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- [00:01]
A
Hello, I'm Aaron Lohr and this is the Endocrine News podcast. Bariatric surgery is a procedure used to manage obesity and obesity related conditions. While studies have shown bariatric surgery leads to significant weight loss, are there cases where it may be important to consider reversing the procedure? What would such cases look like? How effectively can bariatric surgery be reversed? To help us answer these questions, our guest today is Dr. Katherine Hazen. Dr. Hazen is second year endocrine fellow at the University of Rochester Medical center in New York and she presented an abstract at Endo 2025 entitled Going Backwards as a Means of Moving Severe Hypoglycemia after Bariat Surgery. Thank you for being here today.
- [01:01]
B
Hi Erin, thanks for having me. I'm really excited for the opportunity to share this case with you and the.
- [01:07]
A
Listeners and we're excited to hear about it. What is the connection between bariatric surgery and hypoglycemia?
- [01:15]
B
After bariatric surgery, there are a lot of changes in glycemic patterns that happen. The typical pattern that can be seen when it becomes a problem is a pattern of hypoglycemia after eating or postprandial or reactive hypoglycemia. Specifically, in studies looking at patients after Roux En y gastric bypass surgery, there's a greater variability in glucose levels with increased hyperglycemia and hypoglycemia, with hyperglycemia occurring after eating followed by a rapid drop in glucose levels resulting in hypoglycemia for some patients. And the studies have shown that hypoglycemia occurs more frequently and for longer durations compared to healthy individuals who haven't undergone bariatric surgery. Now, the underlying mechanism of how this happens is not completely understood. The initial explanation was that there was an increased number of beta cells or beta cell hyperplasia in the pancreas causing increased insulin secretion. However, looking back at some of the initial studies of this, this was a question that perhaps this is not the case. And as we've learned more, it's thought that perhaps more of this is related to anatomic changes after bariatric surgery that lead to changes in our gut hormones that respond to glucose and the changes in kinetics of glucose counter regulatory hormones like insulin, GLP1, GIP and then enhanced beta cell sensitivity to these hormones as well.
- [02:41]
A
And how is postprandial hypoglycemia after bariatric surgery generally managed? And does the severity of the hypoglycemia impact that management?
- [02:50]
B
Yeah, typical management. The cornerstone is usually we start with dietary modifications. We have our patients meet with registered dietitians and try to make changes to diet that can help with the hypoglycemia if it's more severe. Sometimes we'll also start with medication management at the outset with the dietary modifications, and then proceeding to surgical management would be the last resort. Usually. And the dietary modifications are usually eating multiple small meals per day, avoiding the large amounts of simple, rapidly absorbable carbohydrates and increasing fiber and protein content of meals. Medications can include acarbose, diazoxide, nifedipine, somatostatin analogs, and even GLP1 receptor agonists. And then along with that, we often have patients use continuous glucose monitoring to help alert to hypoglycemia before it happens, so they can intervene before it's severe and at higher risk for complications. And then surgical management, which could include bariatric surgery reversal. And then in the literature, there's also reports of partial pancreatectomy that comes up. But generally, generally this is not recommended as the initial approach to managing post bariatric surgery hypoglycemia.
- [04:06]
A
We've talked a little bit about bariatric surgery maybe being reversed, but how common or uncommon is that?
- [04:13]
B
It's fairly uncommon still to reverse. And looking at studies that report the rates of this, some report less than 0.1% of bariatric surgery cases being reversed. Others may range from 1 to 2% reversal, and most centers do report less than 5% reversal rates. And that's for all reasons for reversing. There's complications from bariatric surgery other than hypoglycemia, such as dumping syndrome, malnutrition, ulcers, chronic abdominal pain, as well as the hypoglycemia that could lead someone to consider bariatric surgery reversal.
- [04:47]
A
So let's jump into your case study. Can you tell us a little bit more about the patient in the study and how they presented?
- [04:52]
B
The patient that we presented had had bariatric surgery with a Roux en Y gastric bypass about 10 years prior to her presentation and more recently had had bariatric surgery revision to make a more restrictive anatomy because she wasn't reaching her weight loss goals. So instead of a Roux en Y proceeding to more of a biliopancreatic diversion duodenal switch type of bariatric surgery, and that was about a year and a half prior to her presentation, and then 19 months before we met the patient, they started to have postprandial hypoglycemia. And it was actually seen at another endocrinology practice and referred to our institution for consideration for a pancreatectomy because of how severe the symptoms were. They were having significant hypoglycemia and fear of hypoglycemia that was resulting in frequent emergency room visits, admissions, and significant fear of dying on the patient's end as well. So she'd had extensive workup with a primary endocrinologist outside our center, which included 72 hour fasts to exclude an insulinoma. And the patient did not develop fasting Hypoglycemia during multiple 72 hour fasts and had used CGM to help alert to hypoglycemia that was occurring.
- [06:09]
A
Can you tell us a little bit about some of the initial tests you ran and what you found?
