Efficacy and safety of lanreotide in postoperative dumping syndrome: A Phase II randomised and placebo-controlled study

Managing gastrointestinal manifestations in systemic sclerosis, a mechanistic approach

INTRODUCTION

Systemic sclerosis (SSc) is a connective tissue disease with heterogeneous presentation. Gastrointestinal (GI) complications of SSc are characterized by esophageal reflux, abnormal motility, and microbiome dysbiosis, which impact patient quality of life and mortality. Preventative therapeutics are lacking, with management primarily aimed at symptomatic control.

AREAS COVERED

A broad literature review was conducted through electronic databases and references from key articles. We summarize the physiology of gastric acid production and GI motility to provide context for existing therapies, detail the current understanding of SSc-GI disease, and review GI medications studied in SSc. Finally, we explore new therapeutic options. We propose a management strategy that integrates data on drug efficacy with knowledge of disease pathophysiology, aiming to optimize future therapeutic targets.

EXPERT OPINION

SSc-GI complications remain a challenge for patients, clinicians, and investigators alike. Management presently focuses on treating symptoms and minimizing mucosal damage. Little evidence exists to suggest immunosuppressive therapy halts progression of GI involvement or reverses damage, leaving many unanswered questions about the optimal clinical approach. Further research focused on identifying patients at risk for GI progression, and the underlying mechanism(s) that drive disease will provide opportunities to prevent long-term damage, and significantly improve patient quality of life.

Society for Endocrinology guidelines for the diagnosis and management of post-bariatric hypoglycaemia

Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres.

AIM

to improve and standardise clinical practice in the diagnosis and management of PBH.

OBJECTIVES

(1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition.

METHOD

A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders.

OUTCOME

We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.

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.

Gastrointestinal hormones and regulation of gastric emptying

PURPOSE OF REVIEW

In this review, we evaluate recent findings related to the association between gastrointestinal hormones and regulation of gastric emptying.

RECENT FINDINGS

Motilin and ghrelin, which act during fasting, promote gastric motility, whereas most of the hormones secreted after a meal inhibit gastric motility. Serotonin has different progastric or antigastric motility effects depending on the receptor subtype. Serotonin receptor agonists have been used clinically to treat dyspepsia symptoms but other hormone receptor agonists or antagonists are still under development. Glucagon-like peptide 1 agonists, which have gastric motility and appetite-suppressing effects are used as a treatment for obesity and diabetes.

SUMMARY

Gastrointestinal hormones play an important role in the regulation of gastric motility. Various drugs have been developed to treat delayed gastric emptying by targeting gastrointestinal hormones or their receptors but few have been commercialized.

Persistent Postgastrectomy Hypoglycemia Unawareness in Patients With Gastric Cancer Unveiled by a Prospective Study

Objective

Late dumping syndrome is a common postgastrectomy complication characterized by reactive hypoglycemia. This study aimed to explore the glycemic trend in patients who underwent gastrectomy for gastric cancer and clarify its changes over time in association with postgastrectomy symptoms.

Summary Background Data

Changes over time in glycemic trend in association with postgastrectomy symptoms have not been evaluated.

Methods

We conducted a prospective study of 71 patients who underwent curative gastrectomy for gastric cancer between November 2017 and April 2020. The patients underwent continuous glucose monitoring twice-at 1- and 12-month postgastrectomy-and were assessed using the Post-Gastrectomy Syndrome Assessment Scale 37-item questionnaire (PGSAS-37) at 1-, 6-, and 12-month postgastrectomy.

Results

Our results revealed that hypoglycemia (<70 mg/dL), especially nocturnal hypoglycemia (00:00-06:00), frequently occurred even at 12-month postgastrectomy. Hypoglycemia improved in total gastrectomy patients but remained unchanged in distal gastrectomy patients, which was still high in both groups at 12-month postgastrectomy. Glycemic variability (SD of the glycemic trend) was exacerbated in both gastrectomy groups. However, the PGSAS-37 symptom scores remained unchanged, and the living status and quality of life tended to improve. Hypoglycemia unawareness, including postprandial hypoglycemia without symptoms and nocturnal hypoglycemia, was evident even 12-month postgastrectomy.

Conclusions

Persistent postgastrectomy hypoglycemia unawareness, including late dumping syndrome without symptoms and nocturnal hypoglycemia, should be recognized as an important issue in postgastrectomy syndrome. Therefore, meticulous long-term evaluation for glycemic trends and care of patients is required.

International consensus on the diagnosis and management of dumping syndrome

Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.