不同等级肥胖症行腹腔镜袖状胃切除术的临床疗效

张娜; 张盛军; 买红娟; 陈启众; 倪睿; 俞永涛; 陈申思; 钱海权

doi:10.3760/cma.j.cn115610-20230526-00237

不同等级肥胖症行腹腔镜袖状胃切除术的临床疗效

Clinical efficacy of laparoscopic sleeve gastrectomy in obesity patients of different grades

摘要

摘要:
目的探讨不同等级肥胖症行腹腔镜袖状胃切除术（LSG）的临床疗效。
方法采用回顾性描述性研究方法。收集2018年1月至2021年12月宁夏医科大学总医院收治的139例不同等级肥胖症患者的临床资料；男37例,女102例；年龄为（32±9）岁。139例患者中,Ⅰ级、Ⅱ级、Ⅲ级肥胖症分别为45、44、50例。观察指标：（1）不同等级肥胖症患者术中及术后情况。（2）不同等级肥胖症患者血液学相关指标。（3）不同等级肥胖症患者减重效果相关指标。正态分布的计量资料以x±s表示,3组间比较采用One‑way Anova分析,两两比较采用LSD检验。偏态分布的计量资料以M（范围）表示,3组间比较采用Kruskal‑Wallis H检验。计数资料以绝对数表示,组间比较采用χ²检验或Fisher确切概率法。重复测量数据采用重复测量方差分析。
结果（1）不同等级肥胖症患者术中及术后情况。45例Ⅰ级肥胖症患者手术时间、术中出血量、术后住院时间、术后30 d内再入院分别为2.0（1.5~2.0）h、50（50~100）mL、5（4~6）d、2例。44例Ⅱ级肥胖症患者和50例Ⅲ级肥胖症患者上述指标分别为2.0（1.5~2.0）h、60（50~187）mL、5（4~6）d、4例和2.0（1.5~2.1）h、60（50~135）mL、 5（4~7）d、4例。3者手术时间、术中出血量、术后住院时间比较,差异均无统计学意义（H=4.11,0.77,3.59,P>0.05）,术后30 d内再入院比较,差异无统计学意义（P>0.05）。（2）不同等级肥胖症患者血液学相关指标。139例患者均完成术后3、6、12个月随访。Ⅰ级肥胖症患者术前,术后3、6、12个月总胆固醇（TC）分别为（4.5±0.9）mmol/L、（4.6±0.9）mmol/L、（4.3±0.8）mmol/L、（4.6±1.1）mmol/L,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为（4.5±0.8）mmol/L、（4.4±0.8）mmol/L、（4.4±1.0）mmol/L、（4.3±0.9）mmol/L和（4.4±1.0）mmol/L、（4.7±1.1）mmol/L、（4.5±0.8）mmol/L、（4.4±0.5）mmol/L,不满足球形检验（χ²=20.81,P<0.05）,采用多变量检验结果显示：3者TC时间效应、组间效应、交互效应比较,差异均无统计学意义（F_时间=0.45,F_组间=0.40,F_交互=0.66,P>0.05）。Ⅰ级肥胖症患者术前,术后3、6、12个月甘油三酯（TG）分别为（2.0±1.1）mmol/L、（1.3±0.4）mmol/L、（1.0±0.4）mmol/L、（1.0±0.4）mmol/L,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为（2.2±1.1）mmol/L、（1.5±0.5）mmol/L、（1.1±0.3）mmol/L、（1.0±0.3）mmol/L和（2.3±1.1）mmol/L、（1.7±0.7）mmol/L、（1.4±0.6）mmol/L、（1.2±0.4）mmol/L,不满足球形检验（χ²=290.49,P<0.05）,采用多变量检验结果显示：3者TG时间效应、组间效应、交互效应比较,差异均有统计学意义（F_时间=80.44,F_组间=4.13,F_交互=2.67,P<0.05）。