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Tack J, Raymenants K, Van de Bruaene C, Scarpellini E. Dumping syndrome: Update on pathophysiology, diagnosis, and management. Neurogastroenterol Motil 2025; 37:e14962. [PMID: 39529492 DOI: 10.1111/nmo.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 10/07/2024] [Accepted: 10/26/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Dumping syndrome is a complex of gastrointestinal symptoms originally studied in peptic ulcer surgery patients. At present, it is most prevalent in patients who underwent bariatric, upper gastrointestinal cancer or anti-reflux surgery. The symptom pattern comprises early and late dumping symptoms. Several management options have been reported including nutritional, pharmacological and surgical approaches. AIMS AND METHODS In this study, we aimed to review the current evidence on dumping syndrome definition, diagnosis and treatment, including preliminary data from newer pharmacological studies. RESULTS Current pathophysiological concepts and analyses of provocative tests has led to a clear definition of dumping syndrome, including both early and late dumping symptoms. The term postbariatric hypoglycemia represents a limited focus on late dumping only. The diagnosis relies on recognition of symptoms and signs in a patient with appropriate surgical history; and can be confirmed by provocative testing or registration of spontaneous hypoglycemia. The initial treatment focuses on dietary intervention, to which meal viscosity enhancers and/or the glycosidase inhibitor acarbose can be added. The most effective therapy is the use of short- or long-acting somatostatin analogues, which is however expensive and entails side effect issues. In case of refractory hypoglycemia, diazoxide or SGLT2 inhibitors can be considered, based on limited evidence. In refractory patients, continuous enteral feeding or (rarely) surgical reinterventions have been advocated, although not supported by solid evidence. Therapies under current evaluation include the broad-spectrum somatostatin analogue pasireotide, GLP-1 receptor antagonists, GLP-1 receptor agonists and administration of stable forms of glucagon are currently under study. CONCLUSIONS Dumping syndrome is a well-defined but probably under-diagnosed complication of upper gastrointestinal, especially bariatric, and surgeries. Diagnosis is confirmed by a provocative test and incremental therapies starting with diet, adding meal viscosity enhancers or glycosidase inhibitors and adding somatostatin analogues in refractory cases. A number of emerging therapies targeting intestinal propulsion, peptide hormone effects and hypoglycemic events are under evaluation.
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Affiliation(s)
- Jan Tack
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
- Division of Gastroenterology and Hepatology, Leuven University Hospitals, Leuven, Belgium
| | - Karlien Raymenants
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
| | - Cedric Van de Bruaene
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
| | - Emidio Scarpellini
- Translational Research Center for Gastrointestinal Diseases (TARGID), University of Leuven, Leuven, Belgium
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Guthrie TM, Lee S, Kothari A, Kumar S, Truby H, de Jersey S. Measuring Dietary Intake of Pregnant Women Post-Bariatric Surgery: Do Women Meet Recommendations? Nutrients 2025; 17:285. [PMID: 39861415 PMCID: PMC11767831 DOI: 10.3390/nu17020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 01/10/2025] [Accepted: 01/11/2025] [Indexed: 01/27/2025] Open
Abstract
Background: Bariatric surgery is increasingly offered to women of childbearing age and significantly reduces food intake and nutrient absorption. During pregnancy, associated risks, including micronutrient deficiency, are accentuated. This study describes maternal dietary intake and adherence to dietary recommendations in pregnant women with a history of bariatric surgery. Methods: Women aged 18-45 with singleton pregnancies post-bariatric surgery were recruited at <23 weeks of gestation and followed until birth. Dietary intake was measured using three non-consecutive 24 h recalls at enrolment and at 28 and 36 weeks using the standardized tool ASA24-Australia. Micronutrient supplementation dose and adherence was reported using the Brief Medication Adherence Questionnaire. Mean macronutrient intake was calculated from all diet recalls. Micronutrient intake was determined from diet recalls and from supplementation. Intake was compared to the recommended daily intakes for pregnancy. Results: Sixty-three women participated in the study. The participants met 65 ± 17.3% (mean ± SD) of estimated energy requirements, 53(23)% (median(IQR)) of fiber requirements, and exceeded fat and saturated fat recommendations. Dietary intake levels of iron, folate, zinc, calcium, and vitamin A were below recommended levels. Gastric bypass recipients consumed significantly less folate (p = 0.008), vitamin A (p = 0.035), and vitamin E (p = 0.027) than women post-gastric sleeve or gastric band. Multivitamins were used by 80% (n = 55) of participants at study enrolment, which increased their mean intake of all micronutrients to meet recommendations. Conclusions: Women who conceive post-bariatric surgery may require targeted support to meet the recommended nutrient intake. Micronutrient supplementation enables women to meet nutrient recommendations for pregnancy and is particularly important for gastric bypass recipients.
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Affiliation(s)
- Taylor M. Guthrie
- Faculty of Health, Medicine & Behavioral Sciences, University of Queensland, St Lucia, QLD 4072, Australia; (A.K.); (S.K.); (H.T.); (S.d.J.)
- Dietetics and Foodservices, Royal Brisbane Women’s Hospital, Herston, QLD 4006, Australia
| | - Sandra Lee
- Maternity Services, Caboolture Hospital, Caboolture, QLD 4510, Australia;
| | - Alka Kothari
- Faculty of Health, Medicine & Behavioral Sciences, University of Queensland, St Lucia, QLD 4072, Australia; (A.K.); (S.K.); (H.T.); (S.d.J.)
- Obstetrics and Gynecology, Redcliffe Hospital, Redcliffe, QLD 4020, Australia
| | - Sailesh Kumar
- Faculty of Health, Medicine & Behavioral Sciences, University of Queensland, St Lucia, QLD 4072, Australia; (A.K.); (S.K.); (H.T.); (S.d.J.)
- Mater Research Institute, University of Queensland, South Brisbane, QLD 4072, Australia
| | - Helen Truby
- Faculty of Health, Medicine & Behavioral Sciences, University of Queensland, St Lucia, QLD 4072, Australia; (A.K.); (S.K.); (H.T.); (S.d.J.)
| | - Susan de Jersey
- Faculty of Health, Medicine & Behavioral Sciences, University of Queensland, St Lucia, QLD 4072, Australia; (A.K.); (S.K.); (H.T.); (S.d.J.)
- Dietetics and Foodservices, Royal Brisbane Women’s Hospital, Herston, QLD 4006, Australia
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Zheng H, Sun L, Wang L, Zhao Y, Gong F, Zhu H. Incidence and risk factors of post-metabolic and bariatric surgery hypoglycemia: a systematic review. Int J Obes (Lond) 2025; 49:31-42. [PMID: 39448871 DOI: 10.1038/s41366-024-01651-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 09/25/2024] [Accepted: 10/07/2024] [Indexed: 10/26/2024]
Abstract
OBJECTIVE This study aimed to systematically review the existing literature to summarize the incidence and risk factors of post-metabolic and bariatric surgery hypoglycemia (MBSH). METHODS We searched PubMed, Medline, Embase, and the Cochrane Library databases for the studies published from inception to August 2023. Randomized controlled trials and analytical studies that investigated the incidence or risk factors of MBSH after different surgery techniques (including Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, duodenal switch, omega-loop gastric bypass, and vertical banded gastroplasty) were involved. The incidence and risk factors of MBSH were extracted and described separately based on different diagnostic criteria and then summarized the risk factors and their statistical findings collectively. RESULTS Twenty-nine studies were reviewed with follow-up ranging from 1 to 22 years. The incidence of MBSH ranged significantly across different diagnostic methods: 2.6-66.4% (self-report), 6.6-61.8% (oral glucose tolerance test), 29.4-78.6% (mixed-meal tolerance test), and 50-75% (continuous glucose monitoring). Patients with a mean age of 49.8 years and 89.0% of them were women with a better glycemic control who undergo RYGB and achieve 86.5% of estimated weight loss from surgery should be particularly vigilant about the possibility of developing MBSH. Distinct biomarkers such as IGF-1 (OR 1.06), fasting glicentin (AUC 0.81), HbA1c (AUC 0.76), and absolute weight reduction (AUC 0.72), greater fluctuations in glucose (OR 1.98) are valuable in promptly detecting MBSH. Specifically, patients with prior cholecystectomy or antidepressant therapy should be particularly cautious. CONCLUSION The review highlights higher MBSH risk in younger women with significant weight loss after RYGB, and those with prior cholecystectomy or antidepressant use. Systematic summarization of MBSH criteria allowed us to identify the predictors for MBSH, which can aid in early diagnosis and treatment, reducing the need for prolonged monitoring.
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Affiliation(s)
- Huaijun Zheng
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lize Sun
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Linjie Wang
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yuxing Zhao
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Fengying Gong
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Huijuan Zhu
- Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
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Stortz E, Lawler H. Tirzepatide Improves Early Dumping Syndrome and Glucose Nadir in Postbariatric Hypoglycemia After Sleeve Gastrectomy. JCEM CASE REPORTS 2024; 2:luae194. [PMID: 39444516 PMCID: PMC11497600 DOI: 10.1210/jcemcr/luae194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Indexed: 10/25/2024]
Abstract
Early dumping syndrome (DS) and postbariatric hypoglycemia (PBH) are challenging conditions with limited treatment options. A 46-year-old woman with prediabetes, obesity, and sleeve gastrectomy presented with digestive symptoms suggestive of DS and postprandial hypoglycemia consistent with PBH. She started tirzepatide 2.5 mg weekly, which decreased postprandial blood glucose peaks, increased postprandial blood glucose nadirs, and improved overall time in range on continuous glucose monitoring (CGM). Her postprandial bloating and diarrhea resolved. To our knowledge, there have been no reported cases of DS or PBH treated with dual-incretin agonists. While glucagon-like peptide-1 (GLP-1) agonists have not been widely attempted in DS and have shown mixed benefit for PBH, combination GLP-1 and gastric inhibitory peptide agonism may represent a novel treatment both for PBH and DS, providing greater improvement in glycemic variation as well as better DS control than GLP-1 agonism alone.
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Affiliation(s)
- Ethan Stortz
- Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Helen Lawler
- Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Price B, Bertrand M, Estrade A, Brinas P, Tuyeras G, Guillaume E, Bordes S, Montastier E, Hanaire H, Ritz P. Validity of Continuous Glucose Monitoring for the Diagnosis of Dumping Syndrome After Metabolic Surgery, in Comparison to the Oral Glucose Tolerance Test. Obes Surg 2024; 34:4189-4195. [PMID: 39436525 DOI: 10.1007/s11695-024-07530-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 10/01/2024] [Accepted: 10/03/2024] [Indexed: 10/23/2024]
Abstract
PURPOSE Dumping syndrome (DS) is a common complication of metabolic surgery, occurring in as many as 40% of bariatric patients. The reference diagnostic test is oral glucose tolerance testing (OGTT) which is often poorly tolerated and may induce false positive results. Continuous glucose monitoring (CGM) is better tolerated and can monitor patients for about 2 weeks in everyday life. This study aimed at testing the diagnostic capacity of CGM in patients with and without DS, as validated by OGTT. MATERIAL AND METHODS This is a retrospective monocentric study including adults after bariatric surgery, who complained of DS-compatible symptoms and who had OGTT. CGM characteristics were compared in DS-positive (n = 37) and DS-negative patients (n = 14). RESULTS None of the CGM parameters differed between the two groups: mean, variability, time in range, and time above or below range. OGTT induced different hematocrit and pulse rate responses (by DS definition) but no difference in blood glucose values. CONCLUSION Despite being a better-tolerated test than OGTT, CGM should not be recommended for the diagnosis of DS. It may still be useful for monitoring glucose values in everyday life to help patients modify their diet, when DS is caused by carbohydrates with high glycemic index. The reference diagnostic test for dumping syndrome is poorly tolerated and artificial. CGM is useful in everyday life, and changes in glucose might be a signal of dumping syndrome. However, CGM is not a valid diagnostic test for dumping syndrome.
