December 12 , 2003

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

<Dr. Simpson> Nice to be hear, and I am ready to do what we need to do.

<playback25> Have you had any one that have had gastric bypass surgery and gain the weight back?

<Dr. Simpson> Well, that can happen, you can gain the weight back. There are several reasons for that. First is that you can fall back to old habits -- fast food, skipping meals, and drinking booze. There is no surgery which can protect you from milkshakes, candy, ice cream, and potatoes, bread, and pasta...But everything in moderation, hence, we have some simple diet and menu plans which will keep you trim and fit. But yes, you can gain the weight back, without it being an anatomical surgery problem. Great question.

<Jody> I am 7 weeks post op and I was wondering why I am hungry alot of the time?

<Dr. Simpson> Well, that is a difficult question to answer without knowing the surgery that you had-- perhaps you can PM the moderator...But there are several reasons-- if you have a pouch, as in RNY or lap band, and are still on a liquid diet you will be hungry or if you are filling the pouch with things that are soft or mushy foods, then you will still be hungry. Or if you are not chewing food well, and forcing the food down with gulps of water, then you will empty the pouch sooner and not be hungry. We suggest filling up with high quality proteins, such as tuna, fish, meats, and the like, and allowing those to be the staple of your diet. Otherwise, you will be hungry all the time, and not have the advantage of the pouch. If you had the lap band. Then you need a fill of the stoma. Good luck.

<Kathy Bilodeau> Why are there so many differences in the methods/rules that each surgeon requires? For instance, some require fat free diets for 2 weeks before surgery, some don't, some require liquids only the day before; some don't. Post-up, some have you on clear liquids for one week, some for two weeks, etc.?

<Dr. Simpson> Well, that is because my book has not yet been published, which will give a guide to all surgeons and post op patients. Forgive the shameless plug. There are a number of reasons, some have to do with what you have had before, for example, if you have a fatty liver, or if you have a lot of excess weight. There are a number of programs after, some have you on liquids for two weeks, if you have a lap band, and some with RNY have you on liquids for several weeks. So there is a lot of variation-- and I hope my book will help unify that. Thanks for allowing me to plug the book. When it is out then it will be in the obesityhelp.com store. Thanks. Good luck.

<kathleen g> Dr. Simpson: When is it appropriate to increase activity after a lap RNY? Are hernias less common after a laparoscopic procedure as opposed to open?

<Dr. Simpson> Well with less of an incision there is less of a chance of a hernia. And in terms of activity we recommend that you do a lot of walking, instead of working out. Walking is the best thing you can do and you can start from the beginning of surgery. Walk from the recovery room to your post op bed. In terms of other stuff, you need to be careful and follow your surgeon's instructions. Because after surgery you go through a time when you are relatively malnourished. It is easier to get a hernia, as your body does not heal quite as fast. So, protein, water, walk. You will do just fine. Thanks.

<heather> Is it possible to get financing for the part of the cost not covered by insurance, my insurance has a 10,--000 cap for this surgery.

<Dr. Simpson> There are a number of companies which specialize in financing --- including getting a second mortgage on the house you live in and there are companies which specialize in health care financing. I know a lady who drives a beater of a car because every month she makes a payment to her finance company because she paid for surgery with her own money. And when you think about that it is the best investment that you can make. You will always have your body with you, but a car you are only in an hour or so a day, and yet people will spend more on a car than on their body. For example, we have a total cost of 14,000 for the lap-band surgery and 17,000 for the duodenal switch surgery -- for all but over the top costs...That is in the range of what most people can finance or get a loan for, or even a credit card payment for. It is a great investment. So, always invest in yourself. Good luck.

<kathleen g> Dr. Simpson: When one's surgeon refers to "an assisted laparoscopic" procedure, is he speaking of what we commonly call laparoscopic? Thank you.

<Dr. Simpson> There is a hand-assisted laparoscopic procedure where we put the hand in the body, and have a special device that keeps it there. Most of us remember to remove our hand at the end of surgery, or we go home with the patient -- but yes, it is laparoscopic, with a larger port where the hand goes.

<heather> Is it true that you get a lot of gas after the surgery?

<Dr. Simpson> Well, I get gas from Exxon, although they spilled oil in Prince William Sound...It all depends on which surgery that you have, and what you eat after surgery. For example, if you have a lot of lactose containing products, dairy, you might get some gas from that. If you have a long limb RNY procedure, or a DS, or a BPD, you might have gas because the food which is not digested goes into the colon and that food is broken down by bacteria which make a malodor forming gas. So, you can get a lot of gas. Depends on the surgery and on the diet.

