腹腔镜袖状胃切除术治疗肥胖合并非酒精性脂肪性肝病的疗效分析
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摘要
目的分析腹腔镜袖状胃切除术(laparoscopic sleeve gastrectomy,LSG)治疗肥胖合并非酒精性脂肪性肝病(nonalcoholic fatty liver disease,NAFLD)病人的短期临床疗效。方法回顾性分析2017年8月至2018年12月在武汉大学中南医院肝胆胰外科收治的行LSG的60例肥胖合并NAFLD病人的临床资料,术后随访3～6个月,评估术后体重、糖脂代谢、肝功能指标的变化,并采用无创性肝脏瞬时弹性超声(FibroTouch)测定肝脏的硬度值(liver stiffness measure,LSM)和脂肪受控衰减参数(fat controlled attenuation parameter,CAP)。聚焦分析手术对胰岛素抵抗、肝脏脂肪含量和肝纤维化情况的影响。结果术前的体质量指数(body mass index,BMI)与LSM和CAP呈显著正相关(P<0.05),无创性肝纤维化指标与LSM和CAP呈显著正相关(P<0.05),胰岛素抵抗模型与CAP呈显著正相关(P<0.05)。术后平均随访4个月(3.13～5.97个月):多余体重减少百分比为(73.2±12.6)%;BMI、空腹血糖、糖化血红蛋白、总胆固醇、三酰甘油均显著降低(P<0.05);高密度脂蛋白胆固醇显著增加(P<0.05)。转氨酶、胰岛素抵抗模型、无创性肝纤维化指标、LSM和CAP显著降低(P<0.05)。术前51.6%的病人进展期肝纤维化(F3以上),术后降为21.4%。术前所有病人均有脂肪肝,轻、中、重度脂肪肝分别占1.7%、8.3%、90.0%,术后25.0%病人恢复正常,轻、中、重度脂肪肝占比为14.3%、25.0%、35.7%。结论 LSG可有效治疗肥胖合并NAFLD,近期效果显著。
Objective To analyze the short-term clinical efficacy of laparoscopic sleeve gastrectomy(LSG)in patients with obesity complicated with nonalcoholic fatty liver disease(NAFLD). Method The clinical data of 60 obese patients with NAFLD who underwent LSG in the Department of Hepatobiliary and Pancreatic Surgery of Zhongnan Hospital of Wuhan University from August 2017 to December 2018 were retrospectively analyzed. The patients were followed up for 3 to 6 months after operation to evaluate the changes of postoperative weight,glucose and lipid metabolism,and liver function parameters. Liver stiffness measurement(LSM) and fat controlled attenuation parameter(CAP)were determined by non-invasive liver Transient Elastography ultrasound(TE,FibroTouch-B). The effects of bariatric surgery on insulin resistance,liver fat content,and liver fibrosis were evaluated. Results Preoperative BMI was significant positively correlated with LSM and CAP(P<0.05),and the non-invasive liver fibrosis index APRI score was positively correlated with LSM and CAP(P<0.05),and insulin resistance model was positively correlated with CAP(P<0.05). After an average follow-up of 4 months(3.13-5.97 months):the percentage of excess weight loss was(73.2±12.6)%; BMI,fasting blood glucose,glycosylated hemoglobin,total cholesterol and triacylglycerol were significantly decreased(P<0.05); high-density lipoprotein cholesterol was significantly increased(P<0.05). Transaminases,insulin resistance model,noninvasive liver fibrosis index,LSM and CAP were significantly decreased(P<0.05). 51.6% of patients had advanced liver fibrosis(F3 or higher)before surgery,which decreased to 21.4% after surgery. All patients had fatty liver before operation. Mild,moderate and severe fatty liver accounted for 1.7%,8.3% and 90.0% respectively. 25.0% patients recovered to normal after operation. Mild,moderate and severe fatty liver accounted for 14.3%,25.0% and 35.7% respectively. Conclusion The Laparoscopic sleeve gastrectomy(LSG) is an effective treatment for obesity combined with NAFLD,and it has a significantly short-term effect.
