中国减重代谢外科发展的瓶颈与对策

中国减重代谢外科经历了曲折却充满收获的20年,但目前依然存在诸多不足,主要包括代谢内、外科对于手术中长期疗效的分歧,病人对减重手术认识不足、认可度低,以及部分减重代谢外科团队手术适应证掌握不准确、手术方式选择不当、手术技术参差不齐、术后并发症处理不及时、术后随访欠规范等一系列问题。在行业协会的正面引导下,落实数据采集、汇报制度,行业培训的规范化,倡导多中心前瞻性研究的标准化管理,加大媒体的宣传力度,必将使我国减重代谢外科突破瓶颈,迎来下一个飞速发展的新起点。     

肥胖与代谢病外科术式的研究进展

病态性肥胖已成为全球流行性疾病之一,可合并2型糖尿病、高血压、冠心病、睡眠呼吸暂停综合征等代谢性疾病严重危害人类的健康与生命。由于传统内科治疗的相対局限性,肥胖与代谢病外科作为一门新兴学科逐渐受到重视与认可。本文旨在初歩总结减重外科手术历史发展及其优缺点,合理选择减重术式,规避相关手术并发症达到最佳的治疗效果。     

减重代谢外科临床研究热点问题进展

回顾近年发表的高质量专业期刊文献,总结当前减重代谢外科临床研究的热点问题及相关进展如下：（1）比较胃袖状切除术（SG）与胃旁路术（RYGB）的临床疗效。现有国外随机临床试验及国内队列研究显示,SG与RYGB在减重效果及缓解肥胖相关代谢异常方面差异无统计学意义。（2）对比减重代谢手术与药物治疗2型糖尿病（T2DM）的效果。减重手术或手术联合药物相较于单纯药物治疗对于T2DM有更好的疗效。（3）青少年减重手术分支。（4）代谢手术共治其他系统疾病。（5）术后长期健康管理。（6）多中心减重代谢手术病例注册系统及数据库的建立完善。     

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,     

减重代谢外科未来的机遇与挑战

减重代谢外科进入中国已有30余年,迅速发展。可以预测的是,在未来的发展道路上也将面临诸多机遇与挑战——无论是经典术式的变迁,手术安全性的保证,新术式的勇敢探求和不良术式的果断摒弃,手术规范化的落实,还是基础与临床科研的突破,都意味着更多的付出。随着代谢综合征发病率的持续攀升,以及人们对健康需求的不断提高,这种机遇与挑战...     

规范与务实——促进我国肥胖症与代谢病外科的健康发展

经过半个多世纪的发展,肥胖症与代谢病外科在西方国家已经形成了一个体系完整的外科专业,而我国引入并开展该学科仅10余年时间。外科治疗肥胖症与相关代谢性疾病,尤其是肥胖型2型糖尿病已得到我国同行和患者的极大兴趣与认可。作为一个新的发展方向,目前我国肥胖症与代谢病外科总的发展趋势良好,但也存在一些问题,如手术名称不够规范、随意放宽手术适应证、对手术方式进行随意更改、疗效评价标准混乱以及术后随访资料不齐等。这些都需要广大同行根据我国实际情况,科学而客观地进行规范,从而促进我国肥胖症与代谢病外科的健康发展。     

腹腔镜减重与代谢外科治疗现状与发展

减重与代谢外科从最初的以减重为唯一目的,发展到治疗肥胖相关的糖、脂代谢和内分泌紊乱,手术适应证不断拓展,治疗范围涵盖2型糖尿病、非酒精性脂肪性肝病、睡眠呼吸暂停综合征等,手术所要求的身体质量指数不断调低。学科内涵不断丰富,对经典手术方式包括Roux－en－Y胃旁路术、胃袖状切除术、可调节胃绑带术和胆胰分流并十二指肠转位术的认识不断加深,在此基础上,新的手术方式不断涌现,包括袖状胃加单吻合口十二指肠转位手术和单吻合口胃旁路手术等。同时,减重外科未来也面临减重器械和胃镜下治疗的挑战。     

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...     

