-
摘要:
肥胖症是目前具有挑战性的全世界公共卫生问题之一。我国≥50%的成人存在超重或肥胖症。肥胖症已被证实为2型糖尿病、心脑血管疾病、结肠癌及其他特定恶性肿瘤的危险因素,严重威胁国人健康及生命质量。近20年来,随着减重手术的成熟发展,其对治疗肥胖症及其相关代谢性疾病的疗效及安全性得到广泛认可,同时提高患者预期寿命和生命质量。然而,部分减重手术后患者需行修正性减重手术,修正性减重手术率为5%~50%。修正性减重手术原因主要为减重效果不佳,包括体质量下降不明显、体质量反弹及相关代谢性疾病未得到明显改善甚至复发,其他原因还包括贫血、营养不良、长期慢性疼痛等。目前国内仅有中国医师协会外科医师分会肥胖和糖尿病外科医师委员会2018年提出的修正性减重手术东亚专家共识,临床实践中关于修正性减重手术的适应证、禁忌证、手术方式等仍无统一标准。笔者总结修正性减重手术的最新研究进展,旨在为临床实践提供指导价值。
Abstract:Obesity is one of the most challenging global public health issues, and more than half of adults in Chia are overweight or obese. Obesity has been shown to be a risk factor for type 2 diabetes, cardiovascular disease, colon cancer and other specific cancers, and has become a serious threat and even a danger to the health and quality of life of the nation. With the mature development of bariatric surgery in the last 20 years, it is now widely recognized for its effectiveness and safety in the treatment of obesity and related metabolic diseases, as well as improving patients′ life expectancy and quality of life. However, previous data from the literatures suggest that some patients require revisional surgery after bariatric surgery, with the incidence of revisional bariatric surgery as 5% to 50%. The main reasons for revisional bariatric surgery are poor post‑operative outcomes, including the lack of significant weight loss, weight regain and no significant improvement or even recurrence of associated metabolic disease, and other reasons include the development of anaemia, malnutrition and long‑term chronic pain. Currently, there is only the East Asian expert consensus on revised bariatric surgery proposed by Chinese Society for Metabolic & Bariatric Surgery in 2018. However, there are still no uniform standards regarding the indications, contraindications and surgical modalities of revisional bariatric surgery in clinical practice. The authors summarize the latest researches of revisional bariatric surgery, in order to provide the guidance value for clinical practice.
-
Keywords:
- Obesity /
- Bariatric surgery /
- Revisional surgery /
- Development /
- Reflection
-
自20世纪90年代以来,我国超重和肥胖症发病率快速上升。目前中国超重和肥胖症人数居全世界首位,严重影响国人健康及社会发展[1‑2]。减重手术是治疗严重肥胖症及其相关并发症的最有效方式,具有减重效果长久、安全性好等优点[3‑5]。但部分患者初次减重手术后出现体质量反弹、糖尿病复发等问题,需行修正性减重手术[6‑7]。笔者总结修正性减重手术的最新研究进展,旨在为临床实践提供指导。
