October 8 , 2004

<Moderator> Welcome to tonight's chat with Dr. Simspon. 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!

<Kasey> Who does the psyshosocial evaluation that my insurance is requesting?

<Dr. Simpson> Any psychiatrist or psychologist will do. Don't tell them about the voices.

<Pam De Priest> I am worried about using my c-pap machine 9 days post-op. because of getting air into my stomach. Should I be concerned?

<Dr. Simpson> We have a lot of patients on CPAP and that is not an issue. You need the CPAP to get a good rest at night. It should not be a problem for you at all.

<ShelleyNC> My Lap RNY is scheduled Nov 2 which is a little more than 3 weeks I have just in the past few day's stopped smoking is this enough time, will I be o.k. for the surgery?

<Dr. Simpson> It should be just fine. Stay away from the tobacco and begin your vitamins now. Concentrate on eating good meals between then and now and learning about nutrition. Good luck.

<martha in Ga> Can you tell if there is any long term problems from having this type of surgery?

<Dr. Simpson> There are always long-term issues with any surgery, especially those in which we rearrange the guts. The first is that you might develop a hernia, or you might develop some adhesions -- which are scar tissue in the gut. Those happen, or can happen after any surgery, with this surgery -- you have to be certain to take your vitamins and supplements and test for them because otherwise you might become deficient in one of them, and it is easier to prevent a problem than it is to treat one later. You should also get a bone scan to check for bone density, and have your primary care doctor follow that. Some people think that the surgery might lead to osteoporosis. Although there has been no data to suggest that would be a problem, the main thing is to keep up with your surgeon, and your primary care doctor and to learn as much as you can about the surgery. I can recommend a good book. Good luck.

<martha in Ga> Can your staple line break down after a few years?

<Dr. Simpson> It is unlikely -- most staple line breakdowns occur in the first few months or in the first month-- after that the stomach is very well healed. The one thing that can happen with the RNY is that the stoma -- or the opening between the small pouch and the intestine can enlarge to where it allows anything through, so you do not maintain a sense of satiety for long and if that is the case that can be corrected with sclerotherapy done by a qualified gastroenterologist. Otherwise -- do not tax your staple line -- measure food twice, do not over stretch things and don't vomit. Good luck.

<dancin d> Is it ok to have a flue shot 3 mos. post op and 55 yrs. old?

<Dr. Simpson> It is fine to have a flu shot, although there is a shortage of the vaccine this year so it might be difficult to find someone to give you the shot. I am going to sacrifice my dose this year. Aaaachew.

<martha in Ga> Will WLS affect a person with IBS, and how?

<Dr. Simpson> Irritable bowel will not be affected by weight loss surgery. Some patients report that it is absent, and some people notice no change at all. But you can have irritable bowel and have the surgery without a problem.

<Arlene> Dr. Simpson, My doctor listed secondary to wt gain comorbidities in my medical record as HTN, HLP, and DJD....what do they mean?

<Dr. Simpson> Hypertension or high blood pressure -- hyper lipidemia or high lipids and cholesterol, and degenerative joint disease or a form of arthritis -- not that you smoke marijuana and have a bad joint.

<Charlotte> My question is, I had open rny three years ago and this past January was hospitalized for bleeding ulcers. Are bleeding ulcers something that is common with gastric by-pass surgery?

<Dr. Simpson> No, they are not common. They happen with people who have weight loss surgery at the same rate as with the normal population. However, they are harder to detect in patients who have the RNY, which is why many surgeons will test for h.pylori -- the bacteria which causes peptic ulcers. So, glad you are better.

<Vitas> I'm also noticing that even though I eat 5oz of food i'm still hungry - and i'm eating high protein foods - what is the weight gain from? why am i still hungry after 5oz?

<Dr. Simpson> There are a number of reasons that you still feel hungry, and it is something that we need to work up. Anatomical, or surgical reasons to feel hungry include: the pouch could have enlarged so that you can accommodate more than five ounces; or the opening, or stoma, between the pouch and intestine could have enlarged so that food does not stay in the pouch that long; or you simply could have an aberration of the satiety mechanism and you are not.

