Severe Recurrent Hypoglycemia after Gastric Bypass Surgery
Abstract
Background Bariatric surgery is, at present, the most effective method to achieve major, long-term weight loss in severely obese patients. Recently, severe recurrent symptomatic hyperinsulinemic hypoglycemia was described as a consequence of gastric bypass surgery (GBS) in a small series of patients with severe obesity. Pancreatic nesidioblastosis, a hyperplasia of islet cells, was postulated to be the cause, and subtotal or total pancreatectomy was the suggested treatment. Methods We observed that severe, disabling hypoglycemia after GBS occurred only in patients with loss of restriction. Whether restoration of gastric restriction might treat severe, recurrent hypoglycemia after GBS is unknown. Results Therefore, gastric restriction was restored by surgical placement of a silastic ring (n = 8, first two patients with additional distal pancreatectomy) or an adjustable gastric band (n = 4) around the pouch in 12 consecutive patients presenting with severe hypoglycemia (blood glucose below 2.2 mM). At follow-up after restoration of gastric restriction (median follow-up 7 months, range 5 to 19 months), 11 patients demonstrated no hypoglycemic episodes, while one had recurrence of hypoglycemia and underwent distal pancreatectomy. Procedural mortality was 0% and morbidity 8.3%. Conclusion Patients suffering from severe recurrent hypoglycemia after GBS can be treated, in most cases, just by restoration of gastric restriction. Distal pancreatectomy should be considered a second-line…
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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 [114]
Silastic ring or gastric band placement to delay nutrient transit led to hypoglycemia resolution in 92% of patients in a small case series.
“Silastic ring or gastric band placement to delay nutrient transit led to hypoglycemia resolution in 92% of patients in a small case series [70].”
From Non-Diabetic Hypoglycemia: Evaluation and Management in Adults (2025) · cites this paper as [70]
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Ahn, S. M., Pomp, A., & Rubino, F. (2010) · Annals of the New York Academy of Sciences · doi:10.1111/j.1749-6632.2011.05984.x · Cited by 25 · see citing works
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“To exclude insulinoma and confirm diffuse pancreatic hypersecretion of insulin, SACS is reportedly helpful in some (1), but not all, cases (4).”
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“However, this has not been a universal finding (7).”
BackgroundEidy, M., Pazouki, A., Raygan, F., Ariyazand, Y., Pishgahroudsari, M., & Jesmi, F. (2013) · Archives of Trauma Research · doi:10.5812/atr.13110 · Cited by 23 · see citing works
“There are similar changes in esophageal activity that cause retrosternal pain, most cases relieve in time (9).”
BackgroundGastric bypass. Principles, complications, and results
Marmuse, J., & Ribeiro‐Parenti, L. (2010) · Journal of Visceral Surgery · doi:10.1016/j.jviscsurg.2010.08.014 · Cited by 21 · see citing works
Hypoglycemia after gastric bypass: An emerging complication
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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
“Adjustable band and ring restriction were reported in early years with uncertain outcomes and few new cases [10, 51].”
BackgroundDieterle, 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
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Metabolic surgery for type 2 diabetes
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“Occasionally, pancreatectomy, gastric restriction, feeding through the remnant stomach, or bypass reversal have been attempted for hypoglycemic management [82,83].”
BackgroundAn update on pancreatic regeneration mechanisms: Searching for paths to a cure for type 2 diabetes
Soldovieri, L., Giuseppe, G. D., Ciccarelli, G., Quero, G., Cinti, F., Brunetti, M., Nista, E. C., Gasbarrini, A., Alfieri, S., Pontecorvi, A., et al. (2023) · Molecular Metabolism · doi:10.1016/j.molmet.2023.101754 · Cited by 19 · see citing works
“On the other hand, pathological conditions like insulinoma or nesidioblastosis can cause uncontrolled proliferation of b-cells [18,19].”
BackgroundInfluentialPatti, M., Goldfine, A. B., Hu, J., Hoem, D., Molven, A., Goldsmith, J. D., Schwesinger, W. H., Rosa, S. L., Folli, F. B., & Kulkarni, R. (2017) · Acta Diabetologica · doi:10.1007/s00592-017-1001-2 · Cited by 17 · see citing works
“Surgical procedures which increase gastric restriction [17, 18] or tube feeding into the gastric remnant [19] have been successful for some patients.”
