November 21, 2003

<**MODERATOR**> HELLO AND WELCOME DR. SIMPSON! NICE TO HAVE YOU HERE.

<Shirley> I have bad veins in my legs due to years of standing on my feet at previous jobs. Do I need to have my legs checked for clots before surgery?

<Dr.Simpson> It is always an easy thing to do, having a test to check for blood clots in the legs, however, what you have is varicose veins, and they are unlikely to be deep venous thrombosis-- however, it is ok to get them checked. Norwegians -- we call them veins that are close together. Good luck. (Get it varicose -- very close) nevermind

<kathleen g> Dr. Simpson: I watched the live RNY surgery via web the other night. It was very interesting and informative. Have you considered broadcasting, perhaps a lap, in the future? Thanks.

<Dr.Simpson> Being a natural ham-- of course. It is sort of a fun thing to do-- although some patients don't like that done, and some do. The only problem is they would have to edit my humor

<Sylvia E Grein>: I would like to know what the basic requirements are in order to have the surgery done.

<Dr.Simpson> Insurance or cash.

<Dr.Simpson> Sorry, couldn't resist....

<Dr.Simpson> The basic requirements are those that are set by the National Institutes of Heatlh Consensus Conference in 1991: You have to have a body mass index of 40, or of 35 with comorbidities of heart disease, diabetes, sleep apnea, or joint disease.... they also require an attempt at dieting before this is done...That is our basic requirement.

<peggy> I had a stomach staple 20 yrs ago now i need something else my ins. dont pay for wls HELP!!!!!!!!!!!!

<Dr.Simpson> You might have to change insurance companies, and find a plan which will cover the weight loss surgery, for a revision. . However, if you are having problems that are from the surgery, such as an increase in gastro esophageal reflux, heartburn, the surgical revision would be indicated not for weight loss, but for another symptom. Otherwise, save your pennies. Good luck.

<kathleen g> Dr. Simpson: When a patient is several years post-op, must they continue to take supplements even though they are back to eating regular food? Thanks.

<Dr.Simpson> You must always take your vitamins. If you don't bad things can happen-- because you cannot eat a normal amount of food, you may, and often cannot get in adequate amounts of vitamins, some minerals. So it is important to always take vitamins, and to have the blood monitored to make certain you do not become deficient in iron, calcium, protein, or ice cream.

<Jane> I am planning to have the surgery where they bring the bowel up. Is one of the side effects of this chronic diarrhea?

<Dr.Simpson> I am not certain what you mean by bringing the bowel up -- but loose stool is a common condition after some weight loss surgeries. That is not considered diarrhea -- we consider diarrhea to be large volume loose stools, not just a small volume. For the duodenal switch and long limb bypass, and bpd, the stools tend to be more loose than tennis shoes on a minor. Good luck.

<deb in MN> I am 4 weeks post op....are prunes OK to eat for some mild constipation?? What else could I be doing?

<Dr.Simpson> You need to drink more water....Ok, you think you drink enough--- nope you are not-- if you are not drinking enough water then you will become constipated. For some folks that is two quarts a day for some it is four quarts a day. The other thing you can do is get some soluble fiber, such as Citrucel and try that....Prunes are just fine--- I like prunes-- prune wine is quite good. Gotta run. Exercise is also a great thing to get the bowels moving.

<Peg> Is depression and anxiaty around people a medical reason for surgery?

<Dr.Simpson> Depression and anxiety are disorders associated with but not specifically caused by obesity...They are disorders that have specific treatments, and they will be treated by those to have those disorders treated by surgery is incorrect. So, if you have depression and anxiety -- get those under control. Surgery will take care of the weight, but not the rest.

<Jane> What is the best advice you can give me for success after the surgery?

<Dr.Simpson> The best advice for success in surgery is this: water, walk, protein.... the more you walk, the faster you will lose weight and recover... the more water you drink, the more you stay hydrated, and have little problem... if you eat a lot of protein, you will find that you will continue to lose and build your muscle mass, feel better, and not eat junk food... finally -- the best thing you can do is empty your cupboards of the foods causing obesity, and send them to me.

