Obesity Surgery

, 18:981 | Cite as

Severe Recurrent Hypoglycemia after Gastric Bypass Surgery

  • Kaspar Z’graggen
  • Ahmed Guweidhi
  • Rudolf Steffen
  • Natascha Potoczna
  • Ruggero Biral
  • Frank Walther
  • Paul Komminoth
  • Fritz Horber
Research Article



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.


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.


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%.


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.


Gastric bypass Gastric banding Dumping Nesidioblastosis Hypoglycemia Gastric restriction 


  1. 1.
    National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. Obes Res. 1998;6 Suppl 2:51S–209S.Google Scholar
  2. 2.
    U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. Healthy people 2010. Nasnewsletter. 2000;15(3):3.Google Scholar
  3. 3.
    Chambliss HO, Finley CE, Blair SN. Attitudes toward obese individuals among exercise science students. Med Sci Sports Exerc. 2004;36(3):468–74.PubMedCrossRefGoogle Scholar
  4. 4.
    Pi-Sunyer FX. Comorbidities of overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999;31 Suppl 11:S602–8.PubMedGoogle Scholar
  5. 5.
    Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med. 1999;341(15):1097–105.PubMedCrossRefGoogle Scholar
  6. 6.
    Safer DJ. Diet, behavior modification, and exercise: a review of obesity treatments from a long-term perspective. South Med J. 1991;84(12):1470–4.PubMedGoogle Scholar
  7. 7.
    Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295(13):1549–55.PubMedCrossRefGoogle Scholar
  8. 8.
    CDC. State-specific prevalence of obesity among adults—United States, 2005. MMWR Morb Mortal Wkly Rep. 2006;55(36):985–8.Google Scholar
  9. 9.
    Zimmermann MB, Gubeli C, Puntener C, Molinari L. Overweight and obesity in 6–12 year old children in Switzerland. Swiss Med Wkly. 2004;134(35–36):523–8.PubMedGoogle Scholar
  10. 10.
    Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obes Res. 2004;12(1):18–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Brolin RE. Bariatric surgery and long-term control of morbid obesity. JAMA. 2002;288(22):2793–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Mun EC, Blackburn GL, Matthews JB. Current status of medical and surgical therapy for obesity. Gastroenterology. 2001;120(3):669–81.PubMedCrossRefGoogle Scholar
  13. 13.
    Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339–50; discussion 50–2.PubMedCrossRefGoogle Scholar
  14. 14.
    Jones KB Jr. Experience with the Roux-en-Y gastric bypass, and commentary on current trends. Obes Surg. 2000;10(2):183–5.PubMedCrossRefGoogle Scholar
  15. 15.
    McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2003;139(11):933–49.PubMedGoogle Scholar
  16. 16.
    Hafner RJ, Watts JM, Rogers J. Quality of life after gastric bypass for morbid obesity. Int J Obes. 1991;15(8):555–60.PubMedGoogle Scholar
  17. 17.
    Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300–14.PubMedCrossRefGoogle Scholar
  18. 18.
    Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005;353(3):249–54.PubMedCrossRefGoogle Scholar
  19. 19.
    Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Goldsmith J, et al. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia. 2005;48(11):2236–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Clancy TE, Moore FD Jr, Zinner MJ. Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia. J Gastrointest Surg. 2006;10(8):1116–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Alvarez GC, Faria EN, Beck M, Girardon DT, Machado AC. Laparoscopic spleen-preserving distal pancreatectomy as treatment for nesidioblastosis after gastric bypass surgery. Obes Surg. 2007;17(4):550–2.PubMedCrossRefGoogle Scholar
  22. 22.
    Sigstad H. Effect of tolbutamide on the dumping syndrome. Scand J Gastroenterol. 1969;4(3):227–31.PubMedGoogle Scholar
  23. 23.
    Doppman JL, Chang R, Fraker DL, Norton JA, Alexander HR, Miller DL, et al. Localization of insulinomas to regions of the pancreas by intra-arterial stimulation with calcium. Ann Intern Med. 1995;123(4):269–73.PubMedGoogle Scholar
  24. 24.
    Fobi MA. Placement of the GaBP ring system in the banded gastric bypass operation. Obes Surg. 2005;15(8):1196–201.PubMedCrossRefGoogle Scholar
  25. 25.
    Steffen R, Biertho L, Ricklin T, Piec G, Horber FF. Laparoscopic Swedish adjustable gastric banding: a five-year prospective study. Obes Surg. 2003;13(3):404–11.PubMedCrossRefGoogle Scholar
  26. 26.
    Kleeff J, Diener MK, Z’graggen K, Hinz U, Wagner M, Bachmann J, et al. Distal pancreatectomy: risk factors for surgical failure in 302 consecutive cases. Ann Surg. 2007;245(4):573–82.PubMedCrossRefGoogle Scholar
  27. 27.
    Anlauf M, Wieben D, Perren A, Sipos B, Komminoth P, Raffel A, et al. Persistent hyperinsulinemic hypoglycemia in 15 adults with diffuse nesidioblastosis: diagnostic criteria, incidence, and characterization of beta-cell changes. Am J Surg Pathol. 2005;29(4):524–33.PubMedCrossRefGoogle Scholar
  28. 28.
    Raffel A, Krausch MM, Anlauf M, Wieben D, Braunstein S, Klöppel G, et al. Diffuse nesidioblastosis as a cause of hyperinsulinemic hypoglycemia in adults: a diagnostic and therapeutic challenge. Surgery. 2007;141(2):179–84; discussion 85–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Holst JJ. Glucagonlike peptide 1: a newly discovered gastrointestinal hormone. Gastroenterology. 1994;107(6):1848–55.PubMedGoogle Scholar
  30. 30.
    Buchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg. 2003;138(12):1310–4; discussion 5.PubMedCrossRefGoogle Scholar
  31. 31.
    Witteles RM, Straus IF, Sugg SL, Koka MR, Costa EA, Kaplan EL. Adult-onset nesidioblastosis causing hypoglycemia: an important clinical entity and continuing treatment dilemma. Arch Surg. 2001;136(6):656–63.PubMedCrossRefGoogle Scholar
  32. 32.
    Bantle JP, Ikramuddin S, Kellogg TA, Buchwald H. Hyperinsulinemic hypoglycemia developing late after gastric bypass. Obes Surg. 2007;17(5):592–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Meier JJ, Butler AE, Galasso R, Butler PC. Hyperinsulinemic hypoglycemia after gastric bypass surgery is not accompanied by islet hyperplasia or increased beta-cell turnover. Diabetes Care. 2006;29(7):1554–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Chari ST, Zapiach M, Yadav D, Rizza RA. Beta-cell function and insulin resistance evaluated by HOMA in pancreatic cancer subjects with varying degrees of glucose intolerance. Pancreatology. 2005;5(2–3):229–33.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2008

Authors and Affiliations

  • Kaspar Z’graggen
    • 1
  • Ahmed Guweidhi
    • 1
  • Rudolf Steffen
    • 1
  • Natascha Potoczna
    • 2
  • Ruggero Biral
    • 3
  • Frank Walther
    • 1
  • Paul Komminoth
    • 4
  • Fritz Horber
    • 2
  1. 1.Berner Viszeralchirurgie and Schweizerisches Pankreaszentrum Klinik Beau-Site BernBernSwitzerland
  2. 2.Adipositaszentrum Klinik Lindberg AGWinterthurSwitzerland
  3. 3.Pathologie LänggasseBernSwitzerland
  4. 4.Institut für Pathologie Triemlispital ZürichZürichSwitzerland

Personalised recommendations