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Parzer V, Resl M, Stechemesser L, Wakolbinger M, Itariu B, Brix JM. [Postoperative management]. Wien Klin Wochenschr 2023; 135:729-742. [PMID: 37821696 PMCID: PMC10567962 DOI: 10.1007/s00508-023-02272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/13/2023]
Abstract
Bariatric surgery results in significant weight loss, reduction or even remission of obesity-associated comorbidities, reduced mortality, and improved quality of life in many patients; however, obesity is a chronic disease, thus follow-up care is required after bariatric surgery. Furthermore, specific issues, such as micronutrient deficiencies and subsequent complications, can arise both in the short-term and the long-term. Abdominal pain after bariatric surgery must always be regarded as a serious symptom. A further focus should be on the diagnosis and treatment of dumping syndrome. Patients with type 2 diabetes should be regularly screened for recurrent hyperglycemia as well as specific sequelae, even though blood glucose levels may be substantially improved or normalized. In addition to centers with multidisciplinary teams, primary care and, in particular, general practitioners will play an increasingly more important role in the follow-up care after bariatric surgery.
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Affiliation(s)
- Verena Parzer
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
| | - Michael Resl
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin mit Diabetologie, Gastroenterologie und Hepatologie, Rheumatologie und Intensivmedizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I mit Gastroenterologie, Hepatologie, Nephrologie, Stoffwechsel und Diabetologie, Uniklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Maria Wakolbinger
- Abteilung für Sozial- und Präventivmedizin, Zentrum für Public Health, Medizinische Universität Wien, Wien, Österreich
| | - Bianca Itariu
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich.
| | - Johanna Maria Brix
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
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2
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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3
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Vilarrasa N, Bretón I, Ballesteros-Pomar M, Lecube A, Goday A, Pellitero S, Sánchez R, Zugasti A, Ciudin A, de Hollanda A, Rubio MA. Recommendations for the diagnosis and treatment of hypoglycaemia after bariatric surgery. ENDOCRINOL DIAB NUTR 2022; 69:723-731. [PMID: 36424342 DOI: 10.1016/j.endien.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/12/2021] [Indexed: 06/16/2023]
Abstract
Postprandial hyperinsulinaemic hypoglycaemia is a common complication of bariatric surgery. Although in general its evolution is mild and self-limited, it can lead to neuroglycopaenia and compromise the patient's safety and quality of life. The aim of this document is to offer some recommendations to facilitate the clinical care of these complex patients, reviewing the aetiopathogenesis, its diagnosis and treatment that, sequentially, will include dietary and pharmacological measures and surgery in refractory cases. In the absence of high-quality studies, the diagnostic and therapeutic approach proposed is based on the consensus of experts of the Grupo de Obesidad de la Sociedad Española de Endocrinología y Nutrición [Obesity Group of the Spanish Society of Endocrinology and Nutrition], GOSEEN. Those undergoing bariatric surgery should be informed of the possibility of developing this complication.
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Affiliation(s)
- Nuria Vilarrasa
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Bellvitge-IDIBELL, ĹHospitalet de Llobregat, Barcelona, Spain. CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain).
