Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment

An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.