October 15 , 2004

<Moderator> Welcome to tonight's chat featuring Dr Simpson. Chat starts at 4pm PST / 7pm EST. Please type in your questions and hit enter. I will show them to Dr Simpson in the order I receive them at the time of chat. Thank you! :)

<George> Is Cigna difficult to work with?

<Dr. Simpson> Cigna -- well, that depends. Sometimes insurance companies are easy to deal with and sometimes they are difficult, and it varies from state to state. For example, in this state we have a very good relationship with a few insurance companies such as Blue Cross -- and yet in other states Blue Cross is difficult. So from state to state it will vary. Find out if they cover the procedure you want and what their requirements are -- and go for it.

<Mandy> I had my DS about a year ago and am down 227lbs, still have about 20 to go. Everything was great until the 9 month mark. Since then, I have had two surgeries to remove adhesions and they are causing me severe pain/eating issues again. I am on TPN for nutrition because I can't eat/drink because of them. Is this common and is there an end in sight? I even tried a nerve block hoping to at least get rid of the pain, no luck. Any ideas?

<Dr. Simpson> Well, it is difficult to know what is going on from what you are telling me. Adhesions are something that form in the abdomen and are a type of scar tissue. They develop after any surgery, and they can be painful but they do get better with time but if you cannot eat or drink it is clear you will need another surgery because TPN is not a good way to live -- that is iv nutrition. Nerve block won't relieve the pain from adhesions, only surgery will ---- but there is no doubt more than you can relay in a paragraph, but yes, there is always an end in site and what you have and are experiencing is not common. Good luck.

<carla> I had a gastric bypass over five years ago, I lost 72 lbs and regained 38. I needed to lose more but have not been able , I was wondering about the revision and if insurance would cover it. I am from new jersey and would like to know if there is someone you can refer me to.

<Dr. Simpson> In New Jersey I think Val Andrei, who works out of Robert Wood and Livingston is a great surgeon. In fact I mentioned him in my book -- which everyone I am sure has a copy of. Difficult to determine if you even need a revision of your surgery, or if you need to have some revision of what you are doing that is something that Dr. Andrei will be able to help you with after an evaluation which will no doubt include an upper GI test to see if your pouch is stretched or if your stoma is enlarged a bit. Good luck.

<marti> I was wanting to know what the general opinion is on pouch size?

<Dr. Simpson> Pouch size usually starts out between a half an ounce and one ounce (30cc) and over two years may enlarge to 9 ounces without any loss of the ability to maintain the weight loss.

<john_p> DR, I am about 6 wks post op & am getting lower back pains. Any thoughts?

<Dr. Simpson> Lower back pain is out of my league; not something that we see commonly after surgery -- sounds like you need an evaluation from a back doctor. Good luck.

<Kit> Hi,do you think B12 injections should be part of gastric bipass follow up? Also Is your book at BN or any other book shops?

<Dr. Simpson> My book is on Amazon.com and I don't know where else -- probably the best place to get it is from my site www.obesitydr.com. B12 injections are not always needed following surgery for weight loss. It is something that should be followed on post operative patients to see if they do need to have that as therapy. Some do not, and why have a shot if you don't need it. There are other forms of B12-- nasal, and under-the-tongue which can be used as effectively but again -- should be tested for instead of just given as routine. Good luck.

<carla> I would like to know how the doctor determines if you need a revision to gastric bypass

<Dr. Simpson> That is a complicated process there are several reasons someone might need a revision. First-- if you had a jejunal-ileal bypass you should be revised to another procedure. Second, if you had an old fashioned stomach stapling (which no one does anymore) you will probably need a revision. If you are having difficulty from the surgery, such as bad reflux, severe episodes of dehydration, or other medical problems related to the surgery you will need a revision. If you have gained weight after surgery, then an evaluation needs to determine why you are gaining weight. If your pouch has enlarged to the size of Alabama, then you might need a revision. If your stoma has enlarged, you might need a revision If you simply out-ate things, and are eating around what is done -- then what needs a revision is probably habits and not the surgery. Good luck. I will have an article in a magazine soon about surgical revisions and there is a nice section in my book.

