Dumping syndrome following gastric bypass: validation of the dumping symptom rating scale

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

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.

Postoperative Dumping Syndrome, Health-Related Quality of Life, Anxiety, Depression, and Eating Disturbances: Results of a Longitudinal Obesity Surgery Study

INTRODUCTION

Given the lack of research on the relationship of post-surgery dumping syndrome and eating disturbances, the purpose of the present longitudinal study was to investigate whether dumping after obesity surgery is associated with pre-/postoperative eating disorder symptoms or addiction-like eating beyond the type of surgery, gender, health-realted quality of life (HRQoL) and anxiety/depressive symptoms.

METHODS

The study included 220 patients (76% women) before (t0) and 6 months after (t1) obesity surgery (sleeve gastrectomy [n = 152], Roux-en-Y gastric bypass [n = 53], omega loop gastric bypass [n = 15]). The Sigstad Dumping Score was used to assess post-surgery dumping syndrome. Participants further answered the Eating Disorder Examination Questionnaire (EDE-Q), Yale Food Addiction Scale 2.0 (YFAS 2.0), Short-Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) at t0 and t1.

RESULTS

The point prevalence of symptoms suggestive of post-surgery dumping syndrome was 33%. Regression analyses indicate an association of dumping with surgical procedure (bypass), female gender, reduced HRQoL, more anxiety/depressive symptoms, and potentially with binge eating but not with eating disorder symptoms in general or with addiction-like eating.

CONCLUSION

The current study failed to show a close relationship between the presence of self-reported dumping syndrome and eating disorder symptoms or addiction-like eating following obesity surgery. Further studies with longer follow-up periods should make use of clinical interviews to assess psychosocial variables and of objective measures to diagnose dumping in addition to standardized self-ratings.

Dumping Syndrome: Pragmatic Treatment Options and Experimental Approaches for Improving Clinical Outcomes

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.

The Effect of Fat Supplementation on the Appearance of Symptoms Associated With Dumping Syndrome in Patients Having Undergone Gastric Surgery: Preliminary Results

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.

Incidence and Intensity of Early Dumping Syndrome and Its Association with Health-Related Quality of Life Following Sleeve Gastrectomy

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.

[Postoperative management]

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.

Dumping syndrome after bariatric surgery: prevalence, pathophysiology and role in weight reduction - a systematic review

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.

Severity of post-Roux-en-Y gastric bypass dumping syndrome and weight loss outcomes: is there any correlation?

PURPOSE

The present research was conducted to evaluate the effect of the severity of dumping syndrome (DS) on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in patients with class III obesity.

METHODS

The present retrospective cohort study used the dumping symptom rating scale (DSRS) to evaluate the severity of DS and its correlation with weight loss outcomes in 207 patients 1 year after their RYGB. The patients were assigned to group A with mild-to-moderate DS or group B with severe DS.

RESULTS

The mean age of the patients was 42.18 ± 10.46 years and their mean preoperative BMI 42.74 ± 5.59 kg/m2. The total weight loss percentage (%TWL) in group B was insignificantly higher than that in group A, but besides that was not significantly different in the two groups.

CONCLUSION

The present findings suggested insignificant relationships between the presence and severity of DS after RYGB and adequate postoperative weight loss.

Severe Dumping Symptoms Are Uncommon Following Transthoracic Esophagectomy But Significantly Decrease Health-Related Quality of Life in Long-Term, Disease-Free Survivors

BACKGROUND

High-quality documentation of dumping symptoms after esophagectomy is currently limited. The aim of the study was to describe the incidence of symptoms associated with dumping syndrome and their relationship with health-related quality of life after esophagectomy.

METHODS

The study cohort was identified from prospective IRB-approved databases from two high-volume esophagectomy centers. Patients that were alive and without evidence of recurrence in April 2018 completed the validated Dumping Symptom Rating Scale and health-related quality of life questionnaires. Compound dumping symptom score was created by combining the individual scores for severity and frequency for each symptom.

RESULTS

In total, 171 patients who underwent esophagectomy 1995-2017 responded to the questionnaires, corresponding to a response rate of 77.0%. Median age was 66 years and median time from operation to survey was 5.5 years. Absent or mild problems in all nine dumping symptoms were reported by 94 (59.5%) patients; 19 (12.0%) patients reported moderate or severe problems in at least three symptoms, the most common being postprandial "need to lie down," "diarrhea," and "stomach cramps." Increasing compound dumping symptom score was associated with significantly decreased function scores in all aspects of health-related quality of life except physical functioning (P < 0.005).