- [06:13]
B
I mentioned before she came to us, she'd had some of this testing done already and that did include those 72 hour fasts. But also it had imaging of the pancreas with an MRI of the abdomen and a dotatate PET CT to look for an insulinoma or mass in the pancreas that might be contributing to this. And there was no mass found. And then on presentation to our institution, there was a calcium stimulation passed with pancreatic venous sampling done as well to try to determine if a region of the pancreas was producing excess insulin that might help guide a partial pancreatectomy procedure, as that's what the initial consultation at our institution was for. And it did show that there was some increased insulin secretion from the body and the tail of the pancreas, which could potentially be used as a target for a distal pancreatectomy.
- [07:01]
A
And can you tell us about some of the therapies used with the patient.
- [07:05]
B
And what happens prior to presentation? There was counseling on dietary modifications, as I discussed. That's the cornerstone of initial management, but that can be really challenging for patients for many reasons and not be effective as well. And so she was moved on to medical management fairly quickly, which included multiple medications. Unfortunately, she didn't tolerate a car, which is often our starting point for postpariatric surgery hypobothemia. But at the time of presentation to our institution was on diazoxide, verapamil, lanreotide and prednisone to help manage the hypoglycemia. Despite that, was still having symptomatic hypoglycemia.
- [07:48]
A
When did bariatric surgery reversal become a strong consideration?
- [07:53]
B
So during an admission Actually, when she was undergoing testing for consideration of a distal pancreatectomy, we reviewed the literature and found that there were reports of distal pancreatectomy not addressing the underlying cause of post bariatric surgery hypoglycemia. And I mentioned that the initial thought was that this was from increased beta cell mass or beta cell hyperplasia. But with the new data suggesting gut hormone changes were the driver and the altered anatomy was driving that, there was concern that removing part of the pancreas wouldn't address the underlying problem. And so bariatric surgery reversal was brought up as an option. And looking at the literature on this, although there's small numbers of patients, only around 100 patients reported with 50 that had undergone Roux en ligastric bypass, 88% of those that had reversal were able to have resolution of their post bariatric surgery hypoglycemia versus those that had a pancreatectomy. Only about 54% were able to have resolution of their symptoms. So at that point when we were considering the options, we thought that a bariatric surgery reversal would be the better approach to treating the underlying cause of her condition. And it required fair amount of shared decision making and interdisciplinary discussion to make sure we were making the best decision with this patient.
- [09:15]
A
And what did you find after the bariatric surgery reversal?
- [09:19]
B
Thankfully, the postoperative course was pretty uneventful and the patient did well without complications. That followed with our clinic a few months after. There was no recurrence of hypoglycemia and she was able to come off of medical management at that point.
- [09:33]
A
In this case, it worked out really well. But are there risks to bariatric surgery reversal?
- [09:38]
B
I'm not a bariatric surgeon, so I'll put that out there, but there are risks with the surgery and it's a little higher morbidity as a second bariatric surgery versus the primary surgery. There's not great standardizations of indications or techniques for reversal. And the reported complications include ileus, anastomotic leaks, abdominal pain, bleeding, infections, pneumonia, ulcers, portal vein thrombosis, dysphagia, and even death from these reversal procedures.
- [10:07]
A
So what should healthcare providers and patients do with this information? When should bariatric surgery reversal even be a consideration?
- [10:14]
B
I think the first step is always to consider other management prior to the surgical reversal. Even before that is ensuring you have an accurate diagnosis and ruling out other causes of hypoglycemia and confirming hypoglycemia is present. Working for dietary modifications. And as I mentioned, that can be really challenging. And then medical management is the next step. Using CGM and trying to use all those tools before you really consider surgical management and using that often as a last resort for very severe cases that don't respond to standard therapies. But it is a really individualized discussion to have with patients and to involve a real multidisciplinary disciplinary team including registered dietitians, endocrinologists, bariatric surgeons, and even if appropriate, pancreatic surgeons as well, and really assessing those risks and benefits and weighing those together to come up with the best individualized plan for the patient.
- [11:10]
A
Well said and I really appreciate you taking the time being on the podcast today. This was a fantastic, fascinating case to share those with some really good information. Thank you so much for taking the time.
- [11:20]
B
Yeah, thanks for having me.
- [11:23]
C
That's all for this episode. I hope you enjoyed hearing Dr. Hazen discuss her interesting case study on reversing bariatric surgery to manage hypoglycemia. Case studies can teach us quite a bit. In fact, the Endocrine Society just recently released its Endocrine self Assessment Program 2025 book. We call it ESAP. ESAP is a comprehensive learning tool that provides details, detailed case discussions, immediate feedback, and personalized progress tracking. ESAP lets you earn continuing medical education and maintenance of certification points and level up your knowledge to provide the highest quality care for your patients. If you're interested in ESAP 2025, we'll provide a link in today's episode description. We'll be back soon with another fascinating dive into the world of endocrinology. Until then, thanks for watching for listening.
- [12:16]
D
Endocrine News Podcasts are a free service of the Endocrine Society. To learn more or to become a member, visit the society's website at www.endocrine.org.