<hot&happy> I am just beginning the process of Roux en Y and I want to know is it as safe as Gastric banding? Why doesn't insurance cover that as well?

<Dr. Simpson> The lap band is far safer than RNY. Some insurance companies don't cover that procedure --- but there is no real reason why they would not. It is safer, and at least as effective in the latest studies which have been published.

<ChrisS> Is it possible for a WLS patient to lose to much weight? My BMI is 39.7 with a long list of comorbids and obese since teens (now in mid 30's).

<Dr. Simpson> Anyone can lose too much weight ---- but that is usually not the problem that we will see -- usually what we see is gaining too much weight.

<tisha> Can you have this surgery if you have had bypass surgery?

<Dr. Simpson> Yes, you can do that.

<Marie> Is it possible to tighten loose abdominal skin without surgery? I have enough belly skin to grab. Running/pilates has made it smaller, but it's still there. Some background info...I'm 22, 6'2, I curently weigh 160, and my highest weight was 265.

<Dr. Simpson> Sometimes you can get that...however, most of the time you will need to have some plastic surgery -- or bondo -- or perhaps some glue.

<Kari A.> I had an upper GI today that said there was no surgical failure, but I'm able to eat pre-op portions. how can that be??

<Dr. Simpson> Well, you might need to have an endoscopy to see the size of the stoma. That is how it can be.

<ChrisS> I'm preop and have steroid epidurals injected in my spine every few months - will this cause any pre/post op problems?

<Dr. Simpson> No -- however, they will need to know because you might need to have some steroids for stress dose -- as we call it. Good luck.

<tisha> It has been since May that I had a bypass done. I need to lose this weight. I'm 265 with high cholesterol and high blood pressure, depression, anxiety. My weight is a big problem forming these factors. Can you please help me? How long after bypass surgery should i wait to have this wls done?

<Dr. Simpson> Surgery will be a good thing for you, and help you remove the weight. It will. Bypass -- ah, a cardiac bypass six to twelve weeks.

<Lisa> I had open d/s in March of 2002. I lost about 100 pounds the first 5 months. I have regained 30 or so. I weigh 245 now. I am miserable. My DR has reputation of being too conservative. Do I have a right to ask for another surgery or?

<Dr. Simpson> The DS -- is probably doing just right. When you say conservative then, I am not certain what you mean but, I think that you probably need to learn how long your common channel is and how long or how much your stomach holds, and go from there.

<ChrisS> I've heard mixed information about whether I'll be able to swallow meds & supplements after surgery - can you clarify? I assume most vitamins & supplements you'd just open the capsule and mix with food - right?

<Dr. Simpson> If you have certain medications you might not be able to crush the medications. Some medications are unable to be crushed and should not be crushed and some of them will not need to be crushed or changed, or anything like that.

<Ben> How can we avoid ulcers post-op? Thanks a lot.

<Dr. Simpson> Taking meditations for anti ulcers -- like Prevacid. Also -- don't piss off your girlfriend.

<Ted> How do you feel about people that do not have insurance going out of country for wls?

<Dr. Simpson> There are some great surgeons out of the country -- call belighter.com who specialize in this. The problems are not the surgeons - the problems are the following: First is follow up. Second, is if there is a problem overseas you might not have the technology to deal with it. For example, if you have a heart attack, they might not have the facilities to stent you or even do any treatment, so that is the problem. Some are great and have everything-- some do not. Check out the other stuff first. Some of us have competitive prices here.

<vegas> Can you give us an overview on your book?

<Dr. Simpson> Yes www.obesitydr.com has excerpts.

<shirl> My insurance is Tricare and I want to have LAP BAND they will only pay for RNY. Is there anything I can do? Thanks

<Dr. Simpson> Save your money and pay for it yourself. It is cheaper than a car, and at the end of five years you will have a better body and you will not have an old car. Or mortgage your house. It is a great investment.

