胆胰分流并十二指肠转位术治疗胃袖状切除术后复胖个案报告并文献复习

目的:探讨胆胰分流并十二指肠转位术作为胃袖状切除术后复胖修正手术的可行性。方法:女性患者,重度肥胖,身体质量指数(BMI)为42.3 kg/m^2,合并2型糖尿病,应用胰岛素治疗血糖控制不佳,糖化血红蛋白(HbA1c)10.5%;首次接受腹腔镜胃袖状切除术,术后1年BMI降至32.4 kg/m^2,HbA1c 8.9%;术后3年,BMI反弹至40.2 kg/m^2,HbA1c为10%。再次接受标准的胆胰分流并十二指肠转位术,即食物肠袢150 cm、共同肠袢100 cm。结果:胆胰分流并十二指肠转位术术后3个月,BMI 39.9 kg/m^2,HbA1c 8.9%,恢复正常进食,排便次数3~4次/d,质软,无特殊不适。结论:胆胰分流并十二指肠转位术作为腹腔镜胃袖状切除术的术后修正手术,对于体重反弹、血糖增高的治疗效果优异,且不影响患者进食习惯,但术后营养并发症较多见,需密切关注。     

缝合切缘预防袖状胃切除术并发症的体会

目的:探讨预防袖状胃切除术后并发症的措施。方法:2010年12月至2015年6月完成袖状胃切除术或袖状胃切除为基础的空肠旁路术共261例。胃内以36Fr球囊胃管支撑,距幽门2~5 cm处开始切割胃大弯,胃窦处选择绿钉仓,其余部位选用蓝钉仓。自第一例袖状胃切除术开始,在切割完成后选用3-0薇乔线全层缝合加强切缘。术后常规不放引流管、不置胃管,术后第1天开始进食流质。统计每例患者完成袖状胃切除术的时间及术后并发症等情况。结果:261例患者临床资料完整,均完成腹腔镜手术,其中男88例(33.7%),女173例(66.3%);男性BMI 41.8 kg/m~2,女性36.1 kg/m~2,两组差异无统计学意义(P0.05)。男性组手术时间平均(101.94±31.05)min,女性组平均(95.49±26.63)min,两组手术时间差异无统计学意义(P0.05)。101例患者BMI≥40 kg/m~2,手术时间平均(96.15±22.7)min,160例患者BMI40 kg/m~`2,手术时间平均(98.63±31.34)min,两者差异无统计学意义(P0.05)。患者术后随访超过6个月,平均住院(6.7±2.5)d,无死亡病例及再手术、漏、梗阻、大出血发生,术后30 d因呕吐再入院3例,术后便血1例,均保守治愈出院。结论:常规加强缝合切缘可预防袖状胃切除术后漏、出血等并发症的发生。     

胃袖状切除复胖后再次胃袖状切除术

目的:探讨腹腔镜胃袖状切除术后再次胃袖状切除术的疗效及安全性。方法:回顾分析2016年6月至2018年1月因首次腹腔镜胃袖状切除术后复胖而再次行胃袖状切除术(ReSG)附加小肠转流术7例患者的临床资料,观察手术时间、住院时间、身体质量指数(BMI)变化情况及围手术期并发症。术前7例患者均行上消化道造影,显示胃底残留或残胃扩张。结果:7例手术均顺利完成,无术中并发症发生。中位手术时间125(110,150)min;中位住院时间8(7,9)d;ReSG术前BMI平均(27.6±2.1)kg/m~2,ReSG术后12个月BMI降为(22.3±2.1)kg/m~2。术后1例患者出现机械性肠梗阻,无其他术后并发症发生。结论:再次胃袖状切除术对于因胃底残留或残胃扩张而复胖的胃袖状切除术后患者是安全、有效的修正术式。     

