title: Severe recurrent hypoglycemia after gastric bypass surgery.
abstract: BACKGROUND
  Bariatric surgery is, at present, the most effective method to achieve major, long-term weight loss in severely obese patients. Recently, severe recurrent symptomatic hyperinsulinemic hypoglycemia was described as a consequence of gastric bypass surgery (GBS) in a small series of patients with severe obesity. Pancreatic nesidioblastosis, a hyperplasia of islet cells, was postulated to be the cause, and subtotal or total pancreatectomy was the suggested treatment.
  
  
  METHODS
  We observed that severe, disabling hypoglycemia after GBS occurred only in patients with loss of restriction. Whether restoration of gastric restriction might treat severe, recurrent hypoglycemia after GBS is unknown.
  
  
  RESULTS
  Therefore, gastric restriction was restored by surgical placement of a silastic ring (n = 8, first two patients with additional distal pancreatectomy) or an adjustable gastric band (n = 4) around the pouch in 12 consecutive patients presenting with severe hypoglycemia (blood glucose below 2.2 mM). At follow-up after restoration of gastric restriction (median follow-up 7 months, range 5 to 19 months), 11 patients demonstrated no hypoglycemic episodes, while one had recurrence of hypoglycemia and underwent distal pancreatectomy. Procedural mortality was 0% and morbidity 8.3%.
  
  
  CONCLUSIONS
  Patients suffering from severe recurrent hypoglycemia after GBS can be treated, in most cases, just by restoration of gastric restriction. Distal pancreatectomy should be considered a second-line treatment.
authors.affiliation: Berner Viszeralchirurgie and Schweizerisches Pankreaszentrum Klinik Beau-Site Bern, Bern, Switzerland.
authors.forename: Kaspar
authors.initials: K
authors.lastname: Z'graggen
authors.forename: Ahmed
authors.initials: A
authors.lastname: Guweidhi
authors.forename: Rudolf
authors.initials: R
authors.lastname: Steffen
authors.forename: Natascha
authors.initials: N
authors.lastname: Potoczna
authors.forename: Ruggero
authors.initials: R
authors.lastname: Biral
authors.forename: Frank
authors.initials: F
authors.lastname: Walther
authors.forename: Paul
authors.initials: P
authors.lastname: Komminoth
authors.forename: Fritz
authors.initials: F
authors.lastname: Horber
mesh_terms: D000328:Adult; D004377:Dumping Syndrome / Q000175:diagnosis / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D007003:Hypoglycemia / Q000209:etiology* / Q000473:pathology / Q000517:prevention & control; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D010180:Pancreatectomy; D012008:Recurrence; D012720:Severity of Illness Index