Endocrine News Podcast Episode 106: Reversing Bariatric Surgery
Date: November 12, 2025
Host: Aaron Lohr, Endocrine Society
Guest: Dr. Katherine Hazen, Endocrine Fellow, University of Rochester Medical Center

Episode Overview

This episode explores the rare, complex decision to reverse bariatric surgery, focusing on its role in treating severe postprandial hypoglycemia. Dr. Katherine Hazen shares insights from a remarkable case study she presented at Endo 2025—delving into diagnostic strategies, management pathways, risks, and the outcomes of reversal surgery after weight-loss procedures.

Key Discussion Points and Insights

1. Understanding Hypoglycemia after Bariatric Surgery

• Bariatric surgery, particularly Roux-en-Y gastric bypass, can cause significant changes in glucose regulation, leading to postprandial (after-eating) hypoglycemia.
• Mechanisms involved:
  • Earlier explanations focused on pancreatic beta cell hyperplasia (increase in insulin-secreting cells).
  • Newer insights point to anatomical changes affecting gut hormones (insulin, GLP1, GIP), and altered regulatory feedback.
  • These factors increase both hyperglycemia and hypoglycemia frequency and severity, with hypoglycemia persisting longer than in non-surgical patients.

  “It’s thought that perhaps more of this is related to anatomic changes after bariatric surgery that lead to changes in our gut hormones… and then enhanced beta cell sensitivity.” – Dr. Hazen [01:37]

2. Standard Management of Post-Bariatric Hypoglycemia

• First-line: Dietary modification—multiple small meals, minimizing simple sugars, increasing fiber and protein.
• Second line: Medication (acarbose, diazoxide, nifedipine, somatostatin analogs, GLP1 receptor agonists), often with continuous glucose monitoring (CGM) to preempt hypoglycemia.
• Final consideration: Surgical intervention, including reversal, reserved for refractory cases.

  “Surgical management, which could include bariatric surgery reversal… generally this is not recommended as the initial approach.” – Dr. Hazen [03:38]

3. Rarity and Indications for Bariatric Reversal

• Bariatric surgery reversal is uncommon:
  • Rates reported as <0.1% up to <5%, regardless of indication.
  • Indications: severe hypoglycemia, dumping syndrome, malnutrition, ulcers, chronic pain.

  “Some report less than 0.1% of bariatric surgery cases being reversed… most centers do report less than 5% reversal rates.” – Dr. Hazen [04:18]

4. Case Study: Severe Hypoglycemia after Multiple Bariatric Procedures

• Patient Background:
  • Underwent Roux-en-Y gastric bypass (~10 years prior), then a revision to biliopancreatic diversion/duodenal switch (1.5 years prior) for further weight loss.
  • Developed severe postprandial hypoglycemia 19 months before being seen.
• Symptoms:
  • Frequent, severe hypoglycemia after meals, ER visits, hospital admissions, significant anxiety.
• Initial Work-up:
  • 72-hour fasts (to exclude insulinoma): No fasting hypoglycemia.
  • Imaging (MRI, dotatate PET-CT): No pancreatic mass.
  • Calcium stimulation test: Mildly increased insulin from body/tail, target for surgery.

  “They were having significant hypoglycemia and fear of hypoglycemia that was resulting in frequent emergency room visits… fear of dying on the patient’s end as well.” – Dr. Hazen [05:31]

5. Intensified Medical Management and Failure

• Multiple medications trialed (acarbose—intolerant, diazoxide, verapamil, lanreotide, prednisone) failed to control hypoglycemia.

  “Despite that, was still having symptomatic hypoglycemia.” – Dr. Hazen [07:45]

6. Decision-Making: Pancreatectomy vs. Reversal

• Distal pancreatectomy considered initially due to mild increased insulin from body/tail.
• Literature review:
  • Pancreatectomy leads to symptom resolution in ~54% of cases.
  • Bariatric reversal leads to symptom resolution in ~88% of reported Roux-en-Y cases.
  • Etiology now believed to be driven by gut hormone changes due to altered anatomy, not pancreatic cell growth.
• Shared decision-making with interdisciplinary team led to reversal.

  “There was concern that removing part of the pancreas wouldn’t address the underlying problem… a bariatric surgery reversal would be the better approach.” – Dr. Hazen [08:13]

7. Outcome and Risks

• Successful reversal:
  • Uneventful recovery, no recurrence of hypoglycemia, off medical therapy.

  “There was no recurrence of hypoglycemia and she was able to come off of medical management at that point.” – Dr. Hazen [09:25]

• Risks of reversal:
  • More technically challenging than primary surgery.
  • Complications: ileus, leaks, pain, bleeding, infections, pneumonia, ulcers, thrombosis, dysphagia, and death.

  “There are risks with the surgery and it’s a little higher morbidity as a second bariatric surgery versus the primary surgery.” – Dr. Hazen [09:40]

8. Clinical Pearls and Recommendations

• Reversal should be last resort, after confirmatory workup and failed dietary/medical management.
• Essential to use a multidisciplinary team (dietitian, endocrinologist, bariatric/pancreatic surgeon).

  “It is a really individualized discussion to have with patients and to involve a real multidisciplinary team.” – Dr. Hazen [10:56]

Notable Quotes & Memorable Moments

• “It’s thought that perhaps more of this is related to anatomic changes after bariatric surgery that lead to changes in our gut hormones… and then enhanced beta cell sensitivity.”
  — Dr. Hazen [01:37]

• “They were having significant hypoglycemia and fear of hypoglycemia that was resulting in frequent emergency room visits… fear of dying on the patient’s end as well.”
  — Dr. Hazen [05:31]

• “Despite that, was still having symptomatic hypoglycemia.”
  — Dr. Hazen [07:45]

• “There was concern that removing part of the pancreas wouldn’t address the underlying problem… a bariatric surgery reversal would be the better approach.”
  — Dr. Hazen [08:13]

• “There was no recurrence of hypoglycemia and she was able to come off of medical management at that point.”
  — Dr. Hazen [09:25]

• “There are risks with the surgery and it’s a little higher morbidity as a second bariatric surgery versus the primary surgery.”
  — Dr. Hazen [09:40]

• “It is a really individualized discussion to have with patients and to involve a real multidisciplinary team.”
  — Dr. Hazen [10:56]

Important Timestamps

• Bariatric surgery & hypoglycemia mechanism: [01:14]
• Management hierarchy: [02:49]
• Rarity of reversal: [04:12]
• Case presentation: [04:52]
• Diagnostic work-up: [06:13]
• Medical (failed) management: [07:05]
• Decision for reversal: [07:52]
• Post-reversal outcome: [09:19]
• Risks of reversal: [09:37]
• Clinical summary/advice: [10:14]

Conclusion

This episode offers a comprehensive, real-world look into the rare scenario where bariatric surgery must be reversed due to life-altering hypoglycemia. Dr. Hazen’s case illustrates the critical importance of detailed diagnosis, stepwise management, shared decision-making, and multidisciplinary care. The case underscores that while reversal is rarely needed and carries significant risks, it can restore health and quality of life in select, refractory cases.