机器人在减重代谢手术后修正手术中的应用进展

随着减重手术的日益增多,相应也带来一些后果,有的患者因体重减少不足、体重恢复或并发症等需二次进行同类型或其他类型的减重手术,即减重代谢手术后修正手术。相比初次减重手术,减重代谢手术后修正手术风险更高,因此机器人手术系统被尝试用来降低减重代谢手术后修正手术相关风险,本文检索减重代谢手术后机器人修正手术的相关文献,对目前应用进展作一综述,并展望其未来。     

减重代谢手术修正手术的发展现状及展望

减重代谢手术开始于20世纪50年代,目前已成为内外科公认的治疗肥胖症及相关代谢性疾病安全且有效的方法之一。减重代谢手术发展至今,随着手术例数的不断增加,减重效果不佳、复胖及术后并发症等问题日渐凸显,修正手术的开展与规范成为该领域的一大热点。本文现就减重代谢手术修正手术的发展现状及前景作一综述。     

肥胖与代谢病减重手术后的修正手术

随着肥胖在世界范围内的发病增加,减重手术的临床应用数量逐渐升高。由于初次减重手术失败而要求修正手术的病人数量也随之增多,比例达到5%~50%[1]。肥胖与代谢病的修正手术是指初次减重手术后减重失败或发生严重并发症,再次行相同类型或改行其他类型的减重手术[2]。临床上关于肥胖与代谢病修正手术的应用存在一定争议,本文从修正手术的适应证、禁忌证及效果等方面论述当前的观点。修正手术的适应证与禁忌证     

从修正手术角度谈国内目前不规范的减重手术

目前美国代谢与减重外科学会(ASMBS)认可的正规减重手术包括可调节胃绑带术(AGB)、袖状胃切除术(SG)、Roux-en-Y胃旁路术(RYGB)、胆胰分流并十二指肠转位术(Biliopancreatic diversion with duodenal switch,BPD-DS)、迷你胃旁路(MGB)、单吻合口胃旁...     

减重代谢手术在肥胖症综合治疗中的应用

肥胖症是一种以异常或过度脂肪蓄积并威胁人体健康为特征的疾病状态。随着经济社会的飞速发展和生活方式的改变,肥胖在我国高度流行并成为威胁人群健康的重要疾病。与传统非手术治疗不同,减重代谢手术疗效确切,不易反弹,安全性好,临床获益证据充分,能够让许多肥胖症尤其是中重度肥胖症患者能够得到充分的救治,目前已经成为肥胖症综合治疗中的一个重要手段。笔者拟从减重手术指征、手术方式选择和围手术期多学科干预3个方面对减重代谢手术在肥胖症综合治疗中的运用进行阐述。     

减重代谢手术远期并发症预防及处理

近年来,我国减重代谢手术发展迅速且术式不断改进。但术后并发症却并未因此减少,每一种新术式均会带来新的问题,新的减重中心的成立均可能带来新的考验。随着我国减重代谢手术术后随访时间的延长,一些远期并发症开始逐渐出现。减重代谢外科医生应更加重视术后并发症的预防,而只有对发展中遇到的问题进行分析解决才能有效预防术后并发症的发生。     

减重手术228例术后并发症分析

目的 探讨减重手术的并发症及其处理方法。方法 回顾分析中国医科大学附属盛京医院2010年1月至2015年1月行减重手术治疗单纯肥胖或肥胖合并2型糖尿病病人228例临床资料,术式包括腹腔镜胃旁路术、袖状胃切除术、胃束带术,总结并分析其并发症情况。结果 腹腔镜胃旁路术143例,其中发生吻合口溃疡并出血2例,吻合口狭窄1例,营养不良2例,胸腔积液1 例,腹腔小肠扭转1例;腹腔镜袖状胃切除术77 例,术后发生持续反流呕吐2例,残留漏 1例;腹腔镜胃束带术8例,取出胃束带 1例。结论 减重手术术后并发症发生率相对较低,且经积极处理后预后均较好。     

减重代谢手术并发症的处理

减重代谢手术治疗肥胖症及2型糖尿病的疗效已得到广泛认可,在国内迅速开展的同时,应预防及时处理手术相关病发症。肥胖导致的肺栓塞是手术死亡的主要因素,吻合口瘘与营养不良分别是术后早期与远期最常见的并发症,总体而言减重代谢手术是非常安全的,充分的术前准备,严密的术后监测,多学科协作积极处理是有效防治术后并发症的保障。     

减重手术在代谢外科中的应用及疗效

正肥胖及其相关并发症对健康的损害已被人们日益重视,在经济社会发展和生活方式改变的背景下,我国肥胖人群已逾8500万[1]。肥胖及相关代谢紊乱引起多种疾病,涵盖了多学科内容,具体可细至分子水平。肥胖及其相关疾病在内科治疗不佳甚至无效的情况下,减重手术能有效、持久地达到减肥、并治愈或改善肥胖相关合并症。我国肥胖代谢外科经过二十余年的发展,已是相对成熟的学科,越来越多的外科医生能够熟练掌握减重手术主流术式,其学术广度和深度不断被发掘、拓展,     

