减重手术对病态性肥胖病人糖代谢影响的研究
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摘要
背景
肥胖与许多威胁人体健康甚至影响患者寿命的疾病的发生和发展有关。肥胖人群常伴有糖代谢紊乱,发生2型糖尿病的相对风险较大。肥胖外科是外科学一个迅速发展的分支,其目的是对因肥胖而导致严重影响健康的人群进行减重治疗。国内减重手术起步较晚,目前缺乏国人肥胖患者减重手术治疗的大宗病例报道,相关基础研究较少。各种减重术式对减重及其伴发病的治疗效果不尽相同,腹腔镜迷你胃短路术作为腹腔镜Roux-en-y胃短路术的改良术式,我们于2007年11月在国内率先开展,该术式对2型糖尿病及BMI较低肥胖患者的效果有待进一步评价。脂肪组织能分泌多种脂肪细胞因子,Visfatin作为一种新发现的脂肪细胞因子,其与肥胖、糖尿病及胰岛素抵抗之间的关系尚待进一步明确。
本研究旨在通过对病态性肥胖症患者减重手术前后糖代谢状况的临床观察及相关脂肪细胞因子的实验研究,初步探讨减重手术对病态性肥胖症糖代谢紊乱的疗效及相关机制。
第一部分腹腔镜可调节胃绑带术对病态性肥胖病人糖代谢影响的研究
目的:研究腹腔镜可调节胃绑带术对病态性肥胖症病人糖代谢的影响并探讨其机制。
方法:2007年1月至2008年3月,先后对79例肥胖症患者行LAGB手术,术后随访时间至少1年。对所有患者进行术前及术后1年的糖代谢状况进行评估。2型糖尿病(T2DM)患者记录糖尿病治疗方式及发病时间。非T2DM患者根据糖耐量试验(OGTT)结果,分为糖耐量正常(NGT)及糖调节受损(IGR),其中IGR再分为空腹血糖受损(IFG)及糖耐量受损(IGT)。资料收集项目包括术前患者基本情况,术前术后糖代谢指标,体重变化指标(BMI、EWL%)、血糖变化指标(FPG、PPG、HbA1C)、胰岛素抵抗指数(HOMA-IR)及伴发病情况。数据均以均数±标准表示,单个指标手术前后的变化采用单因素重复测量的方差分析,率的比较采用x2检验。采用SPSS14.0统计软件进行统计学处理。
结果:1、所有患者均成功施行腹腔镜下手术,无严重并发症及死亡发生。2、术前诊断T2DM 15例(病史<5年者9例,病史>5年者6例),IGR(IFG/IGT) 42例,NGT 22例。术后1年T2DM治愈6例(病程<5年9例中治愈5例,病程>5年6例中治愈1例),IGR(IFG/IGT)27例,NGT37例。3、体重由术前101.3±13.2kg降至术后1年84.4±10.5kg,BMI由术前35.3±4.8 kg/m2降至术后1年29.8±3.9kg/m2,EWL%术后1年达34.5%。空腹血糖从术前5.8±2.0mmol/L降至术后1年5.2±0.9mmol/L,餐后2小时血糖从术前9.3±3.1mmol/L降至术后1年7.8±2.3mmol/L,糖化血红蛋白从术前5.8%±1.2%降至术后1年5.4%±0.9%,HOMA-IR从术前3.22±1.84降至术后1年2.13±1.04。4、术后1年,代谢综合征27例降至13例,高血压14例降至9例,血脂紊乱23例降至12例,脂肪肝69例降至42例。
结论: 1、腹腔镜可调节胃绑带术是有效治疗肥胖症的术式,手术微创、安全。2、肥胖人群糖代谢紊乱比例明显升高,腹腔镜可调节胃绑带术可有效改善肥胖人群糖代谢紊乱甚至治愈2型糖尿病,术后体重下降及胰岛素抵抗改善是其机制。3、糖尿病病程影响手术治疗效果,对肥胖病人早期干预更有效。4、腹腔镜可调节胃绑带术对肥胖患者代谢综合征及其它代谢伴发病有良好疗效。
第二部分腹腔镜胃短路术治疗肥胖症合并2型糖尿病的临床疗效
目的:研究腹腔镜胃短路术治疗肥胖症合并2型糖尿病的临床治疗疗效,探讨其治疗糖尿病的可能机制。
方法:经长海医院伦理委员会同意,2007年11月至2008年8月期间,先后对7例肥胖症合并2型糖尿病患者行腹腔镜胃短路术,其中1例行腹腔镜Roux-en-y胃短路术,6例行腹腔镜迷你胃短路术(国内率先施行)。术后随访时间至少8月。资料收集项目包括患者基本情况(年龄、性别、糖尿病治疗方式、发病时间),手术情况,术前术后体重变化指标(体重、体质量指数、腰围、腰臀比、多余体重下降百分比)、糖尿病变化指标(空腹血糖、餐后两小时血糖、糖化血红蛋白、糖尿病治疗变化、胰岛素抵抗指数、胰腺β细胞功能指数)及代谢伴发病情况。数据均以均数±标准表示,临床指标变化采用重复测量数据的方差分析。采用SPSS14.0统计软件进行统计学处理。
结果:1、全部7例病人均成功在腹腔镜下施行胃短路术,无明显并发症及死亡发生。平均手术时间120分钟,平均术后住院5天。腹腔镜迷你胃短路术操作步骤减少,手术时间更短。2、体重由术前98.6±16.6 kg降至术后12月75.3±7.7kg,BMI由术前33.6±4.7 kg/m2降至术后12月25.9±1.7 kg/m2,EWL%术后1年达72.1%。空腹血糖从术前平均7.1±1.0mmol/L降至术后12月5.0±0.7mmol/L,糖化血红蛋白从术前8.0%±1.0%降至术后12月5.7%±0.6%,HOMA-IR从术前5.38±1.73降至术后12月2.49±0.81,HOMA-β从术前100.3±47.5升至术后12月224.2±127.8。3、术后1年7例糖尿病5例治愈,2例改善;术前5例代谢综合症4例消失;术前4例伴发高血压患者3例停药后血压正常;术前血脂紊乱4例复查全部正常;术前7脂肪肝4例改善;1例糖尿病肾病治愈;1例高血压肾病改善。
