Post-bariatric Surgery Research Articles

BS O06 - Management of Leaks post Bariatric Surgery: Recent Experience from a Tertiary Bariatric Surgery Referral Unit

Abstract Background Bariatric surgery has been consistently demonstrated to provide effective long-term sustained weight loss and remission of several life-threatening conditions. The most common bariatric procedures undertaken globally include laparoscopic sleeve gastrectomy (SG) and gastric bypass2. These procedures are safe and have low associated mortality rates [0.05% SG, 0.09% single anastomosis gastric bypass (SAGB) and Roux-en-Y (RNYGB)]3. However, complications including staple line and anastomotic leaks can occur in up to 3% of patients and are associated with significant morbidity, thus requiring prompt identification and treatment4. Our study aims to analyse management of these leaks and establish an algorithm for our centre. Method This was a retrospective study of consecutive patients who experienced post-bariatric surgery leak between 2018 to 2024, in a regional tertiary bariatric surgery referral unit in the UK, serving a population of 5 million. The study included patients who underwent bariatric surgery in the UK or abroad (SG, RNYGB and SAGB), both primary and revision cases, and were subsequently diagnosed with post-operative leak. Patients were initially managed in our facility or referred to our centre for ongoing management of leak from other centres. Demographics, time to presentation, hospital length of stay (LOS), diagnostic investigations performed, and management approaches were analysed. Results 22 patients (8 bypasses, 14 sleeves) were included. Mean time to presentation from index surgery was 19.6 days and mean LOS was 43.6 days. Initial management included conservative (3), endo-vacuum therapy (EVT) (4), stent (1), surgical (14) [9 laparoscopy and 5 laparotomy]. Surgical management comprised 7 T-tube insertions, 1 Foley catheter, 2 primary repairs, 2 EVTs, 1 washout and drain, and 1 stoma formation. Three patients required no further intervention, six needed different management approaches and three required re-operations. 7 patients were readmitted following discharge. Resolution of leak was achieved in all cases. There was no 90-day mortality. Conclusion Management of postoperative leak following bariatric surgery is a complex issue, requiring early identification, adequate drainage and control of sepsis, and maintenance of nutrition. Successful management requires a proactive and aggressive approach, including early clinical suspicion. Access to a range of interventions to support a dynamic approach to management is critical. The sequence and choice of management of leaks should be individualised according to each patient’s clinical presentation and investigation findings. A combination of different management approaches is often required for successful treatment of leak. Multicentre studies are needed to move closer to a consensus on managing bariatric leaks.

BS SO09 - Use of ursodeoxycholic acid in preventing gallstone formation after bariatric surgery – introduction of a new clinical pathway

Abstract Background Rapid weight loss is a risk factor for symptomatic gallstone formation. Managing gallstone disease such as choledocholithiasis can be more challenging after Bariatric Surgery (BS) due to altered anatomy. Ursodeoxycholic acid (UDCA) is a low-cost and low-risk method of reducing the risk of symptomatic gallstone disease and cholecystectomy by almost a third in patients who have had BS. However, it is not yet included in national guidelines for bariatric surgery. We audited prescription rates of UDCA in patients who underwent BS with a view to introducing it into our standard post BS care bundle. Method Data was collected from 30 consecutive patients who underwent a sleeve gastrectomy or Gastric bypass in November and December 2023. The results informed our practice and a UDCA prescribing pathway was developed using evidence from randomized trials. The pathway was circulated to all members of the bariatric service on 17/1/2024 and discussed at the departmental meeting. The audit loop was closed by collecting data from a further 30 consecutive patients. Demographic data, type of operation, BMI, history of gallstone disease, prescribing data and reasons for non-compliance were collected. The compliance rate to the UCDA pathway was expected to be 100%. Results Data was collected from 60 patients (85% female; median BMI 49; median age 45). No patient who could have benefited received UDCA prior to the intervention. After the intervention, 15/30 (50%) of patients were correctly prescribed UDCA. Therefore, correct prescription of UDCA did not meet target compliance rates. No patient was incorrectly prescribed UCDA. Reasons for non-compliance include human error, concern about the size of the tablet, inadequate knowledge about how to administer (e.g. crushing in liquid) and misconceptions of oral intake after BS. Conclusion UCDA can reduce incidence of symptomatic gallstones following BS, yet use of UDCA in bariatric centres in the UK is thought to be low. We discovered that more time should be dedicated to educating the team about administration methods and how it interacts with the current postoperative diet plan. A UCDA pathway and education of bariatric teams can improve compliance with appropriate UDCA prescribing. Further intervention is required and planned in our centre such as utilising e-prescribing as a prompt to include UDCA in the discharge prescription and considering the use of the drug's liquid form in the short term.

