Single anastomosis sleeve ileal (SASI) bypass combines sleeve gastrectomy with intestinal bipartition to promote weight loss and metabolic improvement. We conducted a systematic review and meta-analysis comparing SASI with sleeve gastrectomy (1 RCT and 4 non-randomized comparative studies (NRCTs)), one-anastomosis gastric bypass (2 RCTs, 4 NRCTs), and Roux-en-Y gastric bypass (2 NRCTs), regarding weight loss, metabolic and nutritional outcomes, and adverse effects. Certainty of evidence was assessed with GRADE for 1-year outcomes. Twenty-six studies (1603 patients) were included, mostly reporting 12-month results. Pooled single-arm analysis from 11 studies showed mean total weight loss of 35.9 kg (95

OBJECTIVE:Identifying the optimal metabolic bariatric surgery approach for patients with severe obesity with a BMI ≥50 kg/m2 remains challenging. The aim of this long-term follow-up of a randomized clinical trial (RCT) was to compare distal long alimentary limb Roux-en-Y gastric bypass (RYGB) with standard RYGB for 10-year weight loss and nutritional outcomes. METHOD:Secondary analysis of a 10-year follow-up of an RCT with initially 113 patients (BMI 50-60 kg/m2) randomized to either standard (n = 57, 50 cm biliopancreatic/150 cm alimentary limb) or distal long alimentary limb RYGB (n = 56, 50 cm biliopancreatic/150 cm common limb) from March 2011 to April 2013 at two Norwegian hospitals. The final data collection date was 15 August 2023. The primary focus was weight loss (BMI reduction, %total weight loss) and other secondary outcomes included cardiometabolic risk factors, nutritional status, and health-related quality of life (HRQOL). RESULTS:Of 113 patients, 79 (69.9%, mean age 50 (s.d. 8.7) years, 50 (63%) females) patients were available for 10-year follow-up (41 standard RYGB, 38 distal RYGB). The 10-year mortality rate was 3.5% (4/113) and all deaths occurred after distal RYGB. One death may have been associated with the surgery in a patient with previously undiagnosed liver cirrhosis at the time of operation. Mean BMI reduction from baseline was 12.0 kg/m2 (95% c.i., 10.8 to 13.2) after standard RYGB and 14.7 kg/m2 (95% c.i., 13.5 to 15.9) after distal RYGB with a between-group difference of 2.7 kg/m2 (95% c.i., 1.0 to 4.5, P = 0.002). The mean percentage total weight loss from baseline was 23.0% (95% c.i., 20.8 to 25.2) after standard RYGB and 28.2% (95% c.i., 26.0 to 30.5) after distal RYGB, with a between-group difference of 5.3% (95% c.i., 2.1 to 8.4, P = 0.001). The distal RYGB group had higher rates of malnutrition (1/57 standard versus 5/56 distal; P = 0.12), diarrhoea (7/57 standard versus 15/56 distal; P = 0.05), and vitamin D deficiency (24/41 standard versus 32/38 distal; P = 0.01). There were no differences between the groups in the prevalence of type 2 diabetes, hypertension, dyslipidaemia, or metabolic syndrome at 10-year follow-up. Four patients underwent revisional surgery due to malnutrition after distal RYGB. There were no statistically significant differences in HRQOL scores between the groups at 10 years (SF-36 physical 44.2 versus 44.1, mental 50.3 versus 47.3; OWLQOL 63 versus 61; all P > 0.2). CONCLUSIONS:Distal long alimentary limb RYGB resulted in greater weight loss after 10 years with a higher risk of malnutrition, diarrhoea, and vitamin D deficiency. TRIAL REGISTRATION:Clinicaltrials.gov NCT00821197.

Importance: Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce. Objective: To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60. Design, Setting, and Participants: This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023. InterventionsLaparoscopic RYGB or laparoscopic DS. Main Outcomes and Measures: The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life. Results: Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery. Conclusions and Relevance: In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60.

