Almanac of Clinical MedicineAlmanac of Clinical MedicineАльманах клинической медицины2072-05052587-9294Moscow Regional Research and Clinical Institute (MONIKI)150310.18786/2072-0505-2021-49-029REVIEW ARTICLEОБЗОРPostprandial hypoglycemia after upper gastrointestinal tract surgery: prevalence and pathophysiology (part 1)Постпрандиальные гипогликемии после оперативных вмешательств на верхних отделах желудочно-кишечного тракта: распространенность и патогенез (часть 1)https://orcid.org/0000-0002-8771-8300YukinaM. Yu.ЮкинаМ. Ю.
Russian Federation

Marina Yu. Yukina - MD, PhD, Leading Research Fellow, Department of Therapeutic Endocrinology.

11 Dm. Ul'yanovа ul., Moscow, 117036.

Tel.: +7 (495) 668 20 73.

Юкина Марина Юрьевна – кандидат медицинских наук, ведущий научный сотрудник отдела терапевтической эндокринологии.

117036, Москва, ул. Дм. Ульянова, 11.

Тел.: +7 (495) 668 20 73.

endo-yukina@yandex.ruhttps://orcid.org/0000-0002-7250-4588ChernovaM. O.ЧерноваМ. О.
Russian Federation

Maria O. Chernova – Resident.

11 Dm. Ul'yanovа ul., Moscow, 117036.

Чернова Мария Олеговна - ординатор по специальности «Эндокринология».

117036, Москва, ул. Дм. Ульянова, 11.

https://orcid.org/0000-0002-8520-8702TroshinaE. A.ТрошинаЕ. А.
Russian Federation

Ekaterina A. Troshina - MD, PhD, Professor, Corresponding Member of the Russian Academy of Sciences, Director of the Institute of Clinical Endocrinology.

11 Dm. Ul'yanovа ul., Moscow, 117036.

Трошина Екатерина Анатольевна – доктор медицинских наук, профессор, член-корреспондент РАН, директор Института клинической эндокринологии.

117036, Москва, ул. Дм. Ульянова, 11.

https://orcid.org/0000-0002-1339-4868EvdoshenkoV. V.ЕвдошенкоВ. В.
Russian Federation

Vladimir V. Evdoshenko - MD, PhD, Head of the Clinical Center for Surgery of Overweight and Metabolic Disorders, Institute of Plastic Surgery and Cosmetology; Professor, Chair of Experimental and Clinical Surgery, Biomedical Faculty, N.I. Pirogov Russian National Research Medical University.

27 Ol'khovskaya ul., Moscow, 105066; 1 Ostrovityanova ul., Moscow, 117997.

Евдошенко Владимир Викторович - доктор медицинских наук, руководитель Клинического центра хирургии лишнего веса и метаболических нарушений ИПХиК; профессор кафедры экспериментальной и клинической хирургии медико-биологического факультета РНИМУ им. Н.И. Пирогова.

105066, Москва, ул. Ольховская, 27; 117997, Москва, ул. Островитянова, 1.

https://orcid.org/0000-0001-6388-1544PlatonovaN. M.ПлатоноваН. М.
Russian Federation

Nadezhda M. Platonova - MD, PhD, Head of Department of Therapeutic Endocrinology.

11 Dm. Ul'yanovа ul., Moscow, 117036.

Платонова Надежда Михайловна - доктор медицинских наук, заведующая отделом терапевтической эндокринологии.

117036, Москва, ул. Дм. Ульянова, 11.

