Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia
Abstract
Introduction Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition. Methods A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy. Results Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but…
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Pancreatic 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 [120]
NIPHS comprises postprandial neuroglycopenic symptoms with documented hyperinsulinemic hypoglycemia, a negative 72 h fasting test, negative conventional imaging studies (MRI, CT), as well as a positive selective arterial calcium stimulation test with hepatic venous sampling (SACS).
“It comprises postprandial neuroglycopenic symptoms with documented hyperinsulinemic hypoglycemia, a negative 72 h fasting test, negative conventional imaging studies (MRI, CT), as well as a positive selective arterial calcium stimulation test with hepatic venous sampling (SACS) [26,27].”
Cites
Farilla, L., Bulotta, A., Hirshberg, B., Li Calzi, S., Khoury, N., Noushmehr, H., Bertolotto, C., Di Mario, U., Harlan, D. M., & Perfetti, R. (2003) · Endocrinology · doi:10.1210/en.2003-0323 · Cited by 664 · cited 1× · see citing works
“It also has been shown to prevent apoptosis in freshly isolated human islets [21], but there are no in vivo studies in humans.”
BackgroundMeier, J. J., Butler, A. E., Galasso, R., & Butler, P. C. (2006) · Diabetes Care · doi:10.2337/dc06-0392 · Cited by 249 · see citing works
Anlauf, M., Wieben, D., Perren, A., Sipos, B., Komminoth, P., Raffel, A., Kruse, M. L., Fottner, C., Knoefel, W. T., Mönig, H., et al. (2005) · American Journal of Surgical Pathology · doi:10.1097/01.pas.0000151617.14598.ae · Cited by 167 · see citing works
Clancy, T. E., Moore, F. D., & Zinner, M. J. (2006) · Journal of Gastrointestinal Surgery · doi:10.1016/j.gassur.2006.04.008 · Cited by 133 · see citing works
Noninsulinoma pancreatogenous hypoglycemia syndrome: An update in 10 surgically treated patients
Thompson, G. B., Service, F. J., Andrews, J. C., Lloyd, R. V., Natt, N., van Heerden, J. A., & Grant, C. S. (2000) · Surgery · doi:10.1067/msy.2000.110243 · Cited by 121 · see citing works
Alvarez, G. C., Faria, E. N., Beck, M., Girardon, D. T., & Machado, A. C. (2007) · Obesity Surgery · doi:10.1007/s11695-007-9096-0 · Cited by 61 · cited 1× · see citing works
“This patient had no symptoms during 10 months of follow-up [19].”
Background
Flagged first, then by citations
Cited by
Sorted by citations
van Beek, A. P., Emous, M., Laville, M., & Tack, J. (2017) · Obesity Reviews · doi:10.1111/obr.12467 · Cited by 288 · see citing works
International consensus on the diagnosis and management of dumping syndrome
Scarpellini, E., Arts, J., Karamanolis, G., Laurenius, A., Siquini, W., Suzuki, H., Ukleja, A., van Beek, A. V., Vanuytsel, T., Bor, S., et al. (2020) · Nature Reviews Endocrinology · doi:10.1038/s41574-020-0357-5 · Cited by 247 · see citing works
Vilarrasa, N., Goday, A., Rubio, M. A., Caixàs, A., Pellitero, S., Ciudin, A., Calañas, A., Botella, J. I., Bretón, I., Morales, M. J., et al. (2016) · Obesity Facts · doi:10.1159/000442764 · Cited by 197 · see citing works
Kefurt, R., Langer, F., Schindler, K., Shakeri-Leidenmühler, S., Ludvik, B., & Prager, G. (2015) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.11.003 · Cited by 143 · see citing works
ASMBS Position Statement on Postprandial Hyperinsulinemic Hypoglycemia after Bariatric Surgery.