Objective Increasing numbers of pregnancies are complicated by pregestational diabetes mellitus, especially type 2 diabetes (T2DM). Some studies have reported similar or greater risks of adverse pregnancy outcomes among women with T2DM relative to type 1 diabetes (T1DM). We aimed to compare the risk of four pregnancy complications: pre-eclampsia, preterm delivery, macrosomia, and perinatal mortality, in pregnant women with T2DM vs T1DM in high-income countries.Design Systematic review with meta-analyses.Methods Systematic literature searches in Medline and Embase were performed. We included observational studies with original data of outcome occurrence in both women with pregestational T2DM and T1DM. Two researchers independently evaluated full-text studies for inclusion and assessed the risk of bias using the Newcastle-Ottawa scale. Finally, we performed four meta-analyses.Results We included 35 publications in total. Meta-analyses demonstrated that, compared to T1DM, T2DM was associated with a lower risk of pre-eclampsia (risk ratio (RR): 0.76; 95% CI: 0.68-0.85), preterm delivery (RR: 0.69; 95% CI: 0.62-0.77), and macrosomia (RR: 0.75; 95% CI: 0.60-0.94). Perinatal mortality was more likely in pregnancies with T2DM (RR: 1.26; 95% CI: 1.06-1.50).Conclusion A summation of the research literature demonstrated that, compared to T1DM, women with T2DM had a lower risk of pre-eclampsia, preterm delivery, and macrosomia, but a higher risk of perinatal mortality.Significance statement Our review of pregnant women with diabetes suggests a higher risk of perinatal mortality for cases with maternal type 2 diabetes, even though the risks of pre-eclampsia, preterm delivery, and macrosomia were higher in cases with type 1 diabetes. Hence, the prevention of the development of type 2 diabetes and focus on improved gestational and diabetic care could be beneficial for fetal health.

Abstract Background The optimal surgical weight loss procedure for patients with a BMI of 50 kg/m2 or more is uncertain. This study compared distal Roux-en-Y gastric bypass (RYGB) with standard RYGB. Methods In this double-blind RCT, patients aged 18–60 years with a BMI of 50–60 kg/m2 were allocated randomly to receive standard (150 cm alimentary, 50 cm biliopancreatic limb) or distal (150 cm common channel, 50 cm biliopancreatic limb) RYGB. The primary outcome (change in BMI at 2 years) has been reported previously. Secondary outcomes 5 years after surgery, such as weight loss, health-related quality of life, and nutritional outcomes are reported. Results Between May 2011 and April 2013, 123 patients were randomized, 113 received an intervention, and 92 attended 5-year follow-up. Mean age was 40 (95 per cent c.i. 38 to 41) years and 73 patients (65 per cent) were women; 57 underwent standard RYGB and 56 distal RYGB. BMI was reduced by 15.1 (95 per cent c.i. 13.9 to 16.2) kg/m2 after standard and 15.7 (14.5 to 16.9) kg/m2 after distal RYGB; the between-group difference was −0.64 (−2.3 to 1.0) kg/m2 (P = 0.447). Total cholesterol, low-density lipoprotein cholesterol, and haemoglobin A1c levels declined more after distal than after standard RYGB. High-density lipoprotein cholesterol levels increased more after standard RYGB. Vitamin A and vitamin D levels were lower after distal RYGB. Changes in bone mineral density, resting metabolic rate, and total energy intake were comparable. Conclusion Distal RYGB did not enable greater weight loss than standard RYGB. Differences in other outcomes favouring distal RYGB may not justify routine use of this procedure in patients with a BMI of 50–60 kg/m2. Registration number: NCT00821197 (http://www.clinicaltrials.gov). Presented in part as abstract to the IFSO (International Federation for the Surgery of Obesity and Metabolic disorders) conference, Madrid, Spain, August 2019.