<Vitas> But only after 9 months? Also gaining 6lbs over a 3 days period doesnt seem right

<Dr. Simpson> Waiting long enough, six pounds over three days is not right. That would mean that you would have to eat over 9000 calories a day during that time and I doubt you are doing that. Do the cottage cheese test, and see how large your pouch is. It is listed in www.oregoncenter.com so you can see it there. Your weight is probably from water, not from fat ---- plan on weighing yourself once a week and keep a food journal of everything that you eat, including snacks, etc and what you drink and count the calories begin a walking program and get a pedometer. Your goal is to walk three miles a day in less than an hour and see your surgeon to make certain you don not have an anatomical reason for your hunger. Good luck.

<Charlotte> Do you think the state of Virginia will be able to perform gastric by-pass surgery again? The insurance companies have made it impossible for now.

<Dr. Simpson> Hard to know. The best way to deal with insurance companies in a state is the following: First, contact the legislature and see if they would be willing to sponsor a bill that would mandate coverage of weight loss surgery. Second, have the private industries who have large insurance contracts demand that the insurance carriers cover it. If that does not work then you will need to save your money in order to have the surgery.

<Pat> Do you do Gastric Bypass?

<Dr. Simpson> Yes.

<Charlotte> I am 5'4 and now need plastic surgery after losing my weight. Is that too old to under go tummy tuck, etc..

<Dr. Simpson> No, not at all -- as long as you are young enough to enjoy the results. Good luck.

<Tammy Yeager> I wanted to know how to avoid stretching out my pouch. Is there a chance that drinking too much water at a time will stretch it?

<Dr. Simpson> If you do not gulp the water it should be just fine. If you chug the water it might stretch the pouch, so that is something to watch out for. The main way is to measure what you eat, and not eat any more than will make you satisfied. Good luck.

<Pat> Do you know anyone who may use WellPath insurance to cover Gastric bypass

<Dr. Simpson> I do not know that insurance company, I am sorry.

<Laura> When you are about a month out from having the Lap RNY, what are the best things you can do to prepare for the surgery and after the surgery?

<Dr. Simpson> Several things: First, begin taking some good vitamins. Second, start a walking program to get in better shape. Finally, learn a lot about nutrition and go from there. Learn to eat balanced meals and do not do that "last supper syndrome."

<Pam De Priest> I wasn't given a binder until today, 9 days post-op should I be concerned about this?

<Dr. Simpson> Some love binders, some hate binders and it is of no ultimate consequence. So do not worry about it at all. It will be fine. Breathe, walk, exercise, protein, water, walk.

<stephanie> If you have already have a midline scar and have had adhesions from before, Open RNY would be best for me?

<Dr. Simpson> It depends --- I did laparoscopic surgery yesterday on a fellow who had multiple abdominal surgeries for diverticulitis and perforation --- it took me a bit of time, but he did just fine.

<Arissa> Dr. Simpson you mentioned to Martha in Ga, that you test for adhesions and hernias. How do you test for them?

<Dr. Simpson> I don't test for adhesions and hernias. They are something that can happen to anyone after surgery. Hernias we can feel on the abdomen.

<cece davis> What are the general statistics for death when having the surgery?

<Dr. Simpson> One in fifty to one in two hundred for RNY, DS, and VBG ---- one in two to ten thousand for lap band.

<martha in ga> What book would you recommend?

<Dr. Simpson> Oh -- you are so kind. My book is called "Weight Loss Surgery: A lighter look at a heavy subject" obtained at www.obesitydr.com.

<flaminblonde> You mentioned that the stoma can increase. At 4 weeks post op, my stoma closed half way..they dilated it 1 mm (to 12) larger than it orginal was...after about 2 or 3 hours I'm hungry again...would this suggest that my stoma has increased in size?

<Dr. Simpson> No, probably not -- that is something that just happens.

<Tamarah> Is it possible that GBS can bring about or contribute to a severe depressive episode in someone who already has a mood disorder ?

