Dumping Syndrome Treatment & Management
- Author: Rajan Kanth, MD; Chief Editor: BS Anand, MD more...
The use of acarbose, an alpha-glycoside hydrolase inhibitor, interferes with carbohydrate absorption and thus may decrease the time delay between hyperglycemia and insulin response. This may lead to coinciding the peak of glucose and insulin levels and thus prevent hypoglycemic symptoms in patients with late dumping. Imhof et al showed that acarbose produced a 5-fold decrease in postprandial glucagon-like peptide 1 levels which, in turn, may lead to a decrease in insulin release.
Acarbose use may be limited by the occurrence of diarrhea secondary to fermentation of unabsorbed carbohydrates as manifested by increased breath hydrogen excretion and symptoms such as flatulence.
Acarbose delays production of monosaccharides by inhibiting alpha-glucosidases associated with the brush border of the intestine. These enzymes are responsible for the digestion of complex polysaccharides and sucrose.
In healthy individuals, acarbose in doses of 100-200 mg significantly blunts the postprandial rise in glucose, insulin, and triglycerides. Acarbose has been shown to significantly lower postprandial blood glucose levels.
Somatostatin and its synthetic analogue octreotide (Sandostatin, SMS 201-995) have been used with short-term success in patients with dumping syndrome, but the long-term efficacy of octreotide is much less favorable. They exert a strong inhibitory effect on the release of insulin and several gut-derived hormones.
In patients with dumping syndrome, octreotide likely decreases gastric emptying by resetting the migrating motor complex to the fasting level.
The effectiveness of octreotide in controlling the symptoms of both early and late dumping has been demonstrated in several randomized control trials.
The mechanisms of action of octreotide in dumping syndrome are as follows:
Delay in the accelerated initial gastric emptying
Delay in small intestinal transit time
Inhibition of enteral hormone release
Induction of a fasting intestinal pattern
Inhibition of insulin release
Inhibition of postprandial vasodilation
The usual initial dose of octreotide is 50 mcg administered subcutaneously bid/tid 30 minutes prior to each meal. The dose may be increased if smaller doses are not effective; however, higher doses are seldom effective if the smaller doses do not work.
Octreotide improves the symptoms in about 90% of patients with severe dumping refractory to other forms of medical interventions.
In all studies, octreotide in the short term decreased the symptom score, pulse rate, and plasma insulin levels when compared with placebo. However, whether long-term octreotide use is as beneficial as short-term use is unclear. Reports on long-term use of octreotide are scarce, and the number of patients in these reports is small.
During octreotide treatment, fecal fat excretion increases significantly. Despite this increase in steatorrhea, an increase in mean body weight is reported. This probably occurs because of increased energy intake as patients are able to tolerate more food.
Octreotide appears to be safe in the long-term management of refractory dumping syndrome; however, the occurrence of diarrhea in patients who already have malabsorption and maldigestion may be a major limiting factor.
Depot long-acting release octreotide (Sandostatin-LAR), as compared with octreotide, resulted in a significantly greater GI-specific quality-of-life index and body weight gain.[24, 27] However, the effect of octreotide on late dumping symptoms was superior to the effect of long-acting octreotide.
Although the results of long-term use of octreotide injections are less dramatic than short-term use, nonetheless, symptoms are reduced by about 50%. Other authors report that long-acting release octreotide is as effective long term as subcutaneous octreotide, with superior symptom control as assessed by the Gastrointestinal Specific Quality of Life Index, better maintenance of body weight, and higher quality of life.
The addition of verapamil may also be considered. Although there is enthusiasm for the use of electrical stimulation of the small intestine to achieve gastrointestinal pacing as a treatment of dumping syndrome, there are no placebo-controlled trials, thus, possible placebo effects cannot be excluded.
Preventing dumping syndrome is preferable to treating its symptoms. Consider anatomic factors that relate to the syndrome, and, if possible, determine the exact type of surgical procedure needed. Numerous alimentary reconstruction methods have been proposed to treat the dumping syndrome. Proximal gastric vagotomy is now the procedure of choice for the surgical management of intractable ulcer disease. Although the long-term ulcer recurrence rate is higher after this procedure compared with antrectomy and truncal vagotomy, it has the lowest incidence of postoperative dumping and diarrhea. If more extensive surgery is necessary, resection is preferable to a Roux-en-Y gastrojejunostomy, because it decreases the rate of dumping syndrome compared with pyloroplasty or loop gastrojejunostomy.