BackgroundIS TESTING FOR POSTPRANDIAL HYPERINSULINEMIC HYPOGLYCEMIA AFTER GASTRIC BYPASS NECESSARY?
Aubry, E., Gasser, M., Meier-Estermann, C., Herren, S., Steffen, R., & Stanga, Z. (2017) · Aktuelle Ernãhrungsmedizin · doi:10.1016/j.clnu.2017.11.013 · Cited by 16 · see citing works
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“Historically, surgical treatments were recommended more commonly and included gastrostomy tube placement, reversal of gastric bypass anatomy, and distal pancreatectomy [17].”
BackgroundHyperinsulinemic hypoglycemia after gastric bypass surgery: what’s up and what’s down?
Yaqub, A., Smith, E. P., & Salehi, M. (2017) · International Journal of Obesity · doi:10.1038/ijo.2017.257 · Cited by 12 · see citing works
Non-Diabetic Hypoglycemia: Evaluation and Management in Adults
Looi, E., & Lawler, H. M. (2025) · Journal of Clinical Medicine · doi:10.3390/jcm14134393 · Cited by 10 · see citing works
“Silastic ring or gastric band placement to delay nutrient transit led to hypoglycemia resolution in 92% of patients in a small case series [70].”
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Botulinum toxin for chronic anal fissure after biliopancreatic diversion for morbid obesity
Vanella, S. (2012) · World Journal of Gastroenterology · doi:10.3748/wjg.v18.i10.1021 · Cited by 10 · see citing works
Roslin, M. (2015) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2014.11.023 · Cited by 10 · see citing works
Diagnosis and management of post-bariatric surgery hypoglycemia
Alkhaled, L., Al‐Kurd, A., Butsch, W. S., Kashyap, S. R., & Aminian, A. (2023) · Expert Review of Endocrinology & Metabolism · doi:10.1080/17446651.2023.2267136 · Cited by 9 · see citing works
Update: Metabolic and Cardiovascular Consequences of Bariatric Surgery
Richardson, D. W., Mason, M. E., & Vinik, A. I. (2011) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2010.12.009 · Cited by 9 · see citing works
“A 72-hour fast is usually not required and typically does not provoke hypoglycemia in these patients, in contrast to those with insulinoma.(102)”
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Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients
Singh, A., Koenen, B., & Kirby, D. F. (2019) · Inflammatory Bowel Diseases · doi:10.1093/ibd/izz246 · Cited by 8 · 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
“[42] use a silastic ring to place under the anastomotic stoma.”
MethodHasan, M. A., Schwartz, S. S., McKenna, V., & Ing, R. (2023) · Obesity Surgery · doi:10.1007/s11695-023-06758-1 · Cited by 7 · see citing works
“[102] reported the use of a gastric band or silastic ring to reduce the pouch diameter in 12 patients presenting with hypoglycemia [102].”
BackgroundInfluentialEidy, M., Jesmi, F., Raygan, F., Pishgahroudsari, M., & Pazouki, A. (2015) · Bariatric Surgical Practice and Patient Care · doi:10.1089/bari.2014.0032 · Cited by 8 · see citing works
Hyperinsulinemic hypoglycemia and liver cirrhosis presenting after duodenal switch: a case report.
Aasheim, E., Frigstad, S., Søvik, T. T., Birkeland, K., & Haukeland, J. W. (2010) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2009.11.007 · Cited by 9 · see citing works
Kubota, T., Yubakami, M., Ushigome, E., Ohashi, T., Shoda, K., Konishi, H., Shiozaki, A., Fujiwara, H., Okamoto, K. K., Fukui, M., et al. (2022) · Annals of Surgery Open · doi:10.1097/as9.0000000000000135 · Cited by 7 · see citing works
Recommendations for the diagnosis and treatment of hypoglycaemia after bariatric surgery.
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Total 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
“Post-surgical weight loss improves the comorbidities related to severe obesity and increases the quality of life while reducing overall obesity-related mortality [8].”