一、修正性减重手术的原因及指征
修正性减重手术是指由于各种原因引起的再次行减重手术,其指征主要有减重效果不明显或术后复胖,肥胖相关合并症如2型糖尿病等改善效果不明显或术后复发,手术以及营养相关性并发症（如出血、吻合口漏、吻合口边缘溃疡、吻合口狭窄、反流性胃炎等）[8‑10]。多数减重手术无需再次手术,然而,修正性减重手术占减重手术总数量的比例日益增加,目前为7%~15%[11‑13]。减重手术后患者复胖的危险因素主要有术前BMI>50 kg/m2、术后对饮食运动指导依从性差、术后抑郁等[14]。目前国内外对于复胖标准尚未达成共识,现有评估患者减重手术后复胖的常见标准包括：（1）体质量下降至最低点后,多余体质量减轻（excess weight loss,EWL）百分比反向增加>25%,或BMI增加>5 kg/m2,或体质量增加>10 kg。（2）EWL百分比由>50%变为≤50%或BMI>35 kg/m2等[14]。2型糖尿病复发也是行修正性减重手术的重要原因之一,复发标准通常是患者在减重手术后1年出现糖化血红蛋白水平持续>6.5%[15]。
袖状胃切除术（sleeve gastrectomy,SG）和Roux⁃en‑Y胃旁路术（Roux‑en‑Y gastric bypass,RYGB）是国内外最常见的2种减重手术方式[16]。目前不同研究中关于减重手术后因各种原因再行修正性减重手术的概率数据差异较大。1项纳入217例肥胖症患者的研究结果显示：约60%的患者行减重手术2年后体质量下降的同时部分或完全缓解糖尿病进展。但其中近1/5的患者在6年随访中出现复胖或糖尿病复发[17]。此外,多项研究结果显示：部分患者行RYGB及SG后3年内实现体质量下降及糖尿病完全缓解,然而约40%的患者在6年随访期内出现复胖或糖尿病复发[18‑20]。有更长的随访研究结果显示：约33%的患者SG后10年内因复胖或胃食管反流需再次手术,而RYGB后复胖发生率高达25%~30%[21]。另有Meta分析结果显示：SG后随访≥7年时,总体修正性减重手术率达到19.9%[22]。以上研究结果显示：部分肥胖症患者行减重手术后仍可能因复胖或糖尿病复发等多种原因行修正性减重手术。因此,修正性减重手术是减重手术的重要组成部分,是解决初次减重手术后复胖和糖尿病复发等问题的关键。
二、修正性减重手术的术前评估
充分的术前评估是成功施行修正性减重手术的关键。常见的术前评估包括体格检查、胃镜、上消化道钡剂造影、CT三维重建检查等[10,23‑24]。临床医师需全面回顾患者初次减重手术史及相关检查检验报告,详细了解术后生活方式、饮食结构等。尤其应评估患者营养状况,并补充现有不足。虽然蛋白质缺乏是减重手术后最常见的大营养素缺乏,但12种微量元素的缺乏也同样常见,应在行修正性减重手术前予以纠正[25]。精神心理因素是影响减重手术后复胖的重要因素之一,因此,心理评估和干预也是决定修正性减重手术是否有效的关键,建议作为常规评估项目之一[14]。
三、常见修正性减重手术的特点
（一）腹腔镜SG后修正性减重手术
腹腔镜SG已成为国内治疗肥胖症的首选手术方式,因其高安全性及低死亡率,且相较于其他手术方式,外科医师较易学习[16]。腹腔镜SG还可显著改善代谢性综合征（如肥胖症合并高血压、糖尿病、血脂异常、阻塞性睡眠呼吸暂停综合征等）。目前普遍认为腹腔镜SG后行修正性减重手术的主要原因是复胖及胃食管反流病。但腹腔镜SG后复胖的主要机制仍存在争议,多与胃底不完全切除、术后胃窦扩张、切除胃体积不足有关。Tsui等[26]的研究结果显示：首次SG后第5、8年,患者行修正性减重手术的比例分别为6.2%、15.3%。而Lazzati等[27]的研究结果显示：首次SG第5、7、10年,行修正性减重手术患者比例分别为4.7%、7.5%、12.2%。即在10年随访时间内,每8例最初接受SG的患者中,1例行修正性减重手术；SG后最常见的修正性减重手术是RYGB（75.2%）,其次为再次行SG（18.7%）,其他方式为胆胰旷置胰十二指肠转位术。
（二）腹腔镜RYGB后修正性减重手术
腹腔镜RYGB后多种修正性减重手术方式可选择。1项5年随访研究结果显示：胆胰旷置胰十二指肠转位术作为腹腔镜RYGB的修正性减重手术比其他手术方式具有更显著的减重效果[28]。其原理仍为限制部分食物摄入和吸收,具有解决再次复胖的潜力。但目前关于胆胰旷置胰十二指肠转位术长期并发症相关数据较少,尚需进一步研究。Angrisani等[29]的研究结果显示：RYGB后修正性减重手术选择SG联合单吻合口十二指肠回肠旁路术和胆胰旷置胰十二指肠转位术后18个月和24个月的平均EWL百分比分别为56.0%和56.4%。此外,Moon等[30]的研究结果亦显示：RYGB后修正性减重手术选择SG联合单吻合口十二指肠回肠旁路术和胆胰旷置胰十二指肠转位术的减重效果显著,且对于行RYGB后仍难以控制的2型糖尿病患者效果显著。但同时也有可能出现营养不良的问题,尚需进一步研究结果评估其安全性。
四、修正性减重手术的利弊
