Surgical treatment of severe dumping syndrome.

Dumping syndrome is a common post-operative complication following gastric surgery. Clinically, severe dumping can be a serious medical condition with a negative impact on the patient's life. In our case report, we present a case of refractory dumping syndrome which developed after laparoscopic subtotal gastrectomy with gastrojejunoanastomosis due to massive gastroptosis with stomach evacuation problems. Conservative gastroenterology treatment was not successful. Due to the progression of weight loss and life-threatening hypoglycaemia, the decision for surgical treatment was made. After the corrective gastro-duodenal and jejuno-jejunal anastomoses, all clinical symptoms resolved completely. With regard to the presented case, we discuss the common treatment options for dumping syndrome: the standard recommendations for dietary habits, pharmacological treatment and finally the surgery and its pitfalls. Due to the absence of randomized trials and guidelines, every patient should be treated in a personalized way.

Utility of continuous glucose monitoring following gastrectomy.

BACKGROUND: Glucose fluctuation after gastrectomy represented by dumping syndrome is a well-known post-gastrectomy syndrome that negatively impacts patient quality of life. However, the current methods of post-gastrectomy glucose monitoring do not comprehensively capture the postoperative blood glucose fluctuations that characterize this. METHODS: We used a continuous glucose monitoring (CGM) system to document the glycemic profiles of patients undergoing gastrectomy and compared these between patients undergoing distal gastrectomy (DG) and total gastrectomy (TG). To evaluate post-gastrectomy syndromes, including dumping syndrome, we used the Post-gastrectomy Syndrome Assessment Scale 37-item questionnaire. The glycemic profiles were also compared using this tool. RESULTS: We studied 57 patients who had undergone DG and 13 who had undergone TG between September 2017 and September 2019. Our results revealed larger diurnal glycemic variability and longer periods of nocturnal hypoglycemia after gastrectomy. The dumping score was worse in the TG than in the DG group (TG 2.4 ± 1.4 vs. DG 1.3 ± 1.2, P = 0.0061). Importantly, 30 of 57 DG patients (52.6%) and 5 of 13 TG patients (38.5%) experienced postprandial hypoglycemia following hyperglycemia without hypoglycemic symptoms. There was no correlation between the dumping symptom score and glycemic variability (ρ = 0.0545, P = 0.6662). CONCLUSIONS: CGM demonstrated diurnal glycemic variability and nocturnal hypoglycemia in patients undergoing gastrectomy. Because some hypoglycemic patients did not develop symptoms and glycemic variability was not necessarily associated with dumping symptom, dumping syndrome must only partially explain the postoperative glucose fluctuations.

Heterogeneity in the Definition and Clinical Characteristics of Dumping Syndrome: a Review of the Literature.

BACKGROUND: No real consensus regarding the definition of dumping syndrome (DS) seems to exist and few subtyping is used in clinical practice. Knowledge is needed for correct design of trials and establishment of uniform treatment strategies. The aim of this study is to explore the distribution of clinical characteristics related to the subtypes of DS. METHODS: A comprehensive search was performed in Cochrane, Google Scholar, PubMed, and ResearchGate. Data were collected on the definition and diagnostics of DS used in each study. RESULTS: Twenty-seven clinical trials were included. Seventeen articles clearly provided a definition of DS and ten of these differentiated between early and late DS. Diagnose of DS was based on clinical symptoms (24 articles), hemodynamic parameters (e.g., tachycardia, hypotension; 9 articles), and biochemical analysis (e.g., blood sugar level; 12 articles). Questionnaires were used in 13 articles. A total of 67 different symptoms were correlated with dumping syndrome. Two symptoms were exclusively correlated with early and nine with late DS. Nine articles differentiated between early and late dumping based on timing since the last meal. Hypoglycemia was correlated with late DS in ten articles. CONCLUSIONS: This study reveals a vast heterogeneity in the definition and clinical characteristics of DS after RYGB. We feel that a standardized definition is required to provide a firm parameter in the evaluation and setup of clinical trials. A better understanding and description of the definition and diagnostic criteria of DS after RYGB is crucial to improve scientific reporting.

