腹腔鏡胃旁路術(shù)治療肥胖合并2型糖尿病的臨床效果①

鮑 峰，向榮超，鮮于劍波，王 東，李國(guó)強(qiáng)，鄧志剛，向春華，智 星，劉 文

(綿陽(yáng)市中心醫(yī)院，四川 綿陽(yáng)，621000)

·論 著·

腹腔鏡胃旁路術(shù)治療肥胖合并2型糖尿病的臨床效果①

鮑 峰，向榮超，鮮于劍波，王 東，李國(guó)強(qiáng)，鄧志剛，向春華，智 星，劉 文

(綿陽(yáng)市中心醫(yī)院，四川 綿陽(yáng)，621000)

目的：探討腹腔鏡Roux-en-Y胃旁路術(shù)(laparoscopic Roux-en-Y gastric bypass，LRYGB)治療肥胖合并2型糖尿病(type 2 diabetes mellitus，T2DM)的臨床效果。方法：回顧分析2009年3月至2013年5月為7例肥胖合并T2DM患者行LRYGB的臨床資料，隨訪3年，分析手術(shù)前后糖脂代謝指標(biāo)的變化。結(jié)果：7例手術(shù)均獲成功，無(wú)一例中轉(zhuǎn)開(kāi)腹，術(shù)前體重指數(shù)(body mass index，BMI)≥27.5 kg/m2，與術(shù)前相比，術(shù)后3年BMI下降[(26.47±1.24) vs.(29.87±2.17)，P<0.05]，空腹血糖[(5.90±0.76) vs.(8.24±2.19)，P<0.05]、糖化血紅蛋白HbA1c[(6.28±0.42) vs.(8.06±1.73)，P<0.05]、總膽固醇[(4.27±0.22) vs. (5.10±0.49)，P<0.05]、三酰甘油[(1.59±0.10) vs. (1.97±0.14)，P<0.05]、低密度脂蛋白[(2.67±0.32) vs.(3.22±0.12)，P<0.05]、高密度脂蛋白[(1.14±0.06) vs.(1.04±0.05)，P<0.05]較術(shù)前均有明顯改善。術(shù)后患者均無(wú)嚴(yán)重并發(fā)癥發(fā)生。結(jié)論：LRYGB治療肥胖合并T2DM可顯著降低患者的BMI，改善血糖、血脂水平，手術(shù)安全、有效，值得臨床推廣應(yīng)用。

肥胖癥；糖尿病，2型；腹腔鏡檢查；胃旁路術(shù)

近年，腹腔鏡Roux-en-Y胃旁路術(shù)(laparoscopic Roux-en-Y gastric bypass，LRYGB)已成為治療肥胖合并2型糖尿病(type 2 diabetes mellitus，T2DM)的有效方法[1-6]，不僅可有效降低體重，還可緩解甚至治愈T2DM及其多種并發(fā)癥[3,7-8]。國(guó)際糖尿病聯(lián)盟(international diabetes federation，IDF)公布的糖尿病治療指南(2011版)中已將亞洲人群糖尿病手術(shù)治療的適應(yīng)證調(diào)整至體重指數(shù)(body mass index，BMI)≥27.5 kg/m2[9]。然而，對(duì)于手術(shù)治療肥胖合并T2DM臨床效果的長(zhǎng)期隨訪資料仍較少[10-11]。自2009年我院普通外科開(kāi)展LRYGB治療肥胖合并T2DM以來(lái)，其中BMI≥27.5 kg/m2并隨訪3年的患者共7例，現(xiàn)回顧性分析7例患者的臨床資料，探討LRYGB治療肥胖合并T2DM的臨床效果。

1 資料與方法

1.1 臨床資料 2009年3月至2013年5月共7例患者，其中男2例，女5例；36～63歲，平均(50.3±8.8)歲，BMI為27.5～33.0 kg/m2，平均(29.9±2.2) kg/m2，糖尿病病程2～12年，平均(5.4±3.4)年。術(shù)前均不同程度使用胰島素治療。術(shù)前由內(nèi)分泌科醫(yī)生按照2009年美國(guó)糖尿病學(xué)會(huì)(American diabetes association，ADA)糖尿病指南明確診斷為T(mén)2DM[12]。患者均被告知手術(shù)風(fēng)險(xiǎn)并知情同意，經(jīng)醫(yī)院倫理委員會(huì)批準(zhǔn)。

