Obes Surg Research Articles

12417 Atypical Patterns Of Hypoglycemia Post-bariatric Surgery Due To Pancreatic Insulinoma

Abstract Disclosure: K.A. Chopra: None. Accurately diagnosing an insulinoma in patients who have had bariatric surgery can be challenging because the autonomic symptoms of palpitations, tremors, anxiety and neuroglycopenic hypoglycemia symptoms of confusion and loss of consciousness may overlap with dumping syndrome or be attributed to non-insulinoma pancreatogenous hypoglycemia. When evaluating hypoglycemia, it is crucial to obtain a detailed history of the pattern and timing of hypoglycemia episodes and collect a critical sample of insulin, proinsulin, c-peptide levels during an episode of low glucose to prevent misdiagnosis. 58-year-old woman with hypertension, obesity, and history of laparoscopic sleeve gastrectomy presented for evaluation of hypoglycemia. The patient lost 100 pounds after her sleeve gastrectomy. Within the past year, the patient had two hospitalizations for severe symptomatic hypoglycemia with associated loss of consciousness. Imaging showed atrophic pancreas and she was discharged with a prescription for daily prednisone without critical sample testing for insulin or c-peptide levels. She sought a second opinion for her hypoglycemia at UCM. Since she was taking prednisone for 10 months prior to initial evaluation at UCM, evaluation for adrenal insufficiency could not be completed initially. She started continuous glucose monitoring which showed multiple daily episodes of hypoglycemia, fasting and at other various timepoints. Fasting labs showed low glucose of 20 mg/dL (RR 60-99 mg/dL), elevated proinsulin 120 pmol/L (RR 3.6- 22 pmol/L), inappropriately normal insulin 16.4 uIU/mL (RR <28.5 uIU/mL), and inappropriately normal c-peptide 0.82 pmol/mL (RR 0.30-2.35 pmol/mL), consistent with insulinoma. CT abdomen showed 1.4 cm arterially enhancing round lesion in the pancreatic body. Endoscopic ultrasound showed 13 mm mass in the pancreatic body with fine needle aspiration with pathology showing a well-differentiated neuroendocrine tumor. She received stress dose hydrocortisone preceding surgery and underwent successful enucleation of 1.6 cm pancreatic neuroendocrine tumor. A few weeks after her surgery, her HPA axis was re-evaluated, and steroids were discontinued. She has had no episodes of hypoglycemia since. Although hypoglycemia can be associated post-bariatric surgery, most patients develop postprandial hypoglycemia due to surgical alterations in alimentary flow leading to increased incretin and insulin secretion (Mulla et al 2016). Therefore, it is important to consider insulinoma in the differential diagnosis of post-bariatric surgery patients presenting without typical postprandial patterns of hypoglycemia. Reference: Mulla CM, Storino A, Yee EU, Lautz D, Sawnhey MS, Moser AJ, Patti ME, Insulinoma After Bariatric Surgery: Diagnostic Dilemma and Therapeutic Approaches. Obes Surg. 2016 Apr;26(4):874-81. Presentation: 6/1/2024

Scientifically Invalid: Evaluating the Safety of the Intragastric Balloon: Spanish Multicenter Experience in 20,680 Cases and with 12 Different Balloon Models : Obes Surg. Published online July 18, 2024. doi:10.1007/s11695-024-07342-x.

Scientifically Invalid: Evaluating the Safety of the Intragastric Balloon: Spanish Multicenter Experience in 20,680 Cases and with 12 Different Balloon Models : Obes Surg. Published online July 18, 2024. doi:10.1007/s11695-024-07342-x.

Transumbilical Stapling Technic of OAGB.

