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

Comparison of Sleeve Gastrectomy with Loop Duodenojejunal Bypass Versus One Anastomosis Gastric Bypass for Type 2 Diabetes: The Role of Pylorus Preservation

BACKGROUND

One anastomosis gastric bypass (OAGB) is recognized as a standard procedure in metabolic surgery. However, concerns about postoperative bile reflux and nutritional risks are prevalent. Comparatively, sleeve gastrectomy with loop duodenojejunal bypass (SG + LoopDJB) bypasses an equivalent length of the foregut as OAGB while maintaining pyloric function. The role of pylorus function remains to be further elucidated regarding these metabolic procedures' therapeutic outcomes and side effects.

METHOD

A retrospective study was conducted in our center to compare the surgical safety and 1-year outcomes of OAGB and SG + LoopDJB regarding type 2 diabetes mellitus (T2DM) remission, weight loss, gastrointestinal disorders, and nutritional status in T2DM patients matched by gender, age, and BMI.

RESULTS

The baseline characteristics were comparable between groups. Compared with OAGB, SG + LoopDJB had longer operative time and length of stay (LOS) but similar major postoperative complications. At 1-year follow-up, OAGB has similar diabetes remission (both 91.9%), weight loss effect (28.1 ± 7.1% vs. 30.2 ± 7.0% for %TWL), and lipidemia improvement to SG + LoopDJB (P > 0.05). However, OAGB presented a higher incidence of hypoalbuminemia (11.9% vs. 2.4%, P = 0.026) but a low incidence of gastroesophageal reflux disease (GERD) symptoms (9.5% vs. 26.2%, P = 0.046) than SG + LoopDJB. There was no statistical difference regarding other gastrointestinal disorders and nutritional deficiencies between groups.

CONCLUSION

Both OAGB and SG + LoopDJB show comparable, favorable outcomes in weight loss, T2DM remission, and lipidemia improvement at the 1-year follow-up. Pylorus preservation, while increasing surgical difficulty and the risk of de novo GERD, may reduce the risk of postoperative hypoalbuminemia.

Inhibition of somatostatin enhances the long-term metabolic outcomes of sleeve gastrectomy in mice

OBJECTIVE

Bariatric surgery is an effective treatment to obesity, leading to weight loss and improvement in glycemia, that is characterized by hypersecretion of gastrointestinal hormones. However, weight regain and relapse of hyperglycemia are not uncommon. We set to identify mechanisms that can enhance gastrointestinal hormonal secretion following surgery to sustain weight loss.

METHODS

We investigated the effect of somatostatin (Sst) inhibition on the outcomes of bariatric surgery using a mouse model of sleeve gastrectomy (SG).

RESULTS

Sst knockout (sst-ko) mice fed with a calorie-rich diet gained weight normally and had a mild favorable metabolic phenotype compared to heterozygous sibling controls, including elevated plasma levels of GLP-1. Mathematical modeling of the feedback inhibition between Sst and GLP-1 showed that Sst exerts its maximal effect on GLP-1 under conditions of high hormonal stimulation, such as following SG. Obese sst-ko mice that underwent SG had higher levels of GLP-1 compared with heterozygous SG-operated controls. The SG-sst-ko mice regained less weight than controls and maintained lower glycemia months after surgery. Obese wild-type mice that underwent SG and were treated daily with a Sst receptor inhibitor for two months had higher GLP-1 levels, regained less weight, and improved metabolic profile compared to saline-treated SG-operated controls, and compared to inhibitor or saline-treated sham-operated obese mice.

CONCLUSIONS

Our results suggest that inhibition of Sst signaling enhances the long-term favorable metabolic outcomes of bariatric surgery.

How does sleeve gastrectomy impact long-term eating-related symptoms, distress, and behavior? A cross-sectional study using the BODY-Q patient-reported outcome measures

BACKGROUND

Patients undergoing sleeve gastrectomy (SG) experience transformative changes in eating-related experiences that include eating-related symptoms, emotions, and habits. Long-term assessment of these endpoints with rigorous patient-reported outcome measures (PROMs) is limited. We assessed patients undergoing SG with the Body-Q Eating Module PROMs.

METHODS

All patients evaluated at the Emory Bariatric Center were given the Body-Q Eating Modules questionnaire at preoperative/postoperative clinic visits. Rasch scores and prevalence of relevant endpoints were assessed across six time-points of interest: preoperatively, post-operative months 0-6, 7-12, 12-24, 24-36, and over 36. Student's t-test and Chi-square test were used for analysis.

