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  > Dr. Jossart & Cirangle 08/06/03

Chat with Dr. Jossart, Dr. Cirangle, August 6, 2003

<**MODERATOR**> KATHLEE PREOP, YOU HAVE THE FIRST QUESTION FOR Dr. Jossart.

I have a vertical scar from a C-Section. Could that have an effect on being considered for a lap RNY instead of an open one?

Most patients who have had a lower abdominal scar, like a C-Section one, have no problems with undergoing a laparoscopic Bariatric procedure, whether it's the Lap-Band, RNY, or DS.

Of course, you should have an experienced advanced laparoscopic surgeon doing your operation who knows how to avoid injury because of prior adhesions.

woohoo! Um I mean thank you Dr. Jossart

<**MODERATOR**> DJCMLEE, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

Hi doc

What are the odds of re injuring a hernia repair? In the belly button area?

DJCMLEE, we perform special maneuvers to try to avoid hernia repair sites. In general, we do not need to enter the belly button directly and can work around it.

thanks Doctor

Your welcome.

<**MODERATOR**> STEPHVA, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

I had open RNY on May 2nd....... EVERYTHING HAS BEEN SMOOTHE SAILING... I JUST FEEL THAT I AM LOSING TOO SLOWLY... I HAVE LOST 41 LBS IN 3 MONS. MY START WEIGHT WAS 272 LBS. I AM 5'1 (IF THAT MAKES A DIFFERENCE). ANYWAY, I AM EXCERSIZING 2 DAYS A WEEK I DO STRUGGLE WITH GETTING ALL THE PROTIEN.. WHY DO YOU THINK I AM LOSING SO SLOW?

StephVA, you need to be exercising 45 min walking a day for 5-6 days a week.

<

Dr. Jossart>What is your caloric intake, and grams of protein, carb, fat intake?

CALORIC NOT SURE- FAT 20 GRAMS

PROTIEN STRUGGLING TO GET 50

Carbs?!

NOT SURE ON CARBS EITHER

I WASN'T TOLD TO COUNT THOSE

HOW MUCH DO YOU RECOMMEND PER DAY?

You need to focus on eating protein first in your diet in order to stay healthy and that will help you minimize your carb (less than 40g day) and your fat (less than 30grams a day).

OK TY

Drink lots of liquids 64 oz in between meals. This will aid in your metabolism and weight loss.

Of Course, increase you activity. Are you drinking during meals?

well i must say i do drink a few sips

during eating

i do get 64oz a day though at least

<**MODERATOR**> CASSIE, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE

Hello, I am now 6 mths post-op from having lap rny, and I was just wondering at this stage how much should I be eating calorie wise and how often do you suggest?, cuz it seems like I am able to eat alot more now. Also, how much can your pouch stretch out to after so long? Thanks!

My recommendations is that you try and keep your caloric intake to less than 800 calories each day for the first year...

Dietary modification and reprogramming your daily habits is what enables you to be successful in the long term...

ty

you should never have more than 3 meals a day and probably should not eat more than about 3-4 oz at a time...

ty for the info

the most common reason for failure with the RNY in the long term is stretching of the pouch and intake of too many calories.

<**MODERATOR**> TEABAGGY, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

I have Multiple Sclerosias and I am taking Methotrexate should I stop taking the medication prior to surgery? It is suppose to supress my immune system.

I think that would be a good idea. Has your MS MD OK'd surgery for you? It sounds like you disease may be active enough for you to take MTX.

Can you recommend any vitamins to take

We have all of our weight loss surgery patients on multivitamins twice a day with other supplements depending on the type of surgery they choose to have.

I have not spoken to my nerologist about it

Teabaggy, you NEED to talk to your neurologist!

But they stronglysuggest i lose weight

okay thanks

Your welcome.

<**MODERATOR**> BBD3YSPOST , YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

How dangerous is an iron level of 5.4 they wanted to hospitalize me but been there done that im back on 6 325 iron tabs a day along with 500 mg vit c with each can i even HOPE this will work??? bp was 63/45 today at rest

MVI with iron if menstruating.

TY

<**MODERATOR**> ESMER, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

I take wellbutrin SR 300mg -qd - how will my surgeon - eh...assumming i am approved.. have me take them? Do they come in liquid also what are my chances for a lap rny with a 20 year old vertical gall bladder incision/scar?

We routinely perform Lap RNY after patients have had open gallbladder surgeries...

Thank you Dr .C

the doctor who is treating you with the wellbutrin should change you over to a Non-sustained release form of the drug and you can crush the meds to take them

Thankyou - again

<**MODERATOR**> SIRENA, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

hello!!, what can you tell me of the sapala wood surgury????? any advice???vs the g. bypass

I have honestly NEVER heard of sapala wood surgery. Dr. Cirangle?

really?? its on tis web site

I haven't heard of this either

wow

In general the accepted Bariatric surgical procedures include the Lap-Band, the RNY gastric bypass, and the Duodenal Switch. Some surgeons still perform the vertical banded gastroplasty but this has fallen out of favor. Hope that helps, Sirena.