<kim N> I had a lap rny on oct 8, I have followed all guidelines to the T and have been walking 2 miles a day briskly. I have lost 39 pounds but the scales have not budged in 2 weeks plus. Is this all I will lose? I started at 261, how much can I expect to lose? I am so afraid this is it!

<Dr. Simpson> Yup that is it-- no more (just kidding)....A true plateau is one where you do not lose weight or INCHES for four weeks---if you have that then you are at a plateau. Normally the body needs to rearrange itself and you stop losing weight, but still lose some inches. So, keep walking, eat fewer carbs, increase the walking, and you will get to goal. Good luck.

<amber> My mother recently had a gp done and she says my sister and I shouldnt ...I am 18 years old and and my bmi is almost 37 would I be considered at this bmi?

<Dr. Simpson> Well, I never have a problem operating on an 18 year old who has a strong family history of obesity, and for those we recommend the lap band, because it is the least invasive and if you need more help, it can be revised later. By the time you work through the insurance issues I would assume that your BMI will creep up there. And besides it is Xmas, and my bmi is already climbing, but then again I am Santa.

<kathleen g> Have you decided how much you will be charging for your book? I'm looking forward to purchasing a copy.

<Dr. Simpson> Well, thank you for asking-- actually it isn't too much up to me, it is a bit up to the printer, publisher, and a few other people. Me, I would ask you send me a couple of bucks, but what can I say-- from what I understand it is a 410 page book with menus, recipes, lots of diagrams and will run about 25 bucks. Should be ready soon. As soon as it is we will have a big banner on my website www.drsimpson.com and it will be at obesityhelp.com bookstore.

<Julie-Upstate NY> Is it possible to have rny weight loss surgery after having fundolication --sorry for the spelling (reflux surgery)?

<Dr. Simpson> It is more difficult to do it after a fundoplicaiton, and perhaps the better surgery to have would be a duodenal switch...Very difficult to do the RNY-gastric bypass after a fundoplication. Good luck.

<Gregg> Besides my bmi, what other factors determine my suitability for wls?

<Dr. Simpson> BMI is the main one, other things might include co morbidities if your BMI is between 35 and 40 -- things like heart disease, diabetes, sleep apnea, high blood pressure or joint disease. In addition you need to have medical and psychological clearance for surgery. For example, we think that if you are depressed you should be on antidepressants for at least a month prior to surgery. And in terms of other health issues, those are addressed on an individualized basis. Many insurance companies are now requiring that patients be on a six month physician supervised diet plan. This shows you have tried something. So, if you are considering the surgery, see your primary care doctor and have them put you on a diet and visit them at least twice a month for weigh ins. And make sure they chart such a visit. Good luck.

<typingangel> I'm not able to hold any food down and I'm 1 month post-op is this normal?

<Dr. Simpson> No, that is not normal. However we need more information, and you need to give this information to your surgeon. You need to let them know if you can keep liquids down and not solids. You need to let them know if there are certain solids that you cannot keep down. You need to let them know that you are measuring the solid food which you are eating, and that you have one ounce, or however large your pouch is and that you are unable to keep that down. There is a whole work up which they will do for your condition, including having an endoscopy of the gut to see if there is some abnormal scarring which is preventing food from going down. Or they may put you on a liquid diet for a while and allow things to calm down. So, keep working on it, and see your surgeon. If you cannot keep liquids down you may need to be in the hospital. Good luck.

<Betsy McIntyre> After the initial consultation about how long does it take after approval for the surgery?

<Dr. Simpson> That is a complicated question and the answer is something like this: If you have everything in place: psych eval, physician supervised diet for six months, you meet the qualifications for surgery then some insurance companies will do the approval in a week, some will take two months, depends on the insurance carrier, and how they operate. From that point it is just a guessing game -- some companies are fast, and many are very slow. I had one lady who ended up waiting months before her insurance company finally approved her. Good luck.

<Ron> I have heard so many negative things about the surgery and I have an issue recently due to blood clots is there any other drastic non surgical methods?

<Dr. Simpson> Diet and exercise.

