When gastric bypass fails: revisiting anatomy with the Branco-Zorron switch for severe PHH: a case report

Postprandial hyperinsulinemic hypoglycemia (PHH) is a significant, rare complication following Roux-en-Y gastric bypass (RYGB). Management is challenging in patients with complex revisional surgical histories, where conservative treatments often fail. This case highlights the need for individualized surgical solutions for severe, refractory PHH in this unique patient population.

We present a 71-year-old woman with a history of a sleeve gastrectomy revised to an RYGB, who developed debilitating hypoglycemic episodes refractory to conservative management. An oral glucose tolerance test (OGTT) yielded results consistent with PHH, revealing a paradoxical glucose drop with an exaggerated insulin and C-peptide response.

Given her complex anatomy and atypical, low-volume gastric remnant consisting primarily of the antrum, a laparoscopic Branco-Zorron switch was performed to restore pyloric function and delay gastric emptying. Postoperatively, the patient experienced sustained resolution of her hypoglycemic symptoms, accompanied by positive weight gain and high satisfaction. Her recovery was complicated by an intra-abdominal abscess, which was successfully managed conservatively.

The Branco-Zorron switch is a promising surgical option for severe, refractory PHH, particularly in patients with complex post-bariatric anatomies. This case underscores the efficacy of tailored reconstructive approaches when standard treatments fail and emphasizes the need for vigilant postoperative care. Despite the limitations of a single case report, this outcome supports considering the procedure for carefully selected patients.