1995中国普通外科杂志Chinese Journal of General SurgeryChinese Journal of General Surgery中国普通外科杂志1005-694743-1213/R湖南省长沙市1005-6947(2022)10-1339-0810.7659/j.issn.1005-6947.2022.10.00921-0678减重代谢专题研究R656.6MONOGRAPHIC STUDY OF BARIATRIC METABOLIC SURGERY单吻合口十二指肠回肠旁路联合袖状胃切除术对中国肥胖型2型糖尿病患者的疗效Efficacy of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in treatment of obese type 2 diabetes patients in China王泽雨WANGZeyu王伦WANGLun赵玉会ZHAOYuhui贾永恒JIAYongheng马巍岐MAWeiqi姜涛JIANGTao吉林大学中日联谊医院 减重与代谢外科,吉林长春130033Department of Bariatric and Metabolic Surgery, China-Japan Union Hospital, Jilin University, Changchun130033, China姜晖姜涛,Email: jiangtao99@jlu.edu.cn
Among many bariatric-metabolic procedures, the single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is one of the most effective treatments for obese type 2 diabetes. However, there are few reports on SADI-S in China. Therefore, this study was conducted to investigate the efficacy of SADI-S in obese type 2 diabetes patients in China to provide a reference for future treatment choices.
Methods
The clinical data of 50 patients with obese type 2 diabetes undergoing SADI-S at China-Japan Union Hospital of Jilin University between October 2018 and August 2021 were retrospectively analyzed. Patients were analyzed for intraoperative and postoperative conditions (operative time, postoperative hospital stay and surgical complications), weight, body mass index (BMI), extra weight loss (%EWL), total weight loss (%TWL), fasting glucose, glycosylated hemoglobin, and complete remission rate of diabetes after surgery. Follow-up was completed as of August 2022.
Results
Of the 50 patients, 24 cases were males and 26 cases were females, with a mean age of 34 (28-43) years. All patients completed SADI-S surgery by laparoscopic (11 cases) or robotic (39 cases) approach without conversion to laparotomy, and no death occurred. The operative time was (187.9±37.9) min and the length of postoperative hospital stay was 6 (6-7) d. Surgical complications occurred in 3 patients (6%), which included two Clavien-Dindo Grade Ⅱ complications (abdominal fluid collections and anastomotic leakage) and one Clavien⁃Dindo grade Ⅲ complication (gastric leakage). The patient with anastomotic leakage was discharged after a combination of conservative treatments, including water fasting, total intravenous nutrition, and intravenous antibiotic therapy. The patient with gastric leakage was discharged after treatment with gastric fistula repair. The patients' weight, BMI, fasting glucose and glycosylated hemoglobin decreased significantly at 3, 6, 12 and 24 months after surgery compared with their preoperative values (all P<0.05). The %EWL values were (57.8±17.5)%, (78.3±18.6)%, (97.3±22.1)%, and (92.5±9.9)%, the %TWL values were 23.2 (19.9-25.9)%, 31.9 (29.3-33.7)%, 39.3 (34.7-45.2)%, 43.0 (39.1-47.1)% and the complete remission rates of type 2 diabetes were 82.0% (41/50), 95.7% (45/47), 100% (36/36), and 100% (8/8) respectively at 3, 6, 12, and 24 months after surgery. SADI-S yielded better efficacy against diabetes in patients with high ABCD scores than those with low ABCD scores at 3 and 6 months after surgery, and yielded remarkable efficacy against diabetes in patients with ABCD scores of all levels.
Conclusion
SADI-S has an excellent effect in treating obese type 2 diabetes in the Chinese population, but its long-term impact needs to be further observed.
减肥手术肥胖症糖尿病,2型胃切除术肠旁路术Bariatric SurgeryObesityDiabetes Mellitus, Type 2GastrectomyIntestinal Bypassversion1.0.0.22299structure-time2022-10-31T17:30:26word-sourceFX
Chinese Journal of General Surgery, 2022, 31(10):1339-1346.