中国肥胖代谢外科发展的困境与突破

中国是目前全球超重和肥胖人口最多的国家, 减重手术是目前治疗肥胖症及相关代谢性疾病最有效的方法。面对严峻的肥胖人口增长情势, 中国肥胖代谢外科发挥了重要的作用。中国肥胖代谢外科的发展与国外相比, 起步较晚, 经过20多年的发展, 目前年手术总量已处于全球前列。在符合行减重手术干预的肥胖患者中, 我国的手术比例是全球最低的国家之一。中国肥胖代谢外科未来的发展有很大的提升空间, 本文对目前中国肥胖代谢外科取得的成绩和所面临的问题(如手术量飞速增长面临着手术方式中腹腔镜袖状胃切除术占比过高、手术标准制定与规范实施、术后管理不当与随访失访、数据库建设的质量化管理带来的随访数据等), 结合现状进行阐述和分析, 相信未来在全体医护的共同努力下, 中国肥胖代谢外科将取得更加辉煌的成就。     

减重代谢外科研究中的热点问题

减重代谢外科通过重建胃肠道的解剖结构达到减少摄食量和营养吸收的目的,并同时产生代谢调节作用。目前,减重代谢外科存在以下几个热点研究问题：减重手术治疗糖尿病的确切机制、肥胖与肿瘤发病的关系、低体重病人行代谢手术的依据、个体化手术设计和手术方式的选择、以及建立临床数据库并基于此进行更深一层的研究,这些问题均关系到减重代谢外科的地位及发展。在减重代谢外科蓬勃发展的时代,积极加强基础研究与临床研究,尤其是结合了基础与临床的转化研究,对于学科的健康有序发展,意义尤为重大。     

减重外科的发展历程及前景

随着肥胖问题的日益严重以及微创减重手术的发展,减重手术在近年来呈现跳跃式的发展,也发展出独立的减重外科分支。减重手术不但是病态性肥胖患者目前唯一有效的治疗方法,而且逐渐发展为代谢性手术,为难治性的肥胖合并糖尿病患者提供了一种新的治疗方法。减重手术的术式数十年发生了很大的变化,目前的减重手术经过不断的改进及发展,已成为一种相对安全和有效的外科治疗方法。新的代谢性手术仍在不断地发展,预期对未来糖尿病的治疗会有很大的突破。减重外科的专科化发展则是减重手术蓬勃发展后的必然趋势,独立的减重外科可以专注于减重手术的服务以及质量提升,对减重及代谢手术的专业训练以及研究发展也都有很大的帮助。随着文明化生活方式的影响,肥胖及糖尿病将会持续成为这个时代重要的健康问题,减重外科的发展更是值得期待。     

减肥手术治疗2型糖尿病近况

减肥有助于治疗肥胖伴发2型糖尿病,但目前尚无有效的药物治疗肥胖症.减肥外科手术能达到明显有效且持续的减重效果.约30%接受减肥手术的患者伴发2型糖尿病,减肥手术后多数患者的2型糖尿病得到缓解(胃肠Bypass手术的有效率为84%～98%,限制食物摄人型手术的有效率为55%～84%).本综述重点讨论各种类型的减肥手术治疗2型糖尿病的疗效及其可能的发生机制.     

Hypertension remission 1 year after bariatric surgery: predictive factors

BackgroundThere is scarce information about predictive factors of hypertension (HT) remission after bariatric surgery (BS). The aims of this study were to determine the clinical characteristics differentiating obese patients with and without HT and to evaluate the predictive factors associated with the risk of persistence of HT after BS.Patients and MethodsFrom January 2007 to December 2009, a review of patients who had undergone BS was performed. Patients were classified as hypertensive if having permanent use of antiHT drugs or clinical BP≥140/90 mm Hg. Weight, waist circumference (WC), and blood pressure were determined with standardized procedures.ResultsFive hundred twenty-6 patients met the inclusion criteria; 264 (50%) were hypertensive, 74 (34%) of whom had type 2 diabetes. Before BS, older age, male gender, and greater WC differentiated hypertensive from normotensive patients. The prevalence of HT significantly fell to 35% (P<.0001) at 12 months after BS. The use of multivariate logistic regression showed that age≥40, male gender and WC≥130 cm were significant predictors of having HT before surgery. Regarding persistence of HT at the 12-month follow-up, the only independent predictors observed were time since diagnosis of HT≥10 years and the number of antiHT drugs used. Presurgical BMI, WC, excess weight (EW), EW loss, surgical procedure, type 2 diabetes, and vitamin D status were not significant predictors.ConclusionsBariatric surgery is associated with a high rate of HT remission. Older age, male gender, and higher WC differentiated hypertensive-obese from normotensive patients. After BS, longer duration and severity of HT were independently associated with no remission of HT.     

