Luis R Benavente-Chenals, MD, Brian J Dunkin, MD, Joanne M Chung, MD, Vadim Sherman, MD, Wega Koss, MD, Patrick R Reardon, MD. The Methodist Hospital Department of Surgery Methodist Institute for Technology, Innovation, and Education Houston, Texas 77030
Non Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS) was first described in 1999 by Service and others. His report was updated in 2000 and found adequate palliation of symptoms in 80% of patients following gradient guided pancreatectomy. In 2005 the group reported similar findings and results in 6 patient patients following Roux en Y gastric bypass surgery.
Since its original description, multiple groups have reported on patients with NIPHS following surgery for the treatment of morbid obesity. Currently, the etiology is not well understood and there is no consensus on the treatment of these patients. We present a case of NIPHS following gastric bypass surgery successfully treated with laparoscopic, spleen preserving extended distal pancreatectomy and review the different treatment options available.
A 37 year old woman was referred for surgical consultation with severe hypoglycemia following roux en y gastric bypass for morbid obesity 3 years ago. The operation include a 100 cm roux limb and 40 cm biliopancreatic limb. Her preoperative weight was 284 lbs, and other medical problems at the time of surgery included hypertension, depression, anxiety and migraines. Two years after surgery she developed lightheadedness, dizziness, slurred speech and sweaty palms, associated with documented hypoglycemia with metered blood sugar between 34 and 50 mg/dl. These episodes occurred twice a week and severely impaired her lifestyle. Her initial workup demonstrated that her symptoms were consistent with endogenous hypersulinism and included random insulin 5 uIU/ml, C-peptide 1.5 ng/mL, proinsulin 32 pmol/l, and negative drug screen for sulfonylureas and other oral hypoglycemic medications. Radiologic workup included a CT scan of the abdomen and pelvis plus an ocreotide scan with did not demonstrate lesions suspicions for insulinoma. Selective calcium stimulation test demonstrated a precipitous increase of the basal insulin levels the splenic and superior mesenteric arteries indicating B cell hyperfunction in the regions irrigated by these vessels. She was taken to the operating room where she underwent a laparoscopic intraoperative ultrasound of the pancreas and spleen-preserving extended distal pancreatectomy. There were no operative complications.
Pathology examination showed visually normal pancreatic tissue. Further studies documented increased density of pancreatic islet cells with increased islet cell function. Her postoperative stay was uneventful and the hypoglycemic episodes resolved.
NIPHS is an uncommon condition which may follow laparoscopic roux-en-Y gastric bypass. This condition may be treated medically or surgically. Surgical options include: Laparoscopic reversal of the bypass, which may lead to weight regain; laparoscopic conversion of the bypass to a sleeve gastrectomy, for which there is only very small numbers of cases with short-term follow up; and laparoscopic, spleen preserving extended distal pancreatectomy, which has a reasonable number of cases with long-term follow up. We report a successful short-term metabolic outcome following a laparoscopic, spleen preserving extended distal pancreatectomy.
Program Number: P090