我国2型糖尿病的外科治疗术式探讨

由于我国的2型糖尿病患者中位体质量指数（BMI）只有24 kg/m2以及我国糖尿病患者存在的饮食差异性,使得目前国内尚缺少充足的减重手术数据和指南,因此,我国医生在国际上公认的术式之外,进行了手术治疗2型糖尿病的术式探索.2011年国际糖尿病联盟（IDF）治疗2型糖尿病的推荐术式主要有：胃旁路手术（GBP）、袖状胃切除术（SG）、胆胰转流手术（BPD）、十二指肠转位术（DS）和可调节胃束带术（AGB）.本文重点分析我国外科医生的进展探索性术式,主要包括：袖状胃切除术加十二指肠空肠旁路术,十二指肠空肠旁路术,袖状胃切除加空回肠旁路术,袖状胃切除加回肠间置术,单纯回肠间置术及空、回肠短路术,胃大弯折叠术以及折叠术加胃束带术,以及其他在内镜下完成的减重术式.每种术式均各有特点,但哪种术式更为适合国内2型糖尿病患者,尚需临床的长期随访及大样本的多中心研究的开展,相信在科学规范前提下,我国的外科医生会摸索出最适合本国2型糖尿病患者的手术方式.     

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。     

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.     

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。     

Changes in HbA1c levels and body mass index after successful decompression surgery in patients with type 2 diabetes mellitus and lumbar spinal stenosis: results of a 2-year follow-up study

Background Context

Lumbar spinal stenosis (LSS) can hinder a patient's physical activity, which in turn can impair glucose tolerance and body weight regulation in patients with type 2 diabetes mellitus (DM-2). Therefore, successful lumbar surgery could facilitate glycemic control and body weight regulation.

多学科综合治疗肥胖症合并2型糖尿病

2型糖尿病常合并肥胖症、高血压、高血脂等代谢综合征症候群。对于此类难以控制的2型糖尿病合并肥胖症的诊断和治疗，内科常用非手术如控制饮食、运动、药物方式治疗；外科则可采用手术方式，改善2型糖尿病及其代谢综合征症候群，达到“治愈”糖尿病和高脂血症的目的。中南大学湘雅三医院对1例肥胖症合并2型糖尿病患者采用多学科协作综合治疗模式，取得了较好疗效。     

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study

BackgroundBariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice.ObjectivesTo compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up.SettingNationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery.MethodsPatients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication.ResultsA total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14–2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27–2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96–3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39–2.76; P < .01). There were no significant differences in CD ≥III complications.ConclusionUsing population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.     

胃肠外科手术治疗肥胖症及2型糖尿病

肥胖症是现今社会所面临的最严重的公共健康问题之一,手术治疗是使肥胖症患者获得长期而稳定的减重效果的唯一方法。自从1954年报道第1例减肥手术以来,外科手术治疗肥胖症在全球范围内获得了很大的发展,逐渐成为治疗病态性肥胖的＂金标准＂。随着研究的不断深入,越来越多的证据表明,胃肠外科手术不仅能减重,同时可以改善甚至治愈肥胖症相关的多种代谢性疾病,尤其是2型糖尿病。目前国内外的胃肠外科医师们正致力于将手术推广到2型糖尿病的治疗中去。外科手术治疗肥胖症及2型糖尿病将有巨大的发展空间。     

Diabetes remission and glycemic response to pre-bariatric surgery diet

Background

Before bariatric surgery, some patients with type 2 diabetes mellitus (T2DM) experience improvement in blood glucose control and reduced insulin requirements while on a preoperative low-calorie diet (LCD). We hypothesized that patients who exhibit a significant glycemic response to this diet are more likely to experience remission of their diabetes in the postoperative period.

Materials and methods

Insulin-dependent T2DM patients undergoing bariatric surgery between August 2006 and February 2011 were eligible for inclusion. Insulin requirements at day 0 and 10 of the LCD were compared. Patients with a ≥50% reduction in total insulin dosage to maintain appropriate blood glucose control were considered rapid responders to the preoperative LCD. All others were non–rapid responders. We analyzed T2DM remission rates up to 1 y postoperatively.