胃旁路术治疗2型糖尿病的研究进展

随着国内外相关减重手术治疗2型糖尿病（T2DM）病例报道的增多,并显现出了良好的短期及长期的临床效果,该方法更加引人关注。然而手术治疗2型糖尿病的机制如何尚无明确结论,认为可能的治疗机制是十二指肠和近端空肠被旷置,从而引发胃肠道激素分泌的变化,使T2DM得到控制。本文分别对手术的类别、治疗效果及治疗机制进行综述。     

Nonalcoholic fatty liver disease in patients with different baseline glucose status undergoing bariatric surgery: analysis of intraoperative liver biopsies and literature review

Background

Bariatric surgery has been investigated as a treatment option for obese patients with nonalcoholic fatty liver disease (NAFLD). Because patients with NAFLD and type 2 diabetes show accelerated progression from liver disease to cirrhosis, it has been suggested that surgery could be indicated for patients with lower degrees of obesity and type 2 diabetes.

减重代谢外科中的维生素D缺乏及其影响

维生素D在钙、磷代谢及细胞生长分化中发挥重要作用,随着研究深入,维生素D在人体营养代谢,特别是糖脂代谢中的重要作用越来越受到重视.减重代谢手术是治疗肥胖症、2型糖尿病和其他相关合并症的有效方法.接受减重代谢手术的患者在术前及术后常出现维生素D的缺乏.本文试综述维生素D在减重代谢手术术前、围手术期、术后的水平及其影响,分析维生素D缺乏原因、对代谢性疾病的影响、对减重代谢手术治疗效果的影响,并探讨减重代谢手术对体内维生素D水平的影响及及补充措施.     

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009–2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.     

Hyposalivation is prevalent in bariatric patients but improves after surgery

BackgroundObesity and type 2 diabetes can be associated with poor oral health. This can be because of hyposalivation leading to chronic oral inflammation (OI) and periodontal disease.ObjectiveTo assess the prevalence of hyposalivation and OI in individuals undergoing Roux-en-Y gastric bypass (RYGB) and determine the relationship with metabolic and anthropometric parameters before and after RYGB.SettingUniversity hospital in Canada.MethodsThis was a cross-sectional and prospective cohort study of 59 patients undergoing RYGB from September 2015 to December 2019. Anthropometric, biochemical, and oral measurements were taken before surgery and 1 and 6 months post RYGB. Oral parameters included salivary flow rate and neutrophil count as marker of OI.ResultsFifty-nine patients were enrolled with 29 completing this study. At baseline, the median age was 47 years and body mass index was 46.5 kg/m², 52 (88.1%) were female and 14 individuals (23.7%) had type 2 diabetes; 54.2% (n = 32) of patients had hyposalivation and 13.6% (n = 8) had high neutrophil count. Patients with hyposalivation had significantly higher fasting glucose (5.7 mmol/L) compared with those without hyposalivation (5.2 mmol/L) but no difference was found between high versus low neutrophil count. At 6 months post RYGB, all variables except oral neutrophil count significantly improved. Hyposalivation persisted in 7 (24%) individuals.ConclusionsIn our bariatric patients, more than half the patients had hyposalivation before RYGB and this was associated with higher fasting glucose. Hyposalivation improved post RYGB in parallel with improvements in metabolic parameters but there was no change in OI. Increased salivation may reduce the risk of periodontal disease.     

手术与多学科综合治疗肥胖症及2型糖尿病

单纯性肥胖症及2型糖尿病的治疗应是多学科的综合治疗,包括饮食结构调整、增加身体活动量、行为纠正和药物治疗。一些病态肥胖患者还需要进行微创减肥手术治疗。尽管近年来微创减肥手术对于治疗单纯性肥胖症及2型糖尿病的疗效明显,但存在的问题是：缺乏相关科室的协作与多学科综合治疗以及患者随访率低,这是手术风险增加、疗效差和并发症增多的主要原因。因此,单纯性肥胖症和2型糖尿病及其合并症应该予以微创胃肠外科与相关多学科的综合治疗并进行长期随诊。     

减重手术治疗2型糖尿病机制研究进展

2型糖尿病患者接受减重手术后糖尿病症状显著缓解并能长期维持,主要是因为术后胃肠道激素的改变,此外体质量下降、饮食减少以及其他的因素也起着一定作用。随着其治疗机制研究的不断深入,减重手术有望成为治疗2型糖尿病的一种主要手段。