Department of Surgery, St Vincent Hospital, 8402 Harcourt Rd., Suite 815, Indianapolis, IN 46260, USA.
Surg Endosc. 2010 Oct;24(10):2547-55. doi: 10.1007/s00464-010-1001-6. Epub 2010 Mar 31.
Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition.
A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy.
Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but was converted to open in three. One patient had an open procedure from start to finish. Pathology showed changes compatible with nesidioblastosis with varying degrees of hyperplasia of islets and islet cells. Follow-up ranged from 8-54 (median, 22) months. All patients initially reported marked relief of symptoms. Over time, two patients had complete resolution of symptoms; three patients developed occasional symptoms (once or twice per month), which did not require any medication; two patients developed more frequent symptoms (more than twice per month), which were controlled with medications; and two patients had severe symptoms refractory to medical therapy (calcium channel blockers, diazoxide, octreotide).
Postprandial hypoglycemia after gastric bypass surgery with endogenous hyperinsulinemia is being increasingly recognized and reported in the literature. Our experience with nine patients is one of the largest. The etiology of this condition is not entirely understood. There may be yet unknown factors involved but increased secretion of glucagon-like peptide 1 and decreased grehlin are being implicated in islet cell hypertrophy. There is no "gold standard" treatment-medical or surgical-but distal pancreatectomy to debulk the hypertrophic islets and islet cells is the main surgical modality in patients with severe symptoms refractory to medical management.
胃旁路术后非胰岛素瘤性高胰岛素性胰源性低血糖症定义了一组具有类似于胰岛素瘤的餐后神经低血糖症状的患者，但在许多情况下更为严重。这种情况下的患者报告很少。我们描述了我们用于治疗这种罕见情况的手术经验。
印第安纳波利斯圣文森特医院进行了一项回顾性研究。2004 年至 2008 年期间，确定了 15 名患有胃旁路术后症状性低血糖的患者。所有患者最初均接受低血糖症的药物治疗。最终有 9 名患者接受了手术治疗。术前检查包括腹部三期对比 CT 扫描、胰腺内镜超声检查、72 小时禁食后混合餐试验和钙刺激选择性动脉造影。所有患者还进行了术中胰腺超声检查。然后，患者接受了彻底的腹部探查、整个胰腺探查和扩大的远端胰腺切除术。
9 名患者接受了手术。症状的平均持续时间为 14 个月。8 名患者（如预期的那样）72 小时禁食呈阴性。8 名患者的腹部三期对比 CT 扫描呈阴性，1 名患者的胰头显示囊肿。所有 9 名患者均进行了扩大的远端（80%）胰腺切除术。8 名患者尝试了腹腔镜手术，但其中 3 名转为开放性手术。1 名患者从始至终进行了开放性手术。病理显示与 nesidioblastosis 相符的变化，胰岛和胰岛细胞有不同程度的增生。随访时间为 8-54 个月（中位数 22 个月）。所有患者最初报告症状明显缓解。随着时间的推移，2 名患者症状完全缓解，3 名患者偶尔出现症状（每月 1-2 次），无需任何药物治疗；2 名患者出现更频繁的症状（每月超过 2 次），用药物控制；2 名患者出现药物治疗无效的严重症状（钙通道阻滞剂、二氮嗪、奥曲肽）。
胃旁路术后伴内源性高胰岛素血症的餐后低血糖症在文献中越来越受到认可和报道。我们对 9 名患者的经验是最大的之一。这种情况的病因尚不完全清楚。可能涉及尚未发现的因素，但胰高血糖素样肽 1 分泌增加和生长激素释放肽减少被认为与胰岛细胞肥大有关。没有“金标准”的治疗方法——药物或手术——但对于药物治疗无效的严重症状患者，远端胰腺切除术切除肥大的胰岛和胰岛细胞是主要的手术方式。
