SAT-702 Going Backwards as a Means of Moving Forward: Severe Hypoglycemia after Bariatric Surgery

Abstract Disclosure: K.S. Hazen: None. H. Han: None. F. Noor: None. H. Khan: None. D.R. Carpizo: None. J.A. Johnson: None. I. Harbuz-Miller: None. A. Zaman: None. Management of postprandial hypoglycemia after bariatric surgery includes dietary modification, medications, and, in severe cases, surgical reversal. Whether hypoglycemia in this situation is driven by altered anatomy versus beta-cell dysfunction is unclear. Pancreatectomy to treat possible beta cell hyperplasia has been proposed as a treatment but may not address the underlying anatomic changes driving hypoglycemia. Here we present a case of severe hypoglycemia after bariatric surgery in a 45-year-old female with a history of blindness from retinitis pigmentosa, renal cell carcinoma, obstructive sleep apnea, hypothalamic hypogonadism, polycystic ovarian syndrome, and obesity status post Roux-en-Y gastric bypass (RYGB) 10 years prior to presentation with revision to a more restrictive anatomy 1.5 years prior to presentation. Testing for genetic causes of obesity was pursued due to severe obesity, inadequate response to RYGB, hypogonadism, and blindness. A heterozygous variant in the VPS13B gene of uncertain clinical significance was found.Hypoglycemia was largely post-prandial but occurred with fasting at times as well. Despite three admissions for 72-hour fasts, hyperinsulinemic hypoglycemia was never established. Despite medical therapy with diazoxide, verapamil, prednisone, and lanreotide, symptomatic severe hypoglycemia persisted. MR abdomen did not show findings consistent with insulinoma. DOTATATE PET CT showed heterogeneity of radiotracer uptake activity in the distal mid pancreatic body without CT correlation. Calcium stimulation with pancreatic venous sampling showed increased insulin secretion from the body and tail of the pancreas, suggesting beta cell hyperplasia and a potential role for distal pancreatectomy. However, as there was concern for beta cell hyperplasia recurrence in remaining pancreas if the underlying cause—RYGB—was not addressed, the patient elected to undergo RYGB reversal. One month post-operatively, her blood glucose ranged from 80-100mg/dL. This case demonstrates the importance of considering bariatric surgery reversal as a management strategy for patients with severe, medication recalcitrant postprandial hypoglycemia prior to considering pancreatectomy. Small studies have shown that RYGB revision can improve hypoglycemia as well as postprandial glucose, insulin, and GLP-1 excursions. In contrast, partial pancreatectomy resolves hypoglycemia in approximately 60% of patients but carries risks including exocrine pancreatic insufficiency and insulin-dependent diabetes mellitus. A multidisciplinary discussion is essential to carefully weigh the risks and benefits of RYGB revision versus partial pancreatectomy. Presentation: Saturday, July 12, 2025