Seizures and epilepsy after bariatric surgery: a systematic review of incidence, mechanisms, and management

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Seizures are clinically important because they carry significant morbidity and are often associated with reversible metabolic triggers. This systematic review synthesized evidence on seizures and epilepsy following bariatric surgery. PubMed, Embase, and Web of Science were searched from inception to January 11, 2025. Nineteen studies were included: three retrospective cohort studies and sixteen case reports. Roux-en-Y gastric bypass accounted for most reported cases, with one case following sleeve gastrectomy. Time from surgery to first seizure ranged from 2 to 180 months. Generalized tonic–clonic seizures were most common. Reported causes were mainly metabolic, particularly hypoglycemia and hyperammonemia, with additional cases linked to hypocalcemia, vitamin deficiencies, and stroke. Cohort data suggest an increased postoperative risk of seizures and epilepsy. Further research is needed to clarify mechanisms and absolute risk. Bariatric surgery Roux-en-Y gastric bypass Seizures Epilepsy Figures Figure 1 Figure 2 1. Introduction Obesity is a global health concern, with a prevalence increasing at an alarming rate -almost tripling since 1975- which poses a significant public health challenge [ 1 , 2 ].This complex medical condition extends beyond an aesthetic or lifestyle matter; it is a significant risk factor for a multitude of health problems, including cardiovascular diseases, diabetes, and mental health disorders [ 3 ]. In response to this epidemic, bariatric surgery has been increasingly adopted as an effective intervention, resulting in a significant weight reduction and management of obesity-related medical conditions [ 4 , 5 ]. Roux-en-Y gastric bypass and gastric sleeve are two of the most common bariatric surgeries, and they have shown consistent results and successful long-term weight-loss outcomes [ 6 ]. Nevertheless, these surgeries are not without potential complications, including effects on neurological health. The effects of obesity on neurological health have been well documented and explored in the literature [ 7 , 8 ]. Several studies have assessed the association between neurological complications and bariatric surgery. A review by Zafar et al. reported complications such as encephalopathy, behavioral and psychiatric disorders, myelopathy, and optic neuropathy [ 9 ]. A study by Antaya et al. focused on the seizure risk following bariatric surgery and found increased rates of seizures in post-bariatric surgery patients compared to a non-surgical obese cohort [ 10 ]. The mechanisms through which bariatric surgery may influence neurological health, particularly the risk of seizures, are complex and multifactorial. Some possible hypotheses include changes in nutrient absorption, hormonal fluctuations, and alterations in gut-brain axis communication, but these pathways have yet to be definitively established [ 11 , 12 ]. The relationship between bariatric surgery and seizures remains incompletely characterized, and the existing literature is scattered across observational studies and isolated case reports. Important clinical questions remain unanswered, including the magnitude of risk, the timing of onset, the most frequent etiologies, and the effectiveness of medical and procedural management strategies. Therefore, this systematic review aims to synthesize available evidence on seizures and epilepsy following bariatric surgery by summarizing incidence estimates, describing clinical characteristics and attributable causes, and outlining management approaches and outcomes from the available literature. 2. Methodology This study was conducted according to the Cochrane Handbook for Systematic Reviews and the PRISMA guidelines [ 13 , 14 ]. The study was registered on PROSPERO. 2.1 Eligibility Criteria To be considered for inclusion, the following study designs were eligible: case reports, case series, cross-sectional, case-control, cohort, and randomized controlled trials (RCTs) in any language. Our study included patients of any age, gender, or race who underwent any of the following bariatric surgeries: Roux-en-Y gastric bypass, Sleeve gastrectomy, Biliopancreatic diversion with duodenal switch (BPD/DS), or single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S). We excluded studies with duplicated data and secondary articles. In addition, studies focusing on measuring the effect of bariatric surgery on pre-diagnosed epileptic participants were excluded. 2.2 Information Sources We performed a primary search for eligible studies published up to 11 January 2025 selecting studies from three main databases: PubMed, Embase, and Web of Science. Furthermore, we surveyed the reference lists of all included studies and searched Google Scholar to identify any additional eligible records. 2.3 Search Strategy Our search strategy was based on keywords related to bariatric surgery and seizures. A draft search strategy was developed to identify additional keywords. Applicable studies were identified by searching for keywords in titles, abstracts, and subject indexing. The PubReMiner word-frequency analysis tool was used to expand our keywords. Three relevant studies were selected to validate our search strategy. We tested whether our search strategy could identify the pre-selected studies. The keywords search strategy was then employed in PubMed, Embase, and Web of Science and successfully identified the pre-selected three studies (see Supplementary file 1, Table S1 ). 2.4 Selection Process Records retrieved from the three databases were imported into Mendeley, where duplicates were removed using software and manual verification. Study selection was performed in three stages: title screening, abstract screening, and full-text review. Titles and abstracts were double-screened by four reviewers, and full texts were assessed by all reviewers using predefined exclusion criteria (non-bariatric, non-seizure outcomes, pre-existing epilepsy/anti-seizure medication use, non-primary studies, and non-human studies). Disagreements were resolved through discussion, with input from the first and last authors when needed. 2.5 Data Collection Process and Data Items Data extraction was designed to address the review objectives and covered three domains: (1) study characteristics and participant details (authors, country, design, sample size, age, sex, comorbidities); (2) surgical and perioperative data (procedure type, prior bariatric surgery, and relevant laboratory findings); and (3) postoperative outcomes and complications, with emphasis on seizures/epilepsy and related metabolic or nutritional disturbances (e.g., hypoglycemia, vitamin and mineral deficiencies), as well as other short- and long-term complications. The standardized extraction sheet was piloted on three eligible studies and refined before independent data extraction from the remaining included studies. 2.6 Risk of Bias Assessment To assess the risk of bias in the included studies, the Joanna Briggs Institute (JBI) risk of bias assessment tool was used [ 15 , 16 ]. By using the appraisal checklists, we aimed to assess the methodological rigor of each included study and determine how effectively it addressed potential bias in its planning, execution, and analytical processes. Then, studies were further classified according to the JBI checklist evaluation as low-, intermediate-, or high-risk of bias, based on positive answers of ≥ 75%, < 75%, ≥ 50%, and < 50%, respectively. Two reviewers independently appraised all included studies in a blind manner; any disagreements were resolved by discussion or consultation with the first author when necessary. 2.7 Data synthesis plan Due to expected clinical and methodological heterogeneity, we performed a narrative synthesis supported by descriptive analyses [ 13 ]. Cohort studies were summarized using the most adjusted effect estimates, including hazard ratios (HRs), risk ratios (RRs), or odds ratios (ORs), with 95% confidence intervals (95% CIs) and absolute measures (e.g., incidence) when available. Case reports were synthesized by tabulating surgery type, time to seizure, seizure phenotype, suspected cause, key laboratory findings, and management, and reporting results as counts and proportions, along with appropriate summary statistics. Meta-analysis was not feasible because comparative studies were insufficiently homogeneous, and publication bias assessment was not performed, given the limited number of comparative studies and the inclusion of case reports [ 13 ]. 