减肥手术对肥胖症合并2型糖尿病的近期疗效评价
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摘要
目的
目前肥胖患者数量迅速增长,减肥手术已经成为治疗肥胖症的最有效手段之一,近年来研究发现,减肥手术治疗肥胖症的同时,对其合并的2型糖尿病(T2DM)有治疗作用。本研究旨在评价现行的三种腹腔镜减肥手术对肥胖症合并T2DM的近期治疗效果,从而为T2DM的手术治疗提供临床依据。
方法
选择2007年至2009年于中国医科大学附属盛京医院进行腹腔镜减肥手术的肥胖症合并2型糖尿病患者15例,其中6例施行腹腔镜可调节胃捆扎带手术(LAGB),5例施行腹腔镜袖状胃切除术(LSG),4例施行腹腔镜胃旁路手术(LGB),术后进行至少6个月的随访,采集每名患者术后1,3,6个月BMI(体重指数)、FPG(空腹血糖)及HbAlc[糖化血红蛋白)值,计算相应的EBMIL%(多余体重指数减少百分比)、△FPG%(空腹血糖减少百分比)及△HbAlc%(糖化血红蛋白减少百分比)。结果应用统计学方法分析。
结果
各组患者术后1,3,6个月BMI、FPG及HbAlc水平均呈现出程度不同的改善。比较术后各随访时间点各组患者EBMIL%(多余体重指数减少百分比)、△FPG%(空腹血糖减少百分比)及△HbAlc%(糖化血红蛋白减少百分比),LAGB组与LSG组相比较在三者差异不大(P>0.05)；LGB组与LSG组、LGB组与LAGB组则在三者均有统计学差异(P<0.05)。即认为：施行腹腔镜胃旁路手术组患者的近期减重和对2型糖尿病治疗效果均较施行腹腔镜可调节胃捆扎带手术或袖状胃切除术患者的疗效明显。而施行腹腔镜可调节胃捆扎带手术与袖状胃切除术患者的减重及2型糖尿病治疗效果无明显差异。
结论
因为LGB的近期减重效果及对2型糖尿病治疗效果更加明显,但因手术创伤及难度较大,术后并发症较多,且可能出现吸收不良、贫血、骨质疏松等较多长期并发症,故适用于年龄偏大,肥胖症或合并的2型糖尿病病情严重的患者,以达到快速减重及缓解2型糖尿病病情的目的。LSG及LGB术后近期的减重及对糖尿病疗效肯定,差异不大,但LSG应用前景更为广阔,因此年轻、肥胖症或合并的2型糖尿病病情较轻的患者,更适用于LSG,以避免LGB长期并发症出现。
Objective
The number of obesity quickly increases currently, bariatric surgery has become one of the most effect methods for therapy of obese patient. Study in recent years found that the bariatric surgeries also has therapeutic effect on obesity T2DM. So the research is designed to investigate the relieving of type 2 diabetes in short-term after obese patients received bariatric surgery,providing clinical basis for the surgical operation treatment of T2DM.
Methods
The clinical data of 15 patients who was diagnosis as obesity combine with T2DM were undergone laparoscopic bariatric surgery in Shengjing hospital of China Medical University from 2007 to 2009. According to the methods of operation The patients were divided into 3 groups:Laparoscopic adjustable gastric banding(LAGB) group(6 cases), Laparoscopic sleeve gastrectomy(LSG)group(5 cases), Laparoscopic gastric bypass(LGB) group (4 cases).Then we make a 6-month follow-up at least, collect the BMI、FPG and HbAlc at different time point,at last we compared the EBMIL%、△FPG% and△HbAlc% between the 3 groups by using a statistical method.
Results
All the group show different post-operation curative improvement on level of BMI、FPG and HbAlc.We make comparison on EBMIL%,△FPG% and△HbAlc% between the 3 groups.The LGB group represented a more satisfactory curative effect for both obesity and T2DM (P＜0.05).However,there was no significant difference between the LAGB group and the LSG group in the preceding 2 facets (P>0.05).So we regard that in shout-term after oprations,LGB is a more effective means for treatment of obesity T2DM,while the other two methods has no significant differences on the 2 aspects.
Conclusions
LGB appears a more effective short-term therapeutical results on obesity T2DM.However,it makes relatively serious hurts and has much difficulties on skills,meanwhile,it is easy to cause more complications both in periopration period and postopration period.So it is more suitable for patients whose age is relatively old,obesity or with a serious state of T2DM to receive a LGB operation,which could lose reduce body weight and ameliorate the illness status more quickly.While the therapy effects of LSG and LGB operations should be also confirmed,and the two methods are likely to fit for the younger patients with obesity or whose T2DM is tempered,moreover, the application prospect of LSG is more extensive.