A Very Low-Calorie Ketogenic Diet Approach for Post-Bariatric Weight Regain: A Pilot Study

Weight regain (WR) after bariatric surgery, particularly sleeve gastrectomy, is a significant challenge, often driven by a combination of metabolic, behavioral, and lifestyle factors. Non-surgical interventions to manage WR are critical, given the increased risks and reduced efficacy of revisional surgeries. In this context, very low-calorie ketogenic diets (VLCKDs) have gained attention for their potential to promote weight loss and improve body composition in individuals struggling with WR. This study assessed the safety and efficacy of a VLCKD in 11 patients who experienced WR following sleeve gastrectomy. Over an 8-week period, patients demonstrated a significant average weight loss of 6.3% (p = 0.005), along with improvements in body composition, including reductions in body fat percentage (p = 0.003) and waist circumference (p = 0.003). Metabolic markers, such as insulin resistance (HOMA-IR), also improved significantly (p = 0.041). Although a decrease in the glomerular filtration rate was observed (p = 0.007), this finding is unlikely to be clinically relevant over the short term. Importantly, no major adverse events were reported, with only mild constipation observed. These results suggest that VLCKDs may be a promising non-surgical approach for managing WR post-bariatric surgery, though further studies are needed to assess long-term effects, especially on renal function.

Comparative Effects of Sleeve Gastrectomy vs. Roux-en-Y Gastric Bypass on Phase Angle and Bioelectrical Impedance Analysis Measures: A Systematic Review and Meta-Analysis

Background/Objectives: The objective of this meta-analysis was to determine the impact of bariatric surgery on phase angle (PhA) and other bioimpedance measures among adults with obesity, comparing the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines, including studies up to May 2024 from MEDLINE, Scopus, Cochrane Library, and Web of Science. Eligible studies assessed PhA changes pre- and post-bariatric surgery in adults with BMI ≥ 30 kg/m2. Data on PhA, fat mass (FM), fat-free mass (FFM), body cell mass (BCM), weight, and BMI were extracted and analyzed. Results: Thirteen studies with a total of 1124 patients were included. Significant PhA reductions were observed at 6 months post-surgery (effect size: −1.00; 95% CI: −1.11 to −0.89; p < 0.001), with a more substantial reduction in RYGB patients compared to SG. FM and FFM decreased significantly at 12 months (FM: −27.58; 95% CI: −32.58 to −22.57; p < 0.001; FFM: −10.51; 95% CI: −12.81 to −8.94; p < 0.001). Weight and BMI showed marked reductions at 6 months (Weight: −31.42 kg; 95% CI: −37.28 to −25.26; p < 0.001; BMI: −11.39; 95% CI: −12.60 to −10.18; p < 0.001), with sustained decreases at 12 and 24 months. Conclusions: Bariatric surgery significantly reduces PhA, FM, FFM, weight, and BMI, with initial greater impacts observed in RYGB compared to SG. PhA shows potential as a marker for monitoring post-surgical recovery and nutritional status. Further long-term studies and standardized measurement protocols are recommended to optimize patient management.

A Systematic Review Exploring Dietary Behaviors, Psychological Determinants and Lifestyle Factors Associated with Weight Regain After Bariatric Surgery