<Linda21249> My last blood test said i was low in iron.. I am 17 months post op.. I just had surgery Sept 1...panni and batwings.. Can being anemic be from results of the surgery? Another question.. any way to speed recovery on arms? They are very Tight

<Dr. Simpson> Your anemia is not from plastic surgery. Your anemia is from iron deficiency, and that needs to be corrected. To speed recovery, you need to walk, walk, and take your vitamins. Tight is good.

<yvonne> Had my surgery four months ago....will my deprssion go away?

<Dr. Simpson> If you have depression then you will need to be treated for it by a shrink, and not from weight loss. Thin people get depressed.

<RedHead> Will you be going to the big OH event in LA at the end of the month? I would love to meet you in person.

<Dr. Simpson> I will be there with bells on.

<Ginger> Do you think that sex is better after wls?

<Dr. Simpson> Well, I do a lot of weight loss surgery and I think my sex is just fine. Most of my patients have a problem NOT getting pregnant because they are like rabbits.

<ashley> I'm pre-op and need to lose 150 pounds. How long on average will it take me to lose that amount of weight?

<Dr. Simpson> It takes a person 3500 calories per pound of fat. If you want to lose 150 lbs then you have to use that many more calories. Simple math.

<ChrisS> I'm preop, is it possible for a WLS patient to lose too much? My BMI is 39.7, obese since 14 now I'm 36, with a long list of comorbids.

<Dr. Simpson> Always possible --- but unlikely. You will do just fine.

<Barb> I am about eight months post op. Started hair loss around 4 months and it continues. My surgeon told me to all some zinc to my diet, but didn't tell me how much and I forgot to ask. So how much should I add and do you have any other suggestions?

<Dr. Simpson> If you have a zinc deficiency that is the problem, and easy to test for. Most hair loss comes from patients who lie to their surgeons, and then pull their hair out in the middle of the night. Usually the hair loss stops at four months, if not then use super glue on the head.

<Laurie> What are the symptons of a stricture? Are they common?

<Dr. Simpson> Vomiting, nausea -- unable to keep things down. They are in about 10 per cent of RNY patients.

<Donnie> My surgeon has indicated that he keeps his patients in the hospital at least 4 days post-op to fully observe any immediate complications. Is this a normal length of time?

<Dr. Simpson> Yes - for lap band I keep them in six hours.

<Beth> I have a question .... I had rny proximal back in March 2004....starting weight was 250 and now for the two past months I have sat at 170... I've watched my diet... I do two hrs of cardio 5x a week. I'm stuck.

<Dr. Simpson> Let us be real here. You are either not aware of how much you are eating or you are not using enough energy. So -- get a band from www.healthwear.com and find out what your energy level is and how much you are eating.

<Marcy> Which do you consider the best and safest way to do an RNY, open or Lap?

<Dr. Simpson> Lap if they do it -- open if they do not.

<OnDaGo> Please compare risk factors and long term success rates for someone who is 500+ pounds compared to someone who is 100 pounds overweight.

<Dr. Simpson> Patients over 500 lbs are a greater risk for everything by six times more than the others but, they need to be done, and they can be done with great success. I have had a lot of 500 lb patients that are now thin, slim, and ready for action - girls watch out.

<sarah> I am a chronic overeater and miserable, been up and down hundreds of times. But my BMI is only 62. Is there a way I can have lap-band surgery without resorting to gain more weight in order to qualify?

<Dr. Simpson> Lap band surgery would work well for you. A BMI of 62 qualifies you.

<Linda21249> Dr Simpson, love your book.. and have refered my brother in Tucson AZ to you ;-)

<Dr. Simpson> Thank you.

<BarbCon PO 2MO OpRNY> I take Strattera for my ADD which 'kills' my pouch. Can I be doing any real damage to it?

<Dr. Simpson> Your pouch is irritated. You should talk with a gastroenterologist and have your pouch looked at, and perhaps you need to be on some prilosec.