Ⅰ级肥胖症患者术前,术后3、6、12个月维生素D分别为（12.9±5.9）μg/L、（16.5±5.9）μg/L、（18.0±6.3）μg/L、（20.1±5.7）μg/L,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为（11.5±4.4）μg/L、（17.1±5.0）μg/L、（18.2±5.6）μg/L、（20.2±6.6）μg/L和（9.8±3.5）μg/L、（17.2±4.6）μg/L、（18.1±4.7）μg/L、（19.5±5.2）μg/L,不满足球形检验（χ²=53.07,P<0.05）,采用多变量检验结果显示：3者维生素D时间效应、交互效应比较,差异均有统计学意义（F_时间=150.88,F_交互=3.86, P<0.05）,组间效应比较,差异无统计学意义（F_组间=0.35,P>0.05）。（3）不同等级肥胖症患者减重效果相关指标。Ⅰ级肥胖症患者术前,术后3、6、12个月体质量,体质量指数（BMI）分别为（88±8）kg、（71±8）kg、（65±8）kg、（61±7）kg,（32±2）kg/m²、（26±2）kg/m²、（24±2）kg/m²、（22±2）kg/m²,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为（106±11）kg、（82±8）kg、（75±9）kg、（70±9）kg,（37±1）kg/m²、（29±2）kg/m²、（26±2）kg/m²、（25±3）kg/m²和（131±20）kg、（101±15）kg、（89±13）kg、（79±12）kg,（45±6）kg/m²、（35±5）kg/m²、（31±4）kg/m²、（27±4）kg/m²,均不满足球形检验（χ²=194.60,179.52,P<0.05）,采用多变量检验结果显示：3者体质量和BMI时间效应、组间效应、交互效应比较,差异均有统计学意义（F_时间=492.59,543.86,F_组间=89.13,95.91,F_交互=13.97,13.32,P<0.05）。Ⅰ级肥胖症患者术后3、6、12个月多余体质量减少百分比（EWL%）为61%±16%、84%±21%、96%±23%,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为55%±7%、72%±16%、85%±19%和45%±12%、64%±15%、78%±7%,不满足球形检验（χ²=51.61,P<0.05）,采用多变量检验结果显示：3者EWL%时间效应、组间效应比较,差异均有统计学意义（F_时间=374.52,F_组间=15.69,P<0.05）,交互效应比较,差异无统计学意义（F_交互=1.08,P>0.05）。Ⅰ级肥胖症患者术后3、6、12个月总体质量减少百分比（TWL%）分别为19%±5%、26%±6%、30%±6%,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为21%±6%、29%±6%、34%±7%和22%±7%、32%±7%、39%±8%,不满足球形检验（χ²=58.54,P<0.05）,采用多变量检验结果显示：3者TWL%时间效应、组间效应、交互效应比较,差异均有统计学意义（F_时间=290.61,F_组间=12.32,F_交互=5.49,P<0.05）。Ⅰ级肥胖症患者术前,术后3、6、12个月腰臀比,内脏脂肪面积分别为0.92±0.04、0.86±0.03、0.84±0.03、0.83±0.03,（129±19）cm²、（79±17）cm²、（63±15）cm²、（57±14）cm²,Ⅱ级和Ⅲ级肥胖症患者上述指标分别为0.98±0.05、0.90±0.05、0.87±0.05、0.86±0.05,（169±20）cm²、（105±23）cm²、（85±20）cm²、（73±20）cm²和1.05±0.09、0.94±0.06、0.91±0.06、0.89±0.05,（218±42）cm²、（144±35）cm²、（114±26）cm²、（96±19）cm²,均不满足球形检验（χ²=289.99,191.92,P<0.05）,采用多变量检验结果显示：3者腰臀比和内脏脂肪面积时间效应、组间效应、交互效应比较,差异均有统计学意义（F_时间=361.39,707.60,F_组间=34.28,12.69,F_交互=8.31,94.89,P<0.05）。
结论 LSG可改善不同等级肥胖症患者TG和维生素D水平,并降低患者体质量、BMI、EWL%、TWL%、腰臀比和内脏脂肪面积。