与初次减重手术比较,修正性减重手术能有效再次减轻体质量,同时可改善肥胖症及其相关代谢性疾病,如减少使用2型糖尿病药物和全面控制血糖[31‑33]。对于初次减重手术后仍有代谢综合征疾病的患者,应予以评估是否需行修正性减重手术。Koh等[34]的Meta分析结果表明：修正性减重手术后92%的糖尿病患者得到改善,其中50%达到完全缓解；81%患者高血压得到改善,其中33%的患者达到完全缓解,而各种修正性减重手术中胆胰旷置胰十二指肠转位术后患者改善比例最高。修正性减重手术对肥胖症相关代谢性疾病有积极作用,并支持将其用于治疗肥胖症合并复发或难治代谢性疾病,但修正性减重手术后对于代谢性疾病得到改善和缓解的机制尚不明确,有待更进一步追踪。
与任何再手术一样,修正性减重手术有较高并发症发生率。Axer等[35]的研究结果显示：修正性减重手术术中及术后并发症发生率较高,尤其是开腹修正性减重手术。与初次减重手术比较,修正性减重手术与更长手术时间、更长住院时间、更高30 d内再入院率以及更高计划外ICU入院率有关,且术中由腹腔镜手术中转为开腹手术的发生率较高[36]。修正性减重手术并发症的评估和处理与初次手术患者的处理一致。然而,由于并发症发生率可能更高,因此,患者的围手术期管理以及对早期症状的辨别尤为重要。
五、结语
随着肥胖症发病率的不断增加,减重代谢外科蓬勃发展。而减重手术无疑是治疗肥胖症及其相关疾病的有力工具,修正性减重手术数量将继续增加[37]。由于粘连和组织增厚,修正性减重手术对于外科医师的技术要求较高,且围手术期并发症风险明显增加,需由经验丰富的多学科团队确保围手术期管理。目前,尚无针对修正性减重手术的标准适应证,对于再次手术的各项策略亦无明确共识。目前关于修正性减重手术的报道有限,且研究纳入患者较少,随访时间较短,尚需多中心研究数据及长期随访结果。
外科医师行修正性减重手术前,应该对患者进行全面检查,通过影像学辅助检查设备对患者解剖的改变进行评估、对患者目前的主观感觉及客观表现详实描述。未来,对任何减重代谢外科医师,提高修正性减重手术质量是重要挑战。笔者相信：通过每位减重代谢外科医师的努力,修正性减重手术能够安全、精准、规范化发展,给更多患者带来福音。
所有作者均声明不存在利益冲突程中, 陈亿, 颜宥彤, 等. 修正性减重手术的发展和反思[J]. 中华消化外科杂志, 2022, 21(11): 1428-1431. DOI: 10.3760/cma.j.cn115610-20220921-00542.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20220921-22542
-
[1] WangY, WangL, QuW. New national data show alarming increase in obesity and noncommunicable chronic disea-ses in China[J]. Eur J Clin Nutr,2017,71(1):149‑150. DOI: 10.1038/ejcn.2016.171.
[2] WangY, ZhaoL, GaoL, et al. Health policy and public health implications of obesity in China[J]. Lancet Diabetes Endocrinol,2021,9(7):446‑461. DOI: 10.1016/S2213-8587(21)00118-2.
[3] ArterburnDE, TelemDA, KushnerRF, et al. Benefits and risks of bariatric surgery in adults: a review[J]. JAMA,2020,324(9):879‑887. DOI: 10.1001/jama.2020.12567.
[4] ChangSH, StollCR, SongJ, et al. The effectiveness and risks of bariatric surgery: an updated systematic review and meta‑analysis,2003‑2012[J]. JAMA Surg,2014,149(3):275‑287. DOI: 10.1001/jamasurg.2013.3654.
[5] NguyenNT, VarelaJE. Bariatric surgery for obesity and metabolic disorders: state of the art[J]. Nat Rev Gastroenterol Hepatol,2017,14(3):160‑169. DOI:10.1038/nrgas tro.2016.170.
[6] ElhagW, El AnsariW, BashahM, et al. Late diabetes relapse after sleeve gastrectomy compared with long‑term remission: characteristics and cardiometabolic outcomes[J]. Metab Syndr Relat Disord,2022[2022-09-21]. https://pubmed.ncbi.nlm.nih.gov/36040366/. DOI:10.1089/met.2022.0043.[Epub ahead of print].