1.2 手術(shù)方法 均行常規(guī)LRYGB，符合指南操作要求[13]。常規(guī)氣管插管，全身麻醉，采用5孔法行LRYGB。助手撥開(kāi)肝左葉，術(shù)者游離胃大彎至His角，于胃左動(dòng)脈第1分支以下無(wú)血管區(qū)分離肝胃韌帶進(jìn)入網(wǎng)膜囊，直線切割閉合器分次將胃底橫行切斷，建立小胃囊，容積15～25 ml；Treitz韌帶下75～150 cm處橫斷空腸，遠(yuǎn)端空腸在橫結(jié)腸前方上提至小胃囊處，行小胃囊與小腸側(cè)側(cè)吻合，近端空腸在胃空腸吻合口下75～100 cm與空腸行“Y”形吻合。檢查吻合口無(wú)滲漏后，分別于右肝下、脾窩放置腹腔引流。見(jiàn)圖1。

圖1 手術(shù)操作方法。A：分離肝胃韌帶進(jìn)入網(wǎng)膜囊。B：直線切割閉合器分次將胃底橫行切斷，建立小胃囊，容積15～25 ml。C：近端空腸在胃空腸吻合口下75～100 cm與空腸行“Y”形側(cè)側(cè)吻合。D：縫合空腸側(cè)側(cè)吻合開(kāi)口。E：小胃囊與小腸側(cè)側(cè)吻合。F：縫合胃空腸側(cè)側(cè)吻合口開(kāi)口。

1.3 術(shù)后指導(dǎo)及隨訪 術(shù)后第1～2天：禁食、抑酸、控制血糖、腸外營(yíng)養(yǎng)支持，鼓勵(lì)患者早期下床活動(dòng)；術(shù)后第3天：上消化道造影未見(jiàn)吻合口滲漏后拔除胃管，開(kāi)始少量飲水及進(jìn)流質(zhì)飲食；術(shù)后第5～7天出院。出院后長(zhǎng)期口服補(bǔ)充復(fù)合維生素及鐵、葉酸等。術(shù)后第3、6、12個(gè)月回院復(fù)查，此后每年復(fù)查1次，隨訪截至2016年5月10日。

1.4 觀察指標(biāo) BMI，空腹血糖(fasting plasma glucose，F(xiàn)PG)、糖化血紅蛋白A1c (hemoglobin A1c，HbA1c)；三酰甘油(triacylglycerol，TG)、總膽固醇(total cholesterol，TC)、低密度脂蛋白(low density lipoprotein，LDL)及高密度脂蛋白(high density lipoprotein，HDL)。

1.5 統(tǒng)計(jì)學(xué)處理 應(yīng)用SPSS 19.0軟件進(jìn)行統(tǒng)計(jì)分析，配對(duì)樣本均數(shù)比較采用配對(duì)t檢驗(yàn)。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié) 果

7例均順利完成LRYGB，并獲得術(shù)后隨訪。無(wú)一例中轉(zhuǎn)開(kāi)腹或死亡病例。術(shù)后均未發(fā)生吻合口狹窄、梗阻、瘺等并發(fā)癥，術(shù)后營(yíng)養(yǎng)不良2例，輕度貧血4例，對(duì)癥處理后好轉(zhuǎn)。術(shù)后3個(gè)月時(shí)，7例患者均無(wú)需使用任何藥物，血糖水平保持長(zhǎng)期正常。術(shù)前BMI平均(29.87±2.17) kg/m2，術(shù)后第3年平均(26.47±1.24) kg/m2，與術(shù)前相比差異有統(tǒng)計(jì)學(xué)意義(P<0.05)?；颊咝g(shù)后第3年FPG、HbA1c、TG、TC、HDL、LDL較術(shù)前均有明顯改善(P<0.05)。見(jiàn)表1、圖2～圖4。