3. Results 3.1 Study Selection Figure 1 outlines the search and selection process using a PRISMA flow diagram. This process focused on identifying studies examining the association between bariatric surgery and seizure outcomes, using 3 databases. Initially, 10,507 records were identified; only 19 studies met the inclusion criteria and were included in our review [ 10 , 17 – 34 ]. 3.2 Risk of Bias Risk of bias varied across included studies. Among 16 case reports, 12 were judged low risk, 3 intermediate risk, and 1 high risk, mainly due to incomplete reporting of clinical details and interventions, and to unclear causality (Fig. 2 A). For the three cohort studies, one was low risk, one intermediate, and one high risk, largely related to limited clarity in exposure and outcome measurement (Fig. 2 B). For details of the risk of bias for each study, see (Supplementary File A, Table S2, S3). 3.3 Study Characteristics Table 1 summarizes the baseline characteristics of the 19 included studies (3 retrospective cohorts and 16 case reports), reporting study design, country, demographics, and sample size. Studies were conducted across multiple countries (including Canada, Sweden, Ireland, Germany, the UK, Belgium, Qatar, Brazil, and the USA), with variable age reporting and a predominance of female participants in both cohorts and case reports. Sample sizes ranged from large population-based cohorts (e.g., 16,958 cases) to single-patient case reports. Table 1 Baseline characteristics of included studies and reported management Author (Year) Country Study design Age (years) Sex / Male % Sample size (Control; Cases) Management / definitive treatment (reported) Antaya (2022) [ 10 ] Canada Retrospective cohort ≥ 18 NA (622,514; 16,958) Not reported Woods et al. (2011) [ 17 ] Ireland Retrospective cohort NA 31.7% (0; 163) Surgical reversal and conversion to sleeve gastrectomy (n = 2) Marsk et al. (2010) [ 18 ] Sweden Retrospective cohort 41.0 ± 10.1 (23.5%; 23.5%) (50,400; 5,040) Not reported Holländer (2023) [ 19 ] Germany Case report 38 Male NA Laparoscopic restoration of normal food passage (complex reconstructive procedure) Kim et al. (2022) [ 20 ] UK Case report 49 Female NA Distal pancreatectomy + splenectomy; small bowel resection of blind Roux limb; acarbose 50 mg with meals; reversal/modification discussed but refused Sedano et al. (2022) [ 21 ] Belgium Case report 39 Female NA Parenteral nutritional supplementation + antiseizure meds (ASM); ASM stopped after 10 months McManus et al. (2021) [ 22 ] USA Case report 45 Female NA Dietary modification + acarbose 100 mg TID Farahmand (2020) [ 23 ] USA Case report 39 Female NA Dietary modification + acarbose + diazoxide El Sheikh (2020) [ 24 ] Qatar Case report 23 Female NA Seizure control (sedation/intubation/antiepileptics) + lactulose + normal saline infusion Conaty et al. (2019) [ 25 ] USA Case report NA Female NA Endoscopic gastrojejunal revision (EGJR) Tornincasa et al. (2018) [ 26 ] Brazil Case report 28 Female NA Gastric bypass reversal + calcium replacement Brown (2018) [ 27 ] USA Case report 45 Female NA Acarbose + octreotide + diazoxide ± exenatide Grogg (2018) [ 28 ] USA Case report 45 Female NA Lactulose + rifaximin + low-protein parenteral diet; lorazepam Atla (2015) [ 29 ] USA Case report 46 Male NA Diazoxide Hahn (2015) [ 30 ] USA Case report 41 Female NA Specialized diet (Cyclinex-2 + citrulline), phenobarbital, dialysis, sodium benzoate/phenylacetate (Ammonul) Rao et al. (2014) [ 31 ] USA Case report 58 Male NA Stepwise escalation: diet → acarbose/octreotide/diazoxide → endoscopic stomal reduction → laparoscopic RYGB reversal (resolved symptoms) Lee et al. (2011) [ 32 ] USA Case report (2 subjects) 35 Female NA Subject 1: diet failed → RYGB reversal (7 yrs). Subject 2: diet/meds failed → distal pancreatectomy (3 yrs) → RYGB reversal (5 yrs) with improvement Choi (2004) [ 33 ] USA Case report 18 Female NA Antiplatelet therapy + rehabilitation (post-bariatric stroke context) Salvado et al. (2000) [ 34 ] Spain Case report 31 Female NA Intramuscular thiamine NA: Not available; USA: United States of America 3.4 Results of Individual Studies Table 2 provides a comprehensive summary of surgical outcomes, seizure characteristics, and relevant lab results from 16 included case reports and 3 cohort studies. The majority of cases (15 out of 16) are associated with Roux-en-Y gastric bypass (RYGB) surgery, with one report linked to gastric sleeve surgery. Interestingly, one case reported a seizure resulting from RYGB after sleeve gastrectomy, highlighting a unique scenario ( post-gastric sleeve RYGB seizure). Table 2 Surgery and seizure characteristics in the included case reports Type of surgery Time since surgery (months) Seizure type Frequency Attributable cause Related lab results Sleeve gastrectomy converted to RYGB NA NA Daily Postprandial hyperinsulinemic hypoglycemia NA RYGB 55.2 Generalized seizure Once Stroke NA RYGB 5.5 NA Once Nesidioblastosis Glucose 39 mg/dL; Insulin 298.64 pmol/L RYGB 124.2 NA Once Postprandial hyperinsulinemic hypoglycemia Glucose 54 mg/dL NA 121.5 Generalized tonic-clonic seizure Once Pyridoxine, cobalamin, niacin deficiency Zinc 35 mg/dL; Copper 51 mg/dL; Iron (TIBC) 33 mg/dL; Vitamin D 18 mg/L Sleeve gastrectomy 2.0 NA Multiple Hypoglycemia CGM hypoglycemia 20% of time; HbA1c 4.9–5.1% RYGB NA NA Multiple Hypocalcemia Calcium 5.2 mg/dL RYGB 55.2 NA Biweekly for one year Hypoglycemia Glucose 40 mg/dL RYGB NA Generalized tonic-clonic seizure Multiple over 3 weeks Endogenous hyperinsulinemic hypoglycemia Glucose 30–80 mg/dL RYGB 180.1 NA NA Hypoglycemia Glucose 46 mg/dL RYGB 60.0 Generalized tonic-clonic seizure Once Hyperammonemia Ammonia 140 mcg/dL RYGB 132.0 Status epilepticus Once Hyperammonemia Ammonia 446 µmol/L RYGB 12.4 Generalized seizure Multiple times (frequency not specified) Nesidioblastosis Glucose 50–80 mg/dL RYGB 22.0 Generalized seizure Multiple times (frequency not specified) Hyperammonemic encephalopathy Ammonia not reported RYGB 2.5 NA Multiple times (frequency not specified) Hypoglycemia Glucose 18 mg/dL RYGB 12.0 Generalized tonic-clonic seizure Two times Thiamine deficiency Total serum protein 48.9 g/L; Albumin 25.3 g/L; Zinc 60 mg/dL; Low thiamine Abbreviations: RYGB, Roux-en-Y gastric bypass; CGM, continuous glucose monitoring; HbA1c, glycated hemoglobin; TIBC, total iron-binding capacity; NA, not available. The time elapsed from surgery to the onset of the first seizure episode varies widely, ranging from 2 to 180.1 months, with an average duration of 59.3 months. This wide range is a possible reflection of surgery and patient factors that need to be investigated and have a high potential to affect the course of developing a seizure Regarding seizure characteristics, 8 studies detailed both the type and frequency, while 7 reports focused solely on frequency. One report did not provide information on either the type or frequency. Generalized tonic-clonic seizures were the predominant type reported, with one case resulting in status epilepticus. Additionally, episodes ranged from single occurrences to multiple episodes occurring every 2 weeks over a year. The causes of post-bariatric seizures were diverse, with 56% attributed to hypoglycemia, 19% to hyperammonemia, and the remaining cases linked to hypocalcemia, vitamin deficiency, and post-bariatric stroke. All case reports presented corresponding lab results, indicating elevated ammonia levels and low glucose, calcium, and vitamin levels, consistent with potential causes of seizures. These findings underscore the importance of understanding the multifaceted factors contributing to post-bariatric seizures. Table 3 includes 3 cohort studies. Only one cohort study focuses solely on assessing the epilepsy risk following bariatric surgery. The study concluded an epilepsy rate of 50.1 per 100,000 person-years among those who did bariatric surgery. The hazard ratio HR was 1.45 (95% Cl = 1.35, 1.56), which is considered statistically significant. Another cohort study included 5040 Swedish participants who underwent RYGB. The aim was to determine the risk of hypoglycemia and associated conditions (confusion, syncope, epilepsy, seizure, and pancreatic surgery) after RYGB, and an adjusted HR was calculated for each. The HRs were 3 (95% CI: 2.1, 4.3) and 7.3 (95% CI: 5, 10.8) for epilepsy and seizures, respectively, both of which were significant. An additional cohort study reviewed the incidence of hyperinsulinemic hypoglycemia among 129 patients who underwent RYGB. The diagnosis was based on reporting neuroglycopenic symptoms. This study compared several parameters, e.g., BMI, to identify risk factors