CONCLUSIONS

Esophagectomy has the potential to change long-term eating patterns; however, the majority of patients in the study did not have severe postoperative dumping symptoms. On the other hand, moderate-to-severe dumping symptoms, which were reported by 12% of patients in this study, were strongly associated with decreased health-related quality of life.

Prevention and treatment of nutritional complications after bariatric surgery

Obesity and the corresponding burden of related diseases is a major public health issue worldwide that is reaching pandemic proportions. Bariatric surgery is the only intervention that has been shown to result in substantial and lasting weight loss, and a decrease in overall mortality for patients with severe obesity. Consequently, the population of patients having undergone this procedure is increasing. Multifactorial weight-dependent and independent mechanisms underlying metabolic diseases could also drive preventable, but potentially life-threatening, long-term nutritional complications. However, given post-bariatric patients are prone to functional gastrointestinal symptoms and substantial weight loss, nutritional complications might be challenging. This Review is focused on the prevention and treatment of nutritional complications after bariatric surgery in the clinical setting.

International consensus on the diagnosis and management of dumping syndrome

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.

Effect of Roux-en-Y gastric bypass on the bioavailability of metoprolol from immediate and controlled release tablets: a single oral dose study before and after surgery

Objective

Roux-en-Y gastric bypass (RYGB) surgery induces major changes in the gastrointestinal tract that may alter the pharmacokinetics of orally administered drugs. Results from pharmacokinetic studies are sparse. This study aimed to investigate the effect of RYGB on the bioavailability of metoprolol from immediate release (IR) and controlled release (CR) tablets in female patient volunteers before and after surgery.

Methods

An explorative, two-phase, single oral dose pharmacokinetic study of metoprolol in female patients undergoing RYGB was carried out. The dose was administered twice in each patient, 1 month before and 6 months after surgery. After intake of either 100 mg of metoprolol IR or CR tablet serum concentration-time profiles of metoprolol were determined. The endpoint was the ratio of AUC_after/AUC_before of metoprolol.

Results

Twelve patients were included in the study (metoprolol IR: 7; metoprolol CR: 5). After intake of a metoprolol IR tablet major intraindividual and interindividual differences for area under the serum concentration versus time curve (AUC) of metoprolol before and after surgery were observed (range ratio AUC_{0-10 hours after}/AUC_{0-10 hours before}: 0.74-1.98). For metoprolol CR tablets a significant reduction in bioavailability of metoprolol was observed after surgery (range ratio AUC_{0-24 hours after}/AUC_{0-24 hours before}: 0.43-0.77).

Conclusion

RYGB may influence the bioavailability of metoprolol from an IR tablet. The magnitude of changes in bioavailability after RYGB requires close monitoring of patients using metoprolol IR tablets and dose adjustment if deemed necessary. RYGB clearly reduces the bioavailability of metoprolol from a CR tablet. After RYGB clinicians may consider to increase the dose according to clinical response.

Prevalence of Dumping Syndrome After Laparoscopic Sleeve Gastrectomy and Comparison with Laparoscopic Roux-en-Y Gastric Bypass

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.

Herbal Medicine for Dumping Syndrome: A Systematic Review and Meta-Analysis

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.

Bulimia nervosa in obese patients qualified for bariatric surgery - clinical picture, background and treatment

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.

Effects of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy on Food Preferences and Potential Mechanisms Involved

PURPOSE OF REVIEW

Bariatric surgery leads to a substantial decrease in energy intake. It is unclear whether this decrease in energy intake is simply due to eating smaller portions of the same food items or a shift in food preference towards less energy-dense foods. This review evaluates the existing literature on changes in food preferences after bariatric surgery and the potential mechanisms involved.

RECENT FINDINGS

Changes in food preferences have been reported; however, the evidence is mainly based on indirect measurements, such as self-reporting. When changes in food preferences are directly assessed, results contradict previous findings, indicating that results based on self-reporting must be interpreted with caution as they do not necessarily reflect actual behaviour. However, it seems that there could be inter-individual differences in the response to surgery. Future studies investigating changes in food preferences should not only focus on direct measured of behaviour but should also consider the heterogeneity of the response after bariatric surgery.