3 討 論

肥胖癥與T2DM是在世界范圍內(nèi)廣泛流行的危害人類(lèi)健康的兩種重要疾病。減肥手術(shù)是目前最成功的治療肥胖癥的方法，手術(shù)在取得顯著、持久減肥效果的同時(shí)顯著緩解了并發(fā)的T2DM。目前,減肥手術(shù)已被美國(guó)糖尿病協(xié)會(huì)寫(xiě)入T2DM治療指南，成為T(mén)2DM的重要治療方案之一[14]。

胃旁路術(shù)最早由Mason醫(yī)生于1967年報(bào)道[15]，手術(shù)方式幾經(jīng)改進(jìn)，最后發(fā)展為目前的Roux-en-Y胃旁路術(shù)(Roux-en-Y gastric bypass，RYGB)，這是目前最主要的減肥術(shù)式之一，對(duì)T2DM的有效緩解率高達(dá)84%[16]，是目前治療肥胖及T2DM的常見(jiàn)術(shù)式[17-19]，對(duì)血糖的改善及體重下降方面優(yōu)于非手術(shù)治療[20-22]。RYGB不僅可糾正肥胖及T2DM患者的代謝紊亂，并有研究表明對(duì)多種代謝相關(guān)性疾病均具有良好的治療作用[23-24]。近年，RYGB治療肥胖合并T2DM在國(guó)內(nèi)得到快速發(fā)展，其治療效果也得到了不少臨床研究的驗(yàn)證[25-26]，為手術(shù)治療肥胖合并T2DM提供了依據(jù)。

時(shí)間BMI(kg/m2)FPG(ρ/mmol·L-1)HbA1c(%)TC(ρ/mmol·L-1)TG(ρ/mmol·L-1)HDL(ρ/mmol·L-1)LDL(ρ/mmol·L-1)術(shù)前29.87±2.178.24±2.198.06±1.735.10±0.491.97±0.141.04±0.053.22±0.12術(shù)后第3年26.47±1.245.90±0.766.28±0.424.27±0.221.59±0.101.14±0.062.67±0.32t值5.423.292.645.335.722.893.90P值0.0020.0170.0390.0020.0010.0280.008

圖2 術(shù)前及術(shù)后3年BMI變化 圖3 術(shù)前及術(shù)后3年HbA1c百分率變化 圖4 術(shù)前及術(shù)后3年糖脂代謝指標(biāo)變化

目前手術(shù)治療肥胖合并T2DM對(duì)患者BMI有較嚴(yán)格的要求，中國(guó)肥胖、T2DM外科治療指南(2014)對(duì)于BMI<27.5 kg/m2的患者推薦為慎重開(kāi)展手術(shù)。對(duì)于BMI<27.5 kg/m2的患者有研究表明術(shù)后臨床效果欠佳。吳良平等[27]為20例BMI<28 kg/m2的T2DM患者行胃旁路術(shù)，隨訪3年發(fā)現(xiàn)與術(shù)前相比，術(shù)后BMI差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，術(shù)后HbA1c控制達(dá)標(biāo)率僅為55.0%。但BMI并非影響手術(shù)效果的唯一因素，Dixon等[28]通過(guò)對(duì)154例華人病例行RYGB后1年血糖情況的logistic回歸分析，認(rèn)為影響手術(shù)效果的因素主要有BMI、糖尿病病程長(zhǎng)短、空腹C肽及體重下降情況。

