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Prevalence, Severity, and Predictors of Symptoms of Dumping and Hypoglycemia following Roux-En-Y Gastric Bypass
Abstract
Background:
Roux-en-Y gastric bypass (RYGB) results in pronounced weight loss in morbidly obese patients but may also cause adverse effects like early dumping and hypoglycemia. Prevalence data on these complications and their potential predictors are sparse.
Objective:
To assess the prevalence and possible predictors of early dumping and hypoglycemia in a population-based cohort of RYGB patients.
Setting:
University Hospital, Denmark.
Design:
A questionnaire survey was performed in the Central Denmark Region including RYGB-operated patients (years 2006-2011, n = 2238) and a nonoperated comparison cohort (n = 89). The Dumping Rating Scale and the Edinburgh Hypoglycemia Scoring System, together with demographic and clinical characteristics, were used, and possible predictors were examined by logistic regression.
Results:
The response rate was 64% (1429/2238). In total, 9.4% (134/1429) and 6.6% (95/1429) experienced moderate or severe symptoms of early dumping and hypoglycemia, respectively, which were significantly higher than in the comparison cohort. Because 3.4% (95% CI: 2.5-4.4) of the RYGB group experienced both early dumping and hypoglycemia, the total prevalence of 1 or both conditions was 12.6 (95% CI 10.9-14.4). Possible predictors for both conditions were body mass index (BMI)<25 kg/m(2) (odds ratio [OR] 1.70 (95% CI: 0.98-2.95) and OR 1.60 (95% CI: .83-3.06), respectively) compared with patients with BMI 25-30 kg/m(2). Younger age seemed to increase the risk of both conditions (<35 yr: OR 1.75 (95% CI: 1.11-2.75) and OR .59 (95% CI: .93-2.72), respectively) compared with patients>45 years.
Conclusion:
Symptoms of early dumping and hypoglycemia were rather common with a prevalence of 1 or both conditions of 12.6% after RYGB. Predictors included younger age and a lower BMI.
... The DSRS has been validated and applied in previous studies [12][13][14]. It evaluates the occurrence, intensity, and frequency of 9 symptom-suggested DS that occur 10 to 30 min after consumption, including fatigue/tiredness, palpitations, sweating/heat sensation, cold sweat/palsy, the need to lie down, diarrhea, nausea and/or vomiting, abdominal "cramp" and fainting, and weakness/shivering. ...
... A growing number of studies have indicated the occurrence of DS after MBS, and MBS has become the most common reason for dumping syndrome in the past decade. According to current literature reports, the prevalence of DS after MBS ranges from 0 to 41.4% [7,8,12,13,[18][19][20]. There may be many reasons for these variations, including different methods of assessing the occurrence of dumping syndrome, differences in surgical procedures, and different time points for reporting dumping symptoms, which makes it difficult to obtain a pooled result. ...
... In this study, we used the DRSS questionnaire, which was validated by Laurenius et al. in 2013 [14], to assess the prevalence and severity of dumping syndrome. Nielsen et al. and Sun et al. [12,13] also used a questionnaire to estimate the prevalence and explore the potential risk factors for dumping syndrome. In agreement with Sun et al. results, the prevalence of mild-to-moderate dumping syndrome was similar to ours (40.98% vs 45.9%). ...
Background and Purpose
Dumping syndrome (DS) is a shared but underappreciated complication after metabolic-bariatric surgery. The purpose of the study was to investigate the prevalence and intensity of symptoms suggestive of DS and their relationship with health-related quality of life (HRQOL) after laparoscopic sleeve gastrectomy (LSG).
Method
A retrospective cohort study was performed for all patients with a history of sleeve gastrectomy between July 2017 and July 2022 in our center. Basial clinic statistics were gathered from electronic medical database, the prevalence and severity of DS were assessed by Dumping Symptom Rating Scale (DSRS), and HRQOL is collected through the Short Form Health Survey 36 (SF-36).
Result
In total, 133 of 202 patients completed the questionnaire (response rate 65.8%). A total of 64.7% (N = 86) of participants were female, aged 34.0 (IQR 26.0–39.0) years at completion of the questionnaire, with a mean body mass index of 35.8 (IQR 31.4–40.5) kg/m2. The prevalence of symptoms suggestive of DS was 45.9% (N = 61), and the associated protective factor was the time between surgery and study. Compared with the patients without DS, patients with DS scored significantly worse on four of eight SF-36 subdomains.
Conclusion
Symptoms suggestive of early dumping syndrome after sleeve gastrectomy are common and are associated with a worse health-related quality of life, which deserves clinical attention. Additional counselling, education, and care are needed to mitigate the decline in quality of life caused by dumping symptoms.
Graphical abstract
... Dumping syndrome is a well-known sequel of Roux-en-Y gastric bypass (RYGB). Studies have reported a prevalence of DS ranging from 3 to 80% after LRYGB [4,5,[11][12][13]. DS can also be seen after non-anastomotic bariatric procedures, such as sleeve gastrectomy (SG). ...
... DS can also be seen after non-anastomotic bariatric procedures, such as sleeve gastrectomy (SG). DS after SG may occur in up to 40% of patients [4,5,[11][12][13]. ...
... It should be noted that severity with 11 questions ranging from 1 to 7 (minimum total score, 11; maximum total score, 77) was divided into mild to moderate (score, 11-44) and severe (more than 44). The frequency with 9 questions ranging from 1 to 6 (minimum total score, 9; maximum total score, 54) was divided into mild to moderate (score, [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] and severe (more than 27). None of the comorbidities such as T2DM, dyslipidemia, HTN, and sleep apnea at 1-year follow-up, gender, and age as well as dumping syndromes were correlated with the changes of %TWL. ...
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.
... Dumping syndrome is defined as post-prandial gastrointestinal and/or vasomotor symptoms, including diarrhea, palpitations, syncope, and weakness [2]. Post-prandial hyperinsulinemic hypoglycemia, or reactive hypoglycemia, is a late dumping process that occurs after RYGB. ...
... While symptoms can vary, they typically include documented post-prandial hypoglycemia and patient-reported symptoms of hypoglycemia, including weakness, fatigue, and in some cases, loss of consciousness or seizures [3]. Up to 1/3 of patients can experience reactive hypoglycemia after RYGB and treatment typically begins with dietary measures and then advances to medications, such as acarbose or somatostatin analogues [2,[4][5][6]. Despite these interventions, a subset of patients remain symptomatic and options, which include surgical reversal or feeding of the remnant stomach, are associated with a high adverse event rate and/or weight recurrence [1,3,7]. ...
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.
... Bariatric surgery is the most effective therapy to treat obesity as it results in the most long-term weight loss [1][2][3][4]. However, post-operatively, some patients develop non-specific post-prandial symptoms that may affect their quality of life including hypoglycemic symptoms [5]. ...
... Studies have identified predictors of symptomatic hypoglycemia. These include female sex, younger age, lower BMI, and a lower HbA1c at the time of evaluation for hypoglycemia symptoms, lower BMI before bariatric surgery, higher weight loss after bariatric surgery, and RYGB [5,[28][29][30]. The aim of this study was not to identify predictors of hypoglycemia but to identify variables associated with a higher likelihood of symptom resolution. ...
Purpose
Following bariatric surgery, patients can develop non-specific symptoms self-described as hypoglycemia. However, confirming hypoglycemia can be technically challenging, and therefore, these individuals are frequently treated empirically. This study aimed to describe what diagnostic evaluation and therapeutic interventions patients referred for post-bariatric surgery hypoglycemia undergo.
Methods
Retrospective observational cohort study of patients with a history of bariatric surgery was evaluated for post-bariatric surgery hypoglycemia in a tertiary referral center from 2008 to 2017. We collected demographic and bariatric surgery information, clinical presentation of symptoms referred to as hypoglycemia, laboratory and imaging studies performed to evaluate these symptoms, and symptom management and outcomes.
Results
A total of 60/2450 (2.4%) patients who underwent bariatric surgery were evaluated in the Department of Endocrinology for hypoglycemia-related symptoms. The majority were middle-aged women without type 2 diabetes who had undergone Roux-en-Y gastric bypass. Thirty-nine patients (65%) completed a biochemical assessment for hypoglycemia episodes. Six (10%) had confirmed hypoglycemia by Whipple’s triad, and four (6.7%) met the criteria for post-bariatric surgery hypoglycemia based on clinical and biochemical criteria. All patients were recommended dietary modification as the initial line of treatment, and this intervention resulted in most patients reporting at least some improvement in their symptoms. Eight patients (13%) were prescribed pharmacotherapy, and two patients required additional interventions for symptom control.
Conclusions
In our experience, evaluation for hypoglycemia-related symptoms after bariatric surgery was rare. Hypoglycemia was confirmed in the minority of patients. Even without establishing a diagnosis of hypoglycemia, dietary changes were a helpful strategy for symptom management for most patients.
Graphical abstract
... Her daily medication schedule consisted of vitamin A (retinyl acetate 5000 units), vitamin E (dl-alpha-tocopheryl acetate 200 units = 200 mg), iron sulphate 525 mg (105 mg elementary iron), a multivitamin B complex: B1, B2, B6 and B12 (thiamine mononitrate 250 mg, riboflavin 10 mg, pyridoxine hydrochloride 250 mg, cyanocobalamin 0.02 mg; twice daily), folic acid 0.4 mg, a calcium and vitamin D supplement (calcium carbonate 2500 mg, cholecalciferol 880 units), valproic acid (450 mg; twice daily) and lamotrigine (100 mg; twice daily). Despite the oral nutritional support and supplementation, recurrent laboratory blood examination revealed persistent nutritional deficits including severe hypalbuminaemia (16 g/l; normal range: 35-52), vitamin A deficiency (115 μg/l; normal range: 300-650), vitamin E deficiency (1.5 mg/l; normal range: [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] and zinc deficiency (36 μg/dl; normal range: 80-120). While other nutritional markers were within normal range including calcium, 25-OH vitamin D, prothrombin time, folic acid and iron panel (intravenous iron and vitamin K had been administered during the first admission). ...
... Symptoms of postprandial hyperinsulinemic hypoglycaemia can develop months to years after surgery, but occur within one to 3 h after meal intake [15]. Hypoglycaemia symptoms are categorized as autonomic, including tremor, sweating and palpitation, or neuroglycopenic, including confusion, weakness, light-headedness, dizziness, blurred vision, disorientation, and eventually loss of consciousness [13,16,17]. Consequently, screening is of utmost importance and can be performed by means of the following criteria: (a) the presence of neuroglycopenic symptoms beyond 1 year after surgery, (b) normal fasting glucose and insulin levels, (c) correlation of symptoms with hypoglycaemia, followed by a spontaneous resolution of hypoglycaemia, and (d) a positive provocative test (e.g. ...
Background:
In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications.
Case presentation:
A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning.
Conclusions:
Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.
... Known risk factors for hypoglycemia in postbariatric patients are younger age, female gender, greater postoperative loss of weight, and pre-operative high insulin sensitivity [14][15][16]. The diagnosis of hypoglycemia is often demanding and requires fulfillment of Whipple's triad often established with provocation testing [13,14,[16][17][18]. ...
