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Chat with Dr. Cirangle, November 5, 2003

<**MODERATOR**> LI YOU HAVE THE FIRST QUESTION PLEASE:)

Dr. Cirangle, I am almost 3 weeks out, and I can't seem to be able to eat more that 300-400 cals per day. Is this normal?

Li, in general eating 300-400 calories a day after surgery is not unusual. If you are eating an adequate amount of protein, you minimal calorie intake will help you optimize your weight loss. In the long term patients should eat less than 800 calories a day.

Is long term a year or more out?

Yes, 1-2 years out... However, if you are still taking in a low number of calories, it's probably ok.

Thank you

:)

<**MODERATOR**> PETUNIA YOU HAVE THE NEXT QUESTION PLEASE:)

how many people who have had the surgery have died? what are the chances for death after having the surgery?

The quoted number in the literature is 2-5% of people who have had surgery. Nationwide it's around 2-3%. It is a risk of the procedure.

<**MODERATOR**> RILEY YOU HAVE THE NEXT QUESTION PLEASE:)

If I do not get in my 70 grams of protein per day that my surgeon recomends, will that slow down my weight loss and why? I am having trouble finding a protein drink i can drink. They all taste horrible. I am currently only getting in about 35-40 per day and my loss seems slow to me? I am 3 weeks post op. I also get alot of mild chest pains that seem to travel from top of incision line upward to the throat area, is this gas? I am also going about every 2 days between bowel movements is this normal.

OK, let's go through this....

How much weight have you lost over how many days?

20 pounds, 20 days

Outstanding. It's not slow at all. Right on track.

okay good

It is difficult early on to get all your protein in since your stomach is still recovering from surgery. Sounds like you have a large incision. Is it painful?

my ??? was not done

not at all, large incision yes breast bone to belly button

I feel great just tired

GNC has several selections: Procomplex, ultrapure protein, metrx, protein plus, all the whey, designer whey; they have a 30day return policy.

yes i took three back already LOL

When does your surgeon want you to start pureed/solid foods.

I am on solids as of last monday

very slowly

I've actually tried a couple of them. I find that ultrapure is pretty good, like a nectar drink.

So at this point, you can do some protein drink in the morning and work on getting in the rest of your protein at your 2 other meals.

Good luck.

ty

<**MODERATOR**> MONICA YOU HAVE THE NEXT QUESTION:):)

Hi Monica.

Are sugar alcohols (Candys such as Atkins bars,carbolite,detour etc) ok when your post op 6 months or more? Do sugar alcohols effect you the same?

Monica, you should try not to get back into eating candy. Regardless, you should count the calories and grams of carbohydrates that sugar alcohols contain. They may also cause dumping in some people.

Ok that you ... : }

<**MODERATOR**> JEAN YOU HAVE THE NEXT QUESTION:)

Thank you Dr. Cirangle for donating your time, I had a front ventral hernia repair in 1994, gastro eval in 1997 for GERD states that the ventral hernia is in need of additional repair. No pain associated at this time. If I have Open RNY and require a T Tuck at the end of goal, Would I be able to have ventral hernia repaired and T-Tuck at the same time? EDG also revealed a Sliding H-Hernia that has not been repaired, can or should this sliding H-Hernia be repaired at the same time as the Open RNY is performed?

Yes.

Yes?

Yes, you can have your ventral hernia repaired and T-Tuck at the same time after you have lost most of your excess body weight.

If the hiatal hernia is large, it probably should be repaired or your anastamosis may end up in your chest.

so, yes.

ty, for you time and answers. :)

<**MODERATOR**> SWEET AMY YOU HAVE THE NEXT QUESTION PLEASE:)

They say in RNY surgery, alot of times you have to go back for a second surgery, due to complications? and the risk there is 3-5 times higher for death? is that true? And why are the hospitals in MO reviewing this procedure? do you know? thank u

Hi Sweet Amy.

Let's step back a bit.... Sweet Amy.