Eisenberg, D., Azagury, D., Ghiassi, S., Grover, B. T., & Kim, J. J. (2017) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2016.12.005 · Cited by 121 · see citing works
MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia
Kittah, N. E., & Vella, A. (2017) · European Journal of Endocrinology · doi:10.1530/eje-16-1062 · Cited by 107 · see citing works
Campos, G. M., Ziemelis, M., Paparodis, R., Ahmed, M., & Belt Davis, D. (2014) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2013.05.012 · Cited by 104 · see citing works
“Earlier reports suggested that increased pancreatic beta cell mass or nesidioblastosis was causative in patients with hyperinsulinemic hypoglycemia [12], and some centers have offered subtotal or total pancreatectomy as a surgical solution for medically refractory hyperinsulinemic hypoglycemia [12,27,30].”
BackgroundRecognition and management of hyperinsulinemic hypoglycemia after bariatric surgery
Malik, S., Mitchell, J., Steffen, K., Engel, S., Wiisanen, R., Garcia, L., & Malik, S. (2015) · Obesity Research and Clinical Practice · doi:10.1016/j.orcp.2015.07.003 · Cited by 80 · see citing works
“Partial, sub-total, and total pancreatic resections have been employed to treat refractory hypoglycemia [23,25,42].”
BackgroundRaverdy, V., Baud, G., Pigeyre, M., Verkindt, H., Torres, F., Preda, C., Thuillier, D., Gelé, P., Vantyghem, M., Caiazzo, R. J., et al. (2016) · Annals of Surgery · doi:10.1097/sla.0000000000001915 · Cited by 67 · see citing works
Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment
Mala, T. (2014) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.01.010 · Cited by 75 · see citing works
“, 2010 [19] 9 Distal (80%) pancreatectomy 8–84, mean 30 3 2 patients had complete symptom resolution, 3 had”
BackgroundInfluentialCeppa, E., Ceppa, D., Omotosho, P., Dickerson, J. A., Park, C. W., & Portenier, D. (2012) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2011.08.008 · Cited by 58 · see citing works
Post-bypass hypoglycaemia: A review of current findings
Ritz, P., & Hanaire, H. (2011) · Diabetes & Metabolism · doi:10.1016/j.diabet.2011.04.003 · Cited by 56 · see citing works
González-González, A., Delgado, M., & Fraga-Fuentes, M. (2013) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2011.05.010 · Cited by 50 · see citing works
Hypoglycaemia following gastric bypass surgery—diabetes remission in the extreme?
Patti, M., & Goldfine, A. B. (2010) · Diabetologia · doi:10.1007/s00125-010-1884-8 · Cited by 47 · see citing works
“Although partial pancreatectomy typically achieves improvements in symptom control and safety in this subset of severely affected patients, it carries substantial morbidity and does not fully resolve hypoglycaemia [8, 9].”
BackgroundLaurenius, A., Werling, M., le Roux, C. L., Fändriks, L., & Olbers, T. (2014) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.04.007 · Cited by 41 · see citing works
“Partial or total pancreatectomy are currently not considered appropriate since symptoms do not always improve or may reoccur, even if β-cell mass is decreased [19–22].”
BackgroundPost‐gastric bypass hypoglycaemia: a review
Shantavasinkul, P. C., Torquati, A., & Corsino, L. (2016) · Clinical Endocrinology · doi:10.1111/cen.13033 · Cited by 39 · see citing works
Roslin, M. S., Dudiy, Y., Brownlee, A. R., Weiskopf, J., & Shah, P. C. (2013) · Surgical Endoscopy · doi:10.1007/s00464-013-3176-0 · Cited by 38 · see citing works
“In fact, entities that were rarely described, such as non-insulinoma-pancreatogenous syndrome [5] and nesidioblastosis [6], have been the subject of Presented at the SAGES 2013 Annual Meeting, April 17–20, 2013, Baltimore, MD.”
BackgroundSomatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia
Haris, B., Saraswathi, S., & Hussain, K. (2020) · Therapeutic Advances in Endocrinology and Metabolism · doi:10.1177/2042018820965068 · Cited by 41 · see citing works
Approach to the Patient with Postprandial Hypoglycemia
Galati, S.-J., & Rayfield, E. J. (2013) · Endocrine Practice · doi:10.4158/ep13132.ra · Cited by 31 · see citing works
“Of these, 7 ranged from symptom-free to requiring medical management postoperatively, while 2 patients underwent further surgery to 95% distal pancreatectomy with symptomatic improvement (80).”
