Metabolic surgery in diabetes
Post-gastric bypass hypoglycemia
In this review, the authors discuss the definitions, diagnosis and management of post-gastric bypass hypoglycemia.
| Summary points |
- Roux-en-Y bypass (RYGB) surgery, while very effective for diabetes remission, is associated with potentially significant complications, including post-RYGB surgery hypoglycemia (PGBH), with prevalence estimates ranging from as low as 1% in older literature to as high as 34%, depending on reporting and the definition used.
- It is important to distinguish PGBH from other forms of hypoglycemia, which are characterized by impaired endogenous insulin production and functional β-cell disorders.
- The underlying pathology of PGBH has yet to be fully elucidated but recent studies point to a role of the incretin hormones glucose-dependent insulinotropic polypeptide and glucagon-like peptide.
- Another proposed mechanism for PGBH is altered intestinal glucose absorption, associated with changes in gut microbiota, bile acid levels and composition.
- The first step in evaluation of a patient in whom PGBH is suspected is obtaining a thorough clinical history, with attention on timing and onset of symptoms and relation to nutrient ingestion; a review of current medications may also be helpful.
- Diagnosis of PGBH should be made based on a mixed meal challenge test rather than an oral glucose challenge test.
- Following diagnosis of PGBH, the goal of therapy should be reduction of frequency and severity of episodes, with the first approach to treatment comprising strict changes in diet and, if necessary, pharmacologic therapies (such as acarbose, somatostatin analogs, diazoxide or calcium channel blockers).
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Rariy CM, Rometo D, Korytkowski M. Curr Diab Rep 2016; 16: 19. doi: 10.1007/s11892-015-0711-5
Thirty-day (early) complications of bariatric surgical procedures
It is important to recognize and manage acute bariatric surgical complications. This chapter outlines complications that occur within the first 30 days after bariatric surgery.
| Summary points |
- There are several potentially serious complications that may occur in the first 30 days following Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), laparoscopic adjustable gastric band (LAGB) and biliopancreatic diversion, and it is important for general surgeons to be able to recognize and manage these.
- A large database study reported a 30-day complication rate following RYGB of 8.7%, with the most commonly encountered early complications including bleeding (2.1%), leak (1.8%), port-site related complications (0.6%) and small bowel obstruction (1.0%).
- In a recent review, the complication rate following SG was not significantly different from that with RYGB; the reported leak rate was 2.3% versus 1.9% in RYGB. Management of leak is a challenging clinical problem with serious sequelae if not promptly recognized and treated.
- In patients who have undergone LAGB, presentation with abdominal pain, nausea, intractable reflux or intolerance of oral intake, fluid should be withdrawn from the band, and a plain abdominal X-ray should be taken to evaluate band slippage. Complications requiring reoperation within the first 30 days are rare: one large study reported a rate of complications requiring emergency reoperation of 0.2%.
- Biliopancreatic diversion/duodenal switch has been shown to have the highest rate of short-term complications, with 30-day morbidity estimates ranging from 7% to 8.6% for one-stage procedures.
- Patients undergoing bariatric surgery are at high risk for venous thromboembolism (VTE), given obesity itself is an independent risk factor, although with widespread use of thromboprophylaxis, the rate of VTE following bariatric surgery ranges between 0.21% and 0.42% within 90 days of surgery.
- Mesenteric thrombosis is a rare, but potentially fatal, complication following laparoscopic bariatric surgery – with an incidence of 0.3% for all bariatric patients and 1% for SG.
- Outcomes after complications in the early postoperative period after bariatric surgery depend upon early recognition and treatment.
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Hamad GG, Guerrero VT. In: Bariatric surgery complications. Edited by Blackstone R. Springer, Cham, 2017. doi: 10.1007/978-3-319-43968-6_2
Late complications of bariatric procedures
This chapter outlines complications that occur at least 30 days after initial bariatric surgery.
| Summary points |
- Late-stage complications in bariatric surgery are defined as those occurring at least 30 days after the initial procedure.
- Late-stage complications associated with these procedures include band slippage and band erosion, megaesophagus, port problems (malfunctions, infection, port-site hernia), intestinal obstruction, marginal ulceration, nutritional deficiencies (protein malnutrition, vitamin deficiency, anemia, Wernicke’s encephalopathy) and gastric outlet obstruction.
- Thirty-day morbidity and mortality are extremely low for laparoscopic adjustable gastric band. Late-stage complication rates range in various studies from 10% to 25%, predominantly band slippage and port-site issues (infection, malfunctioning port), with less common but concerning complications include band erosion and megaesophagus.
- Complications that can occur following Roux-en-Y gastric bypass (RYGB) include intestinal obstruction, a rare but well-known complication of this procedure with rates ranging from 1.5% to 5%, and marginal ulcerations (ulcers occurring at the gastrojejunal anastomosis), which may occur at any time following RYGB.
- Late complications for sleeve gastrectomy are rare, with the main issues with this surgery being nutritional deficiencies and port-site hernias (an issue common to all bariatric procedures).
- Late-stage complications associated with biliopancreatic diversion with duodenal switch include those common to other procedures, including marginal ulcers, intestinal obstruction, and port-site hernias, as well as those specific to this procedure, namely gastric outlet obstruction and nutritional deficiencies relating to the malabsorptive nature of the procedure.
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Kurian M, Creange C. In: Bariatric surgery complications. Edited by Blackstone R. Springer, Cham, 2017. doi: 10.1007/978-3-319-43968-6_3