RESULTS

Overall, 1,352 questionnaires were completed pre-operatively and 493 postoperatively. Survey compliance was 81%. Compared to the pre-operative group, the post-operative group had lower BMI (39.7 vs. 46.4, p < 0.001) and higher age (46.3 vs. 44.9, p = 0.019). Beginning one year after SG, patients experience more frequent eating-related pain, nausea and constipation compared to pre-operative baseline (p < 0.05). They also more frequently experience eating-related regurgitation and dumping syndrome-related symptoms beginning post-operative year two (p < 0.05). In the first year after SG, patients more rarely feel eating-related embarrassment, guilt, and disappointment compared to pre-operative baseline (p < 0.05). These improvements disappear one year after SG, after which patients more frequently experience feeling out of control, unhappy, like a failure, disappointed, and guilty (p < 0.05). In the first year after SG, patients experience an increased frequency in positive eating behaviors (ate healthy foods, showed self-control, stopped before full; (p < 0.05). Only two eating-related behavior improvements persist long-term: feeling in control and eating the right amount (p < 0.05).

CONCLUSIONS

Patients undergoing SG may experience more frequent eating-related symptoms, distress, and behavior in the long-term. These findings can enhance the pre-operative informed consent and guide development of a more tailored approach to postoperative clinical management such as more frequent visits with the dietician.

Ramadan fasting following laparoscopic sleeve gastrectomy: a prospective online survey cohort study in Egypt

Purpose

This study aims to explore the feasibility and implications of Ramadan fasting for patients who have undergone laparoscopic sleeve gastrectomy (LSG), assessing impacts on hydration, nutrient intake, weight management, and gastrointestinal symptoms.

Methods

A prospective online survey was conducted among 218 LSG patients and 83 control individuals with obesity who had not undergone surgery. Participants were surveyed before and after Ramadan, providing data on fasting practices, hunger and satiety levels, fluid and nutrient intake, and the occurrence of gastrointestinal symptoms. Statistical analysis was used to compare outcomes between fasting and non-fasting periods and between LSG patients and control participants.

Results

A total of 70.2% of LSG patients completed the entire month of Ramadan fasting, with a significant correlation found between the duration post-surgery and the ability to fast. Fasting LSG patients reported decreased hunger, increased satiety, and significant reductions in fluid and nutrient intake during Ramadan. Weight loss was reported in 90.8% of fasting patients, with an average total weight loss of 7.2%. Gastrointestinal symptoms were mild and manageable.

Conclusion

The majority of LSG patients can successfully fast during Ramadan with appropriate precautions, including adequate fluid and protein intake. The study highlights the need for patient education and tailored nutritional guidance to ensure safe and effective fasting post-LSG. In order to fast for the entire month, patients may be advised to consider postponing surgery for a few months after Ramadan, avoid overeating during non-fasting hours, and ensure sufficient fluid consumption and protein intake during fasting.

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.

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.

Quality of life after laparoscopic sleeve gastrectomy: Pre-operative, 1-year and 5-year results

Introduction

The negative impact of obesity on the quality of life (QoL) and its association with multiple comorbidities is unquestionable. The primary objective of this study was to compare the QoL of patients before, 1 year and 5 years after laparoscopic sleeve gastrectomy (LSG). Secondary objectives were to evaluate the resolution of obesity-related comorbidities and weight loss success.

Materials and Methods

We included patients who underwent LSG for body mass index (BMI) ≥30 kg/m2 between August 2016 and April 2017 and completed the Moorehead-Ardelt QoL Questionnaire II (MA II). Statistical analysis was conducted using SPSS IBM Statistics for Windows version 21.

Results

In total, 64 patients participated with a female majority (73.44%) and a mean age of 36.09 with an average BMI at 40.47. Percentage of excess BMI loss and excess weight loss (% EWL) at one and 5 years after surgery went from 90.18% to 85.05% and 72.17% to 67.09%, respectively. The total MA II score before LSG was - 0.39 ± 0.94. Postoperatively, it increased to 1.73 ± 0.60 at 1 year and 1.95 ± 0.67 at 5 years. The positive impact of LSG on QoL was more significant in patients presenting ≥30% of weight loss and in females. At 5 years, a significant improvement in many comorbidities was noted except for arterial hypertension, coxalgia, gastro-oesophageal reflux disease and lower extremities' varices.

Conclusion

LSG maintains a long-term QoL improvement, a significant EWL and a resolution of the most common obesity-associated comorbidities such as diabetes, dyslipidaemia and symptoms related to sleep apnoea.