目前肥胖患者数量迅速增长,减肥手术已经成为治疗肥胖症的最有效手段之一,近年来研究发现,减肥手术治疗肥胖症的同时,对其合并的2型糖尿病(T2DM)有治疗作用。本研究旨在评价现行的三种腹腔镜减肥手术对肥胖症合并T2DM的近期治疗效果,从而为T2DM的手术治疗提供临床依据。
方法
选择2007年至2009年于中国医科大学附属盛京医院进行腹腔镜减肥手术的肥胖症合并2型糖尿病患者15例,其中6例施行腹腔镜可调节胃捆扎带手术(LAGB),5例施行腹腔镜袖状胃切除术(LSG),4例施行腹腔镜胃旁路手术(LGB),术后进行至少6个月的随访,采集每名患者术后1,3,6个月BMI(体重指数)、FPG(空腹血糖)及HbAlc[糖化血红蛋白)值,计算相应的EBMIL%(多余体重指数减少百分比)、△FPG%(空腹血糖减少百分比)及△HbAlc%(糖化血红蛋白减少百分比)。结果应用统计学方法分析。
结果
各组患者术后1,3,6个月BMI、FPG及HbAlc水平均呈现出程度不同的改善。比较术后各随访时间点各组患者EBMIL%(多余体重指数减少百分比)、△FPG%(空腹血糖减少百分比)及△HbAlc%(糖化血红蛋白减少百分比),LAGB组与LSG组相比较在三者差异不大(P>0.05)；LGB组与LSG组、LGB组与LAGB组则在三者均有统计学差异(P<0.05)。即认为：施行腹腔镜胃旁路手术组患者的近期减重和对2型糖尿病治疗效果均较施行腹腔镜可调节胃捆扎带手术或袖状胃切除术患者的疗效明显。而施行腹腔镜可调节胃捆扎带手术与袖状胃切除术患者的减重及2型糖尿病治疗效果无明显差异。
结论
因为LGB的近期减重效果及对2型糖尿病治疗效果更加明显,但因手术创伤及难度较大,术后并发症较多,且可能出现吸收不良、贫血、骨质疏松等较多长期并发症,故适用于年龄偏大,肥胖症或合并的2型糖尿病病情严重的患者,以达到快速减重及缓解2型糖尿病病情的目的。LSG及LGB术后近期的减重及对糖尿病疗效肯定,差异不大,但LSG应用前景更为广阔,因此年轻、肥胖症或合并的2型糖尿病病情较轻的患者,更适用于LSG,以避免LGB长期并发症出现。
Objective
The number of obesity quickly increases currently, bariatric surgery has become one of the most effect methods for therapy of obese patient. Study in recent years found that the bariatric surgeries also has therapeutic effect on obesity T2DM. So the research is designed to investigate the relieving of type 2 diabetes in short-term after obese patients received bariatric surgery,providing clinical basis for the surgical operation treatment of T2DM.
Methods
The clinical data of 15 patients who was diagnosis as obesity combine with T2DM were undergone laparoscopic bariatric surgery in Shengjing hospital of China Medical University from 2007 to 2009. According to the methods of operation The patients were divided into 3 groups:Laparoscopic adjustable gastric banding(LAGB) group(6 cases), Laparoscopic sleeve gastrectomy(LSG)group(5 cases), Laparoscopic gastric bypass(LGB) group (4 cases).Then we make a 6-month follow-up at least, collect the BMI、FPG and HbAlc at different time point,at last we compared the EBMIL%、△FPG% and△HbAlc% between the 3 groups by using a statistical method.
Results
All the group show different post-operation curative improvement on level of BMI、FPG and HbAlc.We make comparison on EBMIL%,△FPG% and△HbAlc% between the 3 groups.The LGB group represented a more satisfactory curative effect for both obesity and T2DM (P＜0.05).However,there was no significant difference between the LAGB group and the LSG group in the preceding 2 facets (P>0.05).So we regard that in shout-term after oprations,LGB is a more effective means for treatment of obesity T2DM,while the other two methods has no significant differences on the 2 aspects.
