极度肥胖患者减重代谢手术术式选择的争议与思考
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华中科技大学同济医学院附属协和医院 胃肠外科,湖北 武汉 430022

作者简介:

汪赓,华中科技大学同济医学院附属协和医院主治医师,主要从事减重代谢外科临床及基础方面的研究。

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夏泽锋,Email: xiazefeng@sina.com

基金项目:

国家自然科学基金资助项目(81700488)。


Controversies and considerations regarding type choice of bariatric surgical procedures for extremely obese patients
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Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China

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    摘要:

    极度肥胖是指体质量指数(BMI)≥50 kg/m2的肥胖患者。此类患者不仅严重超重,并且大多合并存在严重的肥胖相关性疾病,包括高血压、糖尿病、心脑血管疾病、阻塞性睡眠呼吸暂停低通气综合征(OSAHS)、胃食管反流病(GERD)等。极度肥胖患者的生活质量和健康受到极大威胁,但传统的药物治疗等方法对其效果十分有限。减重手术是其主要治疗方法,但应该如何选择具体的手术方式,存在较大争议。首先,需要确保手术的安全顺利实施,尽量减低围手术期并发症发生率;其次,需要确保治疗效果,帮助患者达到满意的减重和代谢综合征改善治疗目的;第三,现有临床研究证实,极度肥胖人群的手术治疗效果不如其他肥胖人群,因此,实施初次手术时应考虑到修正手术的预案。目前全球和国内的减重代谢手术方式不断发展更新。各类手术方式因其设计原理不同,各自存在不同的优势与不足。其中胃袖状切除术(SG)开展规模最大。SG具有术式简单、术后并发症少的优点,但也有减重降糖效果有限,代谢综合征治疗不明显的缺点。胃旁路术(RYGB)也是当前流行的主流术式,具有减重降糖效果强,代谢改善明显的优点,但手术过程较为复杂,术后并发症更多等缺点。胆胰转流十二指肠转位手术(BPD-DS)具有最强的减重降糖效果,但手术最为复杂,术后并发症严重。近年来,针对上述手术的优点和缺点,减重代谢医生进行了系列改良,产生了很多新的手术方式。笔者就当前指南推荐术式及当前发展较快的手术方式进行分析探讨,根据当前已有的临床研究证据,分析当前的争议与思考,并就临床实践中的焦点问题进行总结。

    Abstract:

    Obese patients with a body mass index (BMI) ≥50 kg/m2 are classified as extreme/super obese. These patients are not only seriously overweight but also complicated by serious obesity-related diseases such as hypertension, diabetes, cardiovascular and cerebrovascular disease, obstructive sleep apnea-hypopnea syndrome (OSAHS) and gastroesophageal reflux disease (GERD). The quality of life and health of extremly obese patients are greatly affected. However, drug therapies have very limited effects on the extremely obese. Bariatric surgeries are the main therapeutic options, but how to select an appropriate surgical procedure is still considerable controversy. First, the safety and smooth-going of the operation should be guaranteed, and the risk factors for perioperative complications should be minimized; secondly, the therapeutic efficacy should be confirmed to help patients to achieve the goals of satisfactory weight loss and improvements of metabolic syndrome; thirdly, existing clinical studies demonstrate that the treatment efficacy in super-obese population is inferior to that in other obese population, so revisional surgical options should be considered before performing the initial surgery. At present, the types of bariatric metabolic surgery are constantly developing and evolving. Each surgical type has its pros and cons because of its different design principles. Sleeve gastrectomy (SG) is the most popular bariatric surgery. It has the advantages of easy operation and relatively fewer postoperative complications but has the disadvantages of limited efficacy for weight loss and glucose-lowering and making no significant improvements in metabolic syndrome. Roux-en-Y gastric bypass (RYGB) is also currently a mainstream operation. It has strong efficacy for weight loss, glucose-lowering, and metabolic improvements, but it has shortcomings, such as complex operations and more postoperative complications. Biliopancreatic diversion duodenal switch (BPD-DS) has the highest efficacy for weight loss and glucose-lowering, but the procedure is most difficult with severe postoperative complications. In recent years, bariatric metabolic surgeons have created a series of modifications focused on the merits and demerits of the above procedures, resulting in many new surgical techniques. Here, the authors analyze and discuss the surgical methods currently recommended by the guidelines and the surgical methods with rapid development, analyze the current controversies and new insights according to the existing clinical evidence, and summarize the significant issues in clinical practice.

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汪赓,李钢,白洁,刘洋,邓世昌,陶凯雄,夏泽锋.极度肥胖患者减重代谢手术术式选择的争议与思考[J].中国普通外科杂志,2022,31(10):1272-1284.
DOI:10.7659/j. issn.1005-6947.2022.10.002

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  • 收稿日期:2022-07-28
  • 最后修改日期:2022-09-17
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  • 在线发布日期: 2022-10-31