<Dr. Simpson> When you lose weight you can have changes with hormones and that can result in depression -- if it does then you need to be treated and once you are treated and on the road to recovery you will be fine. The problem is that you will feel soooo good later on that you will have to buy clothes at Nordstroms mandatory. Sorry.

<dhc> If, heaven forbid, you or someone in your family found yourself morbidly obese, what surgery would YOU want and why?

<Dr. Simpson> I would want whatever surgery that the surgeon in my area did and did expertly. If I was in San Francisco, I would want Dr. Rabkin to do a duodenal switch. If I was in New Jersey -- Dr. Andrei do a RNY or a lap band and so forth. Some of us do one or two surgeries very well and that is what you should have.

<flaminblonde> What about pouch capacity. I am 7 months out and can eat about 4-5 ounces...depending on what it is...compared to 2 ounces at surgery...is this normal?

<Dr. Simpson> It is normal to have the pouch increase over time. In fact, in one study patients were up to ten ounces after two years and it had no effect on the weight loss.

<c smith> Does age or gender (I'm 59 and female) make a difference in wls?

<Dr. Simpson> No, age and gender make no difference in weight loss surgery, although it is fun to operate on both males and females.

<Doc M 1960> DR Simpson, I am 9 days out and very sore and tired. Is that common?

<Dr. Simpson> Only for the first 12 weeks.

<teressa> Hi dr. i weigh 404 pounds and my doctor has suggested that i lose 40 pounds before he does surgery. Any suggestions for me to lose the weight?

<Dr. Simpson> You could go to the Optifast program, which will allow you to lose some weight before surgery and is medically administered. They are at www.optifast.com. That is pretty easy to do.

<mssinmymind> My insurance at work does not cover any type of bariatric surgery...what type of insurance companies in OK are offering assistance, if any?

<Dr. Simpson> Various states have various insurance companies that are more friendly than others. Those change with time and so forth. But generally the best thing is to ask the various companies directly what they cover. In addition, you can always start to save your money or take out a second mortgage on your home. It is worth it.

<flaminblonde> I notice that after about 10-15 minutes after I eat...I can hear my food passing through...would this suggest an enlarged stoma? Is that fixable if so?

<Dr. Simpson> Gurgling and other sounds are what a lot of people hear when it really starts making vocal sounds -- like hey, feed me-- and you hear the voices -- then it is time for some other intervention.

<Pat> Can you have the surgery when you have acid reflux disease?

<Dr. Simpson> Yes, you can -- sometimes the surgery and the weight loss will improve acid reflux, or heartburn. Sometimes you need other interventions for the reflux. I would suggest you consider seeing a gi doctor for further advice.

<Arlene> DR Simpson, you suggested getting a healthwear band. I wanted to tell you that it is totally awesome and I look forward to walking every day now.

<Dr. Simpson> I am so glad that you got it. It is a great feedback mechanism for you. Keeps you in touch with what you are doing, and it allows you to know what you are eating and what you are using. I use mine to keep me up and walking instead of my major exercise being changing channels with the remote. For those who want a great mechanism, it is online at www.healthwear.com.

<flaminblonde> Define good vitamins? What exactly should we be taking? And B-12...is the shot better than sublingual?

<Dr. Simpson> You want the products to be manufactured in a pharmaceutically licensed manufacturing facility to meet the same standards as pharmaceutical drugs. You want the manufacturer to meet or exceed all GMP (Good Manufacturing Practice) guidelines. You want the facility to have a laboratory that tests for product quality, purity, and dissolution. You want it to be free of common allergens, artificial colors, and flavors and to be free of binders and fillers and that is a good vitamin. A lot of companies do not follow those practices. Some companies can produce it, and since the vitamins and supplements do not come under Food and Drug Administration guidelines -- it is not always a good thing. For example, some patients have lactose intolerance, and some of the fillers used have lactose in them. The same with gluten - some patients cannot tolerate those vitamins. So, that is how you find a good one... of course many will claim that they do that, but not all of them really do. Good luck.

<Kit> Do you need a binder when surgery is done lap?

<Dr. Simpson> You do not need to have a binder for any surgery. Some of us give a binder anyway. Some people love it, some hate it. It does nothing really for you other than to remind you that you had surgery. Good luck.

