key: cord-0012176-v81ma63j authors: Spanakis, Elias; Gragnoli, Claudia title: Successful Medical Management of Status Post-Roux-en-Y-Gastric-Bypass Hyperinsulinemic Hypoglycemia date: 2009-06-24 journal: Obes Surg DOI: 10.1007/s11695-009-9888-5 sha: add1a8259e205bc1c13870eade93f285d38bf927 doc_id: 12176 cord_uid: v81ma63j Roux-en-Y gastric bypass (RYGBP) is the most commonly performed type of bariatric surgery, which is used in the treatment of obesity and type 2 diabetes. Recent case reports and case series have described a rare complication of RYGBP, status post-gastric-bypass hyperinsulinemic hypoglycemia, which was mainly managed successfully with pancreatectomy. In this letter, we describe the first successful management of status post-gastric-bypass hyperinsulinemic hypoglycemia with diazoxide. described cause of hypoglycemia. Dietary modifications (i.e., frequent meals with low percentage of carbohydrates) had failed to improve her symptoms and also caused an unfavorable weight gain of 35 lb. Administration of diazoxide 50 mg twice a day was sufficient to control her symptoms and the patient remains symptom free 16 months after the administration of diazoxide. Attempts to stop diazoxide for at least 2 weeks resulted in the recurrence of hypoglycemia episodes. Post-gastric-bypass hyperinsulinemic hypoglycemia represents a rare complication of RYGBP and, as very few cases have been reported, the appropriate treatment of this condition is unknown. Successful management of this condition has been reported with dietary modifications [4, 5] . However, there is a growing tendency to treat these patients with pancreatic resection. Partial pancreatic resection (at least 75%) is often unsuccessful, necessitating a further total pancreatic resection [6, 8] . The end result of this approach is to cause iatrogenic diabetes, necessitating lifelong treatment with insulin. Diazoxide has been used in the treatment of this condition; however, the result has been up until today unsatisfactory [6] . Diazoxide (a specific adenosinetriphosphate-dependent potassium channel agonist of β cells) has been used successfully in the treatment of a similar condition in infants and children, the persistent hyperinsulinemic hypoglycemia of infancy [9] . Although this approach may not be always successful in the persistent hyperinsulinemic hypoglycemia of infancy, the recommended treatment is pharmacotherapy first (either with diazoxide, somatostatin analogs, or calcium channel blockers) and, if unsuccessful, the recommended treatment is surgery [9] . Recently, Moreira et al. reported the first successful case of management of post-gastric-bypass hyperinsulinemic hypoglycemia with verapamil and acarbose [10] . Others have reported successful management of post-gastricbypass hyperinsulinemic hypoglycemia with dietary modifications [4, 5] , raising the question of whether pancreatectomy should be the first line of treatment. Our letter may represent the second successful case using pharmacological measures; however, it is the first case which describes a successful outcome after 16 months of medical therapy with diazoxide. We would like to raise the following questions: is timing of post-gastric-bypass hyperinsulinemic hypoglycemia medical management relevant in order to obtain a positive patient answer to treatment? Is it possible that if the patient with post-gastric-bypass hyperinsulinemic hypoglycemia is treated promptly with diazoxide, she or he will more likely not need to undergo surgery? In other words, could a very prompt medical treatment with diazoxide prevent the need for surgery? And finally should pancreatectomy (either partial or total) be the first treatment option in patients with post-gastric-bypass hyperinsulinemic hypoglycemia? Bariatric surgery, safety and type 2 diabetes Gainesville: American Society of Bariatric Surgery Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery Symptomatic hypoglycemia complicating pregnancy following Roux-en-Y gastric bypass surgery Hyperinsulinemic hypoglycemia developing late after gastric bypass Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia Laparoscopic spleenpreserving distal pancreatectomy as treatment for nesidioblastosis after gastric bypass surgery Post-gastric bypass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglycemia Diagnosis and management of hyperinsulinaemic hypoglycaemia of infancy Post-prandial hypoglycemia after bariatric surgery: pharmacological treatment with verapamil and acarbose This study was made possible by the Penn State University Physician-Scientist Stimulus Award and by the Dean's Pilot and Feasibility Grant, number D1BTH06321-01, from the Office for the Advancement of Telehealth (OAT), Health Resources and Services Administration, DHHS. This project is funded, in part, under a grant from the Pennsylvania Department of Health using Tobacco Settlement Funds. The department specifically disclaims responsibility for any analyses, interpretations, or conclusions.Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.