for recurrent hypoglycemic episodes. However, one woman was reported to have tonic clonic seizure secondary to hypoglycemia. Table 3 Summary of cohort study findings on seizures/epilepsy after bariatric surgery Study (Author, Year) Surgery exposure group Outcome assessed Main finding / suspected mechanism Effect size (95% CI) Antaya (2022) All bariatric surgeries Seizures Seizures reported secondary to nutritional deficiencies Not reported Marsk et al. (2010) Bariatric surgery (any) vs control Epilepsy Increased epilepsy risk after bariatric surgery HR 1.45 (95% CI 1.35–1.56) Woods et al. (2011) RYGB Seizures and epilepsy Increased risk after RYGB, largely attributed to hypoglycemia Epilepsy: HR 3.0 (95% CI 2.1–4.3) ; Seizures: HR 7.3 (95% CI 5.0–10.8) Abbreviations: CI, confidence interval; HR, hazard ratio; RYGB, Roux-en-Y gastric bypass. Table 1 shows that definitive management was done in all the included studies. It is highly variable and encompasses a range of medical and surgical approaches. One cohort and six case reports mentioned surgical definitive management. One out of the 3 cohort studies with 163 participants reported that two patients underwent reversal and conversion to sleeve gastrectomy. The other two cohort studies did not mention the management. Moreover, four case reports also reported reversal of RYGB. One of these patients underwent laparoscopic restoration, utilizing a Roux limb as a Henley-Longmire interposition between the gastric pouch and remnant sleeve, with a side-to-side gastrojejunostomy. This approach successfully restored standard food passage without compromising the blood supply to the gastric pouch. Subsequent resection of the remaining Roux limb was performed. The remaining two case reports involving surgical management described different approaches, including endoscopic gastrojejunal revision (EGJR) and extended distal pancreatectomy with splenectomy, small bowel resection, and intraoperative pancreatic ultrasonography. On the other hand, the other cases were mainly managed medically. Acarbose-based treatment was reported in three cases, accompanied by dietary modifications to avoid hypoglycemia. Also, Diazoxide was the primary anti-hypoglycemic agent in three studies. Using these agents was the primary way to control the seizure episodes. Nevertheless, three cases that underwent surgical therapy as definitive treatment initially tried these agents without an effective response. Furthermore, two cases were treated with long-term antiseizure treatment. Finally, two cases of post-bariatric seizure that are mainly attributed to high ammonia levels received mainly acute hyperammonemia treatment. 4. Discussion Weight loss surgeries have increased in recent years, and like other surgeries, it has the potential for acute and long-term complications [ 35 ]. Post-bariatric Neurological complications are a significant concern. Systematic reviews found several neurosurgical complications attributed to bariatric surgeries, such as alterations in intracranial pressure, intracranial hypertension, and myelo-encephalopathy [ 36 , 37 ]. One of the significant neurological complications that this review examines is seizures. A retrospective study stated that there is a 45% increased risk of developing seizures after bariatric surgery [ 10 ]. Moreover, many case reports have demonstrated episodes of seizures that are directly and indirectly attributed to bariatric surgery. This review aims to assess the increased risk of developing post-bariatric seizures. The link between bariatric procedures per se and seizures is controversial. One case report has shown control of epilepsy after bariatric surgery [ 38 ]. Also, another case was diagnosed with insulinoma after losing 20 pounds in 6 months for bariatric surgery preparation. The results of this systematic review suggest a link between bariatric surgeries and a higher likelihood of experiencing seizures or developing epilepsy through variable mechanisms. Among the three cohort studies included in the review, one study observed that epilepsy, along with various other late neurological complications, was explicitly associated with bariatric surgeries. A particular study did not identify any specific factors associated with the development of epilepsy (5). Moreover, the other two studies devoted to examining post-bariatric hypoglycemia stated that the risk of developing hypoglycemia-related neurological symptoms, including seizures, is higher compared to the general population. However, all the studies reported that it is considered low and insignificant despite the increased risk. Furthermore, the remaining two cohort studies suggested that the potential mechanism underlying hypoglycemia following RYGB is a persistent increase in GLP-1 levels after meal stimulation, leading to increased insulin secretion (5,6,7). These suggestions confirm that insulin secretion improves after bariatric surgery [ 39 ]. This systematic review also incorporated 15 case reports documenting cases of seizure episodes occurring after bariatric surgery, predominantly Roux-en-Y gastric bypass (RYGB). Among these 15 cases, nine were attributed to recurrent episodes of hypoglycemia. These studies highlight the importance of promptly identifying and treating conditions characterized by hyperinsulinemic hypoglycemia (Nesidioblastosis) to prevent irreversible neurological damage. A systematic review was conducted to summarize the reasons for reversing RYGB. The findings revealed that among 100 participants, 8.5% underwent reversal due to postprandial hypoglycemia. This result aligns with the findings of our systematic review [ 36 ]. Three cases were linked to elevated ammonia levels. One contributing factor to hyperammonemia was post-sleeve steatohepatitis. At the same time, the other two cases were associated with rare urea cycle disorders that were revealed by the altered absorption resulting from bariatric surgery. The primary drawback of the studies was the extensive variation in the post-bariatric surgery time frame during which patients experienced seizures. This limitation raises questions about additional factors that may contribute to seizures. Additionally, most included studies focused on RYGB, leaving limited information on other surgical procedures. Furthermore, some studies needed more detailed information on the specific types and frequencies of seizures observed after bariatric surgery. Also, certain studies mentioned the occurrence of epilepsy after bariatric surgery, but failed to provide clear criteria used for diagnosing epilepsy. This absence of standardized diagnostic criteria raises concerns about the accuracy of epilepsy diagnoses in the reported cases. Interpretation of our findings is limited by the small number of primary studies, variable timing of seizure onset, incomplete reporting of seizure characteristics, and inconsistent diagnostic criteria for epilepsy. Clinically, the findings support postoperative monitoring, patient education, and structured follow-up to enable early detection and management of reversible causes of seizures after bariatric surgery. This highlights the need for additional research to provide sufficient information. 5. Conclusion In conclusion, seizures after bariatric surgery appear uncommon but clinically significant and are most often linked to reversible metabolic disturbances, particularly postprandial hypoglycemia after Roux-en-Y gastric bypass. Although cohort studies suggest an increased relative risk of seizures and epilepsy, the available evidence is limited and heterogeneous. Further prospective studies are needed to define absolute risks, clarify mechanisms, and guide standardized prevention and management strategies. Declarations 6.1 Ethics approval and consent to participate Not applicable. This study is a systematic review and does not involve primary data collection from human or animal participants. 6.2 Consent for publication Not applicable. 6.3 Competing interests The authors declare that they have no competing interests. 6.4 Funding This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 6.6 Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. 6.7 Systematic review registration This systematic review is registered in PROSPERO. 6.8 Clinical trial registration number Not applicable. Author Contribution M.A.D, R.A.S, L.M.B and M.A.Y; conceptualized the review, registered the protocol, and conducted the initial literature search. M.A.D, R.A.S, L.M.B and M.A.Y; contributed to screening, data extraction, and quality assessment. A.D, M.A, H.R and M.F; supervision and conceptualization. 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Endocr Pract. 