结论:1、腹腔镜胃短路术是有效治疗肥胖症合并糖尿病的手术方式,术后减重效果明显,可有效改善甚至治愈2型糖尿病及其它代谢伴发病。2、腹腔镜迷你胃短路术相对简便,安全。3、胃短路术后胰岛素抵抗减轻,胰腺β细胞功能改善,提示肠-胰岛轴激素的改变可能在术后糖尿病治疗中发挥重要作用。
第三部分腹腔镜可调节胃绑带手术前后病态性肥胖病人血清脂联素及腹脂素水平变化的研究
目的:研究病态性肥胖症患者血清脂联素与腹脂素水平在腹腔镜可调节胃绑带手术前后的变化,探讨其与肥胖和2型糖尿病的关系。
方法:分别测定病态性肥胖症组(MO组,20例),病态性肥胖症伴糖尿病组(MO+T2DM组,15例)和正常对照组(NC组,20例)个体的体重、体重指数(BMI )、腰围(WC)、腰臀比(WHR)、空腹血糖(FPG)、空腹胰岛素(FINS),计算胰岛素抵抗指数(HOMA-IR),Visfatin和脂联素的测定采用酶联免疫吸附法(ELISA法)。对两组肥胖症病人施行腹腔镜下可调节胃绑带术,术后1年再次测定上述指标,并计算多余体重下降百分比(EWL%)。两组间比较用t检验及方差分析,每个指标手术前后的变化采用单因素重复测量的方差分析。以Pearson法分析Visfatin和脂联素的水平与临床各项指标关系。
结果: 1. MO组(13.9±4.3mg/L)和MO+T2DM组(9.8±3.3mg/L)血清脂联素水平低于NC组(18.8±5.4mg/L) (P<0.01),脂联素与BMI、WC、WHR、FPG、FINS及HOMA-IR呈负相关。2. MO组(25.7±8.4ng/ml)和MO+T2DM组(32.9±10.5ng/ml)血清visfatin水平高于NC组(12.8±6.7ng/ml) (P<0.01),visfatin与BMI、WC及WHR呈正相关(P<0.05)。3.术后1年,MO组和MO+T2DM组体重分别由术前105.1±9.1kg和103.8±8.65kg降至85.7±10.2kg和88.6±7.1kg (P<0.01),BMI由术前35.4±3.7和34.8±3.5降至30.1±3.2和29.7±3.5 (P<0.01),WC由术前111.5±11.1cm和109.7±7.08cm降至96.1±11.2cm和95.8±6.45cm (P<0.01),WHR由术前0.97±0.14和降至0.91±0.09和0.91±0.07 (P<0.01),FPG由术前5.6±1.4 mmol/L和6.8±1.8 mmol/L降至5.2±0.7 mmol/L和5.6±1.2 mmol/L (P<0.01),FINS由术前12.1±4.2 mIU/L和16.5±5.7mIU/L降至9.2±3.1 mIU/L和10.7±3.7 mIU/L (P<0.01),HOMA-IR由术前3.21±1.41和4.99±1.75降至2.13±0.74和2.66±1.04 (P<0.05),脂联素由术前13.9±4.3 mg/L和10.8±5.3mg/L升至16.5±5.1mg/L和12.4±5.1mg/L (P< 0.05),Visfatin由术前25.7±8.4ng/ml和30.9±10.5ng/ml降至19.3±5.9ng/ml和24.9±8.5ng/ml (P<0.05)。MO组和MO+T2DM组术后1年EWL%分别为35.1%及33.6% (P>0.05)。4.相关分析显示,术后脂联素变化与BMI、FINS变化密切相关(P<0.01),与体重、WC、FPG及HOMA-IR变化相关(P<0.05);术后visfatin变化与WC变化密切相关(P<0.01),与BMI、FINS及HOMA-IR变化相关(P<0.05)
结论: 1、在病态性肥胖症及病态性肥胖症合并2型糖尿病患者中,血清脂联素水平明显降低,血清Visfatin水平明显升高。2、LAGB手术减重可使肥胖症患者的降低的血清脂联素水平上升及升高的Visfatin水平下降。3、脂联素与中心性肥胖及胰岛素抵抗密切相关;Visfatin与中心性肥胖及胰岛素抵抗相关。
BACKGROUND
Obesity can contribute to many diseases that threaten human health even life, one of which is type 2 diabetes. Obese patients are typically at higher risk of progressing to type 2 diabetes. Bariatric surgery is a rapidly growing branch of surgical science, aiming at inducing significant weight loss in those obese patients at high risk of serious health problems. Different bariatric surgical procedures have different effects on obese patients. There has little clinical experiens and experimental research on bariatric surgery in our coutry.