Possible relation between partial small bowel obstruction and severe postprandial reactive hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Although dietary treatment ameliorates symptoms in most patients with postbariatric hypoglycemia (PBH), there is a subgroup with severe symptoms that do not respond sufficiently to either diet or drugs. A clinical observation showed that those patients additionally experienced postprandial abdominal discomfort or pain.

OBJECTIVES

This report describes patients with severe PBH following laparoscopic Roux-en Y gastric bypass undergoing corrective surgery to alleviate partial small bowel obstruction (kink, adhesions, dysfunctional anastomosis) and the subsequent outcome regarding symptoms of PBH.

SETTING

Sahlgrenska University Hospital, Sweden.

METHODS

Retrospective analysis regarding hypoglycemic symptoms from medical records and a complementary telephone interview.

RESULTS

Out of 80 patients treated for severe PBH at our tertiary academic surgical unit over the last 4 years, 38 underwent corrective surgery (adhesiolysis and/or a reconstructed jejuno-jejunostomy). Out of 21 patients using medications to control hypoglycemia before corrective surgery, 19 (90.5%) discontinued the medication, and 5 of 19 (26%) no longer needed to use a blood glucometer or a continuous glucose monitor. Although patients after surgical correction still could experience PBH, symptoms were less frequent and less severe. Postprandial abdominal symptoms decreased, and patients reported improved eating quality. Patient interviews revealed that 8% became entirely free of PBH symptoms after surgery and 71% experienced significant relief.

CONCLUSIONS

We propose a possible association between severe hypoglycemic symptoms after laparoscopic Roux-en Y gastric bypass and partial small bowel obstruction. Patients with PBH not responding adequately to diet and drug treatment may benefit from assessment and intervention for partial small bowel obstruction.

Prevalence and pathophysiology of early dumping in patients after primary Roux-en-Y gastric bypass during a mixed-meal tolerance test

BACKGROUND

Early dumping is a poorly defined and incompletely understood complication after Roux-en-Y gastric (RYGB).

OBJECTIVE

We performed a mixed-meal tolerance test in patients after RYGB to address the prevalence of early dumping and to gain further insight into its pathophysiology.

SETTING

The study was conducted in a regional hospital in the northern part of the Netherlands.

METHODS

From a random sample of patients who underwent primary RYGB between 2008 and 2011, 46 patients completed the mixed-meal tolerance test. The dumping severity score for early dumping was assessed every 30 minutes. A sum score at 30 or 60 minutes of ≥5 and an incremental score of ≥3 points were defined as indicating a high suspicion of early dumping. Blood samples were collected at baseline, every 10 minutes during the first half hour, and at 60 minutes after the start.

RESULTS

The prevalence of a high suspicion of early dumping was 26%. No differences were seen for absolute hematocrit value, inactive glucagon-like peptide-1, and vasoactive intestinal peptide between patients with or without early dumping. Patients at high suspicion of early dumping had higher levels of active glucagon-like peptide-1 and peptide YY.

CONCLUSION

The prevalence of complaints at high suspicion of early dumping in a random population of patients after RYGB is 26% in response to a mixed-meal tolerance test. Postprandial increases in both glucagon-like peptide-1 and peptide YY are associated with symptoms of early dumping, suggesting gut L-cell overactivity in this syndrome.

Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience

Background

Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication.

Methods

All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome.

Results

Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions.

Conclusions

In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.

The short- to mid-term symptom prevalence of dumping syndrome after primary gastric-bypass surgery and its impact on health-related quality of life

BACKGROUND

Early and late dumping are complications of gastric bypass surgery. Early dumping occurs within an hour after eating, when the emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and the release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs between 1 and 3 hours after carbohydrate ingestion and is caused by an exaggerated insulin release, resulting in hypoglycemia. Almost no data are currently available on the prevalence of early and late dumping or their impact on health-related quality of life (QoL).

OBJECTIVES

To study the prevalence of early and late dumping in a large population of patients having undergone a primary Roux-en-Y gastric bypass (RYGB) and its effect on QoL.

SETTING

Cross-sectional study at a single bariatric department in the Medical Center Leeuwarden, The Netherlands between 2008 and 2011.

