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March 24, 2005 Chat with Dr. Jossart at ObesityHelp.com <Moderator> Welcome to tonight's chat with Dr. Dr. Jossart . Chat starts at 8pm PST/11pm EST. Please type out your questions and hit enter will see them and present them to Dr. Jossart at the time of chat in the order we receive them. Thank you! <Dr. Jossart> Good evening! <taylor> My BMI is 37 I am approx. 90- 100 lbs overweight with history of back, knee, and GI problems. Would I qualify for lap banding? <Dr. Jossart> Taylor, as you may or may not know, you are a candidate for weight loss surgery if your BMI is 35-40 with medical diseases related to obesity such as sleep apnea, high blood pressure, diabetes, degenerative joint disease; as well as if you BMI is greater than 40 without any diseases. This is best established in a one on one consultation but if you have back/knee joint disease that is limiting your activities, then probably yes. <Truthseeker> I am one year post op and want to know how I can get myself back on track and away from the darn carbs? <Dr. Jossart> It is about commitment. You need to seek counseling and nutritional therapy if needed. Your surgery is probably still effective and you have to mentally prepare to change. <Amanda(preop)> i was wondering what are my chances of needing a tummy tuck after LAP RNY? and is is necessary for everyone? <Dr. Jossart> It is rare for anyone to have a medical necessity for a tummy tuck unless you are having back problems with the excess skin or skin infections. Whether or not you "want" a tummy tuck later depends on your age, how much weight you lose, and how your abdomen looks/feels a year or 2 later after you've achieved your goal weight. The looseness of your skin depends on a variety of factors, including age, genetics, the actual amount of weight loss, etc. <Anita> I am feeling hungry in between meal, especially in the afternoon, do you have any suggestions? <Dr. Jossart> Anita, you can choose a small, healthy snack such as turkey jerky, slice of deli meat, protein drink, berries, etc. The options are endless as long as they are healthy, higher in protein and low in carbs. Of course this is while you need to still lose weight. Hopefully, you know that your diet must change once your reach your goal weight. <bobby> i am 4 months post op have lost 60 pounds was 420 how much protein should i be getting in at this present time? thanks Dr. Jossart <Dr. Jossart> Bobby, you probably should be ingesting at least 80-100 grams of protein a day. <lisa c> are we to do vitamines forever after surgery? <Dr. Jossart> Yes, since your stomach is the size of a golf ball in a Roux-en-Y gastric bypass it is very difficult to get in enough vitamins/minerals with normal portions of food, so you need to take concentrated vitamins in the form of pills forever. This is part of the commitment to stay healthy after weight loss surgery. Our website http://www.lapsf.com/ can help explain a lot about the different procedures and what is required after each type. <Anita> I am only two weeks out from surgery, I understand that being tired is normal, is there anything I can do to improve my energy level? <Dr. Jossart> Anita, actually, most of my patients are not very tired in the first 2 weeks. In fact they have a renewed energy level. You must take in enough protein, drink enough liquids, take your vitamins, walk everyday, attend support group meetings, etc. <Emily> The only problem i've had after surgery is hard stools. i've done it ALL such as stool softeners, magnesium pills, drinking loads of liquids, exercising, juice, some fruit and veggies, metamucil, and ALL of the obvious things. yet, the problem persists. WHY is this a problem for WLS patients? i NEVER had this once before surgery. how can i get rid of this PAINFUL problem? thank you... <Dr. Jossart> It is common for Roux-en-Y gastric bypass patients to feel constipated after surgery. It is uncommon in the Duodenal Switch, LapBand, and Vertical Gastrectomy. It is usually related to not drinking enough liquids throughout the day >64-80 ounces over the whole day, but also can be related to not enough fiber intake such as with vegetables. You need to ask you surgeon about it. <tos> can you do surgery on someone with the BMI of 80? <Dr. Jossart> Tos, yes, in general, for a BMI of higher than 60 or more, you are at high risk for problems if you undergo a Roux-en-Y gastric bypass or even a Duodenal Switch. The Laparoscopic Vertical Gastrectomy is probably the procedure of choice for patients who are super-super obese (BMI > 60) since it minimizes the chance or leak. Please look at the procedures listed on our website at http://www.lapsf.com/. <sammy> Why does our hair fall out after Surgery? <Dr. Jossart> There are hormonal changes that occur with rapid weight loss. These can cause hair loss. If you go to your local GNC, you can pick up something called hair and nail supplement and it may work to help minimize the hair loss. There are things in it like biotin, flax seed oil, B complex vitamins, coenzyme Q, etc that can help sometimes, but it's not a guarantee. Remember, there are no bald, female, weight loss patients. Your hair regrows once your weight stabilizes. Remember, if you are not taking your vitamins or eating enough protein, that also can be a reason for hair loss that need immediate correction. <FRAN> I am wondering about supplements and absortation? can i take pills or should I use liquad vitamins? <Dr. Jossart> Fran, I think you mean "absorption". you can take pills or liquids. Chewables probably go down better depending on the type of surgery. <Tonnie> I am worried that my depression will stop me from getting ok'd by my PCP. The problem is