Surgical Endoscopy

, Volume 25, Issue 6, pp 1926–1932 | Cite as

Abnormal glucose tolerance testing following gastric bypass demonstrates reactive hypoglycemia

  • Mitchell Roslin
  • Tanuja Damani
  • Jonathan Oren
  • Robert Andrews
  • Edward Yatco
  • Paresh Shah



Symptoms of reactive hypoglycemia have been reported by patients after Roux-en-Y gastric bypass (RYGB) surgery who experience maladaptive eating behavior and weight regain. A 4-h glucose tolerance test (GTT) was used to assess the incidence and extent of hypoglycemia.


Thirty-six patients who were at least 6 months postoperative from RYGB were administered a 4-h GTT with measurement of insulin levels. Mean age was 49.4 ± 11.4 years, mean preoperative body mass index (BMI) was 48.8 ± 6.6 kg/m2, percent excess BMI lost (%EBL) was 62.6 ± 21.6%, mean weight change from nadir weight was 8.2 ± 8.6 kg, and mean follow-up time was 40.5 ± 26.7 months. Twelve patients had diabetes preoperatively.


Thirty-two of 36 patients (89%) had abnormal GTT. Six patients (17%) were identified as diabetic based on GTT. All six of these patients were diabetic preoperatively. Twenty-six patients (72%) had evidence of reactive hypoglycemia at 2 h post glucose load. Within this cohort of 26 patients, 14 had maximum to minimum glucose ratio (MMGR) > 3:1, 5 with a ratio > 4:1. Eleven patients had weight regain greater than 10% of initial weight loss (range 4.9–25.6 kg). Ten of these 11 patients (91%) with weight recidivism showed reactive hypoglycemia.


Abnormal GTT is a common finding post RYGB. Persistence of diabetes was noted in 50% of patients with diabetes preoperatively. Amongst the nondiabetic patients, reactive hypoglycemia was found to be more common and pronounced than expected. Absence of abnormally high insulin levels does not support nesidioblastosis as an etiology of this hypoglycemia. More than 50% of patients with reactive hypoglycemia had significantly exaggerated MMGR. We believe this may be due to the nonphysiologic transit of food to the small intestine due to lack of a pyloric valve after RYGB. This reactive hypoglycemia may contribute to maladaptive eating behaviors leading to weight regain long term. Our data suggest that GTT is an important part of post-RYGB follow-up and should be incorporated into the routine postoperative screening protocol. Further studies on the impact of pylorus preservation are necessary.


Reactive hypoglycemia Roux-en-Y gastric bypass Gastric bypass Morbid obesity 



Dr. Mitchell Roslin is a consultant for Johnson & Johnson, Bard, and Covidien. He is on the surgical advisory board for ValenTx Scientific Intake. He has equity interests in Ventralfix, gets royalties from Allergan, and has a research grant from Covidien. Dr. Paresh Shah has an equity interest in SuturTek and Ventralfix, and is a consultant for Stryker, Covidien, Ethicon, and Davol. Drs. Tanuja Damani, Jonathan Oren, Robert Andrews, and Edward Yatco have no conflicts of interest or financial ties to disclose.