Patient-reported outcomes, weight loss, and remission of type 2 diabetes 3 years after gastric bypass and sleeve gastrectomy (Oseberg); a single-centre, randomised controlled trial

BACKGROUND

Little is known about the comparative effects of various bariatric procedures on patient-reported outcomes. We aimed to compare 3-year effects of gastric bypass and sleeve gastrectomy on patient-reported outcome measures in patients with obesity and type 2 diabetes.

METHODS

The Oseberg trial was a single-centre, parallel-group, randomised trial at Vestfold Hospital Trust, a public tertiary obesity centre in Tønsberg, Norway. Eligible patients were aged 18 years or older with previously verified BMI 35·0 kg/m² or greater. Diabetes was diagnosed if glycated haemoglobin was at least 6·5% (48 mmol/mol) or by their use of anti-diabetic medications with glycated haemoglobin at least 6·1% (43 mmol/mol). Eligible patients were randomly assigned (1:1) to gastric bypass or sleeve gastrectomy. All patients received identical preoperative and postoperative treatment. Randomisation was done with a computerised random number generator and a block size of ten. Study personnel, patients, and the primary outcome assessor were blinded to allocations for 1 year. The prespecified secondary outcomes reported here were 3-year changes in several clinically important patient-reported outcomes, weight loss, and diabetes remission. Analyses were done in the intention to treat population. This trial is ongoing, closed to recruitment and is registered with ClinicalTrials.gov, NCT01778738.

FINDINGS

Between Oct 15, 2012 and Sept 1, 2017, 319 consecutive patients with type 2 diabetes scheduled for bariatric surgery were assessed for eligibility. 101 patients were not eligible (29 did not have type 2 diabetes according to inclusion criteria and 72 other exclusion criteria) and 93 declined to participate. 109 patients were enrolled and randomly assigned to sleeve gastrectomy (n=55) or gastric bypass (n=54). 72 (66%) of 109 patients were female and 37 (34%) were male. 104 (95%) of patients were White. 16 patients were lost to follow up and 93 (85%) patients completed the 3-year follow-up. Three additional patients were contacted by phone for registration of comorbidities Compared with sleeve gastrectomy, gastric bypass was associated with a greater improvement in weight-related quality of life (between group difference 9·4, 95% CI 3·3 to 15·5), less reflux symptoms (0·54, 0·17 to -0·90), greater total bodyweight loss (8% difference, 25% vs 17%), and a higher probability of diabetes remission (67% vs 33%, risk ratio 2·00; 95% CI 1·27 to 3·14). Five patients reported postprandial hypoglycaemia in the third year after gastric bypass versus none after sleeve-gastrectomy (p=0·059). Symptoms of abdominal pain, indigestion, diarrhoea, dumping syndrome, depression, binge eating, and appetitive drive did not differ between groups.

INTERPRETATION

At 3 years, gastric bypass was superior to sleeve gastrectomy in patients with type 2 diabetes and obesity regarding weight related quality of life, reflux symptoms, weight loss, and remission of diabetes, while symptoms of abdominal pain, indigestion, diarrhoea, dumping, depression and binge eating did not differ between groups. This new patient-reported knowledge can be used in the shared decision-making process to inform patients about similarities and differences between expected outcomes after the two surgical procedures.

FUNDING

Morbid Obesity Centre, Vestfold Hospital Trust.

TRANSLATION

For the Norwegian translation of the abstract see Supplementary Materials section.

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.

Practical guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean gastrointestinal patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The present practical guideline is intended for clinicians and practitioners in general medicine, gastroenterology, surgery and other obesity management, including dietitians and focuses on obesity care in patients with chronic gastrointestinal diseases.

METHODS

The present practical guideline is the shortened version of a previously published scientific guideline developed according to the standard operating procedure for ESPEN guidelines. The content has been re-structured and transformed into flow-charts that allow a quick navigation through the text.

RESULTS

In 100 recommendations (3× A, 33× B, 24 × 0, 40× GPP, all with a consensus grade of 90% or more) care of gastrointestinal patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially metabolic associated liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present practical guideline offers in a condensed way evidence-based advice how to care for patients with chronic gastrointestinal diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Clinical Outcomes of Resectional Roux-en-Y Gastric Bypass, Compared to Sleeve Gastrectomy for Severe Obesity

PURPOSE

Resectional Roux-en-Y gastric bypass (RRYGB) is considered an alternative bariatric surgery in countries with a high incidence of stomach cancer because there is no excluded stomach after RRYGB. This study aimed to evaluate the efficacy and safety of RRYGB.