Dumping syndrome, a cause of acquired glycogenic hepatopathy.

A 2-year-old boy, having undergone fundoplication for gastroesophageal reflux disease and fed by gastrostomy, presented with recurrent emesis, syncope with hypoglycemia, and persistently elevated serum liver transaminase levels. Liver biopsy revealed hepatocellular glycogenosis by light and electron microscopy. Further evaluation showed no evidence of diabetes mellitus, glycogen storage disease, or corticosteroid use. Since the hyperglycemic-hyperinsulinemic state of dumping syndrome would provide a mechanism for hepatocellular glycogenosis, the biopsy findings prompted consideration of dumping syndrome. Metabolic evaluation confirmed the diagnosis of dumping syndrome, and appropriate dietary management led to sustained resolution of symptomatology and hypertransaminasemia. Dumping syndrome is proposed to be a cause of hepatocellular glycogenosis, the latter representing a form of acquired glycogenic hepatopathy.

Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia.

AIMS/HYPOTHESIS: Postprandial hypoglycaemia following gastric bypass for obesity is considered a late manifestation of the dumping syndrome and can usually be managed with dietary modification. We investigated three patients with severe postprandial hypoglycaemia and hyperinsulinaemia unresponsive to diet, octreotide and diazoxide with the aim of elucidating the pathological mechanisms involved. METHODS: Glucose, insulin, and C-peptide were measured in the fasting and postprandial state, and insulin secretion was assessed following selective intra-arterial calcium injection. Pancreas histopathology was assessed in all three patients. RESULTS: All three patients had evidence of severe postprandial hyperinsulinaemia and hypoglycaemia. In one patient, reversal of gastric bypass was ineffective in reversing hypoglycaemia. All three patients ultimately required partial pancreatectomy for control of neuroglycopenia; pancreas pathology of all patients revealed diffuse islet hyperplasia and expansion of beta cell mass. CONCLUSIONS/INTERPRETATION: These findings suggest that gastric bypass-induced weight loss may unmask an underlying beta cell defect or contribute to pathological islet hyperplasia, perhaps via glucagon-like peptide 1-mediated pathways.

[Anatomo-functional status of the upper segments of the gastrointestinal tract in patients with dumping syndrome after gastrectomy by the Billroth II method]. / Anatomo-funktsional'noe sostoianie verkhnikh otdelov zheludochno-kishechnogo trakta u bol'nykh, stradaiushchikh demping-sindromom posle rezektsii zheludka po Bil'rot-II.

From study of the condition of the upper gastrointestinal tract in 51 patients suffering from the dumping syndrome after Hofmeister-Finsterer modification of Billroth II gastrectomy, the authors concluded that the intracavitary pressure gradient between the gastric stump and the efferent intestinal loop, as well as the diameter of the gastroenteroanastomosis, influence the dumping syndrome. A method is suggested for measuring the diameter and surface of the gastroenteroanastomosis and measuring the intracavitary pressure in the Gastric and duodenal stump and the efferent and afferent loops of the small intestine.

[The relations between the morphology of the postresection gastric stump after a gastroduodenal ulcer and the dumping syndrome]. / Relatii între morfologia bontului gastric post rezectie dupa ulcerul gastroduodenal si sindromul "dumping".

Of a group of 272 patients subjected to gastric resection for gastric-duodenal ulcer, the "dumping" syndrome was found in 46 (17%). The most frequent (39.7%) was in the Reichel-Polya anastomosis type and the less frequent (9%) in pyloroplasties. The test of induced hyperglycemia by ingesting 15 g/kg body glucose did not show differences in the values of the maximum glycemia in the patients with the "dumping" syndrome versus the other group. The surface of the anastomosis opening and the length of the gastric stump were appreciated with a central imaging endoscope. The surface of the anastomosis opening was found larger in those with a "dumping" syndrome and Reichel-Polya's resection, although the differences are not statistically significant; likewise, there seems to be a less length of the gastric stump and a higher weight difference in those with the "dumping" syndrome. The lack of pyloric sphincter seems to be very important in producing the "dumping" syndrome due to the fact that the alimentary bolus is not fractionated and its sequential evacuation in duodenum and jejunum does not take place.