對(duì)手術(shù)治療肥胖合并T2DM的術(shù)式選擇，目前開(kāi)展較多且被廣泛認(rèn)可的主要有：RYGB、膽胰轉(zhuǎn)流及十二指腸轉(zhuǎn)流術(shù)、胃袖狀切除術(shù)(sleeve gastrectomy，SG)、可調(diào)節(jié)胃束帶術(shù)、迷你胃旁路術(shù)等[29]。LRYGB與腹腔鏡胃袖狀切除術(shù)是目前手術(shù)治療肥胖合并T2DM的常用術(shù)式，均具有較好的控制體重及血糖的作用[1,30]。湯聰?shù)萚31]通過(guò)對(duì)RYGB及SG對(duì)肥胖合并T2DM近、遠(yuǎn)期療效的Meta 分析后認(rèn)為，RYGB及SG手術(shù)均是治療肥胖合并T2DM 的有效措施，其近、遠(yuǎn)期療效隨隨訪時(shí)間無(wú)明顯下降，但RYGB術(shù)后T2DM緩解率較SG高，認(rèn)為RYGB治療T2DM 的療效優(yōu)于SG 手術(shù)。Dogan等[8]通過(guò)對(duì)52例嚴(yán)重肥胖合并T2DM患者行LRYGB術(shù)后隨訪(6.9±2.3)年后發(fā)現(xiàn)，此術(shù)式對(duì)于肥胖合并的糖尿病、血脂紊亂、高血壓等均有明顯的長(zhǎng)期改善作用。因此RYGB是目前治療肥胖合并T2DM的首選術(shù)式[29]。本組7例肥胖合并T2DM患者術(shù)后3年效果良好，糖脂代謝均較術(shù)前顯著改善(P<0.05)。表明手術(shù)治療肥胖合并T2DM的療效顯著。

綜上，LRYGB治療肥胖合并T2DM安全、有效，可顯著降低患者的BMI，改善血糖、血脂水平。相信隨著相關(guān)研究的不斷深入，會(huì)促進(jìn)其更加廣泛的應(yīng)用于臨床。

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(英文編輯：楊慶蕓)

Clinical effect of laparoscopic Roux-en-Y gastric bypass surgery for the treatment of obesity with type 2 diabetes mellitus

BAOFeng,XIANGRong-chao,XIANYUJian-bo,etal.

DepartmentofGeneralSurgery,MianyangCentralHospital,Mianyang621000，China

Objective:To investigate the clinical effect of laparoscopic Roux-en-Y gastric bypass (LRYGB) for the treatment of obesity with type 2 diabetes mellitus (T2DM) patients.Methods:The clinical data of 7 patients of obesity with T2DM performed LRYGB surgery between Mar.2009 and May 2013 in the department of general surgery of Mianyang Central Hospital were analyzed retrospectively.The changes of glucose and lipid metabolism indicators of 7 patients were analyzed after 3 years of follow-up.Results:All 7 cases of obesity with T2DM were successfully operated,and no case was converted to laparotomy,all the patients’ preoperative body mass index (BMI) were ≥27.5 kg/m2.Compared with the preoperative data,postoperative patients’ BMI decreased significantly [(26.47±1.24) vs. (29.87±2.17),P<0.05],and the fasting plasma glucose [(5.90±0.76) vs. (8.24±2.19),P<0.05],the hemoglobin HbA1c [(6.28±0.42) vs. (8.06±1.73),P<0.05],the total cholesterol [(4.27±0.22) vs. (5.10±0.49),P<0.05],the triacylglycerol [(1.59±0.10) vs. (1.97±0.14),P<0.05],the low density lipoprotein [(2.67±0.32) vs. (3.22±0.12),P<0.05],the high density lipoprotein [(1.14±0.06) vs. (1.04±0.05),P<0.05] were significantly improved.There were no severe complications after operation.Conclusions:LRYGB for treatment of obesity with T2DM significantly reduces the patient’s BMI,improves the patient’s blood glucose and blood lipid levels,it is a safe and effective treatment method,worthy of clinical application.

Obesity;Diabetes mellitus,type 2;Laparoscopy;Gastric bypass

1009-6612(2017)01-0012-04

10.13499/j.cnki.fqjwkzz.2017.01.012

鮑 峰(1984—)男，四川省綿陽(yáng)市中心醫(yī)院普通外科主治醫(yī)師，主要從事胃腸外科的研究。

R589.1

A

2016-06-11)

①*通訊作者：向榮超，E-mail:xiangrongchao@163.com