减重代谢外科多学科随访模式构建实证研究

目的探讨多学科随访模式在减重代谢外科质量控制中的实证研究。 方法回顾性分析2016年1月至2016年12月在南京医科大学第一附属医院减重代谢外科接受手术的110例肥胖症患者的临床资料。2016年1月至2016年6月入院的患者由外科医生主导随访,作为传统减重管理组（对照组）;2016年7月至2016年12月入院的患者,其术后随访由多学科团队共同完成,作为多学科随访管理组（研究组）。其中研究组57例,男16例,女41例,年龄（46.1±10.9）岁;对照组53例,男14例,女39例,年龄（42.2±8.3）岁。多学科随访管理组由减重外科医生、减重管理师、内分泌科医生、营养科医生组成;传统减重管理随访组由外科医生和减重管理师构成。比较两组患者的术后随访率、医疗服务满意率和术后营养并发症的发生率、术后胃肠道并发症的发生率、多余体重减少率。 结果研究组术后1年随访率为82.5%,明显高于对照组（χ2=14.907,P<0.05）;研究组患者的多余体重减少率为（83.1±16.1）%,明显高于对照组（t=3.959,P<0.05）;研究组患者对手术效果的满意率为93.0%（53/57）,明显高于对照组的73.6%（39/53）（χ2=4.410,P<0.05）;研究组患者营养并发症发生率为5.3%（3/57）,明显低于对照组的22.6%（12/53）（χ2=4.961,P<0.05）。 结论多学科随访模式能适应代谢外科多学科综合治疗的需要,在提高患者随访率、降低术后并发症的发生、增加患者术后多余体重减少率、提高患者满意度方面,较传统减重管理模式有明显优势。     

内镜下袖状胃成形术减重初探

目的评价内镜下袖状胃成形术(ESG)减重的安全性及有效性。方法收集2017年10月至2018年3月于江苏省人民医院接受ESG的5例患者信息。主要评价指标为术中和术后并发症、缝合时间、住院时间和术后减重效果。结果缝合时间为(66.7±22.75) min,使用缝线(6.16±0.4)根,术中平均出血量40 mL。患者术后无恶心、便秘、呕吐、黑便等并发症,住院时间为(6.16±0.4) d。术后平均随访4.2个月,患者体重减少(15.00±1.99)kg,总体重减少百分比为(15.22±2.21)%,多余体重减少百分比为(50.99±6.54)%。结论ESG术中及术后并发症较少,住院时间短,安全性较好,是一种较有效的减重方法。     

加速康复措施在减重代谢外科中的应用价值

目的通过在减重代谢外科围手术期实施各种加速康复外科（ERAS）措施，总结出加速康复外科措施在减重与代谢病外科中的应用价值。 方法回顾性分析2015年1月至2018年1月南方医科大学附属小榄医院减重与代谢病外科收治的91例肥胖症或2型糖尿病患者的临床病例资料，将患者在围手术期实施快速康复措施的纳入加速康复外科组（ERAS组）；而仅采用传统胃肠外科围手术期措施的患者纳入对照组。对比两组患者在术后疼痛评分、肛门排气时间、并发症、平均住院时间、住院总费用、减重效果、再住院率、再手术率等方面的差异，分析ERAS实施在减重代谢外科中的应用价值。 结果ERAS组术后疼痛NRS评分低于对照组(3.8±1.2) vs. (6.4±1.5)，P<0.05；术后肛门排气时间缩短(1.0±0.3)d vs.(1.9±0.7)d，P<0.05；无严重并发症；术后住院时间短(6.4±1.3)d vs.(13.7±1.5)d ，P<0.05，住院费用降低（46813±3070）元vs. (66973±4520)元，P<0.05；两组的平均术后1年多余体重减除率均>80%。 结论在减重与代谢手术中，实施围手术期快速康复措施，可明显缩短住院时间，减少术后并发症，快速康复，节省费用，具有突出的应用价值。     