Single-port or single-incision laparoscopic surgery (SILS) is esteemed for its efficacy in achieving superior postoperative cosmetic outcomes compared to the conventional laparoscopic approach (Behnia-Willison et al. in Aust N Z J Obstet Gynaecol 52:366-370, 2012; Rogula et al. in Obes Surg 24:1102-1108, 2014; Pitot et al. in Surg Endosc 28:3007-3011, 2014). The introduction of SILS for bariatric procedures can be attributed to the pioneering work of Saber in 2008, who initially applied this technique to laparoscopic sleeve gastrectomy (SG), followed by its utilization in laparoscopic adjustable gastric banding (AGB) (Saber et al. in Obes Surg 18:1338-1342, 2008;Nguyen et al. in Obes Surg 18:1628-1631, 2008). The inaugural application of SILS in Roux-en-Y gastric bypass (RYGB) was documented in 2009, employing a plastic reconstruction methodology. Acknowledging the intricate nature of complex bariatric interventions, we previously detailed a modified SILS approach termed the transumbilical two-site (TUTS) technique for RYGB, which was established as a standard procedure in 2010 (Lee et al. in Surg Obes Relat Dis. 8:208-13, 2012). At that juncture, a solitary article surfaced in 2010 elucidating the dimensions of the small gastric pouch as a mere 8-9cm, falling short of contemporary surgical requisites for optimal outcomes in one anastomosis gastric bypass (OAGB) (Tacchino et al. in Obes Surg 20:1154-1160, 2010). Notably, the TUTS technique, which was successfully implemented for RYGB, had hitherto not been extended to OAGB due to the complexities associated with creating a slender gastric tube spanning 25cm. In a pioneering development this year, we have devised a novel strategy to surmount this challenge. The present study is designed to expound upon the transumbilical stapling technique tailored to the unique demands of OAGB.

Postoperative micronutrient changes in bariatric surgery patients compliant with nutritional supplementation.

Bariatric surgery is commonly used in patients with body mass indexes over 35kg/m and obesity-related comorbidities. Despite the significant clinical benefits of bariatric surgery, nutritional deficiencies post-surgery remain a challenge for both patient and healthcare provider [Toninello et al. in Nutrients 13:1565, 2021, Gasmi et al. in Eur J Nutr 61:55-67, 2022]. Nutritional supplementation is a way of reducing the likelihood of postoperative deficiencies; however, prior studies have shown varying degrees of mostly poor to moderate patient adherence [Spetz et al. in Obes Res Clin Pract 16:407-412, 2022, Mahawar et al. in Obes Surg 29:1551-1556, 2019, Santonicola et al. in J Am Nutr Assoc 41:11-19, 2022, Sherf Dagan et al. in Obes Surg 27:2258-2271, 2017]. Our present study aims to provide insights into the micronutrient biochemical profile in patients previously found to be compliant with supplementation following roux-en-y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). An 11-point outpatient survey was administered to consecutive patients ≥ 18years who had undergone either RYGB or VSG to determine adherence with nutritional supplementation. Medical records were retrospectively reviewed to determine preoperative and postoperative lab values, including vitamins A, B1, B12, and D, thyroid stimulating hormone (TSH), iron binding capacity, transferrin, ferritin, folate, iron, albumin, hemoglobin A1C, zinc, glomerular filtration rate (GFR, and liver function values. Values were classified as "abnormal" or "normal." Preoperative and postoperative values were compared for differences. Postoperative values were also compared between RYGB and VSG. There were no significant differences between preoperative and postoperative values for any nutritional marker aside from vitamin B12. A total of 51/60 patients (85.0%) had normal preoperative B12 measurements, compared with 40/65 (61.5%) patients postoperatively (P = 0.03). Notably, of 25 "abnormal" postoperative measurements, 20 (80%) were elevated values. There were no differences in postoperative deficiencies between RYGB and VSG. Patients in our sample did not have worsened micronutrient deficiencies following bariatric surgery, and there were no differences in micronutrient deficiencies between surgical technique.

Investigating the factor structure and measurement invariance of the eating disorder examination questionnaire (EDE-Q) among cisgender gay men and lesbian women from the United States

