Long-term self-reported symptom prevalence of early and late dumping in a patient population after sleeve gastrectomy, primary, and revisional gastric bypass surgery

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.

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.

Endoscopic revision of gastrojejunal anastomosis for the treatment of dumping syndrome in patients with Roux-en-Y gastric bypass: a systematic review and meta-analysis

BACKGROUND

Dumping syndrome is a known complication of Roux-en-Y gastric bypass (RYGB). Recently, endoscopic gastrojejunal anastomosis (GJA) revision has been employed as a treatment option. The primary aim of this study was to perform a systematic review and meta-analysis for the role of endoscopic GJA revision in patients with RYGB for the treatment of dumping syndrome.

METHODS

Search strategies were developed for PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception through December 2020 in accordance with PRISMA and MOOSE guidelines. Pooled proportions with rates estimated using random effects models were used. Outcomes included pooled technical success, clinical success, adverse events, and rate of reintervention. Heterogeneity was assessed with I² statistics and publication bias by funnel plot using Egger and Begg tests.

RESULTS

Six studies (n = 263 patients; 60.25% female) were included (1 prospective and 5 retrospective). Mean age was 46.27 ± 2.54 years. Average patient weight was 95.59 ± 4.78 kg, BMI of 41.43 ± 3.07 kg/m², and pre-procedure GJA size of 32.23 ± 8.68 mm. Pooled technical and clinical success was 98.15% and 89.5%. Among studies reporting Sigstad scores, endoscopic GJA revision resulted in a significant improvement [mean Sigstad score difference of - 9.96 (95% CI, - 19.951 to - 0.975); P < 0.03]. Mean procedure time was 37.12 ± 10.40 min with an intra-procedural adverse event rate of 2.42%. Over a mean follow-up of 8.03 ± 6.87 months, post-procedure adverse events occurred in 2.96% of patients with a reintervention rate of 11.54%.

CONCLUSION

This systematic review and meta-analysis suggests that endoscopic GJA revision appears an effective and safe treatment for dumping syndrome.

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.

Dumping Syndrome and Postbariatric Hypoglycemia: Supporting Evidence for a Common Etiology

BACKGROUND

Dumping syndrome (DS) and postbariatric hypoglycemia (PBH) are frequent complications of bariatric surgery. Previously known as "early and late dumping," these complications have been separated due to differences in their onset and behaviors.

OBJECTIVES

To investigate a potentially common etiology of DS and PBH using an analysis of a mixed meal test (MMT) study.

SETTING

A large teaching hospital in the Netherlands.

METHODS

From all patients who underwent bariatric surgery in 2008-2011, a random selection completed an MMT (n = 47). Patients scored complaints related to DS and PBH with a standardized questionnaire at several time intervals. The groups were divided into patients with (DS+; n = 22) and without (DS-; n = 25) an increase in DS symptoms after the start of the MMT. Glucose and gut hormone levels were compared. Hypoglycemia was defined as a blood glucose level below 3.3 mmol/L.

RESULTS

The DS+ group had lower blood glucose values compared to the DS- group, which reached significance at 90 and 120 minutes (P < .05). For the DS+ group, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and satiety were higher at various time intervals (P < .05) compared to the DS- group. No differences were found for insulin and hunger score. GLP-1 and PYY were correlated with symptoms of DS.

CONCLUSION

Patients with DS complaints had lower postprandial glucose values. GLP-1 and PYY values were elevated in the DS+ group early and late during the test. These hormones also correlated with DS. These findings support the hypothesis of a common etiology of DS and PBH and a role of GLP-1 and PYY in both complications.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

Remission of Food Addiction Does Not Induce Cross-Addiction after Sleeve Gastrectomy and Gastric Bypass: A Prospective Cohort Study

BACKGROUND

The hypothesis of "cross-addiction" has never been validated, and numerous aspects speak against it.

OBJECTIVES

To compare the differences between sleeve gastrectomy (SG) and gastric bypass (GB) procedures concerning cross-addiction.

SETTING

Center for maximum care in Germany.

METHODS

We performed a prospective analysis of patients undergoing SG or GB as the first surgical treatment for severe obesity. All patients completed validated questionnaires to evaluate food intake (Yale Food Addiction Scale, YFAS), alcohol intake (Alcohol Use Disorders Identification Test), nicotine use (Fagerstrom Test for Nicotine Dependence), exercise (Exercise Addiction Inventory), drug addiction (20-item Drug Abuse Screening Test), and Internet use disorder (Internet Addiction Test) before the operation (T0) and 6 (T6) and 24 (T24) months postoperatively (ClinicalTrials.gov identifier: NCT02757716).

RESULTS

One hundred thirteen patients underwent SG (n = 68) or GB (n = 45). At the follow-up, 61% completed the questionnaires at T6 and 44% at T24. In the YFAS, the percentage of patients diagnosed with food addiction decreased from 69 to 10%, and the mean symptom count decreased from 3.52 ± 1.95 to 1.26 ± 0.99 at T24 (p < 0.0001); these values did not differ between the surgical groups (p = 0.784). No significant evidence of cross-addiction was observed for use of alcohol, nicotine, drugs, the Internet, or exercise in either surgical group. The percentage of patients with moderate nicotine dependence increased in the SG group (+8.9%) at T24, but this was not significant.

CONCLUSION

In this single-center cohort study, surgery for obesity caused significant addiction remission regarding food but without inducing cross-addiction after 2 years. Importantly, no significant differences were seen between the SG and GB procedures.

Short-term outcomes of endoscopic gastro-jejunal revisions for treatment of dumping syndrome after Roux-En-Y gastric bypass

BACKGROUND

Dumping syndrome is a known long-term complication of Roux-en-Y gastric bypass (RYGB). Most cases can be avoided with dietary and lifestyle changes. Severe dumping is characterized by multiple daily episodes with significant impact on quality-of-life. As dumping correlates with rapid pouch emptying through a dilated gastro-jejunal anastomosis (GJA), the aim was to assess endoscopic gastro-jejunal revisions (EGR) regarding feasibility, safety, and outcome.

METHODS

From January 2016 to August 2018, we reviewed the electronic records of all patients with dumping syndrome undergoing EGR with the Apollo OverStitch suturing device (Apollo Endosurgery, Austin, Texas, USA). Demographics, procedure details, and outcome variables were recorded. Sigstad questionnaire was administered before and after surgery to assess symptomatic response.

RESULTS

There were 40 patients (M:F = 13:27) treated with EGR for dumping. Mean procedure time was 18.5 min (12-41) with a median number of 1 suture (range 1-3) used. Mean anastomotic diameter was 22.6 mm (R 18-35) at the beginning and 6.2 mm (R 4-13) at the end of the procedure, with 100% technical success in narrowing the GJA. There were no intra-operative or 30-day complications. Repeat EGR was required in 9 patients (22.5%) for persistent/recurrent dumping. Two patients (5%) required a laparoscopic pouch revision. For patients with minimum 1-month follow-up who were treated only endoscopically, 33/37 (89.2%) had improved or resolved symptoms during the follow-up period. Mean follow-up time was 12.5 months (R1-33.8). Survey responses were available for 25/34 (73.5%) patients. Mean Sigstad score decreased from 13.9 (R 0-28) pre-operatively to 8.6 (R 0-28) after EGR.

CONCLUSION

EGR of the dilated GJA is a highly effective treatment option for dumping syndrome after RYGB. Due to its endoluminal approach, it is a feasible and safe procedure, and effective for immediate symptom resolution in most patients. In some patients, repeat narrowing of the anastomosis is necessary for the maintenance of symptom resolution.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.