lNTRODUCTlON

The obesity pandemic has become a great topic of interest due to its implications for quality of life,comorbidities, increasing mortality, and the economic impact on health services worldwide[1]. Bariatric surgery (BS) is an effective and durable treatment for severe obesity and glucose metabolism disorders,with laparoscopic Roux-Y gastric bypass surgery (RYGB) being the most common procedure[2,3].Nevertheless, laparoscopic sleeve gastrectomy (LSG) has been proposed as a procedure capable of achieving the same goals, but with fewer complications[4].

A common complication in BS is the development of a postprandial hyperinsulinemic hypoglycemic state[5]. Hypoglycemia is defined as a glucose level below 70 mg/dL according to the American Diabetes Association guidelines[6]. The possible causes of hypoglycemia in patients who had undergone BS include late dumping syndrome, nesidioblastosis and, rarely, insulinoma[5,7]. Up to 40 cases of nesidioblastosis have been reported after RYGB, and only one case has been reported after sleeve gastrectomy[8,9]. To our knowledge, there are few reports of insulinoma after BS[10] but no reports after LSG. The purpose of these case reports is to inform clinicians that patients with neuroglycopenic symptoms during the fasting state could have hypoglycemia caused by insulinoma, which is not only due to late dumping syndrome.

座椅處振動的均方根值較大,使得駕駛室的駕乘舒適性較差.將此測點處降噪后的信號進行頻響分析,找出該處的振動特性.通過將其進行快速傅立葉變換(Fast Fourier Transformation,FFT)后,得出座椅處的頻響特性,如圖10所示.由圖10可得座椅處在4種不同車速下,其主要振動頻段在0～10 Hz的范圍內(nèi),剛好與人體敏感頻段重疊.故該類礦用自卸車在任何速度下的駕乘舒適性均不太理想,且車速為30 km/h時的舒適性最差.因此,后續(xù)需要對車輛的簧載懸架系統(tǒng)、駕駛室懸置系統(tǒng)和座椅減振系統(tǒng)進行優(yōu)化,以降低振動幅度提升駕乘舒適性.

CASE PRESENTATlON

Chief complaints

A 43-year-old woman was referred to the obesity clinic due to neuroglycopenic symptoms caused by an insulinoma 2 years after a sleeve gastrectomy.

記錄傳統(tǒng)形心算法和窗寬自適應形心修正算法對同一波形的仿真結果，再將其與真值的差作為誤差.仿真基于10 ns脈沖寬度，ADC采樣率為2G SPS，ADC的量化輸入范圍是0～400 mV，兩種算法對飽和度在50%～1 000%的波形在不同的信噪比(Signal-to-Noise Ratio, SNR)條件下分別進行5 000次仿真，分析算法的精度，統(tǒng)計在不同飽和度和SNR條件下的最大誤差，SNR指ADC輸入量化范圍和噪聲比值.

History of present illness

Hypoglycemia is a well-documented complication after BS. Papamargaritis[12,13] recorded a study where 33% of patients experienced severe hypoglycemia a year after LSG due to late dumping symptomswhich usually occurs 1-3 h after a high-carbohydrate meal triggering a hyperinsulinemic response. Since 2005, up to 40 cases of nesidioblastosis after RYGB have been reported[8], and only one case after LSG was documented in 2019 by Kim[9]. While rare, insulinomas have been reported after BS. Mulla[10] described seven cases of insulinoma, one patient with pancreatic neuroendocrine tumor, and one patient with insulinoma and pancreatic neuroendocrine tumor after BS, 78% of whom were women. In these cases, hypoglycemia was more common in the fasting state.

History of past illness

The patient had no specific personal or family history.

Personal and family history

In 2002, the patient was diagnosed with obesity and dyslipidemia (high triglycerides and cholesterol with low HDL) and treated with improvements in diet, physical activity, and statins without weight control. In 2016, a gastric balloon was placed, and although her body mass index (BMI) in 2018 was 34.4 kg/m, LSG was performed.

