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

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

Tailoring limb length based on total small bowel length in one anastomosis gastric bypass surgery (TAILOR study):study protocol for a randomized controlled trial

Background: The one anastomosis gastric bypass (OAGB) is being performed by an increasing number of bariatric centers over the world. However, the optimal length of the biliopancreatic (BP) limb remains a topic of discussion. Retrospective studies suggest the benefit of tailoring BP-limb length; however, randomized trials are lacking. The aim of this study is to investigate whether tailoring the length of the BP-limb based on total small bowel length (TSBL) leads to better results in terms of weight loss, vitamin deficiencies, and bowel movements compared to a fixed BP-limb length. Methods: The TAILOR study is a double-blind single-center randomized controlled trial. Patients scheduled for primary OAGB surgery will be randomly allocated either to a standard BP-limb of 150 cm or to a BP-limb length based on their TSBL: TSBL 700 cm, BP-limb 210 cm. The primary outcome is to compare the percent total weight loss (%TWL) at 5 years between the two groups. Secondary outcomes include nutritional deficiencies, remission of comorbidities, symptoms of dumping, quality of life, and daily bowel movements. The study includes a total of 212 patients and is designed to detect a 5% difference in the primary endpoint. Discussion: The TAILOR study will provide new insights into the effect of different BP-limb lengths and the role of the TSBL in the OAGB. The study is designed to provide guidance for bariatric surgeons to determine the optimal BP-limb length in the OAGB

Applying an Anti-reflux Suture in the One Anastomosis Gastric Bypass to Prevent Biliary Reflux:a Long-Term Observational Study

INTRODUCTION: The one anastomosis gastric bypass (OAGB) is an effective treatment to induce sustained weight loss in morbidly obese patients. Concerns remain regarding the development of reflux. The aim of this study was to investigate the effect of an "anti-reflux suture" as anti-reflux modification to prevent reflux. METHOD: This is a single-center retrospective cohort study of patients who underwent a primary OAGB at the Center Obesity North-Netherlands (CON) between January 2015 and December 2016. Reflux was defined as symptoms of acid/bilious regurgitation or pyrosis. This was consequently asked and reported at each follow-up visit. Outcomes of patients with an anti-reflux suture were compared to those without. RESULTS: In 414 (59%) of the 703 included patients, an anti-reflux suture was applied. Follow-up at 3 years was 74%. The incidence of reflux did not differ between patients with or without an anti-reflux suture (57 versus 56%, respectively; P = 0.9). The presence of an anti-reflux suture was significantly associated with a lower incidence of conversion to Roux-en-Y gastric bypass (RYGB) for reflux (OR 0.56, 95%CI 0.34-0.91). Patients preoperatively diagnosed with gastroesophageal reflux disease (GERD) were 5.2 times more likely to need a conversion to RYGB for reflux (95%CI 2.7-10.1). CONCLUSION: The presence of preoperative GERD should be weighted heavily in the decision to perform an OAGB as this is a major risk factor for conversion surgery due to reflux. The anti-reflux suture might be a valuable addition to the procedure of the OAGB because it results in fewer conversion surgeries for reflux

Altered bile acid kinetics contribute to postprandial hypoglycaemia after Roux-en-Y gastric bypass surgery

Background/objectives: Bile acids (BA) act as detergents in intestinal fat absorption and as modulators of metabolic processes via activation of receptors such as FXR and TGR5. Elevated plasma BA as well as increased intestinal BA signalling to promote GLP-1 release have been implicated in beneficial health effects of Roux-en-Y gastric bypass surgery (RYGB). Whether BA also contribute to the postprandial hypoglycaemia that is frequently observed post-RYGB is unknown. Methods: Plasma BA, fibroblast growth factor 19 (FGF19), 7α-hydroxy-4-cholesten-3-one (C4), GLP-1, insulin and glucose levels were determined during 3.5 h mixed-meal tolerance tests (MMTT) in subjects after RYGB, either with (RYGB, n = 11) or without a functioning gallbladder due to cholecystectomy (RYGB-CC, n = 11). Basal values were compared to those of age, BMI and sex-matched obese controls without RYGB (n = 22). Results: Fasting BA as well as FGF19 levels were elevated in RYGB and RYGB-CC subjects compared to non-bariatric controls, without significant differences between RYGB and RYGB-CC. Postprandial hypoglycaemia was observed in 8/11 RYGB-CC and only in 3/11 RYGB. Subjects who developed hypoglycaemia showed higher postprandial BA levels coinciding with augmented GLP-1 and insulin responses during the MMTT. The nadir of plasma glucose concentrations after meals showed a negative relationship with postprandial BA peaks. Plasma C4 was lower during MMTT in subjects experiencing hypoglycaemia, indicating lower hepatic BA synthesis. Computer simulations revealed that altered intestinal transit underlies the occurrence of exaggerated postprandial BA responses in hypoglycaemic subjects. Conclusion: Altered BA kinetics upon ingestion of a meal, as frequently observed in RYGB-CC subjects, appear to contribute to postprandial hypoglycaemia by stimulating intestinal GLP-1 release

