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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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ASMBS position statement on the relationship between obesity and cancer, and the role of bariatric surgery: risk, timing of treatment, effects on disease biology, and qualification for surgery. Surg Obes Relat Dis 2020; 16:713-724. [DOI: 10.1016/j.soard.2020.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
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Morano WF, Shaikh MF, Gleeson EM, Galvez A, Khalili M, Lieb J, Renza-Stingone EP, Bowne WB. Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review. World J Surg Oncol 2018; 16:168. [PMID: 30103758 PMCID: PMC6090772 DOI: 10.1186/s12957-018-1467-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Obesity is a risk factor for pancreatic cancer which may be treated with Roux-en-Y gastric bypass and represents an increasing morbidity. Post-RYGB anatomy poses considerable challenges for reconstruction after pancreaticoduodenectomy (PD), a growing problem encountered by surgeons. We characterize specific strategies used for post-PD reconstruction in the RYGB patient. METHODS PubMed search was performed using MeSH terms "Gastric Bypass" and "Pancreaticoduodenectomy" between 2000 and 2018. Articles reporting cases of pancreaticoduodenectomy in post-RYGB patients were included and systematically reviewed for this study. RESULTS Three case reports and five case series (25 patients) addressed PD after RYGB; we report one additional case. The typical post-gastric bypass PD patient is a woman in the sixth decade of life, presenting most commonly with pain (69.2%) and/or jaundice (53.8%), median 5 years after RYGB. Five post-PD reconstructive options are reported. Among these, the gastric remnant was resected in 18 cases (69.2%), with reconstruction of biliopancreatic drainage most commonly achieved using the distal jejunal segment of the pre-existing biliopancreatic limb (73.1%). Similarly, in the eight cases where the gastric remnant was spared (30.8%), drainage was most commonly performed using the distal jejunal segment of the biliopancreatic limb (50%). Among the 17 cases reporting follow-up data, median was 27 months. CONCLUSION Reconstruction options after PD in the post-RYGB patient focus on resection or preservation gastric remnant, as well as creation of new biliopancreatic limb. Insufficient data exists to make recommendations regarding the optimal reconstruction option, yet surgeons must prepare for the possible clinical challenge. PD reconstruction post-RYGB requires evaluation through prospective studies.
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Affiliation(s)
- William F. Morano
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Mohammad F. Shaikh
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Elizabeth M. Gleeson
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - Alvaro Galvez
- Division of Minimally Invasive Surgery, Department of Surgery, Drexel University College of Medicine, 245 N. 15th St, Suite 7150, Philadelphia, PA 19102 USA
| | - Marian Khalili
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
| | - John Lieb
- Division of Gastroenterology & Hepatology, Department of Medicine, Drexel University College of Medicine, 219 N Broad St, 5th Floor, Philadelphia, PA 19107 USA
| | - Elizabeth P. Renza-Stingone
- Division of Minimally Invasive Surgery, Department of Surgery, Drexel University College of Medicine, 245 N. 15th St, Suite 7150, Philadelphia, PA 19102 USA
| | - Wilbur B. Bowne
- Division of Surgical Oncology, Department of Surgery, Drexel University College of Medicine, 245 N. 15th Street, Suite 7150, Philadelphia, PA 19102 USA
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Shah MM, Martin BM, Stetler JL, Patel AD, Davis SS, Sarmiento JM, Lin E. Reconstruction Options for Pancreaticoduodenectomy in Patients with Prior Roux-en-Y Gastric Bypass. J Laparoendosc Adv Surg Tech A 2017; 27:1185-1191. [PMID: 28609220 DOI: 10.1089/lap.2017.0192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with prior Roux-en-Y gastric bypass (RYGB) operations for weight loss present reconstruction challenges during a pancreaticoduodenectomy (PD). With over 60,000 RYGB performed annually, the increasing odds of encountering such patients during a PD make it imperative to understand the RYGB anatomy and anticipate reconstruction options. This article describes the possible reconstruction options and their rationale. METHODS We reviewed our PD reconstruction options, compared them to what have been described in the literature, and derived a consensus from internal conferences comprising bariatric and hepatopancreatobiliary surgeons to describe known reconstruction options. RESULTS In general, reconstruction options can include one of three options: (1) remnant gastrectomy, (2) preservation of gastric remnant, or (3) reversal of gastric bypass. CONCLUSION This article describes individualized reconstruction options for RYGB patients undergoing PD. The reconstruction options can be tailored to the needs of the patient.
