Use of a Low-carbohydrate Enteral Nutrition Formula with Effective Inhibition of Hypoglycemia and Post-infusion Hyperglycemia in Non-diabetic Patients Fed via a Jejunostomy Tube

A Case of Hypoglycemia Diagnosed by Neuropsychiatric Symptoms after Distal Gastrectomy and Total Colectomy

INTRODUCTION

Hypoglycemia can lead to significant adverse effects, including cognitive impairment, fatigue, convulsions, and even loss of consciousness in severe cases. Recent reviews also associate hypoglycemia with severe outcomes, such as mortality, dementia, and cardiovascular events. In gastrointestinal surgery, postoperative hypoglycemia related to dumping syndrome is well documented after gastric procedures. However, hypoglycemia in patients who have undergone both gastrectomy and total colectomy is rare, and the underlying mechanisms and effective management strategies remain unclear.

CASE PRESENTATION

The patient, a 46-year-old woman diagnosed with chronic intestinal pseudo-obstruction (CIPO), had a medical history of distal gastrectomy with Billroth-I reconstruction and colostomy. Recently, she underwent total colectomy, after which she began experiencing symptoms of unexplained malaise, depression, and cognitive decline. She received treatment with medication at a neuropsychiatric department to address these symptoms, but they persisted. Strong anxiety and fatigue led her to engage in frequent drug overdose. She then presented to our hospital. Given her history of gastrointestinal surgery, we considered the possibility of nocturnal hypoglycemia and performed continuous glucose monitoring (CGM), which showed marked hypoglycemia. Nutritional therapy to control hypoglycemia effectively improved her condition, resolving drug overdose behavior completely and reducing the dosage of her psychotropic medications by half.

CONCLUSION

This case highlights the diagnostic utility of CGM and the effectiveness of nutritional management in treating hypoglycemia after total colectomy in addition to gastrectomy and provides new insights into the management of similar postoperative cases.

Effectiveness of a low-glycaemic-index formula on post-gastrectomy hypoglycaemia in patients with gastric cancer: randomized crossover study

BACKGROUND

Patients undergoing gastrectomy often experience postprandial hypoglycaemia, late dumping syndrome, and night-time hypoglycaemia. However, countermeasures for post-gastrectomy hypoglycaemia rely on the patients' own efforts. We sought to investigate how post-gastrectomy hypoglycaemia could be nutritionally improved in patients with gastric cancer.

METHOD

Single-centre prospective, open-labelled, randomized crossover study including patients aged 20-80 years diagnosed with gastric adenocarcinoma, which have undergone total or distal gastrectomy 1-5 years before the study. The patients consumed 100 ml of a low-carbohydrate/high-monounsaturated fatty acid formula orally 30 min after meals and before sleep (400 kcal/day) during the first or second half of a 14-day glucose-monitoring period. The effects of the low-carbohydrate/high-monounsaturated fatty acid formula on the time below range, that is, the percentage of time during which the glucose concentration was <70 mg/dl, and the coefficient of variation (CV) of the glucose concentration when the ideal time below range and CV were set at <5% and ≤36% respectively were assessed. Dumping symptoms were investigated before and after the study.

RESULTS

Thirty-eight patients were included in this study. In patients who had undergone total gastrectomy, the (median) daytime time below range, daytime CV, and night-time time below range remained high at 7.6% ((range) 0.0-45.0), 35.6% ((range) 9.5-50.5), and 10.8% ((range) 0.0-56.3) respectively, even after a long postoperative period. The (median) night-time time below range in patients who had undergone distal gastrectomy and total gastrectomy improved from 3.5% ((range) 0.0-47.9) to 1.4% ((range) 0.0-26.6) (P < 0.001, effect size 0.58) and 10.8% ((range) 0.0-56.3) to 9.4% ((range) 0.0-39.9) (P = 0.078, effect size 0.45) respectively. However, the daytime time below range and CV, as indicators of late dumping syndrome, did not change.

CONCLUSION

The low-carbohydrate/high-monounsaturated fatty acid formula improved post-gastrectomy night-time hypoglycaemia, but not daytime glycaemic variability or hypoglycaemia. Thus, further investigation of nutritional optimization is required.

CLINICAL TRIAL REGISTRATION

Japan Registry of Clinical Trials, jRCT https://jrct.niph.go.jp/, identifier jRCTs s051210200.