MATERIALS AND METHODS

This study included patients who underwent RRYGB and sleeve gastrectomy (SG) between 2011 and 2021. Surgical complications and metabolic and nutritional profiles were compared between the patients preoperatively and at 1, 6, and 12 months after surgery.

RESULTS

Twenty and seventy-six patients underwent RRYGB and SG, respectively; 7 in the SG group were lost to follow-up within 1 year. Surgical complications and baseline characteristics were comparable between two groups, except for diabetes (90.0% vs. 44.7%, p < 0.001). The decrease of HbA1c levels and incidence of reflux esophagitis were lower in the RRYGB group compared to that of SG at 1-year postoperative (-3.0% vs. -1.8%, p = 0.014; 0% vs. 26.7%, p = 0.027). The percentage of total weight loss at 1- year postoperative and incidence of dumping syndrome were comparable between the two groups. The RRYGB group had significantly lower total cholesterol level (161.9 mg/dl vs. 196.4 mg/dl, p < 0.001), but higher incidence of vitamin B12 deficiency (30.0% vs. 3.6%, p = 0.003) at 1 year postoperative compared to those of the SG group.

CONCLUSIONS

The RRYGB group had better postoperative outcomes for diabetes and dyslipidemia without increasing surgical complications compared to that of the SG group. Thus, RRYGB can be considered a safe and effective alternative in areas where gastric cancer is prevalent.

Experiences and information needs of women who become pregnant after bariatric surgery: An interpretive descriptive qualitative study

BACKGROUND

Obesity is known to negatively impact fertility and increase pregnancy related complications. Many women of childbearing age opt for bariatric surgery to lose weight in the preconception period. Physiological changes of bariatric surgery are associated with both benefits and risks for maternal and neonatal outcomes. How women understand these risks and experience pregnancy following bariatric surgery are largely unknown.

OBJECTIVE

To explore the information needs and experiences of Australian women who become pregnant following bariatric surgery.

DESIGN

An interpretive descriptive qualitative study of 11 Australian women with experiences of pregnancy following bariatric surgery participated in a private Facebook discussion group conducted in 2021. Women were recruited via targeted advertisements on social media.

RESULTS

Women identified several information gaps regarding the implications of having bariatric surgery for preconception, pregnancy, and postnatal periods. Family planning, pregnancy nutrition, and breastfeeding advice were key areas of information need. Women's experiences of pregnancy following bariatric surgery included attitudes of judgement and lack of knowledge from their healthcare providers.

CONCLUSIONS

Healthcare professionals caring for women who have had bariatric procedures need to ensure that all women are fully informed about the risks of becoming pregnant within the first 12-months post-surgery. They should also anticipate that despite recommendations, women will become pregnant earlier than advised, and can benefit from non-judgemental and supportive care to ensure risks of poor outcomes are minimised. The findings highlight that the provision of tailored resources and education for women and their healthcare teams are needed.

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.

The Effect of Surgical Weight Loss on Cognition in Individuals with Class II/III Obesity

BACKGROUND

Obesity is a global epidemic and is associated with cognitive impairment and dementia. It remains unknown whether weight loss interventions, such as bariatric surgery, can mitigate cognitive impairment.

OBJECTIVES

We aimed to determine the effect of surgical weight loss on cognition in individuals with class II/III obesity.

DESIGN

We performed a prospective cohort study of participants who underwent bariatric surgery. At baseline and two years following surgery, participants completed metabolic risk factor and neuropsychological assessments.

SETTING

Participants were enrolled from an academic suburban bariatric surgery clinic.

PARTICIPANTS

There were 113 participants who completed baseline assessments and 87 completed two-year follow-up assessments (66 in-person and 21 virtual) after bariatric surgery. The mean (SD) age was 46.8 (12.5) years and 64 (73.6%) were female.

INTERVENTION

Bariatric surgery. There were 77 (88.5%) participants that underwent sleeve gastrectomy and 10 (11.5%) that underwent gastric bypass surgery.

MEASUREMENTS

Cognition was assessed using the NIH toolbox cognitive battery (NIHTB-CB) and the Rey Auditory Verbal Learning Test (AVLT). The primary outcome was the change in NIHTB-CB fluid composite score before and after surgery.

RESULTS

The primary outcome, NIHTB-CB composite score, was stable following bariatric surgery (-0.4 (13.9), p=0.81,n=66). Among secondary outcomes, the NIHTB-CB dimensional card sorting test (executive function assessment), improved (+6.5 (19.9),p=0.01,n=66) while the Rey AVLT delayed recall test (memory assessment) declined (-0.24 (0.83),p=0.01,n=87) following surgery. Improvements to metabolic risk factors and diabetes complications were not associated with improvements to NIHTB-CB composite score. The other 4 NIHTB-CB subtests and Rey AVLT assessments of auditory learning and recognition were stable at follow-up.