BackgroundAlthough the Eating Disorder Examination-Questionnaire (EDE-Q) is one of the most widely used self-report assessments of eating disorder symptoms, evidence indicates potential limitations with its original factor structure and associated psychometric properties in a variety of populations, including sexual minority populations. The aims of the current investigation were to explore several previously published EDE-Q factor structures and to examine internal consistency and measurement invariance of the best-fitting EDE-Q model in a large community sample of cisgender gay men and cisgender lesbian women.MethodsData were drawn from 1624 adults (1060 cisgender gay men, 564 cisgender lesbian women) who participated in The PRIDE Study, a large-scale longitudinal cohort study of sexual and gender minorities from the United States. A series of confirmatory factor analyses (CFAs) were conducted to explore the fit of eight proposed EDE-Q models; internal consistency (Cronbach’s alphas, Omega coefficients) and measurement invariance (multi-group CFA) were subsequently evaluated.ResultsA brief seven-item, three-factor (dietary restraint, shape/weight overvaluation, body dissatisfaction) model of the EDE-Q from Grilo et al. (Obes Surg. 23:657–662, 2013), consistently evidenced the best fit across cisgender gay men and lesbian women. The internal consistencies of the three subscales were adequate in both groups, and measurement invariance across the groups was supported.ConclusionsTaken together, these findings support the use of the seven-item, three-factor version of the EDE-Q for assessing eating disorder symptomatology in cisgender gay men and lesbian women. Future studies can confirm the current findings in focused examinations of the seven-item, three-factor EDE-Q in diverse sexual minority samples across race, ethnicity, socioeconomic status, and age ranges.

Diet as adjunctive therapy for sleep apnea risk: not only how much but also what to eat.

Diet as adjunctive therapy for sleep apnea risk: not only how much but also what to eat.

P-B03 Gastric Band Tubing Causing Small Bowel Obstruction

Abstract Background Laparoscopically adjustable gastric bands (LAGB) have been widely employed as a means of weight loss in bariatric surgery over the past two decades. Although now largely superseded by other bariatric surgical techniques, complications from gastric bands continue to be encountered in surgical practice. We report an unusual case of small bowel obstruction due to an internal hernia caused by gastric band tubing resulting in closed loop small bowel obstruction. This is not commonly encountered and emergency general surgeons need to have a high index of suspicion for this condition as a possible cause for small bowel obstruction. Methods A 40 year old male presented with abdominal pain, vomiting and failure to open bowels or pass flatus for nine days. Twelve years previously (2008) he had had Roux n Y gastric bypass (RYGB), followed by by laparoscopic gastric banding of the RYGB about two years later (2010) also in the private sector. He had a soft but distended abdomen, and empty rectum on rectal examination. CT scan abdomen reported as: Multiple loops of distended small bowel demonstrated. No air seen in rectum, indicative of small bowel obstruction. No pneumoperitoneum. There is dilatation of the mid and distal small bowel seen to an apparent transition point in the mid abdomen where a loop is noted associated with the tubing for the inflation device for the gastric band. This appears to be centred on the cause of obstruction and appears tied around the base of mesentery and may be creating a closed loop obstruction, by having created an internal hernia. This patient had an internal hernia around loop of the gastric band tubing with resultant closed loop small bowel obstruction. The patient underwent diagnostic laparoscopy with ileo-caecal resection and primary anastomosis. He made successful recovery. Deflated gastric band remains in-situ. Results While small bowel obstruction is most commonly due to adhesions in individuals who have had previous laparotomy, it is important to bear in mind other causes such as internal hernias particularly in cases of those with history of previous gastric banding or Roux n Y gastric bypass. Early intervention may be necessary to reduce the likelihood of bowel ischaemia and bowel resection. Laparoscopy is a useful tool in the management of small bowel obstruction. Keywords: gastric band, small bowel obstruction, closed loop, emergency surgery, laparoscopy Conclusions Connection tubing causing small bowel obstruction and colonic erosion as a rare complication after laparoscopic gastric banding: a case report. Liza BK Tan, Jimmy BY So, and Asim Shabbir - J Med Case Reports. 2012; 6: 9. Acute small bowel obstruction due to the connecting tube of a gastric band. Federico Oppliger, M.D. Gonzalo Wiedmaier, M.D. Juan. Published April 07 2017. https://doi.org/10.1016/j.soard.2014.03.021 An unusual complication of gastric banding: recurrent small bowel obstruction caused by the connecting tube. M A Zappa, E Lattuada, E Mozzi, M Francese, I Antonini, S Radaelli, G Roviaro. Obes Surg . 2006 Jul;16(7):939-41. doi: 10.1381/096089206777822250 Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency. Tarek Hashem, Soliman M Soliman, Sherif Wagih 2. Int J Surg Case Rep. 2017;30:66-68. doi: 10.1016/j.ijscr.2016.11.021. Epub 2016 Nov 17

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB).