随着我国经济迅猛发展,人们的生活方式及饮食习惯也发生了巨大的变化,肥胖及糖尿病患者数量显著增多。据国际糖尿病联盟(International Diabetes Federation,IDF)统计[1],2021年中国成人糖尿病患者约1.4亿,预计2045年将增加至1.7亿,位居世界第一。同时[2],中国成年人中肥胖患病率平均每年增长1个百分点,2018年已增长至16.4%。另外,在肥胖和超重人群中,糖尿病患病率显著增加[3],2015—2017年体质量指数(body mass index,BMI)≥30 kg/m2肥胖患者中糖尿病患病率为20.1%[4]。肥胖和持续的高血糖不仅严重威胁着人们的身体健康,还增加了家庭和社会的经济负担[5-12]。相比于传统的“五驾马车”治疗方法,代谢手术已被证明为2型糖尿病更为有效的治疗手段[13]。在众多减重代谢手术中,单吻合口十二指肠回肠旁路联合袖状胃切除术(single-anastomosis duodeno-ileal bypass with sleeve gastrectomy,SADI-S)是治疗肥胖型2型糖尿病最有效的术式之一[14-15]。
SADI-S又被称为单吻合口十二指肠转位术(one anastomosis duodenal switch,OADS)或保留幽门的胃肠减重手术(stomach intestinal pylorus sparing surgery,SIPS)[24]。单吻合口及不打开肠系膜的特点明显降低了手术难度,提高了手术安全性[25-28]:单吻合口使吻合口相关并发症明显降低,不打开肠系膜则降低了疝的发生。在Cottam团队[29]的研究中发现SADI-S术后并发症发生率明显低于胆胰转流十二指肠转位术(biliopancreatic diversion with duodenal switch,BPD/DS)(1.6% vs. 20.9%,P<0.05),其中BPD/DS术后共发生2例吻合口瘘,而SADI-S则未发生;Finno等[30]研究也发现SADI-S的远期并发症发生率显著小于BPD/DS(13.1% vs. 4.4%,P<0.05),并且术后疝的发生更少(4例vs. 17例)。同时,一项匹配队列研究[31]发现SADI-S的远期并发症发生率显著小于Roux-en-Y胃转流术(Roux-en-Y gastric bypass,RYGB),因不良事件的再干预率也远低于RYGB(14.7% vs. 39.3%,P=0.001)。并且RYGB术后残胃癌的发生一直是人们所担心的问题[32],而SADI-S手术保留了幽门,有效地降低了胃癌的发生几率。在本次研究中,SADI-S手术并发症发生率为6%,这与Zaveri等[33]研究中报道的7.7%及Surve等[34]报道的4.3%结果相似。并且3例手术并发症均在达芬奇机器人手术系统下完成,其中腹腔积液及吻合口瘘发生在学习曲线之前,通过我们对学习曲线的研究,当术者达到熟练阶段后,手术的安全性会明显提高[35]。所以SADI-S手术并发症发生率较低,且术者度过学习曲线后,手术安全性会进一步提高。
作为BPD/DS的简化术式,SADI-S治疗肥胖型糖尿病具有极佳的疗效[36]。在减重效果方面,Enochs等[14]对SADI-S、RYGB、袖状胃切除术(sleeve gastrectomy,SG)三种术式的疗效进行了比较,研究结果表明SADI-S的减重疗效远高于RYGB和SG(%EWL:88.4% vs. 78.3% vs. 64.1%,P<0.001)。同样一项基于倾向性评分的研究[37]结果显示SADI-S术后2年%TWL显著高于RYGB(P=0.017)。在本次研究中,SADI-S术后12个月%EWL为97.3%,术后24个月仍保持为92.5%,这与 Sánchez-Pernaute[38]研究结果相似(%EWL=95%)。另外,在Lee等[39]的报道中SG术前BMI与本次研究中(分别为:40.7 kg/m2,41.0 kg/m2)相近,但其术后12个月%TWL仅为26.2%,明显低于SADI-S术后12个月的39.3%。在糖尿病疗效方面,本次研究中SADI-S术后12个月糖尿病完全缓解率为100%,这与Sánchez-Pernaute等[38]及Surve等[34]的研究结果相似(分别为92%,94.4%)。Shen等[40]比较了不同减重手术治疗不同ABCD评分糖尿病患者的疗效,虽然RYGB与SG在治疗高ABCD评分(10~9)患者时均具有较好的疗效,术后12个月糖尿病完全率分别为:100%,81.8%,但两者在低ABCD(2~0)患者中的表现却不理想,糖尿病完全缓解率分别为:12%,21.4%。同样Lee等[39]报道了SG术后1年ABCD评分<4的患者糖尿病完全缓解率为0。而在本次研究中,虽然术后3个月ABCD评分小于4分的患者糖尿病完全缓解率为37.5%,但在术后12个月时糖尿病完全缓解率达到100%。所以,SADI-S在治疗肥胖型糖尿病时,疗效优势明显。
Wang ZY, Wang L, Zhao YH, et al. Efficacy of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in treatment of obese type 2 diabetes patients in China[J]. Chin J Gen Surg, 2022, 31(10):1339-1346. doi:10.7659/j.issn.1005-6947.2022.10.009
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