Correspondence

Asymptomatic Hyperinsulinemic Hypoglycemia after Gastric Banding

N Engl J Med 2005; 353:2822-2823December 29, 2005

Article

To the Editor:

Service et al. (July 21 issue)1 recently reported on six patients with hyperinsulinemic hypoglycemia and nesidioblastosis after Roux-en-Y gastric bypass surgery. The authors postulated that the rapid presentation of nutrients in the duodenum stimulated excessive secretion of glucagon-like peptide 1, leading to islet-cell hypertrophy, proliferation, and neogenesis. This report prompted us to review the incidence of hyperinsulinemic hypoglycemia after laparoscopic adjustable gastric banding (LAGB), the most common bariatric procedure performed in Europe. This procedure effectively achieves gastric restriction and a durable weight loss in obese patients without permanently altering the intestinal anatomy, improves insulin resistance, and prevents the development of type 2 diabetes mellitus and hypertension.2-4

We followed 221 patients who underwent LAGB for morbid (grade III) obesity (according to the classification system of the World Health Organization) and measured serum levels of glucose and insulin at 0 minutes and 120 minutes after administration of 75 g of glucose before surgery and at 6, 12, 18, 24, and 36 months after surgery. No patient had hyperinsulinemic hypoglycemia (serum glucose level, <55 mg per deciliter; serum insulin level, ≥3 μU per milliliter) 120 minutes after the ingestion of glucose before LAGB. During follow-up (433 patient-years), we recorded nine episodes of asymptomatic hyperinsulinemic hypoglycemia in eight patients (five women and three men, 23 to 47 years of age, none of whom were receiving insulin or sulfonylureas at the time of the episode) (Table 1Table 1Body-Mass Index and Metabolic Data Obtained before Laparoscopic Adjustable Gastric Banding and during Episodes of Hyperinsulinemic Hypoglycemia.). All episodes were recorded 120 minutes after glucose ingestion, and six episodes occurred within one year after the patient had undergone LAGB. Assessment according to the homeostatic model (fasting insulin [μU per milliliter]×fasting glucose [mM per liter]÷22.5) indicated a profound reduction in insulin resistance in all eight patients. In seven of them, no further episodes of asymptomatic hyperinsulinemic hypoglycemia occurred during the additional median follow-up period of 12 months (range, 12 to 30).

Our data show that transient asymptomatic hyperinsulinemic hypoglycemia occurs in 3 to 4 percent of patients after LAGB. We hypothesize that the substantial weight loss after this procedure markedly reduces insulin resistance in the context of beta-cell hypertrophy and hyperfunction that are commonly found in obesity.5 Further studies are needed to clarify the pathogenesis of transient hyperinsulinemic hypoglycemia after LAGB.

Marina Scavini, M.D., Ph.D.
Istituto Scientifico San Raffaele, 20132 Milan, Italy

Antonio E. Pontiroli, M.D.
Università degli Studi di Milano, 20100 Milan, Italy

Franco Folli, M.D., Ph.D.
University of Texas Health Science Center, San Antonio, TX 78229-3900
folli@uthscsa.edu

5 References

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   Pontiroli AE, Folli F, Paganelli M, et al. Laparoscopic gastric banding prevents type 2 diabetes and arterial hypertension and induces their remission in morbid obesity: a 4-year case-controlled study. Diabetes Care 2005;28:2703-2709
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   Kloppel G, Lohr M, Habich K, Oberholzer M, Heitz PU. Islet pathology and the pathogenesis of type 1 and type 2 diabetes mellitus revisited. Surv Synth Pathol Res 1985;4:110-125
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Citing Articles (17)

Citing Articles

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   Yunfeng Cui, Dariush Elahi, Dana K. Andersen. (2011) Advances in the Etiology and Management of Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass. Journal of Gastrointestinal Surgery 15:10, 1879-1888
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2. 2