腹腔镜袖状胃切除术治疗重度肥胖症的临床疗效

目的探讨腹腔镜下袖状胃切除术对重度肥胖症(体重指数BMI>35)的临床疗效。方法 2008年8月～2011年5月,对30例重度肥胖症患者实施腹腔镜袖状胃切除术,全身麻醉,腹腔镜下超声刀离断胃周韧带,术中电子胃镜指引下,使用Endo-GIA紧贴胃大弯侧行袖状胃切除。术后随访1年,观察BMI及超重体重下降百分比(excess weight loss,EWL%)的变化情况。结果 30例手术顺利,无术中并发症及中转开腹。术后1年体重指数(28.7±5.3)较术前(35.2±7.2)降低(t=3.98,P<0.001)。术后1年随访EWL%,根据Reinhold等制定的标准,效果极佳24例(80%)(EWL%76%～90%),良好6例(20%)(EWL%55%～73%)。结论腹腔镜袖状胃切除术治疗重度肥胖症近期疗效明显,长期疗效有待进一步观察。     

袖状胃切除附加手术：肥胖与糖尿病治疗的新选择

代谢手术是治疗肥胖症和2型糖尿病的有效方法之一。袖状胃切除术因其操作简单、效果确切而被广泛接受,但单一的袖状胃切除术的减重及糖尿病缓解效果低于胃旁路术,并且存在术后复胖及糖尿病缓解率下降等问题。因此,近年来在袖状胃切除术基础上出现了多种旨在提高袖状胃切除疗效的附加术式,主要包括袖状胃切除加单吻合口十二指肠回肠旁路术（SADI-S）、袖状胃切除加十二指肠空肠旁路术（SG-DJB）、袖状胃切除加单吻合口十二指肠空肠旁路术（SADJB-SG）、袖状胃切除加改良空回肠旁路术（SG-MJIB）、SIPS术、袖状胃切除加空回肠侧侧吻合术（JI-SG）、袖状胃切除加空肠旁路术（SG-JJB）等。虽然有文献对个别这类术式进行过描述,但未发现有综合描述这一类手术的综述,故笔者对这类新术式进行归纳,以期为临床实践提供一定助益。     

腹腔镜袖状胃切除术后胃漏2例诊疗体会

目的:探讨腹腔镜袖状胃切除术后胃漏的发生原因及治疗方法。方法:回顾分析2015年5月至2018年12月接受LSG术后发生胃漏的2例患者的临床资料。结果:病例1男性,33岁,BMI 34.68 kg/m~2,术前诊断为原发性肥胖症及胃间质瘤,行腹腔镜袖状胃切除术+腹腔镜胃间质瘤切除术,为第15例LSG患者,术后第7天发生胃漏;病例2为女性,28岁,BMI 53.65 kg/m~2,术前诊断为代谢综合征及食管裂孔疝,行腹腔镜袖状胃切除术+食管裂孔疝修补术,为第30例LSG患者,术后第8天患者出院,第22天发生胃漏。采用三腔喂养管,同时行胃肠减压、胃瘘口冲洗及肠内营养,并予以黎氏管腹腔冲洗引流,2例胃漏患者分别于治疗后63 d及17 d复查上消化道造影,提示治愈。结论:应用三腔喂养管行胃瘘口冲洗及肠内营养、黎氏管腹腔持续冲洗引流,可有效控制腹腔感染,提高胃漏治愈率,操作简单、易行,效果确切、安全,值得临床推广。     

腹腔镜胃肠部分切除术治疗重度肥胖症

目的 探讨腹腔镜下袖套式胃大部切除和部分小肠切除术治疗重度肥胖症的手术方法、安全性和近期疗效.方法 从2006年12月至2007年9月,为10例重度肥胖症患者进行了腹腔镜下袖套式胃大部切除和部分小肠切除术.手术包括3部分:(1)自大弯侧距幽门5～6 cm处起垂直向上至贲门左侧His角,用内镜下切割吻合器向上切除大弯侧胃,保留和形成宽约2～3 cm的小弯侧管状胃;(2)切除大网膜;(3)切除约1/3～2/5的小肠.结果 本组10例腹腔镜下袖套式胃大部切除和部分小肠切除术全部完成,无1例需中转开腹手术.手术中位时间3.1 h,无术后并发症,术后平均住院7 d.10例患者术前平均体质量指数为36.1 ks/m2,术后1个月、3个月和6个月平均体质量指数分别减少了4.1 ks/m2、5.6 ks/m2和7.3 ks/m2,平均体重分别减轻11.7 kg、17.5 kg和22.0 kg.结论 腹腔镜下袖套式胃大部切除和部分小肠切除术治疗重度肥胖症安全性高、近期疗效满意.     