In this study, we proposed a new concept of bariatric surgery in China, which focuses on the treatment of obesity related diseases, and investigated the effects of bariatric surgery on improving glycemic control of morbidly obese patients and its mechanism based on extensive clinical observations and experimental study on glucose metabolism of morbidly obese patients before and after bariatric surgery.
PartⅠThe effects of laparoscopic gastric bypass on glucose metabolism in morbid obesity
Objectives: To investigate the effects of laparoscopic adjustable gastric banding (LAGB) on glucose metabolism of morbidly obese patients and its mechanism.
Methods: Between July 2007 and March 2008, 79 morbidly obese patients underwent LAGB in our department and had at least 1 year of follow-up. We evaluated pre- and postoperative (after one year) glucose metabolism. All non-T2DM patients had oral glucose tolerance tests. Data collected included demographics, markers regarding weight loss (BMI and EWL%)、diabetes control (FPG、PPG and HbA1C) and HOMA-IR, and metabolic diseases in all patients. Mean and standard deviation were calculated for all these variables. The change in each of these markers of each patient was analyzed by variance statistical analyses of repeated measurements, the ratios comparison by X2 testing, with the aid of SPSS 14.0 software.
Results: 1. All laparoscopical operations were successfully performed and no severe complication or death occurred. 2. Of 79 patients, 15 were preoperatively diagnosed as T2DM, 42 impaired glucose regulation and 22 normal glucose tolerance. One year after surgery, 27 were impaired glucose regulation and 37 were normal glucose tolerance. 6 of 15 T2DM patients were cured. 3. After LAGB, weight decreases from 101.3±13.2 kg to 84.4±10.5kg (P<0.01), BMI from 35.3±4.8 kg/m2 to 29.8±3.9 kg/m2 (P<0.01), FPG from 5.8±2.0mmol/L to 5.2±0.9mmol/L (P<0.01), PPG from 9.3±3.1mmol/L to 7.8±2.3mmol/L (P<0.01), HbA1C from 5.8%±1.2% to 5.4%±0.9% and HOMA-IR from 3.22±1.84 to 2.13±1.04 (P<0.01), and EWL% was 34.5% . 4. 14 of 27 patients with metabolism syndrome, 5 of 14 patients with hypertension, 11 of 23 patients with dyslipidemia and 27 of 69 patients with non-alcoholic fatty liver had the result of amelioration postoperatively.
Conclusion: 1. LAGB is an effective and relatively safe procedure for morbidly obese patients. 2. Significant weight loss and IR decrease after LAGB can improve and even cure glucose metabolism disorders which occur much more frequently in obese patients. 3. The course of T2DM would have an effect on the treatment and early intervention can be more effective. 4. LAGB can also improve the treatment of MS and other obesity-related co-morbidities.
PartⅡThe efficacy of laparoscopic gastric bypass on morbid obesity with type 2 diabetes mellitus
Objective: To investigate the effects of laparoscopic gastric bypass (LGB) on improving glycemic control of morbidly obese patients with diabetes mellitus and its mechanism.
Methods: With the approved of the Hospital Ethics Committee and signed consent from all participants, seven laparoscopic gastric bypass were performed on obesity patients with T2DM between July of 2007 and August of 2008, one of which was laparoscopic Roux-en-y gastric bypass (LRYGB) and the other six, laparoscopic mini-gastric bypass (LMGB) that were performed for the first time in China. All patients had been followed up for at least 8 months.. Pre- and postoperative data, including demographics, weight, body mass index (BMI), waist circumference(WC), waist-to-hip ratio(WHR), excess weight loss percentage(EWL %), fasting plasma glucose(FPG), postprandial plasma glucose(PPG), fasting plasma insulin(FINS), glycosylated hemoglobin(HbA1C), HOMA-IR , HOMA-βand metabolic diseases in all patients, were elavated The process of the surgeries and postoperative complications were recorded., Mean and standard deviation were calculated for all these variables. The changes in these markers of each patient were analyzed by variance statistical analyses of repeated measurements with the aid of SPSS 14.0 software.
