Fay J. Goldenberg

The Use of an Implantable Insulin Pump in the Treatment of Type II Diabetes

We treated five patients with Type II diabetes by means of a subcutaneously implanted intravenous insulin pump and compared their metabolic response with that observed during conventional insulin therapy. The use of the pump improved control of glycemia, as manifested by reductions in mean plasma glucose (from 188 +/- 46 to 106 +/- 12 mg per deciliter [mean +/- S.D.]), fasting glucose (from 187 +/- 42 to 80 +/- 13 mg per deciliter), and postprandial glucose (from 287 +/- 74 to 182 +/- 29 mg per deciliter), together with a diminution of glycemic excursion and normalization of glycosylated hemoglobin A1 (from 12.1 +/- 2 to 8.0 +/- 1 per cent). At the end of the study the pumps had been in place for a mean of 7.0 months (range, 5.5 to 9.7 months) without mishap and with good patient acceptance. Our data suggest that improved blood glucose control can be achieved by means of a permanently implanted continuous insulin-infusion device in ambulatory patients with Type II diabetes who require insulin, and that the need for daily insulin injections can thereby be eliminated.

Improvement in Obesity-associated Medical Conditions following Vertical Banded Gastroplasty and Gastrointestinal Bypass.

Thirty-nine patients undergoing either Silastic® ring vertical banded gastroplasty (SRVG, n = 23) or Roux-en-Y gastrointestinal bypass (RGB, n = 16) over a 1-year period were analyzed retrospectively. Weight loss averaged 40 kg (89 lb). Clinical diabetes mellitus was markedly improved in seven out of nine patients (p = 0.023). Shortness of breath resolved in all 26 patients who had this condition preoperatively (p <0.001). Orthopaedic problems, high blood pressure, and self-assessment of general health and quality of life were also dramatically improved. We conclude that bariatric surgery serves as an effective method to alleviate a multitude of conditions associated with morbid obesity.

Implantable infusion pump management of insulin resistant diabetes mellitus.

Diabetes mellitus with resistance to insulin administered subcutaneously or intramuscularly (DRIASM) is a rare and brittle form of Type I diabetes, found predominantly in young females and characterized by inadequate glycemic response to subcutaneous or intramuscular insulin administration. DRIASM leads to frequent ketoacidosis and obligatory hospitalization for administration of intravenous insulin. The use of a totally implantable infusion pump effected dramatic improvement in the treatment of five patients with this difficult form of diabetes. Frequency of clinical ketoacidosis was reduced from 37 episodes per year to 0.4 episodes per year (99%), and average in-hospital days per month were reduced from 20.8 days to 2.2 days (89%) with a mean follow-up period of 14.4 months. Cost savings were approximately +10,000 per patient month. Quality of life was greatly improved for these individuals.

Lipid effects of obesity operations

To achieve weight reduction, and specifically to lower blood lipids, we performed the first 40- to 4-cm end-to-end jejunoileal bypass in August 1970. Since 1975 we have also used gastric bypass, modified from Alden, for weight reduction. Lipids from 205 jejunoileal bypass and 106 gastric bypass patients have been sequentially analyzed from 1 to 3 years postoperation. After jejunoileal bypass cholesterol was lowered 33% by 6 weeks after surgery (P < 0.001). By 12 months, the cholesterol was lowered 42% from a preoperative value of 189 ± 35 (mean ± 1 SD in mg%) to 110 ± 27, n = 205 → 159, P < 0.001; this reduction was maintained through 36 months postbypass. At 12 months after bypass the other lipids showed similar lowering: total serum lipids, 37% (from 677 ± 181 to 425 ± 106, n = 189 → 158, P < 0.001); phospholipids, 34% (220 ± 47 to 146 ± 35, n = 162 → 137, P < 0.001); SF 0–12 lipoproteins, 30% (275 ± 70 to 194 ± 47, n = 162 → 118, P < 0.001); and SF 12–400 lipoproteins, 42% (from 188 ± 14 to 110 ± 63, n = 162 → 118, P < 0.001). The gastric bypass also resulted in lipid lowering during the first year after the bypass operation. The cholesterol values were lowered 14% (from 191 ± 30 to 165 ± 31 mg%, n = 106 → 51, P < 0.001); total serum lipids, 20% (675 ± 138 to 541 ± 115, n = 82 → 36, P < 0.001); triglycerides, 35% (176 ± 98 to 114 ± 63, n = 106 → 51, P < 0.001); phospholipids, 17% (225 ± 39 to 186 ± 43, n = 79 → 36, P < 0.001); SF 0–12 lipoproteins, 21% (310 ± 85 to 245 ± 80, n = 71 → 28, P < 0.001); and SF 12–400 lipoproteins, 48% (170 ± 89 to 88 ± 99, n = 70 → 28, P < 0.001). Thus, both jejunoileal and gastric bypass lower the blood lipids, however, the jejunoileal effect is generally greater; specifically, the cholesterol reduction after jejunoileal bypass is three times that engendered by gastric bypass.