Asymptomatic Hyperinsulinemic Hypoglycemia after Gastric Banding
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《新英格兰医药杂志》
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.2,3,4
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 1). 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 xfasting glucose ÷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).
Table 1. Body-Mass Index and Metabolic Data Obtained before Laparoscopic Adjustable Gastric Banding and during Episodes of Hyperinsulinemic Hypoglycemia.
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
References
Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 2005;353:249-254.
DeMaria EJ, Jamal MK. Laparoscopic adjustable gastric banding: evolving clinical experience. Surg Clin North Am 2005;85:773-787.
Pontiroli AE, Pizzocri P, Librenti MC, et al. Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications: a three-year study. J Clin Endocrinol Metab 2002;87:3555-3561.
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.
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.
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 1). 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 xfasting glucose ÷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).
Table 1. Body-Mass Index and Metabolic Data Obtained before Laparoscopic Adjustable Gastric Banding and during Episodes of Hyperinsulinemic Hypoglycemia.
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
References
Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med 2005;353:249-254.
DeMaria EJ, Jamal MK. Laparoscopic adjustable gastric banding: evolving clinical experience. Surg Clin North Am 2005;85:773-787.
Pontiroli AE, Pizzocri P, Librenti MC, et al. Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications: a three-year study. J Clin Endocrinol Metab 2002;87:3555-3561.
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.
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.