Results: 1. All laparoscopical operations were successfully performed and no complication or death occurred. Mean operation time was 120 minutes and mean postoperative hospital stay was 5.0 days. LMGB needs less operation time because of its simpler procedure. 2. One year after operation, weight decreased from 98.6±16.6 kg to 75.3±7.7kg (P<0.01), BMI from 33.6±4.7 kg/m2 to 25.9±1.7 kg/m2 (P<0.01), FPG from 7.1±1.0mmol/L to 5.0±0.7mmol/L (P<0.01), HbA1C from 8.0%±1.0% to 5.7%±0.6%, HOMA-IR from 5.38±1.73 to 2.49±0.81 (P<0.01). EWL% was 72.1% and HOMA-βincreased from 100.3±47.5 to 224.2±127.8. 3. Five patients had the result of resolution and the other two patients had the result of amelioration on T2DM postoperatively. Four of the five patients with metabolism syndrome had the result of resolution. Three of the four patients with hypertension had the result of resolution. Four patients with dyslipidemia had the result of resolution. Four of the seven patients with non-alcoholic fatty liver had the result of amelioration. One patient with diabetic nephropathy cured and one had the result of amelioration on hypertensive nephropathy.
Conclusion: 1. LGB is an effective procedure for morbidly obese patients with T2DM. It can significantly reduce weight and bring about resolution or improvement of T2DM, as well as other obesity-related comorbidities. 2. Laparoscopic mini-gastric bypass is a relatively safe and simple procedure. 3. LGB had improved insulin resistance and beta-cell function. The changes of gastroenteritic-insular axis may play a major role on the surgical treatment of diabetes mellitus.
PartⅢThe research on serum adiponectin and visfatin in morbid obesity before and after laparoscopic adjustable gastric banding
Objective: To investigate the changes of serum adiponectin and visfatin levels before and after laparoscopic gastric banding (LAGB) and its association with obesity and type 2 diabetes (T2DM).
Methods: In a prospective study, fasting serum visfatin and adiponectin concentrations were measured before and 1 year after LAGB in 20 morbidly obese patients and 15 morbidly obesity combined T2DM patients. Twenty healthy subjects with a BMI less than 25 kg/m2 served as controls. Pre- and postoperative data, including demographics, weight, body mass index (BMI), waist circumference(WC), waist-to-hip ratio(WHR), excess weight loss percentage(EWL %), fasting plasma glucose(FPG), fasting plasma insulin(FINS) and HOMA , were evaluated Serum adiponectin and visfatin levels were detected by enzyme linked immunosorbent assay (ELISA). Average preoperative and postoperative biochemical markers for the study groups were calculated and analyzed by Student’s t-test and ANOVA, and the average change in these markers within each operation group compared by Repeated Measurement Data Analysis Of Variance. The relationships between different markers were analyzed by Pearson statistics method.
Results: 1. Adiponectin serum concentrations were markedly decreased in obese subjects (13.9±4.3mg/L) and obese combined T2DM subjects (9.8±3.3mg /L) , compared with controls (18.8±5.4mg/L) (P < 0.01). The concentrations of adiponectin are inverse correlation with BMI、WC、WHR、FPG、FINS and HOMA. 2. Visfatin serum concentrations were markedly elevated in obese subjects (25.7±8.4ng/ml) and obese combined T2DM subjects (32.9±10.5ng/ml), compared with controls (12.8±6.7ng/ml) (P<0.05). The concentrations of adiponectin have direct correlation with BMI、WC and WHR. 3. One year after operation, weight decreased from 105.1±9.1kg and 103.8±8.65kg to 85.7±10.2kg and 88.6±7.1kg (P<0.01), BMI from 35.4±3.7kg/m2 and 34.8±3.5 to 30.1±3.2kg/m2 and 29.7±3.5 kg/m2 (P<0.01), WC from 111.5±11.1 and 109.7±7.08cm to 96.1±11.2 and 95.8±6.45cm (P<0.01), WHR from 0.97±0.14 and 0.96±0.12 to 0.91±0.09 and 0.91±0.07(P<0.01), FPG from 5.6±1.4 and 6.8±1.8 mmol/L to 5.2±0.7mmol/L and 5.6±1.2 mmol/L (P<0.01), FINS from 12.1±4.2 and 16.5±5.7mIU/L to 9.2±3.1mIU/L and 10.7±3.7 mIU/L (P<0.01), HOMA-IR from 3.21±1.41 and 4.99±1.75 to 2.13±0.74 and 2.66±1.04 (P<0.05),visfatin from 25.7±8.4ng/mland 30.9±10.5ng/ml to 19.3±5.9ng/ml and 24.9±8.5ng/ml (P < 0.05) in MO and MO+T2DM. Adiponectin serum concentrations increased from 13.9±4.3 mg/L and 10.8±5.3mg/L to 16.5±5.1mg/L and 12.4±5.1mg/L (P<0.05) in MO and MO+T2DM. EWL% was 35.1% in MO and 33.6% in MO+T2DM (P>0.05). 4. The changes of adiponectin were significantly associated with the changes of BMI, FINS, weight, WC、FPG and HOMA-IR. The changes of visfatin were significantly associated with the changes of BMI, FINS and HOMA-IR.
Conclusions: 1. Adiponectin serum concentrations were significantly higher and visfatin serum concentrations significantly lower in morbidly obese and whatever combined T2DM. 2. LAGB was an effective bariatric surgery. After weight loss, decreased serum adiponectin concentrations were elevated and elevated serum visfatin concentrations were reduced in morbidly obese subjects. 3. Adiponectin and Visfatin are significantly correlated with centric obesity and insulin resistance.
