南京医科大学第一附属医院 减重代谢外科，江苏 南京 210029
Department of Bariatric and Metabolic Surgery, the Fist Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
背景与目的 减重代谢手术是重度肥胖的首选治疗方案。但对于BMI≥50 kg/m2的超级肥胖患者，如何选择合适的术式，目前国内尚缺乏相关研究。本研究对袖状胃切除术（SG）和胃旁路术（RYGB）治疗超级肥胖的短期疗效进行分析评价，为术式选择提供参考。方法 回顾性分析2011年10月—2020年9月71例在南京医科大学第一附属医院接受SG或RYGB治疗的超级肥胖患者的围手术期及术后随访资料。结果 71例患者中，37例接受袖状胃切除术（SG组），34例接受胃旁路术（RYGB组）。两组患者基本资料（性别、年龄、体质量、BMI）与术前相关代谢合并症差异均无统计学意义（均P>0.05）。RYGB组平均手术时间较SG组明显延长［（143.4±84.5）min vs.（ 93.2±31.2）min，P=0.001］，两组术后总并发症发生率差异无统计学意义（P>0.05）。术后1年的随访结果显示，两组在体质量、BMI、总体质量减少率及多余体质量减少率方面差异均无统计学意义（均P>0.05）；在相关代谢合并症的缓解方面，术后RYGB组在2型糖尿病和高脂血症方面的缓解率明显优于SG组（88.9% vs. 25.0%，P=0.021；100.0% vs. 22.2%，P<0.001），而肝功能异常的缓解率则较SG组偏低（61.5% vs. 87.5%，P=0.011）；术后营养评估方面，术后1年，RYGB组出现铁缺乏和维生素B12缺乏的比例明显高于SG组（55.9% vs. 13.5%，P<0.001；29.4% vs. 5.4%，P=0.007），RYGB组术后血红蛋白水平低于SG组（121.5 g/L vs. 135.8 g/L，P=0.033），而叶酸水平则相对较高（25.3 nmol/L vs. 17.3 nmol/L，P=0.004）。此外，两组术后维生素D缺乏发生率均超过60%。结论 SG与RYGB治疗超级肥胖症患者安全可行，近期减重效果无明显差异。RYGB对糖脂代谢紊乱的治疗效果更好，但术后营养不良的发生率也更高。SG手术时间短，对伴有严重并发症的超级肥胖患者更加适用，且对肝功能异常的改善更为有效。术后患者需要加强教育和随访，尽量避免营养并发症的发生，具体术式选择需要遵循个体化的原则进行。
Background and Aims Metabolic and bariatric surgery is the primary treatment for severe obesity. However, little is known about the effectiveness of different procedures in super-obesity Chinese patients (BMI≥50 kg/m2). This study was conducted to determine the short-term efficacy of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in treating super obesity patients to provide a reference for procedure selection.Methods The perioperative and postoperative follow-up data of 71 super obese patients who were treated by SG or RYGB in the First Affiliated Hospital of Nanjing Medical University from October 2011 to September 2020 were retrospectively analyzed.Results Of the 71 patients, 37 cases underwent SG (SG group), and 34 cases underwent RYGB (RYGB group). There were no significant differences in the baseline data (sex, age, weight, and BMI) and obesity-related metabolic complications between the two groups (all P>0.05). The average operative time in the RYGB group was longer than that in the SG group [（143.4±84.5）min vs.（ 93.2±31.2）min，P=0.001], and there was no significant difference in the overall incidence of postoperative complications between the two groups (P>0.05). The postoperative one-year follow-up results showed that there were no significant differences in weight, BMI, total weight loss rate, and excess weight loss rate between the two groups (all P>0.05); in terms of the improvements in metabolic complications, the remission rates of type 2 diabetes and hyperlipidemia in RYGB group were higher than those in SG group (88.9% vs. 25.0%, P=0.021; 100.0% vs. 22.2%, P<0.001), while the remission rate of liver malfunction in RYGB group was lower than that in SG group (61.5% vs. 87.5%, P=0.011); as for the postoperative nutritional assessment, the iron deficiency, and vitamin B12 deficiency rates in RYGB group were significantly higher than those in SG group (55.9% vs. 13.5%, P<0.001; 29.4% vs. 5.4%, P=0.007), the hemoglobin level was significantly lower in RYGB group (121.5 g/L vs. 135.8 g/L, P=0.033), while the folate level was higher (25.3 nmol/L vs. 17.3 nmol/L, P=0.004) than those in SG group. In addition, the incidence of vitamin D deficiency was more than 60% in both groups.Conclusion SG and RYGB are safe and feasible for super obese patients, with similar weight loss effects. RYGB is more effective for those with glycolipid metabolism disorder, while its incidence of malnutrition is also higher. SG is more suitable for super-obese patients with severe complications owing to its shorter operative time, and SG is also more effective for improving liver malfunction. Postoperative education and follow-up should be strengthened for patients to avoid the occurrence of severe malnutrition. The specific procedure selection needs to follow the principle of individualization.