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.

Case summary: 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.

Keywords: Case report; GLP-1; Gastric bypass reversal; Hypoglycaemia; Obesity; Postprandial hyperinsulinemic hypoglycaemia; Roux-en-Y gastric bypass.

Fig. 1

Panel a depicts the entero–entero anastomosis (OEE) and the gastro–jejunostomy after Roux-en-Y gastric bypass. Panel b demonstrates the division of the alimentary limb 6 cm below the gastro–jejunostomy and the anastomosis of the proximal part of the alimentary limb to the gastric remnant. A new entero–entero anastomosis is made between the former alimentary and bilio–pancreatic limb following transection of the original entero–entero anastomosis at the bilio–pancreatic limb side. A is previously published in D. Hofsø et al.: Follow-up after bariatric surgery, in the Journal of the Norwegian Medical Association, 2011, by permission from K. Toverud, CMI. B was produced for our paper by K. Toverud, CMI. The images are not covered by the terms of the Creative Commons licence of this publication. For permission to reuse, please contact the rights holder (K. Toverud, CMI).

Fig. 2

Panel a–c respectively: Plasma–glucose, serum–insulin and plasma–GLP-1 levels during tests (peroral □), gastric tube unadapted (GT1 +), gastric tube adapted (GT2 ×), peroral after reversion (POr ♦). ^# indicates the point where the PO test was stopped due to a serious episode of hypoglycaemia (2,0 mmol/l), necessitating iv. glucose injection.