111 Management of Refractory Severe Hypoglycaemia Post Roux-en-Y Gastric Bypass Surgery- a Case Report

Abstract Aim To highlight the treatment challenges and to establish a management algorithm for refractory severe hypoglycaemia following gastric bypass surgery. The dietary, medical and surgical interventions performed will be discussed. Method A 33-year-old male underwent a Roux-en-Y gastric bypass in 2021 for severe obesity (BMI 57) and type 2 diabetes. Two years post operatively, signs of malnourishment developed (lost 62% body weight) alongside post prandial hypoglycaemia. An insulinoma was excluded and late dumping syndrome was diagnosed. Dietetic intervention included high protein and low carbohydrate diet. Nasojejunal feeding and total parenteral nutrition were also used. No benefit was observed; therefore, a series of medical therapies were trialled including Acarbose, Dulaglutide, Octreotide, Canagliflozin and Diazoxide with no improvement of symptoms. Robotic assisted reversal of the bypass was subsequently performed with immediate resolution of hypoglycaemic episodes. Results After ascertaining sufficient small bowel common limb length (over 4 metres), excision of the gastro-jejunostomy and old alimentary limb was performed. A partially stapled gastro-gastric anastomosis was performed to restore conventional anatomy. Post operatively, immediate cessation of hypoglycaemia was observed after introducing diet. Conclusions Post gastric bypass hypoglycaemia can be challenging to treat and often requires a multidisciplinary team approach to manage. After exhausting all non-surgical measures, robotic assisted gastric bypass reversal is a feasible intervention to treat the condition and restore quality of life. Our findings support the literature regarding a move away from performing high risk partial pancreatectomies.