Dumping syndrome after bariatric surgery

Obesity is a global problem. Bariatric surgery is the only way to lose enough weight to achieve health benefits. In addition to these desired effects, there are also undesirable side effects such as early and late dumping.Early dumping occurs within an hour after a meal and consists of complaints such as nausea, diarrhea, sweating and palpitations. Late dumping occurs from one hour after the meal and complaints arise from low blood sugar and the body's response to this such as sweating, shaking, palpitations and drowsiness. This disease is also called postprandial hyperinsulinemic hypoglycaemia (PHH).The studies described in this thesis investigated how often these side effects occur after bariatric surgery and what their genesis is.A proportion of patients following a Roux-en-Y gastric bypass report complaints appropriate to early dumping (18%) or PHH (12%). These patients have a worse quality of life than the patients without dumping.In a randomly selected group of patients who have undergone a gastric bypass, it appears that after a standard meal 26% of patients have symptoms of early dumping and 48% of patients have hypoglycaemia, but without associated complaints.After the meal test, the blood analysis shows that the stimulation of intestinal hormones plays an important role in the development of early dumping. The intestinal hormones also play an important role in PHH, but the sensitivity to insulin in the body and the enhanced function of the Beta cells in the pancreas also are important factors

Mechanisms and pathophysiology of SARS-CoV-2 infection of the adipose tissue

Obesity is an independent risk factor for severe COVID-19, yet there remains a lack of consensus on the mechanisms underlying this relationship. A hypothesis that has garnered considerable attention suggests that SARS-CoV-2 disrupts adipose tissue function, either through direct infection or by indirect mechanisms. Indeed, recent reports have begun to shed some light on the important role that the adipose tissue plays during the acute phase of infection, as well as mediating long-term sequelae. In this review, we examine the evidence of extrapulmonary dissemination of SARS-CoV-2 to the adipose tissue. We discuss the mechanisms, acute and long-term implications, and possible management strategies to limit or ameliorate severe disease and long-term metabolic disturbances

A Delphi consensus of the crucial steps in gastric bypass and sleeve gastrectomy procedures in the Netherlands

Purpose: Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands. Methods: After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps. Results: Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively. Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach’s alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy. Conclusions: The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures

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

BACKGROUND: Dumping syndrome (DS) and postbariatric hypoglycemia (PBH) are frequent complications of bariatric surgery. Previously known as "early and late dumping," these complications have been separated due to differences in their onset and behaviors. OBJECTIVES: To investigate a potentially common etiology of DS and PBH using an analysis of a mixed meal test (MMT) study. SETTING: A large teaching hospital in the Netherlands. METHODS: From all patients who underwent bariatric surgery in 2008-2011, a random selection completed an MMT (n = 47). Patients scored complaints related to DS and PBH with a standardized questionnaire at several time intervals. The groups were divided into patients with (DS+; n = 22) and without (DS-; n = 25) an increase in DS symptoms after the start of the MMT. Glucose and gut hormone levels were compared. Hypoglycemia was defined as a blood glucose level below 3.3 mmol/L. RESULTS: The DS+ group had lower blood glucose values compared to the DS- group, which reached significance at 90 and 120 minutes (P < .05). For the DS+ group, glucagon-like peptide-1 (GLP-1), peptide YY (PYY), and satiety were higher at various time intervals (P < .05) compared to the DS- group. No differences were found for insulin and hunger score. GLP-1 and PYY were correlated with symptoms of DS. CONCLUSION: Patients with DS complaints had lower postprandial glucose values. GLP-1 and PYY values were elevated in the DS+ group early and late during the test. These hormones also correlated with DS. These findings support the hypothesis of a common etiology of DS and PBH and a role of GLP-1 and PYY in both complications

Diminished counterregulatory responses to meal-induced hypoglycemia 4 years after RYGB