<**MODERATOR**> CHRISTINE, PA, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

Iam having surgery tomrrow at 7.30am open RNY and also my Gall-Bladder taken out how much longer will this make the surgery?And will this make the surgery more complicated?

the gallbladder shouldn't take more than an extra 30-40 mins...

so how long do you think everything will take?

it does make the surgery more risky however - the incidence of bile duct injury is about 0.2%

it depends on your surgeon - 1.5 - 2.5 hours

ok thank-You

I have to know - why are you having OPEN surgery, Christine-Pa?

The surgeon only does open

Thank you.

<**MODERATOR**> KAREN IN ORLANDO, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

Hello Dr. Jossart and Dr Cirangle...I guess my main question is why is there such a variance in post op instructions from one surgeon to another...such as length of time from liquid to softs, to solids and some allow soda and alcohol after a certain amount of time...I see such a wide range of doctors instructions discussed in the chatroom and it's mind boggling to me....2nd question...why do so many patients think Lap RNY has more complications than open?

Karen, those are very good questions...

instructions are a personal as choice of clothing. Most doctors recommend what they feel is best...

To answer the first, every surgeon has his or her own training and experience which contributes to a significant amount of variability in care both preop, intraop and postop.

So there is no strict guidelines as to what should and shouldn't be done post-op?

To answer the 2nd questions, I do not have an answer but there are even insurance companies somewhere in the South that consider the "laparoscopic" Roux en Y gastric bypass that's been around since the mid 90's still experimental in the year 2003!

the issue of lap being more risky than open is usually propagated by those who either don't know or those who can't perform laparoscopic procedures

Karen, Dr. Cirangle, Jossart and myself have pretty strict guidelines...

Dr. Jossart...everything is slower in the south...ways of thinking included...lol

all of the medical data proves that in experienced hands, lap RNY is actually probably better both in terms of complications and recovery as well as long term outcome

These guidelines are designed to optimize weight loss while preserving healthy living with minimal complications.

Thanks...my surgeon has performed over 600 Lap's and that is why I chose him...I don't wanna be in the hospital any longer than I have to be

That's great Karen! Good luck!

Thank You Dr. Jossart :)

<**MODERATOR**> EANGEL, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

WHAT IS THE MOST COMMON PROB POST DSERS HAVE ??? ALSO WHAT ARE THE BEST VITS FOR DSERS?

many problems can occur after the DS, probably the most common is diarrhea or gas/bloating...

DO THEY GET BETTER IN TIME ?

we recommend a good multivitamin with folate, ADEK chewables, and calcium as supplements

generally they do get better over time

ty

as your bowel adapts

ic

<**MODERATOR**> DARCYKINS, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart. :-)

Dr., First I would like to say Thank you for coming in here to answer our questions. My first question is, I was in a car accident on July 19th. I have whiplash but that is all. I am doing better now. My abdomen is fine. Is it still possible for me to have the surgery LAP RNY? Also, I have Poly Cystic Ovary Syndrome PCOS...IS that going to make it harder for me to loose weight if I am able to have the surgery AND will the surgery help make the PCOS go away?

If you have recovered from your accident, then it is probably OK depending on the date. I do not believe that your accident would prevent you from having surgery unless you are so disabled that you cannot walk after surgery or maneuver well.

Weight loss surgery does not cure PCOS. Remember, everyone, weight loss surgery does not cure obesity. It only helps you lose weight.

*sigh of relief*

I know that it's not a cure, but does it help?

it can improve fertility issues

Weight loss does help with increasing the likelihood of being more fertile and of course will help with losing weight. What other aspect of PCOS were you hoping to improve?

Also, what are LONG TERM affects that we should know about?

What do you mean Darcy?

I am wanting to loose weight and having the PCOS makes it sooo hard...I have 1 child and am wanting more, but the PCOS has made it very hard to concieve.

Again, weight loss can improve fertility issues but it is not a guarantee.

the RNY is very safe - it has been performed in the US for more than 30 years. As long as you follow your doctors instructions and have yearly follow-up and lab testing, there should be no long term issues

THANK YOU SOOO MUCH!

<**MODERATOR**> JACQUE 1, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

I have just found out I'm prego and VERY happy scared though. I want to keep the weight off and not gain much but be healthy and ideas or recommend readings or web sites? have you had any pts prego post op? w/ good luck I haven't lost since 1 year post op how can I engage the loosing again? iron absorption is hard my HCT is27.9? iron PO bid w/ 1000mg vit C bid as well?

how long ago did you have surgery

2years ago 18june

you will need to be certain that you eat a healthy and balanced diet. You will also need to increase your caloric intake as the pregnancy progresses...

calories how much more?

I recommend increasing the frequency rather than the size of your meals to 5-6 per day. Increase your calorie intake to 1500 per day and be sure to see your doctor monthly

Remember, multivitamins, vitamin B12, folate are also important supplements with calcium. Folate is especially to fetal development.

