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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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Patients admitted to the hospital with DKA are at high-risk for readmission. We have previously demonstrated that implementation of a DKA PowerPlan (PP) that guides IV insulin dosing following acute management and transition to SC insulin reduces the frequency of recurrent DKA and rebound hyperglycemia during the index hospitalization. The purpose of this study was to determine whether the DKA PP reduces all cause and diabetes-related (recurrent DKA, hyperglycemia, hypoglycemia) hospital readmissions at 30 days and 1 year following an index hospitalization, as well to examine the contribution of high risk co-morbidities (psychiatric illness and/or history of alcohol/polysubstance abuse) associated with readmission risk in this group of patients. Retrospective chart review was performed for patients admitted with primary diagnosis of DKA prior to (pre-PP, n=60) and following DKA PP implementation (Post-PP, n=60). The groups were similar in age (Pre- vs. Post-PP: 38 ± 13.5 vs. 40 ± 16.6), BMI (26 ± 6.7 vs. 27 ± 7 kg/m2), gender (%Male: 38% vs. 48%), HbA1c (11.7 ± 2.4 vs. 11.3 ± 2.9%), admission BG (560 vs. 615 mg/dl) and anion gap (AG) (27.6 vs. 27.4), but differed in the prevalence of comorbidities which were higher in the pre-PP group (58 vs. 40%, p = 0.045). All cause readmissions were similar at 30 days (Pre vs. Post-PP: 1.4 ± 0.8 vs. 1.2 ± 0.4) but were lower at 1 year in the post-PP group (5.2 ± 4.7 vs. 3.5 ± 2.7, p = 0.07). Patients with co-morbidities in the post-PP group had lower all-cause (p = 0.023) but not diabetes related readmissions at 1 year, compared to patients with co-morbidities in the pre-PP group. In summary, these findings suggest that a DKA PP may be associated with a reduction in all cause hospital readmission in high risk patients with underlying psychiatric or substance abuse disorders. These results emphasize the need to identify and address patient specific factors that contribute to readmission in this high risk group. Disclosure N. Karajgikar: None. A. Donihi: None. R.A. Salata: None. R. Codario: None. R. Acharya: None. P. Manroa: None. M.T. Korytkowski: Advisory Panel; Self; Novo Nordisk Inc.. Other Relationship; Self; JAEB Center For Health Research.