OBES SURG (2008) 18:1400–1405DOI 10.1007/s11695-008-9500-4
Metabolic Outcomes of Obese Diabetic Patients FollowingLaparoscopic Adjustable Gastric Banding
Rishi Singhal & Mark KitchenSue Bridgwater & Paul Super
Received: 28 December 2007 / Accepted: 10 March 2008 / Published online: 26 April 2008
# Springer Science + Business Media, LLC 2008
improvement in their total cholesterol level. The mean
Introduction Obesity is an independent risk factor in the
arterial pressure improved in 87.5% of the patients.
development of diabetes. Weight loss surgery is the most
Conclusion The metabolic syndrome associated with mor-
effective treatment of morbid obesity. This study examines
bid obesity is difficult to adequately control with medica-
the effect of gastric banding on metabolic profile in
tion. Laparoscopic gastric banding can be considered a
potentially curative treatment option in the management of
Methods Between April 2003 and November 2007, 1,335
patients underwent laparoscopic adjustable gastric banding. Metabolic profile was examined on a subset of 254 patients.
Keywords Diabetes . Metabolic profile . Banding .
Of these, 122 were diabetic. Data collection included body
mass index, weight, blood pressure, HbA1c, fastingglucose, total serum cholesterol, triglyceride, and medica-tions taken for blood pressure and diabetes both preoper-
atively and 1 year postoperatively. Results Comorbid conditions in the diabetic patients in-
Obesity is an independent risk factor in the development of
cluded hypercholesterolemia (49.3%), hypertriglyceridemia
diabetes the severity of which rises with increasing
(53.8%) and hypertension (92%). In 1 year, mean BMI
excess weight []. The risk of atherosclerotic disease in
reduced from 52.9 kg/m2 to 41.5 kg/m2. Of the patients,
patients with diabetes based on 20 years of surveillance of
93.1% experienced an improvement in fasting glucose
the Framingham cohort was increased by a factor of three
levels and 75.4% patients an improvement in HbA1c levels
There is evidence to support the claim that complica-
at the end of 1 year. All patients experienced a decrease in
tions of type 2 diabetes mellitus can be reduced with tight
insulin requirements, and 36.6% were able to totally
control of hyperglycemia []. Therapy with drugs alone in
discontinue using it. Of the patients, 100% showed
diabetes has a failure rate of 50% at the end of 3 years in
improvement in their triglyceride level, and 90.9% showed
maintaining target glycemic levels []. Current therapiesincluding diet, exercise, behavior modification, oral hypo-glycemic agents, and insulin rarely return patients to
R. Singhal M. Kitchen S. Bridgwater P. Super
euglycemia []. There remains therefore a great need to
Upper GI Unit and Minimally Invasive Unit,
find more effective ways of managing diabetes.
The role of weight loss in the control of Type 2 diabetes
has been known for some time The role of surgery in
the management of diabetes was first described in 1955
A systematic review by Buchwald [] in 2004 demonstrated
26 Lloyd Square, 16 Niall Close, Edgbaston,
an improvement in diabetes which was dependent on the
Birmingham B15 3LX, UKe-mail: singhal_rishi@rediffmail.com
type of bariatric surgery performed, but in this review,
studies reporting improvement in diabetes were limited in
necessary and consequently seldom used for any of the
sample size. Studies in the literature reporting the effect of
laparoscopic banding on diabetes are scant and limited to
All the patients received postoperative low-molecular-
weight heparins and graduated compression stockingsduring the surgery. Immediate postoperative mobilizationand discharge on the same day or day following surgery
was encouraged. Postoperatively, the patients were com-menced on oral fluids for 2–4 weeks followed by a soft
All cases of laparoscopic banding performed between
puree diet for a further 2 weeks. In most cases, normal band
April 2003 and November 2007 in a single consultant unit
diet was achieved at the end of 6 weeks. Fluoroscopy-
at Heart of England NHS Foundation trust were included.