减重代谢术后3年内患者体重变化情况及影响因素分析

目的探讨减重代谢术后患者的体重下降情况,并分析其心理社会相关影响因素。 方法2020年1月至2月采用方便抽样法,选取某三级甲等医院减重代谢手术后患者199例为研究对象,采用一般资料问卷、自我效能感量表、一般健康问卷、社会支持评定量表等工具进行问卷调查,采用t检验、方差分析、多重线性回归等进行影响因素分析。 结果减重代谢手术患者术前与术后体质量指数（BMI）的差值为（10.97±7.10）kg/m²,术后减重效果较好,多元线性回归分析结果显示,社会支持、自我效能感、手术方式和居住方式进入回归方程（P<0.05）,共解释患者术后体重下降总变异的28.8%。 结论减重代谢手术患者术后体重下降明显,社会支持水平、自我效能感、手术方式和居住方式是术后减重效果的主要影响因素。     

中、重度青少年肥胖病患者代谢手术治疗后随访研究

目的探讨中、重度青少年肥胖病患者代谢手术治疗后6个月的安全性和有效性。方法选取2015年11月至2019年1月于南京大学医学院附属鼓楼医院内分泌科接受代谢手术的17例13～19岁肥胖病患者,分析术前、术后6个月一般资料、生活方式、人体成分、代谢指标及相关并发症。结果 17例患者未发生中转开腹、死亡等手术并发症;术后进餐时长增加,喜油炸食品及快餐食品减少(P0.05);久坐时间减少[(6.53±2.45)vs(8.76±3.51)h,P0.05]。与代谢手术前相比,术后6个月BMI、WHR、体脂百分比、SBP、DBP下降(P0.01)。糖脂代谢指标、肝肾功能、尿酸等均较术前改善(P0.05);贫血、铁代谢等营养指标未见明显变化。术前存在非酒精性脂肪性肝病、高尿酸血症、IGT等合并症患者术后均缓解(P0.05)。结论代谢手术改变中、重度青少年肥胖病患者不良生活方式,安全有效减重,改善人体成分,缓解肥胖相关代谢紊乱及并发症,中、重度肥胖青少年代谢术后短期获益,代谢手术多学科团队有利于保证手术安全性及有效随访。     

减重手术治疗二型糖尿病的临床疗效观察

选取2015年12月到2018年12月收治肥胖型2型糖尿病患者86例,随机平分为对照组给予传统内科治疗方法,研究组给予代谢减重手术。结果减重手术可有效降低空腹血糖值,改善患者糖化血红蛋白,提高临床疗效。结论减重手术可有效降低患者空腹血糖值,改善患者糖化血红蛋白,提高临床疗效。     

加速康复外科护理在减重代谢手术患者中的效果观察

目的分析在减重代谢手术患者中应用加速康复外科护理理念的临床效果。 方法选择从2015年1月至2018年1月在中山市小榄人民医院减重代谢外科接受手术的91例患者,随机分组研究,42例纳入对照组,采取常规护理,49例纳入观察组,基于快速康复外科护理理念护理,对照分析两组临床效果。 结果从术后观察指标来看,观察组术后肛门排气时间比对照组早,术后下床活动时间比对照组早,进食时间比对照组早,住院时间比对照组短,住院费用比对照组少,P<0.05;从护理满意度来看,观察组高于对照组,P<0.05;从术后并发症发生率来看,观察组低于对照组,P<0.05。 结论加速康复外科护理的应用可以促进减重代谢手术患者术后恢复,减少并发症发生,增加患者对临床护理服务的满意度。     

术前减重在减重代谢手术中的作用：一项系统评价及Meta分析

目的系统评价术前减重是否可以改善减重代谢手术患者的临床疗效。 方法通过检索PubMed、Emabase、Cochrane数据库搜集关于术前减重对接受减重代谢手术治疗患者临床疗效的研究,检索时限均从建库至2020年10月。采用Review Manager 5.3软件进行Meta分析,主要评估术前合并症改善、术中腔镜中转、手术时间、住院时间、非计划二次手术、术后伤口感染、术后出血、术后早期并发症、术后合并症改善、术后体重减轻指标。 结果共纳入包括6 000名患者在内的10项研究。Meta分析显示,与常规对照组相比,术前减重组在术前合并症改善、术中腔镜中转、手术时间、术后早期并发症、术后出血、术后伤口感染、非计划二次手术、住院时间、术后合并症改善、术后6个月减轻指标、术后12个月均无明显获益,两组间差异均无统计学意义。而术前减重组在术后短期3个月内体重减轻更明显。 结论实施减重代谢手术前进行术前减重可能使患者在术后短期内体重减轻更明显,但在围手术期风险、合并症改善、住院时间、远期体重减轻等方面获益并不明显,其临床疗效仍需更多高级别循证研究证据的帮助与支持。     

