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Reversal of gastric bypass. A indicates normal preoperative anatomy; B the prior sleeve gastrectomy. C and D represent the prior conversion from sleeve gastrectomy to Roux-en-Y gastric bypass. The Roux limb was divided 20 cm distal to the gastrojejunostomy (E) and brought up to the gastric remnant as a gastric interposition graft (F). The biliopancreatic limb was then divided (F), and the cut end of the Roux limb was anastomosed to the BP limb. A jejunal feeding tube was placed proximally.
Source publication
Introduction
With the increasing performance of bariatric surgery, rare complications are becoming prevalent. We review the diagnosis and treatment of dysautonomia after bariatric surgery and the limited treatment options available. We summarize the suggested mechanisms and explain why a complete understanding of the etiology has yet to be determin...
Citations
... Consequently, severe hyperinsulinemia ensues, leading to postprandial hypoglycemia 1 to 3 h after meal intake. Other factors suspected to pathophysiologically contribute to postbariatric hypoglycemia include increased non-insulin-mediated disposal of plasma glucose, various adipokines and factors affecting insulin sensitivity, proinflammatory cytokines, and impaired counterregulatory capacity to hypoglycemia (6,(9)(10)(11). ...
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.
... Vaikeaa, sairaalahoitoon johtavaa hypoglykemiaa on kuitenkin todettu vain alle prosentilla lihavuusleikatuista (25). Sen syntymekanismia ei tunneta tarkasti, mut ta syyksi on epäilty muun muassa lisääntynyttä inkretiinihormonien, kuten glukagoninkaltai sen peptidin 1 (GLP1), eritystä suolistosta, mikä ilmenee voimakkaana inkretiini ja insulii nivasteena aterian jälkeen (26)(27)(28). Tila muis tuttaa histologisesti NIPHS:ää, mutta sitä pi detään erillisenä kliinisenä kokonaisuutenaan, joka ilmenee mahalaukun ohitusleikkauksen tai muiden mahalaukun tyhjenemisen säätelyä häiritsevien leikkausten jälkeen (26). ...
In Finnish. Hypoglykemiaa pidetään merkittävänä, kun luotettavalla menetelmällä varmistetun laskimoveren plasman pienen glukoosipitoisuuden (alle 3,0 mmol/l) yhteydessä todetaan hypoglykemiaan sopivia oireita tai löydöksiä, jotka korjaantuvat glukoosipitoisuuden suurentuessa. Merkittävä hypoglykemia on harvinaista henkilöillä, joilla ei ole diabetesta, ja se liittyy useimmiten akuuttiin tai pitkäaikaiseen sairauteen, alkoholin käyttöön tai lääkitykseen. Ellei hypoglykemian syy ole ilmeinen, edetään jatkoselvittelyihin mahdollisen endogeenisen hyperinsulinismin tai harvinaisen perinnöllisen hypoglykemiaa aiheuttavan tilan toteamiseksi. Endogeenisen hyperinsulinismin syitä ovat insuliinia erittävä haimakasvain (insulinooma), lihavuusleikkauksen jälkitila, muu haimaperäinen hypoglykemia ja autoimmuunihypoglykemia. Endogeenisen hyperinsulinismin diagnosointi perustuu pitkään paastokokeeseen glukoosi-, insuliini- ja C-peptidimittauksineen, tarvittaessa insuliini- ja insuliinireseptorivasta-aineiden määrittämiseen sekä haiman kuvantamiseen.
Purpose of Review
This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management.
Recent Findings
As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1–10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH.
Summary
Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.