National Medical Research Center for EndocrinologyНациональный медицинский исследовательский центр эндокринологии Минздрава РоссииInstitute of Plastic Surgery and CosmetologyИнститут пластической хирургии и косметологииN.I. Pirogov Russian National Research Medical UniversityРоссийский национальный исследовательский медицинский университет имени Н.И. Пирогова Минздрава России271120214942852962106202121062021Copyright ©; 2021, Yukina M.Y., Chernova M.O., Troshina E.A., Evdoshenko V.V., Platonova N.M.Copyright ©; 2021, Юкина М.Ю., Чернова М.О., Трошина Е.А., Евдошенко В.В., Платонова Н.М.2021Yukina M.Y., Chernova M.O., Troshina E.A., Evdoshenko V.V., Platonova N.M.Юкина М.Ю., Чернова М.О., Трошина Е.А., Евдошенко В.В., Платонова Н.М.https://creativecommons.org/licenses/by/4.0https://almclinmed.ru/jour/article/view/1503

Nowadays obesity is a major health problem worldwide. Surgery is the most promising treatment for morbid obesity. There are two types of bariatric procedures, one to reduce the food intake volume and the other to limit the absorption of nutrients. Despite the indisputable advantages of bariatric surgery for weight loss, it is necessary to remember the potential risk of severe complications, such as hypoglycemic syndrome at 2 to 3 hours after ingestion of rapidly absorbable carbohydrates manifested by adrenergic and neuroglycopenic symptoms. According to the literature, the prevalence of post-bariatric postprandial hyperinsulinemic hypoglycemia (PHH) varies from 10% to 75%. PHH in post-bariatric patients should be differentiated from the syndrome of non-insulinoma pancreatogenic hypoglycemia and from insulinoma; however, these diseases are described also in patients after bariatric surgery.

The mechanisms of PHH as an outcome of shunting bariatric procedures are currently not fully clear. According to the recent studies, incretin hypersecretion in response to the accelerated flow of carbohydrates into the small intestine plays a leading role in the inappropriate excess production of insulin by the pancreas. In addition, there are hypotheses on a slower normalization of insulin production during more rapid bodyweight decrease and regression of insulin resistance, the role of alpha-cell dysfunction, disturbed negative feedback between insulin and ghrelin, compensatory hyperplasia and hypertrophy of the remaining enterocytes (including L-cells), changes in gut microflora, bile acids level and composition. A number of other mechanisms have also been proposed that require further studies.

В настоящее время ожирение представляет собой одну из главных проблем здравоохранения во всем мире. Оперативное вмешательство - наиболее перспективный метод лечения морбидного ожирения. Различают два варианта бариатрических операций: направленные на уменьшение объема потребления пищи и ограничивающие всасывание питательных веществ. На фоне неоспоримых преимуществ бариатрической хирургии в снижении веса следует помнить о потенциальном риске тяжелых осложнений, таких как развитие гипогликемического синдрома через 2-3 часа после приема легкоусвояемых углеводов с адренергическими и нейрогликопени-ческими симптомами. По данным источников, распространенность постбариатрических по-стпрандиальных гиперинсулинемических гипогликемий (ПГГ) варьирует от 10 до 75%. ПГГ у постбариатрических пациентов следует дифференцировать с синдромом неинсулиномной панкреатогенной гипогликемии и с инсулиномой, однако отметим, что случаи этих заболеваний описаны и у пациентов после бариатрических операций.

Механизмы развития ПГГ в исходе шунтирующих бариатрических операций на данный момент не ясны. Согласно последним исследованиям, ведущую роль в неадекватной избыточной выработке инсулина поджелудочной железой играет гиперсекреция инкретинов в ответ на ускоренное поступление углеводов в тонкую кишку. Существуют также предположения о более медленной нормализации выработки инсулина на фоне более быстрого снижения массы тела и регрессии инсулинорезистентности, роли дисфункции альфа-клеток, нарушении отрицательной связи между инсулином и грелином, компенсаторной гиперплазии и гипертрофии оставшихся энтероцитов (в том числе L-клеток), изменении характера кишечной микрофлоры, уровня и состава желчных кислот. Кроме того, предполагается ряд других механизмов, но они пока недостаточно хорошо изучены.

bariatric surgerygastric bypass surgerypostprandial hypoglycemiadumping syndromeinsulinбариатрические операциигастрошунтированиепостпрандиальные гипогликемиидемпинг-синдроминсулин1. 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