中国减重代谢外科发展及对手术并发症的思考

纵观全世界减重代谢外科经典手术方式和新手术方式的布局与比例,胃袖状切除术以其日渐凸显的优势正成为最被接受和推崇的减重手术方式,其手术量甚至已超过“金标准”手术方式Roux-en-Y胃旁路术。在我国,这种趋势尤为明显。随着部分缺乏胃肠外科临床经验的医师以及更多年轻医师进入减重代谢外科,临床实践中相继出现操作相关手术并发症...     

Laparoscopic revisional bariatric surgery: myths and facts

Background Bariatric surgery is growing worldwide. An increasing number of patients will require revisional procedures because of inadequate weight control, complications, or loss of quality of life.Methods From August 1999 to September 2003, 62 patients were submitted to laparoscopic revisional surgery.Results The primary operations consisted of laparoscopic adjustable gastric banding in 39 cases, banded and nonbanded Roux-en-Y gastric bypass (RYGB) in 17 cases, vertical banded gastroplasty in 4 cases, and biliopancreatic diversion in 2 cases. Although technically demanding, laparoscopic conversion to RYGB was possible in all cases. Mean operative time was 100 min. Mean hospital stay was 77 h. There were no intraoperative or postoperative complications. A good body mass index reduction after the revisional procedure was observed with a 24 month follow-up period.Conclusions Laparoscopic revisional bariatric surgery is safe and effective. However, it should be performed only by experienced bariatric and laparoscopic surgeons.     

Trends in revisional bariatric surgery using the MBSAQIP database 2015-2017

BackgroundThe third most common bariatric surgery is revisional bariatric surgery. The American College of Surgeons tracks outcomes using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database. We used this database to examine trends in revisional bariatric surgery.ObjectiveTo evaluate how trends in bariatric revisional surgery have changed in recent years.SettingUniversity Hospital, United States.MethodsThe Metabolic and Bariatric Surgery Accreditation Quality Initiative Program database for 2015 to 2017 was examined for revisions of bariatric surgery. Patients who underwent revisional bariatric surgery were identified by the primary Current Procedural Terminology code, the REVCONV and PREVIOUS_SURGERY field as well as secondary Current Procedural Terminology codes. There is no exact code for sleeve gastrectomy (SG) to laparoscopic Roux-en-Y gastric bypass (LRYGB), so we used 43644 (GB)+REVCONV+PREVIOUS_SURGERY for this.ResultsFor the years 2015 to 2017 there were 57,683 revisions/conversions of 528,081 patients. The number of revisions increased over the study period by 5213 cases. The most common revision was laparoscopic adjustable gastric band (LAGB) to SG with 15,433 cases and the second was LAGB to LRYGB with 10,485 cases. There were 14,715 LAGB removals. It is more difficult to track SG to LRYGB but there were 8491 unlisted cases, which may have been sleeve to bypass.ConclusionLAGBs are being taken out or converted, and this group makes up the largest portion of revisions and conversions. It is difficult to track SG to LRYGB, but the number of unlisted cases continues to climb. This will likely surpass LAGB conversions with time. The Metabolic and Bariatric Surgery Accreditation Quality Initiative Program should be modified to capture revisions/conversions of SG.     

Preoperative upper endoscopy is useful before revisional bariatric surgery.

BACKGROUND AND OBJECTIVES: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic). METHODS: We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database. RESULTS: Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment. CONCLUSIONS: Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.     

Midterm results of revisional bariatric surgery postsleeve gastrectomy: resleeve versus bypass

BackgroundBariatric surgery has been shown to produce the most predictable weight loss results, with laparoscopic sleeve gastrectomy (SG) being the most performed procedure as of 2014. However, inadequate weight loss may present the need for a revisional procedure.ObjectivesThe aim of this study is to compare the efficacy of laparoscopic resleeve gastrectomy (LRSG) and laparoscopic Roux-en-Y gastric bypass in attaining successful weight loss.SettingPublic hospital following SG.MethodsA retrospective analysis was performed on all patients who underwent SG from 2008–2019. A list was obtained of those who underwent revisional bariatric surgery after initial SG, and their demographic characteristics were analyzed.ResultsA total of 2858 patients underwent SG, of whom 84 patients (3%) underwent either a revisional laparoscopic Roux-en-Y gastric bypass (rLRYGB) or LRSG. A total of 82% of the patients were female. The mean weight and body mass index (BMI) before SG for the LRSG and rLRYGB patients were 136.7 kg and 49.9 kg/m² and 133.9 kg and 50.5 kg/m², respectively. The mean BMI showed a drop from 42.0 to 31.7 (P < .001) 1 year post revisional surgery for the LRSG group and 42.7 to 34.5 (P < .001) for the rLRYGB group, correlating to an excess weight loss (EWL) of 61.7% and 48.1%, respectively. At 5 years post revisional surgery, LRSG patients showed an increase in BMI to 33.8 (EWL = 45.3%), while those who underwent rLRYGB showed a decrease to 34.3 (EWL = 49.2%). Completeness of follow-up at 1, 3, and 5 years for rLRYGB and LRSG were 67%, 35%, and 24% and 45%, 21%, and 18%, respectively.ConclusionsRevisional bariatric surgery is a safe and effective method for the management of failed primary SG. LRSG patients tended to do better earlier on; however, it leveled off with those who underwent rLRYGB by 5 years.     

Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis

BackgroundIt has been well-established that primary bariatric surgery is effective in inducing improvement of diabetes and other associated co-morbidities in patients with obesity. Evidence demonstrating the influence of revisional bariatric surgery on this trajectory, however, is lacking.ObjectivesWe performed a systematic review and meta-analysis to examine the impact of revisional bariatric surgery on obesity-related metabolic outcomes.SettingUniversity Hospital, SingaporeMethodsWe examined outcomes of remission and improvement of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. Revisional surgeries included sleeve gastrectomy, Roux-en-Y gastric bypass, pouch revision, duodenal switch, and minigastric bypass.ResultsOur search identified 33 relevant studies including a total of 1593 patients. Meta-analysis of proportions demonstrated a 92% improvement in diabetes with 50% achieving remission after revisional bariatric surgery. Of patients, 81% achieved improvement of hypertension with 33% achieving complete remission. In both groups, the highest proportion of improvement was observed after revisional duodenal switch. Although reported by fewer studies, a remission of hyperlipidemia was reported in 37% of patients and improvement of obstructive sleep apnea was seen in 86% of patients.ConclusionsRevisional bariatric surgery improves the outcomes of obesity-related co-morbidities and should be considered in patients with persistent metabolic disease after primary bariatric surgery.     

Outcome of bariatric surgery in older patients

Background

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

从减重手术的历史看减重术式的选择

减重手术在西方发展了50年以上。随着我国肥胖人口的增加,肥胖及2型糖尿病的手术治疗逐渐受到重视。通过回顾减重手术的历史,总结出目前适合中国国情的减重术式,包括胃旁路术、袖状胃切除术以及可调节胃绑带术等。根据患者的意愿和病情,综合考虑患者的承受能力以及支持随访等条件,选择最适合的术式,方能达到最佳的减重降糖效果。     

Feeding the gut after revisional bariatric surgery: The fate of 126 enteral access tubes

Background

Revisional bariatric surgery (RBS) is associated with higher complication rates compared with primary bariatric surgery. Feeding tubes (FTs), including gastrostomy and jejunostomy tubes placed during RBS, may serve as a safety net to provide nutrition when oral intake is contraindicated or limited; however, FTs in this setting have not been well investigated.

Risk factors for postoperative bleeding in bariatric surgery

BackgroundPostoperative bleeding remains a relatively common complication following bariatric surgery and may lead to morbidity and even mortality.ObjectiveTo develop a prediction model to identify patients at risk for postoperative bleeding.SettingRode Kruis Ziekenhuis, Beverwijk, the Netherlands. Based on Dutch nationwide obesity audit data.MethodsPatients undergoing primary bariatric surgery were selected from January 2015 to December 2020 from the Dutch Audit for Treatment of Obesity. The primary outcome was postoperative bleeding within 30 days. Assessed predictors included patient factors and operative data. A prediction model was developed using backward stepwise logistic regression. Internal validation was performed using bootstrapping techniques.ResultsA total of 59,055 patients were included; 13,399 underwent a sleeve gastrectomy, and 45,656 underwent a gastric bypass procedure. Postoperative bleeding occurred in 1.5%. The following predictors were identified: male patients (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.21–1.63), patients >45 years of age (OR = 1.50; 95% CI: 1.29–1.76), body mass index <40 kg/m² (OR = 1.22; 95% CI: 1.06–1.41), cardiovascular disease (OR = 1.36; 95% CI: 1.17–1.57), and sleeve gastrectomy (OR = 1.43; 95% CI: 1.24–1.67). Area under the curve for the model was .612. Following bootstrapping for internal validation, a correction of .9817 was applied.ConclusionA clinical decision rule was designed to assess the risk of postoperative bleeding in patients undergoing bariatric surgery. If 3 or more risk factors are present, there is an increased risk for postoperative bleeding. The model can aid in clinical decision-making: implementing extra preventative measures in high-risk patients. External validation is needed to further develop the model.