Results

A total of 51 patients met inclusion criteria and 29 were categorized as rapid responders (57%). The remaining 22 were considered non–rapid responders (43%). The two groups did not differ demographically. Rapid responders had greater T2DM remission rates at 6 (44% versus 13.6%; P = 0.02) and 12 mo (72.7% versus 5.9%; P < 0.01). In patients undergoing laparoscopic gastric bypass, rapid responders showed greater excess weight loss at 3 mo (40.1% versus 28.2%; P < 0.01), 6 mo (55.2% versus 40.2%; P < 0.01), and 12 mo (67.7% versus 47.3%; P < 0.01).

Conclusions

Insulin-dependent T2DM bariatric surgery patients who display a rapid glycemic response to the preoperative LCD are more likely to experience early remission of T2DM postoperatively and greater weight loss.     

Metabolic surgery for inadequately controlled type 2 diabetes in nonseverely obese Japanese: a prospective,single-center study

Background

The beneficial effects of metabolic surgery on weight loss, glycemic control, and cardiovascular improvement for the morbidly obese patient has been vast and undeniable. It is also expected to be effective in diabetic patients with less severe obesity, but the evidence is yet to yield significant impact.

The effect of metabolic surgery on nonobese patients (BMI<30 kg/m2) with type 2 diabetes: a systematic review

Background

The influence of metabolic surgery on the glucose and lipid profiles of nonobese body mass index<30 kg/m² patients with type 2 diabetes, particularly the effect ≥1 year, remains unknown.

Progress in treatment of type 2 diabetes by bariatric surgery

The incidence of type 2 diabetes (T2D) is increasing at an alarming rate worldwide. Bariatric surgical procedures, such as the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, are the most efficient approaches to obtain substantial and durable remission of T2D. The benefits of bariatric surgery are realized through the consequent increased satiety and alterations in gastrointestinal hormones, bile acids, and the intestinal microbiota. A comprehensive understanding of the mechanisms by which various bariatric surgical procedures exert their benefits on T2D could contribute to the design of better non-surgical treatments for T2D. In this review, we describe the classification and evolution of bariatric surgery and explore the multiple mechanisms underlying the effect of bariatric surgery on insulin resistance. Based upon our summarization of the current knowledge on the underlying mechanisms, we speculate that the gut might act as a new target for improving T2D. Our ultimate goal with this review is to provide a better understanding of T2D pathophysiology in order to support development of T2D treatments that are less invasive and more scalable.     

Successful lifestyle modifications may underlie umbilical cord-mesenchymal stromal cell effects in type 2 diabetes mellitus

Type 2 diabetes mellitus(T2DM) is a lifelong condition and a grave threat to human health. Innovative efforts to relieve its detrimental effects are acutely needed. The sine qua non in T2DM management is consistent adherence to a prudent lifestyle and nutrition, combined with aerobic and resistance exercise regimens, together repeatedly shown to lead to complete reversal and even longterm remission. Non-adherence to the above lifestyle adjustments condemns any treatment effort and ultimately the...     

Duodenal-jejunal bypass for the treatment of type 2 diabetes in Chinese patients with an average body mass index<24 kg/m2

BackgroundIt is frequently reported that bariatric surgery often leads to resolution of type 2 diabetes mellitus (T2 DM). Limited experience with duodenal-jejunal bypass (DJB) for the treatment of T2 DM has shown controversial results. We present the first study of DJB for T2 DM patients in China. The objective of this study was to evaluate the effects of DJB in nonobese Chinese patients with T2 DM.MethodsFrom March 2009 to March 2011, a total of 10 T2 DM patients with an average body mass index (BMI) of 23.8±1.2 kg/m² were enrolled in the study. DJB was performed in all patients. BMI and glycometabolic parameters were collected at baseline and 1, 3, 6, 12, and 24 months postoperatively. Remission of T2 DM was defined as a glycosylated hemoglobin (HbA_1c) level of<7% without diabetic medication.ResultsRemission of T2 DM was observed in 1 (10%) of 10 T2 DM patients at 6 months. Without increasing antihyperglycemic agents, fasting plasma glucose (FPG), 2-hour postprandial plasma glucose, and HbA_1c decreased significantly at each postoperative time point, compared with the preoperative baseline. BMI statistically decreased at 1 and 3 months, but did not reach statistical significance at 6, 12, and 24 months.ConclusionsDJB can improve glycemic control in nonobese T2 DM patients without significant weight loss but may not be effective enough to induce remission of T2 DM in nonobese Chinese patients. A larger sample size and more constrictive inclusion criteria may be required for better evaluation.