[Changes in the gastric mucosa in complicated forms of peptic ulcer and postgastrectomy syndromes]. / Izmeneniia slizistoi obolochki zheludka pri oslozhnennykh formakh iazvennoi bolezni i postgastrorezektsionnykh sindromakh.

Complex studies of the secretory function of the stomach have shown its activity to depend upon the type of gastric ulceration. It allows gastric ulcers to be differentiated into those with hyposecretory (primary ulcers) and hypersecretory (associated and secondary ulcers) syndromes. High secretory activity of the stomach with duodenal ulcers is confirmed by the results of morphological investigations.

[Morphology of the pancreas in peptic ulcer and the complications of stomach resection]. / Morfologiia podzheludochnoi zhelezy pri iazvennoi bolezni i oslozhneniiakh rezektsii zheludka.

Morphological examinations of 115 biopsies of the pancreas showed the peptic ulcer and postgastroresection complications not to be the leading factors in the etiology of the pancreatic pathology. Gastric resection does not favour the affection of the pancreas but may aggravate the existing morphological lesions. Despite the lack of crude histological changes in the pancreatic gland in peptic ulcer, ultrastructural signs of a high functional intensity of acinary cells were found which may also be regarded as pathological manifestations. Most marked changes of the histostructure of the pancreatic gland were found in peptic ulcer of the gastroenteroanastomosis. A difference in the A-cell content of pancreatic insulae before and after gastric resection was found. As the pancreatic tissue is frequently intact in the afferent loop syndrome, the leading role of duodenostasis in chronic affection of the pancreatic gland may be disputed.

[Morphology of the liver in peptic ulcer and postgastrectomy complications (electron-microscopic study)]. / Morfologiia pecheni pri iazvennoi bolezni i postgastrorezektsionnykh oslozhneniiakh (elektronno-mikroskopicheskoe issledovanie).

Electron microscopic examinations of 13 liver biopsies obtained from 4 patients with duodenal ulcer, 4 with peptic ulcer of gastroenteroanastomosis and 3 with the dumping syndrome showed these diseases to be accompanied by nonspecific ultrastructural changes in hepatocytes, intercellular connections, the system of bile tubules and microcirculatory bed which are more marked in postgastroresection complications and not always correspond to the histological condition of the organ, particularly when changes in its histological structure are not very marked. From the fact that the range of ultrastructural changes in the livers of patients of these groups are more extensive and variable than histological ones, it may be assumed that the intact histostructure of the organ does not exclude the occurrence of pathological processes in it.

[The morphofunctional state of the gastric stump in patients with the dumping syndrome and its significance for the formulation of diet therapy]. / K kharakteristike morfofunktsional'nogo sostoianiia kul'ti zheludka u bol'nykh s demping-sindromom i ego znacheniia pri postroenii dietoterapii

In 42 patients with the dumping syndrome. the mucosa of the resected gastric stump was examined histologically. Bioptic materials were obtained by applying fibrobiopsy and aspiration biopsy under roentgenological control. The great majority of the examined demonstrated some or other degree of the glandular atrophy attended by a fall of the secretary function. In spite of a considerable time lapsed since gastric resection the gastric glands remained intact and the secretary function of the stump continued to be normal. According to the authors the severity of the dumping syndrome does not depend on the nature of morphological changes in the gastric stump mucosa. A sizable proportion of the examined patients demonstrated various changes in the motor function of the stump, more often an accelerated evacuation. The listed changes in the morphological-functional condition of the gastric stump were given due consideration in compiling a dietary pattern for patients with the dumping syndrome.