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration?

The first-choice therapy for adults with moderate/severe obstructive sleep apnea is continuous positive airway pressure (CPAP). However, studies evaluating whether the therapeutic CPAP level obtained from a titration is affected by sex are surprisingly scarce. Our main objective was to verify if sex influenced the optimal CPAP measurement obtained during a titration. This cross-sectional study was conducted in adults diagnosed with moderate/severe obstructive sleep apnea [baseline apnea-hypopnea index (AHI) ≥ 15.0 events/h] who underwent auto-adjusting CPAP titration (S9 or S10 AutoSet ResMed) in a sleep laboratory setting. All participants used a nasal mask during the titration. The optimal pressure, leak, and residual AHI values were registered. Multiple linear regression was used to evaluate if clinical and polysomnographic data influenced the therapeutic CPAP level setting (95th percentile pressure). A total of 1,006 adults were enrolled: 354 women and 652 men. There were no statistically significant sex-related differences in the CPAP requirements and leak values delineated during the titration; all P-values > .005. However, the median residual AHI was significantly higher in males vs females: 2.7 events/h vs 2.2 events/h (P = .008). Body mass index (β: 0.292, P < .001), baseline AHI (β: 0.167, P < .001), and age (β: 0.065, P = .035) were independent predictors of the therapeutic CPAP level settings. Sex does not significantly influence the therapeutic CPAP settings. However, age, BMI, and baseline AHI emerge as independent predictors of the 95thpercentile CPAP requirement during an auto-adjusting CPAP titration. Duarte RLM, Magalhães-da-Silveira FJ, Gozal D. Are there sex-related differences in therapeutic CPAP levels in adults undergoing in-laboratory titration? JClin Sleep Med. 2021;17(9):1815-1820.

Реалии применения антикоагулянтной терапии при COVID-19

Введение. Поступление вируса SARS-CoV-2 в организм человека сопровождается развитием COVID-19-ассоциированной коагулопатии, часто реализующейся в различных тромботических осложнениях. Актуальные клинические рекомендации описывают основные подходы к лечению и профилактике венозных тромбоэмболических осложнений (ВТЭО), однако реализация их не всегда представляется возможной. В реальной практике встречается значительное количество отклонений и нарушений, в том числе носящих системный характер, связанных как с ограниченностью представлений клиницистов о патогенетических аспектах развития инфекционного процесса, так и с избыточным желанием предотвратить отдельные из них. Цель исследования: изучение состояния реальной клинической практики в области лечения и профилактики развития тромботических осложнений у пациентов c новой коронавирусной инфекцией COVID-19 (НКИ COVID-19). Материалы и методы. В основе работы лежит анонимный опрос 223 врачей-специалистов, занимающихся лечением пациентов с хроническими и острыми заболеваниями сосудов. В опросник включено 18 вопросов, описывающих отношение врачей к проблеме в целом, а также касающихся выбора тактики лечения, применения антикоагулянтных препаратов и методов контроля системы гемостаза. Результаты. Подавляющее большинство участников опроса информированы и озадачены увеличением риска тромботических осложнений при НКИ COVID-19. При этом приоритетной целью антикоагулянтной терапии (АКТ) в острой фазе заболевания участники назвали лечение COVID-19-ассоциированной коагулопатии, а в стадии реконвалесценции — профилактику ВТЭО. Максимальную степень доверия при назначении АКТ имеют низкомолекулярные гепарины. Прямые оральные антикоагулянты, несмотря на отсутствие качественных рандомизированных исследований, подтверждающих их эффективность, большая часть врачей использует на амбулаторном этапе. Вызывает озабоченность значительный разброс вариантов и невысокий процент корректных ответов в вопросах, посвященных лабораторному контролю за системой гемостаза при АКТ. Заключение. Выполненный нами анализ свидетельствует о существенном расхождении реального применения антикоагулянтных препаратов у пациентов с НКИ COVID-19 с действующими клиническими рекомендациями. Кроме того, полученные результаты свидетельствуют о необходимости повышения уровня образованности практикующих специалистов в вопросах свертывания крови. Background. The SARS-CoV-2 virus invasion lead to COVID-19-associated coagulopathy accompanied with increased incidence of thrombotic complications. Current clinical guidelines give the main approaches to the treatment and prevention of them; however their implementation is not always possible in practice. In fact, there are a lot of violations including with a systemic genesis and associated either with the low understanding of infectious process pathogenesis aspects by clinicians or with their excessive desire to prevent coagulation disturbances. the revealing of real clinical practice conditions in the treatment and prevention of thrombotic complications in patients with coronavirus infection COVID-19. Materials/Methods. We provided an anonymous poll for 223 experts treating patients with chronic and acute vascular diseases. The questionnaire included 18 questions to identify as the experts attitude to this challenge as a whole as well as to their choice of treatment tactics, and anticoagulant drugs, and methods of laboratory monitoring of blood coagulation. Results. Most participants know the increased risk of thrombotic complications in COVID-19 and they are puzzled by it The treatment of COVID-19-associated coagulopathy is considered as the priority goal of anticoagulant therapy in the acute phase of COVID-19 whereas the prevention of venous thromboembolic complications is noted as main goal in convalescences. Low molecular weight heparins have gotten the highest confidence in the administration among anticoagulants. In turn, the most of experts use direct oral anticoagulants in outpatients even despite no confirmation is for DOAC’s effectiveness from randomized trials in this time. Besides it was revealed wide spread of opinions and low count of correct responses about laboratory control of the hemostatic system and anticoagulants. Conclusion. The analysis showed a serious inconsistency between the real anticoagulants administration in patients with COVID-19 and the recommendations of clinical guidelines. This circumstance obviates the need to raise educational level of physicians and surgeons in the field of blood coagulation.