Objective To analyze the short-term clinical efficacy of laparoscopic sleeve gastrectomy(LSG)in patients with obesity complicated with nonalcoholic fatty liver disease(NAFLD). Method The clinical data of 60 obese patients with NAFLD who underwent LSG in the Department of Hepatobiliary and Pancreatic Surgery of Zhongnan Hospital of Wuhan University from August 2017 to December 2018 were retrospectively analyzed. The patients were followed up for 3 to 6 months after operation to evaluate the changes of postoperative weight,glucose and lipid metabolism,and liver function parameters. Liver stiffness measurement(LSM) and fat controlled attenuation parameter(CAP)were determined by non-invasive liver Transient Elastography ultrasound(TE,FibroTouch-B). The effects of bariatric surgery on insulin resistance,liver fat content,and liver fibrosis were evaluated. Results Preoperative BMI was significant positively correlated with LSM and CAP(P<0.05),and the non-invasive liver fibrosis index APRI score was positively correlated with LSM and CAP(P<0.05),and insulin resistance model was positively correlated with CAP(P<0.05). After an average follow-up of 4 months(3.13-5.97 months):the percentage of excess weight loss was(73.2±12.6)%; BMI,fasting blood glucose,glycosylated hemoglobin,total cholesterol and triacylglycerol were significantly decreased(P<0.05); high-density lipoprotein cholesterol was significantly increased(P<0.05). Transaminases,insulin resistance model,noninvasive liver fibrosis index,LSM and CAP were significantly decreased(P<0.05). 51.6% of patients had advanced liver fibrosis(F3 or higher)before surgery,which decreased to 21.4% after surgery. All patients had fatty liver before operation. Mild,moderate and severe fatty liver accounted for 1.7%,8.3% and 90.0% respectively. 25.0% patients recovered to normal after operation. Mild,moderate and severe fatty liver accounted for 14.3%,25.0% and 35.7% respectively. Conclusion The Laparoscopic sleeve gastrectomy(LSG) is an effective treatment for obesity combined with NAFLD,and it has a significantly short-term effect.
引文
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[16] 柯重伟,蔡景理.减重手术对肥胖症合并非酒精性脂肪性肝病的治疗[J].内科理论与实践,2008,3(1):34-36.
[17] 黄婷婷,周玉荣,张向军,等.非酒精性脂肪肝治疗进展[J].医学综述,2015,21(8):1406-1409.
[18] 李震,冯毕龙,李丽君,等.袖状胃切除术在减重代谢外科中的发展及应用价值[J/CD].中华肥胖与代谢病电子杂志,2017,3(4):226-230.DOI :10.3877/cma.j.issn.2095-9605.2017.04.009.
[19] Magouliotis DE,Tasiopoulou VS,Sioka E.Impact of Bariatric Surgery on Metabolic and Gut Microbiota Profile:a Systematic Review and Meta-analysis[J].Obes Surg,2017,27(5):1345-1357.DOI:10.1007/s11695-017-2595-8.
[20] Kellerer T,Brandl B,Büttner J,et al.Impact of laparoscopic sleeve gastrectomy on gut permeability in morbidly obese subjects[J].Obes Surg,2019,29(7):2132-2143.DOI:10.1007/s11695-019-03815-6.
[21] 曾静,孙婉璐,陈光榆,等.FibroTouch与FibroScan?肝脏硬度和脂肪定量检测效能的比较[J].中华肝脏病杂志,2016,24(9):652-658.DOI:10.3760/cma.j.issn.1007-3418.2016.09.004.
[2] Ng M,Fleming T,Robinson M,et al.Global,regional,and national prevalence of overweight and obesity in children and adults during 1980-2013:a systematic analysis for the Global Burden of Disease Study 2013[J].Lancet,2014,384(9945):766-781.DOI:10.1016/S0140-6736(14)60460-8.
[3] Zhang XQ,Xu CF,Yu CH,et al.Role of endoplasmic reticulum stress in the pathogenesis of nonalcoholic fatty liver disease[J].World J Gastroenterol,2014,20(7):1768-1776.DOI:10.3748/wjg.v20.i7.1768.
[4] Chalasani N,Younossi Z,Lavine J,et al.The diagnosis and management of nonalcoholic fatty liver disease:Practice guidance from the American Association for the Study of Liver Diseases[J].Hepatology,2018,67(1):328-357.DOI:10.1002/hep.29367.
[5] Dulai PS,Singh S,Patel J,et al.Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease:Systematic review and meta-analysis[J].Hepatology,2017,65(5):1557-1565.DOI:10.1002/hep.29085.
[6] Grohmann M,Wiede F,Dodd GT,et al.Obesity Drives STAT-1-Dependent NASH and STAT-3-Dependent HCC[J].Cell,2018,175(5):1289-1306.e20.DOI:10.1016/j.cell.2018.09.053.
[7] Zhang Y,Wang W,Yang C,et al.Improvement in Nocturnal Hypoxemia in Obese Patients with Obstructive Sleep Apnea after Bariatric Surgery:a Meta-Analysis[J].Obes Surg,2019,29(2):601-608.DOI:10.1007/s11695-018-3573-5.
[8] Salminen P,Helmio M,Ovaska J,et al.Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity:The SLEEVEPASS Randomized Clinical Trial[J].JAMA,2018,319(3):241-254.DOI:10.1001/jama.2017.20313.
[9] Jakobsen GS,Smastuen MC,Sandbu R,et al.Association of bariatric surgery vs medical obesity treatment with long-term medical complications and obesity-related comorbidities[J].JAMA,2018,319(3):291-301.DOI:10.1001/jama.2017.21055.
[10] 朱梦飞,刘静,王洁,等.FibroTouch 及 FibroScan?实施受控衰减参数评价肝细胞脂肪变与肝脏病理比较分析[J].中国实用内科杂志,2014,34(6):589-593.DOI:10.7504/nk2014050402.
[11] Karlas T,Petroff D,Sasso M,et al.Individual patient data Meta-analysis of controlled attenuation parameter(CAP)technology for assessing steatosis[J].J Hepatol,2017,66(5):1022-1030.DOI:10.1016/j.jhep.2016.12.022.
[12] Garg H,Aggarwal S,Shalimar,et al.Utility of transient elastography(fibroscan)and impact of bariatric surgery on nonalcoholic fatty liver disease(NAFLD)in morbidly obese patients[J].Surg Obes Relat Dis,2018,14(1):81-91.DOI:10.1016/j.soard.2017.09.005.
[13] Zeng J,Sun WL,Chen GY,et al.Efficiency of FibroScan? and FibroTouch in liver stiffness measurement and fat quantification:a comparative analysis[J].Zhonghua Gan Zang Bing Za Zhi,2016,24(9):652-658.DOI:10.3760/cma.j.issn.1007-3418.2016.09.004.
[14] Siddiqui MS,Yamada G,Vuppalanchi R,et al.Diagnostic accuracy of noninvasive fibrosis models to detect change in fibrosis stage[J].Clin Gastroenterol Hepatol,2019,pii:S1542-3565(19)30004-7.DOI:10.1016/j.cgh.2018.12.031.[Epub ahead of print]
[15] Esquivel CM,Garcia M,Armando L,et al.Laparoscopic Sleeve Gastrectomy Resolves NAFLD:Another Formal Indication for Bariatric Surgery?[J].Obes Surg,2018,28(12):4022-4033.DOI:10.1007/s11695-018-3466-7.
[16] 柯重伟,蔡景理.减重手术对肥胖症合并非酒精性脂肪性肝病的治疗[J].内科理论与实践,2008,3(1):34-36.
[17] 黄婷婷,周玉荣,张向军,等.非酒精性脂肪肝治疗进展[J].医学综述,2015,21(8):1406-1409.
[18] 李震,冯毕龙,李丽君,等.袖状胃切除术在减重代谢外科中的发展及应用价值[J/CD].中华肥胖与代谢病电子杂志,2017,3(4):226-230.DOI :10.3877/cma.j.issn.2095-9605.2017.04.009.
[19] Magouliotis DE,Tasiopoulou VS,Sioka E.Impact of Bariatric Surgery on Metabolic and Gut Microbiota Profile:a Systematic Review and Meta-analysis[J].Obes Surg,2017,27(5):1345-1357.DOI:10.1007/s11695-017-2595-8.
[20] Kellerer T,Brandl B,Büttner J,et al.Impact of laparoscopic sleeve gastrectomy on gut permeability in morbidly obese subjects[J].Obes Surg,2019,29(7):2132-2143.DOI:10.1007/s11695-019-03815-6.
[21] 曾静,孙婉璐,陈光榆,等.FibroTouch与FibroScan?肝脏硬度和脂肪定量检测效能的比较[J].中华肝脏病杂志,2016,24(9):652-658.DOI:10.3760/cma.j.issn.1007-3418.2016.09.004.