肥胖与许多威胁人体健康甚至影响患者寿命的疾病的发生和发展有关。肥胖人群常伴有糖代谢紊乱,发生2型糖尿病的相对风险较大。肥胖外科是外科学一个迅速发展的分支,其目的是对因肥胖而导致严重影响健康的人群进行减重治疗。国内减重手术起步较晚,目前缺乏国人肥胖患者减重手术治疗的大宗病例报道,相关基础研究较少。各种减重术式对减重及其伴发病的治疗效果不尽相同,腹腔镜迷你胃短路术作为腹腔镜Roux-en-y胃短路术的改良术式,我们于2007年11月在国内率先开展,该术式对2型糖尿病及BMI较低肥胖患者的效果有待进一步评价。脂肪组织能分泌多种脂肪细胞因子,Visfatin作为一种新发现的脂肪细胞因子,其与肥胖、糖尿病及胰岛素抵抗之间的关系尚待进一步明确。
本研究旨在通过对病态性肥胖症患者减重手术前后糖代谢状况的临床观察及相关脂肪细胞因子的实验研究,初步探讨减重手术对病态性肥胖症糖代谢紊乱的疗效及相关机制。
第一部分腹腔镜可调节胃绑带术对病态性肥胖病人糖代谢影响的研究
目的:研究腹腔镜可调节胃绑带术对病态性肥胖症病人糖代谢的影响并探讨其机制。
方法:2007年1月至2008年3月,先后对79例肥胖症患者行LAGB手术,术后随访时间至少1年。对所有患者进行术前及术后1年的糖代谢状况进行评估。2型糖尿病(T2DM)患者记录糖尿病治疗方式及发病时间。非T2DM患者根据糖耐量试验(OGTT)结果,分为糖耐量正常(NGT)及糖调节受损(IGR),其中IGR再分为空腹血糖受损(IFG)及糖耐量受损(IGT)。资料收集项目包括术前患者基本情况,术前术后糖代谢指标,体重变化指标(BMI、EWL%)、血糖变化指标(FPG、PPG、HbA1C)、胰岛素抵抗指数(HOMA-IR)及伴发病情况。数据均以均数±标准表示,单个指标手术前后的变化采用单因素重复测量的方差分析,率的比较采用x2检验。采用SPSS14.0统计软件进行统计学处理。
结果:1、所有患者均成功施行腹腔镜下手术,无严重并发症及死亡发生。2、术前诊断T2DM 15例(病史<5年者9例,病史>5年者6例),IGR(IFG/IGT) 42例,NGT 22例。术后1年T2DM治愈6例(病程<5年9例中治愈5例,病程>5年6例中治愈1例),IGR(IFG/IGT)27例,NGT37例。3、体重由术前101.3±13.2kg降至术后1年84.4±10.5kg,BMI由术前35.3±4.8 kg/m2降至术后1年29.8±3.9kg/m2,EWL%术后1年达34.5%。空腹血糖从术前5.8±2.0mmol/L降至术后1年5.2±0.9mmol/L,餐后2小时血糖从术前9.3±3.1mmol/L降至术后1年7.8±2.3mmol/L,糖化血红蛋白从术前5.8%±1.2%降至术后1年5.4%±0.9%,HOMA-IR从术前3.22±1.84降至术后1年2.13±1.04。4、术后1年,代谢综合征27例降至13例,高血压14例降至9例,血脂紊乱23例降至12例,脂肪肝69例降至42例。
结论: 1、腹腔镜可调节胃绑带术是有效治疗肥胖症的术式,手术微创、安全。2、肥胖人群糖代谢紊乱比例明显升高,腹腔镜可调节胃绑带术可有效改善肥胖人群糖代谢紊乱甚至治愈2型糖尿病,术后体重下降及胰岛素抵抗改善是其机制。3、糖尿病病程影响手术治疗效果,对肥胖病人早期干预更有效。4、腹腔镜可调节胃绑带术对肥胖患者代谢综合征及其它代谢伴发病有良好疗效。
第二部分腹腔镜胃短路术治疗肥胖症合并2型糖尿病的临床疗效
目的:研究腹腔镜胃短路术治疗肥胖症合并2型糖尿病的临床治疗疗效,探讨其治疗糖尿病的可能机制。
方法:经长海医院伦理委员会同意,2007年11月至2008年8月期间,先后对7例肥胖症合并2型糖尿病患者行腹腔镜胃短路术,其中1例行腹腔镜Roux-en-y胃短路术,6例行腹腔镜迷你胃短路术(国内率先施行)。术后随访时间至少8月。资料收集项目包括患者基本情况(年龄、性别、糖尿病治疗方式、发病时间),手术情况,术前术后体重变化指标(体重、体质量指数、腰围、腰臀比、多余体重下降百分比)、糖尿病变化指标(空腹血糖、餐后两小时血糖、糖化血红蛋白、糖尿病治疗变化、胰岛素抵抗指数、胰腺β细胞功能指数)及代谢伴发病情况。数据均以均数±标准表示,临床指标变化采用重复测量数据的方差分析。采用SPSS14.0统计软件进行统计学处理。
结果:1、全部7例病人均成功在腹腔镜下施行胃短路术,无明显并发症及死亡发生。平均手术时间120分钟,平均术后住院5天。腹腔镜迷你胃短路术操作步骤减少,手术时间更短。2、体重由术前98.6±16.6 kg降至术后12月75.3±7.7kg,BMI由术前33.6±4.7 kg/m2降至术后12月25.9±1.7 kg/m2,EWL%术后1年达72.1%。空腹血糖从术前平均7.1±1.0mmol/L降至术后12月5.0±0.7mmol/L,糖化血红蛋白从术前8.0%±1.0%降至术后12月5.7%±0.6%,HOMA-IR从术前5.38±1.73降至术后12月2.49±0.81,HOMA-β从术前100.3±47.5升至术后12月224.2±127.8。3、术后1年7例糖尿病5例治愈,2例改善;术前5例代谢综合症4例消失;术前4例伴发高血压患者3例停药后血压正常;术前血脂紊乱4例复查全部正常;术前7脂肪肝4例改善;1例糖尿病肾病治愈;1例高血压肾病改善。