Shortening and Plication of Entero-enterostomy for Intussusception in Roux-en-Y Gastric Bypass: Video Report.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered by a large percentage of bariatric surgeons' the operation of choice for obesity surgery as reported by Melvin (J Gastrointest Surg. 4:398-400, 2004). It is considered a generally safe procedure with a low percentage of complications. One of these complications is small bowel obstruction which has different etiologies. A rare cause of intestinal obstruction is intussusception at the entero-enterostomy as reported by Arapis et al. (Surg Obes Relat Dis. 1:23-33, 2019) and Sneineh et al. (OBES SURG 30:846-850, 2020). The accurate incidence of intussusception after LRYGB is unknown but Simper et al. (Surg Obes Relat Dis. 4:77-83, 2008) found a 0.15% incidence in their study. Diagnosis of intussusception requires a high index of suspicion because neither physical examination nor imaging is sensitive. CT scan might identify the problem, but a negative CT scan image does not rule out intussusception. Treatment of intussusception varies according to the clinical picture of the patient at the presentation. These variations may include conservative treatment up to resection of the entero-enterostomy and do a re-anastomosis as discussed by Daellenbach et al. (OBES SURG 21:253-263, 2011). The video aims to present an alternative option for surgical management of intussusception of the entero-enterostomy following LRYGB which to our knowledge was not published before.

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement-Update 2020.

PreambleThe International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical communities at large about the role of innovative and new surgical and or endoscopic interventions in treating adiposity-based chronic diseases. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) is a relatively new procedure that has been proposed as an alternative to the conventional duodenal switch (DS) procedure. The IFSO published a position paper on SADI-S/OADS in 2018 with which concluded that this procedure was likely to be a safe and efficacious treatment for adiposity and its related diseases. However, it noted that there was insufficient long-term data and minimal high-level evidence available. The position statement called for patients to be enrolled in long-term multidisciplinary care encouraged the registration of patients in national registries, and called for more randomized controlled trials (RCT) (Obes Surg 28:1207-16, 2018) involving the procedure. The following position statement is an update of the previous position statement. It is issued by the IFSO SADI-S/OADS task force and has been reviewed and approved by both the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed again in 2years.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

The Gravitostat theory: Body fat is lost but is fat-free mass preserved?

The Gravitostat theory: Body fat is lost but is fat-free mass preserved?

