title: A novel technique of Roux-en-Y gastric bypass reversal for postprandial hyperinsulinemic hypoglycaemia: A case report.
abstract: BACKGROUND
  We describe an evaluation of the effects of partial Roux-en-Y gastric bypass (RYGB) reversal on postprandial hyperinsulinaemic hypoglycaemia, insulin and GLP-1 levels.
  
  
  METHODS
  A 37 year old man was admitted with neuroglycopenia (plasma-glucose 1.6mmol/l) 18 months after RYGB, with normal 72h fasting test and abdominal CT. Despite dietary modifications and medical treatment, the hypoglycaemic episodes escalated in frequency. Feeding by a gastrostomy tube positioned in the gastric remnant did not prevent severe episodes of hypoglycaemia. A modified reversal of the RYGB was performed. Mixed meal tests were done perorally (PO), through the gastrostomy tube 1 (GT1), 4 weeks (GT2) after placement and 4 weeks after reversal (POr), with assessment of glucose, insulin and GLP-1 levels.
  
  
  RESULTS
  Plasma-glucose increased to a maximum of 9.6, 5.4, 6.5 and 5.8mmol/l at the PO, GT1, GT2 and POr tests respectively. The corresponding insulin levels were 2939, 731, 725 and 463pmol/l. A decrease of plasma-glucose followed: 2.2, 3.0, 3.9 and 2.9mmol/l respectively and insulin levels were suppressed at 150min: 45, 22, 21 and 14pmol/l, respectively. GLP-1 levels increased in the PO test (60min: 122pmol/l, 21 fold of basal), but was attenuated in the two latter tests (12-23pmol/l at 60min).
  
  
  CONCLUSIONS
  Reduction of plasma-glucose, insulin and GLP-1 excursions and symptoms were seen after gastric tube placement and partial RYGB reversal. This attenuation of GLP-1 response to feeding could reflect an adaptation to nutrients.
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway. Electronic address: elisabeth.qvigstad@ous-hf.no.
authors.forename: E
authors.initials: E
authors.lastname: Qvigstad
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway.
authors.forename: H L
authors.initials: HL
authors.lastname: Gulseth
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway.
authors.forename: H
authors.initials: H
authors.lastname: Risstad
authors.affiliation: Diabetes Complications Research Centre, Conway Institute, University College Dublin, Ireland.
authors.forename: C W
authors.initials: CW
authors.lastname: le Roux
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway; Faculty of Medicine, University of Oslo, Norway.
authors.forename: T J
authors.initials: TJ
authors.lastname: Berg
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway.
authors.forename: T
authors.initials: T
authors.lastname: Mala
authors.affiliation: Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway.
authors.forename: J A
authors.initials: JA
authors.lastname: Kristinsson
keywords: Case report; GLP-1; Gastric bypass reversal; Hypoglycaemia; Obesity; Postprandial hyperinsulinemic hypoglycaemia; Roux-en-Y gastric bypass