Background: Weight regains after bariatric surgery presents a significant challenge to long-term weight management and overall health outcomes. While clinical and surgical factors influencing bariatric outcomes have been extensively reviewed, there remains a notable gap in understanding how behavioral factors—specifically dietary habits, psychological influences, and lifestyle choices—impact long-term weight maintenance. This systematic review addresses this gap, highlighting the unique role of these behavioral factors in sustaining weight loss post-bariatric surgery. Aim: This systematic review aims to explore the behavioral factors—including dietary, psychological, and lifestyle influences—associated with weight regain after bariatric surgery. Methods: A comprehensive search was conducted across multiple databases, focusing on peer-reviewed articles published in English. We included observational studies exclusively focused on adults who experienced weight regain after bariatric surgery, with an emphasis on behavioral factors. Searches were conducted in MEDLINE via PubMed, Embase, Web of Science, Scopus, and Google Scholar, with the last search completed on 10 July 2024. Studies published within the past 10 years were considered. The Joanna Briggs Institute (JBI) critical appraisal tool for cross-sectional studies was used to assess the risk of bias. A total of 16 studies met the inclusion criteria: 12 cross-sectional studies, 3 cohort studies, and 1 in-depth interview study. Results: The review found inconsistencies in the definitions of weight regain across studies. Nonetheless, three primary behavioral factors were identified as potentially contributing to weight regain: dietary non-adherence and eating patterns, psychological determinants, and lifestyle behaviors. Dietary non-adherence included high-calorie food consumption, excessive intake of sweets, carbohydrates, and sweetened beverages, and low protein intake. Psychological factors such as depression, anxiety, emotional eating, and binge eating were prevalent among individuals experiencing weight regain. Lifestyle behaviors, including physical inactivity, smoking, and sedentary habits, also played significant roles. Conclusions: Post-bariatric weight management is multifaceted, necessitating a comprehensive approach that addresses dietary, psychological, and lifestyle factors. Most studies on behavioral factors linked to weight regain were cross-sectional with small sample sizes, limiting the ability to infer causality. Future research should include detailed information on dietary adherence, standardized tools to assess physical activity and sedentary behavior, and validated measures for psychological health. Tailored interventions and continuous support from healthcare professionals are essential for maximizing the effectiveness of bariatric surgery, promoting sustainable weight loss, and enhancing overall health outcomes.

Antepartum Wernicke’s Encephalopathy: Common, and Yet Rarely Diagnosed. Discussion on the Disease and Its Treatment

This review article presents a comprehensive discussion on antepartum Wernicke’s encephalopathy (WE), a serious neurological disorder. This disorder stems from thiamine (Vitamin B1) deficiency, which is critical for normal metabolism and neuronal integrity. During pregnancy, women are more susceptible to this condition due to increased nutritional requirement and metabolic changes. In WE, inadequate thiamine (Vitamin B1) causes disruption of metabolism in cells and impedes neurotransmitter synthesis in the brain, ultimately causing adverse neural consequences. Key risk factors contributing to antepartum WE include conditions that hinder thiamine absorption or increase metabolic demand, such as hyperemesis gravidarum (intense antepartum vomiting), malnutrition, alcoholism, and post-bariatric surgery states. WE's classic triad of symptoms, confusion, ataxia (loss of balance and coordination), and ophthalmoplegia (occlumotor incoordination), are not commonly seen in antepartum WE. Therefore, diagnosing the disorder in pregnancy is challenging and the condition is often misdiagnosed. Pregnancy symptoms like nausea, vomiting, and fatigue often overlap with WE's presentation, complicating diagnosis and confounding treatment. While magnetic resonance imaging (MRI) can reveal characteristic lesions in brain areas such as the thalamus and mammillary bodies, these may not always appear in early stages, adding further diagnostic difficulty. Effective management of antepartum WE relies on early recognition and timely administration of high-dose thiamine, particularly parenteral administration for affected pregnant women. Prompt treatment is critical to preventing irreversible sequalae, neurological and otherwise in both the woman and the child. Once acute symptoms are managed, transitioning to oral thiamine supplementation is the norm to prevent recurrence and maintain normal thiamine levels. Balanced diet of macro-nutrients and maintaining fluid and electrolyte balance, also plays an essential role in recovery. In severe or treatment-resistant cases, more intensive, prolonged thiamine therapy and regular monitoring of maternal and fetal health are necessary, usually managed by a multidisciplinary medical team. This coordinated care approach aims to prevent recurrence and minimize risks associated with WE. The article emphasizes following clinical guidelines, which recommend regular thiamine monitoring and preventive measures in high-risk pregnancies, to improve maternal and fetal outcomes. By adhering to established protocols, healthcare providers can reduce the likelihood of severe complications associated with WE, ensuring better care and recovery for affected pregnant women. Categories: Pregnancy, Neurology, Nutrition.