Conclusions
LGB appears a more effective short-term therapeutical results on obesity T2DM.However,it makes relatively serious hurts and has much difficulties on skills,meanwhile,it is easy to cause more complications both in periopration period and postopration period.So it is more suitable for patients whose age is relatively old,obesity or with a serious state of T2DM to receive a LGB operation,which could lose reduce body weight and ameliorate the illness status more quickly.While the therapy effects of LSG and LGB operations should be also confirmed,and the two methods are likely to fit for the younger patients with obesity or whose T2DM is tempered,moreover, the application prospect of LSG is more extensive.
引文
1 Hu FB, Manson JE, StampferM I, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women [J]. N Engl J Med,2001,345:790-797.
2 武阳平,马冠生.中国居民的超重和肥胖流行现状[J].中华预防学杂志2007,10(5)：316-320.
3 中国肥胖问题工作组.中国学龄儿童青少年超重、肥胖筛查,体重指数分类标准[J].中华流行病学杂志,2007,25(2)：97-102.
4 Steppan CM, Bailey ST, Bhat S, et al. The hormone resistin links obesity to diabetes[J]. Nature, 2009,409:307.
5 Couzin J:Medicine. Bypassing medicine to treat diabetes. Science 2008; 320:438-440.
6 Markus A. Kueper, Klaus M. Kramer, Andreas kirschniak. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients [J]. World J Surg,2008,32:1462-1465.
7 Simon A.Gastointestinal sugmry and gut homlones[J].Cuuent Opinonin Endoa-inology 2 Diabetes,2005,12:89-98.
8 Sugerman HJ,Wolfe LG,Sica DA et al.Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Ann Surg,2003,237:751-756.
9 郑成竹.腹腔镜手术治疗肥胖病的新概念[J].中华消化外科杂志,2007,6(3)：164-165.
10 刘赵琪.外科手术治疗2型糖尿病：肠-胰岛轴机制和展望[J].实用医学杂志,2008,24(18)：452-455.
11 刘金钢.腹腔镜袖状胃切除术治疗单纯性肥胖症1例报告[J].中国实用外科杂志,2007,27(6)：481-482.
12 郑成竹,李磊.腹腔镜减肥手术常见并发症及防治[J].中国实用外科杂志,2007,27(9)：384-386.
13 刘金钢,周勇。腹腔镜可调节捆扎带胃减容与袖状胃切除术治疗病态肥胖症对比分析[J].中国实用外科志,2009,29(1)：94-95.
14 Markus A. Kueper, Klaus M. Kramer, Andreas kirschniak. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients [J]. World J Surg,2008,32:1462-1465.
15 Smith SC,Goodman GN,Edwards CB. Roux-en-Y gastric bypass. A 7-year retrospective review of 3,855 patients.ObesSurg,1995,5:314-318.
16 Ken FujioKa. Follow-up of nutritional and metabolic problems after bariatric surgery [J].Diabetes Care,2005,28 (2):481-484.
1 Hu FB, Manson JE, StampferM I, et al. Diet, lifestyle, and therisk of type 2 diabetes mellitus in women [J]. N Engl J Med,2001,345:790-797.
2 武阳平,马冠生.中国居民的超重和肥胖流行现状.中华预防学杂志,2005,9(5)：316-320.
3 中国糖尿病学会.中国糖尿病防治指南.2007：35-37.
4 Black DW, Goldstein RB,Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity[J]. Obes Surg,2003,13 (55):746-751.
5 李秀钧,董砚虎,程丽霞,等.糖尿病研究进展.中华内分泌杂志,1998,14(2)：72-77.
6 Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care,2002,25:358-363.
7 Santoro S, Milleo FQ, Malzoni CE, et al. Enterohormonal changes after digestive adaptation: five2year results of a surgical p roposal to treat obesity and associated diseases. Obes Surg, 2008,8:17-26.
8 LeeWJ,WangW, Lee YC, et al. Effect of laparoscopic mini-gastric bypass for type 2 diabetesmellitus:comparison of BM I> 35 and<35 kg/m2. J Gastrointest Surg,2008,12:945-952.
9 NIH Conference. Gastrointestinal surgery for severe obesity[J]. Ann IntMed,1991,115:959-961.
10 Kuzmak L I. A review of seven years'experience with silicone gastric banding[J]. Obes Surg, 1991,1:403-408.
11 BelachewM,LegrandM,VincentV, et al. Laparoscopic adjustable gastric banding[J]. World J Surg,1998,22:955-963.
12 Ren CJ, Horgan S, Ponce J. US experience with the LAP2BAND system[J]. Am J Surg,2002, 184:46S-50S.
13 李威杰.腹腔镜胃减容手术.腹腔镜外科杂志,2004,11(2)：164-1677.