<Shirley> my pcp is not for the surgery and refuses to write a letter ot my ins. co. I checked with insurance and I do not need a referral. Is it necessary for a letter to list medical necessity or can you just go by medical records?

<Dr.Simpson> You can always get your medical records , and that should be enough. Give your PCP a copy of my book, when it comes out-- so he can learn about surgery.

<Peg> How much fluid a day can you drink post op?

<Dr.Simpson> A lot--- you should drink two quarts a day, but you can drink more-- so drink away -- water

<Milo> I saw something fleetingly on TV the other night regarding a newer band surgery which is far less invasive and easily reversed. I didn't catch all the story. What am I talking about?

<Dr.Simpson> Well, you are sitting at a computer, talking to no one in particular, hoping that you are not the only one in the room...But the lap band is the newest of all weight loss surgeries first approved in June of 2001 in the United States. It forms the stomach into two parts, an upper and lower pouch, which will be moderated by a lap band, which has a balloon that keeps stoma -- opening small.... the smaller the opening, the longer the food stays in the upper pouch and the longer you feel full; the longer you feel full the less you will eat more; the less you eat the more you lose; the more you lose the cheaper a date you become; the cheaper a date you become, the easier it is to have someone buy you dinner. And so forth. It is a great surgery -- you can read more about it at my website www.drsimpson.com and we even have a little video.

<Patti> Is lap RNY less risky then Open

<Dr.Simpson> Risk is a per cent which applies to broad groups of people and not to an individual -- that is, you can have an increased risk of a leak with a laparoscopic surgery, but that is small. You can have an increased risk of a hernia with open surgery, and that can be big...But it is YOU -- an individual. So you have to decide what is best for you, and the surgeon you like, and if you like them and trust them, then go with what they recommend. If you don't like them, then go somewhere else. Good luck.

<Katherine> Do you recommend one type of surgery over another?

<Dr.Simpson> Yes, I recommend you do the type of surgery that your surgeon does. Simple as that. If your surgeon will offer a choice, then you sit down and make an intelligent decision. If you find that you do not have a choice-- well, that isn't a bad thing, but you can do well with any surgery. Good luck.

<Patti> What is the Name of your book?

<Dr.Simpson> Weight Loss Surgery: A Lighter Look at A Heavy Subject -- should be coming out in about two months...We are working on the final proofs of it now-- however, I have just rearranged the final chapters to decrease the length of the book...Should be fun, and funny, and have a lot of information that only someone who wears a pocket protector will love.

<Jennifer G.> Why must you sip liquid? It can't get stuck, so why is gulping (or drinking normalls) not "allowed"?

<Dr.Simpson> If you gulp, you can force food out of the pouch and into the gut where it will absorb, and you will not feel full. Besides, if you gulp that means you are not chewing well, or it means that you are taking too big a bite. If you have too large a bit of food it can get stuck, which creates pain, and problems. So -- sip, do not gulp liquids (I think that is a Commandment of Simpson ).

<jdp> I know that after surgery we are supposed to start walking immediately, but how long is it recommended to wait to join a gym if you are having lap rny?

<Dr.Simpson> You can join a gym at any time. However, don't work out with weights until such time as your surgeon releases you, which is at a minimum of six weeks and sometimes even longer. If you do too much too early you can get a hernia. So-- join a gym, do water aerobics, cardiovascular stuff, but no weights. I like gyms-- I just hate working out.

<michelek> how recommended is this surgery recommended for teenagers. My son is almost 16 and we are in the 'discussion' phase.

<Dr.Simpson> IF your son meets the criteria-- then this is a good thing. In the meantime I would recommend he get involved in some... physical activity, cut out television time, get rid of fast food, make him make nutritious meals and keep him moving-- physical exercise is great at that age. At my age I am lucky if I can find the remote control.

<Jennifer G.> What kinds of medication must you avoid after RNY?