I can say that in the hands of an experienced laparoscopic surgeon, the RNY is VERY safe. Returning to surgery is rare

I'm not sure what you mean for "risk there is 3-5 times higher for death?" higher than what?

higher chance of problems when they go in to take care of complications

Is MO Missouri? Because I reside in California.

yes it is

two docs here said they are reveiwing it

one isn't doing anymore

Where did that surgeon train, how old is he, is it laparoscopic, what are the issues for those surgeons?

they are doing all kinds there doc

one has like 20 yrs exp

i think it is the malpractice insurance..

Ahhh.... There it is. Laparoscopic surgery for morbid obesity was only developed in the last 8 years and it's the younger surgeons who have become the experts at it.

Every state has different issues with malpractice etc.

<**MODERATOR**> MISSY YOU HAVE THE NEXT QUESTION FOR Dr. Cirangle PLEASE:)

Hi Dr. Cirangle I am at one month pre- surgery. I hear alot about deaths the closer I get to surgery. Who are at the biggest risk of death in this type of surgery and can it be predicted? I must say i am very confident in my surgeon.. just scared feet. Also ..what is your opinion of the lapband vs rxny?

Missy, are you getting the Roux en Y gastric bypass? or the LapBand?

the Roux Y Gastric

Scheduled December 10th

Risks for death are overall health problems, age, prior surgeries, venous stasis, lung disease, smoking, high BMI, male gender, longer operation... The more factors you have the higher risk.

The LapBand is MUCH safer than the Gastric Bypass.

I smoke and my BMI is 44 female

But the LapBand is much more of a tool.

ok

Missy, STOP SMOKING NOW! You WILL get lung problems and your recovery may be rocky.

Patients who smoke have a much higher risk of poor wound healing which is a big component of any intestinal operation.

ok thank you

<**MODERATOR**> CATHY YOU HAVE THE NEXT QUESTION PLEASE:)

I heard on tv tonight that a women died 2 days after surger on Oct.21 at you're hospital. It said something about the staple gun misfiring as one of the reasons. Can you explain what happened? I had the gastric bypass 21 years ago and have a severe absorbtion problem and I am in the process of having it reversed and the newer one done.So I am a bit nervous. Thank you Dr. Cirangle

Kathy, I work with 2 other surgeons. We have had no deaths in the hospital.

I don't keep track of other surgeons.

sorry it was in the Boston Hospital

Also, if I did, that would be priveleged information.

Good luck.

I work at California Pacific Medical Center in San Francisco, California.

<**MODERATOR**> WEIGHTINGTO EXHALE YOU HAVE THE NEXT QEUSTION PLEASE:)

Hi movie name

:)

Pre-OP---Are there any limitations to physical activites once you have open RNY (once healed)? I would like to run a 10K. Also, what information would you suggest should be placed on a medical alert bracelet?

OK, you are not to do any strenous activity for at least 2 months after an OPEN RNY. After that you should be ok to train for a 10K (great!). Good luck.

thank you

<**MODERATOR**> KIM IN VA YOU HAVE THE NEXT QUESTION FOR OUR GUEST PLEASE:)LOL

Greetings Dr. Cirangle, my question is what are they testing for when they test blood gases pre op? And could negative findings cause my surgery date to be postponed?

Hmmm.. Kim from Virginia. You must have asthma or emphysema or something called COPD.

Do you smoke?

nope, yes, but I'm quitting :)

I'm 24 and pretty healthy

barring morbid obesity

When are you quitting? After you get off the computer?.... Seriously, you should have quit the day you decided to have surgery.

What is your BMI?

it is 52 and I quit yesterday, but had one today

When did you see your surgeon?

september 2

I was approved 2 weeks ago

So you need to do whatever you need to do to stop NOW! You will have problems.

You need to be off cigarettes for at least 3-4 weeks for you damaged lungs to recover.

ok doc, I've read about the problems and I'm trying, give me credit, it's not easy

Remember, you will be paralyzed and a machine will do your breathing for you. That morning cough you have with the secretions can cause a pneumonia and worse. Good luck!

you didn't tell me what they are looking for in the blood gases

jeez, what a pep talk

They are looking for how well oxygen goes from your lungs into your blood. If it is poor, you may be considered hi risk. This is unlikely at your age but not unheard of.

ok, thank you, all I wanted to know

Kim, I'm not here to sooth you. Many people come to us looking for justification to keep smoking. It is dangerous. Leads to complications. Adds to those numbers of death and complications that other person was asking about. Some surgeons still operate on such patients and it doesn't help.