The relationship between health literacy level and quality of life in bariatric surgery patients

Abstract Background Today, obesity is an important public health problem. In addition to the intervention programmes developed to prevent obesity, the necessity of medical and surgical treatment is increasing with the growing population. This study was conducted to determine the relationship between health literacy and quality of life in patients undergoing bariatric surgery. Methods This cross-sectional study was conducted with the participation of 136 patients aged 18 years and older who underwent bariatric surgery in a general surgery service between January 2021 and December 2023 and whose contact information was available. The survey participation rate was 75.1%. The questionnaire used for data collection consisted of questions about the sociodemographic information of the participants, The European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the Postbariatric Surgery Quality of Life Scale items. Descriptive statistics, Mann Whitney U, Kruskal Wallis H test and Spearman correlation analysis were used to analyze the data. A value of p < 0.05 was considered statistically significant. Results The mean age of the patients who participated in the study was 38.2 ± 10.8 years; mean BMI was 42.3 ± 6.4 before surgery and 29.0 ± 6.2 after surgery. In the study, 44.1% of the patients who underwent bariatric surgery were found to have inadequate/problematic health literacy level. Participants who had less than a bachelor’s degree (p = 0.009) and low income (p < 0.001) had significantly lower health literacy levels. In addition, a moderate positive correlation was found between overall health literacy score and quality of life score (r = 0.252; p = 0.003). Conclusions In conclusion, this study shows that improved health literacy positively affects quality of life in patients undergoing bariatric surgery and that health literacy education should be emphasized in this context. Key messages • The level of health literacy of bariatric surgery patients is a determining factor on quality of life, and therefore health literacy education is important, especially in identified risk groups. • Increased health literacy can have positive results in terms of psychosocial and physical health and improve quality of life after bariatric surgery.

In-hospital economic impact and mortality of bariatric surgery on congestive heart failure in the USA: a nationwide analysis

Abstract Background Congestive Heart Failure (CHF) remains a significant economic burden in the inpatient setting. There is a complex correlation between obesity and Congestive Heart Failure (CHF). Bariatric surgery has emerged as a critical intervention for patients with morbid obesity. However, there is limited data on how this intervention impacts hospital economic metrics and patient outcomes in the context of CHF post-bariatric surgery. Purpose The purpose of this study is to assess the in-hospital economic impact and mortality among patients with congestive heart failure who have undergone bariatric surgery. Methods We queried the National Inpatient Sample from 2016 to 2020; this retrospective observational cohort study identified CHF patients who had undergone bariatric surgery through ICD-10 codes. Univariate and multivariate logistic regression analyses were performed to determine Total Charges (TOTCH) and Length of Stay (LOS), adjusting for confounders including the Elixhauser comorbidity index, hospital region, quarterly income, and hospital location to identify the economic impact on CHF (Table 1). Results Out of 25,900,000 patients with congestive heart failure, 5,983,684 (23%) were obese, and 208,220 (0.8%) had undergone bariatric surgery. The demographic profile showed a mean age of 63 predominance of females (65%) and the White population (69.5%) (Table 1). The mean TOTCH for patients undergoing bariatric surgery was $66,235, compared to $76,046 for those who did not undergo the surgery, with a significant mean decrease in TOTCH of -$11,454 (p<0.001, 95% CI: -$12,472 to -$10,435). The mean LOS was 5 days for patients with bariatric surgery versus 6 days for those without, showing a mean decrease in LOS of 0.93 days (95% CI: -0.99 to -0.87). Additionally, there was a significant decrease in overall mortality risk among patients who had bariatric surgery (2.1%) compared to those who did not (5%), with an (OR 0.4 p<0.001, 95% CI: 0.38 to 0.43). Conclusion Our research demonstrates that bariatric surgery in obese individuals with congestive heart failure (CHF) markedly decreases in-hospital mortality, reduces hospital charges, and shortens the length of hospital stays. These findings underscore the potential of bariatric surgery as a cost-effective intervention for improving outcomes in patients with CHF and obesity, highlighting the importance of considering surgical weight loss options in the management of CHF.Table 1

Effectiveness of the etonogestrel subdermal implant in users with overweight and obesity: a systematic literature review

BackgroundThe etonogestrel (ENG) subdermal implant is considered a well-tolerated and effective contraception option to avoid unintended pregnancies. However, it is unclear whether being affected by overweight or obesity diminishes the...