Objective: To assess adherence to lipid lowering therapy (LLT), reasons for poor adherence, and achievement of LDL-C treatment goals in children and young adults with familial hypercholesterolemia (FH). Methods: Retrospective review of the medical records of 438 children that started follow-up at the Lipid Clinic, Oslo University hospital, between 1990 and 2010, and followed-up to the end of July 2019. Based on information on adherence to the LLT at the latest visit, patients were assigned to "good adherence" or "poor adherence" groups. Reasons for poor adherence were categorized as: "lack of motivation", "ran out of drugs", or "side effects". Results: Three hundred and seventy-one patients were included. Mean (SD) age and follow-up time at the latest visit was 24.0 (7.1) and 12.9 (6.7) years; 260 patients (70%, 95% CI: 65-74%) had "good adherence" and 111 (30%, 95% CI: 25-35%) had "poor adherence". "Lack of motivation" was the most common reason for poor adherence (n = 85, 23%). In patients with good adherence, compared to patients with poor adherence, age at latest visit (24.6 versus 22.0 years; p = 0.001), years of follow-up (13.5 versus 11.4 years; p = 0.003), and number of visits (8.1 versus 6.5 visits; p <0.001) were significantly higher, whereas LDL-C at the latest visit was lower, (3.1 (0.8) versus 5.3 (1.6) mmol/L; p <0.001) and percentage of patients reaching LDL-C treatment goal was higher, (34.5% versus 2.7%; p <0.001). Gender, BMI, age at first visit and premature cardiovascular disease in first degree relatives were not significantly associated with adherence. Conclusion: Thirty percent of young patients with FH had poor adherence to LLT, with lack of motivation as the main reason. Higher age, more visits and more years of follow-up were associated with good adherence.

BACKGROUND:Long-term evaluations 10 years after Roux-en-Y gastric bypass (RYGB) are limited. We report the development in weight and cardiovascular risk factors during 10 years after laparoscopic RYGB, with evaluation of gastrointestinal symptoms and quality of life (QoL) at 10-year follow-up.METHODS:We performed a prospective longitudinal cohort study. Patients operated with laparoscopic RYGB from May 2004 to November 2006 were invited to 10-year follow-up consultations. Gastrointestinal Symptom Rating Scale (GSRS) questionnaire and two QoL questionnaires were used for analyses of gastrointestinal symptoms and QoL.RESULTS:A total of 203 patients were operated; nine (4.4%) died during follow-up. Of 194 eligible patients, 124 (63.9%) attended 10-year follow-up consultations. Percent excess weight loss (%EWL) and percent total weight loss (%TWL) at 10 years were 53.0% and 24.1%, respectively. %EWL > 50% was seen in 53.2%. Significant weight regain (≥15%) from 2 to 10 years was seen in 63.3%. Remission rates of type 2 diabetes, dyslipidemia, and hypertension were 56.8%, 46.0%, and 41.4%, respectively. Abdominal operations beyond 30 days after RYGB were reported in 33.9%. Internal hernia and ileus (13.7%) and gallstone-related disease (9.7%) were the most common causes. Vitamin D deficiency (<50nmol/L) was seen in 33.3%. At 10 years, bothersome abdominal pain and indigestion symptoms (GSRS scores ≥3) were reported in 42.9% and 54.0%, respectively, and were associated with low QoL.CONCLUSION:We observed significant weight loss and remission of comorbidities 10 years after RYGB. Significant weight regain occurred in a substantial subset of patients. Gastrointestinal symptoms were common and negatively impacted QoL.

Background and Aims: Familial hypercholesterolemia (FH) is a genetic disorder with high low-density lipoprotein cholesterol and high risk of atherosclerotic cardiovascular disease. Early initiation of statin treatment is key to reduce later risk of disease. The transition period from adolescence to young adult has been shown to be a particular vulnerable period for FH children in terms of adherence to treatment. Aim: Investigate compliance to statin treatment among children and young adults with FH.

BACKGROUND:Bariatric surgery has been performed at Oslo University Hospital since 2004. We wished to describe patient characteristics, use of surgical methods and perioperative complications in the period 2004-14.MATERIAL AND METHOD:We performed a retrospective analysis of prospective data collected for the period 2004-14. Complications include events during hospitalisation and up to 6-8 weeks postoperatively.RESULTS:Altogether 2 127 patients underwent surgery for morbid obesity, whereof 1 468 were women. Average age and body mass index were 42 years (range 17-73) and 46.2 kg/m2 (range 26-92). A total of 512 had a body mass index ≥ 50 kg/m2. Obesity-related sequelae were registered in 1 196 patients before surgery. Gastric bypass was performed in 1 966 patients, gastric sleeve resection in 122 (17 of these later underwent duodenal switch) and duodenal switch in 56 patients. All patients were operated laparoscopically, and four procedures were converted to laparotomy. Median hospitalisation time was two days (range 1-78). Complications were registered in 209 patients, 75 of whom had severe complications (grade ≥ IIIb on the Clavien-Dindo classification system). Patients with a body mass index ≥ 50 kg/m2 had a higher incidence of complications (12.5 % vs 8.9 %). Altogether 67 patients underwent further surgery. Six patients died, two of whom more than 30 days after the operation. The incidence of complications was reduced during the period.INTERPRETATION:Bariatric surgery may be performed laparoscopically with a low incidence of complications and short hospitalisation times. A large proportion of the patients who underwent surgery had obesity-related sequalae.

