减重代谢外科手术方式的选择

Choice of bariatric and metabolic surgical procedures

减重代谢手术治疗肥胖及糖尿病等代谢综合征已经成为近年来的临床热点，如何选择适合的术式是临床应用的一大难点。2013版的美国减重代谢外科协会（ASMBS）临床指南中介绍的减重代谢术式主要包括胆胰分流，十二指肠转位术（BPD-DS），腹腔镜可调节胃绑带术（LAGB），腹腔镜胃旁路术（LRYGB）以及腹腔镜袖状胃切除术（LSG），减重代谢手术的术式选择首先要熟悉这些手术的具体适应证以及禁忌证。其次，术式选择还要考虑患者的病情（包括体质指数，合并代谢综合征以及糖尿病程度）、患者的家庭及社会经济地位（完成术后随访的能力，对切割胃以及潜在风险的理解能力以及本人的意愿）、患者的家族史以及疾病史（胃癌高危人群需要慎重选择LRYGB；患有反流性食管炎的患者需要慎重考虑LSG）以及术者自身因素。随着减重代谢外科的发展，各术式的缺陷、特别是长期并发症被发现，如LRYGB后贫血和溃疡发生率高、胃癌风险大以及术后患者需要按时补充维生素和定时随访；而LSG虽风险更低，但降糖效果以及长远的减重效果要逊于LRYGB，这对术者如何平衡获益和风险提出了挑战。减重代谢手术术式选择相关联的因素有很多，既要按照病情需要，同时又要尊重患者的选择，术式不仅仅有减重降糖效果，手术导致的胃肠道改变还会带来副作用，因此还需要兼顾术后的外科相关并发症以及营养并发症。综合考虑各种相关因素并尽量做到个体化手术是减重代谢手术的最终目标。

Bariatric and metabolic surgery has become the clinical hot topic of the treatment of metabolic syndromes including obesity and diabetes mellitus, but how to choose the appropriate surgical procedure remains the difficult problem in clinical practice. Clinical guidelines of American Society for Metabolic and Bariatric Surgery（ASMBS）（version 2013） introduced the procedures of bariatric and metabolic surgery mainly including biliopancreatic diversion with duodenal switch （BPD-DS）, laparoscopic adjustable gastric banding （LAGB）, laparoscopic Roux-en-Y gastric bypass （LRYGB） and laparoscopic sleeve gastrectomy （LSG）. To choose the appropriate bariatric and metabolic procedure, the surgeons should firstly understand the indications and the contraindications of each procedure. Procedure choice should also consider personal condition （body mass index, comorbidities and severity of diabetes）, family and socioeconomic status （postoperative follow-up attendance, understanding of potential surgical risk of gastrectomy and patient＇s will）, family and disease history （patients with high risk of gastric cancer should avoid LRYGB; patients with gastroesophageal reflux disease should avoid LSG） and associated personal factors of surgeons. With the practice of bariatric and metabolic surgery, the defects, especially long- term complications, of different procedures were found. For example, LRYGB resulted in higher incidence of postoperative anemia and marginal ulcer, high risk of gastric cancer as well as the requirement of vitamin supplementation and regular follow-up. Though LSG has lower surgical risk, its efficacy of diabetes mellitus remission and long-term weight loss are inferior to the LRYGB. These results pose challenges to the surgeons to balance the benefits and risks of the bariatric procedures. A lot of factors can affect the choice of bariatric and metabolic procedure. Surgeons should choose the procedure according to patient＇s condition with the consideration of the choice of patients. The bariatric and metabolic surgery not only manages the diabetes mellitus and weight loss, but also results in the reconstruction of gastrointestinal tract and side effect. Postoperative surgical complications and nutritional deficiencyshould also be considered. Thereby, individualized bariatric procedure with the full consideration of each related factors is the ultimate objective of bariatric and metabolic surgery.