July 9, 2004

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

<Missy> Can you acquire diabetes after gastric bypass? How can the doc get an honest reading if you dumped and the drink went right out of you?

<Dr. Simpson> Anyone can acquire diabetes -- losing weight decreases the body's insulin requirements but the potential for diabetes is always there. When you say reading, if you refer to blood sugar - we can get that quite accurately and if you dump, you dump. So, please don't dump, if your question is -- how can you get sugar back into you if you become hypoglycemic? That becomes difficult if you do dump--- but not impossible. We recommend low glycemic index carbs and monitor your sugars carefully. Good question.

<Riley> Dr. Simpson, do you recomend your patients take iron after wls? And is it true we do not absorb Ferrous Sulfate

<Dr. Simpson> You do absorb Ferrous Sulfate -- just not as well as someone with a larger stomach and more surface area. We do recommend for women who still have their periods to take iron for others it is important to watch iron levels and a blood count to make certain that this will not be a problem. Of course, all of this is nicely outlined by your surgeon or there are some good references for it.

<Annie(ND)> What Happens to the Stomach that is not used anymore? and can it cause health probs further down the line

<Dr. Simpson> The stomach that is not used is simply there and hanging out, it is not a problem but it can still get ulcers, cancer, and the like -- there is no evidence that it is more likely to or not because of the surgery.

<vonnie> Hi Dr Simpson my question is about Staple Line breakdown. I just recently found out that mine has broken down if it doesn't get repaired can there be any complications arising from it? I am seeing a surgeon and discussing options what is the best way to repair it?

<Dr. Simpson> The only way to repair a staple line is to do revision surgery --- the real question is what sort of surgery you had, and I will guess it was an open RNY in that case the stomach will have to be transected -- cut into two pieces, and oversewn. Sounds easy, but it is not quite that easy. There are some nice pictures of that in my book.

<Annie(ND)> With all the *bad* things that can happen with this surgery. Like gall stones kidney stones blockages malnutriotion etc....is it truly any better than being overweight with 1 or no co morbidities?

<Dr. Simpson> That is always the trade off but not all those things happen. Not everyone gets kidney stones, and they can be prevented. Gallstones can be taken care of at the time of surgery by removing the gallbladder, it isn't a necessary organ and blockages happen anytime someone has surgery or potentially can happen. Malnutrition is rare after surgery and happens only if the patient does not follow the instructions given by the surgeon. The question is why not have surgery but it is something that can be done. It is a trade off of risks and rewards. We generally say that morbid obesity costs a person an average of twelve years, and that the risk of surgery is 1 in 200 deaths, sometimes higher so it is a question that many struggle with. I would rather have a healthy overweight person than a sick skinny one all in all, obesity surgery is safe, effective, and works well, and patients have an improved quality and quantity of life but not everyone. Sometimes people die -- and there is not much we can do about it, and not a very good way that we can predict who will and who will not. Good question.

<hopefulheather> How soon would I be released to work as a bus driver after having a LAP RNY with no complications?

<Dr. Simpson> Two to four weeks without complications, although if you are a bus driver for a senior center it can be sooner -- especially if it is for my mother-in-law.

<Boo@goal> Explain when a revision is necessary please

<Dr. Simpson> A revision is necessary if there is a mechanical or anatomic problem with the surgery which needs to be corrected, or for which there is no weight being lost, you do not do a revision if someone simply has not followed instructions. I have a whole chapter about revisions in my book-- for each surgery, and which and why we do them and hope to make that an article for the magazine in the next year so get the book, or subscribe to the magazine and you will see it.

<Patty> I will be having lap RNY. What if an ulcer is discovered after the surgery starts?

<Dr. Simpson> We don't see ulcers from that side of the stomach -- you would have to be looking inside the stomach with an endoscope. But if you find one then you treat it with some medicine -- like prilosec or nexium, unless the ulcer was clearly needed to be treated with some surgical option, and that would be rare indeed.

<BRIAN B> What is the best form of powered protein to use?