<Dr.Simpson> LSD and cocaine

<Dr.Simpson> You have to be careful, depending upon the surgery type that you have to not have time released medications, and if the medications are too large-- horse pills -- to make certain you can cut them or crush them... you should also not take some of the cholesterol meds for a week before surgery, and you should closely monitor any medications for diabetes after surgery, as you will be eating so much less you will find that your sugars can go to very low levels.... so go over the medicines with your surgeon and with your pcp, and your pharmacist... find alternatives which are not time released, find alternatives that might be in liquid form, or those that can be crushed... a great tool for crushing medicine is a watercolor paint brush and a coffee grinder---- put the pill in the grinder and crush it with that then collect it with the paint brush and have it in a tablespoon of apple sauce. Hints from Heloise has nothing on me.

<DrYsabella> What is the caloric intake one ought to shoot for, the first 6 months post op? the next 6 months etc?

<Dr.Simpson> I do not encourage my patients to measure calories -- instead it is volume. You have a small stomach (pouch) and you should measure your foods... and you should eat protein first. Make certain you are getting an adequate amount of protein in (say 60 grams per day or whatever your surgeon recommends) and then from there. Do avoid high carb snacks-- avoid ice cream, candy, cookies-- until you reach your goal.

<CJ in VA> I am scheduled for surgery in 2 weeks, they found a soft lymph lump on deck but Dr wants to to proceed since its soft...and take it out that day...your opinion please

<Dr.Simpson> Go with your doctor. They see you, feel it, and have a sense of it... and those decks get awfully messy -- I am always swabbing them.

<Donita> How does an MD determine how much they are going to bypass? Does it measure how much you will lose?

<Dr.Simpson> There is not an exact or even approximate formula between the bypassed amount and the amount of weight which is lost. The restriction is more important than the malabsorption in any case. Most individuals who have reached their goal weight reach it with a proximal bypass, and you can reach it without a bypass with just a lap band or with a VBG.

<TICA> Dr. Simpson, I am 4 days post Lap Rny and am feeling dizzy and just kinds "out of it" for lack of better terms. Is this to be expected?

<Dr.Simpson> Well, you are talking to the wrong person for several reasons-- first, I am not there to evaluate you, second I was born blonde, so feeling dizzy and out of it is something I am use to.... the medication you take may make you feel out of it for some time. Feeling dizzy might be from being dehydrated and not drinking enough water. However, it is safest to talk to your surgeon and have them examine you to make certain that it is not that an alien has taken over your body.

<DrYsabella> Why is CAFFEINE a no-no - other than being useless & unhealthy?

<Dr.Simpson> Caffeine is not a prohibition in my practice -- but then again I am Norwegian, and we Norwegians really cannot function without coffee... so how can I restrict that with my patients. Some surgeons feel that caffeine is too much of an appetite stimulant. Me, I just need it to get the engines going in the early morning hours.

<almost 3 weekspostop> Is it normal for my Lipase levels to be elevated to about 700 after surgery?

<Dr.Simpson> No, that is not a normal laboratory finding after surgery -- that is something that is abnormal and needs to be evaluated by your surgeon.

<CJ in VA> My dr just lost someone 3 mo PO from a clot..now Im very scared of pending surgery.

<Dr.Simpson> Post operative deaths happen, and they can happen to any surgeon at any time for almost any reason. It is good to be scared of surgery, it would not be good if you didn't have some anxiety -- but that is not anything that is in the control of the surgeon. That is in the hands of God, and when you go down this road, there are a lot of things that can happen to you. And while some would love to blame the surgeon, these things happen. Often we can do everything correct and still have a problem....and in this case, it was just that. So, make sure you have your affairs in order, which I recommend to everyone. But if you cannot have faith in your surgeon, then you should find another surgeon. What happened is tragic, but it does occur. Good luck.

<Dr.Simpson> I always appreciate those who pray that God will guide the surgeon's hands....

<DrYsabella> Can soda REALLY stretch the pouch past " OK"?

<Dr.Simpson> Soda -- no, it really cannot-- that is a myth, which is silly-- cause you can burp, and there is another outlet. Soda is worthless as a nutrient, and not helpful in any way so might as well avoid it.

<Jackie> Can you tell me why some docs recommend protein shakes and other are against them?

<Dr.Simpson> Some of us are enlightened.

