Post−Gastric Bypass Hyperinsulinism With Nesidioblastosis: Subtotal or Total Pancreatectomy May Be Needed to Prevent Recurrent Hypoglycemia

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
Journal of Gastrointestinal Surgery (Impact Factor: 2.8). 09/2006; 10(8):1116-9. DOI: 10.1016/j.gassur.2006.04.008
Source: PubMed


Symptomatic hyperinsulinemic hypoglycemia and pancreatic nesidioblastosis have recently been described in a small series of patients after gastric bypass surgery for morbid obesity. In the limited published reports of patients with this condition, hyperinsulinism and nesidioblastosis have been managed with distal or subtotal pancreatectomy, with the extent of resection guided by calcium angiography. However, nesidioblastosis may involve the pancreas diffusely, and limited pancreatic resections may predispose patients to further hypoglycemic episodes. We have treated two patients with refractory hyperinsulinism and symptomatic hypoglycemia after successful gastric bypass surgery. One patient underwent an approximately 80% pancreatectomy with good results but subsequently experienced recurrent drop attacks and fainting from hyperinsulinism; a completion pancreatectomy via a pancreaticoduodenectomy was then required. A second patient had profound hyperinsulinemic hypoglycemia and was treated successfully with a subtotal (95%) pancreatectomy. Our experience, the third published report of post-gastric bypass nesidioblastosis, suggests that the risk of recurrent symptomatic hyperinsulinism after limited pancreatectomy is significant and relative euglycemia may be achieved with subtotal or total pancreatectomy.

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    • "The etiology of hyperinsulinemic hypoglycemia remains controversial, and best treatment recommendations for these conditions are unknown. In patients with recalcitrant postRYGB hyperinsulinemic hypoglycemia, surgical treatment with subtotal or total pancreatectomy has been offered in selected cases [11] [12], because the condition has been linked to de novo postRYGB nesidioblastosis or pancreatic islet overgrowth as its potential cause [12]. However, this pathologic finding has been challenged by other groups, and clinical results with pancreatectomy are suboptimal [13] [14] [15]. "
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    ABSTRACT: The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. Prospective study of consecutive patients offered laparoscopic reversal of RYGB. Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5±12.4 to 1.5±1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
    Surgery for Obesity and Related Diseases 06/2013; 10(1). DOI:10.1016/j.soard.2013.05.012 · 4.07 Impact Factor
    • "Although there is limited data regarding the efficacy of pancreatectomy for nesidioblastosis, successful resolution of hypoglycemia has been reported after partial or subtotal pancreatectomy.[10] On the other hand, recurrent hypoglycemia has also been reported that may require total pancreatectomy.[11] "
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    ABSTRACT: We describe a case of a 40 year old patient with recurrent severe fasting and postprandial symptomatic hypoglycemia that occurred 6 years after gastric bypass surgery. The hypoglycemia was associated with increased insulin and C peptide but all diagnostic modalities for localizing an insulinoma were negative. Medical management failed to control symptoms and the patient underwent subtotal pancreatectomy. Surgical tissue examination confirmed the diagnosis of noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) or nesidioblastosis. Initially after surgery the patient had full remission but after 6 months hypoglycemia recurred. However, this time it was well-controlled with octreotide treatment.
    04/2012; 2(2):45-7. DOI:10.4103/2231-0770.99164
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    • "Some prefer a gastric restrictive procedure , suggesting nesidioblastosis is a robust form of dumping syndrome [16]; others prefer distal pancreatectomy to assuage the symptoms without the morbidity of total pancreatectomy [17]. Furthermore, subtotal or total pancreatectomy has been described as definitive treatment, while accepting the long-term risks of medically refractory hypoglycemia , which should not be underappreciated [14] [15]. "
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    ABSTRACT: Gastric bypass is a proven treatment option for weight loss and the reduction of medical co-morbid conditions in the obese population. Severe refractory and/or recurrent hypoglycemia can occur, especially in postoperative patients who do not comply with the guidelines for oral glucose consumption. In a very small number of patients, the cause is not dietary indiscretions but, instead, factitious insulin administration or nesidioblastosis. The optimal evaluation and management for these diagnoses is not completely lucid yet important for bariatric surgeons and physicians alike to be familiar. Our objectives were to review the appropriate evaluation and treatment options for etiologies of hypoglycemia after gastric bypass and to create an algorithm that biochemically assesses the etiology of hypoglycemia. The setting was a university hospital in the United States. We present the cases of 3 patients who developed symptomatic hypoglycemia from distinct etiologies after laparoscopic Roux-en-Y gastric bypass. We also reviewed the current data regarding diagnosis and treatment. Each patient's evaluation and management is elaborated in detail. We propose a novel algorithm for the biochemical evaluation of hypoglycemia after gastric bypass according to our experience and the review of the literature. Most cases of symptomatic hypoglycemia that develop in gastric bypass patients are associated with dietary indiscretions. However, a small subset of patients can develop refractory, recurrent, hyperinsulinemic hypoglycemia from factitious insulin administration or nesidioblastosis.
    Surgery for Obesity and Related Diseases 08/2011; 8(5):641-7. DOI:10.1016/j.soard.2011.08.008 · 4.07 Impact Factor
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