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Affiliation(s)
- Bethan Price
- Nutrition and Endocrinology Department, CHU de Toulouse, 31059, Toulouse, France
- Diabetes Department, CHU de Toulouse, 31059, Toulouse, France
| | - Monelle Bertrand
- Nutrition and Endocrinology Department, CHU de Toulouse, 31059, Toulouse, France
| | - Ana Estrade
- Nutrition and Endocrinology Department, CHU de Toulouse, 31059, Toulouse, France
| | - Pierre Brinas
- Digestive Surgery Department, CHU de Toulouse, 31059, Toulouse, France
| | - Géraud Tuyeras
- Digestive Surgery Department, CHU de Toulouse, 31059, Toulouse, France
| | - Eric Guillaume
- Diabetes Department, CHU de Toulouse, 31059, Toulouse, France
| | - Stéphane Bordes
- Diabetes Department, CHU de Toulouse, 31059, Toulouse, France
| | - Emilie Montastier
- Nutrition and Endocrinology Department, CHU de Toulouse, 31059, Toulouse, France
| | - Hélène Hanaire
- Diabetes Department, CHU de Toulouse, 31059, Toulouse, France
| | - Patrick Ritz
- Nutrition and Endocrinology Department, CHU de Toulouse, 31059, Toulouse, France.
- CERPOP UMR 1295 Unité Mixte INSERM, Université Toulouse III Paul Sabatier, 31059, Toulouse, France.
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Rieck JH, Heidinger H, Schlöricke E, Schmidt N, Krause S. Is Sigstad's score really capable of detecting post-surgical late dumping syndrome? Langenbecks Arch Surg 2024; 409:94. [PMID: 38472479 DOI: 10.1007/s00423-024-03283-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 03/06/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system. METHODS The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches. RESULTS Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction. CONCLUSION The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.
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Affiliation(s)
- Jan-Henrik Rieck
- Bariatric Surgery, Westküstenklinikum Heide, Esmarchstraße 50, 25746, Heide, Schleswig-Holstein, Germany.
| | - Hagen Heidinger
- Bariatric Surgery, Westküstenklinikum Heide, Esmarchstraße 50, 25746, Heide, Schleswig-Holstein, Germany
| | - Erik Schlöricke
- Bariatric Surgery, Westküstenklinikum Heide, Esmarchstraße 50, 25746, Heide, Schleswig-Holstein, Germany
| | - Nina Schmidt
- Bariatric Surgery, Westküstenklinikum Heide, Esmarchstraße 50, 25746, Heide, Schleswig-Holstein, Germany
| | - Steffen Krause
- Bariatric Surgery, Westküstenklinikum Heide, Esmarchstraße 50, 25746, Heide, Schleswig-Holstein, Germany
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Ramasamy I. Physiological Appetite Regulation and Bariatric Surgery. J Clin Med 2024; 13:1347. [PMID: 38546831 PMCID: PMC10932430 DOI: 10.3390/jcm13051347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
Obesity remains a common metabolic disorder and a threat to health as it is associated with numerous complications. Lifestyle modifications and caloric restriction can achieve limited weight loss. Bariatric surgery is an effective way of achieving substantial weight loss as well as glycemic control secondary to weight-related type 2 diabetes mellitus. It has been suggested that an anorexigenic gut hormone response following bariatric surgery contributes to weight loss. Understanding the changes in gut hormones and their contribution to weight loss physiology can lead to new therapeutic treatments for weight loss. Two distinct types of neurons in the arcuate hypothalamic nuclei control food intake: proopiomelanocortin neurons activated by the anorexigenic (satiety) hormones and neurons activated by the orexigenic peptides that release neuropeptide Y and agouti-related peptide (hunger centre). The arcuate nucleus of the hypothalamus integrates hormonal inputs from the gut and adipose tissue (the anorexigenic hormones cholecystokinin, polypeptide YY, glucagon-like peptide-1, oxyntomodulin, leptin, and others) and orexigeneic peptides (ghrelin). Replicating the endocrine response to bariatric surgery through pharmacological mimicry holds promise for medical treatment. Obesity has genetic and environmental factors. New advances in genetic testing have identified both monogenic and polygenic obesity-related genes. Understanding the function of genes contributing to obesity will increase insights into the biology of obesity. This review includes the physiology of appetite control, the influence of genetics on obesity, and the changes that occur following bariatric surgery. This has the potential to lead to the development of more subtle, individualised, treatments for obesity.
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Affiliation(s)
- Indra Ramasamy
- Department of Blood Sciences, Conquest Hospital, Hastings TN37 7RD, UK
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Wysocki M, Mizera M, Karpińska I, Ptaszkiewicz K, Małczak P, Pisarska-Adamczyk M, Kania M, Major P. Analysis of Changes in Glucose and Lipid Metabolism in Patients with Clinically Severe Obesity and Type 2 Diabetes Mellitus Undergoing Laparoscopic Sleeve Gastrectomy-Prospective Observational Study. Obes Surg 2024; 34:467-478. [PMID: 38105282 PMCID: PMC10811010 DOI: 10.1007/s11695-023-06991-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION We still lack studies providing analysis of changes in glucose and lipid metabolism after laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes mellitus (DM2). We aimed to investigate postoperative changes in glucose and lipid metabolism after LSG in patients with DM2. MATERIAL AND METHODS Prospective, observational study included patients with BMI ≥ 35 kg/m2 and ≤ 50 kg/m2, DM2 < 10 years of duration, who were qualified for LSG. Perioperative 14-day continuous glucose monitoring (CGM) began after preoperative clinical assessment and OGTT, then reassessment 1 and 12 months after LSG. Thirty-three patients in mean age of 45 ± 10 years were included in study (23 females). RESULTS EBMIL before LSG was 17 ± 11.7%, after 1 month-36.3 ± 12.8%, while after 12 months-66.1 ± 21.7%. Fifty-two percent of the patients had DM2 remission after 12 months. None required then insulin therapy. 16/33 patients initially on oral antidiabetics still required them after 12 months. Significant decrease in HbA1C was observed: 5.96 ± 0.73%; 5.71 ± 0.80; 5.54 ± 0.52%. Same with HOMA-IR: 5.34 ± 2.84; 4.62 ± 3.78; 3.20 ± 1.99. In OGTT, lower increase in blood glucose with lesser insulin concentrations needed to recover glucose homeostasis was observed during follow-ups. Overtime perioperative average glucose concentration in CGM of 5.03 ± 1.09 mmol/L significantly differed after 12 months, 4.60 ± 0.53 (p = 0.042). Significantly higher percentage of glucose concentrations above targeted compartment (3.9-6.7 mmol/L) was observed in perioperative period (7% ± 4%), than in follow-up (4 ± 6% and 2 ± 1%). HDL significantly rose, while triglyceride levels significantly decreased. CONCLUSIONS Significant improvement in glucose and lipid metabolism was observed 12 months after LSG and changes began 1 month after procedure.
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Affiliation(s)
- Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital in Cracow, Os. Zlotej Jesieni 1, 31-826, Cracow, Poland.
| | - Magdalena Mizera
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Izabela Karpińska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Kuba Ptaszkiewicz
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | | | - Michał Kania
- Department of Metabolic Diseases and Diabetology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Cracow, Poland
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Masclee GMC, Masclee AAM. Dumping Syndrome: Pragmatic Treatment Options and Experimental Approaches for Improving Clinical Outcomes. Clin Exp Gastroenterol 2023; 16:197-211. [PMID: 37954129 PMCID: PMC10637186 DOI: 10.2147/ceg.s392265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023] Open
Abstract
Dumping syndrome is a common complication after esophageal, gastric and bariatric surgery and has a significant negative impact on the quality of life of patients. This narrative review describes the clinical syndrome, pathophysiology, diagnosis and reports on standard and pragmatic therapeutical treatment options in order to improve the clinical outcome of patients with dumping syndrome. Dumping syndrome consists of early and late dumping symptoms and can be diagnosed using clinical parameters with the help of the Sigstad's score, questionnaires or by provocative testing. The prevalence of dumping syndrome varies depending on the employed definition of dumping syndrome. Overall, dumping syndrome is more frequent nowadays due to increasing numbers of upper gastrointestinal and bariatric surgeries being performed. First treatment step includes dietary adjustment and dietary supplements, which are often sufficient to manage symptoms for the majority of patients. Next step of therapy includes acarbose, which is effective for late dumping symptoms, but the use is limited due to side effects. Somatostatin analogues are indicated after these two steps have failed. Somatostatin analogues are very effective for controlling early and late dumping, also in the long term. Glucagon like peptide-1 receptor agonists, endoscopic and surgical (re)interventions are reported as treatment options for refractory dumping syndrome; however, their use is not recommended in clinical practice due to the limited evidence on and uncertainty of outcomes. These alternatives should be considered only as last resort options in patients with otherwise refractory and invalidating dumping syndrome.
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Affiliation(s)
- Gwen M C Masclee
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center +, Maastricht, the Netherlands
- NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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Migdanis A, Koukoulis GD, Chougias D, Migdanis I, Armeni E, Kanellakis S, Manouras A, Kapsoritakis A, Potamianos S. The Effect of Fat Supplementation on the Appearance of Symptoms Associated With Dumping Syndrome in Patients Having Undergone Gastric Surgery: Preliminary Results. Cureus 2023; 15:e48871. [PMID: 38106774 PMCID: PMC10724605 DOI: 10.7759/cureus.48871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND/OBJECTIVES Data on the effect of dietary fat on dumping syndrome (DS) symptoms are limited. The aim of this study was to assess the effect of the addition of fat to a carbohydrate meal on the appearance of DS symptoms and glycemic response, in patients who had undergone gastric surgery. SUBJECTS/METHODS This was an interventional crossover study. Patients scheduled for gastric surgical procedures related to DS at two surgical units of two public hospitals (General University Hospital of Larissa and General Hospital of Larissa) were considered for study inclusion. Patients presenting symptoms suggestive of diagnosis (n = 12), after the ingestion of a carbohydrate meal, were used as both intervention and control groups. During the intervention process, a fat supplement was added to the carbohydrate meal that was previously used for diagnosis. Glycemic response and the amount and intensity of DS symptoms provoked by the two meals were assessed at both appointments. RESULTS Blood glucose levels were significantly lower in the group that consumed the added fat meal compared with the group that consumed the carbohydrate meal 60 minutes after ingestion (p = 0.028). Furthermore, a significant reduction was noted in the amount of late dumping symptoms (p = 0.021) and the intensity of both early and late dumping symptoms (p = 0.007 and p = 0.012 respectively), after fat addition. Conclusions: Incorporating fat into a carbohydrate meal seems to attenuate postprandial blood glucose rises and reduce the amount and intensity of DS symptoms, in patients who had undergone gastric surgery.
