Combined laparoscopic Roux-en-Y gastric bypass reversal and gastric banding to treat severe hyperinsulinemic hypoglycemia: A case report and surgical video

Introduction: Non insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a recently described complication of Roux-en-Y gastric bypass (RYGB) characterised by pathologic features of nesidioblastosis and hyperinsulinemic hypoglycemias that can occur months to years after surgery. Increased incretin production appears to be one of the involved mechanisms. Currently, there is no Gold Standard treatment. Presentation of case: We present the case of a 57-year-old woman with a history of silastic ring vertical gastroplasty (SRVG) converted into RYGB who suffered from severe daily episodes of neuroglycopenia due to NIPHS, with poor response to conservative and medical treatments. At first, as it is suggested in recent literature, we decided to evaluate whether reversal would efficiently reduce episodes of hypoglycemia by attempting gastrostomy tubing of the remaining stomach. Since gastrostomy proved to be efficient, we reversed the RYGB laparoscopically and added a gastric banding to keep control over the patient's weight. After an asymptomatic period of two months, mild hypoglycemias recurred, on average once every three weeks, easily managed by sugar ingestion. A preexisting gastroparesis was worsened by the intervention, possibly caused by vagus nerve injury secondary to the multiple gastric procedures. A year later, the patient returned to a regular lifestyle. Her weight gain was limited to 8 kg thanks to appropriate adjustments of the gastric band. Discussion: Treatment of NIPHS includes appropriate diet, pharmacotherapy and surgical procedures; partial or total pancreatectomy, laparoscopic reversal of RYGB (with or without sleeve gastrectomy) and gastric banding have been proposed. This is the first described case of severe NIPHS after RYGB successfully treated with combined laparoscopic reversal of gastric bypass and gastric banding to avoid weight regain. Conclusions: We expect this novel approach will help to overcome hypoglycemic episodes from NIPHS, while maintaining weight control and preventing the resurgence of obesity-related comorbidities. Further studies with long term follow-up are necessary.