ODP219 Laparoscopic Gastrostomy tube (LGT) Placement for Management of Post Bariatric Surgery Hypoglycemia Syndrome (PBSHS).

Abstract

Abstract Introduction Bariatric surgery is currently the most effective long term management for morbid obesity. Laparoscopic bariatric surgery whether gastric banding (LGB), sleeve gastrectomy (LSG) or gastric bypass (LRYGB) are now more commonly done. One major complication that can follow these procedures are the hypoglycemic syndromes; post bariatric surgery hypoglycemia syndrome (PBSHS). PBSHS is a spectrum ranging from mild reactive hypoglycemia to hypoglycemia with dumping syndrome to the most severe being post bariatric surgery nesidioblastosis (PBSN). Clinical case; The patient is a 33 yr old Caucasian lady with past history of morbid obesity who had LSG in 2012 with poor weight loss response. This was converted to LRYGB in 2016 with much better weight loss response. Within 1.5 yrs of the LRYGB however she started having recurrent hypoglycemic episodes which were initially mild and mostly postprandial (PP) but rapidly escalated to both fasting and PP states. Work up revealed that she had both reactive and fasting hypoglycemia and despite dietary interventions the episodes escalated and with "defensive eating" she progressively gained weight. Her hypoglycemic spells were confirmed as insulin mediated and consistent with PBSN. Medical therapy escalated to maximum dose acarbose, octreotide and high dose diazoxide. The frequency and severity of the hypoglycemic spells worsened and in 2021 she had over 7 hospital admissions from severe hypoglycemia with additional ED visits despite medication use including emergent glucagon use and CGMS monitoring with a DEXCOM device. She had hypoglycemia unawareness with progressively declining quality of life. Rather than possible attempted reversal of the LRYGB a LGT was placed to see if this would ameliorate her symptoms. She now drinks only non-caloric fluids per oral and all caloric intake is via the LGT. The clinical response has been swift and dramatic. Since LGT placement over 3 mths now she has had no symptomatic hypoglycemic episode and no ED nor hospital admissions. Post LGT placement CGMS profile demonstrated marked improvements in glycemic profile and post LGT mixed meal tests (MMT). A dichotomy was demonstrated between her glycemic profile on MMT for oral vs LGT caloric intake providing confirmation of the therapeutic effect of the LGT placement. Discussion With the increasing utilization of bariatric surgery for management of obesity and diabetes, the prevalence of PBSHS is expected to increase. This complication can be difficult and expensive to manage while negatively impacting weight loss and quality of life. Our case provides proof of principle evidence to suggest LGT placement as a management consideration in severe cases of PBSN. Conclusions LGT placement should be considered as an option in patients with severe PBSN that is poorly controlled with maximal medical and lifestyle interventions. Presentation: No date and time listed