BackgroundHypoglycemia after gastric bypass surgery
Singh, E., & Vella, A. (2012) · Diabetes Spectrum · doi:10.2337/diaspect.25.4.217 · Cited by 30 · see citing works
Roslin, M. S., Gagner, M., Goriparthi, R., & Mitzman, B. A. (2014) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.11.017 · Cited by 28 · see citing works
“In fact, entities, such as the noninsulinoma-pancreatogenous syndrome and nesidioblastosis after RYGB, have been the subject of an increasing number of publications [28,29].”
BackgroundNichols, C. G., York, N., & Remedi, M. S. (2022) · Diabetes · doi:10.2337/db21-0755 · Cited by 31 · see citing works
Hypoglycemia after gastric bypass: An emerging complication
Millstein, R., & Lawler, H. M. (2017) · Cleveland Clinic journal of medicine · doi:10.3949/ccjm.84a.16064 · Cited by 19 · see citing works
“32,33 When SACST is performed, a sampling catheter is placed in the femoral vein.”
Rao, B. B., Click, B., Eid, G., & Codario, R. A. (2015) · Case Reports in Endocrinology · doi:10.1155/2015/384526 · Cited by 19 · see citing works
“Also, a retrospective assessment of 15 patientswhohadundergone pancreatic resection reported persistent hypoglycemic symptoms in 77% of patients after the procedure [3].”
BackgroundInfluentialDieterle, M. P., Husari, A., Prozmann, S. N., Wiethoff, H., Stenzinger, A., Röhrich, M., Pfeiffer, U., Kießling, W. R., Engel, H., Sourij, H., et al. (2023) · Biomedicines · doi:10.3390/biomedicines11061732 · Cited by 19 · see citing works
Surgical Treatment for Postprandial Hypoglycemia After Roux-en-Y Gastric Bypass: a Literature Review
Xu, Q., Zou, X., You, L., Wu, W., Zhu, H., Wang, L., Yuan, T., & Zhao, Y. (2021) · Obesity Surgery · doi:10.1007/s11695-021-05251-x · Cited by 20 · see citing works
“Four of the six patients who underwent repeated pancreatectomy did not achieve satisfactory results: 2 patients still suffered from hypoglycemic episodes, 1 patient required an insulin pump to control glucose, and 1 patient developed severe hyperglycemia after pancreaticoduodenectomy [23, 26, 27, 30].”
BackgroundZanley, E., Shah, N., Craig, C. M., Lau, J., Rivas, H., & McLaughlin, T. (2020) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2020.09.026 · Cited by 19 · see citing works
Dumping syndrome : Update on pathophysiology, diagnosis, and management
Tack, J. F., Raymenants, K., de Bruaene, C. V., & Scarpellini, E. (2024) · Neurogastroenterology & Motility · doi:10.1111/nmo.14962 · Cited by 12 · see citing works
Ball, C., Grondin, S., Pasieka, J., Kirkpatrick, A., Maclean, A., Cantle, P. M., Dixon, E., Schneider, P., & Hamilton, M. (2018) · Journal of Comparative Effectiveness Research · doi:10.2217/cer-2017-0090 · Cited by 11 · see citing works
Hyperinsulinemic Hypoglycemia after Bariatric Surgery
Hu, S., Tang, H., Wang, H.-X., Dong, Z.-Y., Jiang, S.-W., Wang, C.-C., Chen, X., & Yang, W. (2020) · Journal of metabolic and bariatric surgery · doi:10.17476/jmbs.2020.9.1.1 · Cited by 7 · see citing works
“We use the criteria as below [21]: (1) exclusion of an insulinoma by macroscopic, microscopic and immunohistochemical examination; (2) multiple β cells with an enlarged and hyperchromatic nucleus and abundant clear cytoplasm; (3) islets with normal spatial distribution of the various cell types; and (4) no proliferati…”
MethodTotal Pancreatectomy for the Management of Refractory Post-Gastric Bypass Hypoglycemia
Spolverato, G., Bhaijee, F., Anders, R., Salley, K. E. S., Parambi, J., Brown, T., & Pawlik, T. (2015) · Digestive Diseases and Sciences · doi:10.1007/s10620-014-3408-8 · Cited by 7 · see citing works
“Several investigators have, however, noted significant hyperplasia of the Langerhans islet cells and have characterized this as adult pancreatic nesidioblastosis [4, 5, 8, 9].”