... Low HbA 1c could be explained by multiple episodes of hypoglycemia during the months before testing; however, it has not been reported in hypoglycemia patients yet. Greater weight loss in hypoglycemia patients has been reported in previous studies [14,15,27,28] and might overstrain metabolic adaptations after bariatric surgery, especially when occurring over a short period, leading to postprandial overexcretion of insulin. The mechanisms of this oversecretion appear to be multifactorial [29], and as recently discovered also mediated by interleukin 1-β [30]. ...
Background
Postprandial hypoglycemia after bariatric surgery is an exigent disorder, often impacting the quality of life. Distinguishing clinically relevant hypoglycemic episodes from symptoms of other origin can be challenging. Diagnosis is demanding and often requires an extensive testing such as prolonged glucose tolerance or mixed-meal test. Therefore, we investigated whether baseline parameters of patients after gastric bypass with suspected hypoglycemia can predict the diagnosis.
Methods
We analyzed data from 35 patients after gastric bypass with suspected postprandial hypoglycemia and performed a standardized mixed-meal test. Hypoglycemia was defined by the appearance of typical symptoms, low plasma glucose, and relief of symptoms following glucose administration. Parameters that differed in patients with and without hypoglycemia during MMT were identified and evaluated for predictive precision using receiver operating characteristic (ROC) areas under the curve (AUC).
Results
Out of 35 patients, 19 (54%) developed symptomatic hypoglycemia as a result of exaggerated insulin and C-peptide release in response to the mixed-meal. Hypoglycemic patients exhibited lower glycosylated hemoglobin A1c (HbA1c) and higher absolute and relative weight loss from pre-surgery to study date. HbA1c and absolute weight loss alone could achieve acceptable AUCs in ROC analyses (0.76 and 0.72, respectively) but a combined score of absolute weight loss divided by HbA1c (0.78) achieved the best AUC.
Conclusions
HbA1c and weight loss differed in patients with and without symptomatic hypoglycemia during mixed-meal test. These baseline parameters could be used for screening of postprandial hypoglycemia in patients after gastric bypass and may facilitate the selection of patients requiring further evaluation.
Graphical abstract
... Predictors of hypoglycemia identified in prior studies include younger age, female sex, and use of antidepressant medications [3]. Further predictive factors include history of preoperative symptoms suggestive of possible hypoglycemia, lower HbA1c, lower BMI, greater surgical weight loss, and absence of preoperative diabetes [3,[13][14][15]. Preoperative metabolic testing has revealed earlier glucose peak and small but significant increases in insulin secretion during oral glucose tolerance testing in those who subsequently develop PBH [14,16]. ...
Context
Post‐bariatric hypoglycemia (PBH) is a complication of bariatric surgery including Roux‐en‐Y gastric bypass (RYGB). It remains unclear why only some individuals develop PBH.
Objective
To identify clinical characteristics distinguishing post‐RYGB individuals with PBH, versus without symptomatic hypoglycemia (RYGB non‐hypo).
Design and Setting
Cross‐sectional observational study in academic referral centre. Adults 18–70, without current diabetes, were recruited into three groups: (1) PBH ( n = 39); (2) RYGB non‐hypo ( n = 25); and (3) individuals without history of upper gastrointestinal surgery ( n = 17). Outcome measures included between‐group differences in medical history and medication use, and survey‐based scores for hypoglycemia, dumping syndrome, and autonomic symptoms.
Results
PBH participants were 92% female, age 53.4 ± 11.9 y, BMI 31.2 ± 5.6 kg/m ² , versus RYGB non‐hypo (100% female, age 53.2 ± 10.5 y, BMI 32.2 ± 8.0 kg/m ² ) and controls (65% female, age 44.5 ± 14.6 y, BMI 30.8 ± 6.3 kg/m ² ). 87% of PBH reported level 3 hypoglycemia, with emergency visits in 28% and vehicle accidents in 8%. Reduced hypoglycemia awareness was reported by 82%; 13%–17% were classified as unaware (modified Clarke/Gold scores). Preoperative hypoglycemia symptoms and family history were reported by 26% and 18% of PBH. PBH had significantly higher survey scores for hypoglycemia, dumping syndrome, and autonomic symptoms, and higher self‐reported neuropathy, autonomic neuropathy, orthostatic hypotension, reflux esophagitis, intestinal dysmotility, and IBS (all p < 0.05 vs. RYGB non‐hypo). Gabapentin and PPI use was more frequent in PBH.
Conclusion
High rates of IBS, dumping symptoms, and orthostatic hypotension suggest disordered autonomic regulation as a potential contributor to PBH. Self‐reported preoperative symptoms and family history of hypoglycemia suggest possible preoperative differences in glucose metabolism in PBH.
... Previous studies have found that preoperative HbA1c, lower BMI, and greater postoperative weight loss are predictors of PBSH [109,130]. A study by Nielsen et al [131] showed that younger age and lower postoperative BMI were strong predictors of PBSH, while a study by Belligoli et al[132] demonstrated that the incidence of hypoglycemia was higher in younger patients with lower fasting blood glucose levels and higher triglyceride levels before laparoscopic sleeve gastrectomy. It has also been shown that the longer the duration of surgery, the higher the risk of hypoglycemia [109,133]. ...
Diabetes mellitus (DM) and obesity have become public issues of global concern. Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach; however, there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM. In this review, we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM. I believe that our insights will be of great help to clinicians in their daily practice.
... The anatomical and physiological modifications caused by the RYGB are related to accelerated gastric emptying, which is known to interfere with the postprandial glycemic response in patients with and without T2DM [7]. Furthermore, the rapid transit of glucose in the small intestine causes a substantial release of the hormone glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide 1 (GLP-1), among others, which stimulate exaggerated insulin secretion, causing reactive hypoglycemia, aggravated by the inhibition of glucagon release by GLP-1 [8,9]. Therefore, glycemic variability (GV) should also be assessed in RYGB patients since large oscillations of glucose levels may be involved in the pathogenesis of diabetic complications and mortality. ...
Purpose
To evaluate glycemic variability (GV) using continuous glucose monitoring (CGM) in individuals with and without type 2 diabetes mellitus (T2DM) undergoing Roux-en-Y gastric bypass (RYGB).
Methods
This prospective cohort study compared the CGM data of fourteen patients with T2DM (n = 7) and without T2DM (n = 7) undergoing RYGB. After 6 months, these patients were compared to a non-operative control group (n = 7) matched by BMI, sex, and age to the T2DM group.
Results
Fourteen patients underwent RYGB, with a mean BMI of 46.9 ± 5.3 kg/m² and an average age of 47.9 ± 8.9 years; 85% were female. After 6 months post-surgery, the total weight loss (TWL) was 27.1 ± 6.3%, with no significant differences between the groups. Patients without diabetes had lower mean interstitial glucose levels (81 vs. 94 and 98 mg/dl, p < 0.01) and lower glucose management indicator (GMI) (5.2 vs. 5.6 and 5.65%, p = 0.01) compared to the control and T2DM groups, respectively. The coefficient of variation (CV) significantly increased only in patients with diabetes (17% vs. 26.7%, p < 0.01). Both groups with (0% vs. 2%, p = 0.03) and without (3% vs. 22%, p = 0.03) T2DM experienced an increased time below range with low glucose (54–69 mg/dL). However, patients without T2DM had significantly less time in rage (70–180 mg/dL) (97% vs. 78%, p = 0.04).
Conclusion
Significant differences in CGM metrics among RYGB patients suggest an increase in glycemic variability after surgery, with a longer duration of hypoglycemia, especially in patients without T2DM.
Graphical Abstract
... While early dumping often occurs in isolation, the solitary late dumping is a rare phenomenon [38]. Nielsen et al. investigated the prevalence of dumping up to 4.5 years after LRYGB in 1429 patients [39]. Early dumping was present in 9.4% of the patients, while reactive hypoglycemia, i.e., late dumping, in 6.6% of the cases and usually it was fully symptomatic. ...
Introduction
We still lack studies providing analysis of changes in glucose and lipid metabolism after laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes mellitus (DM2). We aimed to investigate postoperative changes in glucose and lipid metabolism after LSG in patients with DM2.
Material and Methods
Prospective, observational study included patients with BMI ≥ 35 kg/m² and ≤ 50 kg/m², DM2 < 10 years of duration, who were qualified for LSG. Perioperative 14-day continuous glucose monitoring (CGM) began after preoperative clinical assessment and OGTT, then reassessment 1 and 12 months after LSG. Thirty-three patients in mean age of 45 ± 10 years were included in study (23 females).
Results
EBMIL before LSG was 17 ± 11.7%, after 1 month—36.3 ± 12.8%, while after 12 months—66.1 ± 21.7%. Fifty-two percent of the patients had DM2 remission after 12 months. None required then insulin therapy. 16/33 patients initially on oral antidiabetics still required them after 12 months. Significant decrease in HbA1C was observed: 5.96 ± 0.73%; 5.71 ± 0.80; 5.54 ± 0.52%. Same with HOMA-IR: 5.34 ± 2.84; 4.62 ± 3.78; 3.20 ± 1.99. In OGTT, lower increase in blood glucose with lesser insulin concentrations needed to recover glucose homeostasis was observed during follow-ups. Overtime perioperative average glucose concentration in CGM of 5.03 ± 1.09 mmol/L significantly differed after 12 months, 4.60 ± 0.53 (p = 0.042). Significantly higher percentage of glucose concentrations above targeted compartment (3.9–6.7 mmol/L) was observed in perioperative period (7% ± 4%), than in follow-up (4 ± 6% and 2 ± 1%). HDL significantly rose, while triglyceride levels significantly decreased.
Conclusions
Significant improvement in glucose and lipid metabolism was observed 12 months after LSG and changes began 1 month after procedure.
Graphical Abstract
... Symptoms of postbariatric hypoglycemia include autonomic and neuroglycopenic symptoms like tremor, visual disturbance, dizziness, palpitation, and perspiration, while severe neuroglycopenic symptoms manifest as syncope, convulsion, and coma (6). The condition is characterized by recurrent postprandial level 1 and 2 hypoglycemic episodes (<3.9 and <3.0 mmol/L, respectively) and, in serious cases (0.1%-6.8%) (7), severe neuroglycopenia requiring hospital admission, impairing quality of life, increasing the risk of accidental death, and contributing to substantial weight regain. The underlying mechanisms of postbariatric hypoglycemia are multifactorial and are related to the anatomic reconfiguration of the gastrointestinal tract causing accelerated intestinal nutrient delivery and transit, leading to augmented glucose absorption and exaggerated release of the insulinotropic gut hormone, glucagon-like peptide 1 (8). ...
OBJECTIVE
Postbariatric hypoglycemia affects >50% of individuals who have undergone Roux-en-Y gastric bypass surgery. Despite the often debilitating nature of this complication, existing treatment options are limited and often inefficient. Dasiglucagon is a stable glucagon analog available in a ready-to-use formulation and was recently shown to mitigate postbariatric hypoglycemia in experimental settings. Here, we aimed to evaluate the hypoglycemic hindering potential of dasiglucagon in an outpatient trial.
