The development of documented, severe hypoglycemic episodes after a Roux-en-Y gastric bypass (RYGB), albeit quite rare (<1%),[1,2] has become a neuroglycopenic syndrome that is of considerable interest to bariatric surgeons, bariatricians, and endocrinologists alike. The spectrum of symptoms was called reactive hypoglycemia, a syndrome seen all too often with the dumping syndrome.
Moreover, the current interest in the duodenopancreatic (hormonal) axis has increased the interest and the debate over the role of the proximal-most small bowel in control of glucose metabolism, the “incretin concept” of insulin release, and obesity itself. 1.    Should the bariatric surgeon “bypass” the duodenum and if so, how much should be bypassed? 2.    Is a limited duodenal bypass appropriate for patients with type 2 diabetes mellitus (T2DM) with only mild-to-moderate obesity? These concerns bring us to the ultimate question—How should we treat the patient who develops severe neuroglycopenic symptoms after RYGB? At the Mayo Clinic in Rochester, Minnesota, my colleagues and I encountered a patient with severe neuroglycopenic symptoms after a RYGB who had failed nonoperative treatment.
We reasoned that the best way to correct the reactive hypoglycemia was to restore the flow of ingested nutrients into the duodenum. At follow up four months postoperatively, her glycopenic symptoms gradually improved markedly (although not totally disappeared) and she did not gain weight.
Surprisingly and to the best of this author’s knowledge, this simple operation has not been described previously. This same procedure can be done in patients with the typical RYGB, and the “bypassed stomach” can remain intact and in situ.
In summary, for patients requiring operative “correction” of NIPHS after RYGB, using the proximal 20cm of the existing Roux limb to divert the ingested food back into the proximal duodenum should in theory reverse (over time) NIPHS. Why we Disagree: A Different Editorial of the Article “Weight Loss, Cardiovascular Risk Factors, and Quality of Life After Gastric Bypass and Duodenal Switch.


I will maintain that, indeed, we and especially our grey beards from the gastrectomy era (1940s–1980s) have had experience (in retrospect) with a similar side effect of the duodenal bypass obligated by gastrectomies with Roux-en-Y reconstruction. Currently, this control of glucose metabolism remains controversial and of considerable interest. But some patients defy all these attempts at nonoperative management, the symptoms are recalcitrant and the neuroglycopenic symptoms are prevalent, dangerous, and even potentially life threatening. Reports of these procedures are limited,[10] and long-term follow up concerning overall success and the timeline of resolution of hypoglycemic symptoms are lacking. The dilemma in this patient was that she had already undergone a revision of her original RYGB that included a gastrectomy of the bypassed stomach, and therefore, was not a candidate for restoration of normal esophagogastroduodenal anatomy nor for conversion to a sleeve gastrectomy. Restoration of duodenal flow of ingested nutrients has been the goal of prior described operations in an attempt to reverse the reactive hypoglycemia; reported results (all anecdotal) have been encouraging.
But one must be patient, because the reversal of the pancreatic islet dysfunction likely takes a significant amount of time. Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet. Nationwide cohort study of post-gastric bypass hypoglycemia including 5,040 patients undergoing surgery for obesity in 1986–2006 in Sweden.
Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS).
Use of diazoxide in management of severe postprandial hypoglycemia in patient after Roux-en-Y gastric bypass. Hypoglycaemia following upper gastrointestinal surgery: case report and review of the literature. Advances in the etiology and management of hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass.


Laparoscopic reconversion of Roux-en-Y gastric bypass to original anatomy: technique and preliminary outcomes.
Laparoscopic conversion of Roux-en-Y gastriC bypass to sleeve gastrectomy as first step of duodenalswitch: Technique and preliminary outcomes. Back then, however, the number of patients at risk was considerably less than the number of patients undergoing RYGB currently. To avoid a segment of defunctionalized jejunum, we took down the jejunojejunostomy and anastomosed the distal end of the original pancreatobiliary limb to the distal part of the transected Roux limb, thereby recovering full intestinal continuity.
Conversion to a sleeve gastrectomy has been considered in an attempt to maintain a bariatric anatomy. This procedure is faster and is technically much easier and safer than conversion to a sleeve gastrectomy or a subtotal pancreatectomy. This operative procedure preserved a weight-loss anatomy, as the patient did not want to regain weight, and restored flow of ingested food through the duodenum by an isolated, isoperistaltic jejunal limb (Henle limb).
Moreover, this procedure preserves a bariatric anatomy similar functionally to a sleeve gastrectomy. In addition, a jejunal feeding tube was placed as well to provide another potential therapeutic option to treat episodic hypoglycemia.



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