I'm just being straightforward. I apologize for my honesty.

<**MODERATOR**> BEV YOU HAVE THE NEXT QUESTION PLEASE:)

Hi Dr. Cirangle: Have any patients had problems getting to goal weight after one year? What can I do to help myself more? I barely eat anything all day, and a small supper. I'm getting depressed watching friends make it to goal much faster. My weight loss is down to minimal (down from 340 to 239, now barely anything). Anoher issue is my sister. She had the surgery the same month, October 2000, and has had chronic wound problems since then. Has anyone else experienced this? It's moved all over her abdomen. Plastic surgeon has removed areas, it travels to another spot. Long question, but huge issue for my sister. She is looking at her second skin graft, if the infection clears.

Bev, what is your starting BMI?

It's so long ago, I can't remember.

How tall are you?

5'8 1/2"

When was your surgery?

October 2000

Your BMI was 50.9 in Oct 2000 and now 35.8. How long has it been at this weight?

About ten months

So it sounds like you have leveled off.... How many ounces of food do you eat?

Usually no much during the day, if at all. At night, 3-6 ounces of protein.

Was your surgery open or laparoscopic? did they separate the stomach in doing the gastric bypass? (Did you have the RNY gastric bypass)

Open roux-en-Y

Stomach separated or just stapled?

Separated.

Do you exercise?

I try to, at least 2-3 times a week, 20-30 minutes. Not always successful in that.

Why Bev?

Long hours working in a hospital medical record dept (manager). Tired when I get home.

Do you snack during the day?

Usually just drink milk or coffee. Protein bar now and then.

Tough job (dealing with doctors who don't do their paper work).

Tell me about it.

How many calories a day?

I would estimate 400-800 per day.

That is great! OK... analyzing...

In the first place, with a starting BMI at over 50 kilograms per meters squared, you are at higher risk for not losing enough weight. Your Roux limb should be 150 cm to help achieve that instead of the usual 75. This has been studied well. Also, that is what they invented the duodenal switch operation...

Patients with a higher BMI were not losing weight and intestinal malabsorption was introduced and this help a lot but at higher risk.

I had a hysterectomy two years later, and had real trouble healing. PICC line, parenteral nutrition, IV antibiotics. What a nightmare!

At this point, my patients are recommended to eat 3 meals a day (no liquids during meals) drinking water in between (64 oz a day - sipping all day of course) and minimizng fats and proteins. They must exercise 5-7 times a week for 45 minutes a day starting from the day they go home from surgery. Good luck.

Bev: Thank you. I will follow your suggestions. Your time is greatly appreciated.

<**MODERATOR**> OAKLANDBARB YOU HAVE THE LAST QUESTION FOR OUR GUEST TONIGHT PLEASE;)

Hi Dr. Cirangle. Go ahead and finish with Bev, if you weren't done. I saw part of one of your chats in the OH magazine today. Do you have these chats often? I was wondering, how much weight do you make people lose before surgery? I found you on this site and was going to call for a consult, but I wasn't sure how hard you make us work before surgery :)

OaklandBarb. Greetings fellow Northern California person. I tell my patients not to gain weight before surgery, since doing so makes surgery much more difficult and more likely to have an open operation. I don't force patients to lose weight since that is what they have beeen doing all their lives. Please look over the website www.LapSF.com and register online. We will then call you soon.

thanks.

right....

don't force us to lose weight...

that sounds nice.

Do you know if Rabkin makes his do so?

(Not that I'm trying to seem obnoxious here, just that I'm pretty fed up with it all).

Barb, also I've only had one patient eat at InNOut the day before surgery. THAT is a mistake. Remember choosing surgery is choosing a healthier lifestyle.

A friend of mine referred me to Rabkin, but I found you on this site and that's looking pretty good.

Thank you. Thanks for your time!

Thanks OB! Please read over everything. Talk to you soon.

Your welcome. > FOR MORE INFO ON Dr. Cirangle go to www.LapSF.com or call 415-561-1310

<**MODERATOR**> THANK YOU TO ALL OUR MEMBERS FOR JOINING US AS WELL!:) IT HAS BEEN A PLEASURE:)

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