结论:1、腹腔镜胃短路术是有效治疗肥胖症合并糖尿病的手术方式,术后减重效果明显,可有效改善甚至治愈2型糖尿病及其它代谢伴发病。2、腹腔镜迷你胃短路术相对简便,安全。3、胃短路术后胰岛素抵抗减轻,胰腺β细胞功能改善,提示肠-胰岛轴激素的改变可能在术后糖尿病治疗中发挥重要作用。
第三部分腹腔镜可调节胃绑带手术前后病态性肥胖病人血清脂联素及腹脂素水平变化的研究
目的:研究病态性肥胖症患者血清脂联素与腹脂素水平在腹腔镜可调节胃绑带手术前后的变化,探讨其与肥胖和2型糖尿病的关系。
方法:分别测定病态性肥胖症组(MO组,20例),病态性肥胖症伴糖尿病组(MO+T2DM组,15例)和正常对照组(NC组,20例)个体的体重、体重指数(BMI )、腰围(WC)、腰臀比(WHR)、空腹血糖(FPG)、空腹胰岛素(FINS),计算胰岛素抵抗指数(HOMA-IR),Visfatin和脂联素的测定采用酶联免疫吸附法(ELISA法)。对两组肥胖症病人施行腹腔镜下可调节胃绑带术,术后1年再次测定上述指标,并计算多余体重下降百分比(EWL%)。两组间比较用t检验及方差分析,每个指标手术前后的变化采用单因素重复测量的方差分析。以Pearson法分析Visfatin和脂联素的水平与临床各项指标关系。
结果: 1. MO组(13.9±4.3mg/L)和MO+T2DM组(9.8±3.3mg/L)血清脂联素水平低于NC组(18.8±5.4mg/L) (P<0.01),脂联素与BMI、WC、WHR、FPG、FINS及HOMA-IR呈负相关。2. MO组(25.7±8.4ng/ml)和MO+T2DM组(32.9±10.5ng/ml)血清visfatin水平高于NC组(12.8±6.7ng/ml) (P<0.01),visfatin与BMI、WC及WHR呈正相关(P<0.05)。3.术后1年,MO组和MO+T2DM组体重分别由术前105.1±9.1kg和103.8±8.65kg降至85.7±10.2kg和88.6±7.1kg (P<0.01),BMI由术前35.4±3.7和34.8±3.5降至30.1±3.2和29.7±3.5 (P<0.01),WC由术前111.5±11.1cm和109.7±7.08cm降至96.1±11.2cm和95.8±6.45cm (P<0.01),WHR由术前0.97±0.14和降至0.91±0.09和0.91±0.07 (P<0.01),FPG由术前5.6±1.4 mmol/L和6.8±1.8 mmol/L降至5.2±0.7 mmol/L和5.6±1.2 mmol/L (P<0.01),FINS由术前12.1±4.2 mIU/L和16.5±5.7mIU/L降至9.2±3.1 mIU/L和10.7±3.7 mIU/L (P<0.01),HOMA-IR由术前3.21±1.41和4.99±1.75降至2.13±0.74和2.66±1.04 (P<0.05),脂联素由术前13.9±4.3 mg/L和10.8±5.3mg/L升至16.5±5.1mg/L和12.4±5.1mg/L (P< 0.05),Visfatin由术前25.7±8.4ng/ml和30.9±10.5ng/ml降至19.3±5.9ng/ml和24.9±8.5ng/ml (P<0.05)。MO组和MO+T2DM组术后1年EWL%分别为35.1%及33.6% (P>0.05)。4.相关分析显示,术后脂联素变化与BMI、FINS变化密切相关(P<0.01),与体重、WC、FPG及HOMA-IR变化相关(P<0.05);术后visfatin变化与WC变化密切相关(P<0.01),与BMI、FINS及HOMA-IR变化相关(P<0.05)
结论: 1、在病态性肥胖症及病态性肥胖症合并2型糖尿病患者中,血清脂联素水平明显降低,血清Visfatin水平明显升高。2、LAGB手术减重可使肥胖症患者的降低的血清脂联素水平上升及升高的Visfatin水平下降。3、脂联素与中心性肥胖及胰岛素抵抗密切相关;Visfatin与中心性肥胖及胰岛素抵抗相关。
BACKGROUND
Obesity can contribute to many diseases that threaten human health even life, one of which is type 2 diabetes. Obese patients are typically at higher risk of progressing to type 2 diabetes. Bariatric surgery is a rapidly growing branch of surgical science, aiming at inducing significant weight loss in those obese patients at high risk of serious health problems. Different bariatric surgical procedures have different effects on obese patients. There has little clinical experiens and experimental research on bariatric surgery in our coutry.