RESEARCH DESIGN AND METHODS
We conducted a randomized, double-blind, placebo-controlled, crossover, proof-of-concept study at the Center for Clinical Metabolic Research at Gentofte Hospital in Denmark. The study included 24 individuals who had undergone Roux-en-Y gastric bypass surgery (n = 23 women) with continuous glucose monitor–verified postbariatric hypoglycemia (≥15 min at <3.9 mmol/L three or more times per week) randomly assigned to two treatment periods of four weeks of self-administered subcutaneous dasiglucagon at 120 μg or placebo. The primary and key secondary outcomes were continuous glucose monitor–captured percentage of time in level 1 and 2 hypoglycemia (<3.9 and <3.0 mmol/L), respectively.
RESULTS
Compared with placebo, treatment with dasiglucagon significantly reduced time in level 1 hypoglycemia by 33% (−1.2 percentage points; 95% CI −2.0 to −0.5; P = 0.002) and time in level 2 hypoglycemia by 54% (−0.4 percentage points; 95% CI −0.6 to −0.2; P < 0.0001). Furthermore, dasiglucagon corrected hypoglycemia within 15 min in 401 of 412 self-administrations, compared with 104 of 357 placebo self-administrations (97.3% vs. 29.1% correction of hypoglycemia rate; P < 0.001). Dasiglucagon was generally well tolerated, with mostly mild to moderate adverse events of nausea.
CONCLUSIONS
Compared with placebo, four weeks of self-administered dasiglucagon effectively reduced clinically relevant hypoglycemia in individuals who had undergone Roux-en-Y gastric bypass surgery.
... condition ranges widely in the literature (6.6-88.0%) depending on the diagnostic methodology used (3,4) and appears to occur more commonly after Roux-en-Y gastric bypass (RYGB) than after other surgical procedures (4,5). ...
Objective:
Post-bariatric surgery hypoglycemia (PBH) is a metabolic complication of Roux-en-Y gastric bypass (RYGB). Since symptoms are a key component of the Whipple's triad to diagnose nondiabetic hypoglycemia, we evaluated the relationship between self-reported symptoms and postprandial sensor glucose profiles.
Research design and methods:
Thirty patients with PBH after RYGB (age: 50.1 [41.6-60.6] years, 86.7% female, BMI: 26.5 [23.5-31.2] kg/m2; median [interquartile range]) wore a blinded Dexcom G6 sensor while recording autonomic, neuroglycopenic, and gastrointestinal symptoms over 50 days. Symptoms (overall and each type) were categorized into those occurring in postprandial periods (PPPs) without hypoglycemia, or in the preceding dynamic or hypoglycemic phase of PPPs with hypoglycemia (nadir sensor glucose <3.9 mmol/L). We further explored the relationship between symptoms and the maximum negative rate of sensor glucose change and nadir sensor glucose levels.
Results:
In 5,851 PPPs, 775 symptoms were reported, of which 30.6 (0.0-59.9)% were perceived in PPPs without hypoglycemia, 16.7 (0.0-30.1)% in the preceding dynamic phase and 45.0 (13.7-84.7)% in the hypoglycemic phase of PPPs with hypoglycemia. Per symptom type, 53.6 (23.8-100.0)% of the autonomic, 30.0 (5.6-80.0)% of the neuroglycopenic, and 10.4 (0.0-50.0)% of the gastrointestinal symptoms occurred in the hypoglycemic phase of PPPs with hypoglycemia. Both faster glucose dynamics and lower nadir sensor glucose levels were related with symptom perception.
Conclusions:
The relationship between symptom perception and PBH is complex, challenging clinical judgement and decision-making in this population.
... Puede clasificar como temprano o tardío, tiene una prevalencia de aproximadamente 13% y se encuentra con mayor frecuencia en mujeres jóvenes. 61 • S ín d r o m e d e d u m p in g t e m p r a n o . Ocurre dentro de la primera hora después de ingerir una comida, típicamente se presentará con diarrea, mareos, rubor y posiblemente hipotensión. ...
Compendio de bolsillo sobre enfermedades hepáticas y digestivas
... Les améliorations métaboliques observées après bypass gastrique sont une normalisation du lipidogramme, une amélioration de l'insulino-résistance et une diminution de l'inflammation visible en histologie [102]. La chirurgie bariatrique reste, cependant, une intervention lourde, risquée pour le patient et pouvant entraîner des complications telles que des déficits nutritionnels [103,104], des calculs biliaires [105], des complications périopératoires [106] et des altérations de la qualité de vie [107,108]. Des alternatives thérapeutiques ont donc un intérêt majeur dans la prise en charge de la NASH. ...
Résumé
La NAFLD ou maladie du foie gras non alcoolique est une des complications de l’obésité et du diabète dont la prévalence augmente fortement. Les causes de la pathologie et de son développement vers sa forme sévère, la NASH ou stéato-hépatite non alcoolique, sont multiples et encore mal comprises. De nombreuses classes pharmacologiques différentes sont en cours d’essais cliniques pour traiter la NASH, mais aucun médicament n’existe actuellement sur le marché. De plus, le diagnostic de certitude n’est possible que par ponction d’une biopsie hépatique et analyse histologique, geste invasif et de haut risque pour le patient. Il apparait donc nécessaire de mieux comprendre l’histoire naturelle de la maladie afin d’identifier des cibles thérapeutiques, mais également d’identifier des marqueurs pour le diagnostic et le suivi de la pathologie à l’aide d’un prélèvement sanguin, qui permettront une amélioration de la prise en charge des patients.
... [19]. Постоянная рвота в послеоперационном периоде, определяемая как один из основных факторов риска развития недостаточности тиамина, встречается главным образом в связи с рестриктивными операциями и реже -у пациентов, перенесших шунтирующие операции [20]. Критическим фактором дефицита В 1 является короткий период полувыведения данного витамина (запасы тиамина в организме обычно достаточны в течение 18-20 дней) [21]. ...
Surgical treatment of obesity is one of the most effective ways to reduce and maintain body weight for a long time. Depending on the type of operation, patients with different frequency develop malabsorption syndrome. As a result, in individuals who have received this type of medical care, at different times after bariatric surgery, micro and macronutrient deficiencies may be detected. Therefore, the long-term safety of this treatment method is associated with the correction of vitamin and trace element deficiencies both before and after bariatric intervention. This review highlights the most common deficiencies that are found in obese patients, as well as methods for their diagnosis and treatment.
... The metabolic diseases can be modulated by lifestyle changes, physical exercise, and several pharmacological interventions, but due to inadequate treatment options or undesirable side effects, people are more prone to obesity. For example, Roux-en-Y gastric bypass surgery, which removes the half portion of the stomach to reduce the absorption of nutrients, is complex and invasive with various side effects [22]. Alternative therapies or pharmaceutical interventions targeting specific biological pathways are urgently needed. ...
Growth differentiation factor 15 or macrophage inhibitory cytokine-1 (GDF15/MIC-1) is a divergent member of the transforming growth factor β superfamily and has a diverse pathophysiological role in cancers, cardiometabolic disorder, and other diseases. GDF15 can control hematopoietic growth, energy homeostasis, adipose tissue metabolism, body growth, bone remodeling, and response to stress signals. The role of GDF15 in cancer development and progression is complicated and depends on the specific cancer type, stage, and tumor microenvironment. Recently, research on GDF15 and GDF15-associated signaling has accelerated due to the identification of the GDF15 receptor: glial cell line-derived neurotrophic factor (GDNF) family receptor α-like (GFRAL). Therapeutic interventions to target GDF15 and/or GFRAL revealed the mechanisms that drive its activity and might improve overall outcomes of patients with metabolic disorders or cancer. The present review highlights the structure and functions of GDF15 and its receptor, emphasizing the pleiotropic role of GDF15 in obesity, tumorigenesis, metastasis, immunomodulation, and cachexia.
... Dumping syndrome is a quite common complication of upper gastrointestinal surgery, with a prevalence ranging to almost 50% of the patients in some series. 16,17 It has also been reported in association with diabetes mellitus or viral infections, deteriorating the intrinsic gastric innervation. Even an idiopathic origin has been described, though with a previous history of gastroenteritis in about 50% of the patients.. 18,19 A distinction is often made between the more frequent early dumping (30-60 min after a meal), due to the rapid entrance of undigested hyperosmolar food into the small intestine and the release of various hormones including insulin and glucagon, incretins and vasoactive intestinal substances, and the less common late dumping (>1 h postingestion), due to an incretin-driven hyperinsulinemic response to high glucose concentrations in the foregut. ...
In case of repeated episodes of abdominal discomfort and vagal symptoms, especially occurring after ingestion of a rich meal, the diagnosis of intermittent volvulus could be considered. The sudden arrival of large amounts of partially digested food in the intestine after spontaneous resolution might be associated with a dumping syndrome. In rare cases, dumping‐like symptoms might be related to an intermittent gastric volvulus. In our patient, solid‐phase gastric emptying scintigraphy led to the diagnosis and was essential in treating the patient.
... Long-term complications are related to nutritional deficiencies requiring long-term vitamin and mineral supplementation[14,15]. Dumping syndrome symptoms can appear as early as 6 weeks postoperatively, and have been reported to affect up to 40% of patients according to large survey studies of individuals who have undergone bypass procedures[16,17]. ...
Laparoscopic sleeve gastrectomy is a relatively simple procedure and has become the most well-known bariatric surgical procedure in Korea and Western countries. However, this procedure has several disadvantages in terms of long-term weight loss and metabolic disease control. Laparoscopic sleeve gastrectomy and additional bypass (sleeve plus) procedures were recently introduced into bariatric surgery in order to combine the physiologic advantages of pyloric-saving reconstruction and the bypass effect. A sleeve gastrectomy was performed first, followed by a bypass procedure. This review describes sleeve plus procedures reported in the literature and compares their outcomes with the most frequently performed techniques.
... The physician should recommend dietary modification and, in more serious cases, medical therapy such as acarbose, diazoxide or octreotide should be considered [59]. Studies suggest that predictors for both conditions include lower BMI and younger age [60]. ...
Purpose of Review
The aim of this review is to outline the obesity physician’s role in managing patients with severe obesity with a particular emphasis on bariatric surgery candidates.
Recent Findings
Obesity is a chronic, relapsing and progressive disease. Scoring systems that evaluate the severity of obesity based on the clinical assessment, rather than the Body Mass Index, are a valuable tool. The clinical assessment should explore the underlying contributors for weight gain and screen for obesity-related complications. Bariatric surgery remains the most effective management approach for severe and complex obesity. Nevertheless, pharmacotherapy and other non-surgical approaches play an important role.
Summary
The bariatric-metabolic physician’s role is paramount in delivering effective care to patients with obesity. The multiple complications of patients with clinically severe obesity highlight the complexity of their management and reinforce the need for adequate assessment and long-term follow-up to ensure optimal clinical outcomes.
... It is usually described in patients who underwent BS at least 12 months before [6]. However, most of the patients are diagnosed with severe neuroglycopenia symptoms, such as loss of consciousness or seizures [7], suggesting that this alteration may begin earlier after BS [8,9]. At present, there are no standardized diagnostic methods for PHH. ...
