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Surgical Management of Postprandial Hyperinsulinemic Hypoglycemia after Roux-en-Y Gastric Bypass

Jessica Ardila-Gatas, MD, Linden Karas, MD, Julia Simkowski, BS, M. Cecilia Lansang, MD, PhD, Ali Aminian. Cleveland Clinic

Introduction: Postprandial hyperinsulinemic hypoglycemia (PPH) usually occurs one year after Roux-en-Y gastric bypass surgery (RYGB), presenting with normal fasting glucose and insulin levels, inappropriately high postprandial insulin and C-peptide levels, and a low glucose level. Anatomical changes after RYGB result in faster gastrointestinal transit and absorption of simple sugars that evoke a stronger GLP-1 response resulting in very high insulin levels followed by rapid hypoglycemia. Management of PPH includes diet adjustment, pharmacotherapy, and rarely surgical intervention. 

Case Description: A 41 year-old non-diabetic female who previously underwent laparoscopic RYGB 8-years ago with good weight loss results developed multiple daily episodes of post-prandial hyperglycemia followed rapidly by symptomatic episodes of hypoglycemia. Her blood sugars would spike to 250-300 mg/dl with meals, and then drop quickly to 30-50 mg/dl with severe neuroglycopenic symptoms. Lab tests and imaging ruled out an insulin-secreting tumor.  Mixed meal tolerance test confirmed presence of PPH. She attempted and failed treatment of her PPH with a very low carbohydrate diet, acarbose, and octreotide. Despite having continuous glucose monitoring (CGM) device, she had frequent and severe life-threatening hypoglycemia episodes. Upper endoscopy showed a 4-cm gastric pouch with a gaping gastrojejunal (GJ) anastomosis measuring 5-cm in diameter. It appeared that she experienced no gastric restriction for liquids or solids. The patient did not want her RYGB reversed.

Therefore we attempted to restore gastric restriction by resecting the dilated candy-cane jejunal limb at the GJ anastomosis and plicating the GJ under endoscopic guidance. A remnant gastrostomy tube was placed in case restoration of restriction was not effective. Furthermore, feeding through G-tube can also help in predicting the response to possible reversal of the RYGB in the future. Final visualization with the endoscope showed a 2-3 cm GJ anastomosis. The patient had an uneventful recovery with blood sugars maintained between 67-140 mg/dl, and was discharged home tolerating a full liquid diet without the need for treatment of hypo- and hyper-glycemia.

Discussion: Here we present the surgical treatment of severe PPH following RYGB by restoration of restriction of GJ anastomosis and placement of G-tube. Management of PPH includes diet adjustment (small frequent meals high in fiber and protein and avoidance of simple sugars), pharmacotherapy (octreotide, acarbose, GLP-1 inhibitor, calcium channel blocker, diazoxide) and surgical intervention.  On rare occasions it is necessary to reverse the RYGB, convert it to sleeve gastrectomy, or restore restriction of the GJ anastomosis by banding or plication.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 85545

Program Number: V269

Presentation Session: Friday Video Loop (Non CME)

Presentation Type: VideoLoop

136

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