减重代谢手术治疗重度肥胖合并2型糖尿病术后1年疗效分析

目的:比较分析腹腔镜胃袖状切除术与腹腔镜胃转流术治疗重度肥胖合并2型糖尿病患者的短期效果。方法:回顾分析48例合并2型糖尿病重度肥胖症患者的临床资料。按手术方式分为胃袖状切除组(n=30)与胃转流组(n=18),术后随访1年,分析比较两组患者体重改善情况及相关糖脂代谢指标的变化。结果:48例均顺利完成手术。术后两组患者体质指数均明显低于术前(P<0.01),两组间差异无统计学意义(P>0.05)。术后6个月、12个月,两组患者空腹血糖、糖化血红蛋白、空腹C肽、胰岛素抵抗指数、胆固醇、甘油三酯均较术前明显改善(P<0.01)。胃袖状切除组与胃转流组糖尿病完全缓解率分别为73%与78%,两组有效率均为100%,两组缓解率相比差异无统计学意义(P>0.05)。结论:腹腔镜胃转流手术与腹腔镜胃袖状切除术均可有效治疗重度肥胖合并糖尿病,近期效果显著,且两种治疗方法临床效果相近。     

减重手术临床并发症的分析

目的:探讨减重手术的并发症及其处理方法。方法:回顾分析31例糖尿病及单纯性肥胖症患者行腹腔镜胃旁路术、胃束带、袖状胃切除、改良胃转流术(袖状胃手术基础上,再行远端空肠与十二指肠球部吻合)的临床资料,总结其并发症情况。结果:本组中,2型糖尿病21例,其中发生左侧胸腔积液1例,吻合口狭窄1例,吻合口溃疡3例,营养不良4例,腹腔内疝1例,粘连性肠梗阻1例,术后胃功能性排空障碍2例。单纯性肥胖症10例,发生减重效果不明显1例,胃小囊及食管扩张1例,注水泵皮下脂肪液化1例,取出胃束带1例。结论:初期开展腹腔镜减重手术难免出现一些并发症,术者应完善术前检查,术中仔细操作以减少不必要的损伤,术后积极采取措施治疗,有的并发症是可以避免的。     

腹腔镜袖状胃切除联合胃空肠转流术治疗肥胖症合并2型糖尿病

腹腔镜下胃空肠转流术与袖状胃切除术被广泛应用于治疗肥胖症。长期随访研究发现,两种手术对伴有2型糖尿病的肥胖症患者的糖尿病症状明显改善,其有效率超过90％[1]。2009年郑成竹等[2]对两种手术的亚太地区适应证总结为：排除内分泌所致的继发性肥胖,BMI＞ 35或BMI＞30同时合并有并发症者。基于以上基础,我院于2008年10月至2009年8月共对13例2型糖尿病患者施行袖状胃切除联合胃空肠转流术,获得明显疗效,报告如下。     

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

Background: The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m². She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m². Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. Results: No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. Conclusion: A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.     