Introduction:
Roux-en-Y gastric bypass (RYGB) is the most common surgical procedure for morbid obesity. However, it can present serious late complications, like postprandial hyperinsulinemic hypoglycemia (PHH). Recent data suggested an increase in intestinal SGLT-1 after RYGB. However, there is no data on the inhibition of SGLT-1 to prevent PHH in patients with prior RYBG. On this basis, we aimed to evaluate (a) the effect of canagliflozin 300 mg on the response to 100 g glucose overload (oral glucose tolerance test [OGTT]); (b) the pancreatic response after intra-arterial calcium stimulation in the context of PHH after RYGB.
Materials and methods:
This is a prospective pilot study including patients (n = 21) with PHH after RYGB, matched by age and gender with healthy controls (n = 5). Basal OGTT and after 2 weeks of daily 300 mg of canagliflozin was performed in all cases. In addition, venous sampling after intra-arterial calcium stimulation of the pancreas was performed in 10 cases.
Results:
OGTT after canagliflozin showed a significant reduction of plasma glucose levels (minute 30: 161.5 ± 36.22 vs. 215.9 ± 58.11 mg/dL; minute 60: 187.46 ± 65.88 vs. 225.9 ± 85.60 mg/dL, p < 0.01) and insulinemia (minute 30: 95.6 ± 27.31 vs. 216.35 ± 94.86 mg/dL, p = 0.03; minute 60: 120.85 ± 94.86 vs. 342.64 ± 113.32 mIU/L, p < 0.001). At minute 180, a significant reduction (85.7%) of the rate of hypoglycemia was observed after treatment with canagliflozin (p < 0.00001). All cases presented normal pancreatic response after intra-arterial calcium administration.
Conclusion:
Canagliflozin (300 mg) significantly decreased glucose absorption and prevented PHH after 100 g OGTT in patients with RYGB. Our results suggest that canagliflozin could be a new therapeutic option for patients that present PHH after RYGB.
... One of the most commonly performed surgeries is the Rouxen-Y gastric bypass surgery, but it is however not free from complications. One major complication is the problem with postprandial hypoglycemia-occurring in up to 1/3 of patients [1,2]. The hypoglycemia typically occur about 1-3h postmeal, and present with typical hypoglycemic symptoms as altered cognition, weakness, seizures, tremor, and ultimately loss of consciousness [3]. ...
Obesity is one of the major health problems of the world, and one of the most common surgical treatments is the Roux-en-Y gastric bypass surgery. This can however lead to problems with postprandial hypoglycemia, but sometimes, the meal test does not render any signs of hypoglycemia. Here, 3 cases are presented with postprandial normoglycemic hypokalemia.
Graphical abstract
Background
A limited subset of patients undergoing Roux-en-Y gastric bypass (RYGB) may develop intractable symptoms that ultimately require reversal to normal anatomy. Existing literature on this subject is characterized by small cohort sizes, substantial variation in surgical techniques, and limited follow-up durations. However, this study presents the largest single-center series to date, comprising seventy patients.
Methods
A prospective analysis was conducted on clinical data from patients who underwent laparoscopic reversal of Roux-en-Y gastric bypass (RYGB). The study evaluated the indications for the procedure, technical considerations, clinical outcomes, and associated complications. Patients were stratified into two groups based on their primary symptoms: Group 1 (abdominal pain; n = 47) and Group 2 (hypoglycemia, malnutrition, or other symptoms; n = 23).
Results
Seventy patients were included in the study, with a mean follow-up period of 2.4 years. The majority of patients (93%, 65/70) were female, and the mean age was 44 ± 11.45 years. The mean body mass index (BMI) at baseline was 28.7 ± 6.3 kg/m². In Group 1, 85% of patients experienced either complete or partial resolution of symptoms, while in Group 2, 96% achieved complete symptom resolution. Thromboembolic complications occurred in 7.1% of patients, and 13% required reoperation. At 12 months post-reversal, mean weight and BMI had increased by 9.1 kg and 3.2 kg/m², respectively. At the most recent follow-up, the total weight gain (Δkg) was 14.9 kg, and the BMI increase (ΔBMI) was 5.1 kg/m².
Conclusion
Reversal of Roux-en-Y gastric bypass (RYGB) is an effective intervention for patients experiencing chronic complications. Patients with hypoglycemia and malnutrition experienced higher rates of symptom resolution compared to those with abdominal pain or small bowel adhesions. The implementation of pyloroplasty, combined with high-dose subcutaneous anticoagulant therapy, was associated with a reduction in complication rates. Given the expected weight regain following reversal, it is essential for both surgeons and patients to align their expectations with anticipated outcomes.
Background: post-bariatric hypoglycemia is a significant concern for patients and physicians, usually occurring within 1-3 years after surgery. Several factors may be associated with PBH. The aim of this study was to evaluate the predictors of PBH after surgery. Methods: In this retrospective cohort study, the medical profiles of 1009 obese patients (BMI≥30 kg/m2) who underwent surgery with one of the RYGB, OAGB, or SG techniques at one of three medical centers affiliated with [BLINDED FOR REVIEW] between 2020 and 2024 were reviewed. Patients were divided into two groups based on the incidence of PBH. The incidence of PBH was defined based on ICD-10-CM diagnosis codes (E16.1, E16.2) or laboratory values (glucose ≤ 70 mg/dL) during the follow-up period. The incidence of PBH was estimated 1, 3, 6, and 12 months after surgery. Predictors of PBH were evaluated by multivariate logistic regression analysis. Results: The incidence of PBH at 3, 6, and 12 months after surgery was 261 (25.9%), 296(29.3%), and 357(35.4%), respectively. Multivariate analysis showed that female gender (OR Adjusted : 1.91, 95 % CI: 1.11, 2.71), education level <high school(OR Adjusted : 1.61, 95 % CI: 1.1, 2.11), insulin versus oral antidiabetic drugs (OR Adjusted : 2.6, 95 % CI: 1.5, 3.7), vitamin deficiency(OR Adjusted : 1.45, 95 % CI: 1.04, 1.85), and RYGB surgery (OR Adjusted : 1.81, 95 % CI: 1.11, 2.51)were significantly associated with an increased risk of PBH. Whereas having type 2 diabetes(OR Adjusted : 0.89, 95 % CI: 0.81, 0.97), HbA1C levels(OR Adjusted : 0.97, 95 % CI: 0.95, 0.99), and longer duration of diabetes(OR Adjusted : 0.95, 95 % CI: 0.91, 0.99) were significantly associated with a decreased risk of PBH. Conclusion: Our study showed that gender, education level, insulin use, vitamin intake, type of surgical procedure, type 2 diabetes, preoperative HbA1C levels, and duration of diabetes were significantly associated with the prediction of PBH. Knowledge of predictors of PBH can help in postoperative care to prevent PBH.
Objective:
This study aimed to systematically review the existing literature to summarize the incidence and risk factors of post-metabolic and bariatric surgery hypoglycemia (MBSH).
Methods:
We searched PubMed, Medline, Embase, and the Cochrane Library databases for the studies published from inception to August 2023. Randomized controlled trials and analytical studies that investigated the incidence or risk factors of MBSH after different surgery techniques (including Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, duodenal switch, omega-loop gastric bypass, and vertical banded gastroplasty) were involved. The incidence and risk factors of MBSH were extracted and described separately based on different diagnostic criteria and then summarized the risk factors and their statistical findings collectively.
Results:
Twenty-nine studies were reviewed with follow-up ranging from 1 to 22 years. The incidence of MBSH ranged significantly across different diagnostic methods: 2.6-66.4% (self-report), 6.6-61.8% (oral glucose tolerance test), 29.4-78.6% (mixed-meal tolerance test), and 50-75% (continuous glucose monitoring). Patients with a mean age of 49.8 years and 89.0% of them were women with a better glycemic control who undergo RYGB and achieve 86.5% of estimated weight loss from surgery should be particularly vigilant about the possibility of developing MBSH. Distinct biomarkers such as IGF-1 (OR 1.06), fasting glicentin (AUC 0.81), HbA1c (AUC 0.76), and absolute weight reduction (AUC 0.72), greater fluctuations in glucose (OR 1.98) are valuable in promptly detecting MBSH. Specifically, patients with prior cholecystectomy or antidepressant therapy should be particularly cautious.
Conclusion:
The review highlights higher MBSH risk in younger women with significant weight loss after RYGB, and those with prior cholecystectomy or antidepressant use. Systematic summarization of MBSH criteria allowed us to identify the predictors for MBSH, which can aid in early diagnosis and treatment, reducing the need for prolonged monitoring.
Dumping and post‐bariatric hypoglycaemia (PBH) are side effects that occur after bariatric surgery. The aim of this study was to estimate the prevalence of dumping and PBH symptoms before Roux‐en‐Y gastric bypass (RYGB) and sleeve gastrectomy (SG) at 6 months, 1 year, 2 years and 5 years after surgery in a Swedish population. A cross‐sectional single‐centre study was performed at Lindesberg Hospital, Region Örebro County, Sweden, between 2020 and 2023. The Swedish version of the Dumping Severity Scale (DSS‐Swe) questionnaire, which includes eight items regarding dumping symptoms and six items regarding hypoglycaemia symptoms, was used. A total of 742 DSS‐Swe questionnaires were included. The average age at surgery was 42.0 years (standard deviation [SD] = 11.9), and the average body mass index was 41.8 kg/m ² (SD = 5.9). The surgical methods consisted of RYGB (66.3%) and SG (33.7%). The proportion of RYGB patients with highly suspected dumping increased from 4.9% before surgery to 26.3% (adjusted odds ratio [OR] = 7.35, 95% confidence interval [CI] = 3.08–17.52) at the 5‐year follow‐up. PBH symptoms increased from 1.4% before surgery to 19.3% at the 5‐year follow‐up (adjusted OR = 17.88, 95% CI = 4.07–78.54). For SG patients, no significant increase in dumping or PBH symptoms was observed. In patients with persistent type 2 diabetes (T2D), there were no cases of highly suspected hypoglycaemia following RYGB or SG. Symptoms of dumping and PBH were common after RYGB, while no clear increase was observed after SG. Persistent T2D seems to be a protective factor against PBH symptoms.
Objectives
We examined the association between Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) and fracture risk, including major osteoporotic fractures (MOF), and the use of anti-osteoporosis medication (AOM). While RYGB is associated with impaired bone health and increased fracture risk, it remains uncertain whether SG has a similar impact, and whether this risk is primarily due to MOF or any fracture.
Design
We conducted a nationwide cohort study covering patients treated with RYGB (n=16,121, 10.2 years follow-up) or SG (n=1,509, 3.7 years follow-up), from 2006-2018, comparing them to an age- and sex-matched cohort (n=407,580).
Methods
We computed incidence rates and adjusted hazard ratios (HR) with 95% confidence intervals (CIs), using Cox regression for any fracture, MOF, and use of AOM with adjustment for comorbidities.
Results
Compared to the general population cohort, RYGB was associated with an increased risk of any fracture (HR 1.56 [95% CI: 1.48; 1.64]) and MOF (HR 1.49 [1.35; 1.64]). SG was associated with an increased risk of any fracture (HR 1.38 [1.13; 1.68]), while the HR of MOF was 1.43 [0.97; 2.12]. The use of AOM was low but similar in all cohorts (approximately 1%).