2018;24:85–6. 10.1016/S1530-891X(20)47146-0 . Grogg J, Feinman J, El Husseini I, Hussain S, 428:, HYPERAMMONEMIC ENCEPHALOPATHY AND NEW-ONSET SEIZURES IN A ROUX-EN-Y AND SHORT BOWEL SYNDROME PATIENT. Crit Care Med. 2018;46(1):198–198. 10.1097/01.ccm.0000528446.22292.0d . Atla PR, Mathur J, Prajapati DN, Nesidioblastosis. A Rare Case of Post Prandial Hypoglycemia in a Patient With Gastric Bypass Surgery: 104. Off J Am Coll Gastroenterol ACG. 2015;110:S42–3. Hahn KJ, Sarges P, Bull-Henry KP. Fatal Hyperammonemia: A Case of Urea Cycle Disorder Unmasked After Roux-en-Y Gastric Bypass: 917. Off J Am Coll Gastroenterol ACG. 2015;110:S395. Rao BB, Click B, Codario R. Successful Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome With Gastric Bypass Reversal: A Case Report: 1037. Off J Am Coll Gastroenterol ACG. 2014;109:S309. Lee CJ, Brown T, Magnuson TH, Egan JM, Carlson O, Elahi D. Hormonal Response to a Mixed-Meal Challenge After Reversal of Gastric Bypass for Hypoglycemia. J Clin Endocrinol Metab. 2013;98(7):E1208–12. 10.1210/jc.2013-1151 . Choi JY, Scarborough TK. Stroke and Seizure following a Recent Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg. 2004;14(6):857–60. 10.1381/0960892041590890 . Salas-Salvadó J, García-Lorda P, Cuatrecasas G, et al. Wernicke’s syndrome after bariatric surgery. Clin Nutr. 2000;19(5):371–3. 10.1054/clnu.2000.0138 . Lim R, Beekley A, Johnson DC, Davis KA. Early and late complications of bariatric operation. Trauma Surg Acute Care Open. 2018;3(1):e000219. 10.1136/tsaco-2018-000219 . Shoar S, Nguyen T, Ona MA, et al. Roux-en-Y gastric bypass reversal: a systematic review. Surg Obes Relat Dis. 2016;12(7):1366–72. 10.1016/j.soard.2016.02.023 . Bongetta D, Zoia C, Luzzi S, et al. Neurosurgical issues of bariatric surgery: A systematic review of the literature and principles of diagnosis and treatment. Clin Neurol Neurosurg. 2019;176:34–40. 10.1016/j.clineuro.2018.11.009 . Cao F, Yang C, Cao P, Xu Y, Wang Y. Seizure Controlled after Laparoscopic Sleeve Gastrectomy Operation: A Case Report of an Obese Epileptic Patient. Arch Intern Med Res. 2020;03(03). 10.26502/aimr.0039 . Quercia I, Dutia R, Kotler DP, Belsley S, Laferrère B. Gastrointestinal changes after bariatric surgery. Diabetes Metab. 2014;40(2):87–94. 10.1016/j.diabet.2013.11.003 . Additional Declarations No competing interests reported. Supplementary Files SupplemetaryFileAcopy.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 21 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviews received at journal 29 Mar, 2026 Reviewers agreed at journal 29 Mar, 2026 Reviewers invited by journal 29 Mar, 2026 Editor assigned by journal 25 Mar, 2026 Submission checks completed at journal 25 Mar, 2026 First submitted to journal 17 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9151756","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":615371185,"identity":"1b12abb5-7d07-4017-bb69-93dc24ebb82d","order_by":0,"name":"Abdulaziz Aldabaeab","email":"","orcid":"","institution":"King Fahd Hospital of the University","correspondingAuthor":false,"prefix":"","firstName":"Abdulaziz","middleName":"","lastName":"Aldabaeab","suffix":""},{"id":615371186,"identity":"3dfa3824-fd17-4942-9be4-2ca63d919c7e","order_by":1,"name":"Mohammed Foula","email":"","orcid":"","institution":"King Fahd Hospital of the University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Foula","suffix":""},{"id":615371187,"identity":"bb8140a6-84c4-4de3-ac60-f65931789913","order_by":2,"name":"Mosab AlArfaj","email":"","orcid":"","institution":"King Fahd Hospital of the University","correspondingAuthor":false,"prefix":"","firstName":"Mosab","middleName":"","lastName":"AlArfaj","suffix":""},{"id":615371188,"identity":"1c37def1-e41f-4684-b901-8b05393ff5d3","order_by":3,"name":"Hefzi AlRatrout","email":"","orcid":"","institution":"King Fahd Hospital of the University","correspondingAuthor":false,"prefix":"","firstName":"Hefzi","middleName":"","lastName":"AlRatrout","suffix":""},{"id":615371189,"identity":"aaa3fd68-3d6d-4ab4-b388-090e4c349fdf","order_by":4,"name":"Maiyada Aldossary","email":"","orcid":"","institution":"Imam Abdulrahman Bin Faisal 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Alshablan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYDACZh4QacFgwMDDeICBwQbIYWw8QIQWCZAWBqDKNJCWBvxaGFC1HAaL4dVi3s578NONGgl7c/azBw783HHebm37YaAtNTbRuLTIHOZLls45JpG4sycv4WDvmdvJ284kArUcS8ttwKFFgpnHQDqHTSLB4ECOwQHettvJZgeAWhgbDuPTYvw755+EvcH5NwYH/7adSzY7/5CgFjPp3DYJxg03cgwO87YdsDO7QdgWM+vcPonEDTfeJRyWbUtOMLsBtCUBn1/4zxjfzvlmA3RY7sGHb9vs7M3Opz988KHGBqcWDJAIVplArHIQsCdF8SgYBaNgFIwMAAAyxWOUmZ+1rgAAAABJRU5ErkJggg==","orcid":"","institution":"Imam Abdulrahman Bin Faisal University","correspondingAuthor":true,"prefix":"","firstName":"Reham","middleName":"","lastName":"Alshablan","suffix":""}],"badges":[],"createdAt":"2026-03-17 18:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9151756/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9151756/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107704600,"identity":"6ef38140-30a9-4add-a120-df022a114c9f","added_by":"auto","created_at":"2026-04-24 08:51:24","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":208419,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of study selection\u003c/p\u003e","description":"","filename":"IMG9015.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9151756/v1/f43f586f9e979b7690a8b3ee.jpeg"},{"id":106004690,"identity":"0374ce6c-747f-4f55-904d-71e938e60a47","added_by":"auto","created_at":"2026-04-02 10:32:38","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140456,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias assessment for each domain for (A) Case reports, (B) Cohort studies.\u003c/p\u003e","description":"","filename":"IMG9016.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9151756/v1/fe7d1371ef8edb8ac5d329b7.jpeg"},{"id":107708511,"identity":"f3e59758-e6a0-4b8a-b9ed-3d7f48388bda","added_by":"auto","created_at":"2026-04-24 09:28:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":739955,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9151756/v1/4ae69ce0-9622-4b14-be69-7df934ff42fd.pdf"},{"id":106004687,"identity":"dc42d7c3-486f-4631-953f-c60ec009c5f3","added_by":"auto","created_at":"2026-04-02 10:32:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":23767,"visible":true,"origin":"","legend":"","description":"","filename":"SupplemetaryFileAcopy.docx","url":"https://assets-eu.researchsquare.com/files/rs-9151756/v1/619cc316ff2de5707771721e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Seizures and epilepsy after bariatric surgery: a systematic review of incidence, mechanisms, and management","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eObesity is a global health concern, with a prevalence increasing at an alarming rate -almost tripling since 1975- which poses a significant public health challenge [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].This complex medical condition extends beyond an aesthetic or lifestyle matter; it is a significant risk factor for a multitude of health problems, including cardiovascular diseases, diabetes, and mental health disorders [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In response to this epidemic, bariatric surgery has been increasingly adopted as an effective intervention, resulting in a significant weight reduction and management of obesity-related medical conditions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Roux-en-Y gastric bypass and gastric sleeve are two of the most common bariatric surgeries, and they have shown consistent results and successful long-term weight-loss outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nevertheless, these surgeries are not without potential complications, including effects on neurological health.