guided adjustments were performed at 2–3 and 5–6 months,
These cases were either performed or were carried out
and further fluoroscopic evaluations were performed only if
under the supervision of a single surgeon. All the patients
fulfilled the criteria for surgical treatment of obesity
For follow up, the patients were seen initially at 6 weeks,
(BMI ≥40 without comorbidities or BMI ≥35 with
then every 3 months for the first 6 months, and every
Data were collected from medical records, operation
Data analysis was performed using Statistical package
notes, and computer records. General practitioners for all
for social services 13 (SPSS® Chicago, IL, USA). Tests
patients who were identified as diabetic were contacted for
performed included Mann–Whitney U test and Wilcoxon
further data. Data collection included body mass index,
signed ranks test. Spearman’s rho was used for nonpara-
weight, blood pressure, HbA1c, glucose, total serum
metric correlations. Statistical significance was accepted for
cholesterol, triglyceride, and medications taken for blood
a p value of ≤0.05. Values have been expressed as mean
pressure and diabetes preoperatively and at 1 year follow-
and range. The data set available at a particular time point
up. All assays were performed in the laboratories at Heart
has been indicated as number data available on/total
of England NHS Foundation trust with internal and external
patients, or patients who were on a particular drug. One-
quality control. Ideal body weight was determined accord-
year data have been expressed as number data available on/
ing to the Metropolitan Life Insurance Company’s 1983
height/weight tables ]. Percent of excess BMI loss wascalculated as recommended by Deitel et al. [Metabolicoutcomes were calculated for the diabetics at the end of1 year.
The following criteria were used to define diabetes:
(1) fasting plasma glucose of >7.0 mmol/l, (2) random
plasma glucose of >11.1 mmol/l, (3) ketonuria and clini-cally symptomatic. Impaired fasting glucose was defined as
Between April 2003 and November 2007, 1,335 laparoscop-
fasting plasma glucose 6.1 to 7.0 mmol/l; impaired glucose
ic gastric band insertions were performed by the lead surgeon
tolerance as an OGTT 2 hour glucose as ≥7.8 but <11.1;
in two different hospitals. Of these, 254 patients were
gestational diabetes defined as above, but occurring during
operated at the Heart of England NHS Foundation trust, and
this cohort has been considered for further analysis.
Hypertension was defined by a history of hypertension,
The mean age of these patients was 44.8 years with a
taking antihypertensive medication preoperatively, or if the
range between 18 and 66. Of these patients, 191 (75.2%)
patient had a persistent raised blood above 140/90 mmHg
were females. The mean preoperative weight and BMI for
as defined by UK National Institute for Clinical Excellence
this subset was 146.3 kg (range 88–268 kg) and 52.5 kg/m2
(range 35.9–88), respectively. A mean excess weight of
All the patients were admitted on the morning of the
83.2 kg was seen preoperatively in these patients with a
operation. Pars flaccida technique was used for placement
of all bands. The band was secured in place by the use of 3
The mean length of stay was 1.0 day (range 0–2 days)
plicating sutures. The first was a gastropexy suture
with an overall operative complication rate of 1.2% (three
(Birmingham stitch), anchoring the fundus to the left crus.
patients). Two of these were in non-diabetic patients, one of
The remaining two were of the gastro–gastro type ].
whom suffered an early band infection (band removed) and
Three different bands were used for these procedures
the other was found to have a band malposition (reposi-
(Allergan Vanguard, Allergan AP large and Swedish bands).
tioned at 3 months). The single complication in a diabetic
Use of a calibration tube and balloon was not considered
patient was a band puncture, which presented at 8 months.
was 8.2 (range 4.9–13.3%; N=114/122). Mean glucose andHbA1c at 1 year were 6.9 mmol/l (N=101/114) and 7.4%
There were 122 diabetics identified from this subset of 254
(N=101/114), respectively. These values were significantly
patients. The mean age of these patients was 46.7 years
different from the preoperative values (Wilcoxon signed
(range 25–66). 81 (66.4%) were females. The mean
ranks test, p<0.01). Of the patients, 93.1% experienced an
preoperative weight and BMI for the diabetic patients was
improvement in fasting glucose levels and 75.4% patients
151.8 kg (range 88–240 kg) and 52.9 kg/m2 (range 35.9–
an improvement in HbA1c levels at the end of 1 year. The
81), respectively. A mean excess weight of 87.4 kg was
%EWL did not have a significant effect on the decrease in
seen preoperatively with a range between 36.1 and 169.7.