BackgroundHypoglycemia Worsened by Glucose Administration: A Case of Hypoglycemia Years After Gastric Surgery.
McManus, N. M., Margart, K. M., & Offman, R. P. (2021) · Journal of Emergency Medicine · doi:10.1016/j.jemermed.2020.11.041 · Cited by 6 · see citing works
Dieterle, M. P., Husari, A., Prozmann, S. N., Wiethoff, H., Stenzinger, A., Röhrich, M., Pfeiffer, U., Kießling, W. R., Engel, H., Sourij, H., et al. (2023) · Biomedicines · doi:10.3390/biomedicines11061741 · Cited by 5 · see citing works
Bariatric surgery in managing diabetes mellitus
Roslin, M. S., & Cripps, C. (2016) · Current Opinion in Gastroenterology · doi:10.1097/mog.0000000000000312 · Cited by 5 · see citing works
“Blood glucose concentrations may vary from euglycemia to hyperglycemia and hypoglycemia [39,40].”
BackgroundLaparoscopic Gastric Bypass: Management of Complications
Menzo, E. L., Szomstein, S., & Rosenthal, R. (2015) · doi:10.1007/978-1-4939-1637-5_29 · Cited by 3
“The incidence of marginal ulceration has been reported between 1 and 16 %, whereas the incidence of strictures has been estimated in up to 27 % [ 20 ].”
BackgroundGarcía, B. F., Peromingo, R., Galindo, J., Arrieta, F., Sánchez, J. F., Vázquez, C., & Botella-Carretero, J. I. (2014) · Endocrinologia y Nutricion · doi:10.1016/j.endonu.2014.04.001 · Cited by 2 · see citing works
Nesidioblastosis post-bariatric surgery in an adult patient: a case report and review of literature
Abdul-Hafez, H., Rabi, K., Sarama, A., Melhem, L., Abed, W., & Maree, M. (2025) · Annals of Medicine and Surgery · doi:10.1097/ms9.0000000000003198 · Cited by 2 · see citing works
“However, these are often negative in cases of nesidioblastosis [ 15 , 18 ] , this aligns with our case that exhibited a normal appearance of the pancreas and biliary system on endoscopic ultrasound, and normal MRI imaging.”
Medically Refractory Nesidioblastosis as a Late Adverse Effect of Roux-en-Y Gastric Bypass
Ladna, M. (2025) · Cureus · doi:10.7759/cureus.84429 · Cited by 1 · see citing works
“…month) which did not require any medications, two developed frequent symptoms (>2 times per month) which were effectively controlled via the addition of medications, and two patients had severe symptoms refractory to any medical therapy (calcium channel blocker [CCB], diazoxide, octreotide) [20].”
Shirakawa, J., Murohashi, Y., Okazaki, N., Yamazaki, S., Tamura, T., Okuyama, T., Togashi, Y., & Terauchi, Y. (2014) · Endocrine journal · doi:10.1507/endocrj.ej14-0290 · Cited by 1 · see citing works
“ide, and also pancreatectomy, have been applied for the management of postprandial hypoglycemia after gastrectomy [5-12].”
BackgroundHyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass
Ha, J., & Park, J. S. (2013) · Journal of Korean Diabetes · doi:10.4093/jkd.2013.14.2.83 · Cited by 1 · see citing works
Post-bariatric hypoglycaemia: from altered gut physiology to targeted therapies
Yang, W., & Tan, T. (2026) · Endocrine Connections · doi:10.1530/ec-25-0850
“Spanakis et al. (63) fi rst reported marked symptomatic improvements in patients with severe PBH treated with diazoxide, followed by reports by Mathavan et al. (64) and Gonzalez et al. (65) describing the use of diazoxide in the severe or refractory cases.”