<Dr.Simpson> Funny you should ask that question. There is a lot more to this answer than you can imagine, and it goes something like this: Those who recommend the shakes feel that their patients will not get enough protein in by their diet, so they need a supplement. However, we do not design the surgeries that way. You can get enough protein in from food--- although some folks will become intolerant. There are some problems with protein shakes and they are (a) you should get protein from food, it is a better source of protein, (b) the shakes taste bad, (c) the shakes cost more for protein than a fine fillet, (d). shakes do not stay with you or produce a feeling of satiety for long, like a nice bit of Chilean Sea bass, and (e) food is good. If you are eating junk instead of protein, and relying on a shake for the protein then you are missing out. Me-- I would rather have you eat good food.

<Susan D. Calif.> Please tell me the function of the old stomach after surgery, and the pouch is made, I have heard it still produces enyzems

<Dr.Simpson> The lower pouch in a RNY is still active, still makes acid, still makes pepcin, still makes hormones... It is still there working away, waiting for food to come-- like a long lost lover waiting for her man to come home. So it is there, and still working-- so respect it.

<drusilda> Back to the liquids. But what about drinking water between meals when there is not likely any food in the stomach? Still have to sip?

<Dr.Simpson> After surgery your pouch is smaller than your mouth, and the only way that a pouch grows is by chronically stuffing it... if you challenge it with a gulp of water, then you can stretch it, if you keep stretching the pouch then you will have a larger pouch, if you have a larger pouch then you will not lose as much weight, if you do not lose as much weight -- then you cannot come out and play, with Dr. Seuss today.

<Jackie> I had open rny on 10/23, I still have no stamina... how long before it returns?

<Dr.Simpson> Total of three months before you feel 100 per cent providing that nothing else happens to you. So, until then start walking, eat protein, keep walking, and don't stop walking until you find the Grim Reaper in 70 years, and if you keep walking you will walk right past him.

<Debbie> How is the small intestine attached to the new pouch. I just don't see how staples can hold everything together?

<Dr.Simpson> Well, staples do hold it together-- but there is also the fairy dust, which we don't tell you about because Peter Pan would object. The staples are small, strong, and machine tested, and do a better job than most humans can sew. The new stapling instruments are great things, and.the staples are quite small and cute-- like my doggie, Bert and Ernie.

<NJBarb> Does someone's blood work have to be absolutely perfect before this type of surgery can be performed?

<Dr.Simpson> The only perfect blood is a Chateau Margeaux 1990 -- and that is wine, not blood. No, perfect is not something that we use in medicine -- but it does have to be in the normal range, if things are not normal then we have to see why it isn't and if it would be a danger to do surgery with the lab values which are outside the range of normal... but, back to the wine-- the other one you can send me is a nice Jordon 1995.

<Deb> Can you have this surgery when you are taking Methotrexate?

<Dr.Simpson> Yes you can-- healing is a bit impaired, but you can.

<CJ in VA> what is percent of rny's getting ulcers?

<Dr.Simpson> Hard to say, some, but not all. No real number.

<TICA> Blood clots are strong in my family history. Being inactive while sleeping concerns me after returning home from the hospital. Any suggestions?

<Dr.Simpson> Don't sleep. Have your legs tested for clots ahead of time, after surgery, and keep walking. Don't stop walking.... Don't stop walking until you have done well, that is, until six months out. Do not stop walking. Never stop walking. Good luck

<Susan D. Calif.> What about time released anti depressants, I take Effexor XR?

<Dr.Simpson> It depends on the surgery that you are having-- if you are having a long limb bypass then you need to get the non sustained release medicine and take the medicine more often.

<Jennifer G.> What about over the counter medications such as tylenol, dayquil, nyquil, cough meds, etc.? Do you have to get sugar free cough syrup?

<Dr.Simpson> Sugar free cough syrup is a good thing. Over the counter medications are generally not a problem.

<almost 3 weekspostop> I had Lap RNY almost 3 weeks ago my pouch is 15mil is that an average size?

<Dr.Simpson> It is smaller than average size, but it will do just fine.

<Linda> My surgeon has done over 300 procedures and never lost a patient, should I be happy or nervous about that? Isn't it just a matter of time statistically?