Prevalence of Depression and Anxiety Among Post-bariatric Surgery Patients: A Cross-Sectional Study

Prevalence of Depression and Anxiety Among Post-bariatric Surgery Patients: A Cross-Sectional Study

Multi-omics insights into the microbiota-gut-brain axis and cognitive improvement post-bariatric surgery

BackgroundAlthough numerous studies have shown that bariatric surgery results in sustained weight loss and modifications in gut microbiota composition and cognitive function, the exact underlying mechanisms are unclear. This study aimed to investigate the effects of bariatric surgery on cognitive function through the microbiota-gut-brain axis (MGBA).MethodsDemographic data, serum samples, fecal samples, cognitive assessment scales, and resting-state functional connectivity magnetic resonance imaging (rs-fMRI) scans were obtained from 39 obese patients before and after (6 months) laparoscopic sleeve gastrectomy (LSG). PCA analysis, OPLS-DA analysis, and permutation tests were used to conduct fecal 16 S microbiota profiling, serum metabolomics, and neuroimaging analyses, and a bariatric surgery-specific rs-fMRI brain functional connectivity network was constructed. Spearman correlation analysis and Co-inertia analysis were employed to correlate significant alterations in cognitive assessment scales and resting-state functional connectivity difference networks with differential serum metabolites and 16 S microbiota data to identify key gut microbiota and serum metabolic factors.ResultsLSG significantly reduced the weight of obese patients, with reductions of up to 28%. Furthermore, cognitive assessment scale measurements revealed that LSG enhanced cognitive functions, including memory (HVLT, p = 0.000) and executive function (SCWT, p = 0.008). Also, LSG significantly altered gut microbiota composition (p = 0.001), with increased microbial abundance and diversity (p < 0.05). Moreover, serum metabolite levels were significantly altered, revealing intergroup differences in 229 metabolites mapped to 72 metabolic pathways (p < 0.05, VIP > 1). Spearman correlation analysis among cognitive assessment scales, gut microbiota species, and serum metabolites revealed correlations with 68 gut microbiota species and 138 serum metabolites (p < 0.05). Furthermore, pairwise correlations were detected between gut microbiota and serum metabolites (p < 0.05). Functional neuroimaging analysis revealed that LSG increased functional connectivity in cognitive-related frontotemporal networks (FPN, p < 0.01). Additionally, normalization of the default mode network (DMN) and salience network (SN) connectivity was observed after LSG (p < 0.001). Further canonical correlation and correlation analysis suggested that the cognitive-related brain network changes induced by LSG were associated with key gut microbiota species (Akkermansia, Blautia, Collinsella, Phascolarctobacterium, and Ruminococcus, p < 0.05) and neuroactive metabolites (Glycine, L-Serine, DL-Dopa, SM (d18:1/24:1(15Z), p < 0.05).ConclusionThese findings indicate the pathophysiological role of the microbiota-gut-brain axis in enhancing cognitive function after bariatric surgery, and the study provides a basis for clinical dietary adjustments, probiotic supplementation, and guidance for bariatric surgery, but further research is still needed.Trial registrationChinese Clinical Trial Registry, ChiCTR2100049403. Registered 02 August 2021, https://www.chictr.org.cn/.

Bacterial and clinical metabolic signatures and their interactions in obese patients post-bariatric surgery

BackgroundObesity is a growing health concern in China, closely linked to metabolic disorders such as type 2 diabetes. Laparoscopic Sleeve Gastrectomy (LSG) is effective in promoting weight loss and improving metabolic outcomes. Emerging evidence highlights the role of gut microbiota in metabolic regulation, yet the specific alterations in gut microbiota and their association with metabolic changes post-surgery in Chinese patients remain unclear. Understanding these shifts could provide key insights into optimizing treatment strategies for metabolic improvement following bariatric surgery.MethodsStool samples and clinical data were collected from 30 obese patients before and 6 months after surgery. The composition of the gut microbiota was analyzed through 16S rRNA sequencing, and Spearman correlation analysis was used to determine the association between gut microbiota and clinical indicators.ResultsThe analysis of 30 patients showed a significant decrease in Body Mass Index (BMI) (36.75 ± 4.09 kg/m2 vs 26.37 ± 3.47 kg/m2, p < 0.0001). Glucose metabolism, including Hemoglobin A1C levels, improved significantly (6.05 ± 0.96 vs 5.05 ± 0.25, p < 0.0001), and liver function as well as serum lipid levels were also notably improved. LSG increased the richness and composition of gut microbiota in obese patients post-surgery. These changes in gut microbiota were closely associated with improved clinical metabolic parameters.ConclusionLSG not only significantly reduces body weight while also alleviating metabolic syndrome and comorbidities by altering gut microbiota.