In this study, we proposed a new concept of bariatric surgery in China, which focuses on the treatment of obesity related diseases, and investigated the effects of bariatric surgery on improving glycemic control of morbidly obese patients and its mechanism based on extensive clinical observations and experimental study on glucose metabolism of morbidly obese patients before and after bariatric surgery.
PartⅠThe effects of laparoscopic gastric bypass on glucose metabolism in morbid obesity
Objectives: To investigate the effects of laparoscopic adjustable gastric banding (LAGB) on glucose metabolism of morbidly obese patients and its mechanism.
Methods: Between July 2007 and March 2008, 79 morbidly obese patients underwent LAGB in our department and had at least 1 year of follow-up. We evaluated pre- and postoperative (after one year) glucose metabolism. All non-T2DM patients had oral glucose tolerance tests. Data collected included demographics, markers regarding weight loss (BMI and EWL%)、diabetes control (FPG、PPG and HbA1C) and HOMA-IR, and metabolic diseases in all patients. Mean and standard deviation were calculated for all these variables. The change in each of these markers of each patient was analyzed by variance statistical analyses of repeated measurements, the ratios comparison by X2 testing, with the aid of SPSS 14.0 software.
Results: 1. All laparoscopical operations were successfully performed and no severe complication or death occurred. 2. Of 79 patients, 15 were preoperatively diagnosed as T2DM, 42 impaired glucose regulation and 22 normal glucose tolerance. One year after surgery, 27 were impaired glucose regulation and 37 were normal glucose tolerance. 6 of 15 T2DM patients were cured. 3. After LAGB, weight decreases from 101.3±13.2 kg to 84.4±10.5kg (P<0.01), BMI from 35.3±4.8 kg/m2 to 29.8±3.9 kg/m2 (P<0.01), FPG from 5.8±2.0mmol/L to 5.2±0.9mmol/L (P<0.01), PPG from 9.3±3.1mmol/L to 7.8±2.3mmol/L (P<0.01), HbA1C from 5.8%±1.2% to 5.4%±0.9% and HOMA-IR from 3.22±1.84 to 2.13±1.04 (P<0.01), and EWL% was 34.5% . 4. 14 of 27 patients with metabolism syndrome, 5 of 14 patients with hypertension, 11 of 23 patients with dyslipidemia and 27 of 69 patients with non-alcoholic fatty liver had the result of amelioration postoperatively.
Conclusion: 1. LAGB is an effective and relatively safe procedure for morbidly obese patients. 2. Significant weight loss and IR decrease after LAGB can improve and even cure glucose metabolism disorders which occur much more frequently in obese patients. 3. The course of T2DM would have an effect on the treatment and early intervention can be more effective. 4. LAGB can also improve the treatment of MS and other obesity-related co-morbidities.
PartⅡThe efficacy of laparoscopic gastric bypass on morbid obesity with type 2 diabetes mellitus
Objective: To investigate the effects of laparoscopic gastric bypass (LGB) on improving glycemic control of morbidly obese patients with diabetes mellitus and its mechanism.
Methods: With the approved of the Hospital Ethics Committee and signed consent from all participants, seven laparoscopic gastric bypass were performed on obesity patients with T2DM between July of 2007 and August of 2008, one of which was laparoscopic Roux-en-y gastric bypass (LRYGB) and the other six, laparoscopic mini-gastric bypass (LMGB) that were performed for the first time in China. All patients had been followed up for at least 8 months.. Pre- and postoperative data, including demographics, weight, body mass index (BMI), waist circumference(WC), waist-to-hip ratio(WHR), excess weight loss percentage(EWL %), fasting plasma glucose(FPG), postprandial plasma glucose(PPG), fasting plasma insulin(FINS), glycosylated hemoglobin(HbA1C), HOMA-IR , HOMA-βand metabolic diseases in all patients, were elavated The process of the surgeries and postoperative complications were recorded., Mean and standard deviation were calculated for all these variables. The changes in these markers of each patient were analyzed by variance statistical analyses of repeated measurements with the aid of SPSS 14.0 software.