PURPOSE: Post-bariatric hypoglycemia is a complication of bariatric surgery, especially Roux-en-Y gastric bypass (RYGB). The counterregulatory hormonal and sympathetic neural responses were measured during a previously reported meal test in which 48% had an almost asymptomatic hypoglycemic event. MATERIALS AND METHODS: Forty-four randomly selected patients 4 years after RYGB. A liquid meal test (MMT) after overnight fasting. Based on the glucose nadir during the MMT, patients were divided in a hypo group (glucose < 3.3 mmol/L) and a non-hypo group (glucose ≥ 3.3 mmol/L). Cortisol, epinephrine, norepinephrine, blood pressure, and heart rate were measured up to 180 min after ingestion of the meal. Incremental areas under the curve (iAUC), peak, and delta hormone responses after the glucose nadir were calculated. Parameters were compared between the hypo and non-hypo groups. RESULTS: A total of 21/44 (48%) had an almost asymptomatic hypoglycemic event. Cortisol and epinephrine responses in the hypo group were not increased compared to the non-hypo group, and there were no signs of increased sympathetic nerve activity. Peak and delta cortisol were lower in the hypo compared to the non-hypo group. Norepinephrine was higher in the hypo group especially in the time frame 60-120 and 120-180 min after start of the meal. CONCLUSION: No increase in epinephrine and a lower cortisol response to hypoglycemia were observed compared to normoglycemia during a meal test in patients after RYGB. Norepinephrine levels were higher in the hypo group. These findings may suggest that possible recurrent hypoglycemia after RYGB results in blunting of counterregulatory responses indicative of hypoglycemia-induced autonomic failure. CLIN TRIAL REGISTER ID: ISRCTN 11738149

Measuring Muscle Mass and Strength in Obesity:A Review of Various Methods

Lower muscle mass in populations with obesity is associated obesity-related diseases like hypertension and type 2 diabetes mellitus. Bariatric surgery leads to sustained weight loss. During the weight reduction, loss of muscle should be minimized. Thus reliable quantification of muscle mass is much needed and therefore the also the need for validated methods. Imaging methods, magnetic resonance imaging and computed tomography scan, have been the gold standard for many years. However, these methods are costly and have limitations such as the maximum weight. Dual-energy X-ray absorptiometry is currently the most used alternative. Other, less expensive methods are very limited in their validation in populations with morbid obesity. This narrative review summarizes the current knowledge regarding measuring muscle mass and strength in obesity

Outcomes of the One Anastomosis Gastric Bypass with Various Biliopancreatic Limb Lengths:a Retrospective Single-Center Cohort Study

Introduction: One anastomosis gastric bypass (OAGB) is an effective and safe treatment for morbidly obese patients. Longer biliopancreatic (BP) limb length is suggested to result in better weight loss outcomes, but to date, no data are available for the OAGB to substantiate this. We hypothesized that applying a longer BP-limb length in the higher BMI classes would result in more weight reduction so that the attained BMI would be comparable to patients with a lower BMI, thereby compensating for differences in baseline BMI. Method: A retrospective cohort study in patients who underwent a primary OAGB at a teaching hospital in the Netherlands between January 2015 and December 2016. BP-limb length was tailored based on preoperative BMI. Patients were divided into three different groups depending on the length of the BP-limb: 150, 180, and 200 cm. Weight loss outcomes after 1 and 3 years and resolution of comorbidities were compared between these groups. Results: Of the 632 included patients, a BP-limb length of 150 cm was used in 172 (27.2%), 180 cm in 388 (61.4%), and 200 cm in 72 (11.4%) patients. Despite more BMI loss, %EWL was lower and attained BMI remained higher in the groups with longer BP-limb lengths. After adjustment for the confounder preoperative BMI, longer BP-limb lengths were not associated with higher BMI loss. There was no difference in remission rates of comorbidities. Conclusion: Attained BMI remained higher in spite of tailoring BP-limb length according to baseline BMI with no differences in remission rates of comorbidities