Abstract:
Objective To investigate the clinical efficacy of laparoscopic sleeve gastrectomy (LSG) in obesity patients of different grades.
Methods The retrospective and descriptive study was conducted. The clinical data of 139 obesity patients of different grades who were admitted to the General Hospital of Ningxia Medical University from January 2018 to December 2021 were collected. There were 37 males and 102 females, aged (32±9)years. Of the 139 patients, there were 45 cases of grade Ⅰ obesity, 44 cases of grade Ⅱ obesity and 50 cases of grade Ⅲ obesity, respectively. Obser-vation indicators: (1) intraoperative and postoperative situations in obesity patients of different grades; (2)hematological related indicators in obesity patients of different grades; (3)body quality related indicators in obesity patients of different grades. Measurement data with normal distribution were represented as Mean±SD, and comparison within three groups was conducted using the One‑way Anova test and comparison between groups was conducted using the LSD test. Measurement data with skewed distribution were represented as M(range), and comparison within three groups was conducted using the Kruskal‑Wallis H test. Count data were described as absolute numbers, and comparison between groups was performed using the chi‑square test or Fisher exact probability. Repeated measurement data were analyzed by the repeated ANOVA.
Results (1) Intraoperative and postoperative situations in obesity patients of different grades. The operation time,volume of intraoperative blood loss,duration of postoperative hospital stay and cases readmitted within 30 days after surgery were 2.0(range, 1.5-2.0)hours,50(range, 50-100)mL, 5(range, 4-6)days and 2 in the 45 cases of grade Ⅰ obesity. The above indicators were 2.0(range, 1.5-2.0)hours, 60(range, 50-187)mL, 5(range, 4-6)days and 4 in the 44 cases of grade Ⅱ obesity and 2.0(range, 1.5-2.1)hours, 60(range, 50-135)mL, 5(range, 4-7)days and 4 in the 50 cases of grade Ⅲ obesity. There was no significant difference in the operation time, volume of intraoperative blood loss,duration of postoperative hospital stay among the three groups of patients (H=4.11, 0.77, 3.59, P>0.05) and there was no significant difference in cases readmitted within 30 days after surgery among the three groups of patients (P>0.05). (2) Hematological related indicators in obesity patients of different grades. All 139 patients were followed up at postoperative 3, 6 and 12 month. The total cholesterol (TC) were (4.5±0.9)mmol/L, (4.6±0.9)mmol/L, (4.3±0.8)mmol/L, (4.6±1.1)mmol/L at preoperative and postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were (4.5±0.8)mmol/L, (4.4±0.8)mmol/L, (4.4±1.0)mmol/L, (4.3±0.9)mmol/L in cases of grade Ⅱ obesity and (4.4±1.0)mmol/L, (4.7±1.1)mmol/L, (4.5±0.8)mmol/L, (4.4±0.5)mmol/L in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=20.81, P<0.05) and results of multi-variate test showed that there was no significant difference in the time effect, intergroup effect and interaction effect of TC among the three groups(F_time=0.45, F_group=0.40, F_interaction=0.66, P>0.05). The triglyceride (TG) were (2.0±1.1)mmol/L, (1.3±0.4)mmol/L, (1.0±0.4)mmol/L, (1.0±0.4)mmol/L at preoperative and postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were (2.2±1.1)mmol/L, (1.5±0.5)mmol/L, (1.1±0.3)mmol/L, (1.0±0.3)mmol/L in cases of grade Ⅱ obesity and (2.3±1.1)mmol/L, (1.7±0.7)mmol/L, (1.4±0.6)mmol/L, (1.2±0.4)mmol/L in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=290.49, P<0.05) and results of multi-variate test showed that there were significant differences in the time effect, intergroup effect and interaction effect of TG among the three groups (F_time=80.44, F_group=4.13, F_interaction=2.67, P<0.05). The vitamin D were (12.9±5.9)μg/L, (16.5±5.9)μg/L, (18.0±6.3)μg/L, (20.1±5.7)μg/L at preoperative and postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were (11.5±4.4)μg/L, (17.1±5.0)μg/L, (18.2±5.6)μg/L, (20.2±6.6)μg/L in cases of grade Ⅱ obesity and (9.8±3.5)μg/L, (17.2±4.6)μg/L, (18.1±4.7)μg/L, (19.5±5.2)μg/L in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=53.07, P<0.05) and results of multi‑variate test showed that there were significant differences in the time effect and interaction effect of vitamin D among the three groups (F_time=150.88, F_interaction=3.86, P<0.05)and there was no significant difference in the intergroup effect of vitamin D among the three groups (F_group=0.35, P>0.05). (3) Body quality related indicators in obesity patients of different grades. The body mass and body mass index (BMI) were (88±8)kg, (71±8)kg, (65±8)kg, (61±7)kg, (32±2)kg/m², (26±2)kg/m², (24±2)kg/m², (22±2)kg/m²at preoperative and postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were (106±11)kg, (82±8)kg, (75±9)kg, (70±9)kg, (37±1)kg/m², (29±2)kg/m², (26±2)kg/m², (25±3)kg/m² in cases of grade Ⅱ obesity and (131±20)kg, (101±15)kg, (89±13)kg, (79±12)kg, (45±6)kg/m², (35±5)kg/m², (31±4)kg/m², (27±4)kg/m² in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=194.60, 179.52, P<0.05) and results of multi‑variate test showed that there were significant differences in the time effect, intergroup effect and interaction effect of body mass and BMI among the three groups(F_time=492.59, 543.86, F_group=89.13, 95.91,F_interaction=13.97, 13.32, P<0.05). The percen-tage of excess weight loss (EWL%) were 61%±16%,84%±21%,96%±23% at postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were 55%±7%,72%±16%,85%±19% in cases of grade Ⅱ obesity and 45%±12%,64%±15%,78%±7% in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=51.61, P<0.05) and results of multi‑variate test showed that there were significant differences in the time effect and intergroup effect of EWL% among the three groups (F_time=374.52, F_group=15.69, P<0.05) and there was no significant difference in the interaction effect of EWL% among the three groups (F_interaction=1.08, P>0.05). The percentage of total body weight loss (TWL%) were 19%±5%, 26%±6%, 30%±6% at postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indicators were 21%±6%, 29%±6%, 34%±7% in cases of grade Ⅱ obesity and 22%±7%, 32%±7%, 39%±8% in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=58.54, P<0.05) and results of multi‑variate test showed that there were significant differences in the time effect, intergroup effect and interaction effect of TWL% among the three groups (F_time=290.61, F_group=12.32, F_interaction=5.49, P<0.05). The waist to hip ratio (WHR) and visceral fat area (VFA) were 0.92±0.04, 0.86±0.03, 0.84±0.03, 0.83±0.03, (129±19)cm², (79±17)cm², (63±15)cm², (57±14)cm² at preoperative and postoperative 3, 6 and 12 month in cases of grade Ⅰ obesity. The above indi-cators were 0.98±0.05, 0.90±0.05, 0.87±0.05, 0.86±0.05, (169±20)cm², (105±23)cm², (85±20)cm², (73±20)cm² in cases of grade Ⅱ obesity and 1.05±0.09, 0.94±0.06, 0.91±0.06, 0.89±0.05, (218±42)cm², (144±35)cm², (114±26)cm², (96±19)cm² in cases of grade Ⅲ obesity. The above indicators among the three groups not meeting the mauchly′s test of sphericity (χ²=289.99, 191.92, P<0.05) and results of multi‑variate test showed that there were significant differences in the time effect, intergroup effect and interaction effect of WHR and VFA among the three groups (F_time=361.39, 707.60, F_group=34.28, 12.69, F_interaction=8.31, 94.89, P<0.05).
Conclusion Treatment of obesity patients of different grades with LSG can improve patients′ TG and vitamin D levels, and reduce patients′ body mass, BMI, EWL%, TWL%, WHR and VFA.

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