Conclusions
Bariatric surgery increased the risk of any fracture and MOF to similar extend. Risks were similar for RYGB and SG. However, SG had a shorter follow-up than RYGB, and the cohort size was rather small. More research is needed for long-term SG fracture risk assessment. The use of AOM was low in all cohorts.
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
Post‐bariatric hypoglycaemia (PBH) is a metabolic complication of bariatric surgery (BS), consisting of low post‐prandial glucose levels in patients having undergone bariatric procedures. While BS is currently the most effective and relatively safe treatment for obesity and its complications, the development of PBH can significantly impact patients' quality of life and mental health. The diagnosis of PBH is still challenging, considering the lack of definitive and reliable diagnostic tools, and the fact that this condition is frequently asymptomatic. However, PBH's prevalence is alarming, involving up to 88% of the post‐bariatric population, depending on the diagnostic tool, and this may be underestimated. Given the prevalence of obesity soaring, and an increasing number of bariatric procedures being performed, it is crucial that physicians are skilled to diagnose PBH and promptly treat patients suffering from it. While the milestone of managing this condition is nutritional therapy, growing evidence suggests that old and new pharmacological approaches may be adopted as adjunct therapies for managing this complex condition.
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.
Postprandial hypoglycemia is a complication to Roux-en-Y gastric bypass (RYGB), but the effects of postprandial exercise and meal glycemic index (GI) on postprandial glucose and glucoregulatory hormone responses are unknown. Ten RYGB-operated and ten age and weight-matched unoperated women completed four test days in random order ingesting mixed meals with high GI (HGI, GI=93) or low GI (LGI, GI=54), but matched on energy and macronutrient content. Ten minutes after meal completion, participants rested or cycled for 30 minutes at 70% of maximum oxygen uptake (VO2-max). Blood was collected for 4 hours. Postprandial exercise did not lower plasma nadir glucose in RYGB after HGI (HGI/rest 3.7±0.5 versus HGI/Ex 4.1±0.4mmol/L, p=0.070). Replacing HGI with LGI meals raised glucose nadir in RYGB (LGI/rest 4.1±0.5mmol/L, p=0.034) and reduced glucose excursions (Δpeak-nadir) but less so in RYGB (-14% [95%CI: -27; -1]) compared with controls (-33% [-51; -14]). Insulin responses mirrored glucose concentrations. Glucagon-like peptide-1 (GLP-1) responses were greater in RYGB versus controls, and higher with HGI versus LGI. Glucose-dependent insulinotropic polypeptide (GIP) responses were greater after HGI versus LGI in both groups. Post-exercise glucagon responses were lower in RYGB than controls, and noradrenaline responses tended to be lower in RYGB, while adrenaline responses were similar between groups. In conclusion, moderate intensity cycling shortly after meal intake did not increase the risk of postprandial hypoglycemia after RYGB. The low GI meal increased nadir glucose and reduced glucose excursions compared with the high GI meal. RYGB participants had lower post-exercise glucagon responses compared with controls.
Background:
Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) lead to lower fasting glucose concentrations, but might cause higher glycemic variability (GV) and increased risk of hypoglycemia. However, it has been sparsely studied in patients without preoperative diabetes under normal living conditions.
Objectives:
To study 24-hour interstitial glucose (IG) concentrations, GV, the occurrence of hypoglycemia and dietary intake before and after laparoscopic RYGB and SG in females without diabetes.
Setting:
Outpatient bariatric units at a community and a university hospital.
Methods:
Continuous glucose monitoring and open-ended food recording over 4 days in 4 study periods: at baseline, during the preoperative low-energy diet (LED) regimen, and at 6 and 12 months postoperatively.
Results:
Of 47 patients included at baseline, 83%, 81%, and 79% completed the remaining 3 study periods. The mean 24-hour IG concentration was similar during the preoperative LED regimen and after surgery and significantly lower compared to baseline in both surgical groups. GV was significantly increased 6 and 12 months after surgery compared to baseline. The self-reported carbohydrate intake was positively associated with GV after surgery. IG concentrations below 3.9 mmol/L were observed in 14/25 (56%) of RYGB- and 9/12 (75%) of SG-treated patients 12 months after surgery. About 70% of patients with low IG concentrations also reported hypoglycemic symptoms.
Conclusions:
The lower IG concentration in combination with the higher GV after surgery, might create a lower margin to hypoglycemia. This could help explain the increased occurrence of hypoglycemic episodes after RYGB and SG.
Die bariatrische Chirurgie zeichnet sich insgesamt durch eine hohe Standardisierung aus, hierdurch konnte eine geringe Komplikationsrate erzielt werden. In den letzten Jahren wurden zunehmend Fast-Track-Konzepte inklusive eines ERAS-Konzepts für bariatrische Operationen eingeführt und im klinischen Alltag implementiert. Bariatrische Patienten weisen ein erhöhtes Risiko für thromboembolische Ereignisse auf. Typische postoperative Komplikationen nach Sleeve-Gastrektomie sind die extraluminale Nachblutung sowie die Klammernahtinsuffizienz. Nach Roux-Y-Magenbypass treten Nachblutungen meist intraluminal auf, zudem kann es zu einer Insuffizienz der Anastomosen kommen. Auch im Langzeitverlauf kann es zu Sekundärerscheinungen und Langzeitkomplikationen nach einer bariatrischen Operation kommen, sodass eine regelmäßige Nachsorge sowie eine Evaluation durch einen bariatrisch erfahrenen Chirurgen im Fall von Beschwerden dringend zu empfehlen ist. Das Komplikationsmanagement umfasst konservative Therapiemaßnahmen wie auch endoskopische sowie operative Maßnahmen.
Over the years, obesity has become a global pandemic. The medical comorbidities associated with obesity have resulted in immense medical costs in the healthcare system Bariatric surgery is currently considered the most effective treatment for individuals with morbid obesity who have failed medical weight loss therapies. Bariatric surgery has been proven to be effective and safe, yielding improvements in quality of life (QOL) and life expectancy. Furthermore, bariatric surgery has been shown to significantly improve obesity-associated comorbidities such as type 2 diabetes (T2D), sleep apnea, hypertension, and hyperlipidemia among many other metabolic improvements. There is also increasing evidence of the impact of bariatric surgery on neurohormonal signaling that control hunger and satiety, but more research is needed to better understand these mechanisms. The majority of bariatric surgeries are performed laparoscopically, resulting in less pain, faster recovery, and reduced morbidity and mortality. Despite the increasing prevalence of bariatric surgery, only 1% of eligible individuals with severe obesity opt for this treatment modality. Barriers to therapy include inadequate patient and provider education, patient preference, financial and insurance obstacles, and access.
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 pre-obesity/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 include 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 functions 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 the functions and treatments of GI hormones and the microbiome, may improve the health of patients with pre-obesity/obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
The causes of postprandial hyperinsulinemic hypoglycemia (PHH) in patients who have undergone an upper gastrointestinal tract surgery are still a matter of debate in the scientific community. Low postoperative body mass index, high postprandial beta-cell activity before the surgery, and younger age are all have been associated with higher PHH risk. It is hypothesized that the insulin-like growth factor-1 increases the tissue sensitivity to insulin and indirectly promotes the development of hypoglycemia. An increase in postprandial secretion of enteropancreatic hormones is still considered to be the main reason for PHH manifestation; however, a particular contribution has been ascribed to glycentin, which could be used as a marker of PHH risk in the future.
At present, there are no clinical guidelines for the diagnosis of PHH. Undoubtedly, the first step in this direction should be the collection of the disease history. The provocative tests have been proposed for the detection of PHH. Today, the 72-hour fast test is still the gold standard in the diagnosis of hypoglycemia. However, most post-bariatric patients do not have fasting hypoglycemia, and insulinoma is extremely rare in this patient category. The use of a prolonged oral glucose tolerance test as the main method is associated with a risk of a false diagnosis, because about 12% of healthy individuals may have their glycemic levels at below 2.8 mmol/l. The mixed meal test has not been validated yet. The best results in the assessment of glucose variability have been obtained with “real time” continuous glucose monitoring the interstitial fluid for several days.
The goal of PHH treatment is to reduce the stimulated insulin secretion. First of all, patients are advised to eat small meals consisting of carbohydrates with a low glycemic index in combination with proteins and lipids, with high fiber content. Should the nutritional modification be ineffective, it is possible to prescribe medical treatment, such as acarbose or somatostatin analogs. Diazoxide and slow calcium channel blockers can be used as the third line of therapy. A recent study has suggested that exogenous agonists of glucagon-like peptide-1 (GLP-1) receptors by stronger bonds with receptors, compared to those with endogenous GLP-1, could enhance glucagon response to hypoglycemia, thereby stabilizing glucose levels. In severe refractory PHH, reconstructive surgery and gastric banding are to be considered. If the expected decrease in insulin hypersecretion by reconstructive surgery is not achieved, partial or complete pancreatectomy remains the only possible approach to prevent hypoglycemia. However, due to the small number and short duration of the studies, effectiveness and safety of these techniques for PHH treatment have not yet been proven.
Aims:
Hypoglycemia is a potentially serious side effect of bariatric surgery but long-term outcomes from prospective, controlled trials are lacking. We therefore examined the incidence of hypoglycemia-related events over up to 31 years in patients treated with bariatric surgery in the Swedish Obese Subjects (SOS) study.
Materials and methods:
The SOS study (n=4047) is a prospective controlled intervention study. The current analysis included 1989 patients treated with bariatric surgery and 2027 control patients with obesity who received usual care. Diagnosed hypoglycemia and events commonly attributed to hypoglycemia (confusion, syncope, epilepsy and seizures), requiring hospital or specialist outpatient treatment were identified by searching the National Patient Register. Analyses were stratified by baseline glycemic status. HRs are adjusted for inclusion year, age, sex, smoking, HbA1c and BMI at baseline. At the time of analysis (December 31, 2018), median follow-up was 22 years.
Results:
Compared with usual care, bariatric surgery was associated with increased incidence of hypoglycemia-related events in patients without baseline diabetes (168 and 219 events, respectively; log-rank P=0.011), with a more pronounced risk during the first years of follow-up (test of time-treatment interaction P=0.010). Multivariate analyses in patients without baseline diabetes indicated male sex (P<0.001), older age (P=0.001) and higher HbA1c levels (P=0.006) as associated with hypoglycemia-related events. No association was found between risk of hypoglycemia-related events and bariatric surgery in patients with baseline diabetes.
Conclusions:
Bariatric surgery is associated with an increased incidence of hypoglycemia-related events in patients without baseline diabetes, especially during the first years following treatment. This article is protected by copyright. All rights reserved.
Adiposopathy is associated with pathophysiological effects on almost every system in the human body including the pulmonary system. Obesity is known to impair pulmonary function, which in turn increases the risk of complications after bariatric surgery. Major pulmonary complications could be life threatening or extremely morbid in the long term. In addition, pre-existing obstructive sleep apnea (OSA) may increase morbidity and mortality from respiratory complications in patients with obesity. Complications like sputum retention, atelectasis, bronchopulmonary infections and pulmonary embolism may cause significant postoperative morbidity and mortality after an elective surgery.