| | - Irene Bretón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Gregorio Marañón, IiSGM, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - María Ballesteros-Pomar
- Servicio de Endocrinología y Nutrición, Complejo Asistencial Universitario de León, León, Spain
| | - Albert Lecube
- Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova, Lleida, Spain. Obesity, Diabetes and Metabolism Research Group (ODIM), IRBLLeida, Universitat de Lleida, CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain)
| | - Albert Goday
- Servicio de Endocrinología y Nutrició, Hospital del Mar, Departament de Medicina, Universitat Autònoma de Barcelona, Spain. CIBERobn (Centros de Investigación Biomédica en Red-CIBER, Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain)
| | - Silvia Pellitero
- Servicio de Endocrinología y Nutrición, Hospital Universitari Germans Trias i Pujol, IMPPC, Institut d Investigació Germans Trias i Pujol (IGTP), Badalona, Barcelona, Spain
| | - Raquel Sánchez
- Servicio de Cirugía General, Complejo Hospitalario Universitario de Vigo, Instituto de Investigación Galicia Sur, Vigo, Pontevedra, Spain
| | - Ana Zugasti
- Sección Nutrición y Dietética, Complejo Hospitalario de Navarra, Pamplona/Iruña, Spain
| | - Andrea Ciudin
- Servicio de Endocrinología y Nutrición, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona (VHIR-UAB), CIBERDEM (CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Spain) Endocrinology and Nutrition Department, Hospital Universitari Vall Hebron, Barcelona, Spain
| | - Ana de Hollanda
- Servicio de Endocrinología y Nutrición, Hospital Clínic Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain. CIBERobn (Centros de Investigación Biomédica en Red-CIBER, Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid)
| | - Miguel Angel Rubio
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, IDISSC, Madrid, Spain
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Recomendaciones para el diagnóstico y tratamiento de las hipoglucemias tras cirugía bariátrica. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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5
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Surgical Treatment for Postprandial Hypoglycemia After Roux-en-Y Gastric Bypass: a Literature Review. Obes Surg 2021; 31:1801-1809. [PMID: 33523415 DOI: 10.1007/s11695-021-05251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity and obesity-related comorbidities. Postprandial hypoglycemia may occur as a long-term complication after RYGB. This study reviews the literature on surgical treatment for intractable post-RYGB hypoglycemia to provide updated information. A search was performed in Embase and PubMed, and 25 papers were identified. Thirteen papers on reversal were included. Resolution of postprandial hypoglycemic symptoms occurred in 42/48 (88%) patients after reversal. Twelve papers on pancreatectomy were included. Resolution occurred in 27/50 (54%) patients after pancreatectomy. The optimal surgical treatment for intractable post-RYGB hypoglycemia has not been defined, but reversal of RYGB seems to be more effective than other treatments. Further research on etiology and long-term evaluation of surgical outcomes may refine treatment options.
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Hu S, Tang H, Wang H, Dong Z, Jiang S, Wang C, Chen X, Yang W. Hyperinsulinemic Hypoglycemia after Bariatric Surgery. JOURNAL OF METABOLIC AND BARIATRIC SURGERY 2020; 9:1-6. [PMID: 36686896 PMCID: PMC9847643 DOI: 10.17476/jmbs.2020.9.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/08/2020] [Accepted: 05/19/2020] [Indexed: 06/13/2023]
Abstract
Postprandial hyperinsulinemic hypoglycemia (PHH) is one of the serious complications after bariatric surgery, it can lead life-threatening neuroglycopenic symptoms, such as seizures, disorientation, impairment of version and loss of consciousness without any premonitory. The presentation, prevalence, diagnosis, pathology and treatment are reviewed in this summary.
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Affiliation(s)
- Songhao Hu
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hanlin Tang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Huaxi Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhiyong Dong
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shuwen Jiang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Cunchuan Wang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaomei Chen
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wah Yang
- Department of Metabolic and Bariatric Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
- State Key Laboratory of Pharmaceutical Biotechnology, LKS Faculty of Medicine, The University of Hong Kong, China
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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7
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Caris F. G, Almarza T. R, Canales T. C, Sabra J. D. Reversión laparoscópica de bypass gástrico con Y de Roux a anatomía normal, en paciente con malnutrición severa y diarrea. Reporte de un caso. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.rchic.2016.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Busetto L, Dicker D, Azran C, Batterham RL, Farpour-Lambert N, Fried M, Hjelmesæth J, Kinzl J, Leitner DR, Makaronidis JM, Schindler K, Toplak H, Yumuk V. Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management. Obes Facts 2017; 10:597-632. [PMID: 29207379 PMCID: PMC5836195 DOI: 10.1159/000481825] [Citation(s) in RCA: 207] [Impact Index Per Article: 29.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Luca Busetto
- Department of Internal Medicine, University of Padova, Padova, Italy
- *Prof. Dr. Luca Busetto, Clinica Medica 3, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy,
| | - Dror Dicker
- Department of Internal Medicine D and Obesity Clinic, Hasharon Hospital, Rabin Medical Center, Petah Tikva, Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Carmil Azran
- Clinical Pharmacy, Herzliya Medical Center, Herzliya, Israel
| | - Rachel L. Batterham
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK
- University College London Hospital Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, UK
- National Institute of Health Research, University College London Hospital Biomedical Research Centre, London, UK
| | - Nathalie Farpour-Lambert
- Obesity Prevention and Care Program Contrepoids, Service of Therapeutic Education for Chronic Diseases, Department of Community Medicine, Primary Care and Emergency, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Martin Fried
- OB Klinika, Centre for Treatment of Obesity and Metabolic Disorders, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jøran Hjelmesæth
- Morbid Obesity Centre, Vestfold Hospital Trust and Department of Endocrinology, Morbid Obesity and Preventive Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Johann Kinzl
- Department of Psychiatry and Psychotherapy II, Medical University Innsbruck, Innsbruck, Austria
| | | | - Janine M. Makaronidis
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK
- National Institute of Health Research, University College London Hospital Biomedical Research Centre, London, UK
| | - Karin Schindler
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Hermann Toplak
- Department of Medicine, Medical University Graz, Graz, Austria
| | - Volkan Yumuk
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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9
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van Beek AP, Emous M, Laville M, Tack J. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev 2017; 18:68-85. [PMID: 27749997 DOI: 10.1111/obr.12467] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- A P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - M Laville
- European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France
| | - J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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11
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Mordes JP, Alonso LC. Evaluation, Medical Therapy, and Course of Adult Persistent Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass Surgery: A Case Series. Endocr Pract 2016; 21:237-46. [PMID: 25100376 DOI: 10.4158/ep14118.or] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evaluation and treatment of hyperinsulinemic hypoglycemia in adults who had undergone gastric bypass surgery. A small number of patients who undergo Roux-en-Y bypass surgery develop postprandial hypoglycemia in the absence of dumping. In some cases, such patients have been treated with pancreatectomy. METHODS We report the demographics, diagnostic results, response to medical therapy, and subsequent course of 6 referral patients with post-Roux-en-Y gastric bypass hypoglycemia. RESULTS Characteristic clinical and metabolic parameters consistent with hyperinsulinemic hypoglycemia were identified. Parameters were similar for both spontaneous and glucose-challenge-induced hypoglycemia. In the context of exclusively postprandial symptoms, simultaneous glucose ≤55 mg/dL, insulin ≥17 μU/mL, C peptide ≥3.0 ng/mL, and insulin to glucose ratio >0.3 were associated with Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia. Five of 6 patients improved on therapy consisting of dietary modification plus either calcium channel blockade, acarbose, or both. Two patients have remained on therapy for 12 to 15 months. The nonresponder was atypical and had had hypoglycemic events for several decades. Three treated patients were subsequently observed to have undergone partial or complete remission from hypoglycemic episodes after 2 to 37 months of therapy. None of the 6 have undergone pancreatectomy, and none have evidence of insulinoma. Invasive diagnostic procedures were of limited utility. CONCLUSION In a subset of patients with post-Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia, medical management can be efficacious and an alternative to partial pancreatectomy. In some cases, the disorder remits spontaneously.
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Affiliation(s)
- John P Mordes
- Department of Medicine, Division of Endocrinology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Laura C Alonso
- Division of Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts
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12
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Shantavasinkul PC, Torquati A, Corsino L. Post-gastric bypass hypoglycaemia: a review. Clin Endocrinol (Oxf) 2016; 85:3-9. [PMID: 26840207 DOI: 10.1111/cen.13033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/27/2015] [Accepted: 01/28/2016] [Indexed: 12/27/2022]
Abstract
Bariatric surgery is a highly effective treatment for severe obesity, resulting in substantial weight loss and normalizing obesity-related comorbidities. However, long-term consequences can occur, such as postbariatric surgery hypoglycaemia. This is a challenging medical problem, and the number of patients presenting with it has been increasing. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it is the surgery most commonly associated with the development of postbariatric surgery hypoglycaemia. To date, the pathogenesis of this condition has not been completely established. However, various factors - particularly increased postprandial glucagon-like peptide (GLP)-1 secretion - have been considered as crucial mediator. The mechanisms responsible for diabetic remission after bariatric surgery may be responsible for the development of hypoglycaemia, which typically occurs 1-3 h after a meal and is concurrent with inappropriate hyperinsulinaemia. Carbohydrate-rich foods usually provoke hypoglycaemic symptoms, which can typically be alleviated by strict dietary modifications, including carbohydrate restriction and avoidance of high glycaemic index foods and simple sugars. Few patients require further medical intervention, such as medications, but some patients have required a pancreatectomy. Because this option is not always successful, it is no longer routinely recommended. Clinical trials are needed to further determine the pathophysiology of this condition as well as the best diagnostic and treatment approaches for these patients.