對相同變量進行訪問的過程中，對線程進行并行執(zhí)行時，若線程A賦值變量X的過程中，線程B應對該變量數(shù)值進行讀取，線程A沒有賦值變量X時，B無法對數(shù)值進行讀取，怎樣解決這樣的問題？由此針對訪問變量X的方式，需要借助syn?chronized關鍵詞進行一定的修飾。該方式一旦被線程A所調(diào)用，其余線程就要經(jīng)歷等待的過程，線程A結束之后即可運用[5]。同步方式就是借助synchronized進行說明，在設計多線程程序中有著廣泛的應用，能夠確保單個線程在相同時間對方法進行訪問，將線程間的同步變?yōu)榱爽F(xiàn)實。協(xié)商、共享不同資源的關鍵就在于同步。

出口去向方面,中國甘薯出口目標市場集中度非常高．ITC官方網(wǎng)站公布的數(shù)據(jù)顯示,2017年我國甘薯出口的主要市場包括中國香港,占中國甘薯出口額總量的85%以上，如表3所示．

Physical examination

After LSG, the patient weighed 74 kg, and her BMI was 32 kg/m. The physical examination showed no obvious cardiovascular or respiratory abnormalities. The abdomen was soft, and the only sign was the presence of postsurgery scars.

Laboratory examinations

Upon hospitalization prior to the surgery, the patient’s hemoglobin A1c level was 4.8% (normal range: ＜5.7%). The C-peptide value was normal at 3.64 ng/mL (1.1-4.4 ng/mL), and insulin was mildly elevated at 16.40 μUI/mL (3.21-16.30 μUI/mL). Lipid levels indicated dyslipidemia with total cholesterol of 224 mg/dL and LDL-c of 142.8 mg/dL. Other biochemical parameters were normal and only an iron deficiency anemia was documented. Thyroid function was normal, with TSH 2.46 μUI/mL (0.27-4.20 μUI/mL), FT41.06 ng/dL (0.93-1.70 ng/dL), and cortisol level 15.04 ug/dL (3.70-19.40 μg/dL), all within the normal range.

Imaging examinations

Histopathological findings revealed a well-differentiated neuroendocrine grade 2 tumor with free edges. Immunohistochemical studies confirmed positive chromogranin and synaptophysin as well as a proliferative activity (Ki67) in 4% of neoplastic cells.

An increase in ghrelin levels has been observed a year after BS[15]. Ghrelin and the type 1a ghrelin receptor (GHS-R1A) are expressed in different types of neuroendocrine tumors. Recently, Wu[16]found that GHS-R1a was found in 60% of insulinomas, suggesting that ghrelin may act through autocrine or paracrine pathways. The proliferative effects of ghrelin and its association with insulinoma have not been studied, although there is a clinical case report where a ghrelin-producing neuroendocrine tumor was transformed into an insulinoma[17].

洋桔梗適合的土壤EC值為1.0～1.3[1]。栽苗后第10 d可施第1次肥，以濃度約為0.1%～0.2%的高磷肥為主，以促進植株根系的生長；生長前期主要施用高N肥，如N∶P∶K=30∶10∶10的水溶肥促進葉片、莖稈生長；在中期每隔10 d左右施用1次平衡肥，如N∶P∶K=20∶20∶20的水溶肥或N∶P∶K=17∶17∶17的復合肥；大約定植后50 d生長到第7節(jié)位時，進入花蕾期要施高鉀肥，如K2SO4；中后期土壤施肥的同時要結合葉面肥，如KH2PO4噴施，每隔7 d噴1次。在花芽形成前隨著苗正常生長而慢慢上調(diào)肥料EC值。

FlNAL DlAGNOSlS

The final diagnosis was insulinoma. This was confirmed by histology and immunohistochemistry of the tumor (Figure 2).

TREATMENT

After a surgery consultation, a laparoscopic insulinoma enucleation was performed without complications. No other tumors were identified in the upper abdomen.