Objective:
After Roux-en-Y gastric bypass (RYGB), postprandial hyperinsulinemic hypoglycemia (PPHH) is particularly critical because of the risk of trauma. The aim of this study was to assess the incidence and identify risk factors for symptomatic PPHH.
Methods:
Patients with RYGB were classified into moderate PPHH (MH) or severe hypoglycemia (SH), which is defined as patients with neuroglycopenic symptoms. Logistic multivariate linear regressions were performed to identify predictive factors for symptomatic PPHH and more specifically for SH with neuroglycopenic symptoms. Patients with diabetes and those with a follow-up shorter than 2 years were excluded.
Results:
Among the 1,138 patients, 44.2% had at least one episode of hypoglycemia with a mean delay of 25.5 (21.3) months, 32.6% had MH, and 11.6% had SH. The annual incidence rate of SH was 2.5% the first year, 3.7% the second year, and 1.5% the third year. Independent predictive factors for higher risk of SH were: younger age (odds ratio [OR] = 1.01; 95% CI: 1.05-16.69; P = 0.0007), lower BMI after RYGB (OR = 1.61; 95% CI: 1.17-2.22; P = 0.0035), and maximal weight loss (OR = 1.04; 95% CI = 1.39-1.23; P = 0.0106), whereas higher preoperative BMI was protective (OR = 0.78; 95% CI: 0.64-0.95; P = 0.0112).
Conclusions:
This observational cohort study showed that the incidence of severe PPHH with neuroglycopenic symptoms after RYGB was higher than expected.
While RYGB persists as the gold standard for weight loss procedures, complications are not infrequent. Adverse events can be categorized by their timing postoperatively, generally occurring in the perioperative setting within 72 h, acutely within the first 8 weeks, or late postoperatively after 8 weeks as acute or chronic events. Expeditious diagnosis and management of life-threatening complications, like gastrointestinal bleed, leak, or small bowel obstruction, are essential, and bariatric surgeons must maintain a low index of suspicion for these events on patient presentation. Furthermore, patients may endorse vague symptoms associated with a variety of possible chronic complications to which the surgeon must be keenly attuned. This chapter provides a framework to identify potential complications after RYGB and aid in establishing a treatment strategy for these patients.
Importance
Population-based studies on the prevalence of symptoms after Roux-en-Y gastric bypass (RYGB) surgery are sparse. Knowledge about possible predictors of these symptoms is important for prevention.Objectives
To examine patients’ overall well-being and the prevalence and predictors of medical, nutritional, and surgical symptoms after RYGB surgery, and their association with quality of life.Design, Setting, and Participants
A survey was conducted from March 3 to July 31, 2014, among 2238 patients who underwent RYGB surgery between January 1, 2006, and December 31, 2011, in the Central Denmark Region. A comparison cohort of 89 individuals who were matched with patients according to sex and body mass index but who did not undergo RYGB surgery were surveyed as a point of reference. Data analysis was conducted from September 1, 2014, to June 25, 2015.Main Outcomes and Measures
Prevalence and severity (based on contacts with health care system, ranging from no contact to hospitalization) of self-reported symptoms following RYGB surgery. Prevalence ratios (PRs) of symptoms associated with different predictors were computed. The association between number of symptoms and quality of life was investigated using the Spearman rank correlation coefficient.Results
Of 2238 patients undergoing RYGB surgery, 1429 (63.7%) responded to the survey. Among these patients, 1266 (88.6%) reported 1 or more symptoms a median of 4.7 years after RYGB surgery. Mean age at the time of the survey was 47.1 years (range, 26.9-68.0 years), and 286 were men (20.0%). A total of 1219 of 1394 patients (87.4%) reported that their well-being was improved after vs before RYGB surgery, while 113 (8.1%) reported reduced well-being. Symptoms after RYGB surgery were reported by 1266 patients (88.6%); 966 patients (67.6%) had been in contact with the health care system about their symptoms vs 31 [34.8%] of those in the comparison group, and 416 (29.1%) had been hospitalized vs 6 [6.7%] of those in the comparison group. The symptoms most commonly leading to health care contact after RYGB surgery were abdominal pain (489 [34.2%]), fatigue (488 [34.1%]), and anemia (396 [27.7%]). The risk of symptoms was higher among women (crude PR, 1.23; 95% CI, 1.11-1.37), among patients younger than 35 years (PR, 1.24; 95% CI, 1.13-1.36), among smokers (PR, 1.11; 95% CI, 1.02-1.20), among unemployed persons (PR, 1.15; 95% CI, 1.06-1.24), and in those with surgical symptoms before RYGB surgery (PR, 1.34; 95% CI, 1.25-1.43). Quality of life was inversely associated with the number of symptoms (r = –0.30; P < .001).Conclusions and Relevance
Most patients reported improved well-being after RYGB surgery, but the prevalence of symptoms was high and nearly one-third of patients were hospitalized, 4- to 5-fold more than among the comparison group. Predictors of symptoms included young age, female sex, smoking, and experiencing symptoms before RYGB surgery. Development of weight loss procedures with fewer subsequent symptoms should be a high priority.
In spite of its evident success, several late complications can occur after gastric bypass surgery. One of these is post-gastric bypass hypoglycaemia. No evidence-based guidelines exist in the literature on how to confirm the presence of this syndrome. This study aims to describe and compare the tests aimed at making a diagnosis of post-gastric bypass hypoglycaemia and to provide a diagnostic approach based upon the available evidence. A search was conducted in PubMed, Cochrane and Embase. A few questionnaires have been developed to measure the severity of symptoms in post-gastric bypass hypoglycaemia but none has been validated. The gold standard for provocation of a hypoglycaemic event is the oral glucose tolerance test or the liquid mixed meal tolerance test. Both show a high prevalence of hypoglycaemia in post-gastric bypass patients with and without hypoglycaemic complaints as well as in healthy volunteers. No uniformly established cut-off values for glucose concentrations are defined in the literature for the diagnosis of post-gastric bypass hypoglycaemia. For establishing an accurate diagnosis of post-gastric bypass hypoglycaemia, a validated questionnaire, in connection with the diagnostic performance of provocation tests, is the most important thing missing. Given these shortcomings, we provide recommendations based upon the current literature.
© 2015 World Obesity.
There is a lack of prevalent data for dumping syndrome (DS) and methods discriminating between different symptoms of the DS. A self-assessment questionnaire, the Dumping Symptom Rating Scale (DSRS), was developed. The aim was to measure the severity and frequency of nine dumping symptoms and to evaluate the construct validity of the DSRS. Pre- and 1 and 2 years after Roux-en-Y gastric bypass surgery, 47 adults and 82 adolescents completed the DSRS. Cognitive interview was performed. Reliability and construct validity were tested. Effect sizes (ES) of changes were calculated. Patients found the questionnaire relevant. A high proportion of the respondents reported no symptoms affecting them negatively at all (floor effects). However, 12 % stated, quite severe, severe, or very severe problems regarding fatigue after meal and half of them were so tired that they needed to lie down. Nearly 7 % reported quite severe, severe, or very severe problems dominated by nausea and 6 % dominated by fainting esteem. The internal consistency reliability was adequate for both severity (0.81-0.86) and frequency (0.76-0.84) scales. ES were small, since some subjects experienced symptoms already preoperatively. Although most patients reported no or mild dumping symptoms 1 and 2 years after gastric bypass surgery, around 12 % had persistent symptoms, in particular, postprandial fatigue, and needed to lie down. Another 7 % had problems with nausea and 6 % had problems with fainting esteem. The DSRS is a reliable screening tool to identify these patients.
Symptomatic hypoglycaemia with related confusion, syncope, epilepsy or seizures is a newly recognised complication of gastric bypass surgery for obesity. The incidence of these conditions is not known. We therefore studied the incidence of post-gastric bypass hypoglycaemia and related symptoms in patients who have undergone gastric bypass and a reference cohort from the general population of Sweden.
This is a nationwide cohort study based on national registries with 5,040 persons who underwent gastric bypass, vertical banded gastroplasty or gastric banding for obesity in Sweden between 1 January 1986 and 31 December 2006 and a cohort of ten referents per patient matched for sex and age randomly sampled from the general population. The incidence rates of hospitalisation for hypoglycaemia, confusion, syncope, epilepsy or seizures before and after dates of surgery or inclusion in the reference cohort were studied.
Preoperative incidences of hospitalisation for hypoglycaemia were similar in the surgical and referent cohorts. After gastric bypass surgery, the adjusted hazard ratios were significantly elevated for hypoglycaemia (2.7 [95% CI 1.2-6.3]), confusion (2.8 [1.3-6.0]), syncope (4.9 [3.4-7.0]), epilepsy (3.0 [2.1-4.3]) and seizures (7.3 [5.0-10.8]). The proportions of gastric bypass patients and reference participants affected by hypoglycaemia were very low (0.2% and 0.04%, respectively). There was no increased risk of hypoglycaemia after vertical banded gastroplasty or gastric banding compared with the referent population.
Obese persons who have undergone gastric bypass have an increased risk of hospitalisation for diagnoses associated with post-gastric bypass hypoglycaemia, although few patients are affected.
Reductions in insulin sensitivity in conjunction with muscle mitochondrial dysfunction have been reported to occur in many conditions including aging. The objective was to determine whether insulin resistance and mitochondrial dysfunction are directly related to chronological age or are related to age-related changes in body composition.
Twelve young lean, 12 young obese, 12 elderly lean, and 12 elderly obese sedentary adults were studied. Insulin sensitivity was measured by a hyperinsulinemic-euglycemic clamp, and skeletal muscle mitochondrial ATP production rates (MAPRs) were measured in freshly isolated mitochondria obtained from vastus lateralis biopsy samples using the luciferase reaction.
Obese participants, independent of age, had reduced insulin sensitivity based on lower rates of glucose infusion during a hyperinsulinemic-euglycemic clamp. In contrast, age had no independent effect on insulin sensitivity. However, the elderly participants had lower muscle MAPRs than the young participants, independent of obesity. Elderly participants also had higher levels inflammatory cytokines and total adiponectin. In addition, higher muscle MAPRs were also noted in men than in women, whereas glucose infusion rates were higher in women.
The results demonstrate that age-related reductions in insulin sensitivity are likely due to an age-related increase in adiposity rather than a consequence of advanced chronological age. The results also indicate that an age-related decrease in muscle mitochondrial function is neither related to adiposity nor insulin sensitivity. Of interest, a higher mitochondrial ATP production capacity was noted in the men, whereas the women were more insulin sensitive, demonstrating further dissociation between insulin sensitivity and muscle mitochondrial function.
This study allocated the symptoms identified during acute hypoglycemia objectively to the autonomic or neuroglycopenic groups of symptoms by the use of factor analysis.
Twenty-five nondiabetic subjects, 14 newly diagnosed insulin-dependent diabetic patients, and 16 insulin-dependent diabetic patients with diabetes greater than 4 yr duration were studied. Acute hypoglycemia was induced with insulin (2.5 mU.kg-1 body wt.min-1 i.v.), and symptoms of hypoglycemia were recorded with a seven-point scale at regular time points throughout the studies. Factor analysis of the symptom scores at the time of the acute autonomic reaction with principal component analysis followed by Varimax rotation was used to separate those symptoms that might belong to neuroglycopenic and autonomic groups.