14 O'Brien PE,BrownWA, Smith PJ, et al. Prospective study of a laparoscop ically p laced, adjustable gastric band in the treatment of morbid obesity[J]. Br J Surg,1999,86:113-118.
15 Zinzindohouse F, Chevallier JM,Douard R, et al. Laparoscop ic gastric banding:a minimally invasive surgical treatment formorbid obesity[J]. Ann Surg,2003,237:1-9.
16 Sugerman H, Starkey J,Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastrop lasty for morbid obesity and their effects on sweets versus non-sweets eaters[J]. Ann Surg,1987,205:613-624.
17 Howard L,MaloneM,Michalek A, et al. Gastric bypass and vertical gastrop lasty a p rospective randomized comp ression and 5 year follow-up [J]. Obes Surg,1995,5:55-60.
18 Wittgrove AC, Clark GW, TremblayLJ. Laparoscopic gastric bypass, Roux-en-Y:preliminary report of five cases[J]. Obesity,4:353-357.
19 Shauer PR, Ikramuddin S, GourashW, et al. Outcomes after laparoscop ic Roux-en-Y gastric bypass for morbid obesity[J]. Am Surg,2000,232:515-529.
20 Higa KD,Boone KB, Ho T. Comp lication of the laparoscopic Roux-en-Y gastric bypass:1,040 patients-what have we learned? [J]. Obesity Surg,2000,10:500-513.
21 Oliak D, Ballantyne,Weber P, et al. Laparoscopic Roux-en-Y gastric bypass:defining the learning curve [J]. Surg Endosc,2003,17:405-408.
22 Karlsson J, Sjostrom L, Sullivan M. Swedish obese subjects (SOS):An interventional study of obesity. Two year follow-up of health-related quality of L ife (HRQL) and eating behaviour after gastric surgery for severe obesity[J]. Int J Obes,1998,22:113-126.
23 Regan JP,Inabmet WB,Gagner M,et al.Early experience with two stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super super obese patient [J].Obes Surg,2003,13(6):861-864.
24 Frezza EE.Laparoscopic vertical sleeve gastrectomy for morbid obesity.The future procedure of choice? [J].Surg Today,2007,37(4):275-281。
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26 Marceau P,Hould FS, Simard S, et al. Biliopancreatic diversionwith duodenal switch[J]. World J Surg,1998,22:947-954.
27 Rubino F, Forgione A, Cummings D E, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes [J].Ann Surg,2006,244(5):741-749.
28 Aiexandrides T K, Skroubis G, Kalfarentzos F. Resolution of diabetes mellitus and metabolic syndrome followingRoux-en-Y gastric bypass and a variant of biliopancreatic diversion in patients with morbid obesity [J]. Obes Surg,2007,17(2):176-184.
29 Rubino F, Forgione A, Cummings D E, et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the patho-physiology of type 2 diabetes [J].Ann Surg,2006,244(5):741-749.
30 Rubino F, Gagner M. Potential of surgery for curing type 2 diabetes mellitus [J].Ann Surg, 2002,236(5):554-559.
31 Patriti A, Facchiano E, Donini A. Effect of duodenal-jejunal exclusion in a nonobese animal model of type 2 diabetes:a new perspective for an old disease [J]. Ann Surg,2004,240(2): 388-389.
32 Flatt P R. Effective surgical treatment of obesity may be mediated by ablation of the lipogenic gut hormone gastric inhibitory polypeptide (GIP):evidence and clinical Oppor-tunity for development of new obesity-diabetes drugs [J]? Diab Vase Dis Res,2007,4(2):151-153.
33 Miyawaki K, Yamada Y, Ban N, et al. Inhibition of gastric inhibitory polypeptide signaling prevents obesity [J]. Nat Med.2002,8(7):738-742.
34 Mason E E. Ileal [correction of ilial] transposition and enteroglucagon/GLP-1 in obesity (and diabetic?) surgery [J]. Obes Surg,1999,9(3):223-228.
35 Cummings D E, Overduin J, FosterSchubert K E. Gastric bypass for obesity:mechanisms of weight loss and diabetes resolution [J]. J Clin Endocrinol Metab,2004,89(6):2608-2615.
36 Le Roux C W, Welbourn R, Werling M,et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass [J]. Ann Surg,2007,246 (5):780-785.
2 武阳平,马冠生.中国居民的超重和肥胖流行现状[J].中华预防学杂志2007,10(5)：316-320.
3 中国肥胖问题工作组.中国学龄儿童青少年超重、肥胖筛查,体重指数分类标准[J].中华流行病学杂志,2007,25(2)：97-102.
