Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia.
Open accessAbstract
Aims/hypothesis Postprandial hypoglycaemia following gastric bypass for obesity is considered a late manifestation of the dumping syndrome and can usually be managed with dietary modification. We investigated three patients with severe postprandial hypoglycaemia and hyperinsulinaemia unresponsive to diet, octreotide and diazoxide with the aim of elucidating the pathological mechanisms involved.Methods Glucose, insulin, and C-peptide were measured in the fasting and postprandial state, and insulin secretion was assessed following selective intra-arterial calcium injection. Pancreas histopathology was assessed in all three patients.Results All three patients had evidence of severe postprandial hyperinsulinaemia and hypoglycaemia. In one patient, reversal of gastric bypass was ineffective in reversing hypoglycaemia. All three patients ultimately required partial pancreatectomy for control of neuroglycopenia; pancreas pathology of all patients revealed diffuse islet hyperplasia and expansion of beta cell mass.Conclusions/interpretation These findings suggest that gastric bypass-induced weight loss may unmask an underlying beta cell defect or contribute to pathological islet hyperplasia, perhaps via glucagon-like peptide 1-mediated pathways.
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Anecdotal evidence suggests that off-label diazoxide administered at doses ranging from 100 mg to 150 mg three times daily may be effective in the treatment of late dumping symptoms, but no effect on early symptoms is expected because of its mode of action.
“Anecdotal evidence suggests that off-label diazoxide administered at doses ranging from 100 mg to 150 mg three times daily may be effective in the treatment of late dumping symptoms, but no effect on early symptoms is expected because of its mode of action (103).”
From Dumping syndrome after esophageal, gastric or bariatric surgery: Pathophysiology, diagnosis, and management (2017) · cites this paper as [103]
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Experimental — accuracy not yet measuredSome persons who have undergone Roux-en-Y gastric bypass for obesity have endogenous hyperinsulinemic hypoglycemia most often due to pancreatic islet nesidioblastosis, but occasionally due to an insulinoma.
“Some persons who have undergone Roux-en-Y gastric bypass for obesity have endogenous hyperinsulinemic hypoglycemia most often due to pancreatic islet nesidioblastosis, but occasionally due to an insulinoma (48 -50).”
From Evaluation and Management of Adult Hypoglycemic Disorders: An Endocrine Society Clinical Practice Guideline (2009) · cites this paper as [49]
The Introduction and Conclusions describe three post-bypass patients with hyperinsulinaemic hypoglycaemia and islet hyperplasia; Patient 1’s pathology specifically showed nesidioblastosis. The Conclusions also report an insulinoma in another post-bypass patient. The paper does not establish that nesidioblastosis is the most common cause of endogenous hyperinsulinaemic hypoglycaemia after bypass. (LLM, conf=0.86)
Experimental — accuracy not yet measuredVarious surgical re-interventions have been used, including gastric tube placement, gastric bypass reversal with or without concomitant sleeve resection and gastric pouch restriction.
“Various surgical re-interventions have been used, including gastric tube placement, gastric bypass reversal with or without concomitant sleeve resection and gastric pouch restriction (Table 5) (66,103,105-123).”
From Dumping syndrome after esophageal, gastric or bariatric surgery: Pathophysiology, diagnosis, and management (2017) · cites this paper as [103]
The Patient 1 section reports that a gastric bypass was taken down, supporting bypass reversal as one surgical re-intervention. The passages do not report gastric tube placement, reversal with sleeve resection, or gastric pouch restriction; Patient 2 says reversal and gastrectomy were considered but not possible. (LLM, conf=0.86)
Experimental — accuracy not yet measuredPancreatic resection, the most commonly reported procedure, was performed in approximately 67% of patients.
“Pancreatic resection, the most commonly reported procedure, was performed in approximately 67% of patients (66,103,105,107,114,116-123).”
From Dumping syndrome after esophageal, gastric or bariatric surgery: Pathophysiology, diagnosis, and management (2017) · cites this paper as [103]
The Patient 1–3 sections report pancreatic resections in all three patients described. The paper does not report that resection was the most commonly performed procedure or that it was performed in approximately 67% of patients across the cases cited. (LLM, conf=0.88)
Experimental — accuracy not yet measuredApproximately 24% of patients who underwent surgical re-intervention because of refractory severe post-Roux-en-Y gastric bypass hypoglycemia received a gastric bypass reversal and approximately 9% had gastric pouch restriction.
“As shown in Table 5, approximately 24% of patients who underwent surgical re-intervention because of refractory severe post-Roux-en-Y gastric bypass hypoglycemia received a gastric bypass reversal (66,103,106-113) and approximately 9% had gastric pouch restriction (66,114,115).”
From Dumping syndrome after esophageal, gastric or bariatric surgery: Pathophysiology, diagnosis, and management (2017) · cites this paper as [103]
Patient 1 reports a gastric bypass take-down after severe hypoglycaemia, so the paper supports an example of reversal. It does not report gastric pouch restriction or the approximately 24% and 9% rates; its Introduction describes a three-patient case series, not the pooled group underlying those percentages. (LLM, conf=0.87)
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References 13 · Cited by 365
- Authors
- Patti, M. E., McMahon, G., Mun, E. C., Bitton, A., Holst, J. J., Goldsmith, J., Hanto, D. W., Callery, M., Arky, R., Nose, V., Bonner-Weir, S., & Goldfine, A. B.
- Affiliations
- Joslin Diabetes Center (US)
- Brigham and Women's Hospital (US)
- Beth Israel Deaconess Medical Center (US)
- University of Copenhagen (DK)
- Corresponding author
- Patti, M. E.
- ORCID
- Venue
- Diabetologia
- Published
- 2005-09-30
- Volume
- 48
- Issue
- 11
- Pages
- 2236-2240
- ISSN
- 0012-186X (ISSN-L)
- 1432-0428
- OpenAlex
- W2003725355
- Semantic Scholar
- b4890279641b9accc06ac9d8011ff6fb28f2429e
- Cited by
- 365
- References
- 13
- Citations by year
- 2026: 7 · 2025: 5 · 2024: 9 · 2023: 8 · 2022: 14 · 2021: 17 · 2020: 11 · 2019: 13 · 2018: 12 · 2017: 16 · 2016: 31 · 2015: 23 · 2014: 23 · 2013: 18 · 2012: 18
- FWCI
- 18.14
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Diabetologia (publishedVersion)
- PubMed (publishedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
- Funders
- National Institutes of Health (RR 01032)
- National Institute of Diabetes and Digestive and Kidney Diseases (K23DK002795, DK 44523, DK-062948, DK02795, R01DK044523, R01DK062948)
- National Center for Research Resources (M01-RR-01032, M01RR001032)
- Topics
- Health Sciences › Medicine › Surgery › Pancreatic function and diabetes
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- postprandial hypoglycemia, gastric bypass, bariatric surgery, partial pancreatectomy, hyperinsulinemia, pancreatic islet hyperplasia, dumping syndrome, obesity, glucagon-like peptide-1, neuroglycopenia
- MeSH terms
- Insulin Secretion, Adult, Aged, Diazoxide, Diet Therapy, Dumping Syndrome, Female, Humans, Hyperplasia, Hypoglycemia, Insulin, Islets of Langerhans, Male, Middle Aged, Pancreas, Pancreatectomy, Octreotide, Gastric Bypass
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