<MikeT> Recently a WLS patient died from a stapler miss fire. Some feel it is miss use of the stapler by the surgeon and others say there is a problem sometimes with the stapler malfunctioning. Do you know what is being done if anything to make WLS safer?

<Dr. Simpson> WLS is safe, but it is a matter of risk. There is no perfect stapler, there is no perfect human...And there is no perfect system, there are real risks of surgery, and if you want something safe then you should avoid surgery and plan on a rigorous exercise program and diet, otherwise there are real risks. Clearly some surgeries are safer than others, for example, the lap band does not invade the bowel, so there are no stapler firings; however, the lap band can erode into the gut (rare) and it can get infected, and it can slip-- it is a devices... so...while the companies who make staplers make them better than a human can sew some stuff and while surgeons are really pretty good at sewing tissue together, there will be people who will not heal as well, or people who will leak, or people who will develop strange problems. So, there is no perfectly safe approach here, and the healthiest and youngest patients can have the worst problems, so, that is a risk, which you need to be aware of. It is rare that a surgeon has a "misfire" since firing a stapler is about as easy as you using a stapler on your desk. Hard to imagine you could misfire it. Technology constantly is changing and making things better for us. For example, now the staplers fire six rows of staples instead of four rows, so there is more hemostasis (less bleeding) and better sealing, but there will still be leaks. Overall, in this country, leak rates have decreased, and we have a number of new things which all of us are trying. So, yes, we are working on it all. Good question.

<Susan 3/18/04> Is there any data on long time post op's mdeical history since WLS? Any complications?

<Dr. Simpson> Man I haven't even had a chance to tell a good joke yet. Well, that all depends on what you mean by a long time post op. There are a number of long term studies, and there are some problems which patients can get into if they do not follow their surgeons orders. For example, if you don't take vitamins, you can develop deficiency, if you do not eat enough protein you can have protein calorie malnutrition. But the surgery has the same long term complications of any surgery. There is always a risk of adhesions and hernias...But otherwise, nothing.

<cm> Are there any particular foods that post-ops should definitely avoid?

<Dr. Simpson> Sure there are: For example, there is no reason to have high glycemic index carbohydrates. There is no reason to take in a lot of junk food, or to eat from fast food restaurants, unless the food is high quality protein. Again, it is a matter of moderation-- if you can moderate these things. But your body is a perfect calorie counter -- even though you don't consider that cinnabon a meal, your body will count every one of those calories. So, again, there are no bad foods, just bad quantities of foods, so you have to learn that part for yourself. Me, I have to avoid candy, and ice cream, and whiskey and fast women.

<Janet> Do you require an EGD and gall bladder ultrasound before surgery? If so why if not why not?

<Dr. Simpson> There is no reason to have an EGD that I can possibly think of, and in terms of gallbladder ultrasound --- since with most of the surgeries I see the gallbladder very well and can touch it, and see if it is diseased --- and take it out, or leave it in, that is something I don't need to do. So, no I don't and that is why I don't.

<Ron> Are there any other less invasive methods of gastric such as a pace maker? I have trouble with blood clots and was told surgery would be very risky.

<Dr. Simpson> The pace maker is experimental and has the same risks as the lap band for surgery. If you have had clots, then get a filter. The pacemaker is not as good as the lap band, requires surgery to change the battery and electrodes, so if you are worried about risk -- then lap band is the least risky. But diet and exercise are by far the least risky option.

<Susan 3/18/04> Is there any data of WLS patients who have had surgery long ago regarding their status with regard to their well being? Any complications?

<Dr. Simpson> I think you asked this same question in another manner. And there is some long term data...No long term complications from the current forms of weight loss surgery -- RNY, lap band, DS, BPD, VBG. Patients who fall back into old habits tend to regain some of their weight. Early surgeries performed -- horizontal stapling, tend to get larger upper stomachs. But otherwise, there is nothing that has turned up about long term problems -- although there are a lot of people predicting the end of the world for WLS patients. Bottom line is, WLS is safe -- effective, and can work.

<Dawn> I had bypass surgery on nov 18...Will i ever be able to drink normally?

<Dr. Simpson> As soon as you play the violin. Well, if you mean drink while you are eating-- depends on the prohibitions placed by your surgeon. If you mean drink alcohol-- well, you will be a cheap date, getting drunk faster than you did before. If you mean drink quantities of liquids, yes you will be able to drink as much as you want. If you mean can you gulp food down and gulp liquids to wash that big chunks of food down-- then no, you will not be able to do that.