Management of a Complicated Internal Herniation After Roux-en-YGastric Bypass in a 28-Week Pregnant Woman

BackgroundSmall bowel obstruction (SBO) due to internal hernia (IH) is awell-known late complication after laparoscopic Roux-en-Y gastric bypass(LRYGB), with an incidence between 0.5 and 10% as reported by Iannelli et al.(Obes Surg. 17(10):1283–6, 2007). Itis reported most frequently 1–2 years after surgery because of the greaterweight loss at that time, with rapid loss of the mesenteric fat consequently asdiscussed by Stenberg et al. (Lancet. 387(10026):1397–404, 2016). Currently, women constitute more than50% of the patients undergoing bariatric surgery and most of them are ofchildbearing age as reported by the World Health Organization (2015). SBO, due to IH, is a rarecomplication during pregnancy, mostly occurring during the third trimester asdiscussed by Torres-Villalobos et al. (Obes Surg 19(7):944–50, 2009), and can result in fetal and maternalmorbidity and even mortality as reported by Vannevel et al. (Obstet Gynecol.127(6):1013–20, 2016). Moreover, thephysiologic changes of pregnancy can mask the symptoms of SBO after LRYGB,leading to significant diagnostic and therapeutic delays as detailed by Wax etal. (Am J Obstet Gynecol 208(4):265–71, 2013). Therefore, an early surgical exploration is necessaryin this particular and uncommon situation as discussed by Webster et al. (Ann RColl Surg Engl 97(5):339–44, 2015).MethodsA 32-year-old female patient, with Ehlers-Danlos syndrome andchronic pain, was in the 28th week of her first pregnancy after bariatricsurgery. She had had an antecolic LRYGB 6 years ago in another institution,resulting in a 35-kg weight loss. She presented to the emergency department withsevere and persistent epigastric pain associated with nausea and vomiting during24 h. On physical examination, her abdomen was painful and tender at theepigastrium and left hypochondrium, and her vital signs were normal. The bloodtests were in the normal range except the white blood cell count at 12′000 G/l.The obstetric and neonatal team was involved, and fetal heart monitoring wasnormal. Abdominal ultrasonography ruled out other causes of pain. An abdominalMRI was performed and displayed a distended proximal small bowel, free abdominalfluid, and bowel mesenteric edema in the left upper quadrant with compression ofthe superior mesenteric vein. Internal hernia with intestinal suffering wassuspected, and the patient consented for emergency laparoscopy.ResultsThe laparoscopic exploration, reduction of the internal hernia, andclosure of the mesenteric defects are demonstrated step-by-step in the presentedintraoperative video. The postoperative course was uncomplicated for bothpatient and fetus. Oral feeding was resumed at day 1, with no residual symptom,and the patient was discharged on postoperative day 3. At 1-month follow-up, shehad no complaint and her pregnancy had resumed a normal course. She delivered ahealthy baby at 36 weeks without any complication.ConclusionsInternal herniation after LRYGB represents a rare, high-riskcomplication during pregnancy. A low threshold for imaging, preferably byabdominal MRI, is recommended. Multidisciplinary management, includingobstetricians and bariatric surgeons, is necessary in order to avoid maternaland fetal adverse outcomes. During surgery, recognition of the anatomy is oftendifficult, and parts of the bowel are distended and fragile. Starting to run thebowel backwards from the ileocecal valve is a crucial surgical step for reducinginternal hernias during LRYGB, and reduces both the risk to worsen the situationand of bowel injury, making its management less hazardous.

SAT-474 Amiodarone-Induced Thyrotoxicosis After Weight Loss Following Sleeve Gastrectomy