METHODS

In 2013, this descriptive cohort study approached by email or post all patients who underwent a primary RYGB in the setting between 2008 and 2011 in one hospital. These patients were asked to fill in standardized questionnaires measuring their QoL (RAND-36), anxiety and depression (HADS), fatigue (MFI-20) and any disease specific indicators of early and late dumping syndrome.

RESULTS

The questionnaire was completed and returned by 351 of 613 patients (57.1%) and 121 nonobese volunteers. Participants were mostly female (80%), aged 42 (40-54 years), with an excess weight loss of 76.8% [IQR 61-95] after RYGB surgery 2.3 [ IQR 1.6-3.4] years earlier. Self-reported complaints of moderate to severe intensity suggestive of early and late dumping were present in 18.8% and 11.7% of patients, respectively. Patients with early and late dumping demonstrated significantly lower scores on the RAND-36 and HADS compared with patients without dumping. No differences were seen in the MFI-20 scores between patients with or without early and late dumping.

CONCLUSION

In this descriptive cohort, self-reported complaints suggestive of early and late dumping of moderate-to-severe intensity were, respectively, 18.8% and 11.7% in a cohort after primary gastric bypass surgery. These complaints were associated with markedly reduced health-related QoL.

Should bariatric surgery be performed in adolescents?

Adolescent obesity has markedly increased worldwide in both its extent and prevalence in recent decades and obesity prevention strategies are failing. As a result, effective treatment strategies are urgently needed. As behavioral and pharmacological treatment approaches have only moderate effects in severe obesity, bariatric surgery has begun to emerge as a treatment option. In this debate article, we offer arguments opposing and supporting bariatric surgery in the treatment of severe obesity in adolescents. Bariatric surgery has superior therapeutic outcomes with respect to weight loss and resolution of comorbid diseases over other existing treatments. However, long-term outcomes after bariatric surgery in adolescents are only just beginning to emerge. Furthermore, the procedures are generally considered irreversible, apart from gastric banding. Most importantly, not all adolescents seem to benefit greatly from bariatric surgery and we are not yet able to reliably identify those who stand to gain the greatest benefit. The authors agree that adolescent bariatric surgery should be offered exclusively within formal adolescent obesity programs, delivered by specialist multidisciplinary child/adolescent obesity teams, and within specialist centers, in order to optimize outcomes and minimize potential detrimental effects. Patients and their family/carers must be educated regarding the benefits and risks, potential side effects, expected changes in eating behavior and the lifelong requirement for regular medical follow-up after surgery. Before embarking upon a surgical treatment pathway in adolescents with severe obesity, it may also be beneficial to ensure compliance to treatment is demonstrated, in order to minimize the risk of nutritional deficiencies and associated potential complications.

Dumping symptoms is triggered by fat as well as carbohydrates in patients operated with Roux-en-Y gastric bypass

BACKGROUND

Dumping syndrome after Roux-en-Y gastric bypass (RYGB) is traditionally associated with the consumption of refined carbohydrates, but the role of dietary fat is unclear.

OBJECTIVES

This study compares symptoms after consumption of a carbohydrate-rich or fat-rich beverage to determine perceived symptoms, glycemic control, and pulse rate.

SETTING

University hospital.

METHODS

We assessed perceived symptoms (Sigstad's Dumping Index) and glycemic control (P-glucose and S-insulin) as well as autonomic nervous system activity (reflected by arterial pulse rate) after a standardized liquid meal test (440 kcal/300 mL carbohydrates [CARB] or fat [FAT]) in a randomized crossover blinded setting. Blood samples were drawn before and 1, 15, 30, and 60 minutes after finishing each meal and the area under the curve (AUC) was calculated.

RESULTS

Twelve patients 42±10 months after undergoing RYGB were studied. AUC differed between drinks for glucose (P = .003) and insulin (P = .005). Pulse rate increased more after CARB than after FAT (P = .01). AUC for perceived symptoms in the Sigstad's Dumping Index were similar after meals (P = .79), yet the pattern of type of symptoms differed.

CONCLUSION

In patients with RYGB, a meal with predominant fat content resulted in as much perceived dumping symptoms as a carbohydrate-profiled meal. As expected, an increase in glucose and insulin levels were found only after carbohydrate intake and the pulse rise was more pronounced for carbohydrates than fat. Dietary counseling in patients undergoing RYGB should address dietary fat as well as traditional information about carbohydrates to avoid dumping symptoms.

Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management

Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.

Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management

BACKGROUND

Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1-3 h after carbohydrate ingestion, caused by an incretin-driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome.