<Ysabella> Here's a FEAR question. I had surgery 2 months ago. Then I could eat 1.5 ounces. A week ago it was 2 ounces (to full-- not gorged). Today it was 5.5 ounces---how can this happen so fast and is it a horrible sign?

<Dr. Simpson> It is a horrible sign, it means that some day you can eat more. That is normal after surgery, but the only way that you stretch a pouch is if you chronically over feed the pouch. The only way you stretch a stoma is if you enlarge it by forcing large bits of food down it and stretching the stomach. If you are doing that, then yes it is a horrible sign, but we say -- measure your food twice and eat it once-- why on earth would you eat 5.5 ounces of food. By the way, it is normal to stretch things out over time, and it is not a problem, as you will still lose weight even if your pouch is up to ten ounces or so. So, measure twice, eat once, vomit never. Otherwise, I would say that you should do the following trick...Check your pouch size with tuna fish, not cottage cheese. You will find at some times in the month you will eat more, and some days you will not eat enough. Eat slowly, use small forks and plates and spoons and do not consume a lot of carbs. You will be fine. Good luck.

<Debbie> My surgeon does not use heparin shots, should I be concerned?

<Dr. Simpson> Every surgeon has his/her own protocol for weight loss surgery-- some use them, some do not. You have to go with your surgeon's protocol, not your protocol, your surgeon, more than likely, knows what they are doing and has a reason for their use of DVT prophylaxis. I use low molecular weight heparin, sequential compression stockings, and make my patients walk a ton after surgery. If they don't walk then I push them out of the fifth floor and make them walk back up. But I am mean.

<diane> Why am i still so tired, i have monthly b-12 shots take all my vitamans and calcium?

<Dr. Simpson> I don't know why you are tired, but you can have your blood checked for a number of things. I would start out by having your blood count done to see if you have anemia. Second, I would have a pre-albumin checked to see if you are eating enough protein and your body is processing it. Next, I would start a walking program and go from there. Finally, if you are having B 12 shots, I would see if that is enough, or too much, or if it is --like Goldilocks said -- just right. Goldilocks was my sister.

<cm> Dr. Simpson, is there anyway to prevent the dreaded "hair loss" ?

<Dr. Simpson> Super glue. Only 30 per cent of patients develop hair loss and you can help prevent it by eating properly, getting enough protein, taking your vitamins and zinc, and if you have hair loss then don't dump all that stuff on your head which has more chemicals than Love's Canal. Some just get hair loss from stress --- which makes me wonder why I have such a full head of hair.

<Diana VA *4WksPost*> Hello! My incision is longer than most because my surgeon fixed my hernia in addition to the gastric bypass. He used staples and it is still gapping and leaking near my bellybutton. How long does it take to close up and stop draining??

<Dr. Simpson> That is a good question and it depends on several factors. First, did someone ring the button? Oh, sorry...It can take several weeks for those wounds to heal, and you should keep in contact with your surgeon and they have a number of things for you to do to prevent the wounds from having more problems. Good luck.

<Despina> I'm am 3 weeks out and am now dealing with constipation. What's your advice on this?

<Dr. Simpson> That is simple, and you won't believe me...You need to drink more water. You become constipated because the colon absorbs water, and if you are not drinking enough water then you will become constipated. The second cause of constipation is not having enough soluble fiber in your diet. So get some Citrucel, and drink it with a full glass of water as a chaser. The last thing which helps is a lot of walking-- and or running-- which really gets the bowels moving-- so if you want your bowels to move, then get out there and move yourself. Good luck. Hope everything comes out in the end.

<Susan 3/18/04> In your opinion, which is the best surgery? 250 lbs 5'1" diabetic

<Dr. Simpson> The best surgery is the one that your surgeon will do. If they do VBG, lap band, DS, RNY whatever they do, and like to do, that is the best surgery. If you have a choice of surgeons, great -- you can see how you like the surgeons and hear them pitch their surgery, because the surgeon is going to be taking care of you, and you want to have a good rapport with them. So whatever he/she does, that is the best surgery. Good luck.

<Carol Herzog> I've been told that fair skinned people, redheads, etc tend to have more connective tissue problems....ACL's stretching/ tearing, midline hernias (incisional hernias), and tendency to bleed more. I was wondering if you saw this in your practice. I'm a fair skinned red head, and any time I've had a midline incision, I've herniated, even after a lap gallbladder. Of course, I have another hernia from open wls (above my incisional hernia repair w/mesh from a c-section).