Protein supplementation preserves muscle mass in persons against sleeve gastrectomy.

Sleeve gastrectomy surgery can lead to deficiencies in both macro and micronutrients, with protein being particularly crucial due to its role in muscle mass, physiological, and metabolic functions. Inadequate protein intake due to physiological, psychological, or financial reasons may prevent achieving the recommended intake levels. The significance of this issue is often underappreciated. This study evaluates the impact of protein supplementation on muscle mass in individuals undergoing sleeve gastrectomy and emphasizes the need for more comprehensive dietary training by expert dietitians. Data were collected from 60 participants (15 male, 45 female, aged 20-54) who visited the surgery clinic. Participants were divided into two groups: those receiving the recommended protein supplement (15 g/day) with post-bariatric surgery diet training (BSD + PS), and those receiving only the post-bariatric surgery diet (BSD). A pre-surgery questionnaire gathered health and general information. Daily energy and nutrient intakes were recorded using 24-h food consumption logs on the day before surgery and at 7 days, 1 month, and 3 months postoperatively. Anthropometric measurements, including muscle and fat mass, and International Physical Activity Questionnaire (IPAQ) data were also collected. The characteristics of participants in both groups were similar, although there were more females in the BSD + PS group (86.7%) compared to the BSD group (63.3%). Despite an increase in energy and nutrient intake over time, levels remained below the recommended amounts in both groups. A significant difference was found in protein supplement consumption between the groups (p = 0.000). Repeated measures showed significant differences in body muscle mass percentage over time (F = 202.784; p = 0.000). In individuals who underwent sleeve gastrectomy surgery, deficiencies in macro and micronutrient intake were observed below reference levels. For this reason, the first approach in the treatment of obesity should always be medical nutrition therapy accompanied by a dietician. When designing post-bariatric surgery nutrition programs, it should be taken into consideration that nutrition protocols and trainings should be followed more closely and given in more detail under the supervision of a specialist before supplements are considered.

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 &amp;lt;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

8202 Retrospective Analysis of Mixed-Meal Testing in People with Suspected Spontaneous Post-Prandial Hypoglycemia

Abstract Disclosure: N. Sankaran: None. R. Jalleh: None. C. Bischoff: None. C. Marathe: None. Introduction: While there is no consensus on the optimal confirmatory test for postprandial hypoglycemia, guidelines suggest evaluation with a mixed meal test that is most likely to provoke symptoms of hypoglycemia as nominated by the patient. However, studies evaluating post-bariatric surgery hypoglycemia indicate that meals with a lower carbohydrate content are less likely to be associated with postprandial hypoglycemia. It is hypothesized that a greater carbohydrate load may result in an excessive second-phase insulin response resulting in hypoglycemia. We evaluated the outcomes of consecutive mixed meal tests in individuals with suspected spontaneous postprandial hypoglycemia and the relationship with the percentage carbohydrate content of the test meal. Methods: We retrospectively analysed the data of 103 unselected patients who were referred to undergo a 5-hour mixed meal test following an overnight fast, between the years 2010 - 2023 at the Royal Adelaide Hospital. Correlations were determined using a linear regression model and Student’s t-test was used to compare the mean carbohydrate meal content in those with and without postprandial hypoglycemia. Outcomes: Outcomes that were measured included post-meal blood glucose, plasma insulin, plasma C-peptide levels and the macronutrient composition of the meal. Subjective reporting of symptoms during the test were also noted and correlated with the symptoms included in the Edinburgh Hypoglycemia Score. Results: 33/103 participants were excluded as they had previously undergone islet cell transplant or bariatric surgery. Out of the remaining 70 participants referred for confirmatory MMT testing, 51 were female and 19 were male. The ages of the participants ranged from 16 to 74, with the median age of 40 years. 9 participants (6 females and 3 males) had abnormal results with glucose below 3.0mmol/L. 34 participants experienced hypoglycemia with glucose levels recorded below 4.0mmol/L during the test. There was no difference in carbohydrate content consumed (61.1g, P=0.30) or percentage carbohydrate (64.5%, P=0.17) in the group without postprandial hypoglycemia compared with those with postprandial hypoglycemia (carbohydrate content 67.9 g, 69.6% carbohydrate). No correlation could be identified between the percentage of carbohydrate content of the meal with the glucose nadir (P=0.75), peak insulin concentration (P=0.99) or peak C-peptide concentration (P=0.40). The percentage of carbohydrate content of the meal was neither associated with hypoglycemia (P=0.17) or symptoms (P=0.41). Conclusion: On mixed meal testing, postprandial symptoms and hypoglycemia does not correlate with either carbohydrate load or the percentage carbohydrate content of the nominated meal. Presentation: 6/1/2024

