Obesity Abstracts

Bariatric surgery has increasingly been associated with complications including hyperinsulinaemic hypoglycaemia associated primarily with early and late dumping syndrome, with a suggested prevalence of 0.36% (1). The symptoms can be extremely problematic with late dumping often presenting several years after surgery (1). Here we summarise the management in two such patients. Case 1: A 44 year old lady with a history of successful Roux-en-Y gastric bypass surgery (6 years prior) presented with a 24 months of autonomic and neuroglycopenic symptoms relieved by the ingestion of carbohydrate. Capillary blood glucose monitoring revealed hypoglycaemia, glucose level falling to 1.6 mmol/l post prandially. Mixed meal testing, confirmed late dumping and inpatient 48 h fast excluded insulinoma. Strict low carbohydrate diet with the exclusion of liquid carbohydrate was followed with specialist bariatric dietetic input and medical trial of Acarbose and Diazoxide, both failed to provide sustained glycaemic control. Freestyle Libre™ was utilised as a novel way to predict glycaemic trend and measure success of treatment. She underwent successful test dosing with subcutaneous Octreotide and she was later switched to Sandostatin LAR 30 mg IM injections every 28 days. Case 2: A 49-year-old lady, known to have had Roux-en-Y bariatric gastric bypass surgery (7 years prior) was investigated for episodes of symptomatic hypoglycaemia. She underwent mixed meal testing which revealed evidence of late dumping syndrome. Insulinoma was excluded biochemically with 48 h fasting. Initial trial of Acarbose and Diazoxide failed to control hypoglycaemia. A test dose of Octreotide was successful and 50 mcg OD S/C with significant improvement in hypoglycaemic episodes. Once again Freestyle Libre™ was used to assist in patient management. These cases demonstrate the difficulties of management of late dumping syndrome notable several years after successful bariatric surgery. Here we have successfully used the effect of Octreotide in delaying gastric emptying, inhibiting insulin secretion, and increasing gut transit time (2) to manage refractory dumping syndrome. This treatment has significantly improved the quality of life of these patients, albeit for the short term (3). We have also shown how the use of Freestyle Libre™ was a novel way of monitoring treatment and in the post bariatric surgical setting.