CONCLUSIONS

Following bariatric surgery, the age-adjusted composite cognitive outcome did not change, but an executive subtest score improved. These results suggest that bariatric surgery may mitigate the natural history of cognitive decline in individuals with obesity, which is expected to be faster than normal aging, but confirmatory randomized controlled trials are needed. The decline in delayed recall also warrants further studies to determine potential differential effects on cognitive subtests.

Impact of gastric and bowel surgery on gastrointestinal drug delivery

General surgical procedures on the gastrointestinal tract are commonly performed worldwide. Surgical resections of the stomach, small intestine, or large intestine can have a significant impact on the anatomy and physiological environment of the gastrointestinal tract. These physiological changes can affect the effectiveness of orally administered formulations and drug absorption and, therefore, should be considered in rational drug formulation design for specific pathological conditions that are commonly associated with surgical intervention. For optimal drug delivery, it is important to understand how different surgical procedures affect the short-term and long-term functionality of the gastrointestinal tract. The significance of the surgical intervention is dependent on factors such as the specific region of resection, the degree of the resection, the adaptive and absorptive capacity of the remaining tissue, and the nature of the underlying disease. This review will focus on the common pathological conditions affecting the gastric and bowel regions that may require surgical intervention and the physiological impact of the surgery on gastrointestinal drug delivery. The pharmaceutical considerations for conventional and novel oral drug delivery approaches that may be impacted by general surgical procedures of the gastrointestinal tract will also be addressed.

Prevalence of Dumping Syndrome and Its Determinants Among Post-Bariatric Surgery Adult Patients at King Fahad General Hospital, Jeddah, 2019-2020

Background Bariatric surgery is one of the most effective interventions for morbid obesity. Despite its benefits, unwanted consequences such as dumping syndrome (DS) have been reported following the procedure. This study aims to estimate the prevalence of DS and identify the factors associated with it in Saudi Arabia. Methodology This cross-sectional study collected data from patients who underwent bariatric surgery at King Fahad General Hospital, Jeddah, Saudi Arabia, in 2019-2020. A validated questionnaire was used to collect the data. The questionnaire included demographic items such as age and sex and items relating to DS such as nausea, vomiting, and palpitations. A modified version of the Sigstad diagnostic scoring system was used to confirm the diagnosis. Results Of the 240 investigated cases, two-thirds (67.5%) were females. The most reported symptoms were nausea (37.9%), vomiting (36.7%), desire to lie down (25.5%), restlessness (25.5%), and abdominal fullness (23.7%). Based on the modified Sigstad diagnostic scoring system, 75 (31.4%) patients met the criteria for DS. The bivariate analysis showed the prevalence was significantly higher in females (36.4%), those with university qualifications (40.3%), and those with high monthly income (62.5%) (p<0.05). Also, dietary behaviors in terms of frequency, size of meals, and drinking liquids with meals were significantly associated with the prevalence of DS, where the lowest prevalence was recorded among those who ate more than one small meal (10.9%), while the highest prevalence was found in those who ate more than one large meal (81.8%); also, the prevalence was significantly higher in patients who drank liquids with meals (40.8%) than those who drank liquids between meals (26.8%) (p<0.05). Conclusion In this single institutional study, we report a 31.4% prevalence of DS among our cohort. The predictors of the syndrome include gender, education level, monthly income, eating more than one large meal per day, and drinking liquids with meals. In the future, these predictors will be explained to patients before and after bariatric surgery to reduce the prevalence of such inconvenient syndromes.

European guideline on obesity care in patients with gastrointestinal and liver diseases - Joint ESPEN/UEG guideline

BACKGROUND

Patients with chronic gastrointestinal (GI) disease such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, gastroesophageal reflux disease (GERD), pancreatitis, and chronic liver disease (CLD) often suffer from obesity because of coincidence (IBD, IBS, celiac disease) or related pathophysiology (GERD, pancreatitis and CLD). It is unclear if such patients need a particular diagnostic and treatment that differs from the needs of lean GI patients. The present guideline addresses this question according to current knowledge and evidence.

OBJECTIVE

The objective of the guideline is to give advice to all professionals working in the field of gastroenterology care including physicians, surgeons, dietitians and others how to handle patients with GI disease and obesity.