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Affiliation(s)
- Athanasios Migdanis
- Faculty of Medicine, University of Thessaly, Larissa, GRC
- Department of Nutrition and Dietetics, University of Thessaly, Trikala, GRC
| | | | - Dimitrios Chougias
- Department of Gastroenterology, General University Hospital of Larissa, Larissa, GRC
| | - Ioannis Migdanis
- Faculty of Medicine, University of Thessaly, Larissa, GRC
- Department of Nutrition and Dietetics, University of Thessaly, Trikala, GRC
| | - Eleni Armeni
- Faculty of Medicine, University of Thessaly, Larissa, GRC
| | - Spyridon Kanellakis
- Department of Nutrition and Dietetics, Harokopio University of Athens, Athens, GRC
| | | | - Andreas Kapsoritakis
- Department of Gastroenterology, General University Hospital of Larissa, Larissa, GRC
- Faculty of Medicine, University of Thessaly, Larissa, GRC
| | - Spyridon Potamianos
- Department of Gastroenterology, General University Hospital of Larissa, Larissa, GRC
- Faculty of Medicine, University of Thessaly, Larissa, GRC
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Yang JC, Zhang GX, Leng C, Chen G, Cheng Z, Du X. Incidence and Intensity of Early Dumping Syndrome and Its Association with Health-Related Quality of Life Following Sleeve Gastrectomy. Obes Surg 2023; 33:3510-3516. [PMID: 37804471 DOI: 10.1007/s11695-023-06863-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND AND PURPOSE Dumping syndrome (DS) is a shared but underappreciated complication after metabolic-bariatric surgery. The purpose of the study was to investigate the prevalence and intensity of symptoms suggestive of DS and their relationship with health-related quality of life (HRQOL) after laparoscopic sleeve gastrectomy (LSG). METHOD A retrospective cohort study was performed for all patients with a history of sleeve gastrectomy between July 2017 and July 2022 in our center. Basial clinic statistics were gathered from electronic medical database, the prevalence and severity of DS were assessed by Dumping Symptom Rating Scale (DSRS), and HRQOL is collected through the Short Form Health Survey 36 (SF-36). RESULT In total, 133 of 202 patients completed the questionnaire (response rate 65.8%). A total of 64.7% (N = 86) of participants were female, aged 34.0 (IQR 26.0-39.0) years at completion of the questionnaire, with a mean body mass index of 35.8 (IQR 31.4-40.5) kg/m2. The prevalence of symptoms suggestive of DS was 45.9% (N = 61), and the associated protective factor was the time between surgery and study. Compared with the patients without DS, patients with DS scored significantly worse on four of eight SF-36 subdomains. CONCLUSION Symptoms suggestive of early dumping syndrome after sleeve gastrectomy are common and are associated with a worse health-related quality of life, which deserves clinical attention. Additional counselling, education, and care are needed to mitigate the decline in quality of life caused by dumping symptoms.
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Affiliation(s)
- Jun-Cheng Yang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Gui-Xiang Zhang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Cuo Leng
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Gang Chen
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
- Department of General Surgery, The Second Clinical Medical College, The Fifth People's Hospital Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, 610041, China
| | - Zhong Cheng
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Xiao Du
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
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12
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Parzer V, Resl M, Stechemesser L, Wakolbinger M, Itariu B, Brix JM. [Postoperative management]. Wien Klin Wochenschr 2023; 135:729-742. [PMID: 37821696 PMCID: PMC10567962 DOI: 10.1007/s00508-023-02272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/13/2023]
Abstract
Bariatric surgery results in significant weight loss, reduction or even remission of obesity-associated comorbidities, reduced mortality, and improved quality of life in many patients; however, obesity is a chronic disease, thus follow-up care is required after bariatric surgery. Furthermore, specific issues, such as micronutrient deficiencies and subsequent complications, can arise both in the short-term and the long-term. Abdominal pain after bariatric surgery must always be regarded as a serious symptom. A further focus should be on the diagnosis and treatment of dumping syndrome. Patients with type 2 diabetes should be regularly screened for recurrent hyperglycemia as well as specific sequelae, even though blood glucose levels may be substantially improved or normalized. In addition to centers with multidisciplinary teams, primary care and, in particular, general practitioners will play an increasingly more important role in the follow-up care after bariatric surgery.
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Affiliation(s)
- Verena Parzer
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
| | - Michael Resl
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin mit Diabetologie, Gastroenterologie und Hepatologie, Rheumatologie und Intensivmedizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I mit Gastroenterologie, Hepatologie, Nephrologie, Stoffwechsel und Diabetologie, Uniklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Maria Wakolbinger
- Abteilung für Sozial- und Präventivmedizin, Zentrum für Public Health, Medizinische Universität Wien, Wien, Österreich
| | - Bianca Itariu
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich.
| | - Johanna Maria Brix
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
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13
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Tripyla A, Ferreira A, Schönenberger KA, Näf NH, Inderbitzin LE, Prendin F, Cossu L, Cappon G, Facchinetti A, Herzig D, Bally L. Relationship Between Symptom Perception and Postprandial Glycemic Profiles in Patients With Postbariatric Hypoglycemia After Roux-en-Y Gastric Bypass Surgery. Diabetes Care 2023; 46:1792-1798. [PMID: 37499048 DOI: 10.2337/dc23-0454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Post-bariatric surgery hypoglycemia (PBH) is a metabolic complication of Roux-en-Y gastric bypass (RYGB). Since symptoms are a key component of the Whipple's triad to diagnose nondiabetic hypoglycemia, we evaluated the relationship between self-reported symptoms and postprandial sensor glucose profiles. RESEARCH DESIGN AND METHODS Thirty patients with PBH after RYGB (age: 50.1 [41.6-60.6] years, 86.7% female, BMI: 26.5 [23.5-31.2] kg/m2; median [interquartile range]) wore a blinded Dexcom G6 sensor while recording autonomic, neuroglycopenic, and gastrointestinal symptoms over 50 days. Symptoms (overall and each type) were categorized into those occurring in postprandial periods (PPPs) without hypoglycemia, or in the preceding dynamic or hypoglycemic phase of PPPs with hypoglycemia (nadir sensor glucose <3.9 mmol/L). We further explored the relationship between symptoms and the maximum negative rate of sensor glucose change and nadir sensor glucose levels. RESULTS In 5,851 PPPs, 775 symptoms were reported, of which 30.6 (0.0-59.9)% were perceived in PPPs without hypoglycemia, 16.7 (0.0-30.1)% in the preceding dynamic phase and 45.0 (13.7-84.7)% in the hypoglycemic phase of PPPs with hypoglycemia. Per symptom type, 53.6 (23.8-100.0)% of the autonomic, 30.0 (5.6-80.0)% of the neuroglycopenic, and 10.4 (0.0-50.0)% of the gastrointestinal symptoms occurred in the hypoglycemic phase of PPPs with hypoglycemia. Both faster glucose dynamics and lower nadir sensor glucose levels were related with symptom perception. CONCLUSIONS The relationship between symptom perception and PBH is complex, challenging clinical judgement and decision-making in this population.
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Affiliation(s)
- Afroditi Tripyla
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antonio Ferreira
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katja A Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Noah H Näf
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas E Inderbitzin
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Francesco Prendin
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Luca Cossu
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Giacomo Cappon
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Andrea Facchinetti
- Department of Information Engineering, University of Padova, Padova, Italy
| | - David Herzig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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D'hoedt A, Vanuytsel T. Dumping syndrome after bariatric surgery: prevalence, pathophysiology and role in weight reduction - a systematic review. Acta Gastroenterol Belg 2023; 86:417-427. [PMID: 37814558 DOI: 10.51821/86.3.11476] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Background Dumping syndrome is a frequent and wellknown adverse event after bariatric surgery and covers a dynamic spectrum of early and late dumping. Accelerated gastric emptying is generally considered to be the cause of gastrointestinal and vasomotor complaints. However, there is much uncertainty regarding the exact pathophysiology of dumping. It has been speculated that the syndrome is a desired consequence of bariatric surgery and contributes to more efficient weight loss, but supporting data are scarce. Methods A systematic search was conducted in PubMed in July-August 2021. The prevalence of dumping after the most frequently performed bariatric procedures was analyzed, as well as underlying pathophysiology and its role in weight reduction. Results Roux-en-Y gastric bypass (RYGB) is associated with the highest postoperative prevalence of dumping. The fast transit induces neurohumoral changes which contribute to an imbalance between postprandial glucose and insulin levels, resulting in hypoglycemia which is the hallmark of late dumping. Early dumping can, when received in a positive way, become a tool to maintain a strict dietary pattern, but no significant relationship to the degree of weight loss has been shown. However, late dumping is detrimental and promotes overall higher caloric intake. Conclusion Dumping syndrome is common after bariatric surgery, especially after RYGB. The pathophysiology is complex and ambiguous. Currently available data do not support dumping as a necessary condition to induce weight loss after bariatric surgery.
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Affiliation(s)
- A D'hoedt
- Faculty of Medicine, KULeuven, Leuven, Belgium
| | - T Vanuytsel
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium. Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (ChroMeta) KULeuven, Leuven, Belgium
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15
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Al-Jafari M, Alrosan S, Alkhawaldeh IM, Zein Eddin S, Abu-Jeyyab M, Zuaiter SN. Dumping Syndrome in Children: A Narrative Review. Cureus 2023; 15:e41407. [PMID: 37546099 PMCID: PMC10402847 DOI: 10.7759/cureus.41407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Dumping syndrome (DS) is a typical side effect of stomach surgery, which includes cancer, non-cancer esophageal and gastric surgery, and bariatric surgery. It is marked by the fast evacuation of undigested food from the stomach into the small intestine, which causes a variety of symptoms. Early dumping symptoms include gastrointestinal symptoms such as stomach discomfort, diarrhea, and nausea, as well as vasomotor symptoms such as drowsiness and face flushing, and occur within the first hour following a meal. Late dumping symptoms appear one to three hours after a meal and are related to reactive hypoglycemia, resulting in hypoglycemia, sweating, palpitations, and confusion. Early dumping pathophysiology involves abnormalities in stomach structure and function, which result in rapid transit of stomach contents to the duodenum, insufficient digestion, and fluid transfers from the vascular compartment to the intestine. Late dumping occurs as a result of hyperinsulinemia caused by the fast passage of undigested foods to the gut. Symptom-based questionnaires and diagnostic testing such as plasma glucose measurement and stomach emptying studies can be used to confirm a diagnosis of DS. The primary approach to managing DS is dietary modifications, including eating smaller, more frequent meals and avoiding high glycemic index carbohydrates. Dietary supplements and medications may be used to slow down gastric emptying or control blood glucose levels. Pharmacological options include alpha-glycosidase inhibitors, somatostatin analogs, glucagon-like peptide-1 analogs, and sodium-glucose cotransporter inhibitors. In severe cases, refractory to conservative measures, surgical interventions may be considered. DS can arise in children following gastric surgery for obesity or corrective surgery for congenital abnormalities. It is frequently misdiagnosed and can have serious implications, such as hypoglycemia-related cognition deficits. Screening and early identification using glucose tolerance testing and continuous glucose monitoring (CGM) are critical in at-risk youngsters. Children's treatment techniques are similar to those used in adults, with dietary changes and medication therapies serving as the cornerstone of care. Overall, DS is a complex condition that requires a multidisciplinary approach to diagnosis and management. Further research is needed to improve understanding of its pathophysiology and optimize treatment strategies, particularly in children. This review aims to provide a well-rounded informative summary of the most recent literature on the under-recognized clinical and scientific aspects of DS among the children age group. It incorporates the quality of life, pathophysiology, diagnosis, prevalence, and treatment.