<Laura> How soon after surgery are you able to return to water aerobics as a form of exercise?

<Dr. Simpson> Depends on the surgeon and your incision. I typically tell patients to wait for three weeks after surgery if their wound is fine. Otherwise, we take it on a case by case basis. It is hard to imagine the term "water aerobics" when you don't have gills.

<janettes> My hgb &hct are ok, on the low end of normal but I have become very pale and have weakness...any suggestions for labs?

<Dr. Simpson> Well, there are a number -- I would suggest you get a complete blood count, total iron biding capacity, ferritin level, as well as a B12 and folate level. And if you are pale- -- hey, that is the "in" look these days, as opposed to those who like to bake in the sun and catch melanoma.

<Robin B> Have you noticed many of your patients having difficulty with low blood sugar even if that wasn't previously a problem?? What do you recommend for a patient that has or feels like they are having low blood sugar episodes?

<Dr. Simpson> I have not noticed people with low blood sugar at all. Many patients think they have it, and when we test for it that is not the case. What they mistake for it is "appetite" and the desire to have something sweet or with sugar. For those patients it is time to learn a new behavior when that feeling comes instead of going for calories, go for water, go for a walk instead of going for food ---- exercise. It is your last bit of body rebellion that wants to have a thin mint in reality -- very few people have that as a problem after this surgery. In fact, in over 13 years of doing this I have not seen one patient with it but had a lot of patients who thought they had it. The other is to make good food choices for your meals, go with high protein, or protein first, then with carbohydrates that are "complex" or have a low glycemic index (for an explanation of that see my website, www.drsimpson.com). Good luck.

<martha in ga> Can WLS affect your hormones in a way that it could affect your sex life?

<Dr. Simpson> Well, I don't know about hormones so much, but I can tell you this: After a few months there seems to be a sexual awakening in a lot of patients and our biggest issue is to try and keep the fertile ones from becoming pregnant. Otherwise, they do seem to like sex again. Perhaps it is a body image thing, who knows? Perhaps it is hormones, although this pattern seems to continue after they have reached goal for a while. I tell my patients to not have sex for 17 years.

<mzparksy> Is lap band surgery as successful as g. bypass? Have lupus and lap band was suggested.

<Dr. Simpson> They are both effective. You lose weight more quickly with the gastric bypass although plenty of patients lose just as much weight with the lap band. The lap band appears to be longer lasting in its effect, that is even up to three years we are seeing weight loss. I predict in the next five years the lap band will be the most common weight loss surgery offered in the United States.

<Patty> What is the rest of your stomach used for after lap RNY? Since I had lap on 8/30/04 I get frequent stomach aches. Is this normal?

<Dr. Simpson> As it is in Europe and Australia. Stomach aches are not normal and need to be worked up by a physician. The rest of the stomach sits there and still makes acid, gastrin, and a few other things but aching is not normal -- unless it is me getting out of bed early in the morning, then it is normal and the creaking sound is just my bones before they are lubed with the WD-40, known as coffee.

<Debbie> What type of diet do you put your patients on post-op? My surgeon says no carbs - protein only for the first 8 months. Others differ in their opinions. What is your opinion, and does it have any effect on the actual weight loss?

<Dr. Simpson> It all depends on the type of surgery that the patient has. Different surgeries give different types of needs for patients after surgery. For example, in the duodenal switch patients, we have to have them on a lot of protein because they malabsorb protein so much; with lap band we place them on a very balanced diet; with RNY it depends if it is long or short limb, as long limb needs more protein so we determine their choices based on what they have. Remember, we are doing something to you that will profoundly effect you and therefore we need to make certain that it isn't a "diet" and that instead it is how you eat -- and it is about choices for food, and personal accountability. Good luck.

<Teleri> I am obese and have been for most of my life. I have tried things such as Weight Watchers and other "structured" and "unstructured" programs. I make changes and things work temporarily but the weight comes back and then some. I have heard a lot about WLS although I am still skeptical...is this safe, I feel a little akward talking to anyone other than my husband about it. It is something I have considered for sometime. What can you offer that will help convince me to pursue WLS?