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Affiliation(s)
- Mihir M Shah
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - Benjamin M Martin
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - Jamil L Stetler
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - Ankit D Patel
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - S Scott Davis
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - Juan M Sarmiento
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
| | - Edward Lin
- Emory Endosurgery Unit, Division of Gastrointestinal and General Surgery, Emory University , Atlanta, Georgia
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van Beek AP, Emous M, Laville M, Tack J. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev 2017; 18:68-85. [PMID: 27749997 DOI: 10.1111/obr.12467] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1-3 h after carbohydrate ingestion, caused by an incretin-driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome. METHODS A systematic literature review was performed through February 2016. Evidence-based medicine was used to develop diagnostic and management strategies for dumping syndrome. RESULTS Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom-based questionnaires, glycemia measurements and oral glucose tolerance tests. First-line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re-intervention or continuous enteral feeding may be necessary for treatment-refractory dumping syndrome, but outcomes are variable. CONCLUSIONS Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.
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Affiliation(s)
- A P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - M Laville
- European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France
| | - J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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Younan G, Tsai S, Evans DB, Christians KK. A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It. J Gastrointest Surg 2017; 21:1186-1191. [PMID: 28447199 PMCID: PMC5486682 DOI: 10.1007/s11605-017-3405-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.
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Affiliation(s)
- George Younan
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Susan Tsai
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Douglas B. Evans
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Kathleen K. Christians
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
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Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis 2014; 10:1220-5. [PMID: 25002326 DOI: 10.1016/j.soard.2014.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/09/2014] [Accepted: 01/14/2014] [Indexed: 12/15/2022]
Abstract
An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.
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Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
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Body mass index and outcomes from pancreatic resection: a review and meta-analysis. J Gastrointest Surg 2011; 15:1633-42. [PMID: 21484490 DOI: 10.1007/s11605-011-1502-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/23/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There are 1.6 billion adults worldwide who are overweight, with body mass indices (BMI) between 25 and 30, while more than 400 million are obese (BMI >30). Obesity predicts the incidence of and poor outcomes from pancreatic cancer. Obesity has also been linked to surgical complications in pancreatectomy, including increased length of hospital stay, surgical infections, blood loss, and decreased survival. However, BMI's impact on many complications following pancreatectomy remains controversial. METHODS We performed a MEDLINE search of all combinations of "BMI" with "pancreatectomy," "pancreatoduodenectomy," or "pancreaticoduodenectomy." From included studies, we created pooled and weighted estimates for quantitative and qualitative outcomes. We used the PRISMA criteria to ensure this project's validity. RESULTS Our primary cohort included 2,736 patients with BMI <30, 1,682 with BMI >25, and 546 with BMI between 25 and 30. Most outcomes showed no definitive differences across BMIs. Pancreatic fistula (PF) rates ranged from 4.7% to 31.0%, and four studies found multivariate association between BMI and PF (range odds ratio 1.6-4.2). Pooled analyses of PF by BMI showed significant association (p < 0.05). CONCLUSION BMI increases the operative complexity of pancreatectomy. However, with aggressive peri- and post-operative care, increases in BMI-associated morbidity and mortality may be mitigated.
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Pedrazzoli S, Canton SA, Sperti C. Duodenum-preserving versus pylorus-preserving pancreatic head resection for benign and premalignant lesions. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 18:94-102. [PMID: 20694480 DOI: 10.1007/s00534-010-0317-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Sergio Pedrazzoli
- Department of Medical and Surgical Sciences, IV Surgical Clinic; University of Padova; Ospedale Giustinianeo, Via Giustiniani 2 35128 Padua Italy
| | - Silvio Alen Canton
- Department of Medical and Surgical Sciences, IV Surgical Clinic; University of Padova; Ospedale Giustinianeo, Via Giustiniani 2 35128 Padua Italy
| | - Cosimo Sperti
- Department of Medical and Surgical Sciences, IV Surgical Clinic; University of Padova; Ospedale Giustinianeo, Via Giustiniani 2 35128 Padua Italy
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de la Cruz-Muñoz N, Hartnett S, Sleeman D. Laparoscopic pancreatoduodenectomy after laparoscopic gastric bypass. Surg Obes Relat Dis 2010; 7:326-7. [PMID: 20678970 DOI: 10.1016/j.soard.2010.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 06/02/2010] [Accepted: 06/02/2010] [Indexed: 11/29/2022]
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