Folate is especially IMPORTANT to normal fetal development.

okay thnx and references?

all of the risk of pregnancy after WLS is your babies - if you have vitamin deficiencies it will be the baby that will have problems

<**MODERATOR**> RENEE 69, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

I AM HAVING OPEN RNY ON FRIDAY...I HAD A STOMACH STAPLLING IN 98,IT DID NO GOOD.WHAT ARE THE CHANCES OF THIS HAPPENING AGAIN? THE DOC I HAVE NOW, SAID MY STOMACH IS VERY LARGE

1500 mg of calcium

chromagen forte may also help (easy to take iron)

Renee, with the current method of performing the RNY, it is much less likely, although not impossible, to regain weight after RNY surgery.

There is also Chromagen Prenatals.

take them at different times (2-4 hours apart)

I NEVER LOST BEFORE

Renee, the old stomach stapling technique was flawed. Your stomach was never made small enough. I believe that you should do well.

THANKS...I HOPE SO

Remember, however that diet and exercise still play an important role!!! It's not just surgery.

<**MODERATOR**> SARA 18/F, YOU HAVE THE NEXT QUESTION FOR DR. CIRANGLE.

I AM GONNA BE A YEAR OUT OF RNY 8-19-03 HOW MUCH SHOULD I BE EATING NOW I CAN EAT LIKE 1 CUP FF COTTAGE CHEESE IS THAT TO MUCH? ALSO IM 18 AND 5'8 WHAT SHOULD BE MY GOAL WEIGHT MY DOC NEVER GAVE ME ONE? ALSO WHY CAN I EAT MORE SOMEDAYS THAN OTHERS AND HOW CAN I JUMPSTART LOSS I EXCERSIZE VIGOURESLY 7 DAYS A WEEK AND STARTED OUT AT 263 AND NOW AM 153 BUT WEIGHT LOSS SLOWED DOWN I DO EAT MORE NOW BUT AM NOT SURE HOW MUCH I SHOULD EAT

at one year you should still be eating about 4-5 oz or less at each meal. Your target weight should be a BMI of 22-24.

so then i can eat to much

With you height at 5'8 and your weight 153 your BMI is 23!

1 cup of cottage cheese

that may be a good idea

You are there!

but im not done losing

thats all?

Your goal weight is 152.

well how come i can eat so much

you said 4-5 oz

i can eat 1 cup of ff cottage cheese

I would not get your BMI below 22

and how much should i be eating in a day

if you have reached your goal weight, about 1000 cal per day or however many will allow you to stabilize

<**MODERATOR**> SWEETSUE 1952, YOU HAVE THE NEXT QUESTION FOR Dr. Jossart.

I am one of SFLap post op patients and was told that I am now anemic and have developed an inactive thyroid. On top of that I have herniated my incision. How common are these problems? I am now on tyroid medication and things have slowly started moving again. My worry is that why all of a sudden am I having these problems? Am I doing something wrong?

Sue, which surgery did you have?

I had the DS. I started out at 450 and now am at 290 (according to my home scales)

when was your surgery

My surgery date was 08/2002

Anemia still occurs in a low percentage of patients. Iron supplementation is usually enough to replenish your levels...

Dr Jossart and Cirangle were my surgeons. You guys are the bomb!!

I assume that you had a hand-assisted DS.

Or open?

I am not sure if that was the case. I had an open with 43 staples to be removed!

The risk of hernia formation in a larger incision is high in any morbidly obese patient regardless of the type of surgery that person is undergoing.

You did not do anything wrong.

you have done very well

How tall are you Sue?

Well, Dr Cirangle I hope you feel the same way tomorrow when I see you!!! I am 5 foot 5 inches

Sue, will you be at the support group meeting tomorrow

Yes, and I have an appointment with you at 3pm too!

So you started with a BMI of 75 and it's now 48! Congratulations.

Thank you guys so much!

your welcome

<**MODERATOR**> DREGGIECAT, YOU HAVE THE LAST QUESTION FOR DR. CIRANGLE.

What causes the feeling in the breast bone area like something has gotten stuck on the way down and you have to make yourself throw up in order to feel better?Could the opening to the new stoma be to small?I had lap ryn in march 2003.

either the connection has narrowed or you are eating too much or too quickly

is it common to narrow

and what do i need to do to find out if this is the problem?

narrowing or stricture occurs with varying rates - generally 2-4% incidence

I eat slow and chew everything well

Is it a big deal to correct?

you should see your doctor and he will probably want to either get a special x-ray or have you get an endoscopy

will the endoscopy stretch it

strictures are fairly easy to fix - a small balloon is used to dilate them

how

through the flexible scope that is placed through your mouth

Good luck Dreggie.

thank you

I was afraid that was my problem and have been putting off calling the Dr.

<**MODERATOR**> THANK YOU DR. CIRANGLE AND Dr. Jossart FOR TAKING THE TIME TO JOIN US THIS EVENING!!

THANK YOU Dr. Jossart, THANK YOU DR. CIRANGLE! FOR MORE INFORMATION...PLEASE VISIT WWW.LAPSF.COM

<

Dr. Cirangle>thank you all - excellent questions

Good night everyone.

bye ty

goodnight....enjoyed this

nite tyvm

GREAT CHAT

THANK YOU ALL !

good night and good health to all

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