腹腔镜胃旁路术治疗低体质量指数2型糖尿病的临床疗效

Clinical effect of laparoscopic gastric bypass for the treatment of type 2 diabetes mellitus patients with low body mass index

目的 探讨腹腔镜胃旁路术（LRYGB）治疗低BMI 2型糖尿病患者的临床疗效.方法 回顾性分析2010年4月至2015年2月第三军医大学大坪医院收治的70例行LRYGB的2型糖尿病患者的临床资料.30例患者BMI＞ 30 kg/m2,设为高BMI组;40例患者BMI＜ 30 kg/m2,设为低BMI组.参照《中国肥胖和2型糖尿病外科治疗指南（2014）》疗效评价标准评价患者术后糖尿病转归情况.采用住院、门诊和电话方式进行随访,随访时间截至2015年2月.术后1、3、6、12、24个月定期随访,检测BMI、腹围、空腹血糖、糖化血红蛋白、血压、TC、TG、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇.正态分布的计量资料以-x±s表示,采用独立样本t检验;重复测量数据采用重复测量的方差分析.率的比较采用x2检验.结果 70例患者均顺利完成LRYGB,围术期无死亡、出血、肠梗阻等发生.70例患者均获得术后随访,中位随访时间为6个月（1 ～ 24个月）.5例术后发生并发症,其中吻合口漏1例,胃空肠吻合口狭窄1例,吻合口溃疡2例,贫血1例,均经对症治疗后缓解.高BMI组和低BMI组患者手术前后,BMI、腹围、糖化血红蛋白、血压、TC、TG、高密度脂蛋白胆固醇和低密度脂蛋白胆固醇分别为（35.4-±4.5）kg/m2 ～（24.9-±1.5）kg/m2和（26.8-±2.3）kg/m2～（21.9 ±2.0）kg/m2,（110-±15）cm～（81±8）cm和（92±8）cm～（79±8）cm,6.4％±1.4％～6.0％±0.5％和6.3％±2.1％～6.2％±0.8％,（133±15）mmHg～（132±10）mmHg/（75±9）mmHg～（73±4）mmHg和（133±11） mmHg～（132±14） mmHg/（74±8） mmHg ～ （72±7） mmHg（1 mmHg=0.133 kPa）,（6.0±2.3） mmol/L ～（5.0±1.8） mmol/L和（4.9±1.2） mmol/L ～ （4.0±0.5） mmol/L,（3.2±1.7） mmol/L～（1.0±0.2）mmol/L和（3.6±2.6） mmol/L～（1.0±0.4） mmol/L,（1.0±0.2） mmol/L ～（1.6±0.3）mmol/L和（1.2±0.8）mmol/L ～ （1.3±0.2） mmol/L,（3.0±0.7）mmol/L ～ （2.9±1.2） mmol/L和（2.5±0.7）mmol/L～ （2.5±0.9） mmol/L,其变化趋势比较,差异均无统计学意义（F=1.65,1.72,0.75,1.04,0.98,1.53,1.70,1.05,0.84,P＞0.05）;空腹血糖分别为（8.6±3.5） mmol/L ～ （5.6±0.9） mmol/L和（8.6±3.3） mmol/L ～ （6.5±1.7） mmol/L,其变化趋势比较,差异有统计学意义（F=2.21,P＜0.05）.高BMI组患者术后3、6、12、24个月空腹血糖低于低BMI组患者,两组比较,差异均有统计学意义（t=2.87,3.88,3.10,2.80,P＜0.05）.高BMI组30例患者中完全缓解26例,部分缓解4例;低BMI组40例患者中完全缓解28例,部分缓解8例,明显改善3例,无效1例,两组比较,差异有统计学意义（x2=4.69,P＜0.05）.结论 LRYGB治疗2型糖尿病安全、可行,尽管BMI＜ 30 kg/m2的2型糖尿病患者完全缓解率低于BMI＞ 30 kg/m2的患者,但其综合疗效仍然是值得肯定的.

