Simpson> If you are full you will not be hungry -- your head might have an appetite, but your stomach will be full. The head has its own way, as any woman will tell you.

<sue> are there standard tests a pre lap bander can get out of the way ( with primary doctor) before consultation with the surgeon ?

<Dr. Simpson> It all depends on the surgeon -- some have a list they want, and it is best to call their office and ask them. Some have more than others, there is no "standard," some of us base it upon our examination and history of the patient.

<Carmen> I weigh 279 and I am pre-op, does everyone that is this heavy always need plastic surgery for hanging skin?

<Dr. Simpson> No.

<wendee> I was told we wont be able to drink through a straw, what is the reason for that. My teeth are very sensitive is the reason for the straw?

<Dr. Simpson> Not a clue. I think straw is nice for bedding. Straws may increase air gulping, so some surgeons don't like that. See the dentist about your sensitive teeth.

<Carmen> How soon after surgery can you drive, vacuum, lift light weight?

<Dr. Simpson> I had knee surgery in 1987 and have avoided the vacuum since then. Dangerous instrument that thing, also housework I have avoided. You can lift about ten or fifteen pounds after surgery, and you have to see how long you can lift more --- I tell my non-lap band patients at least six months for the driving, I tell them that they should begin driving when they are off all narcotics for at least a day and when their reaction time is back to normal. I have been told that I still shouldn't be driving.

<sue> when on clears can we add a protein suplmt. to our clears like ( unjury)?

<Dr. Simpson> You won't need the protein on clears, so don't worry about it.

<SHARON SILVEY> I am wondering if 61 is to old for the surgery.

<Dr. Simpson> No.

<liz> My Dr. wants me to have a endoscopy. Is it an uncomfortable procedure?

<Dr. Simpson> For some it is, for others it is not.

<danielle> what does promixal stand for - what does distal mean

<Dr. Simpson> In my book we have diagrams of the various procedures, proximal and distal. It refers to the amount of intestine which is bypassed. The book is called "Weight Loss Surgery: a lighter look at a heavy subject."

<Babygirl> What is the youngest you will operate on

<Dr. Simpson> 16

<danielle> does the RNY cause cancer in the long run

<Dr. Simpson> No.

<Janette> I had a RNY 7-13-04 and went from 363#s to 201 so far (-162 lbs) Should I keep loosing for a while?

<Dr. Simpson> That is up to you. Yes, you should keep losing unless you are six foot five inches tall and to lose more you need to move more, and make good food choices.

<emmywing> Hi I had the SRVG done in 98 I have kept off 75 pounds but have this horrible problem with bile reflux. I have constant heartburn and nausea and I vomit bile and stomach acids several times a week. Can you tell me what causes this and what needs to be done to fix it. I have heard that it is a common complication of the SRVG. I also was told that the RNY would fix it is that true?

<Dr. Simpson> The RNY does not fix reflux, it makes an emptying easier, but it does not fix it at all. That is a popular myth popularized by some weight loss surgeons who have no clue about the anatomy of the stomach and esophagus and think that the RNY is a great operation for reflux -- they are sadly mistaken. You need to have an evaluation about the reflux, determine where when and why it happens and consider the surgical options from that perspective.

<sharon silvey> I am diabetic and have a condition where the muscle doesnt push the food through and take medicine for it. Would it keep me from surgery.

<Dr. Simpson> No.

<Babygirl> will this surgery affect a woman getting pregnant?

<Dr. Simpson> Well, that has more to do with a man than surgery. If you have a man, you can get pregnant, but the surgery will not help you get pregnant but you might find you feel better about yourself and you might find that your ovaries work better when you lose weight and you might find yourself more fertile and if you come in contact with a willing guy, then you might make a baby but I refrain from going into detail. The storks fly better after that surgery.

<cateyes"n"GA> DR. Simpson I took the h-pylori test and it was high, now I am on a cocktail of pills for two weeks . After i stop can this bacteria come back?

<Dr. Simpson> Yes they can come back.

<Bonnie> Do you do the lap band over a rny? If so, how long and what's the success/problem rate?

<Dr. Simpson> There was a great article comparing the two operations and the issues around both the lap band is the safest surgical procedure we have, and after three years the rate of weight loss intersect. That is there is no statistical difference between them.