Hypoglycemia was induced to a mean +/- SE plasma glucose nadir of 1.3 +/- 0.1 mM in nondiabetic subjects, to 2.0 +/- 0.3 mM in newly diagnosed diabetic patients, and 1.4 +/- 0.2 mM in patients with diabetes of greater than 4 yr duration. The most frequently reported autonomic symptoms were sweating, trembling, and warmness, and the most frequently reported neuroglycopenic symptoms were inability to concentrate, weakness, and drowsiness. Neuroglycopenic symptoms were reported more commonly at the onset of hypoglycemia, which was identified by the development of symptoms. Factor analysis grouped trembling, anxiety, sweating, warmness, and nausea together, and this grouping was labeled an autonomic factor. A second factor was identified that included dizziness, confusion, tiredness, difficulty in speaking, shivering, drowsiness, and inability to concentrate, which was labeled a neuroglycopenic factor.
This study demonstrated the high frequency with which neuroglycopenic symptoms occur at the onset of hypoglycemia and the symptoms that could be used by an individual patient as a warning of the development of acute hypoglycemia, although the rapid reduction of plasma glucose is faster than experienced by the ambulant diabetic patient. Factor analysis assisted with the allocation of symptoms to either the autonomic or neuroglycopenic groupings, but the allocation of some symptoms remained undefined, and care must be taken when assessing symptoms such as hunger, weakness, blurred vision, and drowsiness when comparing the frequency of autonomic versus neuroglycopenic symptoms. To reduce the confusion resulting from the use of different symptom questionnaires in studies of hypoglycemia, a sample questionnaire is presented, the development of which was assisted by our analysis.
The allocation of hypoglycaemic symptoms to autonomic or neuroglycopenic groups tends to occur on an a priori basis. In view of the practical need for clear symptom markers of hypoglycaemia more scientific approaches must be pursued. Substantial evidence is presented from two large scale studies we performed which support a three factor model of hypoglycaemic symptomatology, based on the statistical associations discovered among symptoms reported by diabetic patients. Study 1 involved 295 insulin-treated out-patients and found that 11 key hypoglycaemic symptoms segregated into three clear factors: autonomic (sweating, palpitation, shaking and hunger) neuroglycopenic (confusion, drowsiness, odd behaviour, speech difficulty and incoordination), and malaise (nausea and headache). The three factors were validated on a separate group of 303 insulin-treated diabetic out-patients. Confirmatory factor analyses showed that the three factor model was the optimal model for explaining symptom covariance in each group. A multi-sample confirmatory factor analysis tested the rigorous assumptions that the relative loadings of symptoms on factors across groups were equal, and that the residual variance for each symptom was identical across groups. These assumptions were successful, indicating that the three factor model was replicated in detail across these two large samples. It is suggested that the results indicate valid groupings of symptoms that may be used in future research and in clinical practice.
To identify methods to increase response to postal questionnaires.
Systematic review of randomised controlled trials of any method to influence response to postal questionnaires.
292 randomised controlled trials including 258 315 participants INTERVENTION REVIEWED: 75 strategies for influencing response to postal questionnaires.
The proportion of completed or partially completed questionnaires returned.
The odds of response were more than doubled when a monetary incentive was used (odds ratio 2.02; 95% confidence interval 1.79 to 2.27) and almost doubled when incentives were not conditional on response (1.71; 1.29 to 2.26). Response was more likely when short questionnaires were used (1.86; 1.55 to 2.24). Personalised questionnaires and letters increased response (1.16; 1.06 to 1.28), as did the use of coloured ink (1.39; 1.16 to 1.67). The odds of response were more than doubled when the questionnaires were sent by recorded delivery (2.21; 1.51 to 3.25) and increased when stamped return envelopes were used (1.26; 1.13 to 1.41) and questionnaires were sent by first class post (1.12; 1.02 to 1.23). Contacting participants before sending questionnaires increased response (1.54; 1.24 to 1.92), as did follow up contact (1.44; 1.22 to 1.70) and providing non-respondents with a second copy of the questionnaire (1.41; 1.02 to 1.94). Questionnaires designed to be of more interest to participants were more likely to be returned (2.44; 1.99 to 3.01), but questionnaires containing questions of a sensitive nature were less likely to be returned (0.92; 0.87 to 0.98). Questionnaires originating from universities were more likely to be returned than were questionnaires from other sources, such as commercial organisations (1.31; 1.11 to 1.54).
Health researchers using postal questionnaires can improve the quality of their research by using the strategies shown to be effective in this systematic review.
To determine which (if any) pre-surgery obesity-related co-morbidities predict complications after bariatric surgery.
Claims data are analyzed for 1,760 patients aged 18-62 who were covered by one of seven New York State health plans and underwent bariatric surgery during 2002-2005. Data covered 6 months before to 18 months after surgery. Pre-surgery obesity-related comorbidities studied include: diabetes, hyperlipidemia, hypertension, asthma, arthritis, sleep apnea, GERD, and depression. Specific post-surgery complications examined are: stenosis, complications associated with the anastomosis, dumping syndrome, and sepsis.
Obesity-related co-morbidities prior to surgery are significantly correlated with the probability of developing complications up to 180 days after bariatric surgery. For example, sepsis was significantly more likely in patients who had diabetes, arthritis, or sleep apnea prior to surgery. An additional pre-surgery comorbidity is associated with a 27.5% higher likelihood of dumping syndrome, 24.5% higher likelihood of complications associated with the anastomosis, and 23.5% higher probability of sepsis in the first 180 days after surgery. Among the individual co-morbidities studied, sleep apnea and GERD are most predictive of complications.
Patients who exhibit multiple obesity-related co-morbidities prior to bariatric surgery are at significantly elevated risk of post-surgery complications and merit closer monitoring by health care professionals after bariatric surgery. Limitations of this study include nonexperimental data and an unknown degree of under-reporting of pre-surgery co-morbidities in claims data.
Objectives: To evaluate changes over time in drug use among patients undergoing Roux-en-Y gastric bypass (RYGB) surgery and a matched population-based comparison cohort. Background: A little is known about the prescription drug use before and after RYGB surgery. Methods: Nationwide population-based cohort study included 9908 patients undergoing RYGB in Denmark during 2006 to 2010 and 99,080 matched general population members. We calculated prevalence ratios (PRs) comparing prescription drug use 36 months after RYGB/index date with use 6 months before this date (baseline). Results: At baseline, more RYGB patients (median 40 years, 22% males) used a prescription drug (81.5% vs 49.1%). After 3 years, the use had decreased slightly among RYGB patients [PR = 0.93; 95% confidence interval (CI) = (0.91, 0.94)], but increased in the comparison cohort (PR = 1.05; 95% CI = 1.04-1.06). In the RYGB cohort, large, sustained decreases occurred for treatment of metabolic syndrome-related conditions, such as any glucose-lowering drug (PR = 0.28; 95% CI = 0.25-0.31) and lipid-modifying drugs PR = 0.50; 95% CI = 0.46-0.55). Use of inhalants for obstructive airway diseases (PR = 0.79; 95% CI = 0.74-0.85) also decreased. Use of neuropsychiatric drugs was two-fold higher at baseline in the RYGB cohort (22.8% vs 10.9%) and increased further after RYGB-that is, antidepressants (PR = 1.13; 95% CI = 1.07-1.19), antipsychotics (PR = 1.39; 95% CI = 1.21-1.60), and potential treatment of neuropathy (PR = 1.39; 95% CI = 1.28-1.51). Conclusions: Three years after RYGB surgery, we found large reductions in the use of treatment of metabolic syndrome-related conditions, inhalants for obstructive airway diseases and glucocorticoid use. In contrast, frequent use of neuropsychiatric drugs further increased after RYGB. Copyright
Objective
To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients.MethodsA questionnaire including the Edinburgh hypoglycemia scale was mailed to patients who underwent either Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) at a single center. Based on the questionnaire, the patients were categorized as having high or low suspicion for post surgical, postprandial hypoglycemic symptoms.ResultsOf the 1119 patients with valid addresses, 40.2% (N = 450) responded. Among the respondents, 34.2% had a high suspicion for symptoms of post bariatric surgery hypoglycemia. In multivariate analyses, in addition to female sex (P = 0.001), RYGB (P = 0.004), longer time since surgery (P = 0.013), and lack of diabetes (P = 0.040), the high suspicion group was more likely to report pre-operative symptoms of hypoglycemia (P < 0.001), compared to the low suspicion group. Similar results were observed when the high suspicion group was restricted to those requiring assistance from others, syncope, seizure with severe symptoms, or medically confirmed hypoglycemia (N = 52).Conclusions
One third of patients who underwent RYGB or VSG reported postprandial symptoms concerning for postsurgical hypoglycemia, which was related to the presence of pre-operative hypoglycemic symptoms. Pre-operative screening for hypoglycemic symptoms may identify a group of patients at increased risk of postbariatric surgery hypoglycemia.
Hypoglycemic episodes are described after bariatric surgery.
To report the prevalence of hypoglycemia after a 75 g oral glucose load (OGTT) after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB), and to identify predicting factors.
Bariatric surgery referral center.
Prospective cohort of 351 consecutive patients before and 12 months after bariatric surgery, on whom an OGTT was performed. The main outcome measure was postchallenge hypoglycemia (PCHy), defined as a 120 minute plasma glucose value<2.8 mmol/L (50.4 mg/dL).
Only patients with an RYGB presented with PCHy. It occurred in 23 patients or a prevalence of 10.4% after an RYGB. The OR was 25.5 (95% CI 3.4-191; P<.001) compared with before surgery. Patients with PCHy after surgery had a lower glycated hemoglobin (HbA1c), and a lower 2-hour postchallenge value before surgery. Before surgery, patients with normal glucose tolerance had an increased risk of PCHy after surgery (OR 8.6, 95% CI 2.0-37.6; P< .001).
The prevalence of OGTT-induced hypoglycemia is increased 25.5 times, 12 months after an RYGB. This is not observed after a gastric banding.
Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Background
Data on gastrointestinal (GI) side effects of bariatric surgery are limited due to incomplete reporting, cross sectional samples, and non-standardized assessments.
Objective
To report on GI side effects over the first 6 months following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).
Setting
Academic Medical Center, United States.
Methods
One hundred forty-four patients completed a standardized clinical interview 6 months after operation, including questions on the occurrence and frequency of episodes of dumping syndrome, vomiting, and plugging for each of the past 6 months; monthly rates were stable, so results were averaged over the entire period. Although data were collected as part of a randomized controlled trial, randomization group and the interaction of group by surgical procedure were not related to GI side effects. Thus, results are reported by procedure only (RYGB; n = 87, LAGB; n= 56).
Results
RYGB patients had a higher preoperative Body Mass Index (BMI) than LAGB patients (46.8 ± 6.8 vs. 43.5 ± 4.8 kg/m2, respectively, p = 0.001), were more likely to report dumping (45.7% vs. 4.7%, p < 0.0001) and were less likely to report plugging (45.7% vs. 79.1%, p = 0.0005). Vomiting did not differ significantly by procedure (68.6% vs. 65.1%, p = 0.7). Most patients experienced each GI side effect less than once per week.