HbA1c levels (r=−0.28; p=0.149) and fasting glucose
In comparison with the non-diabetics (N=132), statistically
higher mean preoperative and excess weights were noticed
Forty-two patients were on insulin with a mean daily
in the diabetics with no statistical difference in their BMIs
preoperative dose of 150.7 U. One-year insulin data were
available for 41 patients. Fifteen had discontinued insulin
Of these patients, 109 had Type 2 diabetes, 8 had im-
(36.6%), 25 had their dose reduced, and 1 patient was on
paired glucose tolerance, with 5 patients being diagnosed
the same daily dose at the end of 1 year. The mean dose of
with gestational diabetes. Eighty-two patients were on
insulin for patients still on it at the end of 1 year was 37.2 U
metformin, 42 on insulin, 13 on sulphonylureas, and 25
(Wilcoxon signed ranks test, p<0.01). The %EWL did not
on thiazolidinediones. Associated conditions included hy-
have a significant effect on the decrease in insulin levels at
percholesterolemia (49.3%), hypertriglyceridemia (53.8%),
the end of 1 year (r=0.299; p=0.176).
Preoperatively, 82 patients were on metformin with a
mean dose of 2,026 mg. One-year data were available for
Weight loss Excess percent BMI loss in these patients at 3,
77 patients. Twenty-six were able to discontinue metformin
6, and 12 months were 21.7 (19.6–23.9), 32.3 (26.5–38),
(34.2%). Twenty-six had their dose reduced, 20 experi-
and 37.8 (33–42.5), respectively. Excess percentage weight
enced no change, and 5 patients had increase in the dose of
loss at for the same time period was 19.7% (17.8–21.6),
metformin. One patient was started on metformin during
39.4% (24.1–34.7), and 34.3% (29.8–38.7), respectively.
follow-up due to biochemical failure in the improvement
There was no statistically significant difference with
of diabetes. The mean dose of metformin for patients still
regards to the weight loss between the diabetics (N=122)
on it at the end of 1 year 1,589 mg (Wilcoxon signed ranks
Thirteen patients were on sulphonylureas preoperatively
with a mean dose of 116.9 mg. Three patients were able to
discontinue these. The mean dose at the end of 1 year was60 mg (Wilcoxon signed ranks test; p=0.04). Twenty-five
Hyperglycemia Mean preoperative glucose was 9.1 (range
patients were on thiazolidinediones preoperatively. Thirteen
3.9–26.0 mmol/l; N=114/122). Mean preoperative HbA1c
Table 1 Excess weight andBMI loss in diabetics vs.
Table 2 Metabolic profile of diabetics at the end of 1 year follow-up
Values have been expressed as means±standard deviation. Number of patients with diabetes=122. The data set available at a particular time pointhas been indicated as (number data available on/ total patients, or patients who were on a particular drug). One-year data has been expressed asnumber data available on/patients who had preoperative data. a Wilcoxon signed ranks test.
Dyslipidemia An elevated level of total serum cholesterol
p<0.01). The Mean arterial pressure improved in 87.5%
and serum trigylcerides was present in 49.3% and 53.8% of
the patients, respectively. There was a reduction in total
The %EWL did not have a significant effect on the
serum cholesterol levels from a mean of 5.1 (N=98/122) to
decrease in systolic (r=−0.051; p=0.812) and diastolic
4.4 (N=71/98) at the end of 1 year (Wilcoxon signed ranks
(r=−0.282; p=0.182) blood pressure. This was also seen
test, p=0.05). There was a change in serum triglyceride
for the fall in mean arterial pressures (r=−0.171; p=0.425).
level from a mean of 3.9 (N=98/122) to 2.6 (N=71/98;Wilcoxon signed ranks test, p=0.007). Of the patients,
Impaired glucose tolerance/gestational diabetes All
90.9% showed improvement in their total cholesterol level,
patients with impaired glucose tolerance (N=8) experienced
and 100% showed improvement in their serum triglyceride
similar improvements in HbA1c, fasting glucose, dyslipi-
levels. The %EWL did not have a significant effect on the
demia, and hypertension. None of the patients had
decrease in total cholesterol levels (r=0.347; p=0.399) and
progression to type 2 diabetes. Similar results were also
serum triglyceride (r=−0.347; p=0.399).
seen in the patients with gestational diabetes (N=5).