<Dr. Simpson> Steak. Most of the time people do not need protein supplementation. However, sometimes they do, and if you do then you want a protein powder that is "bioavailable" meaning, that the body can absorb it and that it contains essential amino acids. Whey based proteins powders are the best -- but again, I think these taste like sawdust and would much rather have my patients get protein from food than from curdled milk product.

<shawna> What causes hernia's and how are they repaired?

<Dr. Simpson> Hernias are a hole in the fascia (the fascia is gristle in the muscle--not the muscle, but the tough stuff). When we do surgery we cut open that fascia and then we sew it back together when we finish the operation. Where we open it there is a natural weakness, which takes a long time to get better especially after weight loss surgery because you do go through a period of malnutrition. So if you put some stress on that area -- like lifting your children, or working out too early, you can cause that fascia to tear, or to open a bit -- or to weaken, and it will bulge and then you have a hernia. The danger of hernias is that bowel can become trapped in them, and if it does can perforate which is how Queen Caroline died 400 years ago from an umbilical hernia. To fix them is to either put a patch of material on them, to reinforce them and the downside is that if that material becomes infected it needs to come out or to simply sew it back together -- if it is small enough. There is some new material made from pig collagen (fascia or gristle) which is resistant to infection -- but is a bit expensive to use for everyday hernias, but in high risk ones it is a good thing to use. So, if you are a football fan-- ask for pigskin.

<Lanita> I have tried every diet there is to lose weight, what else can i do to lose weight until i can talk with my doctor about having surgery?

<Dr. Simpson> Eat less and move more, hard to do, but it is the best diet plan that there is. You might try the South Beach diet -- or the Simpson diet is another good one (we call it the Road Kill Diet) but get a podometer and start taking 10000 steps per day -- walk more. So it is tough, otherwise I wouldn't be here, there is no magic diet -- although mine is pretty good -- possum on the grill of a Ford.

<ERIN-AK> ok.. Here's a weird one.. for the past week all the solids I have eaten, proteins only have made me very queezy, and no I'm not preggers.. what is it.. 6 month check said everything is fine last week.. and I am n ot eating funky foods.. jerky, isopure juice drinks and protein bars.. and some chicken

<Dr. Simpson> Might be the protein drinks that make you queasy, and it is not unusual. Sometimes certain things don't sit well and protein bars sometimes don't. We have a saying in surgery -- ok, I have a saying in surgery -- in the post op period go through it this way: swim, fly, walk. The first month, don't eat anything unless it swims -- like shrimp (ok they crawl but they are fun to catch, those little buggers really fight with those tiny hooks) the second month things that fly (I know chickens really don't fly, but if you toss them from a plane they sort of do) and the third month things that walk. Avoid fried foods, and overdone meats... the last thing the stomach tolerates well is overdone, fried, red meat and some days some things will settle better than others-- and you may have strange dietary problems for a while -- part of the charm.

<Melissa> Which weightloss surgery has less down time and less scaring to the body?

<Dr. Simpson> The lap band is the least invasive, the least down time and has the least scar.

<Faye> I had my first visit with the surgeon for the gastric bypass surgery. Iam 5'4 and 235 and my bmi is 39..it looks like i could have surgery as early as late august or early september...i would like to begin exercising and dieting now to get a head start on the surgery and i was curious as to what would be a minimum bmi or weight that i would be able to still have the surgery...my comorbidity factors are type 2 diabetes, high blood pressure and high cholesterol

<Dr. Simpson> 35

<Richard|WA> Do you know the absorbtion rate difference between proximal distal etc? like is distal a 50% absorbtion and proximal 75% absorbtion etc

<Dr. Simpson> It varies from person to person -- we actually have studied our patients with a duodenal switch and found that they absorb about 30 per cent of the fat and 30 per cent of the protein and most of the carbs. We have not studied the proximal bypass patients -- or lap band. However, it is clear that it is not the malabsorption that is the issue -- rather it is the restriction in the amount that one can eat that is, you eat less, and therefore you lose more.