METHODS

The present guideline was developed according to the standard operating procedure for ESPEN guidelines, following the Scottish Intercollegiate Guidelines Network (SIGN) grading system (A, B, 0, and good practice point (GPP)). The procedure included an online voting (Delphi) and a final consensus conference.

RESULTS

In 100 recommendations (3x A, 33x B, 24x 0, 40x GPP, all with a consensus grade of 90% or more) care of GI patients with obesity - including sarcopenic obesity - is addressed in a multidisciplinary way. A particular emphasis is on CLD, especially fatty liver disease, since such diseases are closely related to obesity, whereas liver cirrhosis is rather associated with sarcopenic obesity. A special chapter is dedicated to obesity care in patients undergoing bariatric surgery. The guideline focuses on adults, not on children, for whom data are scarce. Whether some of the recommendations apply to children must be left to the judgment of the experienced pediatrician.

CONCLUSION

The present guideline offers for the first time evidence-based advice how to care for patients with chronic GI diseases and concomitant obesity, an increasingly frequent constellation in clinical practice.

Effect of Obesity Surgery on Taste

Obesity surgery is a highly efficacious treatment for obesity and its comorbidities. The underlying mechanisms of weight loss after obesity surgery are not yet fully understood. Changes to taste function could be a contributing factor. However, the pattern of change in different taste domains and among obesity surgery operations is not consistent in the literature. A systematic search was performed to identify all articles investigating gustation in human studies following bariatric procedures. A total of 3323 articles were identified after database searches, searching references and deduplication, and 17 articles were included. These articles provided evidence of changes in the sensory and reward domains of taste following obesity procedures. No study investigated the effect of obesity surgery on the physiological domain of taste. Taste detection sensitivity for sweetness increases shortly after Roux-en-Y gastric bypass. Additionally, patients have a reduced appetitive reward value to sweet stimuli. For the subgroup of patients who experience changes in their food preferences after Roux-en-Y gastric bypass or vertical sleeve gastrectomy, changes in taste function may be underlying mechanisms for changing food preferences which may lead to weight loss and its maintenance. However, data are heterogeneous; the potential effect dilutes over time and varies significantly between different procedures.

Smartphone application-based follow-up care of patients after bariatric surgery: A mixed-method study of usability

OBJECTIVE

Due to potential short-term and long-term complications, adequate lifelong follow-up is crucial for patients after bariatric surgery. However, compliance with postoperative follow-up is poor despite clear national and international guidelines. This feasibility trial aimed to evaluate the usability of a smartphone application-based follow-up program in patients after bariatric surgery.

METHODS

Patients were included after having undergone a primary bariatric surgery. Instead of attending meetings in our outpatient clinic, they were followed up using a smartphone application. After 6 months, the System Usability Scale (SUS) was used to measure participant perception. Additional interviews were performed to gain more insight into the usability of the app.

RESULTS

Between August 2020 and February 2021, 52 patients met the inclusion criteria and agreed to participate in the study, of whom 5 (9.6%) dropped out of the study. At the time of analysis, 31 patients have been followed up for 6 months, among whom 26 patients completed the SUS questionnaire. The mean overall score of SUS is 82.1 ± 19.8. In the qualitative analysis, participants were generally positive about the follow-up care and found it easy to use, despite some minor technical problems.

CONCLUSION

Our smartphone app-based follow-up program was proven to be effective in the aftercare succeeding bariatric surgery. Our data indicates that the satisfaction, efficiency, learnability, and ease of use of the smartphone application were coherent in the acceptance and use of mobile technology by patients.

A surprising finding during solid-phase gastric emptying scintigraphy

In case of repeated episodes of abdominal discomfort and vagal symptoms, especially occurring after ingestion of a rich meal, the diagnosis of intermittent volvulus could be considered. The sudden arrival of large amounts of partially digested food in the intestine after spontaneous resolution might be associated with a dumping syndrome.

Management of Postoperative Complications Following Bariatric and Metabolic Procedures

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.

Systemic Disease Associations with Disorders of Gut-Brain Interaction and Gastrointestinal Transit: A Review

Functional gastrointestinal disorders (FGID) are now classified within the Rome IV framework as disorders of gut-brain interaction (DGBI). Disorders of gastrointestinal transit (as defined by abnormalities on contemporary gastrointestinal motility testing) frequently are associated with symptoms that are also characteristic of DGBIs. In this narrative review, we outline a non-inclusive set of systemic diseases or risk factors that have been classically associated with DGBIs and disorders of gastrointestinal transit; these include diabetes mellitus, paraneoplastic syndromes, surgery, Parkinson's disease, systemic sclerosis, endocrinopathies, polypharmacy, and post-infectious syndromes.