[7] YangPJ, SuYH, ShenSC, et al. Predictors of diabetes relapse after metabolic surgery in Asia[J]. Surg Obes Relat Dis,2022,18(4):454‑461. DOI: 10.1016/j.soard.2021.11.018.
[8] SuperJ, CharalampakisV, TahraniAA, et al. Safety and feasibility of revisional bariatric surgery following laparoscopic adjustable gastric band‑outcomes from a large UK private practice[J]. Obes Res Clin Pract,2021,15(4):381-386. DOI: 10.1016/j.orcp.2021.06.001.
[9] MirkinK, AlliVV, RogersAM. Revisional bariatric surgery[J]. Surg Clin North Am,2021,101(2):213‑222. DOI:10.10 16/j.suc.2020.12.008.
[10] 张沣,陈晓宁,孙岩,等.减重代谢手术修正手术的发展现状及展望[J].腹腔镜外科杂志,2021,26(3):235‑238. DOI:10. 13499/j.cnki.fqjwkzz.2021.03.235. [11] AngrisaniL, SantonicolaA, IovinoP, et al. IFSO worldwide survey 2016: primary, endoluminal, and revisional procedures[J]. Obes Surg,2018,28(12):3783‑3794. DOI: 10.1007/s11695-018-3450-2.
[12] PonceJ, DeMariaEJ, NguyenNT, et al. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in 2015 and surgeon workforce in the United States[J]. Surg Obes Relat Dis,2016,12(9):1637-1639. DOI: 10.1016/j.soard.2016.08.488.
[13] EnglishWJ, DeMariaEJ, HutterMM, et al. American Society for Metabolic and Bariatric Surgery 2018 estimate of meta-bolic and bariatric procedures performed in the United States[J]. Surg Obes Relat Dis,2020,16(4):457‑463. DOI: 10.1016/j.soard.2019.12.022.
[14] 朱晒红,汤海波,朱利勇.减重手术后复胖原因与治疗对策[J].中华消化外科杂志,2021,20(9):943‑948. DOI: 10.3760/cma.j.cn115610-20210624-00307. [15] MirasAD, Pérez‑PevidaB, AldhwayanM, et al. Adjunctive liraglutide treatment in patients with persistent or recurrent type 2 diabetes after metabolic surgery (GRAVITAS): a randomised, double‑blind, placebo‑controlled trial[J]. Lancet Diabetes Endocrinol,2019,7(7):549‑559. DOI:10. 1016/S2213-8587(19)30157-3.
[16] 杨华,陈缘,董志勇,等.中国肥胖代谢外科数据库:2020年度报告[J/CD].中华肥胖与代谢病电子杂志,2021,7(1):1‑7. DOI: 10.3877/cma.j.issn.2095-9605.2021.01.001. [17] SchauerPR, BhattDL, KirwanJP, et al. Bariatric surgery versus intensive medical therapy for diabetes‑5‑year outcomes[J]. N Engl J Med,2017,376(7):641‑651. DOI:10.10 56/NEJMoa1600869.
[18] ConteC, Lapeyre‑MestreM, HanaireH, et al. Diabetes remi-ssion and relapse after bariatric surgery: a nationwide population‑based study[J]. Obes Surg,2020,30(12):4810-4820. DOI: 10.1007/s11695-020-04924-3.
[19] de OliveiraV, MartinsGP, MottinCC, et al. Predictors of long‑term remission and relapse of type 2 diabetes mellitus following gastric bypass in severely obese patients[J]. Obes Surg,2018,28(1):195‑203. DOI: 10.1007/s11695-017-2830-3.
[20] ArterburnDE, BogartA, SherwoodNE, et al. A multisite study of long‑term remission and relapse of type 2 diabetes mellitus following gastric bypass[J]. Obes Surg,2013,23(1):93‑102. DOI: 10.1007/s11695-012-0802-1.
[21] ZhuJ, DuL, LuL, et al. Laparoscopic re‑sleeve gastrectomy with single anastomosis duodenoileal switch (RS-SADIS) for weight regain or unsatisfied weight loss after initial sleeve gastrectomy[J]. Obes Surg,2021,31(10):4647-4648. DOI: 10.1007/s11695-021-05517-4.
