Impact of cholecystectomy in patients with post-bariatric hypoglycemia

Abstract

Introduction: Metabolic surgery stands as the foremost treatment for obesity and its associated comorbidities. Nonetheless, post-bariatric hypoglycemia (PBH) emerges as a prevalent complication. PBH pathophysiology implicates heightened insulin and glucagon-like peptide 1 (GLP-1) levels, with bile acids (BA) contributing to GLP-1 release. A plausible association exists between cholecystectomy and PBH, attributed to alterations in bile acids metabolism and ensuing hormonal responses. This retrospective cohort study aimed to evaluate the impact of cholecystectomy on PBH pharmacological treatment, diagnostic timelines, and metabolic parameters. Materials and methods: Patients diagnosed with PBH after bariatric surgery were evaluated based on their history of cholecystectomy. Demographic, anthropometric, and clinical data were collected. Mixed meal tolerance tests (MMTT) results were compiled to assess metabolic responses. Results: Of the 131 patients with PBH included in the study, 29 had prior cholecystectomy. The time to PBH diagnosis was similar across groups. Patients with prior cholecystectomy required higher doses of acarbose (p=0.046), compared to those without prior cholecystectomy. Additionally, MMTT revealed higher insulin (t=60 min: p=0.010 and t=90 min: p=0.034) and c-peptide levels (t=60 min: p=0.008) and greater glycemic variability in patients with prior cholecystectomy (p=0.049), highlighting the impact of cholecystectomy on glucose metabolism. Conclusion: Our study offers novel insights into PBH pharmacotherapy, indicating that PBH patients with a history of cholecystectomy need elevated doses of acarbose for symptom control, relatively PBH patients without such surgical history. Furthermore, our findings underscore the pivotal role of hyperinsulinism in PBH etiology, emphasizing the significance of the BA-GLP-1-insulin axis.