Abstract
Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.
Highlights
Dumping syndrome is a frequent complication of cancer and non-cancer oesophageal and gastric surgery, as well as bariatric surgery
According to reports published in the past 15 years, bariatric surgery has become the main cause of postoperative dumping syndrome . 14,15 Dumping syndrome has mainly been reported after Roux-en-Y gastric bypass (RYGB) and partial gastrectomy[12,13], but might occur after restrictive bariatric procedures such as sleeve gastrectomy, vertical banded gastroplasty and the laparoscopic adjustable gastric band, which all reduce the volume capacity of the proximal stomach[4]
Studies involving glucose tolerance testing show a very high occurrence of increased pulse rate, a marker of early dumping syndrome, and a lower occurrence of hypoglycaemia, a marker of late dump ing syndrome. These findings suggest that early dumping syndrome might be more prevalent than late dumping syndrome[1,17,20]
Summary
The process was coordinated by a chair (J.T.) and a co-chair (E.S.), referred to as the chairs. Using the Mine score for symptom assessments, a higher proportion of patients reported early dumping syndrome than late dumping syndrome after gastric surgery for cancer[24]. As a result of associated gastrointestinal symptoms, the rapid gastric emptying and the frequent association with postprandial diarrhoea, reactive hypoglycaemia seems to be an underlying mechanism that is similar to that of dumping syndrome after surgery These patients responded well to dietary adjustment (frequent small meals)[61]. This observation supports the concept that the test might be reproducible for the occurrence of hypoglycaemia In these studies, at OGTT testing, the persistence of a rise in pulse rate or a rise in haematocrit level at 30 min with treatment was lower than the persistence of hypoglycaemia, suggesting that either this aspect is less reproducible, or that pasireotide is more effective in treating early dumping syndrome (pulse rate rise and haematocrit rise) than in treating late dumping syndrome (hypoglycaemia). Several studies evaluated the ingestion of up to 15 g of guar gum or pectin with each meal to slow gastric emptying, reduce the release of gastrointestinal hormones, improve hyperglycaemia and control symptoms of dumping syndrome[45,100,101,102,103,104,105,106]
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