Pharmacokinetics of Glucocorticoid Replacement Before and After Bariatric Surgery in Patients With Adrenal Insufficiency

Adequate glucocorticoid replacement in patients with primary or secondary adrenal insufficiency is essential to maintain general well-being. Little is known about the effects of bariatric surgery on glucocorticoid absorption. This study evaluates glucocorticoid absorption before and after bariatric surgery, with assessment of plasma cortisol profiles in five patients receiving glucocorticoid replacement therapy for primary (n = 1) or secondary (n = 4) adrenal insufficiency. One patient underwent sleeve gastrectomy (SG), one a one-anastomosis gastric bypass (mini-GB), and three a Roux-en-Y gastric bypass (RYGB). Pharmacokinetic calculations were based on plasma cortisol measurements performed during the first 6 hours after ingestion of the morning dose. Plasma cortisol profiles were very similar before and after surgery; only minor differences were observed. After SG, plasma peak cortisol concentration and cortisol area under the curve (AUC) were higher by 23% and 24%, respectively, and time to peak cortisol was 10 minutes shorter. The mini-GB had no marked effect on pharmacokinetic parameters. In the three patients who underwent RYGB, AUC changes ranged from -12% to 20%. In conclusion, in this small number of patients with adrenal insufficiency, plasma cortisol profiles were similar before and after bariatric surgery. However, in view of individual differences in response to different types of surgery, we recommend postoperative cortisol profiling to guide appropriate glucocorticoid dose adjustment. Copyright (C) 2018 Endocrine Societ

Influence of dietary protein and its amino acid composition on postoperative outcomes after gastric bypass surgery: a systematic review

CONTEXT: Bariatric surgery is an effective method to reduce morbid obesity. Nutritional counseling is essential to achieve maximal treatment success and to avoid long-term complications. Increased dietary protein intake may improve various postoperative results. OBJECTIVE: The aim of this systematic review is to examine the relationship between intake of dietary protein or supplementation with amino acids and postoperative outcomes after gastric bypass surgery. DATA SOURCES: A systematic literature search was conducted in 4 electronic databases: Cochrane, Embase, PubMed, and Scopus. STUDY SELECTION: The initial search retrieved 7333 hits, which included 2390 duplicates. DATA EXTRACTION: Tweny-three studies with varying study designs, interventions, and outcomes were included. RESULTS: Studies did not provide convincing evidence of a beneficial effect on any postoperative outcome. CONCLUSIONS: The study of the influence of protein and its amino acid composition represents an important developing domain of knowledge and warrants further attention considering the popularity of bariatric surgery. Future studies should include a clear description of the quantity and composition of proteins and amino acids in the diet or supplement

An observational study on the effects of nadroparin-based and citrate-based continuous venovenous hemofiltration on calcium metabolism

Backgrounds: To study calcium homeostasis during citrate-based compared to nadroparin-based CVVH in critically-ill patients with acute renal failure. Methods: 11 patients were observed during citrate anticoagulation, 9 with nadroparin and 10 controls. Citrate was chosen for patients with active or at risk for bleeding. Results: The controls had, at 24 h, a median serum iCa of 1.1 mmol/l, the citrate group 0.87 mmol/ l and the nadroparin group 1.1 mmol/l (citrate vs. control p = 0.001, citrate vs. nadroparin p = 0.002). At 48 h, iCa was not significantly different anymore. Ca balance was negative for the citrate group in contrast to the nadroparin group ( p = 0.012). Median serum PTH was higher (30.0 pmol/l vs. 6.5 pmol/l, p = 0.003) in the citrate group. Conclusion: With a relative low target-serum-iCa (0.8-0.9 mmol/l) citrate CVVH- treated patients had a negative daily calcium balance and a temporarily lower iCa level resulting in an enhanced PTH response in comparison to nadroparin. Copyright (c) 2007 S. Karger AG, Basel

Remission of Type 2 Diabetes Mellitus in Patients After Different Types of Bariatric Surgery: A Population-Based Cohort Study in the United Kingdom