<Dr. Simpson> I cannot convince you of anything. I have a hard time convincing my one dog to eat dinner and the other dog not to eat his dinner - maybe Bert (the one dog) needs a lap band. Anyway --- not that I am trying to sell my book here (for the $1.67 royalty I get), but my book is a comprehensive guide to the various weight loss surgeries, their risks, as well as how to take care of yourself afterward and what test you will need. If you feel you might "fail" weight loss surgery because you have failed every diet that is a NORMAL reaction and that is something that we get from every patient that we see. But guess what -- most do great at weight loss surgery including my son, here, who has lost 450 lbs. -- he might have failed a diet or two. Good luck. The book is at www.obesitydr.com

<ShelleyNC> How long does it take to perform the Lap RNY the surgeon I have chosen does it in about 50min, does this sound right?

<Dr. Simpson> Sounds like he does them well and often, so that is pretty good.

<Goldie> I'm pre-op and have an appt. with the surgeon on Thurs. What are the usual pre-surgery tests that are ordered?

<Dr. Simpson> It depends on age and your overall health. Some want a sleep study to rule in or out sleep apnea, some want heart testing, most want psych testing and everyone wants some routine lab chemistries.

<Doodles> Hi dr. I am 6 months post op, had hernia repair during bypass, but now when I cough, its like a balloon about 4 inches up from the bellybutton, do I have another hernia?

<Dr. Simpson> Yup, you have a hernia. Welcome to the post op world known as "hernia club." It is exclusive -- got to have a hernia to join. You are now a member. Now get it fixed.

<c smith> Is it more difficult for diabetics to eat correctly after surgery? And how long before diabetic issues are resolved?

<Dr. Simpson> Diabetics do just fine after surgery, and their diet is just fine to be on following the weight loss surgery. Most patients will find that they require less medication following surgery, so you will need to be watched carefully. I generally take patients off of all diabetic medication following surgery and have them test themselves.

<Lisa> Hi Dr. I am self employed and my insurance company does not cover this procedure either. I was hoping to switch insurance companies and then start the journey of trying to get approved for surgery. If insurance companies find out I switched to their insurance only to have this surgery do they have a problem with that and deny you the coverage?

<Dr. Simpson> No, not at all. It happens all the time. But do them a favor, stick with them for a while if they are going to be good to you. Be good to them in the long term and build a good relationship with them.

<gb> Will weight loss before surgery slow down weight loss after surgery?

<Dr. Simpson> No -- think of it this way -- you will lose weight before surgery, be in better shape for surgery and unlike every diet you have been on -- this one will work. Good luck.

<Goldie> What is a healthwear band?

<Dr. Simpson> The healthwear band is a band that you wear on your right arm which calculates the calories that you use in a day. You download that information over the internet and you then enter the things that you ate and it will tell you the calorie balance, that is, how many calories you ate, vs. how many you used during the day and it will help you to manage what you do and what you eat. It is a great device. We require it of our patients who will undergo a duodenal switch or for revision surgery.

<Elaine> What are the possible complications and percentage of people who have them?

<Dr. Simpson> There are a lot of potential complications with any surgery and I have a whole list of them in my book, which is available at www.obesitydr.com. Five to ten per cent have some complications from the surgery in the early period, which can be anything from a minor increase in the temperature to a wound infection. Good luck.

<flaminblonde> Ok...I'll admit it...I'm an alcoholic...never really was one before...but since I don't dump...am I at risk for developing NASH than that of someone who didn't have WLS?

<Dr. Simpson> Alcohol is particularly difficult in patients after RNY because you often do not have the same symptoms from drinking. You get drunk fast, but it goes away quickly. If you have alcoholism, seek treatment and stop drinking. NASH is caused from a carbohydrate metabolism, which leads to fatty liver. Lose weight, eat right, and your liver will be fine. And put the alcohol away.

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

<lilacs931> Is there any particular problems to be aware of if you have a RNY after having had a lapband?

<Dr. Simpson> No -- most go the other way -- have a RNY then a lap band on top of it.

<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> Thank you all again. Have a good weekend.