BackgroundSabah, S. A., Haddad, E. A., Qadhi, I., AlMuhaini, M., AlAwtan, A., AlQabandi, O. A., Alkhayat, A., Saleem, A. F., & Behbehani, M. (2025) · Langenbeck s Archives of Surgery · doi:10.1007/s00423-025-03680-1 · Cited by 5 · see citing works
“Studies have shown that revision to RYGB significantly improves or resolves hypoglycemia in most patients, making it a clinically justified option when conservative measures (e.g., dietary changes, medications) fail [ 27 , 28].”
Dumping Syndrome After One Anastomosis Gastric Bypass—A Systematic Review
Kermansaravi, M., Shahsavan, M., Amr, B., Stier, C., Parmar, C., & Chiappetta, S. (2025) · Obesity Surgery · doi:10.1007/s11695-025-07860-2 · Cited by 5 · see citing works
“Other measures include surgical placement of a silastic ring or band [48] and reversal surgeries in severe cases who failed all non-surgical options [2, 32, 49].”
Then, C., Nam‐Apostolopoulos, Y., Seißler, J., & Lechner, A. (2012) · PubMed · doi:10.6092/1590-8577/1319 · Cited by 5 · see citing works
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Hypoglycemia and Hypoglycemic Syndromes
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[Dumping syndrome: Diagnostics and therapeutic options].
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“Both patients reported loss of restriction complicated by hyperinsulinemic hypoglycemia, thus restoration of restriction was indicated and consisted of pouch downsizing and a new Fobi band placement [18].”
BackgroundSelf-citationBack to Sleeve: an Extreme Solution for Specific Complications of the Roux-en-Y Gastric Bypass
Schneck, A., Stenard, F., & Iannelli, A. (2015) · Obesity Surgery · doi:10.1007/s11695-015-1770-z · Cited by 4 · see citing works
Post-Bariatric Surgery Hypoglycemia
Bantle, J. P. (2016) · The Endocrine Society eBooks · doi:10.1210/mtp5.9781943550043.ch43 · Cited by 3 · see citing works
Effects of gastric bypass on FoxO1 expression in the liver and pancreas of diabetic rats
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“Pancreatic islet cell hyperplasia has been rarely observed in patients who undergo GBS (30,31).”
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Les complications de la chirurgie bariatrique
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“Dans une série, 11 patients sur 12 ont pu être traités par cette méthode [78].”
Postprandial Hyperinsulinemic Hypoglycemia in Bariatric Surgery
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Hypoglycemia after Roux-en-Y gastric bypass surgery
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Hypoglycemia in Pancreatic Disease
Mordes, M. J. T. A. J. P. (2015) · doi:10.3998/panc.2015.11 · Cited by 2 · see citing works
“Surgical approaches to the problem have included gastric banding, based on the hypothesis that some cases are due “late severe dumping syndrome” (43).”
BackgroundInfluentialHypoglycémies réactionnelles ou fonctionnelles
Slama, G. (2011) · Médecine des Maladies Métaboliques · doi:10.1016/s1957-2557(11)70268-1 · Cited by 1 · see citing works
- Authors
- Z’graggen, K., Guweidhi, A., Steffen, R., Potoczna, N., Biral, R., Walther, F., Komminoth, P., & Horber, F.
- Affiliations
- Triemli Hospital (CH)
- Corresponding author
- Horber, Fritz
- Venue
- Obesity Surgery
- Published
- 2008-04-26
- Volume
- 18
- Issue
- 8
- Pages
- 981-988
- ISSN
- 0960-8923 (ISSN-L)
- 1708-0428
- OpenAlex
- W2055803430
- Cited by
- 125
- References
- 37
- Citations by year
- 2026: 1 · 2025: 3 · 2024: 3 · 2023: 10 · 2022: 6 · 2021: 3 · 2020: 7 · 2019: 6 · 2018: 1 · 2017: 6 · 2016: 10 · 2015: 8 · 2014: 10 · 2013: 11 · 2012: 5
- FWCI
- 11.96
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Obesity Surgery (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Surgery › Minimally Invasive Surgical Techniques
- Health Sciences › Medicine › Surgery › Pancreatic function and diabetes
- Keywords
- recurrent hypoglycemia, gastric bypass
- MeSH terms
- Adult, Dumping Syndrome, Female, Follow-Up Studies, Humans, Hypoglycemia, Male, Middle Aged, Obesity, Morbid, Pancreatectomy, Laparoscopy, Recurrence, Severity of Illness Index, Gastric Bypass
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