<Dr. Simpson> Hernia patients develop hernias -- like my garden has weeds. It is as simple as that, and it has nothing to do with the color of your hair and everything to do with proper diet after surgery, not lifting anything you shouldn't lift, and avoiding things like constipation, and so forth. So, if you think it is your hair color, I might suggest you get the amber-nuggut from Clairol.

<karen> I had RNY done on 11/17/03. I have been having a problem the last few days with an excessive amount of saliva being produced. It actually makes my pouch fill up and sometimes even makes me nauseous. What is the cause of this and how can I help this problem?

<Dr. Simpson> The cause of that is over filling your pouch. The answer is --- MEASURE and don't over fill. DO NOT TOP off --- now, my friends from Oregon and New Jersey do not understand this concept. Why? Because they do not have self-serve gasoline in those states. But if you live in somewhere like the rest of civilization (anywhere by New Jersey or Oregon) then you understand if you top off a gas tank, you will have a lethal mess -- same with your pouch-- DON'T TOP OFF. If you live in New Jersey or Oregon-- there is no hope.

<Jim Saul> Dr Simpson I seem to get the hiccups after eating. Is this a normal occurrence

<Dr. Simpson> Sometimes it is a bit, after surgery -- because the food irritates the diaphragm. Again, measure twice and do not over fill.

<Ysabella> When a surgeons print out says "your pouch will never get bigger than 2 ounces" is it 2 ounces water or 2 ounces steak or 2 ounces octopus? (they are all different in VOLUME, after all)

<Dr. Simpson> Do not mistake weight for volume. We talk about volume, and your pouch will get larger. I prefer steak, by the way. Although Calamari is quite good.

<Diana VA *4WksPost*> Is it unusual to be cold most of the time after the surgery...I've never been this cold in my life!

<Dr. Simpson> It is common to be cold after surgery and here is why...When you have a lot of excess fat, your body gets very warm at its core. To prevent that your body will dilate the veins in the surface just under your skin. When you lose weight you still have those dilated veins there, and in some you have those in the legs we call them varicose veins. We Norwegians think varicose veins are veins that are close together --- anyway, those dilated veins are still there. They don't go back, so it is easy for you to have a lot of heat escape your body. That is why I chose to do bariatric surgery in Arizona, because I got tired of hearing cold complaints in the state of Washington. But then most of my patients have air conditioning, and I still hear those complaints. Get a sweater. And think -- now you can buy one off the rack!

<Gregg> OK, you mentioned using anti-depressants for a month prior to surgery if you are depressed. How many people with a bmi of 37+ are NOT depressed?

<Dr. Simpson> A number of them are not--- a number of patients are just fine with that, just because you are overweight...Does not mean you have to be depressed...Some people are not-- depression is chemical, and a bit environmental, so if you are depressed, get some help. If you are not depressed, then great.

<Dr. Simpson> Looks like we are coming to the end of our session.

<**MODERATOR**> THIS IS THE LAST QUESTION FOR TONIGHT:)

<Jennifer D> Micro pouch (grape size) Vs. the Traditional pouch : that the latter "wears off" as the Micro never changes. Is this true and I thought it was the opening leaving the pouch that streches.

<Dr. Simpson> The pouch stretches -- and micro pouches stretch, it is just a bit more work -- remember a pouch is like a balloon. When you first blow up a balloon it is hard to get it -- you have to blow real hard. As the ballloon gets bigger it takes less effort to get it larger. The idea of the micro pouch is that it is quite hard to get it up there -- and takes a lot of effort. However, it can be done -- and I have some patients who are proof that it can be done. If the opening stretches --- which is called the stoma...also known as the anastomosis...that can also lead to weight gain.

<Dr. Simpson> Thank you everyone for a nice chat.

<**MODERATOR**> THANK YOU SO MUCH TO DR. TERRY SIMPSON FOR JOINING US HERE TONIGHT! YOUR CHATS ARE ALWAYS FUN! THANKS TO OUR MEMBERS FOR THEIR PATIENCE AND ATTENDANCE AS WELL!

<Dr. Simpson> I will not be hear next week as I have a meeting to go to...and looking forward to seeing you all later. Good night.

<**MODERATOR**> GOODNIGHT EVERYONE! THANKS DR. SIMPSON!