心理干预对手术室老年围术期手术患者焦虑心理的影响

目的研究心理干预对手术室老年围术期手术患者焦虑心理的影响。方法选取2013年4月至2014年4月该院收治的600例老年手术患者,随机分为研究组和对照组各300例,对照组给予常规护理,研究组在对照组的基础上给予心理干预,应用汉密尔顿焦虑量表(HAMA)评价两组患者的焦虑情况,比较两组患者手术前1 d、手术当天以及术后第3日的心率、血压以及HAMA评分。结果两组患者术前1 d的HAMA评分比较无统计学意义(P>0.05),研究组手术当天以及术后第3日HAMA评分显著优于对照组(P<0.05);两组患者手术前1 d以及术后第3天心率和血压比较均无统计学意义(P>0.05),手术当天研究组心率和血压值显著优于对照组(P<0.05)。结论心理干预能显著减轻手术室老年围术期手术患者的焦虑心理,降低患者血压和心率的变化幅度。     

青少年肥胖症代谢手术后3年效应观察与分析

目的探究青少年肥胖症病人接受减重代谢手术后中期效益及影响。 方法回顾性分析2014年11月至2015年10月于长春嘉和外科医院接受减重代谢手术的16例青少年肥胖症患者（13~21岁）的临床资料,对他们术前及术后3年间的体重、体质量指数（BMI）、甘油三酯（TC）、高密度脂蛋白（HDL）及低密度脂蛋白（LDL）进行统计分析。 结果16名入组患者的平均体重、BMI、空腹TC、LDL在术后3年均有不同幅度下降,平均空腹HDL有所升高,数据分析均有统计学意义（P<0.05）。 结论减重代谢手术可以明确并且持续性地减轻青少年肥胖症病人的体重,同时改善血脂异常问题。青少年一旦达到肥胖II级应当尽早手术。     

Medical and gastroenterologic management of the post-bariatric surgery patient

Morbid obesity is a serious disease resulting in considerable morbidity. Bariatric surgery is an important treatment modality of morbid obesity. It appears to be safe and effective in reduction of excess weight in carefully selected patients. However, it carries a risk of many short- and long-term complications, some of them unique to bariatric surgery. Knowledge of possible postoperative complications and their management will allow the achievement of the best results. Despite many types of bariatric procedures developed, only a few are currently performed. Since the number of bariatric procedures performed annually increases, primary care physicians and gastroenterologists will be increasingly challenged by post-bariatric surgery patients. Hence, better understanding of the anatomy and adaptive changes in bariatric patients allows for a more efficient evaluation and management of post-bariatric surgery problems. This article reviews common complications in post-bariatric surgery patients and provides guidelines for their evaluation and management.     

围术期全程护理模式在糖尿病腹部手术患者中的应用效果

目的对围术期全程护理模式在糖尿病腹部手术患者治疗中的临床运用情况加以分析。方法随机抽选2019年4月—2020年3月该院所接诊的择期实施腹部手术的糖尿病患者78例作为研究对象,按护理模式不同分成对照组与全程组。前者采取常规护理措施,在此前提下,后者再予以围术期全程护理模式;对以上两组患者的临床护理情况加以观察。结果全程组患者术中血糖、术后血糖、切口愈合时间以及住院时间等明显低于对照组,差异有统计学意义(P<0.05);全程组患者并发症发生率(5.1%)比对照组患者(23.1%)低,差异有统计学意义(χ²=5.186,P<0.05);全程组患者的护理满意度(97.4%)显著高于对照组(79.5%),差异有统计学意义(χ²=4.522,P<0.05)。结论对行腹部手术治疗的糖尿病患者实施围术期全程护理模式,效果甚佳。     