that alot of my depression stems from my morbid obesity. Will this stop me from getting Weightloss Surgery? <Dr. Jossart> If your depression is stable and being treated, then you should be ok. It is up to the psychiatrist or psychologist who evaluates you. All of our patients go through extensive preoperative evaluation for this. Remember weight loss surgery is a dramatic lifestyle change. For those who don't know, if an untreated clinically depressed person experiences a drastic change in lifestyle and is unable to cope properly, that individual is likely to become suicidal. <Regina> How important is support after surgery <Dr. Jossart> Regina, extremely important. As you see from all the questions that are being asked tonight. The more education/support the more likely you will be successful. <Ron in TX> Why do surgeon's differ so widely on their rules post surgery? i.e. diet, restrictions, etc. Some seem more strict than others, and vise versa. <Dr. Jossart> Ron, you want to find a surgeon who has very clear reasons and can show your results of why and how their postoperative care optimizes your weight loss. If it makes sense to you, then it usually is the right thing. Of course, there are surgeons who may just say: "That's the way I've always done it..." <tanya> i have had 2 fills in my 10cc band right now i have 8.5 but i dont feel like i have any restriction at all <Dr. Jossart> Tanya, that sounds pretty full. You may want to do you next fill under fluoroscopy to check the band position, to look for an erosion, etc. I presume you don't feel full from chicken, fish, beef. You won't feel full with carbs or liquids. <walter> is a ds the right surgery for replacing a nissan wrap, or can the nissan wrap stay and a wls fit in some how?d <Dr. Jossart> Walter, that's tricky. Taking apart a Nissen wrap can be risky to do anything with weight loss surgery. You can't really have an Nissen wrap stay, and you probably wont need to. After a Nissen, you can probably have either Roux-en-Y gastric bypass or even a DS if the surgeon is good. <tina> i am on georgia medicaid i seen on my dr. appel did the surgery with that type of insurace after it is approved how long does it take to get prepared for the surgery if i am appoved? <Dr. Jossart> Tina, it depends on your medical problems and how many tests you need to clear you for surgery. Everyone is different. Of course, there is the waiting list for your surgeon to consider also. You should ask your surgeon since he or she knows the process specific to them better than I can tell you. <Ginger> What is the best surgery? <Dr. Jossart> Ginger, that is best discussed in a surgical consultation. Please look at my website to find out more about the different types: http://www.lapsf.com/. <Amber in VA> What do you eat during the first few weeks? <Dr. Jossart> In general, all of my patients are on a thin liquid diet with protein drinks to let your stomach heal without problems. <Eric> What do most people lose in the first year? <Dr. Jossart> Eric, it depends on the type of surgery. <Vivian> Dr. Jossart WHAT IS SAFER LAP OR OPEN RNY? <Dr. Jossart> Vivian, like anything, the safety is dependent on your surgeon. If the surgeon only does open surgery, then open surgery is safer. If I'm your surgeon, since I specialized in advanced laparoscopic surgery, you will do fine and probably even better with laparoscopic surgery. Of course, if I did open surgery you would be fine but you would be more likely to have wound infections, hernias, longer hospitalization, pain from the larger incision, etc. <Emily> When we take fiber supplements such as "colon cleanse" do we have to take a half dosasge? I worry that it may swell up too much and expand the stomach so I've never used it yet but want to give it a try IF it's safe to use 11 months post op. Thank you. <Dr. Jossart> Emily, it's probably safer to take less, but try increasing liquid intake as well as adding more vegetables to your diet before trying "to cleanse your colon." <Jeff> How many calories a day should someone around 350lbs have after surgery? <Dr. Jossart> Jeff, there is no minimum amount. Most of my patients are can only drink/eat 400-600 calories a day. However with such a low calorie diet, you must maintain a minimum protein intake of 70-80 grams or more. <Joan> Does everyone need to see a therapist after surgery? <Dr. Jossart> Not everyone. It is encouraged if you are having trouble with food choices, since you are probably dealing with "head hunger" or stress eating and need to talk about your stresses in your life. Remember, having weight loss surgery doesn't get rid of the annoying boss, the troubled teenage kid, or other unrelated problems all of us are dealing each day. You need to find a new "friend" since most obese patients relied on food as their "best friend." <Monica> concerning excess skin post gbs. Is there a certain ethnic that has more skin after surgery? i realize that your weight before surgery has a lot to do with it also. But maybe one ethnic group has more elasticity. <Dr. Jossart> Monica, I don't know why you are asking this but it is an interesting question. As I said, there are genetic factors with skin elasticity. <TODD> What are some of the medical conditions that would make a patient a "high risk"patient for doing WLS? Or are we all "high risk" due to our co-morbitities? <Dr. Jossart> Todd, high risk means patients who have many of the diseases that can directly affect healing and recovery and tolerance of general anesthesia: Unstable coronary artery disease, steroid-dependent asthma, kidney failure, heart failure, insulin-dependent unstable diabetes, extremely severe sleep apnea, BMI > 55-60, etc. <SHERI> How do I know what vitiams are