Tumour-induced hypoglycaemia: a narrative review
Barber, T. M., Bannon, C. A. M., Weickert, M. O., Kyrou, I., & Randeva, H. S. (2021) · Journal of Laboratory and Precision Medicine · doi:10.21037/jlpm-20-110 · Cited by 1 · see citing works
“Although partial pancreatectomy as a treatment option of post-RYGB surgery has had variable results (54-58), a majority of patients appear to have continuation of their hypoglycaemic symptoms post-pancreatectomy, and therefore this surgical option has been abandoned for the purpose of alleviating hypoglycaemia (2).”
BackgroundDisorders Associated with Hypoglycaemia in Children
Shah, P., Footit, E., & Kapoor, R. R. (2019) · Wiley eBooks · doi:10.1002/9781119152712.ch16
HIPOGLUCEMIA HIPERINSULINÉMICA POSTPRANDIAL LUEGO DE LA CIRUGÍA BARIÁTRICA
Álvarez, M. G., Gutt, S., Yuma, M., Polo, P., González, S., Menéndez, E., Vanoli, G., Montemerlo, H., Ackerman, M., Coronel, J., et al. (2019) · Revista de la Sociedad Argentina de Diabetes · doi:10.47196/diab.v53i1.137
Nesidioblastosis del adulto tras derivación gástrica
López, V., Builes-Barrera, C., Osorio, G., Morales, C., Toro, J., & Román-Gónzález, A. (2017) · Revista Colombiana de Cirugía · doi:10.30944/20117582.40
Amouyal, C., & Moutel, S. (2015) · EMC - Traité de médecine AKOS · doi:10.1016/s1634-6939(15)68668-9
Hypoglycemia after gastric bypass: an old problem resurfaces.
Andersen, D. (2014) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.05.008
Verfahren und Stellenwert der metabolischen Chirurgie
Müller, B., Ambrus, G., & Fischer, L. (2012) · Intensivmedizin up2date · doi:10.1055/s-0032-1325781
Advances in the management and treatment of gastroenteropancreatic neuroendocrine tumors
Feliberti, E., Perry, R., & Vinik, A. (2011) · Clinical Investigation · doi:10.4155/cli.11.120
Hipoglucemias persistentes en paciente intervenida de cirugía bariátrica
Gonzalez-Molero, I., Arnés, J. A. G., López, M., & Gallego, J. (2011) · Medicina Clínica · doi:10.1016/j.medcli.2011.01.001
Hypoglycemia After Gastric Bypass
Alvarez, G. D. C. (2020) · Gastric Bypass · doi:10.1007/978-3-030-28803-7_35
Bariatric Surgery in the Therapy of Type 2 Diabetes Mellitus
Roslin, M. S., Goriparthi, R., Sabrudin, S. A., & Peristeri, A. (2015) · Springer eBooks · doi:10.1007/978-3-319-20797-1_55-1
- Authors
- Mathavan, V. K., Arregui, M., Davis, C., Singh, K., Patel, A., & Meacham, J.
- Affiliations
- St Vincent Hospital (US)
- Indiana University Health (US)
- Corresponding author
- Mathavan, Viney K.
- ORCID
- Davis, Chad
- Venue
- Surgical Endoscopy
- Published
- 2010-03-31
- Volume
- 24
- Issue
- 10
- Pages
- 2547-2555
- ISSN
- 0930-2794 (ISSN-L)
- 1432-2218
- OpenAlex
- W2039361827
- Cited by
- 61
- References
- 0
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 2 · 2023: 4 · 2022: 2 · 2021: 3 · 2020: 5 · 2019: 3 · 2018: 1 · 2017: 4 · 2016: 8 · 2015: 3 · 2014: 9 · 2013: 5 · 2012: 1
- FWCI
- 4.38
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Surgical Endoscopy (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Surgery › Pancreatic function and diabetes
- Health Sciences › Medicine › Epidemiology › Neuroendocrine Tumor Research Advances
- Keywords
- hyperinsulinemia, nesidioblastosis, islet hyperplasia, laparoscopic pancreatic resection, postprandial hypoglycemia, glucagon-like peptide-1, bariatric surgery complications
- MeSH terms
- Adult, Female, Humans, Hyperinsulinism, Hypoglycemia, Male, Middle Aged, Pancreas, Pancreatectomy, Laparoscopy, Syndrome, Gastric Bypass, Postprandial Period, Nesidioblastosis
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