Diet approach before and after bariatric surgery

Bariatric surgery (BS) is today the most effective therapy for inducing long-term weight loss and for reducing comorbidity burden and mortality in patients with severe obesity. On the other hand, BS may be associated to new clinical problems, complications and side effects, in particular in the nutritional domain. Therefore, the nutritional management of the bariatric patients requires specific nutritional skills. In this paper, a brief overview of the nutritional management of the bariatric patients will be provided from pre-operative to post-operative phase. Patients with severe obesity often display micronutrient deficiencies when compared to normal weight controls. Therefore, nutritional status should be checked in every patient and correction of deficiencies attempted before surgery. At present, evidences from randomized and retrospective studies do not support the hypothesis that pre-operative weight loss could improve weight loss after BS surgery, and the insurance-mandated policy of a preoperative weight loss as a pre-requisite for admission to surgery is not supported by medical evidence. On the contrary, some studies suggest that a modest weight loss of 5–10% in the immediate preoperative period could facilitate surgery and reduce the risk of complications. Very low calories diet (VLCD) and very low calories ketogenic diets (VLCKD) are the most frequently used methods for the induction of a pre-operative weight loss today. After surgery, nutritional counselling is recommended in order to facilitate the adaptation of the eating habits to the new gastro-intestinal physiology. Nutritional deficits may arise according to the type of bariatric procedure and they should be prevented, diagnosed and eventually treated. Finally, specific nutritional problems, like dumping syndrome and reactive hypoglycaemia, can occur and should be managed largely by nutritional manipulation. In conclusion, the nutritional management of the bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians.

     

Surgical options for obesity

Several bariatric procedures are available that have excellent long-term weight loss results and are backed by several large clinical trials. Purely restrictive procedures like VBG have fallen out of favor because of inadequate long-term weight loss. Gastric bypass and the BPD are well-studied and show significant resolution of obesity-related comorbidities. Long-term nutritional consequences are seen more commonly after malabsorptive procedures like the BPD than after hybrid malabsorptive-restrictive procedures like the gastric bypass. Because compliance and long-term nutritional follow-up are mandatory after any bariatric procedure, purely malabsorptive procedures should be reserved for super obese patients who are at risk for inadequate long-term weight loss. Furthermore, minimally invasive techniques have evolved and essentially have eliminated the high incidence of postoperative wound complications and incisional hernias frequently seen after open gastric bypass. Until the development ofa similarly successful procedure, gastric bypass will continue to be the gold standard bariatric procedure with its concurrent sustained weight loss benefits and resolution of comorbidities.     

Spondyloarthritis after bariatric surgery: is there a link?

Presently, bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss in severely obese. On the other hand, several early and late complications have been described after this procedure. This article reports two patients who developed a spondyloarthritis-like syndrome after bariatric surgery. Probable etiopathogenic mechanisms are discussed.     

Nutritional deficiencies associated with bariatric surgery

Morbidly obese patients often have nutritional deficiencies, particularly in fat-soluble vitamins, folic acid and zinc. After bariatric surgery, these deficiencies may increase and others can appear, especially because of the limitation of food intake in gastric reduction surgery and of malabsorption in by-pass procedures. The latter result in more important weight loss but also increase the risk of more severe deficiencies. The protein deficiency associated with a decrease in the fat-free mass has been described in both procedures. It can sometimes require an enteral or parenteral support. Anemia can be secondary to iron deficiency, folic acid deficiency and even to vitamin B12 deficiency. Neurological disorders such as Gayet-Wernicke encephalopathy due to thiamine deficiency, or peripheral neuropathies may also be observed. Malabsorption of fat-soluble vitamins and other nutrients, especially if diagnosed after by-pass surgery, rarely cause clinical symptoms. However, some complications have been reported such as bone demineralization due to vitamin D deficiency, hair loss secondary to zinc deficiency or hemeralopia from vitamin A deficiency. A careful nutritional follow-up should be performed during pregnancy after obesity surgery, because possible deficiencies can affect the health of both the mother and child. In conclusion, increased awareness of the risk of deficiency and the systematic dosage of micronutrients are needed in the pre- and postoperative period in obese patients undergoing bariatric surgery. The case by case correction of these deficiencies is mandatory, and their systematic prevention should be evaluated.