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Affiliation(s)
- Prapimporn C Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Alfonso Torquati
- Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Leonor Corsino
- Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University, Durham, NC, USA
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13
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Endoluminal Revision (OverStitch TM , Apollo Endosurgery) of the Dilated Gastroenterostomy in Patients with Late Dumping Syndrome After Proximal Roux-en-Y Gastric Bypass. Obes Surg 2016; 26:1978-84. [DOI: 10.1007/s11695-016-2266-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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14
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Abstract
Obesity is a major public health problem worldwide. Obesity-related illnesses, such as coronary heart disease, type 2 diabetes, hypertension, dyslipidemia, stroke, sleep apnea, and several forms of cancer (endometrial, breast, and colon), contribute to a significant number of deaths in the USA. Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB) procedure, has demonstrated significant improvements in obesity and obesity-related co-morbidities and is becoming more popular as the number of obese individuals rises. Despite the reported benefits of bariatric surgery, there are potential complications that physicians need to be aware of as the number of patients undergoing these procedures continues to increase. One challenging and potentially life-threatening complication that to date is not well understood is post-RYGB surgery hypoglycemia (PGBH). In this review, we will present the definition, historical perspective, diagnostic approach, currently available treatment options, and anecdotal assessment and treatment algorithm for this disorder.
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Affiliation(s)
- Chevon M Rariy
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
| | - David Rometo
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
| | - Mary Korytkowski
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
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Cadegiani FA, Silva OS. Acarbose promotes remission of both early and late dumping syndromes in post-bariatric patients. Diabetes Metab Syndr Obes 2016; 9:443-446. [PMID: 27994477 PMCID: PMC5153290 DOI: 10.2147/dmso.s123244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Acarbose is a glucosidase inhibitor that slows carbohydrate digestion. It could thus be effective to promote remission of dumping syndrome (DS). Previous studies associating acarbose and late dumping, although not early dumping, have been reported. Herein, we aimed to evaluate the role of acarbose in dumping syndrome prevention and treatment and in resistive exercises resistance in bariatric subjects. METHODS Bariatric patients with DS and complete adherence to diet plan and resistive exercises were included (n=25). Number of early and late episodes, self-referred intensity of each episode, and ability to increase intensity of resistive exercise were evaluated, on a 0-10 scale. Acarbose was administered orally (50 mg) for 6 months, 4-5 times a day before meals. RESULTS Acarbose administration was associated with a decrease in the number of early (2.18-0.31) and late (2.79-0.12) episodes per week and intensity of each episode (6.10-1.65) and an increase in the ability to perform resistive exercises (3.03-7.12). Complete remission of DS was seen in 21 patients (84%), which persisted for 6 months with the use of acarbose. CONCLUSION Acarbose prevented dumping in almost all studied subjects and helped improve exercise capacity.
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Affiliation(s)
- Flavio A Cadegiani
- Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP
- Correspondence: Flavio A Cadegiani, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, R. Pedro de Toledo 781, 04039-032 São Paulo, SP, Brazil, Tel +55 61 98139 5395, Fax +55 61 3346 4733, Email
| | - Osvalmir Sá Silva
- Corpometria Institute, an Obesity and Endocrinology Center, Brasilia, DF, Brazil
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16
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Vilarrasa N, Goday A, Rubio MA, Caixàs A, Pellitero S, Ciudin A, Calañas A, Botella JI, Bretón I, Morales MJ, Díaz-Fernández MJ, García-Luna PP, Lecube A. Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry. Obes Facts 2016; 9:41-51. [PMID: 26901345 PMCID: PMC5644871 DOI: 10.1159/000442764] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Severe postprandial hypoglycemia after bariatric surgery is a rare but invalidating complication. Our aim was to describe the different tests performed for its diagnosis and their outcomes as well as the response to the prescribed pharmacological and surgical treatments. METHODS Multicenter, retrospective systematic review of cases with recurrent severe postprandial hypoglycemia. RESULTS Over 11 years of follow-up, 22 patients were identified. The test most used to provoke hypoglycemia was the oral glucose load test followed by the mixed meal test which was the least standardized test. With pharmacological treatment, 3 patients were symptom-free (with octreotide) and in 12 patients hypoglycemic episodes were attenuated. Seven patients had persistent hypoglycemic episodes and underwent surgery. Partial pancreatectomy was performed in 3 patients who had positive selective arterial calcium stimulation, and nesidioblastosis was confirmed in 2 patients. Reconversion to normal anatomy was performed in 3 patients, and 1 patient underwent a resection of the 'candy cane' roux limb, with resolution of hypoglycemia in all cases. CONCLUSIONS There is high heterogeneity in the evaluation and treatment options for postoperative hypoglycemia. In patients that do not respond to pharmacological treatment, reconstruction of gastrojejunal continuity may be the safest and most successful procedure.