Importance: To our knowledge, an observational study on the remission of type 2 diabetes mellitus (T2DM) after different types of bariatric surgery based on data from general practice has not been carried out. Objective: To assess the effect of different types of bariatric surgery in patients with T2DM on diabetes remission compared with matched control patients, and the effect of the type of bariatric surgery on improvement of glycemic control and related clinical parameters. Design, Setting, and Participants: A retrospective cohort study conducted from May 2013 to May 2014 within the Clinical Practice Research Datalink involving 2978 patients with a record of bariatric surgery (2005-2012) and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or greater. We identified 569 patients with T2DM and matched them to 1881 patients with diabetes without bariatric surgery. Data on the use of medication and laboratory results were evaluated. Exposures: Bariatric surgery, stratified by type of surgery (gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, or other/unknown). Main Outcomes and Measures: Remission of T2DM (complete discontinuation of glycemic therapy, accompanied with a subsequently recorded hemoglobin A1c level<6.0%). Results: Among patients undergoing bariatric surgery, we found a prevalence of 19.1% for T2DM. Per 1000 person-years, 94.5 diabetes mellitus remissions were found in patients who underwent bariatric surgery compared with 4.9 diabetes mellitus remissions in matched control patients. Patients with diabetes who underwent bariatric surgery had an 18-fold increased chance for T2DM remission (adjusted relative rate [RR], 17.8; 95% CI, 11.2-28.4) compared with matched control patients. The greatest effect size was observed for gastric bypass (adjusted RR, 43.1; 95% CI, 19.7-94.5), followed by sleeve gastrectomy (adjusted RR, 16.6; 95% CI, 4.7-58.4) and gastric banding (adjusted RR, 6.9; 95% CI, 3.1-15.2). Body mass index and triglyceride, blood glucose, and hemoglobin A1c levels sharply decreased during the first 2 years after bariatric surgery. Conclusions and Relevance: Population-based data show that bariatric surgery strongly increases the chance for remission of T2DM. Gastric bypass and sleeve gastrectomy have a greater effect than gastric banding. Although the risks and possible adverse effects of surgery should be weighed against its benefits, bariatric surgery and, in particular, gastric bypass or sleeve gastrectomy may be considered as new treatment options for T2DM

Remission of Type 2 Diabetes Mellitus in Patients After Different Types of Bariatric Surgery : A Population-Based Cohort Study in the United Kingdom

Importance: To our knowledge, an observational study on the remission of type 2 diabetes mellitus (T2DM) after different types of bariatric surgery based on data from general practice has not been carried out. Objective: To assess the effect of different types of bariatric surgery in patients with T2DM on diabetes remission compared with matched control patients, and the effect of the type of bariatric surgery on improvement of glycemic control and related clinical parameters. Design, Setting, and Participants: A retrospective cohort study conducted from May 2013 to May 2014 within the Clinical Practice Research Datalink involving 2978 patients with a record of bariatric surgery (2005-2012) and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 35 or greater. We identified 569 patients with T2DM and matched them to 1881 patients with diabetes without bariatric surgery. Data on the use of medication and laboratory results were evaluated. Exposures: Bariatric surgery, stratified by type of surgery (gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, or other/unknown). Main Outcomes and Measures: Remission of T2DM (complete discontinuation of glycemic therapy, accompanied with a subsequently recorded hemoglobin A1c level<6.0%). Results: Among patients undergoing bariatric surgery, we found a prevalence of 19.1% for T2DM. Per 1000 person-years, 94.5 diabetes mellitus remissions were found in patients who underwent bariatric surgery compared with 4.9 diabetes mellitus remissions in matched control patients. Patients with diabetes who underwent bariatric surgery had an 18-fold increased chance for T2DM remission (adjusted relative rate [RR], 17.8; 95% CI, 11.2-28.4) compared with matched control patients. The greatest effect size was observed for gastric bypass (adjusted RR, 43.1; 95% CI, 19.7-94.5), followed by sleeve gastrectomy (adjusted RR, 16.6; 95% CI, 4.7-58.4) and gastric banding (adjusted RR, 6.9; 95% CI, 3.1-15.2). Body mass index and triglyceride, blood glucose, and hemoglobin A1c levels sharply decreased during the first 2 years after bariatric surgery. Conclusions and Relevance: Population-based data show that bariatric surgery strongly increases the chance for remission of T2DM. Gastric bypass and sleeve gastrectomy have a greater effect than gastric banding. Although the risks and possible adverse effects of surgery should be weighed against its benefits, bariatric surgery and, in particular, gastric bypass or sleeve gastrectomy may be considered as new treatment options for T2DM