<Dr.Simpson> Statistics are just that -- Statistics,. no matter what. You can worry-- you can also have a surgeon who has lost three to six patients in 300 procedures, and that would be fine-- It is just a statistic... that is all it is. You are an individual, not a statistic. Part of you cannot die, or leak, or bleed, or get an abscess or do well. You will either have no problems or a problem or two or three. So get your house in order. Sounds like you have a fine surgeon, and go for it.

<Dr. Ken> Do you recommend a liquid diet prior to RNY surgery?

<Dr.Simpson> No

<Shirley> If a drain is left in your side after surgery can you tell me where the fluid is coming from?

<Dr.Simpson> Not used to a simple answer: Inside. Sorry. I was told I have to give a better answer than that.... Can't resist sometimes. I am kind of a smart aleck sometimes-- in case you have not noticed.... The fluid comes from the abdomen, which has fluid in it at all times, and it drains the fluid out of the abdomen and into the drain. It also is a monitor for leaks, and bleeding, and a few other things.

<Deb> Why would a doctor not completely close off the larger part of your stomach? The surgeon I met with said he leaves a small opening.

<Dr.Simpson> I guess I am not certain what he is doing, or why -- so, I am at a loss to answer this question, and I am rarely at a loss for words. If you transect the upper and lower pouch there is no opening between them, if you staple them off there is no opening between them...if there is a small opening, then food can go down it-- although if you have a vbg that is a small opening, or a lap band is a small opening...So it is hard to determine -- I would ask him or her.

<DrYsabella> Do you foresee Insurance Companies tightening up on requirments for surgery as it gets more popular? Humana has stopped for a year, one hospital near Boston has stopped all WLS (supposedly due to 2 deaths) and longer MD followed diets are being required by many insurers.

<Dr.Simpson> Yes, because of the bottom line for insurance companies is money, not your health. They want to save money so they will have more stringent requirements, or they will require that you pay a larger part of the surgery, or they will classify some parts of the surgery as experimental and you will have to pay for it.

<kathleen g> Dr. Simpson: How does a surgeon check for post-op clots? Thanks.

<Dr.Simpson> The ultrasound of the lower legs will check for clots in the legs, we do not have a way to check for clots in the pelvis....But leg clots are easy and quick.

<Got My Date-Dec.15> I have to do a bowel prep 2 days prior to surgery, both days with nothing to eat, and clear liquids to drink. Does it really take 2 whole days for my system to clear out?

<Dr.Simpson> It can take longer than that to have the system cleared out...But two days is fine. Some have one day bowel preps, some have no bowel preps.... in my practice if you have colyte and vodka it is called a Simpson Cocktail -- somehow I don't think you will find it at your local bar.

<Jennifer G.> Will compression stocking (the kind diabetics might wear) help with blood clots when you are at home?

<Dr.Simpson> Compression stockings are a moderate preventive measure, but not a major one.

<Terri> I have read that women who have had RNY tend to have children with lower birth weights subsequent to the surgery, even after waiting 18-24 months post surgery?

<Dr.Simpson> I have not seen that statistic, nor found it to be that way.

<DrYsabella> What is the general time period when Seratonin normally falls after WLS--and when does it usually return to its previous level?

<Dr.Simpson> I don't know that exactly -- couldn't tell you.

<**MODERATOR**> NOW FOR THE LAST QUESTION FOR OUR GUEST TONIGHT:)

<Imapostop> I have a friend who is 4 months out and 2 months pregnant she is scared to tell her surgeon does her baby have a chance?

<Dr.Simpson> She should tell her surgeon, she should tell her ob doctor, and she should be monitored carefully for these things. Her baby always has a chance. Lap band is a great surgery for women of child bearing years because we can open the band stoma and allow more normal nutrition...So she will have to work on this. Good luck.

<Dr.Simpson> Thank you everyone .Have a nice weekend.

<**MODERATOR**> THANK YOU SO MUCH TO OUR SPECIAL GUEST DR. TERRY SIMPSON FOR JOINING US HERE TONIGHT! AND THANK YOU TO ALL OF OUR MEMBERS