<Patty> what are some of the reasons lap RNY would turn to open RNY?

<Dr. Simpson> Anytime we do laparoscopic surgery we reserve the right to open the patient because things can happen. Too much scar to get through --- or the instruments don't fit well, or any number of technical reasons and if you are opened it is simply Good Judgement by the surgeon to do so.

<kathleen g> Dr. Simpson: I'm having my second AVN hip replaced on Monday. As an open RNY patient of four months, is there anything I need to inform the anesthesiologist prior to surgery? Thanks.

<Dr. Simpson> Not really, there is not but good luck on the hip, they will give you antibiotics and you will do well.

<Richard|WA> Can drinking water Constantly or any liquid.. say like 30oz in a half hour stretch your pouch? or does it really just past thru like a funnel?

<Dr. Simpson> It should pass through unless you gulp a lot of it and try to chug it -- but it should passively go through the pouch easily, if however, it does not-- then you can stretch it out so do not gulp -- sip like a fine Kentucky bourbon Kaintecky (however they say it down south).

<Kathie/HI@Goal> Dr. S... How long after abdominoplasty does it take for the feeling to come back? I am 5 months post-TT and it is still numb as can be!!

<Dr. Simpson> It can still come back a bit after two years, however, after the first two months you are about where you will be. Numb numb numb (old joke)

<Lynn E.> Dr. Simpson, I am 4.5 months post-op and have lost 80 pounds. I'm very pleased with the surgery and the results, however, I am concerned about "anorexia-type" symptoms that I'm experiencing. I'm afraid to eat.

<Dr. Simpson> Do not worry about that -- I don't think that will be a problem and in a few months you will be in the chatroom asking what to do about the plateau you are on and that you are eating too much, everyone will want to tell you to eat more. Don't listen to them, listen to your surgeon and the nutritionist, not to the other folks -- and you will regain your appetite if it is lost and don't worry about the fear of eating. However, if you are truly concerned that you might be changing one eating disorder for anorexia, then I would suggest you begin to chart what you do eat -- on www.fitday.com, for example, or write it down, including the quantity and make an appointment to see a psychiatrist to see if this is normal or not. Remember, you will have reduced portions -- by design, and your appetite will not quite be what it was. Although I remember one fellow after an open Duodenal switch his first question to me was," Hey doc, when can I get a little something to eat." Good luck.

<shawna> does the surgeon have to take special precautions when a patient has sleep apnea, if so what?

<Dr. Simpson> The main precautions are after surgery because you are taking narcotics ---- then you may not wake up enough but during surgery you won't have a problem

<Goldie> I had my RNY 8-19-03 and am down 105#. Started at 318#. Am I doing OK? I feel like I am not loosing like I should.

<Dr. Simpson> That is a great weight loss and I applaud you for it, you can always lose more by walking.

<Carmella> Dr Simpson, Do you have to be under a certain weight to have Lap surgery instead of open.

<Dr. Simpson> Some patients have a bmi which is too large for some surgeries and some instruments but that is also dependent on the body type for lap band we can pretty much do it all laparoscopically and for some RNY we cannot-- all depends, the surgeon will make the call.

<Lynn E.> With the prevalence of "Atkins-friendly" foods, I have attempted to eat "low net carb" foods, and have dumped. How are "sugar alcohols" processed by people who have had WLS?

<Dr. Simpson> Sugar alcohols will cause dumping, so avoid them -- they are not worth it. You do not have to eat low carb foods in fact, that is a myth. You should eat carbs that have a low glycemic index -- and for those charts you can either use my book, or you can get a book called The Glucose Revolution, which is another best seller (but not by me). Low glycemic index foods should not cause dumping, by the way.

<KaarenND> I had open RNY surgery Feb 6 of this year. Two or three times a week when I eat I end up throwing up but it isn't food, just white stuff. looks like I coughed up a large jellyfish. Will this get better? I eat slow and chew well but things get stuck sometimes anyway.