Objective To evaluate the clinical effect of laparoscopic Roux-en-Y gastric bypass （LRYGB） for the treatment of type 2 diabetes mellitus patients with low body mass indexes （BMI）.Methods The clinical data of 70 patients with type 2 diabetes mellitus who underwent LRYGB at Daping Hospital of Third Military Medical University from April 2010 to February 2015 were retrospectively analyzed.Thirty patients with BMI 〉 30 kg/m2 were allocated to the high BMI group,and 40 patients with BMI 〈 30 kg/m2 were allocated to the low BMI group.The postoperative prognosis of diabetes mellitus in patients was evaluated according to ＆quot; Guidelines for surgical treatment of obesity and type 2 diabetes mellitus in China （2014）＆quot;.The patients were followed up by inpatient,outpatient examination and telephone interview till February 2015.Body weight,abdominal perimeter,fasting blood glucose,glycosylated hemoglobin （HbAlc）,blood pressure,total cholesterol （TC）,triglyceride （TG）,high density lipoprotein cholesterol （HDL-C） and low density lipoprotein cholesterol （LDL-C） were regularly detected at postoperative month 1,3,6,12,24.Measurement data with normal distribution were presented as x ± s and were analyzed by the t test.Repeated measures data were analyzed by the repeated measures AN0VA.The comparison of rate was analyzed using the chi-square test.Results All the 70 patients underwent successfully LRYGB without death,hemorrhage or intestinal obstruction in the perioperative period and received follow-up with a median time of 6 months （range,1-24 months）.Five patients had postoperative complications,including 1 case of stomal leakage,1 of gastric-jejunal stoma stenosis,2 of stomal ulcer and 1 of anemia,and had remission of symptoms after symptomatic treatment.The BMI,abdominal perimeter,HbAlc,blood pressure,TC,TG,HDL-C,LDL-C before and after operation between the high BMI and low BMI group were （35.4 ± 4.5）kg/m2-（24.9±1.5）kg/m2 and （26.8 ±2.3）kg/m2-（21.9±2.0）kg/m2,（110±15）cm-（81 ±8）cm and （92± 8）cm-（79±8）cm,6.4%±1.4%-6.0%±0.5% and6.3%±2.1%-6.2% ±0.8%,（133 ±15）mmHg-（132 ± 10） mmHg/（75 ±9）mmHg-（73 ±4） mmHg （1 mmHg =0.133 kPa） and （133 ± 11） mmHg-（132 ± 14） mmHg/ （74 ± 8） mmHg-（72 ± 7） mmHg,（6.0 ± 2.3） mmol/L-（5.0 ± 1.8） mmol/L and （4.9 ± 1.2） mmol/L-（4.0 ± 0.5）mmol/L,（3.2±1.7）mmol/L-（1.0±0.2）rnmol/L and （3.6±2.6）mmol/L-（1.0±0.4）mmol/L,（1.0± 0.2） mmol/L-（1.6 ± 0.3） mmol/L and （1.2 ± 0.8） mmol/L-（1.3 ± 0.2） mmol/L,（3.0 ± 0.7） mmol/L-（2.9 ± 1.2） mmol/L and （2.5 ± 0.7） mmol/L-（2.5 ± 0.9） mmol/L,respectively,with no significant differences in the changing trends （F =1.65,1.72,0.75,1.04,0.98,1.53,1.70,1.05,0.84,P 〉 0.05）.The fasting blood glucose before and after operation in the high BMI group and low BMI group were （8.6 ± 3.5） mmol/L-（5.6 ± 0.9） mmol/L and （8.6 ± 3.3） mmol/L-（6.5 ± 1.7） mmol/L,respectively,with a significant difference in the changing trends （F =2.21,P 〈0.05）.The fasting blood glucose in the high BMI group at postoperative 3,6,12,24 month were lower than those in the low BMI group （t =2.87,3.88,3.10,2.80,P 〈 0.05）.Twentysix patients had complete remission and 4 patients had partial remission in the high BMI group,among 40 patients in the low BMI group,28 patients had complete remission,8 patients had partial remission,3 patients had significant improvement and 1 patient had non-remission,with a significant difference （x2 =4.69,P 〈 0.05）.Conclusion LRYGB is safe and feasible for the treatment of type 2 diabetes mellitus with a good comprehensive therapeutic effect,although complete remission rate of patients with BMI 〈30 kg/m2 is lower than patients with BMI 〉30 kg/m2.