超级肥胖病人行腹腔镜胃袖状切除术应用加速康复外科路径效果研究

目的 探讨超级肥胖病人腹腔镜胃袖状切除术（LSG）围手术期应用快速康复外科（ERAS）路径的安全性和近期效果。方法　回顾性分析2017年1月至2021年3月天津医科大学总医院普通外科收治的200例肥胖病人临床资料，所有病人均进入ERAS路径，并接受LSG。比较肥胖组（BMI 27.5~<50，156例）和超级肥胖组（BMI≥50，44例）病人术中及术后情况。结果 ERAS路径总体完成率和各具体流程组间差异无统计学意义（P>0.05）。与肥胖组比较，超级肥胖组中术前美国麻醉医师协会（ASA）分级Ⅲ级比例显著高于肥胖组（56.8 vs. 14.1%，P<0.0001），手术时间显著延长［（149.4±41.8）min vs. （132.4±45.2）min，P<0.05］，术后入住重症监护室（ICU）比例显著增高（22.7% vs. 3.2%，P<0.0001）。两组病人术中使用吻合器钉仓数量、术中非计划增加Trocar孔数的病例比例、住院时间、术后住院时间差异均无统计学意义（P>0.05）。术后30 d内共发生术后并发症51例次，无30 d非计划再手术病人，30 d非计划再入院病人8例，且均为肥胖组病人。超级肥胖组病人术后30 d绝对体重减少［（21.1±7.1）kg vs. （13.2±3.6）kg，P<0.0001］、绝对BMI减少（7.3±2.7 vs. 4.6±1.1，P<0.0001）、总体重减少百分比［（13.7±5.1）% vs. （11.9±2.6）%，P<0.01］均显著高于肥胖组；额外体重减少百分比［（25.7±9.9）% vs.（39.0±19.7）%，P<0.0001）］和额外BMI减少百分比［（25.7±9.9）% vs.（39.0±19.7）%，P<0.0001］均显著低于肥胖组。结论　对超级肥胖病人使用ERAS路径安全有效，并未增加围手术期并发症发生率及非计划再入院率，但应加强围手术期监护，强化心肺等器官功能支持治疗。     

Robot-Assisted Sleeve Gastrectomy in Morbidly Obese Versus Super Obese Patients

Background and Objectives:

This study evaluates our technique for robot-assisted sleeve gastrectomy for morbidly obese and super obese patients and our outcomes.

Methods:

A retrospective analysis of patients who underwent robot-assisted sleeve gastrectomy at a single center was performed. The procedure was performed with the da Vinci Si HD Surgical System (Intuitive Surgical, Sunnyvale, California). The staple line was imbricated with No. 2-0 polydioxanone in all cases. The super obese (body mass index ≥50 kg/m²) subset of patients was compared with the morbidly obese group in terms of demographic characteristics, comorbidities, operative times, perioperative complications, and excess body weight loss.

Results:

A total of 35 patients (15 female and 20 male patients) with a mean body mass index of 48.17 ± 11.7 kg/m² underwent robot-assisted sleeve gastrectomy. Of these patients, 11 were super obese and 24 were morbidly obese. The mean operative time was 116.3 ± 24.7 minutes, and the mean docking time was 8.9 ± 5.4 minutes. Mean blood loss was 19.36 ± 4.62 mL, and there were no complications, conversions, or perioperative deaths. When compared with the morbidly obese patients, the super obese patients showed no significant difference in operative time, blood loss, and length of hospital stay. There was a steep decline in operating room times after 10 cases of robot-assisted sleeve gastrectomy.

Conclusion:

This study shows the feasibility and safety of robot-assisted sleeve gastrectomy. Robotic assistance might help overcome the operative difficulties encountered in super obese patients. It shows a rapid reduction in operative times with the growing experience of the entire operative team. Robot-assisted sleeve gastrectomy can be a good procedure by which to introduce robotics in a bariatric surgery center before going on to perform Roux-en-Y gastric bypass and revision procedures.     

Early Results of Laparoscopic Biliopancreatic Diversion with Duodenal Switch: A Case Series of 40 Consecutive Patients

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is an operation which provides one of the greatest maintained weight losses of any bariatric procedure.We looked at the safety and efficacy of laparoscopic BPD-DS for morbid obesity. Methods: A 150-200 ml sleeve gastrectomy was created and anastomosed to the distal 250 cm of divided ileum. The median length of the common channel was 100 cm. All patients were prospectively followed up to 12 months. Results: 40 consecutive patients underwent laparoscopic BPD-DS as a primary procedure for morbid obesity. Median patient body mass index (BMI) was 60 kg/m2 (range 42-85 kg/m2). Mean age was 43 ± 1 years (± SEM), with 12 males and 28 females. One patient was converted to open laparotomy (2.5%). Median operative time was 210 ± 9 minutes (range 110-360 minutes) with a significant correlation between BMI and operative time (p = 0.04). Median length of stay was 4 days (range 3- 210 days). There was one 30-day mortality (2.5%). Major morbidities occurred in 6 patients (15%), including 1 anastomotic leak (2.5%), 1 venous thrombosis (2.5%), 4 staple-line hemorrhages (10%) and 1 subphrenic abscess (2.5%). Median follow-up at 6 months (range 1-12 months) resulted in 46% ± 2% excess weight loss (EWL) and at 9 months 58% ± 3% EWL. Conclusion: Laparoscopic BPD-DS is a complex, yet feasible, procedure resulting in effective weight loss with an acceptable morbidity. A BMI >65 was associated with increased morbidity and mortality. A long-term study is needed to confirm efficacy and proper patient selection.     