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Affiliation(s)
| | - Sallam Alrosan
- Internal Medicine, Saint Luke's Health System, Kansas, USA
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16
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Pereira SE, Rossoni C, Cambi MPC, Faria SL, Mattos FCC, De Campos TBF, Petry TBZ, Da Silva SA, Pereira AZ, Umeda LM, Nogueira C, De Araújo Burgos MGP, Magro DO. Brazilian guide to nutrition in bariatric and metabolic surgery. Langenbecks Arch Surg 2023; 408:143. [PMID: 37039877 DOI: 10.1007/s00423-023-02868-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 03/21/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE Brazilian nutrition recommendations for bariatric and metabolic surgery aim to provide knowledge, based on scientific evidence, on nutritional practices related to different surgical techniques in the surgical treatment of obesity and metabolic diseases. MATERIALS AND METHODS A systematic literature search was carried out with the appropriate MeSH terms using Medline/Pubmed/LiLACS and the Cochrane database, with the established criteria being based on the inclusion of articles according to the degree of recommendation and strength of evidence of the Classification of Recommendations, Evaluation, Development, and Evaluation System (GRADE). RESULTS The recommendations that make up this guide were gathered to assist in the individualized clinical practice of nutritionists in the nutritional management of patients with obesity, including nutritional management in the intragastric balloon; pre and postoperative nutritional treatment and supplementation in bariatric and metabolic surgeries (adolescents, adults, elderly, pregnant women, and vegetarians); hypoglycemia and reactive hyperinsulinemia; and recurrence of obesity, gut microbiota, and inflammatory bowel diseases. CONCLUSION We believe that this guide of recommendations will play a decisive role in the clinical practice of nutritionists who work in bariatric and metabolic surgery, with its implementation in health services, thus promoting quality and safety in the treatment of patients with obesity. The concept of precision nutrition is expected to change the way we understand and treat these patients.
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Affiliation(s)
- Silvia Elaine Pereira
- Postgraduate Program in Nutritional Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Carina Rossoni
- Faculty of Medicine (ISAMB), Instituto of Environmental Health, Universidade de Lisboa, Lisbon, Portugal.
| | | | - Silvia Leite Faria
- Postgraduate Program in Human Nutrition, University of Brasilia, Brasilia, Brazil
| | | | | | | | - Silvia Alves Da Silva
- Postgraduate Program in Nutritional in Bariatric Surgery, Federal University of Pernambuco, Recife, Brazil
| | | | - Luciana Mela Umeda
- Medical Residency Program in Endrocrinology and Metabology, Ipiranga Hospital, São Paulo, Brazil
| | - Carla Nogueira
- Postgraduate Program in Human Nutrition, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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17
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Lobaton-Ginsberg M, Sotelo-González P, Ramirez-Renteria C, Juárez-Aguilar FG, Ferreira-Hermosillo A. Insulinoma after sleeve gastrectomy: A case report. World J Clin Cases 2022; 10:6227-6233. [PMID: 35949856 PMCID: PMC9254200 DOI: 10.12998/wjcc.v10.i18.6227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/24/2022] [Accepted: 04/28/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective and durable treatment for severe obesity and glucose metabolism disorders, and its prevalence has increased from 5% to 37% since 2008. One common complication after bariatric surgery is a postprandial hyperinsulinemic hypoglycemic state. While rare, insulinomas can cause this state, where symptoms are more common in the fasting state; thus, evaluation of insulin secretion is needed. Until now, there have been no reports of insulinoma after LSG.
CASE SUMMARY We describe the case of a 43-year-old woman who was referred to the obesity clinic 2 years after LSG was performed. She had symptoms of hypoglycemia predominantly in the fasting state and documented hypoglycemia of less than 30 mg/dL, which are compatible with Whipple’s triad. Initially, dumping syndrome was suspected, but after a second low fasting plasma glucose was documented, a 72-h fasting test was performed that tested positive. Computed tomography and endoscopic ultrasound were performed, identifying the presence of a homogeneous hypoechoic semioval tumoral lesion in the pancreas. The diagnosis was compatible with insulinoma. After laparoscopic enucleation of the insulinoma, the symptoms and hypoglycemia disappeared. The histopathological report described a well-differentiated grade 2 neuroendocrine tumor with positive chromogranin and synaptophysin and Ki67 immunopositivity in 4% of the neoplastic cells.
CONCLUSION Insulinoma after LSG is a rare condition, and clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state.
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Affiliation(s)
| | - Pilar Sotelo-González
- Servicio de Endocrinología, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico City 06720, Mexico
| | - Claudia Ramirez-Renteria
- Unidad de Investigación Médica en Enfermedades Endocrinas, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Fany Gabriela Juárez-Aguilar
- Servicio de Anatomía Patológica, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, IMSS, Mexico City 06720, Mexico
| | - Aldo Ferreira-Hermosillo
- Unidad de Investigación Médica en Enfermedades Endocrinas, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
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18
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Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
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19
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Poljo A, Pentsch A, Raab S, Klugsberger B, Shamiyeh A. Incidence of Dumping Syndrome after Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2021; 10:23-31. [PMID: 36687750 PMCID: PMC9847648 DOI: 10.17476/jmbs.2021.10.1.23] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 06/17/2023]
Abstract
PURPOSE Dumping syndrome (DS) is an important but often underreported problem occurring after bariatric surgery. It is believed that gastric bypass procedures like Roux-en-Y Gastric By-pass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) are more likely to cause DS than the pylorus-preserving Sleeve Gastrectomy (SG). The aim of this study was to evaluate the incidence of DS in patients undergoing SG, RYGB and OAGB. MATERIALS AND METHODS A retrospective clinical study with 180 patients undergoing SG (n=50), RYGB (n=53) and OAGB (n=77) between 2016-2018 was performed. All clinical and demo-graphic data were assessed. The percentage of excess weight loss (%EWL) was used to evaluate weight reduction. 127/180 (70.6%) patients took part in an additional phone interview. The incidence of DS was evaluated using validated Sigstad Score. RESULTS Information about the occurrence of dumping symptoms and patient satisfaction was obtained from 127 patients. Median follow-up was 20.0±11.4 months. Significant differences between the surgical procedures were found for the duration of surgery, complications, weight loss, incidence of DS and satisfaction postoperatively. DS occurred in 15.6% after SG, 56.4% after RYGB and 42.9% after OAGB. A higher weight loss was observed in patients who experienced dumping symptoms. CONCLUSION The present results show a clear superiority of SG regarding both perioperative results and incidence of DS compared to RYGB and OAGB and may impact clinicians and patients in their choice of procedure.
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Affiliation(s)
- Adisa Poljo
- Clinic for General and Visceral Surgery, Kepler University Clinic, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - Andreas Pentsch
- Clinic for General and Visceral Surgery, Kepler University Clinic, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - Sandra Raab
- Clinic for General and Visceral Surgery, Kepler University Clinic, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - Bettina Klugsberger
- Clinic for General and Visceral Surgery, Kepler University Clinic, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
| | - Andreas Shamiyeh
- Clinic for General and Visceral Surgery, Kepler University Clinic, Linz, Austria
- Faculty of Medicine, Johannes Kepler University, Linz, Austria
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20
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Rebelos E, Moriconi D, Scalese M, Denoth F, Molinaro S, Siciliano V, Anselmino M, Taddei S, Ferrannini E, Nannipieri M. Impact of Postprandial Hypoglycemia on Weight Loss After Bariatric Surgery. Obes Surg 2021; 30:2266-2273. [PMID: 32133587 DOI: 10.1007/s11695-020-04465-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Postprandial hypoglycemia (PPHG) is a well-known complication after bariatric surgery (BS). However, it is not known whether PPHG affects weight loss after BS. AIMS To assess the impact of PPHG on weight loss after BS in subjects without and with type 2 diabetes mellitus (T2D). METHODS Data from 338 subjects who had undergone gastric bypass (RYGB) or sleeve gastrectomy (LSG) and were followed up for at least 2 years were analyzed. At each follow-up visit, the patient's anthropometric and biochemical characteristics were recorded and the Edinburgh Questionnaire was performed to evaluate the presence of PPHG symptoms. RESULTS Before surgery: younger age and lower BMI predicted PPHG after BS (p = 0.02 and p = 0.0008, respectively). Also, the baseline OGTT indicated that subjects who developed PPHG had an earlier glucose peak and more often had low glucose levels at 2 h compared with the no-PPHG group (p = 0.03 and p = 0.004, respectively). After surgery: Mild-to-moderate PPHG occurred equally after RYGB and LSG (38% vs 25%, p = ns when accounting for confounders), and in T2D who achieved remission and those who did not (29.5% vs 28.6%, ns). At the 2-year follow-up, occurrence of PPHG was independently associated with smaller weight loss (p = 0.0006). CONCLUSIONS Mild-to-moderate PPHG is a frequent complication after bariatric surgery and results in smaller weight loss after 2 years. Age, baseline BMI, and an earlier glucose peak during OGTT predict PPHG after bariatric surgery.
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Affiliation(s)
- Eleni Rebelos
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Diego Moriconi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | | | | | | | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Monica Nannipieri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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21
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Do Gut Hormones Contribute to Weight Loss and Glycaemic Outcomes after Bariatric Surgery? Nutrients 2021; 13:nu13030762. [PMID: 33652862 PMCID: PMC7996890 DOI: 10.3390/nu13030762] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 02/07/2023] Open
Abstract
Bariatric surgery is an effective intervention for management of obesity through treating dysregulated appetite and achieving long-term weight loss maintenance. Moreover, significant changes in glucose homeostasis are observed after bariatric surgery including, in some cases, type 2 diabetes remission from the early postoperative period and postprandial hypoglycaemia. Levels of a number of gut hormones are dramatically increased from the early period after Roux-en-Y gastric bypass and sleeve gastrectomy—the two most commonly performed bariatric procedures—and they have been suggested as important mediators of the observed changes in eating behaviour and glucose homeostasis postoperatively. In this review, we summarise the current evidence from human studies on the alterations of gut hormones after bariatric surgery and their impact on clinical outcomes postoperatively. Studies which assess the role of gut hormones after bariatric surgery on food intake, hunger, satiety and glucose homeostasis through octreotide use (a non-specific inhibitor of gut hormone secretion) as well as with exendin 9–39 (a specific glucagon-like peptide-1 receptor antagonist) are reviewed. The potential use of gut hormones as biomarkers of successful outcomes of bariatric surgery is also evaluated.
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22
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Zanley E, Shah ND, Craig C, Lau JN, Rivas H, McLaughlin T. Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass. Surg Obes Relat Dis 2020; 17:456-465. [PMID: 33160876 DOI: 10.1016/j.soard.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/29/2020] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. OBJECTIVES To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. SETTING Stanford University Hospital and Clinics. METHODS Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. RESULTS A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. CONCLUSIONS G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.
