Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome with Gastric Bypass Reversal: A Case Report and Review of the Literature
Open accessAbstract
Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal.Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden.Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.
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Various 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 [109]
The Case Report and Discussion describe gastrostomy tube placement, gastric bypass reversal, and gastric pouch reduction. The Discussion also describes modified sleeve gastrectomy as a revision of bypass, but does not say it was performed concomitantly with reversal. No page numbers are available in our copy. (LLM, conf=0.86)
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 [109]
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References 11 · Cited by 19
Research works printed but not linked: 7
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- Authors
- Rao, B. B., Click, B., Eid, G., & Codario, R. A.
- Affiliations
- University of Pittsburgh Medical Center (US)
- Allegheny Health Network (US)
- VA Pittsburgh Healthcare System (US)
- Corresponding author
- Codario, Ronald A.
- Venue
- Case Reports in Endocrinology
- Publisher
- Hindawi Limited
- Published
- 2015
- Volume
- 2015
- Pages
- 1-4
- ISSN
- 2090-6501 (ISSN-L)
- 2090-651X
- PMC
- PMC4617428
- OpenAlex
- W2171264645
- Cited by
- 19
- References
- 11
- Citations by year
- 2024: 2 · 2023: 3 · 2022: 1 · 2021: 3 · 2019: 2 · 2018: 3 · 2017: 2 · 2016: 3
- FWCI
- 2.69
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Case Reports in Endocrinology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Surgery › Pancreatic function and diabetes
- Health Sciences › Medicine › Surgery › Minimally Invasive Surgical Techniques
- Keywords
- postprandial hypoglycemia, endogenous hyperinsulinemic hypoglycemia, incretin response, morbid obesity, bariatric surgery complications, hypoglycemic seizures
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