Remedial surgery can be considered in patients whose condition is refractory to medical treatment or in patients unwilling to continue medical therapy. Patients should be approached conservatively, because most patients improve with time and remedial surgery is not always effective.
Several surgical procedures have been designed to rectify the symptoms of dumping. These include surgical narrowing of the gastrojejunal stoma, conversion of Billroth II anastomosis to Billroth I gastroduodenostomy, jejunal interposition, conversion to Roux-en-Y gastrojejunostomy, and pyloric reconstruction. No long-term studies have assessed the effectiveness of these procedures. Furthermore, no controlled trials have examined the efficacy of one procedure compared to the other.
For early gastric cancer, the postoperative outcome is better in those having a pylorus-preserving gastrectomy. Unfortunately, about one quarter of patients undergoing a pylorus-preserving gastrectomy may have sufficiently symptomatic delayed gastric emptying that the quality of their life may be adversely affected.
One strategy for surgical correction of the pathophysiology of dumping is to slow gastric emptying.
Porter and Claman reported good results by narrowing the gastrojejunal stoma.
Determining the exact size of the stomal reconstruction is difficult.
Stomal strictures with gastric outlet obstruction are common adverse effects of the operation.
This technique has been abandoned in favor of other procedures.
Conversion of Billroth II to Billroth I anastomoses
Conversion of a Billroth II to a Billroth I gastroduodenostomy improves dumping syndrome in 75% of patients.
This procedure restores the physiologic delivery of the meal to the duodenum, without risk of gastric outlet obstruction.
Overall, the procedure is useful because of its simplicity and low rate of complications.
In this procedure, the pyloroplasty scar is identified and is cut along its length. The sphincter muscle is identified and approximated. The incision is then closed longitudinally.
In a series of 14 patients reported by Koruth et al, 9 showed excellent results, whereas another 3 had good resolution of their dumping symptoms.
Cheadle and coworkers reported a series of 9 patients, 8 of whom had excellent results.
This procedure is low-risk and seems to be fairly effective in patients who have severe dumping after pyloroplasty.
Schoemaker is credited with the first attempt at interposing an isoperistaltic jejunal loop after gastric surgery.
Henley has reported extensive use of an interposed jejunal segment between the gastric pouch and the duodenum for correction of postgastrectomy dumping in more than 300 patients. In his series, all patients improved, including those with early postprandial dumping. However, other smaller series have failed to show such excellent results with the use of isoperistaltic interposition.
Sawyers and Herrington had only a 20% satisfactory result in 10 patients. In an 11-year experience using antiperistaltic jejunal loops in 28 patients, they reported excellent results in 20 patients and good results in another 6 patients. In their experience, a 10-cm reversed jejunal segment effectively prolongs the gastric emptying time without obstruction.
Unsuccessful results with interposition of 6 cm of reversed jejunal segments have been reported, whereas good results have been reported with 10-cm segments.
Using longer lengths of jejunum has resulted in ulcerations and stenosis in the interposed segment. Care should be taken to rotate the interposed segment no greater than 180° to avoid undue torsion on the mesentery. Mesenteric defects should be carefully repaired to avoid internal herniation.
Reversed segments have been shown to be effective for as long as 10 years after interposition.
Double iso-antiperistaltic jejunal limb pouches have also been used, but their efficacy is inferior to the antiperistaltic loop interposition.
Conversion to a Roux-en-Y gastrojejunostomy as a remedial operation has gained favor relatively recently. With this operation, favorable outcomes have been reported in 85-90% of patients. Of patients with dumping symptoms after Billroth I and II gastrectomy, 85-90% have favorable outcomes with Roux-en-Y conversion.
Vogel et al reported 19 of 22 patients with favorable outcomes with this operation. Of the 3 failures, 1 had persistent dumping syndrome, whereas the other 2 patients had Roux stasis syndrome.
