title: A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy.
abstract: Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m(2)). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m(2), weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m(2)), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m(2) after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting.
  
  
  CONCLUSIONS
  Roux-en-Y gastric bypass and SG produce marked sustained weight reduction. However, there is a marked individual variability in this reduction, and post-operative weight loss follows a normal distribution with extremes of 'good' and 'poor' response.Profound anorexia and excessive weight loss post-SG may be associated with markedly elevated circulating fasted PYY and post-meal PYY and GLP1 levels.Octreotide treatment can produce symptomatic relief and weight regain for post-SG patients that have an extreme anorectic and weight loss response.The present case highlights the value of measuring circulating gut hormone levels in patients with post-operative anorexia and extreme weight loss.
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Andrea
authors.initials: A
authors.lastname: Pucci
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Wui Hang
authors.initials: WH
authors.lastname: Cheung
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK.
authors.forename: Jenny
authors.initials: J
authors.lastname: Jones
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; National Institute of Health Research, Biomedical Research Centre, University College London Hospitals , London, W1T 7DN , UK.
authors.forename: Sean
authors.initials: S
authors.lastname: Manning
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Kingett
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Marco
authors.initials: M
authors.lastname: Adamo
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; Clinical and Experimental Surgery Department , Medical Research Institute, University of Alexandria , Hadara, Alexandria, 21561 , Egypt.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Elkalaawy
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Jenkinson
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Finer
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Doyle
authors.affiliation: UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK.
authors.forename: Majid
authors.initials: M
authors.lastname: Hashemi
authors.affiliation: Department of Medicine , Rayne Institute Centre for Obesity Research, University College London , 5 University Street, London, WC1E 6JJ , UK ; UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, University College London Hospitals , Ground Floor West Wing, 250 Euston Road, London, NW1 2PG , UK ; National Institute of Health Research, Biomedical Research Centre, University College London Hospitals , London, W1T 7DN , UK.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Batterham