title: One-Anastomosis Jejunal Interposition with Gastric Remnant Resection (Branco-Zorron Switch) for Severe Recurrent Hyperinsulinemic Hypoglycemia after Gastric Bypass for Morbid Obesity.
abstract: The anatomical and physiological changes after Roux-en-Y gastric bypass for morbid obesity can lead to severe hyperinsulinemic hypoglycemia with neuroglycopenia in a small percentage of patients. The exact physiologic mechanism is not completely understood. Surgical reversal to the original anatomy and distal or total pancreatectomy are current therapeutic options to reverse the hypoglycemic effect, with substantial associated morbidity. Our group reports a pilot clinical series of a novel surgical technique using one-anastomosis jejunal interposition with gastric remnant resection (Branco-Zorron Switch).
  
  
  
  Patients with severe symptomatic hyperinsulinemic hypoglycemia refractory to conservative therapy were treated using the technique. The procedure started with resection of the remnant stomach close to pylorus. The alimentary limb was sectioned at 20 cm from the gastrojejunal anastomosis, and the rest of the alimentary limb was resected until the Y-Roux anastomosis. A hand-sutured anastomosis was then performed with the proximal alimentary limb and the remnant antrum.
  
  
  
  Four patients were successfully submitted to the procedure with reversal of the symptomatology and normalization of insulin levels, postprandial glucose levels, and oral glucose tolerance test, with a mean follow-up of 24.3 months. Mean operative time was 188 min, and patients recovered without postoperative complications.
  
  
  
  Patients suffering from severe hyperinsulinemic hypoglycemia after gastric bypass may be efficiently treated by this innovative procedure, avoiding extreme surgical therapy such as pancreatectomy or restoring the gastric anatomy, while still maintaining sustained weight loss. Studies with larger series and longer follow-up are still needed to define the role of this therapy in managing this entity.
authors.affiliation: Center of Innovative Surgery (ZIC), Department of General, Visceral and Transplant Surgery, Campus Virchow Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany. Ricardo.Zorron@charite.de.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Zorron
authors.affiliation: Clinic CEVIP, Curitiba, Brazil.
authors.forename: Alcides
authors.initials: A
authors.lastname: Branco
authors.affiliation: Clinic CEVIP, Curitiba, Brazil.
authors.forename: Jose
authors.initials: J
authors.lastname: Sampaio
authors.affiliation: Department of General, Visceral, Thorax and Vascular Surgery, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Bothe
authors.affiliation: Department of General, Visceral, Thorax and Vascular Surgery, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany.
authors.forename: Tido
authors.initials: T
authors.lastname: Junghans
authors.affiliation: Department of General, Visceral, Thorax and Vascular Surgery, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Germany.
authors.forename: Gyurdzhan
authors.initials: G
authors.lastname: Rasim
authors.affiliation: Center of Innovative Surgery (ZIC), Department of General, Visceral and Transplant Surgery, Campus Virchow Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Johann
authors.initials: J
authors.lastname: Pratschke
authors.affiliation: Center of Innovative Surgery (ZIC), Department of General, Visceral and Transplant Surgery, Campus Virchow Klinikum and Department of General, Visceral, Vascular and Thoracic Surgery, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Safak
authors.initials: S
authors.lastname: Guel-Klein
mesh_terms: D000714:Anastomosis, Surgical; D002908:Chronic Disease; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D018530:Gastric Stump / Q000601:surgery*; D006801:Humans; D006946:Hyperinsulinism / Q000209:etiology / Q000601:surgery*; D007003:Hypoglycemia / Q000209:etiology / Q000601:surgery*; D007583:Jejunum / Q000601:surgery*; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D010865:Pilot Projects; D012008:Recurrence
keywords: Bariatric surgery; Gastric bypass; Hyperinsulinemia; Hypoglycemia; Morbid obesity; NIPHS; Non-insulinoma pancreatogenous hyperinsulinemic hypoglycemia syndrome