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Affiliation(s)
- Elizabeth Zanley
- Department of Medicine, Stanford University, Stanford, California
| | - Neha D Shah
- Department of Clinical Nutrition, Stanford Health Care, Stanford, California
| | - Colleen Craig
- Department of Medicine, Stanford University, Stanford, California
| | - James N Lau
- Department of General Surgery, Stanford University, Stanford, California
| | - Homero Rivas
- Department of General Surgery, Stanford University, Stanford, California
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Abstract
Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5-10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.
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Affiliation(s)
- Silvia Bettini
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Anna Belligoli
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Roberto Fabris
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy
| | - Luca Busetto
- Luca Busetto Center for the Study and the Integrated Management of Obesity, Padova University Hospital, Padova, Italy.
- Clinica Medica 3, Azienda Ospedaliera di Padova, Via Giustiniani 2, Padova, 35128, Italy.
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24
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Scarpellini E, Arts J, Karamanolis G, Laurenius A, Siquini W, Suzuki H, Ukleja A, Van Beek A, Vanuytsel T, Bor S, Ceppa E, Di Lorenzo C, Emous M, Hammer H, Hellström P, Laville M, Lundell L, Masclee A, Ritz P, Tack J. International consensus on the diagnosis and management of dumping syndrome. Nat Rev Endocrinol 2020; 16:448-466. [PMID: 32457534 PMCID: PMC7351708 DOI: 10.1038/s41574-020-0357-5] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.
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Affiliation(s)
- Emidio Scarpellini
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Joris Arts
- Gastroenterology Division, St Lucas Hospital, Bruges, Belgium
| | - George Karamanolis
- 2nd Department of Internal Medicine - Propaedeutic, Hepatogastroenterology Unit, Attikon University Hospital, Medical School, Athens University, Athens, Greece
| | - Anna Laurenius
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Walter Siquini
- Politechnic University of Marche, "Madonna del Soccorso" General Hospital, San Benedetto del Tronto, Italy
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Japan
| | - Andrew Ukleja
- Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andre Van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Serhat Bor
- Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Eugene Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marloes Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Heinz Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Per Hellström
- Department of Medical Sciences, Gastroenterology/Hepatology, Uppsala University, Uppsala, Sweden
| | - Martine Laville
- Department of Endocrinology, Claude Bernard University, Lyon, France
| | - Lars Lundell
- Department of Surgery Hospital, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Ad Masclee
- Department of Gastroenterology-Hepatology, University Hospital Leiden, Leiden, Netherlands
| | | | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium.
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25
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Sancak S, Çeler Ö, Çırak E, Karip AB, Tumiçin Aydın M, Esen Bulut N, Mahir Fersahoğlu M, Altun H, Memişoğlu K. Timing of Gestation After Laparoscopic Sleeve Gastrectomy (LSG): Does It Influence Obstetrical and Neonatal Outcomes of Pregnancies? Obes Surg 2020; 29:1498-1505. [PMID: 30661209 DOI: 10.1007/s11695-018-03700-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIM We aimed to evaluate the effect of pregnancy timing after laparoscopic sleeve gastrectomy (LSG) on maternal and fetal outcomes. METHODS Women with LSG were stratified into two groups with surgery-to-conception intervals of ≤ 18 months (early group) or > 18 months (late group). Only the first delivery after LSG was included in this study. We compared maternal characteristics, pregnancy, and neonatal outcomes and adherence to the Institute of Medicine's (IOM) recommendations for gestational weight gain (GWG) in the two groups. RESULTS Fifteen patients conceived ≤ 18 months after surgery, with a mean surgery-to-conception interval of 5.6 ± 4.12 months, and 29 women conceived > 18 months following LSG, with a mean surgery-to-conception interval of 32.31 ± 11.38 months, p < 0.05. There was no statistically significant difference between the two groups regarding birth weight, gestational age, cesarean deliveries (CD), preterm birth, whether their child was small or large for their gestational age, or in the need of neonatal intensive care. There was no correlation between mean weight loss from operation till conception, mean weight gain during pregnancy, and mean body mass index (BMI) at conception between birth weight in either study group. Inadequate and normal GWG was significantly higher in the early group, whereas excessive GWG was significantly higher in the late group (X2, 20.780; p = < 0.001). CONCLUSION The interval between LSG and conception did not impact maternal and neonatal outcomes. Pregnancy after LSG was overall safe and well-tolerated.
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Affiliation(s)
- Seda Sancak
- Fatih Sultan Mehmet Education and Research Hospital, Endocrinology and Metabolism Disorders, Department of Internal Medicine, University of Health Sciences, Atasehir, 34752, İstanbul, Turkey.
| | - Özgen Çeler
- Fatih Sultan Mehmet Education and Research Hospital, Endocrinology and Metabolism Disorders, Department of Internal Medicine, University of Health Sciences, Atasehir, 34752, İstanbul, Turkey
| | - Elif Çırak
- Fatih Sultan Mehmet Education and Research Hospital, Department of Internal Medicine, University of Health Sciences, Atasehir, İstanbul, Turkey
| | - Aziz Bora Karip
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
| | - M Tumiçin Aydın
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
| | - Nuriye Esen Bulut
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
| | - M Mahir Fersahoğlu
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
| | - Hasan Altun
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
- General Surgery Clinic, Liv Hospital, Ulus, Istanbul, Turkey
| | - Kemal Memişoğlu
- General Surgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Atasehir, Istanbul, Turkey
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Ahmad A, Kornrich DB, Krasner H, Eckardt S, Ahmad Z, Braslow A, Broggelwirth B. Prevalence of Dumping Syndrome After Laparoscopic Sleeve Gastrectomy and Comparison with Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg 2020; 29:1506-1513. [PMID: 30635813 DOI: 10.1007/s11695-018-03699-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dumping syndrome is a well-known side effect of laparoscopic gastric bypass (LRYGB), and it is commonly believed that dumping syndrome is less likely to occur after laparoscopic sleeve gastrectomy (LSG), due to the preservation of the pyloric sphincter. However, it is not uncommon for patients undergoing LSG at our center to report symptoms suggestive of dumping syndrome. OBJECTIVE To assess the prevalence of symptoms of dumping syndrome after LSG compared with LRYGB. SETTING A single surgical group at a high-volume (700 cases per year) Bariatric and Metabolic Surgery Center of Excellence. METHODS One thousand four hundred seventy-one LRYGB (366) and LSG (1105) patients received a questionnaire to assess symptoms of dumping syndrome, utilizing a modified version of the Sigstad scoring system. Dumping syndrome was considered to be present when the questionnaire score exceeded a threshold value. RESULTS A total of 360 responses were received (249 LSG, 111 LRYGB). 26.5% (66) LSG and 41.4% (46) LRYGB exceeded the threshold for dumping syndrome (p < 0.01). 84.8% (56) LSG and 84.7% (39) LRYGB reported early dumping syndrome (p > 0.05). Thirty-six percent (24) LSG and 28% (13) LRYGB reported late dumping syndrome (p > 0.05). Twenty-seven percent (62) LSG and 44.4% (44) LRYGB reported at least one symptom of dumping syndrome with sweets (p < 0.05). 34.3% (85) LSG and 35.5% (39) LRYGB reported symptoms when drinking with or within 30 min of a meal (p > 0.05). 14.5% (36) LSG and 17.3% (19) LRYGB reported symptoms after alcohol consumption (p > 0.05). CONCLUSION Dumping syndrome after LSG is prevalent but has not been widely reported. This finding may impact clinicians and patients in their choice of procedure and has relevance in post-operative education and care.
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Affiliation(s)
- Arif Ahmad
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA.
| | | | - Helaine Krasner
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Sarah Eckardt
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Zoha Ahmad
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - AnnaMarie Braslow
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
| | - Barbara Broggelwirth
- Mather Hospital Northwell Health, 625 Belle Terre Road, Port Jefferson, NY, 11777, USA
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27
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Davis EM, Sandoval DA. Glucagon‐Like Peptide‐1: Actions and Influence on Pancreatic Hormone Function. Compr Physiol 2020; 10:577-595. [DOI: 10.1002/cphy.c190025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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28
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Evers SS, Kim KS, Bozadjieva N, Lewis AG, Farris D, Sorensen MJ, Kim Y, Whitesall SE, Kennedy RT, Michele DE, Seeley RJ, Sandoval DA. Continuous glucose monitoring reveals glycemic variability and hypoglycemia after vertical sleeve gastrectomy in rats. Mol Metab 2020; 32:148-159. [PMID: 32029224 PMCID: PMC7005148 DOI: 10.1016/j.molmet.2019.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Post–bariatric surgery hypoglycemia (PBH) is defined as the presence of neuroglycopenic symptoms accompanied by postprandial hypoglycemia in bariatric surgery patients. Recent clinical studies using continuous glucose monitoring (CGM) technology revealed that PBH is more frequently observed in vertical sleeve gastrectomy (VSG) patients than previously recognized. PBH cannot be alleviated by current medication. Therefore, a model system to investigate the mechanism and treatment is required. Methods We used CGM in a rat model of VSG and monitored the occurrence of glycemic variability and hypoglycemia in various meal conditions for 4 weeks after surgery. Another cohort of VSG rats with CGM was used to investigate whether the blockade of glucagon-like peptide-1 receptor (GLP-1R) signaling alleviates these symptoms. A mouse VSG model was used to investigate whether the impaired glucose counterregulatory system causes postprandial hypoglycemia. Results Like in humans, rats have increased glycemic variability and hypoglycemia after VSG. Postprandial hypoglycemia was specifically detected after liquid versus solid meals. Further, the blockade of GLP-1R signaling raises the glucose nadir but does not affect glycemic variability. Conclusions Rat bariatric surgery duplicates many features of human post–bariatric surgery hypoglycemia including postprandial hypoglycemia and glycemic variability, while blockade of GLP-1R signaling prevents hypoglycemia but not the variability.
VSG causes glycemic variability during ad lib feeding condition. Single liquid meal ingestion causes post-VSG hypoglycemia. Blockade of GLP-1 receptor prevents post-VSG hypoglycemia.
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Affiliation(s)
- Simon S Evers
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Ki-Suk Kim
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | | | - Alfor G Lewis
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Diana Farris
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Matthew J Sorensen
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Youngsoo Kim
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Steven E Whitesall
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Robert T Kennedy
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Daniel E Michele
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Darleen A Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48105, USA; Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA.
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29
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Karadağ C, Demircan S, Çalışkan E. Effects of laparoscopic sleeve gastrectomy on obstetric outcomes within 12 months after surgery. J Obstet Gynaecol Res 2019; 46:266-271. [PMID: 31770822 DOI: 10.1111/jog.14165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/10/2019] [Indexed: 02/02/2023]
Abstract
AIM To determine the obstetric and neonatal outcomes of pregnant patients having undergone laparoscopic sleeve gastrectomy (LSG) in the previous 12 months. METHODS This retrospective and observational study included 144 pregnant women: 48 had pregnancies within 12 months after LSG (Group A), 42 became pregnant more than 1 year after surgery (Group B) and 54 obese pregnant women who had a body mass index (BMI) >30 kg/m2 , were categorized as the control group because they did not undergo surgery (Group C). The participants' early gestational BMI, predelivery BMI and gestational weight gain were determined and the obstetric and neonatal outcomes of the groups were compared. RESULTS The time interval from surgery to conception was 7.8 ± 3.4 months and 25.8 ± 13.4 months for Groups A and B, respectively (P < 0.01). There were no significant differences in the rates of gestational hypertension, pre-eclampsia, preterm delivery and cesarean section between the groups. The number of patients with gestational diabetes mellitus was significantly higher in Group C than in Groups A and B (P = 0.004). The number of large-for-gestational-age infants was higher in Group C than in Groups A and B (P = 0.046). The number of small-for-gestational-age infants was significantly higher in Group A than in Groups B and C (P = 0.025). CONCLUSION Pregnancy within one year after LSG is related to an increased risk of small-for-gestational-age infants. LSG decreases the risk of gestational diabetes mellitus independent of the time interval between surgery and conception.