<ChrisS> I'm preop and have not found any protein drinks I like that have over 24 gr of protein per drink (Atkins & LowCarb Slim fast) will that be enough?

<Dr. Simpson> You need to get protein in your diet, and 24 grams per day is not enough. In the back of my book is the table that you can look at which will show you how much protein you need to have. Protein drinks are not something l like because I like the taste of real food and shakes should be ice cream not protein made from horse hooves. So-- eat Elk or cats for protein.

<Jason> I have heard thiamin defeciency is common - how do you prevent that?

<Dr. Simpson> Take thiamin, not common.

<Kari A> What would cause the stoma to enlarge? I've never done anything to "out eat" my pouch. My surgeon had me stay on the 4 mo post-op diet. I'm 1 year out today and stopped losing at 4 months. I've always eaten 4 oz of food.

<Dr. Simpson> Stomas enlarge because of a number of things -- some technical, some eating large things -- don't eat a horse without chewing it first. Have it examined by a scope.

<suzy> Hello Dr. Simpson, I am two weeks out and have just started eating creamed soups and yogurt, etc. which was suggested by my doctor. My problem is that I have been so hungry and although I'm supposed to be eating 1/4 cup of soup, yogurt, etc. at one time, I'm not! I'm eating a whole can of soup, and a full cup of yogurt. I'm feeling 'out of control.' How important is it that I adhere to the smaller amounts? If it's extremely important, I don't want to be breaking the rules!

<Dr. Simpson> They are not rules. You will be hungry with liquids. You can drink more water -- very few calories in water.

<Linda21249> Anyway to prevent kidney stones since the gastric bypass?

<Dr. Simpson> Take calcium with your meals --- and drink a lot of water.

<undecided> I am in my mid 30's and considering rny. In 40-50 what will my life be like? Will I be healthy?

<Dr. Simpson> You will be older, healthy -- who knows.

<suzy> How soon after 'banding' can one begin an exercise program in your opinion, Dr. Simpson?

<Dr. Simpson> Start walking today. You can do anything with walking but lifting --- not for a while. Wait until you have six weeks at least, and check before you do that.

<donnap> I believe that the national average of people who gain all lost weight back after conventional dieting is above 90%. What is the % of bypass patients who gain back a significant amount of weight?

<Dr. Simpson> 25 per cent with RNY -- 10 per cent with DS and 10 to 14 per cent with lap band but not always significant amount of weight. But those are the figures.

<Lori> What type of protein is best, shake or from actual food?

<Dr. Simpson> Food is always best. Tastes better, bioavailable, and sticks with you ---- shakes go through. Some people they really go through.

<Kit> My fear is breaking my stomach staples in the first few weeks after gastric bypass(lap) surgery. I know that this sounds crazy, but can it happen? Thanks.....

<Dr. Simpson> Yes, it can happen --- so measure what you put in your mouth ---- and don't live in Seattle where the rain will rust them.

<undecided> What is the worst thing that could happen by having the rny?

<Dr. Simpson> You could die or have a long recovery in a rehab hospital for months or die from a jealous lover because you are so hot after weight loss surgery.

<suzy> How much info on 'banding' is covered in your book? Thanks.

<Dr. Simpson> A lot of it. Great book.

<Tina/Graham, NC> My question is: I'm awaiting approval to have Lap RNY. My job is a teacher assistant to 4/5/6 yr old children. How soon would I be able to return to work after surgery?

<Dr. Simpson> Three weeks.

<suzy> Follow-up is important I believe. Do you advise counseling to deal with 'head hunger?'

<Dr. Simpson> Yes.

<Moderator> Last question of the night goes to...

<Tina/Graham, NC> Why do people get depressed after having WLS? Tthank you.

<Dr. Simpson> Because wls does not solve all your problems - just weight; and if you lose weight rapidly you could release some hormones which cause it --- or other things we don't understand yet, but it happens. And if it happens you need to have someone prescribe some good drugs for you. Good luck.

<Dr. Simpson> Thank you all.

<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.