6666 Asymptomatic Fasting Hypoglycemia After Sleeve Gastrectomy

Abstract Disclosure: K. Mitrollari: None. H.K. Deveaux: None. A. Gundeti: None. A.P. Calimag: None. T. Yasmeen: None. Introduction: Post-bariatric surgery hypoglycemia (PBSH), though previously considered rare, is increasingly recognized, occurring not only after Roux-en-Y gastric bypass (RYGB,) but also following various bariatric procedures. PBSH can manifest as postprandial or fasting hypoglycemia, requiring thorough investigation and prevention due to potential asymptomatic presentations that may lead to severe consequences, including coma and death. Case Report A 45-year-old female with a history of type 2 DM, ESRD on HD, gastric sleeve surgery, bilateral trans-metatarsal amputations, coronary artery disease, and congestive heart failure presented with bilateral lower extremity wounds. On admission her venous blood glucose was 71 mg/dL. Glycohemoglobin was 3.9% and fructosamine was 225 (205-285 umol/L). Her glycohemoglobin levels consistently remained below 6.4% status post sleeve gastrectomy off diabetes medications. Throughout admission, she experienced almost daily episodes of fasting asymptomatic hypoglycemia correlated with venous sample with lowest blood glucose reading 38 mg/dL. Initially, these episodes were attributed to NPO status for procedures or decreased PO intake. Her diet consisted of fast food brought by her family, which she reported was similar to her diet at home. Workup during a hypoglycemic episode (glucose 51 mg/dL,) revealed insulin 4 mUnits/L, proinsulin 7.1 pmol/L (&amp;lt;=7.2 pmol/L), C-peptide 25.7 ng/mL (0.8-3.9 ng/mL), and beta-hydroxybutyrate 0.5 mmol/L (0.0-0.3 mmol/L). Negative insulin antibodies and sulfonylurea panel, normal cortisol, and ACTH levels were noted. The patient was placed on a 10% dextrose infusion to avoid further episodes of hypoglycemia. However, she continued to experience hypoglycemia and was started on oral diazoxide. A CT pancreas with and without contrast was unremarkable, and endoscopic ultrasonography only revealed a 10 mm accessory spleen. The patient was discharged with counseling on glucose monitoring, dietary changes, and follow-up with endocrinology. Conclusion: PBSH should be considered as a differential diagnosis in patients with unexplained hypoglycemia and a history of bariatric surgery. PBSH mimics insulinoma or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) with elevated insulin, proinsulin, C-peptide, and low beta-hydroxybutyrate during hypoglycemia, however NIPHS is exclusive to non-bariatric patients. Imaging is crucial to rule out insulinoma, and invasive tests such as endoscopic ultrasound aid diagnosis. PBSH is a diagnosis of exclusion; therefore, workup involves ruling out other causes of hypoglycemia. First-line treatment involves diet modification, with medications like diazoxide or acarbose considered if dietary changes prove insufficient. This case underscores the complexity of hypoglycemia, implicating bariatric surgery as a contributing factor. Presentation: 6/3/2024

9337 Postprandial And “Fasting” Hypoglycemia In A Patient With A History Of Gastric Bypass Surgery And Carcinoid Syndrome