   P. Ritz, H. Hanaire. (2011) Post-bypass hypoglycaemia: A review of current findings. Diabetes & Metabolism 37:4, 274-281
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   H. Ashrafian, T. Athanasiou, J. V. Li, M. Bueter, K. Ahmed, K. Nagpal, E. Holmes, A. Darzi, S. R. Bloom. (2011) Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. Obesity Reviews 12:5, e257-e272
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   Karen E Foster-Schubert. (2011) Hypoglycemia complicating bariatric surgery: incidence and mechanisms. Current Opinion in Endocrinology, Diabetes and Obesity 18:2, 129-133
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   Donald W. Richardson, Mary Elizabeth Mason, Aaron I. Vinik. (2011) Update: Metabolic and Cardiovascular Consequences of Bariatric Surgery. Endocrinology & Metabolism Clinics of North America 40:1, 81-96
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   Antonio E. Pontiroli, Donatella Gniuli, Geltrude Mingrone. (2010) Early Effects of Gastric Banding (LGB) and of Biliopancreatic Diversion (BPD) on Insulin Sensitivity and on Glucose and Insulin Response after OGTT. Obesity Surgery 20:4, 474-479
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   Prakash Seshadri, M. James Lenhard, Joseph Bennett, Isaias Irgau, Warren Butt. (2009) Rare case of insulinoma diagnosed after laparoscopic gastric banding. Surgery for Obesity and Related Diseases 5:1, 123-127
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   Feng Yang, Deliang Fu, Quanxing Ni. (2008) Hyperinsulinemic Hypoglycemia After Bariatric Surgery. The American Journal of Gastroenterology 103:4, 1047-1048
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   Feng Yang, Deliang Fu, Quanxing Ni. (2008) Hyperinsulinemic Hypoglycemia After Bariatric Surgery. The American Journal of Gastroenterology 0:0, 080326032705923-???
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    Pablo Abellán, Rosa Cámara, Juan Francisco Merino-Torres, Antonia Pérez-Lazaro, María Isabel del Olmo, José Luis Ponce, José Miguel Rayón, Francisco Piñón. (2008) Severe hypoglycemia after gastric bypass surgery for morbid obesity. Diabetes Research and Clinical Practice 79:1, e7-e9
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    Antonio E. Pontiroli. (2008) Surgical treatment of obesity: Impact on diabetes and other comorbidities. Nutrition, Metabolism and Cardiovascular Diseases 18:1, 1-6
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    Jeremy J. Heit. (2007) Calcineurin/NFAT signaling in the β-cell: From diabetes to new therapeutics. BioEssays 29:10, 1011-1021
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    Joseph R. Wax, Michael G. Pinette, Angelina Cartin, Jacquelyn Blackstone. (2007) Female Reproductive Issues Following Bariatric Surgery. Obstetrical & Gynecological Survey 62:9, 595-604
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    Joseph R. Wax, Deirdre Heersink, Michael G. Pinette, Angelina Cartin, Jacquelyn Blackstone. (2007) Symptomatic Hypoglycemia Complicating Pregnancy Following Roux-en-Y Gastric Bypass Surgery. Obesity Surgery 17:5, 698-700
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15. 15

    Franco Folli, Antonio E. Pontiroli, Wayne H. Schwesinger. (2007) Metabolic Aspects of Bariatric Surgery. Medical Clinics of North America 91:3, 393-414
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    Álvaro Larrad-Jiménez, Carlos Sánchez-Cabezudo Díaz-Guerra, Pedro de Cuadros Borrajo, Irene Bretón Lesmes, Basilio Moreno Esteban. (2007) Short-, Mid- and Long-Term Results of Larrad Biliopancreatic Diversion. Obesity Surgery 17:2, 202-210
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17. 17

    Allison B Goldfine, Edward Mun, Mary Elizabeth Patti. (2006) Hyperinsulinemic hypoglycemia following gastric bypass surgery for obesity. Current Opinion in Endocrinology and Diabetes 13:5, 419-424
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