[22] ClappB, WynnM, MartynC, et al. Long term (7 or more years) outcomes of the sleeve gastrectomy: a meta-analysis[J]. Surg Obes Relat Dis,2018,14(6):741‑747. DOI:10.10 16/j.soard.2018.02.027.
[23] QiuJ, LundbergPW, Javier BirrielT, et al. Revisional baria-tric surgery for weight regain and refractory complications in a single mbsaqip accredited center: what are we dealing with?[J]. Obes Surg,2018,28(9):2789‑2795. DOI: 10.1007/s11695-018-3245-5.
[24] Deręgowska‑CylkeM, PalczewskiP, CylkeR, et al. Imaging after laparoscopic sleeve gastrectomy‑literature review with practical recommendations[J]. Pol J Radiol,2021,86:e325-e334. DOI: 10.5114/pjr.2021.106795.
[25] WawrzyniakA, KrotkiM. The need and safety of vitamin supplementation in adults with obesity within 9 months post sleeve gastrectomy (SG): assessment based on intake[J]. Sci Rep,2022,12(1):14295. DOI: 10.1038/s41598-022-18487-z.
[26] TsuiST, YangJ, NieL, et al. Association of revisions or conversions after sleeve gastrectomy with annual bariatric center procedural volume in the state of New York[J]. Surg Endosc,2020,34(7):3110‑3117. DOI: 10.1007/s00464-019-07068-3.
[27] LazzatiA, BechetS, JoumaS, et al. Revision surgery after sleeve gastrectomy: a nationwide study with 10 years of follow‑up[J]. Surg Obes Relat Dis,2020,16(10):1497-1504. DOI: 10.1016/j.soard.2020.05.021.
[28] AngrisaniL, SantonicolaA, IovinoP, et al. Bariatric surgery and endoluminal procedures: IFSO worldwide survey 2014[J]. Obes Surg,2017,27(9):2279‑2289. DOI:10.10 07/s11695-017-2666-x.
[29] AngrisaniL, SantonicolaA, IovinoP, et al. Bariatric surgery survey 2018: similarities and disparities among the 5 IFSO chapters[J]. Obes Surg,2021,31(5):1937‑1948. DOI: 10.1007/s11695-020-05207-7.
[30] MoonRC, AlkhairiL, WierAJ, et al. Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI‑S and BPD‑DS) for weight regain[J]. Surg Endosc,2020,34(10):4422‑4428. DOI: 10.1007/s00464-019-07219-6.
[31] PędziwiatrM, MałczakP, WierdakM, et al. Revisional gastric bypass is inferior to primary gastric bypass in terms of short‑ and long‑term outcomes‑systematic review and meta‑analysis[J]. Obes Surg,2018,28(7):2083‑2091. DOI: 10.1007/s11695-018-3300-2.
[32] DardamanisD, NavezJ, CoubeauL, et al. A Retrospective comparative study of primary versus revisional Roux‑en‑Y gastric bypass: long‑term results[J]. Obes Surg,2018,28(8):2457‑2464. DOI: 10.1007/s11695-018-3186-z.
[33] Mora OliverI, Cassinello FernándezN, Alfonso BallesterR, et al. Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain[J]. Cir Esp (Engl Ed),2019,97(10):568‑574. DOI: 10.1016/j.ciresp.2019.07.012.
[34] KohZJ, ChewC, ZhangJ, et al. Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis[J]. Surg Obes Relat Dis,2020,16(10):1442‑1454. DOI: 10.1016/j.soard.2020.05.029.
[35] AxerS, SzaboE, AgerskovS, et al. Predictive factors of complications in revisional gastric bypass surgery: results from the Scandinavian Obesity Surgery Registry[J]. Surg Obes Relat Dis,2019,15(12):2094‑2100. DOI: 10.1016/j.soard.2019.09.071.
[36] El ChaarM, StoltzfusJ, MeliticsM, et al. 30‑day outcomes of revisional bariatric stapling procedures: first report based on mbsaqip data registry[J]. Obes Surg,2018,28(8):2233‑2240. DOI: 10.1007/s11695-018-3140-0.
[37] 王存川,姜舒文.肥胖代谢外科的发展与反思[J].中华消化外科杂志,2021,20(1):89-93. DOI: 10.3760/cma.j.cn115610-20201223-00799.
计量
- 文章访问数: 1515
- HTML全文浏览量: 0
- PDF下载量: 0
下载:
