减重代谢手术围手术期管理的几个关键问题
|
摘要
近年来,减重代谢手术广泛开展,由于肥胖及糖尿病病人自身的特殊性,围手术期的管理也有其特殊性。关键问题包括:术前的诊断和鉴别诊断、术前合并症的处理、术前和术后干预等。术前减重可以降低手术难度,减少并发症发生,而围手术期的睡眠呼吸暂停综合征的处理相对复杂。另外,在深静脉血栓的预防方面,东西方国家可能有所差异。
Bariatric and metabolic surgery has gained its rapid development recently. However,their perioperative management remains special due to the complex nature of obesity and type 2 diabetes mellitus. Special attention regarding the perioperative management of bariatric and metabolic surgery includes preoperative diagnosis and differential diagnosis, management of obesity related preoperative comorbidities, preoperative and postoperative management. Preoperative weight loss could decrease the surgical difficulty and surgical related compilations.Perioperative management of obstructive sleep apnea syndrome is relatively complicated. Meanwhile,measures regarding the deep venous thromboembolism prophylaxis are different in eastern and western countries.
Bariatric and metabolic surgery has gained its rapid development recently. However,their perioperative management remains special due to the complex nature of obesity and type 2 diabetes mellitus. Special attention regarding the perioperative management of bariatric and metabolic surgery includes preoperative diagnosis and differential diagnosis, management of obesity related preoperative comorbidities, preoperative and postoperative management. Preoperative weight loss could decrease the surgical difficulty and surgical related compilations.Perioperative management of obstructive sleep apnea syndrome is relatively complicated. Meanwhile,measures regarding the deep venous thromboembolism prophylaxis are different in eastern and western countries.
引文
[1]Carli F,Zavorsky GS.Optimizing functional exercise capacity in the elderly surgical population[J].Curr Opin Clin Nutr Metab Care,2005,8(1):23-32.
[2]Topp R,Swank AM,Quesada PM,et al.The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty[J].PM R,2009,1(8):729-735.
[3]Valkenet K,Port I,Dronkers J,et al.The effects of preoperative exercise therapy on postoperative outcome:a systematic review[J].Clin Rehabil,2011,25(2):99-111.
[4]Lemanu DP,Singh PP,MacCormick AD,et al.Effect of preoperative exercise on cardiorespiratory function and recovery after surgery:a systematic review[J].World J Surg,2013,37(4):711-720.
[5]Mills E,Eyawo O,Lockhart I,et al.Smoking cessation reduces postoperative complications:a systematic review and meta-analysis[J].Am J Med,2011,124(2):144-154.
[6]Best MJ,Buller LT,Gosthe RG,et al.Alcohol misuse is an independent risk factor for poorer postoperative outcomes following primary total hip and total knee arthroplasty[J].J Arthroplasty,2015,30(8):1293-1298.
[7]Nath B,Li Y,Carroll JE,et al.Alcohol exposure as a risk factor for adverse outcomes in elective surgery[J].J GastrointestSurg,2010,14:1732-1741.
[8]Ostlund MP,Backman O,Marsk R,et al.Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery[J].JAMA Surg,2013,148(4):374-377.
[9]Edholm D,Kullberg J,Haenni A,et al.Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat,and facilitates laparoscopic gastric bypass in morbidly obese[J].Obes Surg,2011,21(3):345-350.
[10]Van Nieuwenhove Y,Dambrauskas Z,Campillo-Soto A,et al.Preoperativevery low-calorie diet and operative outcome after laparoscopic gastric bypass:a randomized multicenter study[J].Arch Surg,2011,146(11):1300-1305.
[11]Cassie S,Menezes C,Birch DW,et al.Effect of preoperative weight loss in bariatric surgical patients:a systematic review[J].Surg Obes Relat Dis,2011,7(6):760-767.
[12]Anderin C,Gustafsson UO,Heijbel N,et al.Weight loss before bariatric surgery and postoperative complications:data from the Scandinavian Obesity Registry(SOReg)[J].Ann Surg,2015,261(5):909-913.
[13]Livhits M,Mercado C,Yermilov I,et al.Does weight loss immediately before bariatric surgery improve outcomes:a systematic review[J].Surg Obes Relat Dis,2009,5(6):713-721.
[14]Thorell A,Hagstrom-Toft E.Treatment of diabetes prior to and after bariatric surgery[J].J Diabetes Sci Technol,2012,6(5):1226-1232.
[15]Harter RL,Kelly WB,Kramer MG,et al.A comparison of the volume and pH of gastric contents of obese and lean surgical patients[J].Anesth Analg,1998,86(1):147-152.
[16]Maltby JR,Pytka S,Watson NC,et al.Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients[J].Can J Anaesth,2004,51(2):111-115.
[17]Maltby JR.Fasting from midnight:the history behind the dogma[J].Best Pract Res Clin Anaesthesiol,2006,20(3):363-378.
[18]Siyam M,Benhamou D.Anaesthetic management of adult patients with obstructive sleep apnea syndrome[J].Ann Fr Anesth Reanim,2007,26(1):39-52.
[19]Ziemann-Gimmel P,Hensel P,Koppman J,et al.Multi-modal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery[J].Surg Obes Relat Dis,2013,9(6):975-980.
[20]Chaparro LE,Clarke H,Valdes PA,et al.Adding prega-balin to a multimodal analgesic regimen does not reduce pain scores following cosmetic surgery:a randomized trial[J].J Anesth,2012,26(6):829-835.
[21]于一凡,王勇,刘金钢.减重手术228例术后并发症分析[J].中国实用外科杂志,2015,35(5):552-554.
[22]Frey WC,Pilcher J.Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery[J].Obes Surg,2003,13(5):676-683.
[23]Beaussier M,Bouaziz H,Aubrun F,et al.Wound infil-tration with local anesthetics for postoperative analgesia.Results of a national survey about its practice in France[J].Ann Fr Anesth Reanim,2012,31:120-125.
[24]Alkhamesi NA,Kane JM,Guske PJ,et al.Intraperitoneal aerosolization of bupivacaine is a safe and effective method in controlling postoperative pain in laparoscopic Roux-en-Y gastric bypass[J].J Pain Res,2008,1:9-13.
[25]Wassef M,Lee DY,Levine JL,et al.Feasibility and analgesic efficacy of the transversus abdominis plane block after singleport laparoscopy in patients having bariatric surgery[J].J Pain Res,2013,6:837-841.
[26]Mechanick JI,Kushner RF,Sugerman HJ,et al.American Association of Clinical Endocrinologists.The Obesity Society,and American Society for Metabolic&Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional,metabolic,and nonsurgical support of the bariatric surgery patient[J].EndocrPract,2008,14(suppl 1):1-83.
[27]吴良平,文其武,曾松华,等.腹腔镜胃旁路术治疗2型糖尿病44例疗效分析[J].中国实用外科杂志,2014,34(11):1060-1063.
[28]Brolin RE.Gastric bypass[J].Surg Clin North Am,2001,81(5):1077-1095.
[29]Eichenberger A,Proietti S,Wicky S,et al.Morbid obesity and postoperative pulmonary atelectasis:an underestimated problem[J].Anesth Analg,2002,95(6):1788-1792.
[30]Fleischmann E,Kurz A,Niedermayr M,et al.Tissue oxygenation in obese and non-obese patients during laparoscopy[J].Obes Surg,2005,15(6):813-819.
[31]Chung F,Subramanyam R,Liao P,et al.High STOP-Bang score indicates a high probability of obstructive sleep apnoea[J].Br J Anaesth,2012,108(5):768-775.
[32]Mehta V,Vasu TS,Phillips B,et al.Obstructive sleep apnea and oxygen therapy:a systematic review of the literature and meta-analysis[J].J Clin Sleep Med,2013,9(3):271-279.
[33]Lindberg E,Berne C,Elmasry A,et al.CPAP treatment of a population-based sample-what are the benefits and the treatment compliance?[J].Sleep Med,2006,7(7):553-560,.
[34]DeMaria EJ,Portenier D,Wolfe L.Obesity surgery mortality risk score:proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass[J].Surg Obes Relat Dis,2007,3(2):134-140.
[35]Rennotte MT,Baele P,Aubert G,et al.Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery[J].Chest,1995,107(2):367-374.
[36]Steele KE,Prokopowicz GP,Chang HY,et al.Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus[J].Surg Obes Relat Dis,2012,8(3):305-330.
[37]Gould MK,Garcia DA,Wren SM,et al.Prevention of VTE in nonorthopedic surgical patients:antithrombotic therapy and prevention of thrombosis,9th ed:American College of Chest Physicians evidence-based clinical practice guide-lines[J].Chest,2012,141(suppl):e227-e277.
[38]Froehling DA,Daniels PR,Mauck KF,et al.Incidence of venous thromboembo-lism after bariatric surgery:a populationbased cohort study[J].Obes Surg,2013,23(11):1874-1879.
[39]Rajasekhar A,Streiff MB.Vena cava filters for management of venous thromboembolism:a clinical review[J].Blood Rev,2013,27(5):225-241.
[2]Topp R,Swank AM,Quesada PM,et al.The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty[J].PM R,2009,1(8):729-735.
[3]Valkenet K,Port I,Dronkers J,et al.The effects of preoperative exercise therapy on postoperative outcome:a systematic review[J].Clin Rehabil,2011,25(2):99-111.
[4]Lemanu DP,Singh PP,MacCormick AD,et al.Effect of preoperative exercise on cardiorespiratory function and recovery after surgery:a systematic review[J].World J Surg,2013,37(4):711-720.
[5]Mills E,Eyawo O,Lockhart I,et al.Smoking cessation reduces postoperative complications:a systematic review and meta-analysis[J].Am J Med,2011,124(2):144-154.
[6]Best MJ,Buller LT,Gosthe RG,et al.Alcohol misuse is an independent risk factor for poorer postoperative outcomes following primary total hip and total knee arthroplasty[J].J Arthroplasty,2015,30(8):1293-1298.
[7]Nath B,Li Y,Carroll JE,et al.Alcohol exposure as a risk factor for adverse outcomes in elective surgery[J].J GastrointestSurg,2010,14:1732-1741.
[8]Ostlund MP,Backman O,Marsk R,et al.Increased admission for alcohol dependence after gastric bypass surgery compared with restrictive bariatric surgery[J].JAMA Surg,2013,148(4):374-377.
[9]Edholm D,Kullberg J,Haenni A,et al.Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat,and facilitates laparoscopic gastric bypass in morbidly obese[J].Obes Surg,2011,21(3):345-350.
[10]Van Nieuwenhove Y,Dambrauskas Z,Campillo-Soto A,et al.Preoperativevery low-calorie diet and operative outcome after laparoscopic gastric bypass:a randomized multicenter study[J].Arch Surg,2011,146(11):1300-1305.
[11]Cassie S,Menezes C,Birch DW,et al.Effect of preoperative weight loss in bariatric surgical patients:a systematic review[J].Surg Obes Relat Dis,2011,7(6):760-767.
[12]Anderin C,Gustafsson UO,Heijbel N,et al.Weight loss before bariatric surgery and postoperative complications:data from the Scandinavian Obesity Registry(SOReg)[J].Ann Surg,2015,261(5):909-913.
[13]Livhits M,Mercado C,Yermilov I,et al.Does weight loss immediately before bariatric surgery improve outcomes:a systematic review[J].Surg Obes Relat Dis,2009,5(6):713-721.
[14]Thorell A,Hagstrom-Toft E.Treatment of diabetes prior to and after bariatric surgery[J].J Diabetes Sci Technol,2012,6(5):1226-1232.
[15]Harter RL,Kelly WB,Kramer MG,et al.A comparison of the volume and pH of gastric contents of obese and lean surgical patients[J].Anesth Analg,1998,86(1):147-152.
[16]Maltby JR,Pytka S,Watson NC,et al.Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients[J].Can J Anaesth,2004,51(2):111-115.
[17]Maltby JR.Fasting from midnight:the history behind the dogma[J].Best Pract Res Clin Anaesthesiol,2006,20(3):363-378.
[18]Siyam M,Benhamou D.Anaesthetic management of adult patients with obstructive sleep apnea syndrome[J].Ann Fr Anesth Reanim,2007,26(1):39-52.
[19]Ziemann-Gimmel P,Hensel P,Koppman J,et al.Multi-modal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery[J].Surg Obes Relat Dis,2013,9(6):975-980.
[20]Chaparro LE,Clarke H,Valdes PA,et al.Adding prega-balin to a multimodal analgesic regimen does not reduce pain scores following cosmetic surgery:a randomized trial[J].J Anesth,2012,26(6):829-835.
[21]于一凡,王勇,刘金钢.减重手术228例术后并发症分析[J].中国实用外科杂志,2015,35(5):552-554.
[22]Frey WC,Pilcher J.Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery[J].Obes Surg,2003,13(5):676-683.
[23]Beaussier M,Bouaziz H,Aubrun F,et al.Wound infil-tration with local anesthetics for postoperative analgesia.Results of a national survey about its practice in France[J].Ann Fr Anesth Reanim,2012,31:120-125.
[24]Alkhamesi NA,Kane JM,Guske PJ,et al.Intraperitoneal aerosolization of bupivacaine is a safe and effective method in controlling postoperative pain in laparoscopic Roux-en-Y gastric bypass[J].J Pain Res,2008,1:9-13.
[25]Wassef M,Lee DY,Levine JL,et al.Feasibility and analgesic efficacy of the transversus abdominis plane block after singleport laparoscopy in patients having bariatric surgery[J].J Pain Res,2013,6:837-841.
[26]Mechanick JI,Kushner RF,Sugerman HJ,et al.American Association of Clinical Endocrinologists.The Obesity Society,and American Society for Metabolic&Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional,metabolic,and nonsurgical support of the bariatric surgery patient[J].EndocrPract,2008,14(suppl 1):1-83.
[27]吴良平,文其武,曾松华,等.腹腔镜胃旁路术治疗2型糖尿病44例疗效分析[J].中国实用外科杂志,2014,34(11):1060-1063.
[28]Brolin RE.Gastric bypass[J].Surg Clin North Am,2001,81(5):1077-1095.
[29]Eichenberger A,Proietti S,Wicky S,et al.Morbid obesity and postoperative pulmonary atelectasis:an underestimated problem[J].Anesth Analg,2002,95(6):1788-1792.
[30]Fleischmann E,Kurz A,Niedermayr M,et al.Tissue oxygenation in obese and non-obese patients during laparoscopy[J].Obes Surg,2005,15(6):813-819.
[31]Chung F,Subramanyam R,Liao P,et al.High STOP-Bang score indicates a high probability of obstructive sleep apnoea[J].Br J Anaesth,2012,108(5):768-775.
[32]Mehta V,Vasu TS,Phillips B,et al.Obstructive sleep apnea and oxygen therapy:a systematic review of the literature and meta-analysis[J].J Clin Sleep Med,2013,9(3):271-279.
[33]Lindberg E,Berne C,Elmasry A,et al.CPAP treatment of a population-based sample-what are the benefits and the treatment compliance?[J].Sleep Med,2006,7(7):553-560,.
[34]DeMaria EJ,Portenier D,Wolfe L.Obesity surgery mortality risk score:proposal for a clinically useful score to predict mortality risk in patients undergoing gastric bypass[J].Surg Obes Relat Dis,2007,3(2):134-140.
[35]Rennotte MT,Baele P,Aubert G,et al.Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery[J].Chest,1995,107(2):367-374.
[36]Steele KE,Prokopowicz GP,Chang HY,et al.Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus[J].Surg Obes Relat Dis,2012,8(3):305-330.
[37]Gould MK,Garcia DA,Wren SM,et al.Prevention of VTE in nonorthopedic surgical patients:antithrombotic therapy and prevention of thrombosis,9th ed:American College of Chest Physicians evidence-based clinical practice guide-lines[J].Chest,2012,141(suppl):e227-e277.
[38]Froehling DA,Daniels PR,Mauck KF,et al.Incidence of venous thromboembo-lism after bariatric surgery:a populationbased cohort study[J].Obes Surg,2013,23(11):1874-1879.
[39]Rajasekhar A,Streiff MB.Vena cava filters for management of venous thromboembolism:a clinical review[J].Blood Rev,2013,27(5):225-241.