Weight regain after bariatric surgery often starts after 1–2 y, but studies evaluating strategies to prevent weight regain are lacking. The aim of this intervention was to evaluate the efficacy of a 2-y-group-based lifestyle intervention starting approximately 2 y after Roux-en-Y gastric bypass (RYGB) compared with usual care on weight regain and related metabolic risk factors. A total of 165 patients with a mean of 21 months (range 14–32) after RYGB were randomized to a lifestyle intervention group (LIG) or a usual care group (UCG). Of the 165 participants 86% completed the study. The LIG was offered 16 group meetings over 2 y with focus on healthy diet, physical activity, and behavioural strategies to prevent weight regain, in addition to usual care. Mean (SD) total weight loss at study start was 30.1 ± 8.2%, while weight regain during the intervention was 4.9 ± 7.4 and 4.6 ± 9.2% in the LIG and UCG, respectively (P = 0.84). There were no differences in metabolic risk factors between the groups. The LIG participants attended 8 ± 4 group meetings, with no difference in weight regain between participants with high compared to lower participation. In all the participants, a positive association between weight increase from nadir to study start and weight regain during the intervention was found. Participants who reported physical activity ≥ 150 min/wk had smaller % weight regain compared with less active participants (β = − 5.2 [SE 2.0, 95% CI − 9.1 to − 1.4]). We found no difference in weight regain between LIG and UCG.

Standard Roux-en-Y gastric bypass (RYGB) may not ensure adequate weight loss or improvement of comorbidities in patients with body mass index (BMI) ≥50kg/m2. Objectives: Evaluate if distal RYGB (50cm biliopancreatic and 150cm common channel) improves BMI loss and remission of type 2 diabetes compared to standard RYGB (50cm biliopancreatic and 150cm alimentary limb) in patients with BMI 50-60kg/m2.

Roux-en-Y gastric bypass is associated with increased risk of bone fractures. Malabsorptive procedures may be associated with secondary hyperparathyroidism and detrimental effects on bone health. We aimed to compare the effects of standard and distal gastric bypass on bone turnover markers 2 years after surgery. Patients with body mass index (BMI) 50–60 kg/m2 (n = 113) were randomized to standard or distal gastric bypass, 105 patients (95%) completed 2-year follow-up. Serum C-terminal telopeptide of type I collagen (CTX-1), procollagen type I N-propeptide (PINP), and bone-derived alkaline phosphatase (BALP) was measured at baseline and up to 2 years after surgery. ANCOVA and linear mixed models were used to compare groups. The levels of bone turnover markers increased significantly in both groups, with no statistically significant difference between groups. Two years after standard and distal gastric bypass mean (SD) CTX-1 were 0.81 (0.32) and 0.83 (0.31) μg/L (p = 0.38), mean PINP was 77.6 (23.2) and 77.7 (29.3) μg/L (p = 0.42), and BALP 47.9 (21.9) vs. 50.7 (19.6) μg/L (p = 0.38), respectively. Multiple linear regression analyses showed that PINP and BALP correlated positively (p = 0.01 and p < 0.001) with PTH, but only BALP was significantly higher in patients with secondary hyperparathyroidism (p = 0.001). Type of surgery, vitamin D serum concentrations, and 2-year BMI were all independently associated with PTH levels. A comparable increase in bone turnover markers 2 years after standard and distal gastric bypass was observed. There was a higher prevalence of secondary hyperparathyroidism after distal gastric bypass, but this did not impact bone turnover markers. Clinical Trials.gov number NCT00821197.