AMIODARONE-INDUCED THYROTOXICOSIS AFTER WEIGHT LOSS FOLLOWING SLEEVE GASTRECTOMYINTRODUCTION:Bariatric surgeries have shown major health benefits improvement in co-morbidities such as HTN and DM. We are less familiar with how these surgeries affect the pharmacokinetics of drugs.1,2CLINICAL CASE:Our patient is a 65-year-old man with a fib/v tach and no prior thyroid history. He was on amiodarone 200 mg daily since September 2016. He had sleeve gastrectomy in March 2019 at weight 380 lbs. By June 2019, weight was 278 lbs.In June 2019, he had palpitations, diarrhea, and heat intolerance for one month. Labs showed: TSH <0.01 (0.4 – 4.5 MCIU/L), FT4 6.5 (0.8 – 1.8 NG/DL), and TT3 309 (76 – 181 NG/DL). Other labs: TPO antibodies <1 IU/mL (<9 IU/mL) TSI <89 (<140% baseline). Thyroid sonogram was heterogeneous without noduleHe started Methimazole (MMI) 20mg BID and Prednisone 40mg daily. In the next seven weeks, symptoms and TFTs improved. FT4 was 3.1 NG/DL, TT3 was 85 NG/DL, but TSH remained <0.01 MCIU/L. Because of the rapid improvement, he was felt to have type 2 AIT (destructive thyroiditis). MMI was quickly tapered. Prednisone was tapered to 30mg daily.At week 8, he was hospitalized for septic shock from diverticulitis and perianal abscess. He also had leukopenia attributed to MMI and sepsis. MMI was stopped. Amiodarone was stopped by cardiology. TFTs during hospitalization improved on only steroids: TSH was 0.01 MCIU/ML, FT4 was 2.34 NG/DL, and TT3 was 0.56 NG/ML. He was discharged on Prednisone 30mg daily with plans to taper off steroids.CONCLUSION:Our patient is the second reported case of AIT after bariatric surgery-induced weight loss. Amiodarone is a highly lipophilic drug that accumulates in adipose tissue. Rapid weight loss may result in the release of large amounts of amiodarone into the circulation with resultant thyrotoxicosis. As clinicians, we should be aware that patients who undergo bariatric surgery are at risk for complications that are not only directly related to the operation but also related to rapid weight loss that affects how the body handles drugs.REFERENCES1.Bourron O, Ciangura C, Bouillot J-L, Massias L, Poitou C, Oppert J-M. Amiodarone-induced hyperthyroidism during massive weight loss following gastric bypass. Obes Surg. 2007;17(11):1525–1528. http://www.ncbi.nlm.nih.gov/pubmed/18219784. Accessed September 21, 2019.2.Geraldo M de SP, Fonseca FLA, Gouveia MR de FV, Feder D. The use of drugs in patients who have undergone bariatric surgery. Int J Gen Med. 2014;7:219–224. doi:10.2147/IJGM.S55332

Endoscopic Repair of Large Gastric Perforation Following Pneumatic Dilation of Sleeve Gastrectomy Stenosis.

Sleeve gastrectomy has become the most commonly performed bariatric surgery in the USA (English et al.in Surg Obes Relat Dis. 14(3):259-63, 2018). Despite the rising popularity of this procedure, gastric stenosis is a known complication with an incidence of up to 4% (Rebibo et al. in Obes Surg. 26(5):995-1001, 2016). Endoscopic pneumatic balloon dilation is increasingly utilized to treat this condition and to ameliorate symptoms of nausea, vomiting, reflux, and/or dysphagia (Dhorepatil et al. in BMC Surg. 18(1):52, 2018). Pneumatic balloon dilation does carry a risk of gastric perforation of up to 3% in the limited literature to date (Donatelli et al. in Surg Obes Relat Dis. 13(6):943-50, 2017), historically requiring immediate surgical consultation for repair (Donatelli et al. Surg Obes Relat Dis. 13(6):943-50, 2017). In this case series, two cases of gastric perforation during pneumatic dilation for gastric sleeve stenosis were repaired successfully endoscopically with use of an endoscopic suturing system, resulting in correction of gastric defect and elimination of symptoms.