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Affiliation(s)
- Cihan Karadağ
- Okan University School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Sinem Demircan
- İstanbul Medeniyet University School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
| | - Eray Çalışkan
- Okan University School of Medicine, Department of Obstetrics and Gynecology, İstanbul, Turkey
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Hong S, Park B, Noh H, Choi DJ. Herbal Medicine for Dumping Syndrome: A Systematic Review and Meta-Analysis. Integr Cancer Ther 2019; 18:1534735419873404. [PMID: 31549529 PMCID: PMC6759702 DOI: 10.1177/1534735419873404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Dumping syndrome is a common complication of surgical treatment of gastric cancer, but conventional therapy has limitations related to symptom care due to its structural cause and the decreased quality of life. Objectives: The objective of this review was to assess the clinical evidence for the effectiveness of herbal medicine as a treatment for dumping syndrome. Methods: A literature review was conducted using 16 databases from their inceptions to March 2018. All randomized controlled trials (RCTs) of herbal medicine used to treat dumping syndrome patients were included and meta-analyzed. Methodological quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 174 dumping syndrome patients of 3 trials met all inclusion criteria. Two trials assessed the effectiveness of herbal medicine on the symptom response rate compared with conventional pharmacotherapy. Their results suggested significant effects in favor of herbal medicine (risk ratio [RR] = 1.37, 95% confidence interval [CI] = 1.16-1.63, P = .0003, heterogeneity τ2 = 0, χ2 = 0.02, P = .88, I2 = 0%). One trial assessed its effectiveness on the improvement rate of overall symptoms compared with conventional conservative complex therapy, such as postural management, diet regulation, and counseling (RR = 1.23, 95% CI = 0.96-1.58). Conclusions: Due to the small sample size, scarcity of reported articles, and lack of quality of the current RCTs, it was concluded that the effectiveness of herbal medicine in treating dumping syndrome is unclear.
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Affiliation(s)
- Seungcheol Hong
- Dongguk University, Seoul, Republic of Korea.,Ilsan Oriental Hospital, Dongguk University Medical Centre, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Bongki Park
- Mirae Korean Medicine Clinic, Cheonan-si, Chungcheongnam-do, Republic of Korea
| | | | - Dong-Jun Choi
- Dongguk University, Seoul, Republic of Korea.,Ilsan Oriental Hospital, Dongguk University Medical Centre, Goyang-si, Gyeonggi-do, Republic of Korea
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31
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Sekuła M, Boniecka I, Paśnik K. Bulimia nervosa in obese patients qualified for bariatric surgery - clinical picture, background and treatment. Wideochir Inne Tech Maloinwazyjne 2019; 14:408-414. [PMID: 31534571 PMCID: PMC6748054 DOI: 10.5114/wiitm.2019.81312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 11/27/2018] [Indexed: 11/17/2022] Open
Abstract
Eating is a basic human physiological need which is necessary to keep the body alive. Eating disorders are diagnosed when eating (or not eating) and associated body weight gain anxiety become the main interest of an individual and all other spheres of life depend on it. Bulimia nervosa is a psychiatric disorder which is more and more commonly diagnosed in patients suffering from obesity and in patients after surgical treatment of obesity. In patients eligible for bariatric surgery this disorder should be diagnosed appropriately early and treated successfully before the procedure, because bulimia nervosa does not regress spontaneously. When untreated, it may last for years, reducing the efficacy of a surgical treatment of obesity, or even lead to complications that are health- and life-threatening for patients.
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Affiliation(s)
- Marzena Sekuła
- University of Social Sciences and Humanities, University of Social Psychology, Warsaw, Poland
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Iwona Boniecka
- Department of Clinical Dietetics, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Paśnik
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
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32
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Sun W, Zhang Y, Shen Q, Zhang W, Yao Q, Yang Y. Prevalence and risk factors for symptoms suggestive of hypoglycemia and early dumping syndrome after sleeve gastrectomy. Surg Obes Relat Dis 2019; 15:1439-1446. [PMID: 31427225 DOI: 10.1016/j.soard.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/25/2019] [Accepted: 06/12/2019] [Indexed: 02/06/2023]
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Vavricka SR, Greuter T. Gastroparesis and Dumping Syndrome: Current Concepts and Management. J Clin Med 2019; 8:jcm8081127. [PMID: 31362413 PMCID: PMC6723467 DOI: 10.3390/jcm8081127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 02/07/2023] Open
Abstract
Gastroparesis and dumping syndrome both evolve from a disturbed gastric emptying mechanism. Although gastroparesis results from delayed gastric emptying and dumping syndrome from accelerated emptying of the stomach, the two entities share several similarities among which are an underestimated prevalence, considerable impairment of quality of life, the need for a multidisciplinary team setting, and a step-up treatment approach. In the following review, we will present an overview of the most important clinical aspects of gastroparesis and dumping syndrome including epidemiology, pathophysiology, presentation, and diagnostics. Finally, we highlight promising therapeutic options that might be available in the future.
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Affiliation(s)
- Stephan R Vavricka
- Center of Gastroenterology and Hepatology, CH-8048 Zurich, Switzerland.
- Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland.
| | - Thomas Greuter
- Department of Gastroenterology and Hepatology, University Hospital Zurich, CH-8091 Zurich, Switzerland
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34
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Effect of single anastomosis duodenal-ileal bypass with sleeve gastrectomy on glucose tolerance test: comparison with other bariatric procedures. Surg Obes Relat Dis 2019; 15:1091-1097. [DOI: 10.1016/j.soard.2019.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 03/31/2019] [Accepted: 04/13/2019] [Indexed: 01/22/2023]
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Guarino D, Moriconi D, Mari A, Rebelos E, Colligiani D, Baldi S, Anselmino M, Ferrannini E, Nannipieri M. Postprandial hypoglycaemia after Roux-en-Y gastric bypass in individuals with type 2 diabetes. Diabetologia 2019; 62:178-186. [PMID: 30315341 DOI: 10.1007/s00125-018-4737-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/09/2018] [Indexed: 02/08/2023]
Abstract
AIMS/HYPOTHESIS Postprandial hypoglycaemia (PPHG) is a complication of Roux-en-Y gastric bypass (RYGB) surgery in normoglycaemic individuals. In type 2 diabetes, RYGB improves glucose metabolism, but whether this improvement is related to the later development of PPHG is not known. We investigated the presence and mechanisms of PPHG in individuals with type 2 diabetes undergoing RYGB. METHODS A total of 35 obese individuals with type 2 diabetes underwent an OGTT before and 24 months after surgery. PPHG was defined as a plasma glucose level of ≤3.3 mmol/l when not taking glucose-lowering agents. Insulin sensitivity was assessed by oral glucose insulin sensitivity index and beta-cell function by mathematical modelling of the plasma glucose, insulin and C-peptide concentrations. RESULTS After surgery, PPHG occurred in 11 of 35 individuals who underwent RYGB. Before surgery, BMI was lower, glycaemic control less good and time of glucose peak earlier in the PPHG vs No PPHG group, and the duration of diabetes was shorter with PPHG (all p ≤ 0.05). In addition, insulin sensitivity was greater in the PPHG than No PPHG group (p = 0.03). After surgery, BMI and fasting glucose and insulin levels decreased similarly in the two groups; insulin secretion during the first hour of the OGTT increased more in the PPHG than No PPHG group (p = 0.04). Beta-cell glucose sensitivity increased more in individuals with PPHG than those without (p = 0.002). Over the same time interval, the glucagon-like peptide 1 (GLP-1) response was lower in individuals with PPHG before surgery (p = 0.05), and increased more after surgery. At 2 h after glucose ingestion in the OGTT, postsurgery plasma glucagon level was significantly lower in the PPHG than No PPHG group. CONCLUSIONS/INTERPRETATION In morbidly obese individuals with type 2 diabetes, spontaneous PPHG may occur after bariatric surgery independently of a remission of diabetes. Before surgery, individuals had a shorter duration and were more insulin sensitive. Two years after surgery, these individuals developed greater beta-cell glucose sensitivity, and showed greater insulin and GLP-1 release early in the OGTT.
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Affiliation(s)
- Daniela Guarino
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
- CNR Institute of Clinical Physiology, Pisa, Italy
| | - Diego Moriconi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Andrea Mari
- CNR Institute of Neurosciences, Padua, Italy
| | - Eleni Rebelos
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Daria Colligiani
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Simona Baldi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | | | | | - Monica Nannipieri
- Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy.
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Martines G, Perrino S. Nutritional Support After Bariatric Surgery. NUTRITIONAL SUPPORT AFTER GASTROINTESTINAL SURGERY 2019:89-111. [DOI: 10.1007/978-3-030-16554-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Parretti HM, Hughes CA, Jones LL. 'The rollercoaster of follow-up care' after bariatric surgery: a rapid review and qualitative synthesis. Obes Rev 2019; 20:88-107. [PMID: 30345630 DOI: 10.1111/obr.12764] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/26/2018] [Accepted: 08/09/2018] [Indexed: 12/15/2022]
Abstract
Benefits of bariatric surgery for obesity related comorbidities are well established. However, in the longer term, patients can become vulnerable to procedure specific problems, experience weight regain and continue to need monitoring and management of comorbidities. Effective longer term follow-up is vital due to these complex needs post-surgery. Current guidance recommends annual long-term follow-up after bariatric surgery. However, attendance can be low, and failure to attend is associated with poorer outcomes. Understanding patients' experiences and needs is central to the delivery of effective care. This rapid review has synthesized the current qualitative literature on patient experiences of healthcare professional (HCP) led follow-up from 12 months after bariatric surgery. A recurring theme was the need for more and extended follow-up care, particularly psychological support. Enablers to attending follow-up care were patient self-efficacy as well as HCP factors such as a non-judgemental attitude, knowledge and continuity of care. Barriers included unrealistic patient expectations and perceived lack of HCP expertise. Some preferences were expressed including patient initiated access to HCPs and more information preoperatively to prepare for potential post-surgery issues. Insights gained from this work will help identify areas for improvement to care in order to optimize longer term outcomes.