\u003c/p\u003e \u003cp\u003eThe effects of obesity on neurological health have been well documented and explored in the literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Several studies have assessed the association between neurological complications and bariatric surgery. A review by Zafar et al. reported complications such as encephalopathy, behavioral and psychiatric disorders, myelopathy, and optic neuropathy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A study by Antaya et al. focused on the seizure risk following bariatric surgery and found increased rates of seizures in post-bariatric surgery patients compared to a non-surgical obese cohort [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The mechanisms through which bariatric surgery may influence neurological health, particularly the risk of seizures, are complex and multifactorial. Some possible hypotheses include changes in nutrient absorption, hormonal fluctuations, and alterations in gut-brain axis communication, but these pathways have yet to be definitively established [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe relationship between bariatric surgery and seizures remains incompletely characterized, and the existing literature is scattered across observational studies and isolated case reports. Important clinical questions remain unanswered, including the magnitude of risk, the timing of onset, the most frequent etiologies, and the effectiveness of medical and procedural management strategies. Therefore, this systematic review aims to synthesize available evidence on seizures and epilepsy following bariatric surgery by summarizing incidence estimates, describing clinical characteristics and attributable causes, and outlining management approaches and outcomes from the available literature.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThis study was conducted according to the Cochrane Handbook for Systematic Reviews and the PRISMA guidelines [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The study was registered on PROSPERO.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eTo be considered for inclusion, the following study designs were eligible: case reports, case series, cross-sectional, case-control, cohort, and randomized controlled trials (RCTs) in any language. Our study included patients of any age, gender, or race who underwent any of the following bariatric surgeries: Roux-en-Y gastric bypass, Sleeve gastrectomy, Biliopancreatic diversion with duodenal switch (BPD/DS), or single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S). We excluded studies with duplicated data and secondary articles. In addition, studies focusing on measuring the effect of bariatric surgery on pre-diagnosed epileptic participants were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Information Sources\u003c/h2\u003e \u003cp\u003eWe performed a primary search for eligible studies published up to 11 January 2025 selecting studies from three main databases: PubMed, Embase, and Web of Science. Furthermore, we surveyed the reference lists of all included studies and searched Google Scholar to identify any additional eligible records.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Search Strategy\u003c/h2\u003e \u003cp\u003eOur search strategy was based on keywords related to bariatric surgery and seizures. A draft search strategy was developed to identify additional keywords. Applicable studies were identified by searching for keywords in titles, abstracts, and subject indexing. The PubReMiner word-frequency analysis tool was used to expand our keywords. Three relevant studies were selected to validate our search strategy. We tested whether our search strategy could identify the pre-selected studies. The keywords search strategy was then employed in PubMed, Embase, and Web of Science and successfully identified the pre-selected three studies (see Supplementary file 1, Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Selection Process\u003c/h2\u003e \u003cp\u003eRecords retrieved from the three databases were imported into Mendeley, where duplicates were removed using software and manual verification. Study selection was performed in three stages: title screening, abstract screening, and full-text review. Titles and abstracts were double-screened by four reviewers, and full texts were assessed by all reviewers using predefined exclusion criteria (non-bariatric, non-seizure outcomes, pre-existing epilepsy/anti-seizure medication use, non-primary studies, and non-human studies). Disagreements were resolved through discussion, with input from the first and last authors when needed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Collection Process and Data Items\u003c/h2\u003e \u003cp\u003eData extraction was designed to address the review objectives and covered three domains: (1) study characteristics and participant details (authors, country, design, sample size, age, sex, comorbidities); (2) surgical and perioperative data (procedure type, prior bariatric surgery, and relevant laboratory findings); and (3) postoperative outcomes and complications, with emphasis on seizures/epilepsy and related metabolic or nutritional disturbances (e.g., hypoglycemia, vitamin and mineral deficiencies), as well as other short- and long-term complications. The standardized extraction sheet was piloted on three eligible studies and refined before independent data extraction from the remaining included studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Risk of Bias Assessment\u003c/h2\u003e \u003cp\u003eTo assess the risk of bias in the included studies, the Joanna Briggs Institute (JBI) risk of bias assessment tool was used [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. By using the appraisal checklists, we aimed to assess the methodological rigor of each included study and determine how effectively it addressed potential bias in its planning, execution, and analytical processes. Then, studies were further classified according to the JBI checklist evaluation as low-, intermediate-, or high-risk of bias, based on positive answers of \u0026ge;\u0026thinsp;75%, \u0026lt;\u0026thinsp;75%, \u0026ge;\u0026thinsp;50%, and \u0026lt;\u0026thinsp;50%, respectively. Two reviewers independently appraised all included studies in a blind manner; any disagreements were resolved by discussion or consultation with the first author when necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Data synthesis plan\u003c/h2\u003e \u003cp\u003eDue to expected clinical and methodological heterogeneity, we performed a narrative synthesis supported by descriptive analyses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Cohort studies were summarized using the most adjusted effect estimates, including hazard ratios (HRs), risk ratios (RRs), or odds ratios (ORs), with 95% confidence intervals (95% CIs) and absolute measures (e.g., incidence) when available. Case reports were synthesized by tabulating surgery type, time to seizure, seizure phenotype, suspected cause, key laboratory findings, and management, and reporting results as counts and proportions, along with appropriate summary statistics. Meta-analysis was not feasible because comparative studies were insufficiently homogeneous, and publication bias assessment was not performed, given the limited number of comparative studies and the inclusion of case reports [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Selection\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the search and selection process using a PRISMA flow diagram. This process focused on identifying studies examining the association between bariatric surgery and seizure outcomes, using 3 databases. Initially, 10,507 records were identified; only 19 studies met the inclusion criteria and were included in our review [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Risk of Bias\u003c/h2\u003e \u003cp\u003eRisk of bias varied across included studies. Among 16 case reports, 12 were judged low risk, 3 intermediate risk, and 1 high risk, mainly due to incomplete reporting of clinical details and interventions, and to unclear causality (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). For the three cohort studies, one was low risk, one intermediate, and one high risk, largely related to limited clarity in exposure and outcome measurement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). For details of the risk of bias for each study, see (Supplementary File A, Table S2, S3).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Study Characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the baseline characteristics of the 19 included studies (3 retrospective cohorts and 16 case reports), reporting study design, country, demographics, and sample size. Studies were conducted across multiple countries (including Canada, Sweden, Ireland, Germany, the UK, Belgium, Qatar, Brazil, and the USA), with variable age reporting and a predominance of female participants in both cohorts and case reports. Sample sizes ranged from large population-based cohorts (e.g., 16,958 cases) to single-patient case reports.