<Denise> how would you tell if you have a blockage in your pouch

<Dr. Simpson> You won't be able to swallow your own saliva, and that becomes a social problem unless you live where I do, in Arizona, where we have a lot of spittoons in the saloons. Of course, you won't be able to drink the booze either, so that might be a bigger problem because why would you be in a saloon if you can't drink but all you can do is spit.

<abby> How soon after GBS it is safe to have another operative procedure? I need to have a revision of my TKR but felt it was better to do the GBS first so I recover at a lower weight

<Dr. Simpson> Six weeks.

<Anastasia> Is there such a things as loosing too fast? I am 2.5 months post-op and am down 75 lbs makeing me only 41 lbs from my Dr.'s goal for me

<Dr. Simpson> IF you lose muscle mass, and are protein - calorie deficient, then yes --- on the other hand, if you are maintaining energy level, and doing well then the only problem with losing too fast is jealousy.

<sharon silvey> Does Medicare usually pay if you have several comorbidities?

<Dr. Simpson> Sometimes.

<Bonnie> DR Simpson, I had trouble order the workbook from the website. I spoke with Kathleen in your office yesterday. She was wonderful. Jut have to compliment you on an excellent staff person.

<Dr. Simpson> She is adorable, and pleasant, and nice, and will kick my behind if I say different.

<Polly> I was wanting to know if with the RNY LAP if the infection risk is much much lower than it is with the open

<Dr. Simpson> No.

<Christine..Pa...> Had a hernia operation in Oct 2004 and have another do yuo think Lap oscope would be better, due to so many times stomache has been cut, Iam more prone for more hernias

<Dr. Simpson> Hernia rate after weight loss surgery is 22 per cent and once you have one, you are prone to get more. Sometimes laparoscopy is better, but sometimes it is not feasible.

<Linda Williamson> Crystal Light has been recommended as an alternative to water. Are there hidden problems or is it the equivalent to water?

<Dr. Simpson> It is water and flavoring --- so it should be just fine.

<Mary> How do you know if you have a staple disruption?

<Dr. Simpson> Depends on where the staples are and what they are holding together. If it is a leak -- then you will be sick, if it is between the upper and lower stomach then you need an upper GI to determine that, if you live in Seattle then they rust out.

<Franziska> How would RNY effect absorbtion of medications? Does it differ by type or class of medication? How is this handled?

<Dr. Simpson> It isn't handled. Some medicines do not absorb as well after RNY, and you have to monitor that, by the effect the medicine has. If you have a distal procedure then taking time released medications might not work as well as others. We go through a list of these in our first book.

<Kathleen Barnes> Dr. Simpson, when I have my LapBand put on, will you take out my gallbladder as well?

<Dr. Simpson> If it needs it, yes, if it does not then no.

<sharon silvey> What is a DS

<Dr. Simpson> Duodenal switch, an operation that is fairly complicated and only a few of us do that procedure. A good weight loss procedure.

<geinie> What steps are necessary to be approved for bariatric surgey if you are on medicaid, the state medical insurance for low income?

<Dr. Simpson> Every state is different, so it is impossible to know -- but your bariatric surgeon will know and can guide you through the process.

<Carmen> After how long can you do exercising?

<Dr. Simpson> You can start walking the day of surgery and keep walking until you reach the ocean, then I recommend you swim, or hold your breath.

<Christy> what is the average cost for gastric bypass surgery?

<Dr. Simpson> 15 to 30 thousand.

<Carmen> what can I do so that I don't need to have plastic surgery to remove skin?

<Dr. Simpson> Don't have anything that will cause the skin to stretch but that might not be an option if you are asking me, so I don't think there is anything you can do. However exercise is the best way to make certain you have the least amount of excess skin, I like sharpeis.

<Margaret L> How long after sugery do you have to wait to start thinking about starting a family?

<Dr. Simpson> Two years -- or, forever if you are related to my family.

<Kathleen Barnes> How long after surgery can I go swimming?

<Dr. Simpson> Generally three weeks -- so if you reach the ocean before then, turn around.

<Moderator> Last question goes to...

<Narnia> If you have lap band surgery how long do you have to wait to have another surgery. I may need surgery on my ankle.

<Dr. Simpson> Six weeks. Thank you all for another nice Friday. I will not be here next week, so we will see some of you in two weeks. My books are available from www.obesitydr.com and my free newsletter is at the www.drsimpson.com website.

<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. Thank you very much, Dr. Simpson. We enjoy your chats every week. We all thank you and have a great weekend.

<Dr. Simpson> Thank you all.