Laparoscopic biliopancreatic diversion with duodenal switch

The biliopancreatic diversion with duodenal switch combines a sleeve gastrectomy with a duodenoileal switch to achieve maximum weight loss. Consistent excess weight loss between 70% to 80% is achieved with acceptable decreased long-term nutritional complications. With a higher entry weight, the super obese patient (body mass index [BMI] >50 kg/m(2)) benefits the greatest from a procedure that produces a higher mean excess weight loss. The laparoscopic approach to this procedure has successfully created a surgical technique with optimum benefit and minimal morbidity, especially in the super obese patient.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Anatomic Landmarks in the Sleeve Gastrectomy

Background and Objectives:

The vertical sleeve gastrectomy is a common bariatric procedure. The operation is relatively standard, but there are still variations among surgeons. The two main variations are bougie size and extent of distal resection. Some surgeons will start the gastric resection at 2 cm proximal to the pylorus, whereas others start at 6 cm. Our hypothesis is that there are anatomic landmarks that are constant and can be used to help standardize the procedure.

Methods:

Twenty-eight morbidly obese patients undergoing laparoscopic bariatric surgery (gastric bypass or sleeve gastrectomy) had the distance from the pylorus to the second branch of the right gastroepiploic artery on the inferior border of the greater curvature of the stomach measured. Body mass index, height, weight, age, and sex were also analyzed.

Results:

The study comprised 22 women and 6 men with a mean age of 46.2 years (range, 22–68 years). The mean body mass index was 43.2 kg/m² (range, 37.2–62.4 kg/m²). The mean distance from the pylorus to the second branch of the right gastroepiploic vessel was 4.52 cm (range, 3.5–5.5 cm).

Conclusion:

The second branch of the right gastroepiploic artery can be used as a constant anatomic landmark. It is found about 4.5 cm from the pylorus. This can be safely used as a landmark for marking the distal extent of resection during a vertical sleeve gastrectomy and obviates the need to formally measure the distance from the pylorus.     

Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years

OBJECTIVE: To complete a long-term (>10 years) follow-up of patients undergoing isolated roux-en-Y gastric bypass for severe obesity. BACKGROUND: Long-term results of gastric bypass in patients followed for longer than 10 years is not reported in the literature. METHODS: Accurate weights were recorded on 228 of 272 (83.8%) of patients at a mean of 11.4 years (range, 4.7-14.9 years) after surgery. Results were documented on an individual basis for both long- and short-limb gastric bypass and compared with results at the nadir BMI and % excess weight loss (%EWL) at 5 years and >10 years post surgery. RESULTS: There was a significant (P < 0.0001) increase in BMI in both morbidly obese (BMI < 50 kg/m) and super obese patients (BMI > 50 kg/m) from the nadir to 5 years and from 5 to 10 years. The super obese lost more rapidly from time zero and gained more rapidly after reaching the lowest weight at approximately 2 years than the morbidly obese patients. There was no difference in results between the long- and short-limb operations. There was a significant increase in failures and decrease in excellent results at 10 years when compared with 5 years. The failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients and 34.9% for super obese patients. CONCLUSIONS: The gastric bypass limb length does not impact long-term weight loss. Significant weight gain occurs continuously in patients after reaching the nadir weight following gastric bypass. Despite this weight gain, the long-term mortality remains low at 3.1%.