Acarbose promotes remission of both early and late dumping syndromes in post-bariatric patients

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.

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia.

METHODS

This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change.

RESULTS

A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125 days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12 months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms.

CONCLUSION

TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

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.

A Delayed Presentation of Late Dumping Syndrome After Ivor Lewis Procedure

An accurate and timely diagnosis of dumping syndrome after gastric and oesophageal surgery is often difficult. A delay in making this diagnosis and instituting therapy can result in significant morbidity and avoidable complications. As bariatric surgery becomes more prevalent, the importance of a timely diagnosis of dumping syndrome is increasing. We present a case of a 77-year-old man who was admitted into the intensive care unit with a reduced conscious state secondary to hypoglycemia. The patient was subsequently diagnosed with late dumping syndrome in the context of an Ivor Lewis procedure seven years prior. Despite having a history of recurrent neuroglycopenic symptoms, there was a delay in diagnosis as dumping syndrome had not previously been considered until this admission. After confirmation of the diagnosis, the patient was commenced on dietary adjustments and acarbose, with a resolution of post-prandial hypoglycaemia. The authors discuss dietary and pharmacological therapy to manage hypoglycaemia associated with dumping syndrome.

Randomized, double-blind, placebo-controlled crossover trial of once daily empagliflozin 25 mg for the treatment of postprandial hypoglycaemia after Roux-en-Y gastric bypass

Aims To investigate the effect of empagliflozin on glucose dynamics in individuals suffering from postbariatric hypoglycaemia (PBH) after Roux-en-Y gastric bypass (RYGB). Methods Twenty-two adults with PBH after RYGB were randomized to empagliflozin 25 mg or placebo once daily over 20 days in a randomized, double-blind, placebo-controlled, crossover trial. The primary efficacy outcome was the amplitude of plasma glucose excursion (peak to nadir) during a mixed meal tolerance test (MMTT). Outcomes of the outpatient period were assessed using continuous glucose monitoring (CGM) and an event-tracking app. Results The amplitude of glucose excursion during the MMTT was 8.1±2.4 mmol/L with empagliflozin vs 8.1±2.6 mmol/L with placebo (mean±SD, p=0.807). CGM-based mean amplitude of glucose excursion (MAGE) during the 20 day-period was lower with empagliflozin than placebo (4.8±1.3 vs 5.2±1.6. p=0.028). Empagliflozin reduced the time spent with CGM values >10.0 mmol/L (3.8±3.5 % vs. 4.7±3.8 %, p =0.009), but not the time spent with CGM values <3.0 mmol/L (1.7±1.6 % vs. 1.5±1.5 %, p=0.457). No significant difference was observed in the quantity and quality of recorded symptoms. Eleven adverse events occurred with empagliflozin (three drug-related) and six with placebo. Conclusions Empagliflozin 25 mg reduces glucose excursions but not hypoglycaemia in individuals with PBH.

Medical Nutrition Therapy and Other Approaches to Management of Post-bariatric Hypoglycemia: A Team-Based Approach

PURPOSE OF REVIEW

This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management.

RECENT FINDINGS

As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1-10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH. Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

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.

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.

Common and Rare Complications of Bariatric Surgery

As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed.

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

Background: Dumping syndrome is a common complication of surgical treatment of gastric cancer, but conventional therapy has limitations related to symptom care due to its structural cause and the decreased quality of life. Objectives: The objective of this review was to assess the clinical evidence for the effectiveness of herbal medicine as a treatment for dumping syndrome. Methods: A literature review was conducted using 16 databases from their inceptions to March 2018. All randomized controlled trials (RCTs) of herbal medicine used to treat dumping syndrome patients were included and meta-analyzed. Methodological quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 174 dumping syndrome patients of 3 trials met all inclusion criteria. Two trials assessed the effectiveness of herbal medicine on the symptom response rate compared with conventional pharmacotherapy. Their results suggested significant effects in favor of herbal medicine (risk ratio [RR] = 1.37, 95% confidence interval [CI] = 1.16-1.63, P = .0003, heterogeneity τ² = 0, χ² = 0.02, P = .88, I² = 0%). One trial assessed its effectiveness on the improvement rate of overall symptoms compared with conventional conservative complex therapy, such as postural management, diet regulation, and counseling (RR = 1.23, 95% CI = 0.96-1.58). Conclusions: Due to the small sample size, scarcity of reported articles, and lack of quality of the current RCTs, it was concluded that the effectiveness of herbal medicine in treating dumping syndrome is unclear.

Gastric Function in Children with Oesophageal Atresia and Tracheoesophageal Fistula

Oesophageal atresia and tracheoesophageal fistula (OA-TOF) are a multifaceted condition which affects patients throughout their lives. Even though it is one of the most common gastrointestinal malformations, most of the current studies focus on gastro-oesophageal reflux disease, anastomotic strictures, and feeding difficulties. However, there is increasing evidence that a proportion of patients with OA-TOF also have abnormal gastric function. This review aims to provide a comprehensive understanding of studies of gastric function in patients with OA-TOF. The etiology of this abnormality has been hypothesized to be congenital and/or acquired. Several modalities are currently available for the investigation of gastric function, each of them trying to answer specific clinical questions. This review summarizes the studies that have looked at gastric function in the OA-TOF cohort with gastric emptying studies (gastric emptying scintigraphy and ¹³C octanoic breath test), gastric manometry, electrogastrography, and oral glucose tolerance test. However, these modalities are limited due to poor age-specific normative values and heterogeneous methodologies used. The evaluation of symptoms in this cohort is crucial, modalities for abnormal gastric function are also described. With appropriate investigations and symptoms questionnaires, treatment strategies can be implemented to correct abnormal gastric function and thereby improve the outcomes and quality of life of patients with OA-TOF. This review highlights the need for large international multicentre collaborative studies and high-quality prospective randomized controlled trials to improve our understanding of gastric function in this cohort.