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Affiliation(s)
- H M Parretti
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - C A Hughes
- Fakenham Weight Management Services, Fakenham, Norfolk, UK.,University of East Anglia, Norwich, Norfolk, UK
| | - L L Jones
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
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Nor Hanipah Z, Punchai S, Birriel TJ, Lansang MC, Kashyap SR, Brethauer SA, Schauer PR, Aminian A. Clinical features of symptomatic hypoglycemia observed after bariatric surgery. Surg Obes Relat Dis 2018; 14:1335-1339. [DOI: 10.1016/j.soard.2018.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 01/10/2023]
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Emous M, Wolffenbuttel BH, van Dijk G, Totté E, van Beek AP. Long-term self-reported symptom prevalence of early and late dumping in a patient population after sleeve gastrectomy, primary, and revisional gastric bypass surgery. Surg Obes Relat Dis 2018; 14:1173-1181. [DOI: 10.1016/j.soard.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/08/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
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Evaluation of postprandial hypoglycemia in patients with nonalcoholic fatty liver disease by oral glucose tolerance testing and continuous glucose monitoring. Eur J Gastroenterol Hepatol 2018; 30:797-805. [PMID: 29634665 PMCID: PMC5999378 DOI: 10.1097/meg.0000000000001118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Nonalcoholic fatty liver disease (NAFLD) is often associated with insulin resistance and glucose intolerance. Postprandial hypoglycemia frequently occurs in NAFLD patients; however, the details remain unclear. PATIENTS AND METHODS The 75-g oral glucose tolerance test (75gOGTT) in 502 patients with biopsy-proven NAFLD and continuous glucose monitoring (CGM) in 20 patients were performed, and the characteristics and causes of postprandial hypoglycemia were investigated. RESULTS The proportion of patients in the Hypo subgroup [plasma glucose (PG) at 180 min<fasting-PG (FPG)] among patients with normal glucose tolerance was significantly higher than that with diabetes mellitus and impaired glucose tolerance or impaired fasting glucose. FPG and hemoglobin A1c (HbA1c) were lower, and area under the curve of total insulin secretion within 120 min (<120 min) was higher in Hypo than Hyper in overall patients. Although FPG and PG at 30 min were higher in Hypo than Hyper, HOMA-IR and the insulinogenic index were not different in normal glucose tolerance and impaired glucose tolerance or impaired fasting glucose. In multivariate logistic regression analysis, low HbA1c, low fasting immunoreactive insulin, and high area under the curve of total insulin secretion (<120 min) were found to be independent factors associated with hypoglycemia. CGM showed postprandial hypoglycemia until lunch in 70% of NAFLD patients. However, no remarkable relationship in terms of hypoglycemia was identified between the 75gOGTT and CGM. CONCLUSION Postprandial hypoglycemia was identified in many NAFLD patients detected by 75gOGTT and CGM. It was clarified that important causes of postprandial hypoglycemia were related to low HbA1c, an early elevation of PG, low fasting and relatively low early insulin secretion, and delayed hyperinsulinemia.
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Mingrone G, Bornstein S, Le Roux CW. Optimisation of follow-up after metabolic surgery. Lancet Diabetes Endocrinol 2018; 6:487-499. [PMID: 29396249 DOI: 10.1016/s2213-8587(17)30434-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 02/06/2023]
Abstract
Bariatric surgery has many benefits beyond weight loss, including improved control of glycaemia, blood pressure, and dyslipidaemia; hence, such surgery has been rebranded as metabolic surgery. The operations are, unfortunately, also associated with major surgical and medical complications. The medical complications include gastro-oesophageal reflux disease, malnutrition, and metabolic complications deriving from vitamin and mineral malabsorption. The benefits of surgery can be optimised by implementing specific protocols before and after surgery. In this Review, we discuss the assessment of the risk of major cardiac complications and severe obstructive sleep apnoea before surgery, and the provision of adequate lifelong postsurgery nutritional, vitamin, and mineral supplementation to reduce complications. Additionally, we examine the best antidiabetic medications to reduce the risk of hypoglycaemia after gastric bypass and sleeve gastrectomy, and the strategies to improve weight loss or reduce weight regain. Although optimising clinical pathways is possible to maximise metabolic benefits and reduce the risks of complications and micronutrient deficiencies, evolution of these strategies can further improve the risk-to-benefit ratio of metabolic surgery.
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Affiliation(s)
- Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy; Diabetes and Nutritional Sciences, Hodgkin Building, Guy's Campus, King's College London, London, UK.
| | - Stefan Bornstein
- Diabetes and Nutritional Sciences, Hodgkin Building, Guy's Campus, King's College London, London, UK; Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Carel W Le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland; Division of Investigative Science, Imperial College London, London, UK
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Basbug A, Ellibeş Kaya A, Dogan S, Pehlivan M, Goynumer G. Does pregnancy interval after laparoscopic sleeve gastrectomy affect maternal and perinatal outcomes? J Matern Fetal Neonatal Med 2018; 32:3764-3770. [PMID: 29712482 DOI: 10.1080/14767058.2018.1471678] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background: Obesity is a global health epidemic and is associated with many maternal and neonatal complications. Laparoscopic sleeve gastrectomy (LSG) is among the surgical treatments for obesity. The appropriate timing of pregnancy following LSG remains controversial and few studies have evaluated this public health issue. Objective: To evaluate the effect of pregnancy timing after LSG on maternal and perinatal outcomes. Study design: We performed a retrospective observational study of 23 pregnant women who underwent LSG at a tertiary hospital in Turkey. Women who became pregnant within 18 months of undergoing LSG were included in the early pregnancy after LSG group, and those who became pregnant after 18 months were included the late pregnancy after LSG group. Maternal and perinatal outcomes were evaluated, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders, preterm birth, mode of delivery, small and large for gestational age births (small for gestational age (SGA), large for gestational age (LGA)), birth injury, and congenital malformations. Results: Body mass index (BMI) at conception was higher in the early pregnancy after LSG group than in the late pregnancy after LSG group (30.48 versus 27.25, respectively; p = .03). Pregnancy interval after LSG did not impact maternal-fetal complications or mode of delivery. After a 75 g oral glucose tolerance test (OGTT) for GDM, 75% (n = 6) of the early pregnancy group presented with early dumping syndrome, compared to only 13.3% (n = 2) of the late pregnancy after LSG group (p = .009). Conclusions: LSG may reduce obesity-related gestational complications, such as GDM and LGA. The interval between LSG and conception did not impact maternal or neonatal outcomes. Screening for GDM can result in dumping syndrome in pregnancies after LSG.
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Affiliation(s)
- Alper Basbug
- a Department of Obstetrics and Gynecology , Duzce University, Faculty of Medicine , Duzce , Turkey
| | - Aşkı Ellibeş Kaya
- a Department of Obstetrics and Gynecology , Duzce University, Faculty of Medicine , Duzce , Turkey
| | - Sami Dogan
- b Department of General Surgery , Duzce University, Faculty of Medicine , Duzce , Turkey
| | - Mevlut Pehlivan
- b Department of General Surgery , Duzce University, Faculty of Medicine , Duzce , Turkey
| | - Gokhan Goynumer
- c Department of Obstetrics and Gynecology , SB Istanbul Medeniyet University Goztepe Education and Research Hospital , Istanbul , Turkey
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Belligoli A, Sanna M, Serra R, Fabris R, Pra' CD, Conci S, Fioretto P, Prevedello L, Foletto M, Vettor R, Busetto L. Incidence and Predictors of Hypoglycemia 1 Year After Laparoscopic Sleeve Gastrectomy. Obes Surg 2018; 27:3179-3186. [PMID: 28547566 DOI: 10.1007/s11695-017-2742-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Hypoglycemia is a known adverse event following gastric bypass. The incidence of hypoglycemia after laparoscopic sleeve gastrectomy (LSG) is still under investigation. The aim of our study was to verify the presence of oral glucose tolerance test (OGTT)-related hypoglycemia after LSG and to identify any baseline predictors of its occurrence. METHODS We analyzed 197 consecutive non-diabetic morbid obese patients that underwent LSG. All patients were studied before and 12 months after LSG. Evaluation included anthropometric parameters, 3-h OGTT for blood glucose (BG), insulin and c-peptide, lipid profile, interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), highly sensitive C-reactive protein (hsCRP), and leptin. Hypoglycemia was defined as BG ≤ 2.7 mmol/l. RESULTS After surgery, 180 patients completed the OGTT. Eleven patients did not complete the test for gastric intolerance, and in six patients, the test was stopped earlier for the onset of severe symptomatic hypoglycemia. Of the patients, 61/186 (32.8%) had at least one OGTT-related hypoglycemia. The highest frequency of hypoglycemic events occurred 150' after glucose load (20.2%). At baseline, patients with hypoglycemic events after surgery (Hypo) were younger (40 ± 11 vs 46 ± 10 years; p < 0.001), less obese (BMI 46 ± 5.7 vs 48.4 ± 7.9 kg/m2; p < 0.05), and had a worse lipid profile as compared to patients without hypoglycemic events (N-Hypo). Moreover, after LSG, Hypo patients compared with N-Hypo presented a higher weight loss (%EBMIL 80 ± 20 vs 62 ± 21%; p < 0.001). Low age, low fasting glucose, and high triglyceride levels before LSG were independent predictors of hypoglycemia development after surgery (r 2 = 0.131). CONCLUSION These findings confirm the high incidence of post-prandial hypoglycemia 1 year after LSG. Hypoglycemia is more frequent in younger patients with lower fasting glucose and higher triglyceride levels before surgery.
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Affiliation(s)
- Anna Belligoli
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy. .,Clinica Medica 3, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35100, Padova, Italy.
| | - Marta Sanna
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Roberto Serra
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Roberto Fabris
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Chiara Dal Pra'
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Scilla Conci
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Paola Fioretto
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Luca Prevedello
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Mirto Foletto
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Roberto Vettor
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
| | - Luca Busetto
- Center for the Study and the Integrated Management of Obesity, University Hospital of Padova, Padova, Italy
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Impact of Laparoscopic Sleeve Gastrectomy on Gastrointestinal Motility. Gastroenterol Res Pract 2018; 2018:4135813. [PMID: 29849586 PMCID: PMC5907392 DOI: 10.1155/2018/4135813] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/04/2018] [Indexed: 01/19/2023] Open
Abstract
Objective Laparoscopic sleeve gastrectomy (LSG) was considered mainly as a restrictive procedure due to anatomic alterations in the upper gastrointestinal tract. Additionally, due to neurohormonal alterations, LSG modifies the gastrointestinal motility, which controls appetite and feeling of satiety. Aim The aim of the study was to review the impact of laparoscopic sleeve gastrectomy on gastrointestinal motility. Material and Methods A search of the medical literature was undertaken in Pubmed, Web of Science, and Cochrane library. Esophageal, gastric, bowel motility were assessed separately. Results Nine studies assessed esophageal motility. The data remain debatable attributing to the heterogeneity of follow-up timing, surgical technique, bougie size, and distance from pylorus. The stomach motility was assessed in eighteen studies. Functionally, the sleeve was divided into a passive sleeve and an accelerated antrum. All scintigraphic studies revealed accelerated gastric emptying after LSG except of one. Patients demonstrated a rapid gastroduodenal transit time. The resection of the gastric pacemaker had as a consequence aberrant distal ectopic pacemaking or bioelectrical quiescence after LSG. The bowel motility was the least studied. Small bowel transit time was reduced; opposite to that the initiation of cecal filling and the ileocecal valve transit was delayed. Conclusion Laparoscopic sleeve gastrectomy has impacts on gastrointestinal motility. The data remain debatable for esophageal motility. Stomach and small bowel motility were accelerated, while the initiation of cecal filling and the ileocecal valve transit was delayed. Further pathophysiological studies are needed to evaluate the correlation of motility data with clinical symptoms.