The mechanism by which this conversion works in providing relief from dumping is unknown, but it may be due to interruption of the migration motor complex, diminished jejunal contractions, and retrograde jejunal contractions.
This procedure is easier to perform and has fewer long-term adverse effects.
Hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass due to the changes in gut hormonal milieu. Management includes strict low carbohydrate diet, followed by pharmacotherapy.
The dumping syndrome that occurs after gastric bypass surgery is not due to an increase in pancreatic beta cell formation or mass; instead, it is due to hypersensitivity of the postprandial insulin response. This inappropriately increased insulin secretion may be due to excessively high incretin levels, or to "…a failure to adequately decrease insulin secretion…."
Within 30 minutes after a high-carbohydrate meal, 12 of 14 patients were shown-to develop hyperglycemia and hyperinsulinemia (noninsulinoma, pancreatogenous hypoglycemic syndrome [NIPHS]) some 30 minutes after a test meal, whereas this and the associated symptoms did not occur with a low-carbohydrate diet.
Dietary considerations are important after bariatric surgery, and the patient’s diet may need to be specifically formulated to deal with symptoms such as dumping, altered bowel habit, nausea and vomiting, dehydration, food intolerance, and overeating.
Diffuse islet cell hyperplasia and expansion of the beta cell mass have been described in 3 patients with severe postprandial hyperglycemia and hyperinsulinemia unresponsive to diet, octreotide, and diazoxide.
Laparoscopic conversion of laparoscopic Roux-en-Y gastric bypass to laparoscopic sleeve gastrectomy, biliopancreatic diversion with duodenal switch, or original anatomy has been tried recently as a feasible and safe option for cases refractory to medical treatment.[47, 48, 49] However, 33-40% of patients after laparoscopic sleeve gastrectomy may still have symptoms of dumping syndrome 6-12 months after surgery. In these cases, symptoms include both early and late dumping symptoms, but there is progressive increase in late symptoms.
Because no operation for intractable dumping is uniformly successful, new approaches have been considered
In dogs prepared with truncal vagotomy, distal gastrectomy, and Roux-en-Y reconstruction, retrograde electrical pacing of the Roux-en-Y reconstruction significantly delayed gastric emptying and absorption of a glucose meal and decreased postcibal hemoconcentration.
Summary of remedial operations
For patients with prior pyloroplasty, pyloric reconstruction should be the initial remedial operation.
For patients with Billroth I and Billroth II gastrectomies, Roux-en-Y reconstruction is the simplest and most effective therapy.
For patients who already have a Roux-en-Y reconstruction, a 10-cm antiperistaltic jejunal loop should be interposed.
Dumping syndrome is a common postsurgical complication after gastric surgery. The symptoms of dumping produce considerable morbidity. Fortunately, the indications for gastric surgery are declining, although the need for gastric surgery in emergency cases has not changed.
Initially, patients with this condition should be treated medically with dietary modifications and octreotide. Close attention should be given to the patient's nutritional status. If medical management fails to provide adequate symptom relief, remedial surgery should be offered with the understanding that even surgical intervention may not be successful.
Dietary prohibitions and instructions are very important in the management of dumping syndrome. Note the following:
Daily energy intake is divided into 6 meals.
Fluid intake during and with meals is restricted. Avoiding liquids for at least half an hour after a meal is helpful.
Simple sugars are best avoided.
Milk and milk products are generally not tolerated and should be avoided.
Because carbohydrate intake is restricted, protein and fat intake should be increased to fulfill energy needs.
Most patients have relatively mild symptoms and respond well to dietary manipulations. In some patients with postprandial hypotension, lying supine for 30 minutes after meals may delay gastric emptying and also increase venous return, thereby minimizing the chances of syncope.
Supplementation with dietary fiber has proven effective in the treatment of hypoglycemic episodes. Many medical therapies have been tested, including pectin, guar gum, and glucomannan. These dietary fibers form gels with carbohydrates, resulting in delayed glucose absorption and prolongation of bowel transit time.
This dietary change to a low-carbohydrate, high protein diet, as well as the use of alpha-glucosidase inhibitors, may be useful to control the symptoms of dumping. [51, 52] This is preferential to subtotal or total pancreatectomy in those persons with severe symptoms.
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