Incidence of Dumping Syndrome after Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and One-Anastomosis Gastric Bypass

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.

Laparoscopic Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Type 2 Diabetes Mellitus in Nonseverely Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Recently, randomized controlled trials (RCTs) have indicated that bariatric surgery in nonseverely obese patients with a body mass index (BMI) less than 35 kg/m² might be even superior to medical therapy with regard to type 2 diabetes mellitus (T2DM) remission, but the efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) compared with laparoscopic sleeve gastrectomy (LSG) in nonseverely obese patients has not been conclusively determined. The objective of this study is to compare LRYGB versus LSG for T2DM in nonseverely obese patients.

METHODS

A meta-analysis identifying RCTs evaluating LRYGB versus LSG for T2DM in nonseverely obese patients was conducted. The primary outcome was T2DM remission. Additional analyses comprised percent excess weight loss (%EWL), BMI, waist circumference, hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), serum lipid level, medication use, quality of life, and adverse events.

RESULTS

Four RCTs concerning total 296 patients were included. T2DM remission rate and %EWL were of no difference between the two bariatric procedures. LRYGB was associated with lower BMI, waist circumference, low-density lipoprotein, and higher high-density lipoprotein than LSG. However, HbA1c, FPG, total cholesterol, and triglyceride were not significantly different between the two surgical groups. The medication use and quality of life were improved in both two groups. The gastroesophageal reflux diseases of LRYGB group were less than that of LSG group. Dumping syndromes were noted more frequently in the LRYGB group.

CONCLUSIONS

Both LRYGB and LSG have comparative effect on resolving T2DM in nonseverely obese patients at midterm follow-up. Further RCTs should address the potential risks and long-term effects of LRYGB and LSG in nonseverely obese patients.

Approach to the Patient: Management of the Post-Bariatric Surgery Patient With Weight Regain

CONTEXT

Weight regain (WR) after bariatric surgery is emerging as a common clinical problem due to the increase in the number of procedures performed. Early interventions are necessary to curtail the potential recurrence of comorbid conditions. However, it is often difficult to recognize WR early enough to introduce mitigating measures because there are no current guidelines for timely diagnosis and assessment of the severity of this condition.

OBJECTIVE

We present a practical approach for the early recognition of WR, based on 11-year follow-up data from our multiethnic bariatric surgery patient population.

METHODS

We classify WR according to the rate of increase in weight relative to nadir weight, normalized per 30-day interval. We also review pertinent literature about the etiologic factors contributing to WR after bariatric surgery.

RESULTS

According to our algorithm, mild, moderate, and rapid WR are defined as weight increases of 0.2% to <0.5%, 0.5% to 1.0%, and more than 1.0% of nadir weight per 30 days, respectively. Treatment options, including dietary counseling, use of antiobesity medication, and consideration of surgical revision, are described. A case is presented to illustrate the utility of timely identification of WR and the importance of collaboration between bariatric surgeons, obesity medicine specialists, and dietitians.

CONCLUSION

Our approach emphasizes the importance of regular long-term follow-up for all bariatric surgery patients.

BODY-Q patient-reported outcomes measure (PROM) to assess sleeve gastrectomy vs. Roux-en-Y gastric bypass: eating behavior, eating-related distress, and eating-related symptoms

BACKGROUND

Post-operative changes in eating behavior, eating-related distress and eating-related symptoms play an important role in the lives of bariatric surgery patients. However, there are no studies that assess these outcomes using a specifically designed patient-reported outcome measure (PROM) for patients undergoing bariatric surgery. We use our newly developed and validated scales as part of the well-established BODY-Q PROMs to compare laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass patients (LRYGB).

METHODS

We analyzed data from an international multi-center prospective cohort study of patients over 18 who underwent bariatric surgery. We used multivariable linear regression models to assess the difference between LRYGB and LSG for the new BODY-Q scales, which include eating behavior, eating-related distress and eating-related symptoms. All analyses were corrected for significant confounding variables.

RESULTS

Out of 1420 patients, 920 underwent LRYGB and 500 underwent LSG. The LRYGB group had a higher percentage total weight loss (p < 0.001). There was no significant difference in eating behavior (e.g., stop eating before feeling full, avoiding unhealthy snacks, etc.) or eating-related distress (e.g., feeling ashamed or out of control after eating). Patients who underwent LSG scored significantly better on the post-prandial eating-related symptoms scale (e.g., vomiting, reflux; p < 0.001). Symptoms more prevalent in the LRYGB patients were related to dumping syndrome whereas symptoms more prevalent in LSG patients were related to reflux.