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of included studies and reported management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSex / Male %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSample size (Control; Cases)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eManagement / definitive treatment (reported)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntaya (2022) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCanada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRetrospective cohort\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e(622,514; 16,958)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eNot reported\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoods et al. (2011) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIreland\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRetrospective cohort\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e31.7%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e(0; 163)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSurgical reversal and conversion to sleeve gastrectomy (n\u0026thinsp;=\u0026thinsp;2)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarsk et al. (2010) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSweden\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eRetrospective cohort\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e41.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e(23.5%; 23.5%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e(50,400; 5,040)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eNot reported\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHoll\u0026auml;nder (2023) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eGermany\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eLaparoscopic restoration of normal food passage (complex reconstructive procedure)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKim et al. (2022) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eDistal pancreatectomy\u0026thinsp;+\u0026thinsp;splenectomy; small bowel resection of blind Roux limb; acarbose 50 mg with meals; reversal/modification discussed but refused\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSedano et al. (2022) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBelgium\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eParenteral nutritional supplementation\u0026thinsp;+\u0026thinsp;antiseizure meds (ASM); ASM stopped after 10 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcManus et al. (2021) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eDietary modification\u0026thinsp;+\u0026thinsp;acarbose 100 mg TID\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFarahmand (2020) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eDietary modification\u0026thinsp;+\u0026thinsp;acarbose\u0026thinsp;+\u0026thinsp;diazoxide\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEl Sheikh (2020) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eQatar\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSeizure control (sedation/intubation/antiepileptics) + lactulose\u0026thinsp;+\u0026thinsp;normal saline infusion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConaty et al. (2019) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eEndoscopic gastrojejunal revision (EGJR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTornincasa et al. (2018) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBrazil\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e28\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eGastric bypass reversal\u0026thinsp;+\u0026thinsp;calcium replacement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrown (2018) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAcarbose\u0026thinsp;+\u0026thinsp;octreotide\u0026thinsp;+\u0026thinsp;diazoxide\u0026thinsp;\u0026plusmn;\u0026thinsp;exenatide\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrogg (2018) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eLactulose\u0026thinsp;+\u0026thinsp;rifaximin\u0026thinsp;+\u0026thinsp;low-protein parenteral diet; lorazepam\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtla (2015) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e46\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eDiazoxide\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHahn (2015) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e41\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSpecialized diet (Cyclinex-2\u0026thinsp;+\u0026thinsp;citrulline), phenobarbital, dialysis, sodium benzoate/phenylacetate (Ammonul)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRao et al. (2014) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e58\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eStepwise escalation: diet \u0026rarr; acarbose/octreotide/diazoxide \u0026rarr; endoscopic stomal reduction \u0026rarr; laparoscopic RYGB reversal (resolved symptoms)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLee et al. (2011) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report (2 subjects)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e35\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSubject 1: diet failed \u0026rarr; RYGB reversal (7 yrs). Subject 2: diet/meds failed \u0026rarr; distal pancreatectomy (3 yrs) \u0026rarr; RYGB reversal (5 yrs) with improvement\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChoi (2004) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAntiplatelet therapy\u0026thinsp;+\u0026thinsp;rehabilitation (post-bariatric stroke context)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSalvado et al. (2000) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSpain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCase report\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e31\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eIntramuscular thiamine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNA: Not available; USA: United States of America\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Results of Individual Studies\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a comprehensive summary of surgical outcomes, seizure characteristics, and relevant lab results from 16 included case reports and 3 cohort studies. The majority of cases (15 out of 16) are associated with Roux-en-Y gastric bypass (RYGB) surgery, with one report linked to gastric sleeve surgery. Interestingly, one case reported a seizure resulting from RYGB after sleeve gastrectomy, highlighting a unique scenario ( post-gastric sleeve RYGB seizure).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgery and seizure characteristics in the included case reports\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime since surgery (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSeizure type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAttributable cause\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRelated lab results\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleeve gastrectomy converted to RYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDaily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostprandial hyperinsulinemic hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNesidioblastosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 39 mg/dL; Insulin 298.64 pmol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostprandial hyperinsulinemic hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 54 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized tonic-clonic seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePyridoxine, cobalamin, niacin deficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eZinc 35 mg/dL; Copper 51 mg/dL; Iron (TIBC) 33 mg/dL; Vitamin D 18 mg/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleeve gastrectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCGM hypoglycemia 20% of time; HbA1c 4.9\u0026ndash;5.