Dumping syndrome can lead to hypoglycemia
Dumping syndrome is a common complication following BS, with prevalence ranging from 25% to 75%, depending upon the type of procedure performed.16,17 There are 2 types: early and late. Early dumping syndrome occurs within 30 minutes of eating. Symptoms are related to the robust release of gastrointestinal hormones caused by rapid gastric emptying. Symptoms include nausea, abdominal pain, diarrhea, flushing, hypotension, and tachycardia.
Late dumping is characterized as postprandial hypoglycemia occurring one to 3 hours after eating. Late dumping is likely caused by a combination of changes within the pancreatic beta cells and abnormal insulin response to glucose.16-18 Rapid gastric emptying leads to rapid release of glucose in the gut, which, in turn, leads to brisk insulin secretion. Since glucose is absorbed faster than insulin’s half-life, the resulting (relatively) high levels of insulin may cause hypoglycemia.16-18
Sigstad’s scoring system can be used to confirm suspected cases of dumping syndrome (TABLE 316,17,19). A diagnosis can also be made with an oral glucose challenge in which pulse, blood pressure, glucose, and hematocrit are measured after ingestion of 50 g glucose. The test is positive if heart rate increases by 10 beats per minute, hematocrit increases by 3% 30 minutes after ingestion, or glucose falls below 60 mg/dL 2 to 3 hours after ingestion.17
First-line treatment of dumping syndrome consists of dietary modifications. The goal is to slow the rate of gastric emptying by eating smaller, more frequent meals; separating beverages from food; decreasing carbohydrates; and increasing fiber and protein content.
If results are suboptimal after dietary changes, medications can be prescribed including acarbose to prevent postprandial hypoglycemia; anticholinergics such as dicyclomine to slow gastric emptying; and somatostatin to decrease gastric emptying and inhibit GI hormone release.17 Lastly, for resistant and severe postprandial hypoglycemia, a few patients have undergone pancreatectomy, but only about 65% experienced improvement in symptoms and 12% developed diabetes post-surgically.20
Gout attacks may initially increase, but then decrease
BS affects the incidence of gout attacks in patients with a history of gout. One comparative study of approximately 150 patients demonstrated that those with a history of gout had significantly more gout attacks in the first month after BS compared with obese patients with a history of gout undergoing other upper GI surgeries.21 There was no difference between malabsorptive and restrictive procedures. But after the first month, BS patients had significantly fewer gout attacks and lower uric acid levels than their obese counterparts.21
Protein rich diets, catabolism potentiated by aggressive caloric restriction following BS, and dehydration contribute to the initial increase. Therefore, patients who have had at least one gout attack in the year prior to surgery or who are on hypouricemic medication may benefit from at least one month of prophylactic therapy (eg, allopurinol and colchicine) after surgery.
GERD and ulceration: How to respond
Obesity is a known risk factor for GERD, but the effect of BS on GERD is uncertain and seems to vary with the procedure performed. RYGB decreases GERD and is, therefore, used as both a secondary treatment in those not responding to medications and a revision treatment for fundoplication and other types of BSs. Sleeve gastrectomy and adjustable gastric banding have mixed effects on GERD. A systematic review by de Jong et al revealed a decreased prevalence of reflux symptoms and GERD medication use after LAGB; however, during longer follow-up, 15% of previously unaffected patients reported experiencing GERD.22 The 2011 International Sleeve Gastrectomy Expert Panel Consensus Statement retrospectively noted a postoperative incidence of GERD as high as 31%.23
BS patients with GERD should be treated with a proton pump inhibitor. If this fails, refer patients to a gastroenterologist for further evaluation.24
Ulcers after BS may be an indication for revision surgery. Data are mixed regarding increased risk of marginal ulceration from nonsteroidal anti-inflammatory drug (NSAID) use, but NSAIDs have been linked to an increased risk of anastomotic leakage.25-28 Thus, it seems prudent to avoid NSAIDs in people who have undergone BS.
Keeping watch over psychiatric comorbidities
A recent meta-analysis by Dawes et al29 showed that about 23% of patients pursuing BS have a comorbid mood disorder. Specifically, the preoperative prevalence of depression (19%) and binge-eating disorder (17%) were found to be higher than rates in the general population.29 The meta-analysis found improvement in the prevalence of depression with fewer symptoms and less antidepressant medication use in the first 3 years after surgery and a decrease in the rate of binge-eating disorder, although there were fewer supporting data for the latter. These findings were observed with both restrictive and malabsorptive procedures.