SUN-LB058 Metastatic Insulinoma after Bariatric Surgery: A Diagnostic Challenge

Background: Post bariatric hypoglycemia (PBH) is an increasingly recognized complication of bariatric surgery. Onset typically occurs more than 1-year post-op with episodes typically occurring postprandially. In contrast, insulinoma causes fasting and postprandial hypoglycemia and has been described after bariatric surgery, with 9 reported cases. Case: A 69-year-old woman presented to the emergency department after syncope in the setting of hypoglycemia to 39 mg/dL. Medical history was notable for Roux-en-Y gastric bypass 9 years ago. She had been experiencing fatigue in the 8 months prior with episodes of diaphoresis, hunger and mental fogginess that occurred randomly throughout the day and resolved with hard candy. An inpatient supervised fast resulted in Whipple triad with blood glucose 32 mg/dL and insulin 28 uU/mL (N 2.6-24.4) within 3 hrs of starting the test, thus making it difficult to exclude PBH. Therefore, a repeat fast was performed after minimal carbohydrate intake. This test yielded similar results with hypoglycemia occurring within 2.5 hrs. Based on this, medical treatment with octreotide and diazoxide was initiated. CT abdomen showed atrophic pancreas with no mass and an enhancing liver mass suggestive of a hemangioma. However, MRI abdomen revealed a 2.9 cm pancreatic tail mass and 3 hypervascular liver lesions concerning for metastasis. Subsequently, biochemical results from the supervised fast confirmed hyperinsulinemic hypoglycemia likely due to metastatic insulinoma based on imaging studies: C-peptide 4.67 ng/mL (N 0.8-3.85), proinsulin >800 pmol/L (N <=18.8), ß hydroxy butyrate 0.04 mmol/L (N <= 0.28). Pancreatic mass FNA via endoscopic ultrasound was suspicious for neuroendocrine tumor (NET). Liver mass biopsy showed metastatic NET. Hypoglycemia worsened despite continuous IV dextrose infusion and medical therapy necessitating distal pancreatectomy, splenectomy and partial hepatectomy for tumor debulking. Pathology revealed a 1.4 cm grade 2 well- differentiated NET in the pancreatic tail (mitotic rate 1 per 10 hpfs, Ki67 5%) and 2 foci of metastasis in the liver (8 and 0.9 cm). Unfortunately, the patient developed unexplained refractory shock with multiorgan failure post-operatively and passed away after 7 days. Conclusion:To our knowledge, this is the first case reported of malignant insulinoma after bariatric surgery. Malignant metastatic insulinoma is very rare. It causes severe hypoglycemia that can occur in the very early PP period similar to PBH, which could delay diagnosis. Inconclusive initial imaging should not preclude comprehensive workup in severe persistent hypoglycemia. Reference: Mulla, CM et al. Insulinoma After Bariatric Surgery: Diagnostic Dilemma and Therapeutic Approaches. Obes Surg. 2016. 26:874-881 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Endoscopic vacuum therapy for a large esophageal perforation after bariatric stent placement.

Endoscopic vacuum therapy for a large esophageal perforation after bariatric stent placement.

Laparoscopic SADI-S as a salvage procedure for failed gastric bypass and sleeve gastrectomy: How I do it

Malabsorptive procedures such as duodenal switch (DS) and biliopancreatic diversion are extremely effective bariatric operations, yet account for<1.5% of all bariatric procedures performed worldwide at present [ [1] Angrisani L. Santonicola A. Iovino P. Formisano G. Buchwald H. Scopinaro N. Bariatric Surgery Worldwide 2013. Obes Surg. 2015; 25: 1822-1832 Crossref PubMed Scopus (1063) Google Scholar ]. Reasons for such low volume include perceived technical complexity of these operations and concerns for major postoperative complications including severe nutritional deficiencies. The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the standard DS procedure, which can achieve equivalent clinical benefit but with less associated risk of postoperative nutritional complications [ 2 Sanchez-Pernaute A. Herrera M.A. Perez-Aguirre M.E. et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg. 2010; 20: 1720-1726 Crossref PubMed Scopus (146) Google Scholar , 3 Sanchez-Pernaute A. Rubio Herrera M.A. Perez-Aguirre E. et al. Proximal duodenal-ileal end-to-side bypass with sleeve gastrectomy: proposed technique. Obes Surg. 2007; 17: 1614-1618 Crossref PubMed Scopus (132) Google Scholar , 4 Sanchez-Pernaute A. Rubio M.A. Cabrerizo L. Ramos-Levi A. Perez-Aguirre E. Torres A. Single-anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) for obese diabetic patients. Surg Obes Relat Dis. 2015; 11: 1092-1098 Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar , 5 Gebelli J.P. Gordejuela A.G. Ramos A.C. et al. Sadi-S with right gastric artery ligation: technical systematization and early results. Arq Bras Cir Dig. 2016; 29: 85-90 Crossref Google Scholar ].