Bariatric Times

JUN 2013

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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14 Checklists in Bariatric Surgery Bariatric Times • June 2013 P Checklists in Bariatric Surgery Column Editor RAUL J. ROSENTHAL, MD, FACS, FASMBS CHECKLIST #9 Post-Gastric Bypass Hypoglycemia Bariatric Times. 2013;10(6):14 Clinical Editor, Bariatric Times, Professor of Surgery and Chairman, Department of General Surgery; Director, The Bariatric and Metabolic Institute; Director, General Surgery Residency Program and Fellowship in Minimally Invasive and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida Column Co-editors READER HANDOUT: Cut, copy, and distribute. P CHECKLISTS IN BARIATRIC SURGERY CHECKLIST #9 Post-Gastric Bypass Hypoglycemia SAMUEL SZOMSTEIN, MD, FACS, FASMBS Associate Director of the Bariatric Institute and Section of Minimally Invasive Surgery at the Cleveland Clinic in Weston, Florida, and Clinical Associate Professor of Surgery, Florida International University E. LO MENZO MD, PhD, FACS, FASMBS by RAUL J. ROSENTHAL, MD, FACS, FASMBS; SAMUEL SZOMSTEIN, MD, FACS, FASMBS; and EMANUELE LO MENZO, MD, PhD, FACS, FASMBS Bariatric Times. 2013;10(6):14 P POSSIBLE ETIOLOGIES: P __Dumping syndrome __Factitious insulin administration __Nesidioblastosis __Insulinoma P P SIGNS & SYMPTOMS: __GI: Nausea, vomiting, bloating, colicky abdominal pain, diarrhea __Vasomotor: Diaphoresis, flushing, fainting HISTORY: __Large amount of concentrated sweets, presence of vasomotor (diaphoresis, flushing, fainting) symptoms after meals __Yes __No (If yes, consider dumping syndrome) TREATMENT: __Continuous glucose monitoring system (CGMS) __Serum glucose and insulin during symptoms If glucose <45mg/dL with insulin > 6μU/mL: the diagnosis is post-bariatric hypoglycemia. Continue with algorithm. __If patient exhibits associated dumping syndrome symptoms: P Oral glucose tolerance test (OGTT): 75g: False positive 12.5% __Glucose <45mg/dL at 2 hours: suggestive of late dumping syndrome __Glucose 45–140mg/dL at 2 hours: no dumping—perform 72-hrs fasting test P In-hospital 72-hrs fasting test: __Baseline serum glucose, insulin, C peptide, proinsulin, β-hydroxyl-butyrate, sulfonylurea P Oral glucose tolerance test (OGTT) 50g: __Heart rate increase ≥10bpm in first hour: suggestive of early dumping syndrome __If patient DOES NOT exhibit associated dumping syndrome symptoms: P C-peptide level __If <0.6ng/mL and history compatible, then consider factitious insulin administration • In hospital 72-hrs fasting test __If >0.6ng/mL, then proinsulin level • If <5pmol/L, negative=Nesidioblastosis • If negative radiographic testing, negative 72-hrs test, and negative dumping syndrome __Consider calcium stimulated selective arteriography. Ultimate diagnosis is histological • If >5pmol/L=insulinoma. __Diagnosis confirmed by CT scan, MRI, U/S, and indium-111 pentatreotide (GLP-1) scan P Urine Sulfonylurea panel __If positive, then factitious hypoglycemia __Intake of insulin or oral hypoglycemic agents (especially sulfonylureas) (Check for factitious hypoglycemia—see section on diagnosis) P DIAGNOSIS: P Pharmacologic P Dietary __Modified low carbohydrates diet P Behavioral __Stop insulin and oral hypoglycemic agents __Diazoxide (ß-cell inhibitor) __Calcium channel blockers (Verapamil, Nifedipine) __ Acarbose (decreased absorption of carbohydrates) __ Octreotide (decreased small bowel motility, inhibition of insulin release, splanchnic vasodilatation). __ Exendin (GLP-1 agonist), although not yet scientifically proven, is being used by endocrinologist under investigational protocols. P Surgical (for failures) __Dumping (Pouch/gastrojejunostomy restriction) __Nesidioblastosis • Remnant gastrostomy tube. If remission, then consider gastric bypass reversal or conversion to sleeve gastrectomy. • Distal pancreatectomy (high recurrence rates) vs. total pancreatectomy (not recommended because of the long-term effects of diabetes) __Insulinoma • Enucleation Reference: Ceppa EP, Ceppa DP, Omotosho PA, et al.. Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature. Surg Obes Relat Dis. 2012;8(5):641–647. Disclaimer: The information in this handout is for educational purposes only and should not be used as a primary source of treatment. Sponsored by Matrix Medical Communications Publishers of Please visit www.bariatrictimes.com to download the PDF of this handout OR scan the QR code to the right for a direct link to the Bariatric Times website. Staff Surgeon, The Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic Florida, Weston, Florida. W elcome to "Checklists in Bariatric Surgery." This column's aim is to help bariatric surgeons quickly review the reasons for potential problems when caring for bariatric patients. In this ninth installment of the column, we discuss post-gastric bypass hypoglycemia. We hope you clip and save this convenient checklist and find it useful as a reference tool in your everyday practice. Please stay tuned for more checklists in upcoming issues of Bariatric Times. FUNDING: No funding was provided. DISCLOSURES: Dr. Rosenthal receives educational grants from Covidien, Baxter, Karl Storz, W.L. Gore, and Ethicon EndoSurgery. He is on the advisory board of MST. Drs. Szomstein and Lo Menzo report no conflicts of interest relevant to the content of this article. ADDRESS FOR CORRESPONDENCE: Raul J. Rosenthal MD, FACS, FASMBS, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL 33331; Phone (954) 659-5228; Fax (954) 659-5256; E-mail: rosentr@ccf.org

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