Conclusions
Although self-reported GI side effects were common over the first 6 months after operation, the frequency of episodes was relatively low. Longer-term follow-up is needed to determine whether symptoms worsen or improve over time.
Background:
Roux-en-Y gastric bypass is the most commonly performed operation for the treatment of morbid obesity in the US. Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food. In this study we assessed the role dumping has in weight loss and its relationship with the patient's eating behavior.
Methods:
Fifty patients who underwent gastric bypass between January 2008 and June 2008 were enrolled. Two questionnaires, the dumping syndrome questionnaire and the Three-Factor Eating Questionnaire (TFEQ), were used to record the patients' responses. The diagnosis of dumping syndrome was based on the Sigstad scoring system, where a score of 7 and above was considered positive. TFEQ evaluated the patients' eating behavior under three scales: cognitive restraint, uncontrolled eating, and emotional eating. The results were analyzed with descriptive and parametric statistics where applicable.
Results:
The prevalence of dumping syndrome was 42 %, with 66.7 % of the subjects being women. The nondumpers were observed to have a greater mean decrease in body mass index than the dumpers at 1 and 2 years (18.5 and 17.8 vs. 14.4 and 13.7 respectively). There was no definite relationship between the presence of dumping syndrome and the eating behavior of the patient. However, the cognitive restraint scores, greater than 80 %, were associated with an average decrease in BMI of 19 and 20.8 at 1 and 2 years compared with 14.6 and 12.4 in those with scores less than 80 % (p = 0.01 and p = 0.03, respectively).
Conclusion:
The presence of dumping syndrome after gastric bypass does not influence weight loss, though eating behaviors may directly influence it.
Obesity is a risk factor for diabetes, cardiovascular disease events, cancer and overall mortality. Weight loss may protect against these conditions, but robust evidence for this has been lacking. The Swedish Obese Subjects (SOS) study is the first long-term, prospective, controlled trial to provide information on the effects of bariatric surgery on the incidence of these objective endpoints. The SOS study involved 2010 obese subjects who underwent bariatric surgery [gastric bypass (13%), banding (19%) and vertical banded gastroplasty (68%)] and 2037 contemporaneously matched obese control subjects receiving usual care. The age of participants was 37-60 years and body mass index (BMI) was ≥34 kg/m(2) in men and ≥38 kg/m(2) in women. Here we review the key SOS study results published between 2004 and 2012. Follow-up periods varied from 10 up to 20 years in different reports. The mean changes in body weight after 2, 10, 15 and 20 years were -23%, -17%, -16% and -18% in the surgery group and 0%, 1%, -1% and -1% in the control group, respectively. Compared to usual care, bariatric surgery was associated with a long-term reduction in overall mortality (primary endpoint) [adjusted hazard ratio (HR)=0.71, 95% confidence interval (CI) 0.54-0.92; P=0.01] and decreased incidences of diabetes (adjusted HR=0.17; P<0.001), myocardial infarction (adjusted HR=0.71; P=0.02), stroke (adjusted HR=0.66; P=0.008) and cancer (women: adjusted HR=0·58; P=0.0008; men: n.s.]. The diabetes remission rate was increased several-fold at 2 years [adjusted odds ratio (OR)=8.42; P<0.001] and 10 years (adjusted OR=3.45; P<0.001). Whereas high insulin and/or high glucose at baseline predicted favourable treatment effects, high baseline BMI did not, indicating that current selection criteria for bariatric surgery need to be revised. © 2012 The Association for the Publication of the Journal of Internal Medicine.
Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18-35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.
A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.
Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.
A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.
Dumping syndrome is a frequent complication of esophageal, gastric or bariatric surgery. Rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest, is a key event in the pathogenesis of this syndrome. This occurrence causes a shift of fluid from the intravascular component to the intestinal lumen, which results in cardiovascular symptoms, release of several gastrointestinal and pancreatic hormones and late postprandial hypoglycemia. Early dumping symptoms comprise both gastrointestinal and vasomotor symptoms. Late dumping symptoms are the result of reactive hypoglycemia. Besides the assessment of clinical alertness and endoscopic or radiological imaging, a modified oral glucose tolerance test might help to establish a diagnosis. The first step in treating dumping syndrome is the introduction of dietary measures. Acarbose can be added to these measures for patients with hypoglycemia, whereas several studies advocate guar gum or pectin to slow gastric emptying. Somatostatin analogs are the most effective medical therapy for dumping syndrome, and a slow-release preparation is the treatment of choice. In patients with treatment-refractory dumping syndrome, surgical reintervention or continuous enteral feeding can be considered, but the outcomes of such approaches are variable.
We are enthusiastic about the potential for multiple imputation and other methods 14 to improve the validity of medical research results and to reduce the waste of resources caused by missing data. The cost of multiple imputation analyses is small compared with the cost of collecting the data. It would be a pity if the avoidable pitfalls of multiple imputation slowed progress towards the wider use of these methods. It is no longer excusable for missing values and the reason they arose to be swept under the carpet, nor for potentially misleading and inefficient analyses of complete cases to be considered adequate. We hope that the pitfalls and guidelines discussed here will contribute to the appropriate use and reporting of methods to deal with missing data.
The prevalence of obesity-induced type 2 diabetes mellitus is increasing worldwide. The objective of this review and meta-analysis is to determine the impact of bariatric surgery on type 2 diabetes in association with the procedure performed and the weight reduction achieved.
The review includes all articles published in English from January 1, 1990, to April 30, 2006.
The dataset includes 621 studies with 888 treatment arms and 135,246 patients; 103 treatment arms with 3188 patients reported on resolution of diabetes, that is, the resolution of the clinical and laboratory manifestations of type 2 diabetes. Nineteen studies with 43 treatment arms and 11,175 patients reported both weight loss and diabetes resolution separately for the 4070 diabetic patients in these studies. At baseline, the mean age was 40.2 years, body mass index was 47.9 kg/m2, 80% were female, and 10.5% had previous bariatric procedures. Meta-analysis of weight loss overall was 38.5 kg or 55.9% excess body weight loss. Overall, 78.1% of diabetic patients had complete resolution, and diabetes was improved or resolved in 86.6% of patients. Weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures. Insulin levels declined significantly postoperatively, as did hemoglobin A1c and fasting glucose values. Weight and diabetes parameters showed little difference at less than 2 years and at 2 years or more.
The clinical and laboratory manifestations of type 2 diabetes are resolved or improved in the greater majority of patients after bariatric surgery; these responses are more pronounced in procedures associated with a greater percentage of excess body weight loss and is maintained for 2 years or more.
BACKGROUND: The dumping syndrome that follows Roux-en-Y gastric bypass for morbid obesity is considered to, be the primary mechanism of improved weight loss as compared with the purely restrictive vertical banded gastroplasty. To evaluate the influence of dumping on post-operative weight loss, severity of dumping was determined using Sigstad's clinical diagnostic index. METHODS: One hundred and thirty seven gastric bypass and 19 gastroplasty patients were assessed 18-24 months following surgery. Sigstad's criteria for the dumping syndrome were met by 75.9% of gastric bypass and no gastroplasty patients. Among gastric bypass patients, no relationships were found between severity of dumping and weight loss, as measured by per cent of excess body weight loss or change in body mass index. Weight loss was significantly greater with gastric bypass than gastroplasty patients (72.5 compared to 47.9% of excess body weight loss). All gastroplasty and 24.1% of gastric bypass patients were classified as non-dumpers. The difference in weight loss between surgical procedures was not related to dumping: gastric bypass non-dumpers lost significantly more weight (69.1% excess body weight loss) than gastroplasty patients. CONCLUSIONS: This study fails to demonstrate a significant relationship between dumping severity and weight loss. It is inferred that the superior weight loss of gastric bypass compared to gastroplasty has some other etiology.
Glucose tolerance decreases with age. For determining the cause of this decrease, 67 elderly and 21 young (70.1 +/- 0.7 vs. 23.7 +/- 0.8 years) participants ingested a mixed meal and received an intravenous injection of glucose. Fasting glucose and the glycemic response above basal were higher in the elderly than in the young participants after either meal ingestion (P < 0.001) or glucose injection (P < 0.01). Insulin action (Si), measured with the meal and intravenous glucose tolerance test models, was highly correlated (r = 0.72; P < 0.001) and lower (P <or= 0.002) in the elderly than in the young participants. However, when adjusted for differences in percentage body fat and visceral fat, Si no longer differed between groups. When considered in light of the degree of insulin resistance, all indexes of insulin secretion were lower (P < 0.01) in the elderly participants, indicating impaired beta-cell function. Hepatic insulin clearance was increased (P < 0.002), whereas total insulin clearance was decreased (P < 0.002) in the elderly subjects. Multivariate analysis (r = 0.70; P < 0.001) indicated that indexes of insulin action (Si) and secretion (Phi(total)) but not age, peak oxygen uptake, fasting glucose, degree of fatness, or hepatic insulin clearance predicted the postprandial glycemic response. We conclude that the deterioration in glucose tolerance that occurs in healthy elderly subjects is due to a decrease in both insulin secretion and action with the severity of the defect in insulin action being explained by the degree of fatness rather than age per se.
Anatomic and physiologic changes introduced by gastric surgery result in clinically significant dumping syndrome in approximately 10% of patients. Dumping is the effect of alteration in the motor functions of the stomach, including disturbances in the gastric reservoir and transporting function. Gastrointestinal hormones play an important role in dumping by mediating responses to surgical resection. Treatment options of dumping syndrome include diet, medications, and surgical revision. Poor nutrition status can be anticipated in patients who fail conservative therapy. Management of refractory dumping syndrome can be a challenge. This review highlights current knowledge about the mechanisms of dumping syndrome and available therapy.
The ability of people with insulin-treated diabetes to remember severe hypoglycaemia and the consistency of their self-estimated awareness of hypoglycaemia are not well documented but are important in clinical practice. The aim of this study is to assess recall of severe hypoglycaemia in patients with type 1 diabetes and to evaluate the feasibility of a simple method for clinical classification of the awareness of hypoglycaemia.
A one-year prospective study was performed on a cohort of patients with type 1 diabetes (n = 230). The rate of severe hypoglycaemia reported retrospectively at the end of the study was compared to the prospectively recorded rate during the study period. Self-estimated awareness was explored in questionnaires at baseline and at the end, and assessments were evaluated by the occurrence of severe hypoglycaemic episodes.
Almost 90% of the participants correctly recalled whether they had had severe hypoglycaemia. However, those with high prospectively recorded numbers had incomplete recall, resulting in a 15% underestimation of the overall rate. On the basis of the answer to the question "Do you recognise symptoms when you have a hypo?", the population was classified into three groups: 40% with normal awareness, 47% with impaired awareness and 13% with unawareness. The groups with impaired awareness and unawareness had 5.1 and 9.6 times higher rates of severe hypoglycaemia, respectively, compared to the group with normal awareness (p < 0.001).
People with type 1 diabetes generally remember severe hypoglycaemic episodes during a one-year period. A simple method is proposed for classifying the state of awareness of hypoglycaemia in clinical practice.