Feeding gastrostomy and duodenostomy using the round ligament of the liver versus conventional feeding jejunostomy after esophagectomy: a meta-analysis

Esophageal cancer patients require enteral nutritional support after esophagectomy. Conventional feeding enterostomy to the jejunum (FJ) is occasionally associated with small bowel obstruction because the jejunum is fixed to the abdominal wall. Feeding through an enteral feeding tube inserted through the reconstructed gastric tube (FG) or the duodenum (FD) using the round ligament of the liver have been suggested as alternatives. This meta-analysis aimed to compare short-term outcomes between FG/FD and FJ. Studies published prior to May 2022 that compared FG or FD with FJ in cancer patients who underwent esophagectomy were identified via electronic literature search. Meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate Odds Ratios (ORs) with 95% confidence intervals (CIs). Five studies met inclusion criteria to yield a total of 1687 patients. Compared with the FJ group, the odds of small bowel obstruction (OR 0.09; 95% CI, 0.02-0.33), catheter site infection (OR 0.18; 95% CI, 0.06-0.51) and anastomotic leakage (OR 0.53; 95% CI, 0.32-0.89) were lower for the FG/FD group. Odds of pneumonia, recurrent laryngeal nerve palsy, chylothorax and hospital mortality did not significantly differ between the groups. The length of hospital stay was shorter for the FG/FD group (median difference, -10.83; 95% CI, -18.55 to -3.11). FG and FD using the round ligament of the liver were associated with lower odds of small bowel obstruction, catheter site infection and anastomotic leakage than FJ in esophageal cancer patients who underwent esophagectomy.

Mitigation of Rebound Hyperglycemia With Real-Time Continuous Glucose Monitoring Data and Predictive Alerts

BACKGROUND

Excess carbohydrate intake during hypoglycemia can lead to rebound hyperglycemia (RH). We investigated associations between RH and use of real-time continuous glucose monitoring (rtCGM) and an rtCGM system's predictive alert.

METHODS

RH events were series of sensor glucose values (SGVs) >180 mg/dL starting within two hours of an antecedent SGV <70 mg/dL. Events were characterized by their frequency, duration (consecutive SGVs >180 mg/dL × five minutes), and severity (area under the glucose concentration-time curve). To assess the impact of rtCGM, data gathered during the four-week baseline phase (without rtCGM) and four-week follow-up phase (with rtCGM) from 75 participants in the HypoDE clinical trial (NCT02671968) of hypoglycemia-unaware individuals were compared. To assess the impact of predictive alerts, we identified a convenience sample of 24 518 users of an rtCGM system without predictive alerts who transitioned to a system whose predictive alert signals an SGV ≤55 mg/dL within 20 minutes (Dexcom G5 and G6, respectively). RH events from periods of blinded versus unblinded rtCGM wear and from periods of G5 and G6 wear were compared with paired t tests.

RESULTS

Compared to RH events in the HypoDE baseline phase, the mean frequency, duration, and severity of events fell by 14%, 12%, and 23%, respectively, in the follow-up phase (all P < .05). Compared to RH events during G5 use, the mean frequency, duration, and severity of events fell by 7%, 8%, and 13%, respectively, during G6 use (all P < .001).

CONCLUSIONS

Rebound hypreglycemia can be objectively quantified and mitigated with rtCGM and rtCGM-based predictive alerts.

Prognostic outcomes after direct percutaneous endoscopic jejunostomy in elderly patients: comparison with percutaneous endoscopic gastrostomy

BACKGROUND AND AIMS

Direct percutaneous endoscopic jejunostomy (DPEJ) is an alternative method of enteral feeding to percutaneous endoscopic gastrostomy (PEG). Although long-term outcomes of PEG have been reported, little is known regarding the outcomes of DPEJ.

METHODS

A retrospective cohort study was conducted including 115 and 651 consecutive attempts of DPEJ and PEG, respectively, in a total of 766 elderly patients between April 2004 and March 2019. Patients' clinical background, procedural and long-term outcomes, survival analysis, and cause of death were analyzed.

RESULTS

Successful placement rates were 93.9% and 97.1% for DPEJ and PEG, respectively. There was no significant difference in procedure-related adverse events (AEs) between the DPEJ and PEG groups. Rates of pneumonia, vomiting, and upper GI bleeding were significantly lower, whereas those of fistula enlargement and ileus were significantly higher in the DPEJ group as long-term AEs. The median survival periods were 694 and 734 days for DPEJ and PEG, respectively, with no significant differences between the 2 groups. Multivariate analysis revealed that age 80 years old or older, C-reactive protein level of 1.0 mg/dL or higher, and the presence of diabetes were independent risk factors for mortality after DPEJ. Respiratory tract infection was the primary cause of death in both groups.

CONCLUSIONS

DPEJ is considered a safe and feasible method of access for enteral feeding as well as PEG. Although the survival period after DPEJ may be expected to be as long as that with PEG, DPEJ-specific AEs should be kept in mind on long-term feeding.