METHODS

A systematic literature review was performed through February 2016. Evidence-based medicine was used to develop diagnostic and management strategies for dumping syndrome.

RESULTS

Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom-based questionnaires, glycemia measurements and oral glucose tolerance tests. First-line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re-intervention or continuous enteral feeding may be necessary for treatment-refractory dumping syndrome, but outcomes are variable.

CONCLUSIONS

Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.

Long-term effects of gastric bypass surgery on psychosocial well-being and eating behavior: not all that glitters is gold

OBJECTIVES

The aim of this pilot study was to evaluate long-term effects of Roux-en-Y gastric bypass (RYGB) on physical and psychosocial health as well as eating behavior of obese patients.

METHODS

We compared 23 patients 7 years after RYGB to 23 body mass index (BMI), sex, and age matched obese control patients by means of self-reporting questionnaires: Hospital Anxiety and Depression Scale (HADS), Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form (Q-LES-Q SF), Dutch Eating Behavior Questionnaire (DEBQ), and Alcohol Use Disorders Identification Test (AUDIT). Data are presented as median ± interquartile rage.

RESULTS

Physical health had improved and body image (80 ± 25% vs. 20 ± 49%, p < 0.001) was better in post-RYGB patients when compared to controls. HADS-depression score (4 ± 8 vs. 11 ± 9; p = 0.005) was lower post-RYGB. Satisfaction with physical health (2 ± 2 vs. 2 ± 1, p = 0.037), daily life functioning (4 ± 2 vs. 2 ± 2, p = 0.050), and hobbies (4 ± 1 vs. 2 ± 2, p = 0.011) was higher post-RYGB, but social relationships and sexual performance were not perceived as superior. In addition, post-RYGB patients were more prone to eat on external cues (13 ± 7 vs. 19 ± 13; p = 0.007).

CONCLUSION

Seven years post-RYGB, patients reported a significant improvement of physical health and higher satisfaction with daily life, but not with social relationships or sexual performance. Eating behavior post-RYGB was more influenced by external cues.

Early dumping syndrome is not a complication but a desirable feature of Roux-en-Y gastric bypass surgery

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

Risk of Dumping Syndrome after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass: Early Results of a Multicentre Prospective Study

Background. Bariatric surgery is an important field of surgery. An important complication of bariatric surgery is dumping syndrome (DS). Aims. To evaluate the incidence of DS in patients undergoing bariatric surgery. Methods. 541 patients included from 5 nutrition and bariatric centers in France underwent either LSG or LRYGB. They were evaluated at 1 month (M1) and 6 months (M6) postoperatively by an interview and completion of a dumping syndrome questionnaire. Results. 268 patients underwent LSG (Group A) and 273 underwent LRYGB. From the LRYGB patients 229 had mechanical gastrojejunoanal anastomosis with 30 mm linear stapler (Group B) and 44 had manual (hand sewn) 15 mm gastrojejunal anastomosis (Group C). Overall incidence of DS was 8.5% at M1 and M6. In LSG group (Group A), only 4 patients (1.49%) reported episodes of DS at M1 and 3 (1.12%) at M6. In Group B, 41 patients (17.90%) reported episodes of DS at M1 and 43 (18.78%) at M6. Group C experienced one case (2.27%) of DS at M1 and none (0%) at M6. Conclusions. Patients undergoing LRYGB, especially with larger gastrojejunal anastomosis, are more prone to developing DS following surgery than patients undergoing LSG or LRYGB with calibrated manual anastomosis.

Prevalence, severity, and predictors of symptoms of dumping and hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) results in pronounced weight loss in morbidly obese patients but may also cause adverse effects like early dumping and hypoglycemia. Prevalence data on these complications and their potential predictors are sparse.

OBJECTIVE

To assess the prevalence and possible predictors of early dumping and hypoglycemia in a population-based cohort of RYGB patients.

SETTING

University Hospital, Denmark.

DESIGN

A questionnaire survey was performed in the Central Denmark Region including RYGB-operated patients (years 2006-2011, n = 2238) and a nonoperated comparison cohort (n = 89). The Dumping Rating Scale and the Edinburgh Hypoglycemia Scoring System, together with demographic and clinical characteristics, were used, and possible predictors were examined by logistic regression.

RESULTS

The response rate was 64% (1429/2238). In total, 9.4% (134/1429) and 6.6% (95/1429) experienced moderate or severe symptoms of early dumping and hypoglycemia, respectively, which were significantly higher than in the comparison cohort. Because 3.4% (95% CI: 2.5-4.4) of the RYGB group experienced both early dumping and hypoglycemia, the total prevalence of 1 or both conditions was 12.6 (95% CI 10.9-14.4). Possible predictors for both conditions were body mass index (BMI)<25 kg/m² (odds ratio [OR] 1.70 (95% CI: 0.98-2.95) and OR 1.60 (95% CI: .83-3.06), respectively) compared with patients with BMI 25-30 kg/m². Younger age seemed to increase the risk of both conditions (<35 yr: OR 1.75 (95% CI: 1.11-2.75) and OR .59 (95% CI: .93-2.72), respectively) compared with patients>45 years.

CONCLUSION

Symptoms of early dumping and hypoglycemia were rather common with a prevalence of 1 or both conditions of 12.6% after RYGB. Predictors included younger age and a lower BMI.

Effects of Fat and Protein Preloads on Pouch Emptying, Intestinal Transit, Glycaemia, Gut Hormones, Glucose Absorption, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass

BACKGROUND

The aim was to determine the effects of fat and protein preloads on pouch emptying (PE), caecal arrival time (CAT), glucose absorption, blood glucose (BSL), gut hormones, haemodynamics and gastrointestinal (GI) symptoms in subjects who had undergone Roux-en-Y gastric bypass (RYGB) >12 months previously.

METHODS

Ten RYGB subjects were studied on three occasions, in randomised order, receiving 200-ml preloads of either water, fat (30 ml olive oil) or whey protein (55 g), 30 min before a mixed meal. PE, CAT, BSL, plasma 3-O-methyl-D-glucopyranose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1) and glucagon, blood pressure (BP), heart rate (HR) and GI symptoms were assessed over 270 min.

RESULTS

Although fat and protein preloads did not alter PE of either solids or liquids, the CAT of solids, but not liquids, was longer than that after the water preload (fat 68 ± 5 min and protein 71 ± 6 min vs. water 46 ± 5 min; P = 0.02). BSL elevated promptly after the meal on all days (P < 0.001), but after protein, the magnitude and integrated increases in the first 75 min were less than fat and water preloads (area under the curve (AUC(0-75 min)), 18.7 ± 18.2 vs. 107.2 ± 30.4 and 76.1 ± 19.3 mmol/L/min; P < 0.05). Compared to water preload, the protein and fat preloads were associated with greater increases in plasma insulin, GLP-1 and glucagon concentrations, a reduction in BP, and greater increases in HR, fullness, bloating and nausea. Plasma 3-OMG levels were lower after the protein than after the water and fat preloads (P < 0.001).

CONCLUSIONS

Given its effects to attenuate post-prandial glycaemia, reduce intestinal glucose absorption and potentiate the "incretin response", without inducing more adverse post-prandial GI symptom, protein preload may prove clinically useful in RYGB patients and warrant further evaluation, particularly in those with type 2 diabetes (T2DM) and/or dumping syndrome.

ß-cell pancreatic dysfunction plays a role in hyperglycemic peaks observed after gastric bypass surgery of obese patients

BACKGROUND

Early and intense hyperglycemic peaks are observed after Roux-en-Y gastric bypass (RYGB).

OBJECTIVES

The aim of this observational study was to compare the ß-cell pancreatic function of patients with (PEAK) and without hyperglycemic peaks (NOPEAK).

SETTING

Referral bariatric surgery center.

METHODS

Insulin secretion rate, clearance, and sensitivity and ß-cell and rate sensitivities were computed after a 75-g oral glucose tolerance test in 42 patients who underwent RYGB.

RESULTS

PEAK patients (n = 18; 30-min glycemia>10.4 mmol/L) did not differ from NOPEAK patients (n = 24) in their presurgery or weight loss characteristics. PEAK patients had significantly higher plasma concentrations of glucose and C-peptide than did NOPEAK patients, whereas insulin and glucagon-like peptide-1 concentrations did not differ. The insulin secretion rate and whole-body insulin clearance (208%) were significantly greater, but insulin sensitivity was significantly less (48%) in PEAK patients. Insulin secretion normalized to plasma glucose was significantly lower in PEAK patients, and the disposition index was reduced (35% to 41% of the values in NOPEAK patients).

CONCLUSION

We conclude that RYGB reveals a series of dysfunctions leading to hyperglycemia in a subset of patients. In PEAK patients, an insufficient adaptation of ß-cell function to glycemia, an increased insulin clearance, and a decreased insulin sensitivity cumulated to contribute to hyperglycemic peaks.

Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery

Objective. Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery. Methods. This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms. Results. Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001). Conclusion. These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.

Effects of Posture and Meal Volume on Gastric Emptying, Intestinal Transit, Oral Glucose Tolerance, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass

BACKGROUND

The purpose of this study is to determine the effects of posture and drink volume on gastric/pouch emptying (G/PE), intestinal transit, hormones, absorption, glycaemia, blood pressure and gastrointestinal (GI) symptoms after gastric bypass (Roux-en-Y gastric bypass (RYGB)).

METHODS

Ten RYGB subjects were studied on four occasions in randomized order (sitting vs. supine posture; 50 vs. 150 ml of labelled water mixed with 3 g 3-O-methyl-D-glucose (3-OMG) and 50 g glucose). G/PE, caecal arrival time (CAT), blood glucose, plasma insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), 3-OMG, blood pressure, heart rate and GI symptoms were assessed over 240 min. Controls were ten volunteers with no medical condition or previous abdominal surgery, who were studied with the 150-ml drink in the sitting position.

RESULTS

Compared to controls, PE (P < 0.001) and CAT (P < 0.001) were substantially more rapid in RYGB subjects. In RYGB, PE was more rapid in the sitting position (2.5 ± 0.7 vs. 16.6 ± 5.3 min, P = 0.02) and tends to be faster after 150 ml than the 50-ml drinks (9.5 ± 2.9 vs. 14.0 ± 3.5 min, P = 0.16). The sitting position and larger volume drinks were associated with greater releases of insulin, GLP-1 and PYY, as well as more hypotension (P < 0.01), tachycardia (P < 0.01) and postprandial symptoms (P < 0.001).

CONCLUSIONS

Pouch emptying, blood pressure and GI symptoms after RYGB are dependent on both posture and meal volume.

[Dumping syndrome: Diagnostics and therapeutic options]

BACKGROUND

Dumping syndrome is a common complication after surgery of the upper gastrointestinal tract with symptoms ranging from mild gastrointestinal discomfort and moderate vasomotor disturbances, to severe hyperinsulinemic hypoglycemia. Due to the increasing number of bariatric procedures being performed worldwide, bariatric surgery has become the most common cause for this disease entity.

OBJECTIVE

The aim of this review is to highlight the evidence for the physiological mechanisms contributing to dumping syndrome after the two most common bariatric surgery procedures, Roux-en-Y gastric bypass and sleeve gastrectomy, to discuss technical aspects of the procedures underlying the development of the syndrome, patient-related predictive factors and other differential diagnoses, together with diagnostic and therapeutic algorithms.

Appetite and body weight regulation after bariatric surgery

Bariatric surgery continues to be remarkably efficient in treating obesity and type 2 diabetes mellitus and a debate has started whether it should remain the last resort only or also be used for the prevention of metabolic diseases. Intense research efforts in humans and rodent models are underway to identify the critical mechanisms underlying the beneficial effects with a view towards non-surgical treatment options. This non-systematic review summarizes and interprets some of this literature, with an emphasis on changes in the controls of appetite. Contrary to earlier views, surgery-induced reduction of energy intake and subsequent weight loss appear to be the main drivers for rapid improvements of glycaemic control. The mechanisms responsible for suppression of appetite, particularly in the face of the large weight loss, are not well understood. Although a number of changes in food choice, taste functions, hedonic evaluation, motivation and self-control have been documented in both humans and rodents after surgery, their importance and relative contribution to diminished appetite has not yet been demonstrated. Furthermore, none of the major candidate mechanisms postulated in mediating surgery-induced changes from the gut and other organs to the brain, such as gut hormones and sensory neuronal pathways, have been confirmed yet. Future research efforts should focus on interventional rather than descriptive approaches in both humans and rodent models.

[Dumping syndrome following gastric surgery]

BACKGROUND

Dumping syndrome is the term used to describe a common set of symptoms following gastric surgery, and is characterised by postprandial discomfort which can entail nutritional problems. The condition was well known when surgery was the usual treatment for peptic ulcer disease. The increasing number of operations for morbid obesity means that the condition is once again of relevance, and health personnel will encounter these patients in different contexts. This article discusses the prevalence, symptomatology and treatment of dumping syndrome.

MATERIAL AND METHOD

This review article is based on a selection of articles identified in PubMed and assessed as having particular relevance for elucidating this issue, as well as on the authors' own clinical experience.

RESULTS

Early dumping syndrome generally occurs within 15 minutes of ingesting a meal and is attributable to the rapid transit of food into the small intestine. Nausea, abdominal pain, diarrhoea, a sensation of heat, dizziness, reduced blood pressure and palpitations are typical symptoms. Lethargy and sleepiness after meals are common. Late dumping syndrome occurs later and may be attributed to hypoglycaemia with tremors, cold sweats, difficulty in concentrating, and loss of consciousness. Dumping-related symptoms occur in between 20 and 50% of patients following gastric surgery. Early dumping syndrome is more frequent than late dumping syndrome. It is estimated that 10-20% of patients have pronounced symptoms and 1-5% have severe symptoms. The diagnosis is usually made on the basis of typical symptoms. Most patients experience alleviation of the symptoms over time and with changes in diet and eating habits. Further patient evaluation and drug or surgical intervention may be relevant for some individuals.

INTERPRETATION

Dumping-related symptoms are common after gastric surgery. The extent of obesity surgery in particular means that health personnel should be familiar with this condition.

Increased risk of OGTT-induced hypoglycemia after gastric bypass in severely obese patients with normal glucose tolerance

BACKGROUND

Hypoglycemic episodes are described after bariatric surgery.

OBJECTIVE

To report the prevalence of hypoglycemia after a 75 g oral glucose load (OGTT) after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB), and to identify predicting factors.

SETTING

Bariatric surgery referral center.

METHODS

Prospective cohort of 351 consecutive patients before and 12 months after bariatric surgery, on whom an OGTT was performed. The main outcome measure was postchallenge hypoglycemia (PCHy), defined as a 120 minute plasma glucose value<2.8 mmol/L (50.4 mg/dL).

RESULTS

Only patients with an RYGB presented with PCHy. It occurred in 23 patients or a prevalence of 10.4% after an RYGB. The OR was 25.5 (95% CI 3.4-191; P<.001) compared with before surgery. Patients with PCHy after surgery had a lower glycated hemoglobin (HbA1c), and a lower 2-hour postchallenge value before surgery. Before surgery, patients with normal glucose tolerance had an increased risk of PCHy after surgery (OR 8.6, 95% CI 2.0-37.6; P< .001).

CONCLUSIONS

The prevalence of OGTT-induced hypoglycemia is increased 25.5 times, 12 months after an RYGB. This is not observed after a gastric banding.

Pylorus preserving loop duodeno-enterostomy with sleeve gastrectomy - preliminary results

Background

Bariatric operations mostly combine a restrictive gastric component with a rerouting of the intestinal passage. The pylorus can thereby be alternatively preserved or excluded. With the aim of performing a “pylorus-preserving gastric bypass”, we present early results of a proximal postpyloric loop duodeno-jejunostomy associated with a sleeve gastrectomy (LSG) compared to results of a parallel, but distal LSG with a loop duodeno-ileostomy as a two-step procedure.

Methods

16 patients underwent either a two-step LSG with a distal loop duodeno-ileostomy (DIOS) as revisional bariatric surgery or a combined single step operation with a proximal duodeno-jejunostomy (DJOS). Total small intestinal length was determined to account for inter-individual differences.

Results

Mean operative time for the second-step of the DIOS operation was 121 min and 147 min for the combined DJOS operation. The overall intestinal length was 750.8 cm (range 600-900 cm) with a bypassed limb length of 235.7 cm in DJOS patients. The mean length of the common channel in DIOS patients measured 245.6 cm. Overall excess weight loss (%EWL) of the two-step DIOS procedure came to 38.31% and 49.60%, DJOS patients experienced an %EWL of 19.75% and 46.53% at 1 and 6 months, resp. No complication related to the duodeno-enterostomy occurred.

Conclusions

Loop duodeno-enterosomies with sleeve gastrectomy can be safely performed and may open new alternatives in bariatric surgery with the possibility for inter-individual adaptation.