  1. 1.
    Manson JE, Skerret PJ, Greenland P, VanItallie TB (2004) The escalating pandemic s of obesity and sedentary lifestyle: a call to action by clinicians. Arch Intern Med 164:249–258PubMedCrossRefGoogle Scholar
  2. 2.
    Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G, Eid GM, Mattar S, Ramanathan R, Barinas-Mitchel E, Rao RH, Kuller L, Kelley D (2003) Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg 238:467–484PubMedGoogle Scholar
  3. 3.
    Torquati A, Lutfi R, Abumrad N, Richards WO (2005) Is Roux-en-Y gastric bypass surgery the most effective treatment for type 2 diabetes mellitus in morbidly obese patients? J Gastrointest Surg 9:1112–1116PubMedCrossRefGoogle Scholar
  4. 4.
    Parikh M, Ayoung-Chee P, Romanos E, Lewis N, Pachter HL, Fielding G, Ren C (2007) Comparison of rates of resolution of diabetes mellitus after gastric banding, gastric bypass and biliopancreatic diversion. J Am Coll Surg 205:631–635PubMedCrossRefGoogle Scholar
  5. 5.
    Alexandrides TK, Skroubis G, Kalfarentzos F (2007) Resolution of diabetes mellitus and metabolic syndrome following Roux-en-Y gastric bypass and a variant of biliopancreatic diversion in patients with morbid obesity. Obes Surg 17:176–184PubMedCrossRefGoogle Scholar
  6. 6.
    Gumbs AA, Modlin IM, Ballantyne GH (2005) Changes in insulin resistance following bariatric surgery: role of caloric restriction and weight loss. Obes Surg 15:462–473PubMedCrossRefGoogle Scholar
  7. 7.
    Service FJ, Natt N, Thompson GB, Grant CS, van Heerden JA, Andrews JC, Lorenz E, Terzic A, Lloyd RV (1999) Noninsulinoma pancreatogenous hypoglycemia:a novel syndrome of hyperinsulinemic hypoglycemic in adults independent of mutations in Kir6.2 and SUR1 genes. J Clin Endocrinol Metab 84:1582–1589PubMedCrossRefGoogle Scholar
  8. 8.
    Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV (2005) Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 353:249–254PubMedCrossRefGoogle Scholar
  9. 9.
    Bantle JP, Ikramuddin S, Kellogg TA, Buchwald H (2007) Hyperinsulinemic hypoglycemia developing late after gastric bypass. Obes Surg 17:592–594PubMedCrossRefGoogle Scholar
  10. 10.
    Moreira RO, Moreira RBM, Machado NAM, Goncalves TB, Coutinho WF (2008) Post-prandial hypoglycemia after bariatric surgery: pharmacological treatment with verapamil and acarbose. Obes Surg 18:1618–1621PubMedCrossRefGoogle Scholar
  11. 11.
    Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Goldsmith J, Hanto DW, Callery M, Arky R, Nose V, Bonner-Weir S, Goldfine AB (2005) Severe hypoglycemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia 48:2236–2240PubMedCrossRefGoogle Scholar
  12. 12.
    Clancy TE, Moore FD, Zinner MJ (2006) Post-gastric bypass hyperinsulinism with nesidioblastosis:subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia. J Gastroint Surg 10:1116–1119CrossRefGoogle Scholar
  13. 13.
    Alvarez GC, Faria EN, Beck M, Girardon DT, Machado AC (2007) Laparoscopic spleen-preserving distal pancreatectomy as treatment for nesidioblastosis after gastric bypass surgery. Obes Surg 14:550–552CrossRefGoogle Scholar
  14. 14.
    De Leon DD, Deng S, Madani R, Ahima RS, Drucker DJ, Stoffers DA (2003) Role of endogenous glucagon-like peptide-1 in islet regeneration after partial pancreatectomy. Diabetes 52:365–371PubMedCrossRefGoogle Scholar
  15. 15.
    List JF, Habener JF (2004) Glucagon-like peptide 1 agonists and the development and growth of pancreatic beta cells. Am J Physiol Endocrinol Metab 286:E875–E881PubMedCrossRefGoogle Scholar
  16. 16.
    Brubaker PL, Drucker DJ (2004) Minireview: glucagon-like polypeptides regulate cell proliferation and apoptosis in the pancreas, gut and central nervous system. Endocrinology 145:2653–2659PubMedCrossRefGoogle Scholar
  17. 17.