Abstract Disclosure: S. Ntelis: None. M. Pennant: None. Background: Hypoglycemia is an increasingly recognized complication of bariatric surgery that can occur years after the procedure. Episodes most commonly occur 1-3 hours after meals. Fasting hypoglycemia is not typical and raises concerns for other etiologies, including adrenal insufficiency and other causes of endogenous hyperinsulinism. Clinical Case: A 51-year-old woman with a history of carcinoid tumor of unknown origin with liver metastases, treated with monthly octreotide injections, and history of Roux-en-Y gastric bypass presented with multiple episodes of symptomatic hypoglycemia up to 24 mg/dl. Symptoms included tremor and diaphoresis and improved with juice. Morning cortisol was 22.7 mcg/dL (n &amp;gt; 19.4 mc/dL), ruling out adrenal insufficiency. A continuous glucose monitor (CGM) was placed, and she was advised to have frequent low-carbohydrate meals mixed with healthy fats and protein. She was also advised to add cornstarch to meals, until mixed-meal testing could be performed. She was hospitalized for a seizure provoked by hypoglycemia after a heavy high-carbohydrate meal, and treatment with acarbose 25 mg three times daily was started. Mixed-meal testing was consistent with post-prandial hyper-insulinemic hypoglycemia, with elevated insulin (58 mcIU/ml, n: 2.6-24.9 mcIU/ml) and c-peptide (11.2 ng/ml, n: 1.1-4.4 ng/ml) levels during an episode of symptomatic hypoglycemia (glucose 22 mg/dL) 2.5 hours after the patient’s meal. CGM showed hypoglycemia mostly occurring after meals and some episodes of hypoglycemia early in the morning, that occurred after late-night snacks. Clinical picture and laboratory testing were suggestive of post-bariatric surgery hypoglycemia. Poor hepatic glycogen reserve, secondary to the liver metastases, was considered a contributing factor. Interestingly, although hypoglycemia was mediated by hyperinsulinemia, treatment with a somatostatin analogue provided no benefit. The frequency of hypoglycemia decreased with adherence to a low-carbohydrate diet, and episodes mostly occurred when acarbose use was delayed. Octreotide was transitioned to lantreotide. Due to persistence of early-morning low glucose values on follow-up, further work-up was pursued to rule out etiologies of fasting hypoglycemia. Glucose values remained &amp;gt;70 mg/dl during 72 hours of fasting. IGF-I (115 ng/ml, n: 53-287 ng/ml) and IGF-II (608 ng/ml, n: 267-616 ng/ml) levels were normal, and insulin antibodies were undetectable. Post-bariatric surgery hypoglycemia was confirmed and acarbose dose was increased to 50 mg three times daily. Conclusion: Postprandial hypoglycemia is a late complication of bariatric surgery. Early-morning hypoglycemia can also be seen after bariatric surgery in patients who have late-night meals and snacks. Presentation: 6/1/2024

Post Bariatric Surgery Nursing Care

Morbid obesity is defined as having a body mass index (BMI) above 40 or having a BMI of 35 and comorbidities along with obesity. Bariatric surgeries can be grouped into three. These are restrictive surgeries, malabsorption (impairing absorption) surgeries, and both restrictive and malabsorption surgeries. In bariatric surgery, restrictive surgeries such as vertical band gastroplasty (VGB), adjustable gastric banding (AGB) surgeries, malabsorption surgeries such as biliopancreatic diversion (BPD)/duodenal switch (DS) surgeries, and both restrictive and malabsorption surgeries such as Roux-en-Y gastric bypass (RYGB) surgeries, are commonly performed. Post-bariatric surgery care should include a multidisciplinary team consisting of a surgeon, an endocrinologist, a psychiatrist, a dietitian, and a nurse specializing in bariatric surgery. Nursing care after obesity surgery is evaluated as early postoperative care (1-3 days) and late postoperative care. Close observation, careful and complete evaluation are important in the specialist nursing care of bariatric surgery patients. In bariatric surgery, patients are provided with routine post-operative nursing care such as oxygen and hemodynamic monitoring, pain management, mobilization, wound care, deep vein thrombosis prophylaxis, early and frequent ambulation, drain care, fluid balance nutrition, training, and emotional support.

Association Between Resting Metabolic Rate And Aerobic Capacity With Low-back-pain In Post-bariatric Surgery Patients

Association Between Resting Metabolic Rate And Aerobic Capacity With Low-back-pain In Post-bariatric Surgery Patients

S2121 Timing of Glucagon-Like Peptide 1 Receptor Agonists Initiation Post-Bariatric Surgery and its Impact on Weight Loss Outcomes

S2121 Timing of Glucagon-Like Peptide 1 Receptor Agonists Initiation Post-Bariatric Surgery and its Impact on Weight Loss Outcomes