<Dr. Simpson> Sounds like you have a stomach that is just having a rough day, sometimes they do after surgery, no matter what you do. Sometimes this happens when you don't have enough water in you and sometimes it is a little more difficult than others to get things in. Again, one of the joys of surgery. It does become better with time-- keep measuring what you eat, and eat slowly and don't gulp.

<MARIE (BOSTON): dr Simpson how much B12 should I be taking every day? remember I have cfs/fms

<Dr. Simpson> You should base the B12 use on what you have -- and have it measured by a lab and followed by either your primary care physician or a hematologist most do not absorb pill forms of B12, but do the sublingual (under the tongue) just taking it is not a good idea-- as you will waste it if you take it that way so have it checked first, and followed, then you may only need it once a month.

<Patty> after wls is it safe and a good idea to constantly sipping water?

<Dr. Simpson> It is always safe to sip water -- water is good, water is great. However, not all bottled water is as safe as tap water, and we are aware of that here in Phoenix because our tap water tastes so bad that I compete with the dogs for the mud puddles outside. We drink a lot of bottled water -- and some bottled water does not have the same standards as tap water. So there is an increasing incidence of a bacteria found in certain bottled waters. Interestingly enough-- lightly carbonated spring water is safer than the non-sparkling water and yes, it is safe to drink that.

<shawna> Can you get pregnant after wls if so how long after?

<Dr. Simpson> I have been unable to get pregnant and I have done a lot of wls. Then again, I am a man but still I cant seem to get over that. We advise that patients wait at least two years after weight loss surgery to become pregnant and I advise my patients to avoid sex for 17 years after weight loss surgery and I never understand why patients are not compliant.

<DonnaL> I have had a potassium problem in the past--as low as 2.3 oince I have surg could this become a problem again?

<Dr. Simpson> That is not one of the common problems after weight loss surgery. However, if your potassium level was low because of some medication that you took or because of some kidney ailment-- it could become low again however, weight loss surgery is not, in and of itself, a problem.

<Boo@goal> Explain when a revision is necessary please

<Dr. Simpson> A revision is necessary if you have a mechanical problem with the original surgery, that is causing a problem . There is a lot that can be said about this and I have a whole chapter devoted to revisions in my book -- and will be writing an article for the magazine about revisions later in the year.

<Carmella> Can a gallbadder be removed thru lap or do you have to have open

<Dr. Simpson> It can be removed laparoscopically by most surgeons at anytime -- in any garage in the world. I recommend Mr. Goodwrench.

<Kansas> Had Mason-Shunt in 1979. Have gained back weight. Is my stomach totally stretched out or can I do something to reshink size without surgery.

<Dr. Simpson> It is difficult to say if your stomach has stretched, or if there is some other problem unless we have some studies to look at it. You cannot reshrink a stomach -- in spite of what people like to say-- stomachs become large from chronically overeating them. They do not become large because of one meal and if it is, and you can not maintain a normal weight, then you might need to have a revision of your surgery and some good nutritional information ahead of time.

<Moderator> And the last question of the night goes to...

<Kristi 4 days 2 go> I am having surg in 4 days, is there anything I should avoid in my final days until surgery?

<Dr. Simpson> Avoid the "last supper syndrome" because if you eat too much you might get an overly fatty liver which is not fun to deal with in the operating room and start to walk, and get in shape and be of good cheer you are going on a great journey -- and it will be worth it in the end.

<Moderator> Thank you all for joining us this evening. To learn more about Dr. Simpson, please visit his website. http://www.drsimpson.com/, or call 602-234-8998 (Fax: 602-230-8344) to schedule a consult. You can get his book at www.obesitydr.com.

<Dr. Simpson> For those of you who wish to see excepts from my book, you can go to www.obesitydr.com and see a few things -- it is filled with comprehensive stuff, and a lot of humor.

<Moderator> Thank you Dr. Simpson, have a great weekend. Thanks to all the members for joining us.

<Dr. Simpson> Thank you all for another fun Friday evening.