Results: 1. All laparoscopical operations were successfully performed and no complication or death occurred. Mean operation time was 120 minutes and mean postoperative hospital stay was 5.0 days. LMGB needs less operation time because of its simpler procedure. 2. One year after operation, weight decreased from 98.6±16.6 kg to 75.3±7.7kg (P<0.01), BMI from 33.6±4.7 kg/m2 to 25.9±1.7 kg/m2 (P<0.01), FPG from 7.1±1.0mmol/L to 5.0±0.7mmol/L (P<0.01), HbA1C from 8.0%±1.0% to 5.7%±0.6%, HOMA-IR from 5.38±1.73 to 2.49±0.81 (P<0.01). EWL% was 72.1% and HOMA-βincreased from 100.3±47.5 to 224.2±127.8. 3. Five patients had the result of resolution and the other two patients had the result of amelioration on T2DM postoperatively. Four of the five patients with metabolism syndrome had the result of resolution. Three of the four patients with hypertension had the result of resolution. Four patients with dyslipidemia had the result of resolution. Four of the seven patients with non-alcoholic fatty liver had the result of amelioration. One patient with diabetic nephropathy cured and one had the result of amelioration on hypertensive nephropathy.
Conclusion: 1. LGB is an effective procedure for morbidly obese patients with T2DM. It can significantly reduce weight and bring about resolution or improvement of T2DM, as well as other obesity-related comorbidities. 2. Laparoscopic mini-gastric bypass is a relatively safe and simple procedure. 3. LGB had improved insulin resistance and beta-cell function. The changes of gastroenteritic-insular axis may play a major role on the surgical treatment of diabetes mellitus.
PartⅢThe research on serum adiponectin and visfatin in morbid obesity before and after laparoscopic adjustable gastric banding
Objective: To investigate the changes of serum adiponectin and visfatin levels before and after laparoscopic gastric banding (LAGB) and its association with obesity and type 2 diabetes (T2DM).
Methods: In a prospective study, fasting serum visfatin and adiponectin concentrations were measured before and 1 year after LAGB in 20 morbidly obese patients and 15 morbidly obesity combined T2DM patients. Twenty healthy subjects with a BMI less than 25 kg/m2 served as controls. Pre- and postoperative data, including demographics, weight, body mass index (BMI), waist circumference(WC), waist-to-hip ratio(WHR), excess weight loss percentage(EWL %), fasting plasma glucose(FPG), fasting plasma insulin(FINS) and HOMA , were evaluated Serum adiponectin and visfatin levels were detected by enzyme linked immunosorbent assay (ELISA). Average preoperative and postoperative biochemical markers for the study groups were calculated and analyzed by Student’s t-test and ANOVA, and the average change in these markers within each operation group compared by Repeated Measurement Data Analysis Of Variance. The relationships between different markers were analyzed by Pearson statistics method.
Results: 1. Adiponectin serum concentrations were markedly decreased in obese subjects (13.9±4.3mg/L) and obese combined T2DM subjects (9.8±3.3mg /L) , compared with controls (18.8±5.4mg/L) (P < 0.01). The concentrations of adiponectin are inverse correlation with BMI、WC、WHR、FPG、FINS and HOMA. 2. Visfatin serum concentrations were markedly elevated in obese subjects (25.7±8.4ng/ml) and obese combined T2DM subjects (32.9±10.5ng/ml), compared with controls (12.8±6.7ng/ml) (P<0.05). The concentrations of adiponectin have direct correlation with BMI、WC and WHR. 3. One year after operation, weight decreased from 105.1±9.1kg and 103.8±8.65kg to 85.7±10.2kg and 88.6±7.1kg (P<0.01), BMI from 35.4±3.7kg/m2 and 34.8±3.5 to 30.1±3.2kg/m2 and 29.7±3.5 kg/m2 (P<0.01), WC from 111.5±11.1 and 109.7±7.08cm to 96.1±11.2 and 95.8±6.45cm (P<0.01), WHR from 0.97±0.14 and 0.96±0.12 to 0.91±0.09 and 0.91±0.07(P<0.01), FPG from 5.6±1.4 and 6.8±1.8 mmol/L to 5.2±0.7mmol/L and 5.6±1.2 mmol/L (P<0.01), FINS from 12.1±4.2 and 16.5±5.7mIU/L to 9.2±3.1mIU/L and 10.7±3.7 mIU/L (P<0.01), HOMA-IR from 3.21±1.41 and 4.99±1.75 to 2.13±0.74 and 2.66±1.04 (P<0.05),visfatin from 25.7±8.4ng/mland 30.9±10.5ng/ml to 19.3±5.9ng/ml and 24.9±8.5ng/ml (P < 0.05) in MO and MO+T2DM. Adiponectin serum concentrations increased from 13.9±4.3 mg/L and 10.8±5.3mg/L to 16.5±5.1mg/L and 12.4±5.1mg/L (P<0.05) in MO and MO+T2DM. EWL% was 35.1% in MO and 33.6% in MO+T2DM (P>0.05). 4. The changes of adiponectin were significantly associated with the changes of BMI, FINS, weight, WC、FPG and HOMA-IR. The changes of visfatin were significantly associated with the changes of BMI, FINS and HOMA-IR.
Conclusions: 1. Adiponectin serum concentrations were significantly higher and visfatin serum concentrations significantly lower in morbidly obese and whatever combined T2DM. 2. LAGB was an effective bariatric surgery. After weight loss, decreased serum adiponectin concentrations were elevated and elevated serum visfatin concentrations were reduced in morbidly obese subjects. 3. Adiponectin and Visfatin are significantly correlated with centric obesity and insulin resistance.
引文
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