1.1 資料來源 選取2016年1-12月在德陽市人民醫(yī)院門診進行體檢的健康學齡前兒童1 452例為研究對象，經(jīng)血常規(guī)檢查確診，排除其他類型的貧血、其他疾病導致的貧血、合并感染、肝腎功能不全、心腦血管疾病、內(nèi)分泌疾病、1個月內(nèi)無消化道或呼吸道感染、3個月內(nèi)使用過糖皮質(zhì)激素及免疫制劑者、正在接受缺鐵性貧血治療者。所有研究對象均為健康體檢兒童，非因疾病原因接受檢查。研究對象男815例，女637例；年齡6個月～6歲，平均 (3.14±0.57)歲，其中<1歲378例、1～3歲595例、4～6歲479例。本研究經(jīng)醫(yī)院倫理委員會批準，所有研究對象家屬對本研究知情并簽署知情同意書。

OUTCOME AND FOLLOW-UP

Computed tomography (CT) demonstrated the presence of a focal asymmetric reinforcement area in the head of the pancreas (Figure 1A). Endoscopic ultrasound showed the presence of a tumoral lesion in the pancreas in close proximity to the main pancreatic duct and splenomesenteric confluence without evidence of invasion (Figure 1B and C).

After surgery, the neuroglycopenic symptoms were relieved, and the patient had no hypoglycemic events. Her current treatment is diet and physical activity, targeting a BMI of 31.1 kg/m.

DlSCUSSlON

Since 2013, 468609 BSs have been performed worldwide[2]. LSG was initially introduced as a first-stage restrictive procedure to a more complex definitive one. At present, it is performed as a stand-alone BS[7]. Since 2008, the prevalence of the LSG procedure has increased from 5% to 37% worldwide[2], but in Mexico, it is performed only in 13% of patients, whereas LRYGB is performed in 85.8%, with a bypass/sleeve ratio of 7:1. In our center, LSG accounts for 20% of total BSs (200 procedures since 2010).

LSG comprises vertical longitudinal resection of the greater gastric curve that includes the fundus,body, and antrum as well as the formation of a tubular conduit with a capacity of ＜ 100 mL. Weight loss is achieved by restrictive and humoral effects[8,11].

In March 2020, 2 years after LSG was performed, the patient developed neuroglycopenic symptoms including short-term memory loss, lingual nerve paresthesia, and nonspecific visual alterations predominantly during the morning in a fasting state. These symptoms were suppressed with food intake. Two months later, she visited a physician who documented fasting plasma glucose of 27 mg/dL, and in June 2020, the symptoms occurred more frequently, and she gained 14 kg. In the beginning, late dumping symptoms were suspected, but in September 2020, fasting plasma glucose of 30 mg/dL was documented, so she was hospitalized for the evaluation of hypoglycemia in a 72-h supervised fast test. She had baseline plasma glucose of 67 mg/dL, nonsuppressed insulin of 16.4 IU/mL, and C-peptide of 3.64 ng/mL. In the first hour after initiation, she developed Whipple’s triad symptoms, and her lab results detected plasma glucose of 38 mg/dL, insulin of 25.9 IU/mL, and C-peptide of 4.31 ng/mL. Thus, it was decided to stop the protocol and initiate 1000 mL of 20% glucose solution in 12 h.

最后，我深情地對大家說，其實，我們在北大的出路非常多，機會非常多，你可以選擇通過成人高考進入北大學習，或就讀北大網(wǎng)絡教育學院以及各種專題培訓班，學習結束后便可獲得北大畢業(yè)證書或相關證明。

The mechanism of the post-BS hyperinsulinemic hypoglycemic state and the changes in beta cell proliferation are not fully understood. In the LSG, the faster transit of undigested nutrients to the distal gastrointestinal tract due to rapid gastric emptying upregulates the production of GLP-1 secreted by enteroendocrine L cells in the distal intestine. This increase can normalize blood glucose and regulate insulin synthesis and proinsulin gene expression, as well as glucagon and somatostatin secretion[3].GLP-1 has multiple beneficial effects on β cells, including an increase in their number by inhibiting apoptosis and enhancing neogenesis as well as promoting its proliferation. In a study carried out in 2016 by Xu[14], it was found that a chemically modified GLP-1 (mGLP-1) analog promotes the proliferation of pancreatic mouse β cells, upregulating the expression of cyclin E, CDK2, Bcl-2, Bax, and p21.The cyclin E-CDK2 complex plays an important role in the regulation of the G1 phase of the G1/S cell cycle, while p21 is a universal cyclin-dependent kinase (CKI) inhibitor. Meanwhile, the-andgenes, two important members of the-gene family, have opposite functions, inhibiting or promoting cell apoptosis, respectively[14].

