Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry

Abstract

Background: Severe postprandial hypoglycemia after bariatric surgery is a rare but invalidating complication. Our aim was to describe the different tests performed for its diagnosis and their outcomes as well as the response to the prescribed pharmacological and surgical treatments. Methods: Multicenter, retrospective systematic review of cases with recurrent severe postprandial hypoglycemia. Results: Over 11 years of follow-up, 22 patients were identified. The test most used to provoke hypoglycemia was the oral glucose load test followed by the mixed meal test which was the least standardized test. With pharmacological treatment, 3 patients were symptom-free (with octreotide) and in 12 patients hypoglycemic episodes were attenuated. Seven patients had persistent hypoglycemic episodes and underwent surgery. Partial pancreatectomy was performed in 3 patients who had positive selective arterial calcium stimulation, and nesidioblastosis was confirmed in 2 patients. Reconversion to normal anatomy was performed in 3 patients, and 1 patient underwent a resection of the ‘candy cane' roux limb, with resolution of hypoglycemia in all cases. Conclusions: There is high heterogeneity in the evaluation and treatment options for postoperative hypoglycemia. In patients that do not respond to pharmacological treatment, reconstruction of gastrojejunal continuity may be the safest and most successful procedure.

Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management

“…Acarbose is an α‐glycosidase hydrolase inhibitor that slows carbohydrate digestion in the small intestine, thus blunting postprandial hyperglycemia and subsequent hypoglycemia. Several small studies demonstrated that acarbose improved glucose tolerance, reduced GI hormone release, reduced the incidence of hypoglycemia and improved symptoms in patients with dumping syndrome (Table ) . However, the use of acarbose as a treatment approach for dumping syndrome is limited by the fact that it affects only late dumping symptoms and may result in side effects related to carbohydrate maldigestion, such as bloating, flatulence and diarrhoea.…”

“…Somatostatin inhibition of GLP‐1 secretion is mediated via activation of the somatostatin receptor subtype (sst) 5, with a lesser effect through sst2 . Both short‐acting and long‐acting formulations of somatostatin analogues have demonstrated efficacy by slowing gastric emptying, improving hypoglycemia and reducing early and late dumping symptoms (Table ) .…”

“…Anecdotal evidence suggests that off‐label diazoxide administered at doses ranging from 100 mg to 150 mg three times daily may be effective in the treatment of late dumping symptoms, but no effect on early symptoms is expected because of its mode of action . A recent multicenter, retrospective, systematic case series reported that treatment of six patients who developed hyperinsulinemic hypoglycemia after bariatric surgery with diazoxide (168.7 ± 94 mg/day orally) resulted in a partial response (defined as a 50% reduction in the number and severity of hypoglycemic events) in three patients (50%) . Nifedipine, a calcium channel blocking agent, successfully controlled persistent hyperinsulinemic hypoglycemia in a case report of an adult patient with dumping syndrome that occurred after gastric bypass surgery .…”

Medical nutrition therapy for post-bariatric hypoglycemia: practical insights

“…Hypoglycemia is an increasingly recognized complication of bariatric surgery, occurring after both roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (SG) [1–5]. Post-bariatric hypoglycemia (PBH) typically occurs one to three hours after meals, with increased severity after intake of high glycemic index carbohydrates [6, 7].…”

Robotic Near-Total Pancreatectomy for Nesidioblastosis after Bariatric Surgery

“…Although rare, several other cases have been reported [2]. Pancreatectomy is an acceptable treatment for this condition [1–3]. We aim to present a video of a case of near-total distal robotic pancreactectomy for the treatment of nesidioblastosis after Roux-en-Y gastric bypass.…”