The preferred surgical procedure for treating morbid obesity is debated. Patient-reported outcome measures (PROMs) are relevant for evaluation of the optimal bariatric procedure.

OBJECTIVES:Patients are at risk of anemia post Roux-en-Y gastric bypass (RYGB). We sought to determine the prevalence of anemia and related nutritional deficiencies 5 years after RYGB and to evaluate adherence to nutritional supplements with iron, vitamin B12, and folate.MATERIAL AND METHODS:Patients operated with RYGB 2004-2006 were eligible for evaluation. Blood samples were collected and use of nutritional supplements was recorded preoperatively, and at outpatients' consultations 1, 2, and 5 years postoperatively. Of 203 patients operated, 184 (91%) completed the 5 year follow-up and were included in the study. Of these, 97% had valid measurements of hemoglobin both at baseline and after 5 years.RESULTS:During the 5 years after RYGB, the prevalence of anemia increased from 4% preoperatively to 24% in females, and from 0% to 7% in males. Ferritin levels decreased gradually in both genders. Iron deficiency increased from 6% preoperatively to 42% at 5 years in females, and from 0% to 9% in males. Vitamin B12 deficiency was not altered while folate deficiency decreased from 10% preoperatively to 1% at 5 years. Five years after surgery 25% reported the use of supplements with iron, while 83% used vitamin B12 and 65% used multivitamins with folate.CONCLUSIONS:We observed a long-term increase in anemia and iron deficiency after RYGB in both genders, but most pronounced in women. Our postoperative protocol for prevention of vitamin B12 and folate deficiencies appear acceptable. Iron status and iron supplementation seems to need stronger emphasis during follow-up after RYGB.

Bariatric surgery may be associated with reduced bone density, osteoporosis and increased risk of fractures. Distal gastric bypass may increase the risk of bone loss even more due to malabsorption. We have previously shown an increased incidence of secondary hyperparathyroidism two years after distal gastric bypass as compared to standard gastric bypass. Whether these findings translate into increased risk of fractures remains unknown. Bone turnover markers are valid surrogate markers and predictors of future osteoporosis and bone fractures.

Mini abstract: Bile acids have been suggested as possible key mediators of the metabolic effects after bariatric surgery. With 5-year follow-up data from a randomized clinical trial, we compare bile acid profile after gastric bypass and duodenal switch, and explore the relationship between bile acids and weight loss, lipid profile and glucose metabolism. Abstract Background: Bile acids have been proposed as key mediators of the metabolic effects after bariatric surgery. Currently no reports on bile acid profiles after duodenal switch exist, and long-term data after gastric bypass are lacking. Objective: To investigate bile acid profiles up to 5 years after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch, and to explore the relationship between bile acids and weight loss, lipid profile and glucose metabolism. Methods: We present data from a randomized, clinical trial of 60 patients with body mass index 50–60 kg/m 2 operated with gastric bypass or duodenal switch. Repeated measurements of total and individual bile acids from fasting serum during 5 years after surgery were performed. Results: Mean concentrations of total bile acids increased from 2.3 µmol/L (95% CI, -0.1 to 4.7) at baseline to 5.9 µmol/L (3.5 to 8.3) 5 years after gastric bypass and from 1.0 µmol/L (95% CI, -1.4 to 3.5) to 9.5 µmol/L (95% CI, 7.1 to 11.9) after duodenal switch, mean between-group difference was -4.8 µmol/L (95% CI, -9.3 to -0.3), P=.036. Mean concentrations of primary bile acids increased more after duodenal switch, while secondary bile acids increased proportionally across the groups. Higher levels of total bile acids at 5 years were associated with lower body mass index, greater weight loss and lower total cholesterol. Conclusions: Total bile acid concentrations increased substantially over 5 years after both gastric bypass and duodenal switch, with greater increases in total and primary bile acids after duodenal switch.