CONCLUSION

Patients who underwent LRYGB had a significantly better weight loss after surgery, but they scored worse on post-prandial symptoms in comparison to LSG patients. This information may be relevant for patients in the pre-operative counseling setting, as it may influence their decision for surgical procedure selection.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

The Prognostic Value of the Dutch Sweet Eating Questionnaire on Weight Loss After Metabolic Surgery: a Randomized Controlled Trial

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have shown different weight loss results. These differences might be partly due to dumping after LRYGB, forcing sweet eaters to switch to a healthy diet. The Dutch Sweet Eating Questionnaire (DSEQ) is validated to measure sweet eating. This study aims to investigate if sweet eating measured with the DSEQ influences weight loss.

METHODS

In this multicenter randomized controlled trial, patients were included between 2013 and 2017 in two Dutch high-volume hospitals, and randomized with a 1:1 ratio between LRYGB and LSG. Primary outcome measure was weight loss. Secondary outcome measure was sweet eating behavior, measured with the DSEQ. Data was collected at baseline, 1 year and 2 years postoperatively.

RESULTS

Data was analyzed of 623 patients who underwent LRYGB (n = 308; 49.4%) or LSG (n = 315; 50.6%). Follow-up rates at 2 years postoperative were 67.1% for weight and 35.3% for DSEQ. At 2 years postoperative, mean BMI was significantly higher after LSG than LRYGB (respectively 30.88 versus 28.87 kg/m², p < 0.001), and the percentage of sweet eaters was significantly higher after LSG than LRYGB (respectively 8.6% versus 2.6%, p = 0.049). None of the preoperative sweet eaters were sweet eaters 2 years after LRYGB (0.0%), versus 11.8% 2 years after LSG. No correlation was found between postoperative sweet eating behavior and %EBMIL.

CONCLUSION

No significant correlation was found between preoperative or postoperative sweet eating measured with the DSEQ and weight loss. The decision-making for the procedure type is more complex than weight loss and dietary habits, and should also involve quality of life and presence of comorbidities. These factors should be addressed in future research along with longer term results.

TRIAL REGISTRATION

Dutch Trial Register NTR-4741.

Micronutrient management following bariatric surgery: the role of the dietitian in the postoperative period

Bariatric surgery is increasingly being utilized to manage obesity and obesity related comorbidities, but may lead to the development of micronutrient deficiencies postoperatively. The anatomical, physiological, nutritional and behavioral reasons for micronutrient vulnerabilities are reviewed, along with recommendations for routine monitoring and replacement following surgery. The role the dietitian and their contribution in the postoperative identification, prevention and management of micronutrient vulnerabilities in bariatric patients is described. Specific considerations such as the nutritional and dietetic management of pregnant and lactating women post-bariatric surgery is also discussed.

Endoscopic Gastrojejunal Revision (Transoral Outlet Reduction) for Persistent Hypoglycemia After Gastric Bypass

BACKGROUND

The patient presented with symptomatic postprandial biweekly hypoglycemic seizures. Her hypoglycemic episodes were aggravated by stress and also occurred during sleep. She managed these hypoglycemic episodes with an endocrinologist, trying both nutritional and medical management without successful control of her symptoms. An endoscopic gastrojejunal revision (EGJR) was recommended to provide more restriction and prolong transit time into the Roux limb to decrease the chance of postoperative dumping syndrome and subsequent hypoglycemia.

METHODS

This video is a case study of an EGJR done for persistent postoperative hypoglycemia. The gastroscope was introduced and using Argon Plasma Coagulation at a flow of 8 liters/min and 30 watts; the mucosa around the gastrojejunal stoma was ablated circumferentially. This was done to decrease bleeding from needle placement and to promote adherence of the mucosa after the sutures were placed. The purse-string technique was favored for this procedure due to an inherent reduction in suture tension. Several full-thickness bites were taken to narrow the stoma from 20 to 4 mm in diameter.

RESULTS

The patient was discharged home the same day following the procedure. She was placed on a two week liquid bariatric postoperative diet. At two week follow-up, the patient reported normal  blood sugars and no hypoglycemic episodes since surgery. At six month follow-up, the patient reported significant improvement in her hypoglycemia symptoms, and no further syncopal episodes or seizures.

CONCLUSION

We believe this case demonstrates that endoscopic gastrojejunal revision (or EGJR) is an effective treatment option for postprandial hypoglycemia following Roux-en-Y gastric bypass.