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Davis DB, Khoraki J, Ziemelis M, Sirinvaravong S, Han JY, Campos GM. Roux en Y gastric bypass hypoglycemia resolves with gastric feeding or reversal: Confirming a non-pancreatic etiology. Mol Metab 2018; 9:15-27. [PMID: 29449181 PMCID: PMC5869737 DOI: 10.1016/j.molmet.2017.12.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postprandial hypoglycemia is an infrequent but disabling complication of Roux-en-Y gastric bypass (RYGB) surgery. Controversy still exists as to whether the postprandial hyperinsulinemia observed is due to inherent changes in pancreatic β-cell mass or function or to reversible alterations caused by RYGB anatomy. We aimed to determine if gastric feeding or reversal of RYGB would normalize postprandial glucose and hormone excursions in patients with symptomatic hypoglycemia. METHODS We completed a prospective study of six patients with severe symptomatic RYGB hypoglycemia who underwent RYGB reversal. An additional subject without hypoglycemia who underwent RYGB reversal was also studied prospectively. Mixed meal tolerance testing (MTT) was done orally (RYGB anatomy), via gastrostomy tube in the excluded stomach in the setting of RYGB, and several months after RYGB reversal. RESULTS All subjects reported symptomatic improvement of hypoglycemia after reversal of RYGB. Weight gain after reversal was moderate and variable. Postprandial glucose, insulin, and GLP-1 excursions were significantly diminished with gastric feeding and after reversal. Insulin secretion changed proportional to glucose levels and insulin clearance increased after reversal. Glucagon/insulin ratios were similar throughout study. We further compared the impact of modified sleeve gastrectomy reversal surgery to those with restoration of complete stomach and found no significant differences in weight regain or in postprandial glucose or hormone levels. CONCLUSIONS Reversal of RYGB is an effective treatment option for severe postprandial hypoglycemia. The pathophysiology of this disorder is primarily due to RYGB anatomy resulting in altered glucose, gut, and pancreatic hormone levels and decreased insulin clearance, rather than inherent β-cell hyperplasia or hyperfunction.
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Affiliation(s)
- Dawn Belt Davis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705, USA.
| | - Jad Khoraki
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA
| | - Martynas Ziemelis
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA
| | - Sirinart Sirinvaravong
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Jee Young Han
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Guilherme M Campos
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA.
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Differences in Anthropometric and Metabolic Parameters Between Subjects with Hypoglycaemia and Subjects with Euglycaemia After an Oral Glucose Tolerance Test Six Months After Laparoscopic Sleeve Gastrectomy. Obes Surg 2017; 26:2747-2755. [PMID: 27112589 DOI: 10.1007/s11695-016-2187-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hypoglycaemia after an oral glucose tolerance test (OGTT) can occur in up to 33 % of subjects after laparoscopic sleeve gastrectomy (LSG). The underlying pathophysiology is not well understood. We aimed to compare the anthropometric and metabolic characteristics of subjects with post-OGTT hypoglycaemia (HYPO) to subjects with post-OGTT euglycaemia (EU) 6 months after LSG. METHODS Eighteen morbidly obese patients with normal glucose tolerance (NGT) were evaluated with an OGTT before and 6 months after LSG. Serum glucose and insulin were measured before and every 30 min after glucose ingestion up to 120'. The patients were categorized as HYPO or EU based on lowest glucose levels 90' to 120' post-OGTT 6 months after LSG (hypoglycaemia defined as glucose levels <60 mg/dl). OGTT derived indices of insulin secretion; insulin sensitivity and beta cell function were also evaluated. RESULTS Eight patients (44.4 %) were categorized as HYPO. Preoperatively, subjects with HYPO had lower BMI (p = 0.02) compared to that with EU. Postoperatively, subjects with HYPO had lower BMI (p = 0.01), lower weight (p = 0.01), and higher percentage of total weight loss (%TWL) (p = 0.03) compared to that with EU. The beta cell function index was higher in the HYPO group postoperatively compared to EU (p = 0.02)-especially during the latter portion of the OGTT. No difference was detected in insulin secretion and insulin sensitivity indices between the two groups preoperatively or postoperatively. CONCLUSIONS Subjects with NGT who developed HYPO 6 months after LSG are leaner, with higher TWL% and higher beta cell function at the latter portion of the OGTT compared to those with EU.
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Rottenstreich A, Elazary R, Ezra Y, Kleinstern G, Beglaibter N, Elchalal U. Hypoglycemia during oral glucose tolerance test among post-bariatric surgery pregnant patients: incidence and perinatal significance. Surg Obes Relat Dis 2017; 14:347-353. [PMID: 29306610 DOI: 10.1016/j.soard.2017.11.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/31/2017] [Accepted: 11/28/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND While hypoglycemia during an oral glucose tolerance test (OGTT) has been shown to occur in a considerable portion of nonpregnant post-bariatric surgery (BS) patients, its incidence among pregnant post-BS patients evaluated for gestational diabetes has only been sparsely studied. OBJECTIVES We investigated OGTT results and pregnancy outcomes in pregnant women who underwent 3 types of bariatric procedures before pregnancy. SETTING A university hospital. METHODS From medical records, data were collected on glucose measurements during a 100-g, 3-hour OGTT, as well as maternal and fetal outcomes. RESULTS Of 119 post-BS pregnant patients included in the study, 55 underwent laparoscopic sleeve gastrectomy, 34 laparoscopic adjustable gastric banding, and 30 laparoscopic Roux-en-Y gastric bypass surgery. Hypoglycemia (<55 mg/dL) was encountered in 59 (49.6%) patients during the OGTT. Among them, the nadir plasma glucose levels occurred 2 hours after glucose ingestion in 25 (42.4%) and after 3 hours in 34 (57.6%), with a median value of 47 (44-52) mg/dL. The risk of hypoglycemia was higher among women with prior laparoscopic Roux-en-Y gastric bypass surgery (83.3%) than among those with prior laparoscopic sleeve gastrectomy (54.5%; P = .009) or laparoscopic adjustable gastric banding (11.8%; P<.0001). Time from surgery to conception was significantly shorter among women with evidence of hypoglycemia during OGTT (median 711 versus 1246 days, P = .002). Compared with patients without evidence of hypoglycemia, patients who experienced hypoglycemia had lower rates of gestational diabetes (P = .03) but higher proportions of low birth weight (P = .01) and small for gestational age infants (P = .03). CONCLUSIONS Because hypoglycemia is common during OGTT among post-BS parturients, other diagnostic methods should be considered in this setting. The association found between hypoglycemia and poor fetal growth warrants investigation as to whether interventions to prevent hypoglycemia will improve fetal outcome.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Ram Elazary
- Department of Surgery, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Yossef Ezra
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Geffen Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, Jerusalem, Israel; Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Nahum Beglaibter
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus Campus, Jerusalem, Israel
| | - Uriel Elchalal
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Gasser M, Meier C, Herren S, Aubry E, Steffen R, Stanga Z. Is testing for postprandial hyperinsulinemic hypoglycemia after gastric bypass necessary? Clin Nutr 2017; 38:444-449. [PMID: 29208421 DOI: 10.1016/j.clnu.2017.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/16/2017] [Accepted: 11/17/2017] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Postprandial hyperinsulinemic hypoglycemia (pHH) is an increasingly reported complication after Roux-en-Y gastric bypass (RYGB). As pHH can cause life-threatening emergencies if occurring without warning symptoms, challenge testing may detect patients at risk. The study objective was to determine the frequency of occurrence of pHH with or without symptoms of hypoglycemia after RYGB. METHODS We undertook an observational cohort study of consecutive, unselected patients approximately one year after uncomplicated RYGB. To simulate normal habits, all patients received a standardized carbohydrate-rich solid mixed meal. Plasma glucose and insulin were measured at 30, 60, 90, 120, and 150 min thereafter. Symptoms were classified as autonomous or neuroglycopenic. Patients with hypoglycemia (plasma glucose <3.0 mmol/L [55 mg/dL]), were tested a second time with a protein-rich solid mixed meal. RESULTS 113 patients were included. Total weight loss at the first follow-up check (14 ± 0.4 months) was 33.97 ± 9.3%. After the carbohydrate-rich meal, glucose dropped to <3.0 mmol/L in 13.2% (n = 15) of patients vs no drop to <3.0 mmol/L after a protein-rich meal. The pHH occurred in 11.5% (n = 13) of patients. Asymptomatic patients (5.3%, n = 6) carried an increased risk (p = 0.008) for pHH. One patient needed emergency treatment after sudden loss of consciousness after the carbohydrate-rich meal. CONCLUSIONS The occurrence of pHH was quite high in our study population with 11.5% thereof 5.3% asymptomatic. We therefore suggest that detection of these patients warrants a screening of patients after RYGB. At-risk patients should than be adequately advised to avoid carbohydrate-rich meals in order to optimize risk management.
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Affiliation(s)
- Michèle Gasser
- European Center of Excellence for Bariatric and Metabolic Surgery, Bern, Switzerland
| | - Claudia Meier
- European Center of Excellence for Bariatric and Metabolic Surgery, Bern, Switzerland
| | - Sylvia Herren
- European Center of Excellence for Bariatric and Metabolic Surgery, Bern, Switzerland
| | - Emilie Aubry
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Switzerland
| | - Rudolf Steffen
- European Center of Excellence for Bariatric and Metabolic Surgery, Bern, Switzerland.
| | - Zeno Stanga
- Division of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital, University of Bern, Switzerland
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Weight regain in patients with symptoms of post-bariatric surgery hypoglycemia. Surg Obes Relat Dis 2017; 13:1728-1734. [PMID: 28844575 DOI: 10.1016/j.soard.2017.06.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/01/2017] [Accepted: 06/17/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Weight regain (WR) and symptoms of post-bariatric surgery hypoglycemia (PBSH) are metabolic complications observed in a subset of postbariatric patients. Whether hypoglycemic symptoms are an important driver of increased caloric intake and WR after bariatric surgery is unknown. OBJECTIVE This study aims to determine whether patients with PBSH symptoms have greater odds for WR. SETTING Tertiary academic hospital. METHODS Patients who underwent Roux-en-Y gastric bypass or sleeve gastrectomy at our tertiary academic hospital from August 2008 to August 2012 were mailed a survey, from which weight trajectory and PBSH symptoms were assessed. Percent WR was calculated as 100×(current weight-nadir weight)/(preoperative weight-nadir weight) and was compared between dates of survey completion and bariatric surgery. The primary outcome was WR≥10%, as a reflection of the median WR among respondents. Multivariable logistic regression was used to determine clinical factors that indicate greater odds for WR≥10% at the P<.05 level. RESULTS Of 1119 potential patients, 428 respondents (40.6%) were eligible for analysis. WR was observed in 79.2% (n = 339), while 20.8% (n = 89) experienced either weight loss or no WR at a mean of 40.6±14.5 months. Median WR was 10.8% (interquartile range, 5.6-19.4). Odds of WR≥10% was significantly increased in those who experienced PBSH symptoms (odds ratio [OR] = 1.66; 95% confidence interval [CI]: 1.04-2.65), reported less adherence to nutritional guideline (OR = 2.36; 95% CI: 1.52-3.67), and had a longer time since surgery (OR = 1.05; 95% CI: 1.03-1.07). CONCLUSIONS We found evidence that the presence of PBSH symptoms was associated with WR. Future studies should elucidate the role of hypoglycemia among other factors in post-bariatric surgery WR.
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López-Serrano A, Ortiz Polo I, Sanz de la Vega J, Moreno-Osset E. Role of the gastroenterologist in the management of the obese patient. GASTROENTEROLOGÍA Y HEPATOLOGÍA (ENGLISH EDITION) 2017; 40:409-416. [DOI: 10.1016/j.gastre.2017.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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