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypocalcemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCalcium 5.2 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBiweekly for one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 40 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized tonic-clonic seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple over 3 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndogenous hyperinsulinemic hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 30\u0026ndash;80 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 46 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized tonic-clonic seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHyperammonemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAmmonia 140 mcg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStatus epilepticus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnce\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHyperammonemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAmmonia 446 \u0026micro;mol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple times (frequency not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNesidioblastosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 50\u0026ndash;80 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple times (frequency not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHyperammonemic encephalopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAmmonia not reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple times (frequency not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGlucose 18 mg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneralized tonic-clonic seizure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTwo times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThiamine deficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal serum protein 48.9 g/L; Albumin 25.3 g/L; Zinc 60 mg/dL; Low thiamine\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e RYGB, Roux-en-Y gastric bypass; CGM, continuous glucose monitoring; HbA1c, glycated hemoglobin; TIBC, total iron-binding capacity; NA, not available.\u003c/p\u003e\u003cp\u003eThe time elapsed from surgery to the onset of the first seizure episode varies widely, ranging from 2 to 180.1 months, with an average duration of 59.3 months. This wide range is a possible reflection of surgery and patient factors that need to be investigated and have a high potential to affect the course of developing a seizure\u003c/p\u003e \u003cp\u003eRegarding seizure characteristics, 8 studies detailed both the type and frequency, while 7 reports focused solely on frequency. One report did not provide information on either the type or frequency. Generalized tonic-clonic seizures were the predominant type reported, with one case resulting in status epilepticus. Additionally, episodes ranged from single occurrences to multiple episodes occurring every 2 weeks over a year.\u003c/p\u003e \u003cp\u003eThe causes of post-bariatric seizures were diverse, with 56% attributed to hypoglycemia, 19% to hyperammonemia, and the remaining cases linked to hypocalcemia, vitamin deficiency, and post-bariatric stroke. All case reports presented corresponding lab results, indicating elevated ammonia levels and low glucose, calcium, and vitamin levels, consistent with potential causes of seizures. These findings underscore the importance of understanding the multifaceted factors contributing to post-bariatric seizures.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e includes 3 cohort studies. Only one cohort study focuses solely on assessing the epilepsy risk following bariatric surgery. The study concluded an epilepsy rate of 50.1 per 100,000 person-years among those who did bariatric surgery. The hazard ratio HR was 1.45 (95% Cl\u0026thinsp;=\u0026thinsp;1.35, 1.56), which is considered statistically significant. Another cohort study included 5040 Swedish participants who underwent RYGB. The aim was to determine the risk of hypoglycemia and associated conditions (confusion, syncope, epilepsy, seizure, and pancreatic surgery) after RYGB, and an adjusted HR was calculated for each. The HRs were 3 (95% CI: 2.1, 4.3) and 7.3 (95% CI: 5, 10.8) for epilepsy and seizures, respectively, both of which were significant. An additional cohort study reviewed the incidence of hyperinsulinemic hypoglycemia among 129 patients who underwent RYGB. The diagnosis was based on reporting neuroglycopenic symptoms. This study compared several parameters, e.g., BMI, to identify risk factors for recurrent hypoglycemic episodes. However, one woman was reported to have tonic clonic seizure secondary to hypoglycemia.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of cohort study findings on seizures/epilepsy after bariatric surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy (Author, Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery exposure group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMain finding / suspected mechanism\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffect size (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntaya (2022)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll bariatric surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSeizures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSeizures reported secondary to nutritional deficiencies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarsk et al. (2010)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBariatric surgery (any) vs control\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEpilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncreased epilepsy risk after bariatric surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eHR 1.45 (95% CI 1.35\u0026ndash;1.56)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoods et al. (2011)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRYGB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSeizures and epilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncreased risk after RYGB, largely attributed to hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEpilepsy: \u003cb\u003eHR 3.0 (95% CI 2.1\u0026ndash;4.3)\u003c/b\u003e; Seizures: \u003cb\u003eHR 7.3 (95% CI 5.0\u0026ndash;10.8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e CI, confidence interval; HR, hazard ratio; RYGB, Roux-en-Y gastric bypass.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows that definitive management was done in all the included studies. It is highly variable and encompasses a range of medical and surgical approaches. One cohort and six case reports mentioned surgical definitive management. One out of the 3 cohort studies with 163 participants reported that two patients underwent reversal and conversion to sleeve gastrectomy. The other two cohort studies did not mention the management. Moreover, four case reports also reported reversal of RYGB. One of these patients underwent laparoscopic restoration, utilizing a Roux limb as a Henley-Longmire interposition between the gastric pouch and remnant sleeve, with a side-to-side gastrojejunostomy. This approach successfully restored standard food passage without compromising the blood supply to the gastric pouch. Subsequent resection of the remaining Roux limb was performed. The remaining two case reports involving surgical management described different approaches, including endoscopic gastrojejunal revision (EGJR) and extended distal pancreatectomy with splenectomy, small bowel resection, and intraoperative pancreatic ultrasonography.\u003c/p\u003e \u003cp\u003eOn the other hand, the other cases were mainly managed medically. Acarbose-based treatment was reported in three cases, accompanied by dietary modifications to avoid hypoglycemia. Also, Diazoxide was the primary anti-hypoglycemic agent in three studies. Using these agents was the primary way to control the seizure episodes.\u003c/p\u003e \u003cp\u003eNevertheless, three cases that underwent surgical therapy as definitive treatment initially tried these agents without an effective response. Furthermore, two cases were treated with long-term antiseizure treatment. Finally, two cases of post-bariatric seizure that are mainly attributed to high ammonia levels received mainly acute hyperammonemia treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWeight loss surgeries have increased in recent years, and like other surgeries, it has the potential for acute and long-term complications [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Post-bariatric Neurological complications are a significant concern. Systematic reviews found several neurosurgical complications attributed to bariatric surgeries, such as alterations in intracranial pressure, intracranial hypertension, and myelo-encephalopathy [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. One of the significant neurological complications that this review examines is seizures. A retrospective study stated that there is a 45% increased risk of developing seizures after bariatric surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMoreover, many case reports have demonstrated episodes of seizures that are directly and indirectly attributed to bariatric surgery. This review aims to assess the increased risk of developing post-bariatric seizures. The link between bariatric procedures per se and seizures is controversial. One case report has shown control of epilepsy after bariatric surgery [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Also, another case was diagnosed with insulinoma after losing 20 pounds in 6 months for bariatric surgery preparation.