Hypertension Of the patients, 92.0% had either a history ofhypertension, were on anti-hypertensive medication, orwere found to be hypertensive at the time of surgery. The
mean preoperative systolic and diastolic pressures were 148and 84 mmHg, respectively (N=122/122). At 1 year, they
The effect of weight loss in the amelioration of diabetes is
were 126 and 76 mmHg, respectively, (N = 115/122;
well known The effect of laparoscopic gastric banding
Wilcoxon signed ranks test; p<0.01, p<0.01). The mean
on the metabolic profile in patients has been previously
preoperative and 1 year Mean Arterial pressure were
discussed in the literature. A recent 4-year study of obese
105.4 and 92.7, respectively (Wilcoxon signed ranks test,
patients carried out by Pontiroli et al. found that no patients
undergoing laparoscopic gastric banding progressed to type
significant link between excess weight loss and the fall in
II diabetes compared to 17% of those in the diet treatment
arm []. They concluded that in morbid obesity, sustainedand long-lasting weight loss obtained through laparoscopic
gastric banding prevents the occurrence of type II diabetes. Similarly, Ferchak et al. have concluded that weight loss
There was a statistically significant reduction in the sys-
prevents progression from IGT to diabetes [
tolic, diastolic, and mean arterial pressures over the course
One of the most recent articles on this subject by Dixon
of 1 year. There was no significant link between excess
et al. had similar conclusions. In this unblinded randomized
weight loss and the reduction of these blood pressure
controlled trial, the effect of gastric banding surgery vs
medical therapy and weight loss by life style changes indiabetics was studied. The primary outcome measure wasremission of type 2 diabetes. Although a 76% remission of
diabetes was found with gastric banding surgery, this studyonly included diabetics with a BMI between 30 and 40 and
Laparoscopic gastric banding is obviously effective in
with a relatively recent onset of diabetes [
producing weight loss over a 1-year period. Although a great
Studies examining other comorbidities such as gastro-
deal of research has been performed particularly focussing on
esophageal reflux disease, asthma, dyslipidemia, hyperten-
resolution of comorbidities with obesity surgery, studies spe-
sion, depression, arthritis, joint and back pain, stress
cifically examining comorbidity in diabetics undergoing gastric
incontinence, and sleep apnea have observed similar
banding are scant. In this study, a significant improvement in
improvements with gastric banding surgery [, ].
diabetes and associated metabolic syndrome was observed. Improvements in the metabolic profile of these diabetic obese
patients appeared to be independent of the degree of weight loss,perhaps highlighting the pivotal role of calorie restriction rather
A mean excess weight loss of 34.3% was noticed in the
than absolute weight loss in this finding
diabetics undergoing laparoscopic banding at the end of
There were no significant complications in the diabetic
1 year compared to 38% by O’Brien et al. [However, the
subset undergoing laparoscopic gastric banding emphasiz-
mean preoperative weight and BMI of patients was much
ing the low-risk nature of this treatment. These data support
higher in our series, which could explain the lower excess
the view that gastric banding is a safe intervention which
weight loss , ]. There was no statistical difference in
significantly impacts on the improvement and resolution of
the amount of weight loss between the diabetics and
type II diabetes and related metabolic syndrome in the
non-diabetics, which is contrary to earlier published
Improvement in all parameters of diabetes was noticed, and
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PORTARIA Nº 457, DE 21 DE MAIO DE 2012 Aprova o Protocolo Clínico e Diretrizes O Secretário de Atenção à Saúde, no uso das atribuições, e Considerando a necessidade de se atualizar parâmetros sobre a hepatite autoimune no Brasil e de diretrizes nacionais para diagnóstico, tratamento e acompanhamento dos indivíduos com esta doença; Considerando que os Protocolos Clínicos e Dir
Level of Agitation of Patients Presenting to an ED Level of Agitation of Psychiatric Patients Presenting to an Emergency Department Leslie S. Zun, M.D., M.B.A.; and La Vonne A. Downey, Ph.D. Received May 25, 2007; accepted Oct. 18, 2007. From the Department of Emergency Medicine, Rosalind Franklin University ofMedicine and Science/Chicago Medical School, and the Department of Object