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Affiliation(s)
- Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Hospital Universitario de Bellvitge-IDIBELL, Lx00B4;Hospitalet de Llobregat, Barcelona, Spain
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17
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Malik S, Mitchell JE, Steffen K, Engel S, Wiisanen R, Garcia L, Malik SA. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract 2015; 10:1-14. [PMID: 26522879 DOI: 10.1016/j.orcp.2015.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/17/2015] [Accepted: 07/06/2015] [Indexed: 02/06/2023]
Abstract
Hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass (RYGB) due to the changes in gut hormonal milieu. Physicians should be aware of this complication to ensure timely and effective treatment of post-RYGB patients, who present to them with hypoglycemic symptoms. Possible causes of hypoglycemia in these patients include late dumping syndrome, nesidioblastosis and rarely insulinoma. Systematic evaluation including history, biochemical analysis, and diagnostic testing might help in distinguishing among these diagnoses. Continuous glucose monitoring is also a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success. Treatment should begin with strict low carbohydrate diet, followed by medication therapy. Therapy with diazoxide, acarbose, calcium channel blockers and octreotide have been proven to be beneficial, but the response apparently is highly variable. When other treatment options fail, surgical options can be considered.
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Affiliation(s)
- Sarah Malik
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | - James E Mitchell
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States.
| | - Kristine Steffen
- Neuropsychiatric Research Institute, Fargo, ND, United States; North Dakota State University, United States
| | - Scott Engel
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | | | | | - Shahbaz Ali Malik
- University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
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18
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Abstract
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.
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19
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Indications and outcomes of reversal of Roux-en-Y gastric bypass. Surg Obes Relat Dis 2015; 11:821-6. [DOI: 10.1016/j.soard.2014.11.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 11/12/2014] [Accepted: 11/26/2014] [Indexed: 11/23/2022]
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20
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Sarker A, Meek CL, Park A. Biochemical consequences of bariatric surgery for extreme clinical obesity. Ann Clin Biochem 2015; 53:21-31. [DOI: 10.1177/0004563215588116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 01/01/2023]
Abstract
Obesity, defined as a body mass index over 30 kg/m2 for adults, poses a major healthcare challenge with important economic, personal and social consequences. Although public health measures, lifestyle change and pharmacological therapies have an important role in the management of obesity, patients with established morbid obesity (body mass index over 40 kg/m2) may also require bariatric surgery. Bariatric or metabolic surgery is associated with effective and enduring weight loss but is also known to improve glucose homeostasis, blood pressure and dyslipidaemia. Patients who have bariatric surgery need lifelong clinical follow-up to identify and prevent nutritional deficiencies and other complications. Clinical biochemistry laboratories have an important role in the nutritional assessment of obese patients and in the identification of complications following bariatric surgery. The aim of this article is to review the different bariatric procedures available and to summarize their complications, especially nutrient deficiencies and those of particular relevance to clinical biochemistry laboratories.
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Affiliation(s)
- Anita Sarker
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Claire L Meek
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
- Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Adrian Park
- Department of Clinical Biochemistry and Immunology, Cambridge Universities NHS foundation trust, Addenbrooke’s Hospital, Cambridge, UK
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21
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Kefurt R, Langer FB, Schindler K, Shakeri-Leidenmühler S, Ludvik B, Prager G. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test. Surg Obes Relat Dis 2014; 11:564-9. [PMID: 25737101 DOI: 10.1016/j.soard.2014.11.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM). SETTING University Hospital, Austria. METHODS To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test. RESULTS CGM detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while MMT indicated hypoglycemia in 29% of the patients. CGM also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM. CONCLUSIONS Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB.
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Affiliation(s)
- Ronald Kefurt
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix B Langer
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Karin Schindler
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Bernhard Ludvik
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria.
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22
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Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres A, Weiner R, Yashkov Y, Frühbeck G. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg 2014; 24:42-55. [PMID: 24081459 DOI: 10.1007/s11695-013-1079-8] [Citation(s) in RCA: 395] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.