4.4 構建傳播力是武術對外教材“走出去”的必要措施傳播力，實質(zhì)就是實現(xiàn)有效傳播的能力[6]。教材“走出去”的關鍵，實際上就是要提升自身的有效傳播能力。當前，對于中國武術對外教材“走出去”戰(zhàn)略的實現(xiàn)，最重要的就是構建自身的傳播力，讓其具備強硬的競爭實力，才能走的更加長遠。

The diagnosis of hypoglycemia after BS is challenging. The first step after identifying the presence of symptoms is to verify their relationship to hypoglycemia. A detailed clinical history must be performed to identify family or personal history of neuroendocrine tumors, if patients are taking any hypoglycemic medication such as sulfonylureas or if the symptoms are more common in fasting state, as in our case.

In a stepwise manner, biochemical analysis must be performed to rule out other causes[18]. Plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and cortisol levels should be measured.The development of provocative studies such as a 72-h fasting test is also recommended[10,18]. The goal is to determine whether beta-cell peptides are appropriately suppressed during hypoglycemia. If autonomous insulin secretion is identified, insulinoma should be suspected[10,18]. The next step is to determine the anatomical localization and to exclude other tumors. Multidetector contrast-enhanced imaging CT or dual phase helical CT with thin sections are the preferred initial imaging options. In patients in whom noninvasive radiologic techniques are negative or to improve the sensitivity for identifying an insulinoma, endoscopic ultrasound (EUS) must be performed. EUS has 80%-92%sensitivity for detecting tumors as small as 5 mm. Additionally, EUS-guided fine needle aspiration allows pathologic confirmation in 57% of patients. If the techniques mentioned above fail to detect the tumor, selective arteriography and intra-arterial calcium stimulation tests with hepatic venous sampling can be performed. They should be used only as a last resort because they are invasive techniques[5,10].In our case, we performed CT and EUS that allowed us to identify insulinoma.

Finally, histopathologic and immunohistochemical confirmation is necessary to classify the type of tumor and to determine the patient’s follow-up[19].

The definitive treatment for insulinoma comprises complete surgical resection. However, there are other treatment options such as octreotide or EUS-guided alcohol tumor ablation, radiofrequency ablation (RFA), or embolization[20]. There is superior short-term recovery, shorter length of stay,decreased hemorrhage, and improved cosmesis when performing minimally invasive pancreatic resection compared to open pancreatic surgery[10]. However, the technique used depends on the size,extension, localization, and type of lesion. Atypical resection, including enucleation and partial or middle pancreatectomy, has the advantage of pancreatic parenchyma preservation, thereby reducing the risk of late exocrine and/or endocrine insufficiency[20]. As in the case of our patient, when the lesion was small, benign, solitary, and superficial and when the pancreatic duct was not involved, the best surgical approach was laparoscopic enucleation[21]. It is important to note that positive resection margins are not associated with increased recurrence rates[10].

CONCLUSlON

This is the first case of insulinoma after sleeve gastrectomy. Although this is a very rare case, clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state.

FOOTNOTES

Lobaton-Ginsberg M participated in the conception and design of the report and wrote the paper; Sotelo-González MP made substantial contributions to the acquisition, analysis, and interpretation of the patient data and helped write the paper; Juárez-Aguilar FG performed the histopathological and immunohistochemical report; Ramírez-Rentería C and Ferreira-Hermosillo A were involved in the coordination and design of the report and the revision of the manuscript; all authors read and approved the final manuscript.

Informed written consent was obtained from the patient for the publication of this report and any accompanying images.

The authors declare that they have no conflict of interest to disclose.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Mexico

Miry Lobaton-Ginsberg 0000-0001-8227-087X; Pilar Sotelo-González 0000-0002-4132-5093; Claudia Ramirez-Renteria 0000-0003-3025-8339; Fany Gabriela Juárez-Aguilar 0000-0002-6204-3677; Aldo Ferreira-Hermosillo 0000-0002-5159-9856.

Chen YL

Wang TQ

Chen YL