right for me after the surgery? <Dr. Jossart> Your surgeon should be able to tell you. If he or she cannot, you need to find someone else. <Monica> What about sleep apnea, should more precautions be taken during or after surgery. I also sleep with a cpap machine for 2 years now. <Dr. Jossart> Monica, many of my patients have sleep apnea; most of them, I actually diagnosed and put on CPAP. If your sleep apnea is treated well with your CPAP, you just need to be at a hospital than is aware of how to take care of patients with this problem. At our hospital, sleep apnea patients are monitored with oxygen monitors after surgery. Do your research. <SeattleGal> Dr. Jossart, I am a pre-op, deciding between BPD/DS and RNY. As far as your patients go, has there been a difference in success rate over time (weight loss)? Also, is there an operation and post-op complication rate difference for either? (Just in your own experience?) And, would you take a patient referred from WA state? <Dr. Jossart> Seattle Gal: As you will see from reviewing our website http://www.lapsf.com/, we do 4 different procedures: LapBand, Lap Roux-en-Y gastric bypass, Lap Duodenal Switch (BPD/DS, DS, etc) and the Vertical Gastrectomy. The weight loss after the last 3 are very similar. Each operation entails a slightly different way to achieve weight loss. We have had NO leaks with the Roux-en-Y gastric bypass. The Duodenal Switch is higher risk. The Lap Band has slower weight loss. Finally, the Vertical Gastrectomy seems to be one of the safest that I do for any size patient. I have patients from Washington to Connecticut to Texas, Arizona, Southern California, etc. I'd be happy to speak to you and even do a Phone consultation. You can register online on our website to become a patient. Everyone is different in how they want to lose weight. <Brika> I am currently breastfeeding an 8 month old baby. I'd like to have surgery witout having to wait until I stop nursing her... as I'd like to continue until she's at least 1 1/2 years. Wondering if you've ever heard of anyone having surgery and still being able to breastfeed an infant once the baby is eating other foods besides breastmik? I've looked everywhere for an answer.. Thanks! <Dr. Jossart> Brika, that is a very specific, difficult question. You can probably continue to breast feed but the difficult part is to say how much nutrients compared to if you didn't have surgery are you going to be able to give your baby via breast milk? I don't think there is an answer. That is why the LapBand and the Vertical Gastrectomy are good operations since there is absolutely no malabsorption, no constipation, etc. In the LapBand you can even deflate the balloon to eat more. <beth> why do the ins. companys give you such a hard time about having the surgery? <Dr. Jossart> Ah! The 20 million dollar question. Actually, the 16.7 million dollar question. It's business for them, as you've probably heard. It's shareholders, it's profit. As a matter of fact, in a General Surgery News Journal that I read in addition to all the other journals that I go through, there was an article about Anthem Blue Cross and Blue Shield. Did you know that the CEO of Anthem in 2001 made 16.7 million dollars in salary that year. That's a lot of your health care premiums not going to doctors to do weight loss surgery, CT scans, colonoscopies, hip repairs, etc etc. <Monica> What is the one piece of advice to give someone who is thinking about gbs - so they will be sucessful. <Dr. Jossart> Stay focused. In our 40 page diet manual (in 10 point font), we have a whole section on the "10 commandments of Weight Loss Surgery". One of these basically says: Thou shall always keep the memory of the past and the hope of the future as a clear image in thy mind." Remember, Monica, weight loss surgery is ONLY a tool. Sure, gastric bypass may give you dumping and the duodenal switch diarrhea if you eat fatty foods, but all of these surgeries limit the amount of food you can ingest. However, it's only the healthy foods that help you feel full, the solid protein foods such as chicken, beef, lean port, fish. Your ability to eat more that the 2-4 bites is limited so that you can limit your carbs. But the trick is: You need to eat protein first. You feel full. You drink liquids. Take your vitamins. Drink liquids. Attend support group meetings, do online chats, email your doc, see a nutritionist, see your therapist. This is about a lifestyle change, a surgically induced change. Your window for weight loss is not a window in which your surgery stops working. It is a window about behavioral change. If you don't lose enough weight in the first 9-12 months, you may never or have a tough time losing it. It is about support our patients after surgery. There needs to be a team effort. <Moderator> and the last question goes to.... <lj> Can you strech your pouch by drinking liquids?? <Dr. Jossart> After weight loss surgery, you should not drink during your meal since adding liquids may cause you to vomit and may theoretically stretch your pouch if you do it a lot. We have all of our patients eliminate carbonated beverages after surgery for that very same reason about worrying about the pouch stretching. <Moderator> Dr. Jossart of Laparoscopic Associates of San Francisco Website: http://www.lapsf.com/ Phone: 415-561-1310 Fax: 415-561-1713 E-mail: WeightLoss@lapsf.com <Moderator> Excellent Chat tonight Dr. Jossart, Thank you for coming tonight and helping out the Members with all their Questions. Have a good night. Thank you all for coming, have a great night. <Dr. Jossart> Thanks. Good night everyone. Remember it's about education and commitment. Good journey!

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