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Affiliation(s)
- M Fried
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic,
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23
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García BF, Peromingo R, Galindo J, Arrieta F, Sánchez J, Vázquez C, Botella-Carretero JI. Case report subtotal pancreatectomy as treatment for severe hypoglycemia after gastric bypass. ACTA ACUST UNITED AC 2014; 61:391-3. [PMID: 24837353 DOI: 10.1016/j.endonu.2014.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/31/2014] [Accepted: 04/01/2014] [Indexed: 12/12/2022]
Affiliation(s)
- B F García
- Departamento de Endocrinología y Nutrición, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, España
| | - R Peromingo
- Departamento de Cirugía General, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Galindo
- Departamento de Cirugía General, Hospital Universitario Ramón y Cajal, Madrid, España
| | - F Arrieta
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, España; CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, España
| | - J Sánchez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Vázquez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, España; CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, España
| | - J I Botella-Carretero
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, IRyCIS, Madrid, España; CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn), Madrid, España.
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24
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Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis 2014; 10:1220-5. [PMID: 25002326 DOI: 10.1016/j.soard.2014.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/09/2014] [Accepted: 01/14/2014] [Indexed: 12/15/2022]
Abstract
An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.
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Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
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25
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Campos GM, Ziemelis M, Paparodis R, Ahmed M, Davis DB. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis 2013; 10:36-43. [PMID: 24120983 DOI: 10.1016/j.soard.2013.05.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/24/2013] [Accepted: 05/25/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. METHODS Prospective study of consecutive patients offered laparoscopic reversal of RYGB. RESULTS Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5 ± 12.4 to 1.5 ± 1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. CONCLUSIONS Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
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Affiliation(s)
- Guilherme M Campos
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Martynas Ziemelis
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rodis Paparodis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Muhammed Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn Belt Davis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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26
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Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Obesity (Silver Spring) 2013; 21 Suppl 1:S1-27. [PMID: 23529939 PMCID: PMC4142593 DOI: 10.1002/oby.20461] [Citation(s) in RCA: 740] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 12/27/2012] [Indexed: 02/06/2023]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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27
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Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract 2013; 19:337-72. [PMID: 23529351 PMCID: PMC4140628 DOI: 10.4158/ep12437.gl] [Citation(s) in RCA: 279] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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28
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Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Surg Obes Relat Dis 2013; 9:159-91. [PMID: 23537696 DOI: 10.1016/j.soard.2012.12.010] [Citation(s) in RCA: 430] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 12/27/2012] [Indexed: 02/06/2023]
Abstract
The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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29
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Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres AJ, Weiner R, Yashkov Y, Frühbeck G. Interdisciplinary European Guidelines on metabolic and bariatric surgery. Obes Facts 2013; 6:449-68. [PMID: 24135948 PMCID: PMC5644681 DOI: 10.1159/000355480] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 09/09/2013] [Indexed: 12/12/2022] Open
Abstract
In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity-European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASO's OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.
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Affiliation(s)
- Martin Fried
- OB Klinika, Centre for Treatment of Obesity and Metabolic Disorders, 1st Faculty of Medicine, Charles University, Prague, Czech Republic, Istanbul, Turkey
| | - Volkan Yumuk
- Division of Endocrinology, Metabolism and Diabetes, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Jean-Michel Oppert
- Department of Nutrition, Heart and Metabolism Division, Pitie Salpetriere University Hospital (AP-HP) University Pierre et Marie Curie-Paris 6, Institute of Cardiometabolism and Nutrition (ICAN) Paris, France
| | | | - Antonio J. Torres
- Department of Surgery Complutense University of Madrid, Hospital Clinico ‘San Carlos’, Madrid, Spain
| | - Rudolf Weiner
- Sachsenhausen Hospital and Centre for Minimally Invasive Surgery, Johan Wolfgang Goethe University, Frankfurt/M., Germany, Spain
| | - Yuri Yashkov
- Obesity Surgery Service, Centre of Endosurgery and Lithotripsy Moscow, Russia, Spain
| | - Gema Frühbeck
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, CIBERobn, Instituto de Salud Carlos III, Pamplona, Spain
- *Gema Frühbeck, R Nutr MD PhD, Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, CIBERobn, Instituto de Salud Carlos III, Avda. Pio XII, 36, 31008 Pamplona (Spain),
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