    Farilla L, Bulotta A, Hirshberg B, Li Calzi S, Khoury N, Noushmehr H, Bertolotto C, Di Mario U, Harlan DM, Perfetti R (2003) Glucagon-like peptide 1 inhibits cell apoptosis and proves glucose responsiveness of freshly isolated human islets. Endocrinology 144:5149–5158PubMedCrossRefGoogle Scholar
  18. 18.
    Meier JJ, Butler AE, Galasso R, Butler PC (2006) Hyperinsulinemic hypoglycemia after gastric bypass surgery is not accompanied by islet hyperplasia or increased beta-cell turnover. Diabetes Care 29:1554–1559PubMedCrossRefGoogle Scholar
  19. 19.
    Jenkins DJ, Wolever TM, Taylor RH, Barker H, Fielden H, Baldwin JM, Bowling AC, Newman HC, Jenkins AL, Goff DV (1981) Glycemic index of foods: a physiological basis for carbohydrate exchange. Am J Clin Nutr 34:362–366PubMedGoogle Scholar
  20. 20.
    Kiens B, Richter EA (1996) Types of carbohydrate in an ordinary diet affect insulin action and muscle substrates in humans. Am J Clin Nutr 63:47–53PubMedGoogle Scholar
  21. 21.
    Thomas DE, Elliott EJ, Baur L (2007) Low glycaemic index or low glycaemic load diets for overweight and obesity. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD005105.pub2
  22. 22.
    Linner JH (1982) Comparative effectiveness of gastric bypass and gastroplasty. Arch Surg 117:695–700PubMedGoogle Scholar
  23. 23.
    Laws HL, Piantadosi S (1980) Superior gastric reduction procedure for morbid obesity. A prospective randomized trial. Ann Surg 193:334–336CrossRefGoogle Scholar
  24. 24.
    Pories WJ, Flickinger EG, Meelheim D, Van Rij AM, Thomas FT (1982) The effectiveness of gastric bypass over gastric partition in morbid obesity: consequences of distal gastric and duodenal exclusion. Ann Surg 196:389–399PubMedCrossRefGoogle Scholar
  25. 25.
    Sugerman HJ, Starkey JV, Birkenhauer R (1987) A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 205:613–622PubMedCrossRefGoogle Scholar
  26. 26.
    Sugerman HJ, Wolper HL (1984) Failed gastroplasty for morbid obesity: revised gastroplasty vs. Roux-en-Y gastric bypass. Am J Surg 148:331–336PubMedCrossRefGoogle Scholar
  27. 27.
    Eckhauser FE, Knoll JA, Strodel WE (1983) Remedial surgery following failed gastroplasty for morbid obesity. Ann Surg 198:585–591PubMedCrossRefGoogle Scholar
  28. 28.
    Magro DO, Geloneze B, Delfini R, Pareja BC, Callejas F, Pareja JC (2008) Long-term weight regain after gastric bypass: a 5-year prospective study. Obes Surg 18:648–651PubMedCrossRefGoogle Scholar
  29. 29.
    Christou NV, Look D, Maclean LD (2006) Weight gain after short-and long-limb gastric bypass in patients followed longer than 10 years. Ann Surg 244:734–740PubMedCrossRefGoogle Scholar
  30. 30.
    Loewen M, Barba C (2008) Endoscopic sclerotherpy for dilated gastrojejunostomy of failed gastric bypass. Surg Obes Relat Dis 4:539–542PubMedCrossRefGoogle Scholar
  31. 31.
    Thompson CC, Slattery J, Bundga ME, Lautz DB (2006) Preoral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surg Endosc 20:1744–1748PubMedCrossRefGoogle Scholar
  32. 32.
    Cummings DE, Weigle DS, Frayo RS, Breen PA, Ma MK, Dellinger EP, Purnell JQ (2002) Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med 346:1623–1630PubMedCrossRefGoogle Scholar
  33. 33.
    Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB (2002) Binge eating among gastric bypass patients and long-term follow-up. Obes Surg 12:270–275PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Mitchell Roslin
    • 1
  • Tanuja Damani
    • 1
  • Jonathan Oren
    • 2
  • Robert Andrews
    • 3
  • Edward Yatco
    • 1
  • Paresh Shah
    • 1
  1. 1.Department of SurgeryLenox Hill HospitalNew YorkUSA
  2. 2.Department of Orthopedic SurgeryNew York UniversityNew YorkUSA
  3. 3.Department of SurgeryBeth Israel Deaconess Medical CenterBostonUSA

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