\u003c/p\u003e \u003cp\u003eThe results of this systematic review suggest a link between bariatric surgeries and a higher likelihood of experiencing seizures or developing epilepsy through variable mechanisms. Among the three cohort studies included in the review, one study observed that epilepsy, along with various other late neurological complications, was explicitly associated with bariatric surgeries. A particular study did not identify any specific factors associated with the development of epilepsy (5). Moreover, the other two studies devoted to examining post-bariatric hypoglycemia stated that the risk of developing hypoglycemia-related neurological symptoms, including seizures, is higher compared to the general population. However, all the studies reported that it is considered low and insignificant despite the increased risk.\u003c/p\u003e \u003cp\u003eFurthermore, the remaining two cohort studies suggested that the potential mechanism underlying hypoglycemia following RYGB is a persistent increase in GLP-1 levels after meal stimulation, leading to increased insulin secretion (5,6,7). These suggestions confirm that insulin secretion improves after bariatric surgery [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis systematic review also incorporated 15 case reports documenting cases of seizure episodes occurring after bariatric surgery, predominantly Roux-en-Y gastric bypass (RYGB). Among these 15 cases, nine were attributed to recurrent episodes of hypoglycemia. These studies highlight the importance of promptly identifying and treating conditions characterized by hyperinsulinemic hypoglycemia (Nesidioblastosis) to prevent irreversible neurological damage.\u003c/p\u003e \u003cp\u003eA systematic review was conducted to summarize the reasons for reversing RYGB. The findings revealed that among 100 participants, 8.5% underwent reversal due to postprandial hypoglycemia. This result aligns with the findings of our systematic review [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThree cases were linked to elevated ammonia levels. One contributing factor to hyperammonemia was post-sleeve steatohepatitis. At the same time, the other two cases were associated with rare urea cycle disorders that were revealed by the altered absorption resulting from bariatric surgery. The primary drawback of the studies was the extensive variation in the post-bariatric surgery time frame during which patients experienced seizures. This limitation raises questions about additional factors that may contribute to seizures. Additionally, most included studies focused on RYGB, leaving limited information on other surgical procedures. Furthermore, some studies needed more detailed information on the specific types and frequencies of seizures observed after bariatric surgery. Also, certain studies mentioned the occurrence of epilepsy after bariatric surgery, but failed to provide clear criteria used for diagnosing epilepsy. This absence of standardized diagnostic criteria raises concerns about the accuracy of epilepsy diagnoses in the reported cases.\u003c/p\u003e \u003cp\u003eInterpretation of our findings is limited by the small number of primary studies, variable timing of seizure onset, incomplete reporting of seizure characteristics, and inconsistent diagnostic criteria for epilepsy. Clinically, the findings support postoperative monitoring, patient education, and structured follow-up to enable early detection and management of reversible causes of seizures after bariatric surgery. This highlights the need for additional research to provide sufficient information.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, seizures after bariatric surgery appear uncommon but clinically significant and are most often linked to reversible metabolic disturbances, particularly postprandial hypoglycemia after Roux-en-Y gastric bypass. Although cohort studies suggest an increased relative risk of seizures and epilepsy, the available evidence is limited and heterogeneous. Further prospective studies are needed to define absolute risks, clarify mechanisms, and guide standardized prevention and management strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.1 Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This study is a systematic review and does not involve primary data collection from human or animal participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.2 Consent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.3 Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.4 Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.6 Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.7 Systematic review registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review is registered in PROSPERO.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.8 Clinical trial registration number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.A.D, R.A.S, L.M.B and M.A.Y; conceptualized the review, registered the protocol, and conducted the initial literature search. M.A.D, R.A.S, L.M.B and M.A.Y; contributed to screening, data extraction, and quality assessment. A.D, M.A, H.R and M.F; supervision and conceptualization. All authors contributed to the writing and critical revision of the manuscript and approved the final version.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHecker J, Freijer K, Hiligsmann M, Evers SMAA. Burden of disease study of overweight and obesity; the societal impact in terms of cost-of-illness and health-related quality of life. 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Diabetes Metab. 2014;40(2):87\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.diabet.2013.11.003\u003c/span\u003e\u003cspan address=\"10.1016/j.diabet.2013.11.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Bariatric surgery, Roux-en-Y gastric bypass, Seizures, Epilepsy","lastPublishedDoi":"10.21203/rs.3.rs-9151756/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9151756/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBariatric surgery is increasingly performed worldwide, and postoperative neurological complications can occur. Seizures are clinically important because they carry significant morbidity and are often associated with reversible metabolic triggers. This systematic review synthesized evidence on seizures and epilepsy following bariatric surgery. PubMed, Embase, and Web of Science were searched from inception to January 11, 2025. Nineteen studies were included: three retrospective cohort studies and sixteen case reports. Roux-en-Y gastric bypass accounted for most reported cases, with one case following sleeve gastrectomy. Time from surgery to first seizure ranged from 2 to 180 months. Generalized tonic\u0026ndash;clonic seizures were most common. Reported causes were mainly metabolic, particularly hypoglycemia and hyperammonemia, with additional cases linked to hypocalcemia, vitamin deficiencies, and stroke. Cohort data suggest an increased postoperative risk of seizures and epilepsy. Further research is needed to clarify mechanisms and absolute risk.\u003c/p\u003e","manuscriptTitle":"Seizures and epilepsy after bariatric surgery: a systematic review of incidence, mechanisms, and management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-02 10:32:31","doi":"10.21203/rs.3.rs-9151756/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-21T15:12:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T20:38:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T14:42:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206325871640390970667945790939929079012","date":"2026-03-31T13:37:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192905707723321113699532092950090514885","date":"2026-03-31T13:18:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-29T16:25:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69519386604494508404230894364608905986","date":"2026-03-29T15:57:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-29T12:58:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-25T18:18:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-25T05:30:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2026-03-17T18:16:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"54d01771-3e68-4b5a-90ef-4ec9ca7913ec","owner":[],"postedDate":"April 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T15:24:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-02 10:32:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9151756","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9151756","identity":"rs-9151756","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}