4 Steppan CM, Bailey ST, Bhat S, et al. The hormone resistin links obesity to diabetes[J]. Nature, 2009,409:307.
5 Couzin J:Medicine. Bypassing medicine to treat diabetes. Science 2008; 320:438-440.
6 Markus A. Kueper, Klaus M. Kramer, Andreas kirschniak. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients [J]. World J Surg,2008,32:1462-1465.
7 Simon A.Gastointestinal sugmry and gut homlones[J].Cuuent Opinonin Endoa-inology 2 Diabetes,2005,12:89-98.
8 Sugerman HJ,Wolfe LG,Sica DA et al.Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Ann Surg,2003,237:751-756.
9 郑成竹.腹腔镜手术治疗肥胖病的新概念[J].中华消化外科杂志,2007,6(3)：164-165.
10 刘赵琪.外科手术治疗2型糖尿病：肠-胰岛轴机制和展望[J].实用医学杂志,2008,24(18)：452-455.
11 刘金钢.腹腔镜袖状胃切除术治疗单纯性肥胖症1例报告[J].中国实用外科杂志,2007,27(6)：481-482.
12 郑成竹,李磊.腹腔镜减肥手术常见并发症及防治[J].中国实用外科杂志,2007,27(9)：384-386.
13 刘金钢,周勇。腹腔镜可调节捆扎带胃减容与袖状胃切除术治疗病态肥胖症对比分析[J].中国实用外科志,2009,29(1)：94-95.
14 Markus A. Kueper, Klaus M. Kramer, Andreas kirschniak. Laparoscopic sleeve gastrectomy: standardized technique of a potential stand-alone bariatric procedure in morbidly obese patients [J]. World J Surg,2008,32:1462-1465.
15 Smith SC,Goodman GN,Edwards CB. Roux-en-Y gastric bypass. A 7-year retrospective review of 3,855 patients.ObesSurg,1995,5:314-318.
16 Ken FujioKa. Follow-up of nutritional and metabolic problems after bariatric surgery [J].Diabetes Care,2005,28 (2):481-484.
1 Hu FB, Manson JE, StampferM I, et al. Diet, lifestyle, and therisk of type 2 diabetes mellitus in women [J]. N Engl J Med,2001,345:790-797.
2 武阳平,马冠生.中国居民的超重和肥胖流行现状.中华预防学杂志,2005,9(5)：316-320.
3 中国糖尿病学会.中国糖尿病防治指南.2007：35-37.
4 Black DW, Goldstein RB,Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity[J]. Obes Surg,2003,13 (55):746-751.
5 李秀钧,董砚虎,程丽霞,等.糖尿病研究进展.中华内分泌杂志,1998,14(2)：72-77.
6 Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care,2002,25:358-363.
7 Santoro S, Milleo FQ, Malzoni CE, et al. Enterohormonal changes after digestive adaptation: five2year results of a surgical p roposal to treat obesity and associated diseases. Obes Surg, 2008,8:17-26.
8 LeeWJ,WangW, Lee YC, et al. Effect of laparoscopic mini-gastric bypass for type 2 diabetesmellitus:comparison of BM I> 35 and<35 kg/m2. J Gastrointest Surg,2008,12:945-952.
9 NIH Conference. Gastrointestinal surgery for severe obesity[J]. Ann IntMed,1991,115:959-961.
10 Kuzmak L I. A review of seven years'experience with silicone gastric banding[J]. Obes Surg, 1991,1:403-408.
11 BelachewM,LegrandM,VincentV, et al. Laparoscopic adjustable gastric banding[J]. World J Surg,1998,22:955-963.
12 Ren CJ, Horgan S, Ponce J. US experience with the LAP2BAND system[J]. Am J Surg,2002, 184:46S-50S.
13 李威杰.腹腔镜胃减容手术.腹腔镜外科杂志,2004,11(2)：164-1677.
14 O'Brien PE,BrownWA, Smith PJ, et al. Prospective study of a laparoscop ically p laced, adjustable gastric band in the treatment of morbid obesity[J]. Br J Surg,1999,86:113-118.
15 Zinzindohouse F, Chevallier JM,Douard R, et al. Laparoscop ic gastric banding:a minimally invasive surgical treatment formorbid obesity[J]. Ann Surg,2003,237:1-9.
16 Sugerman H, Starkey J,Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastrop lasty for morbid obesity and their effects on sweets versus non-sweets eaters[J]. Ann Surg,1987,205:613-624.
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