ImportanceUp to one-third of patients undergoing bariatric surgery have a body mass index (BMI) of more than 50. Following standard gastric bypass, many of these patients still have a BMI greater than 40 after peak weight loss.ObjectiveTo assess the efficacy and safety of standard gastric bypass vs distal gastric bypass in patients with a BMI of 50 to 60.Design, Setting, and ParticipantsDouble-blind, randomized clinical parallel-group trial at 2 tertiary care centers in Norway (Oslo University Hospital and Vestfold Hospital Trust) between May 2011 and April 2013. The study included 113 patients with a BMI of 50 to 60 aged 20 to 60 years. The 2-year follow-up was completed in May 2015.InterventionsStandard gastric bypass (alimentary limb, 150 cm) and distal gastric bypass (common channel, 150 cm), both with a biliopancreatic limb of 50 cm and a gastric pouch of about 25 mL.Main Outcomes and MeasuresPrimary outcome was the change in BMI from baseline until 2 years after surgery. Secondary outcomes were cardiometabolic risk factors, nutritional outcomes, adverse events, gastrointestinal symptoms, and health-related quality of life.ResultsAt baseline, the mean age of the patients was 40 years (95% CI, 38-41 years), 65% were women, mean BMI was 53.5 (95% CI, 52.9-54.0), and mean weight was 158.8 kg (95% CI, 155.3-162.3 kg). The mean reduction in BMI was 17.8 (95% CI, 16.9-18.6) after standard gastric bypass and 17.2 (95% CI, 16.3-18.0) after distal gastric bypass, and the mean between-group difference was 0.6 (95% CI, -0.6 to 1.8; P = .32). Reductions in mean levels of total and low-density lipoprotein cholesterol were greater after distal gastric bypass than standard gastric bypass, and between-group differences were 19 mg/dL (95% CI, 11-27 mg/dL ) and 28 mg/dL (95% CI, 21 to 34 mg/dL), respectively (P < .001 for both). Reductions in fasting glucose levels and hemoglobin A1c were greater after distal gastric bypass. Secondary hyperparathyroidism and loose stools were more frequent after distal gastric bypass. The number of adverse events and changes in health-related quality of life did not differ between the groups. Importantly, 1 patient developed liver failure and 2 patients developed protein-caloric malnutrition treated by elongation of the common channel following distal gastric bypass.Conclusions and RelevanceDistal gastric bypass was not associated with a greater BMI reduction than standard gastric bypass 2 years after surgery. However, we observed different changes in cardiometabolic risk factors and nutritional markers between the groups.Trial RegistrationClinicaltrials.gov Identifier: NCT00821197.

BACKGROUND: We describe an evaluation of the effects of partial Roux-en-Y gastric bypass (RYGB) reversal on postprandial hyperinsulinaemic hypoglycaemia, insulin and GLP-1 levels.CASE SUMMARY: A 37 year old man was admitted with neuroglycopenia (plasma-glucose 1.6 mmol/l) 18 months after RYGB, with normal 72 h fasting test and abdominal CT. Despite dietary modifications and medical treatment, the hypoglycaemic episodes escalated in frequency. Feeding by a gastrostomy tube positioned in the gastric remnant did not prevent severe episodes of hypoglycaemia. A modified reversal of the RYGB was performed. Mixed meal tests were done perorally (PO), through the gastrostomy tube 1 (GT1), 4 weeks (GT2) after placement and 4 weeks after reversal (POr), with assessment of glucose, insulin and GLP-1 levels.RESULTS: Plasma-glucose increased to a maximum of 9.6, 5.4, 6.5 and 5.8 mmol/l at the PO, GT1, GT2 and POr tests respectively. The corresponding insulin levels were 2939, 731, 725 and 463 pmol/l. A decrease of plasma-glucose followed: 2.2, 3.0, 3.9 and 2.9 mmol/l respectively and insulin levels were suppressed at 150 min: 45, 22, 21 and 14 pmol/l, respectively. GLP-1 levels increased in the PO test (60 min: 122 pmol/l, 21 fold of basal), but was attenuated in the two latter tests (12-23 pmol/l at 60 min).CONCLUSIONS: Reduction of plasma-glucose, insulin and GLP-1 excursions and symptoms were seen after gastric tube placement and partial RYGB reversal. This attenuation of GLP-1 response to feeding could reflect an adaptation to nutrients. 2016 Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd.