减重代谢外科围手术期并发症的预防和诊治

Prevention, diagnosis and treatment of perioperative complications of bariatric and metabolic surgery

减重代谢外科手术治疗肥胖症和2型糖尿病在我国迅速普及。正确预防及识别围手术期手术相关并发症是保证手术安全的前提。减重代谢外科手术常见并发症包括深静脉血栓、肺动脉栓塞、吻合口出血、吻合口瘘和吻合口溃疡。深静脉血栓的预防重于治疗，具体措施包括物理预防（梯度加压弹力袜和间断充气加压腿套）和药物预防（普通肝素和低分子肝素）；治疗主要为溶栓或手术取栓。肺动脉栓塞的治疗包括缓解肺动脉高压、抗凝、溶栓、手术取栓、介入治疗及体外膜肺氧合（ECMO）。出血是减重术后发生较少但较为严重的并发症，腹腔镜胃旁路术（LRYGB）后吻合口出血原因主要为止血不彻底或腹腔镜缝合技术薄弱．腹腔镜袖状胃切除术（LSG）常见的出血位置在胃残端近幽门部，可能与爆钉、缝合技术薄弱等有关；对于活动性或大量出血导致血流动力学不稳定的患者，应及时再手术治疗。LRYGB吻合口瘘分为胃肠吻合口瘘及肠肠吻合口瘘，术后吻合口瘘的治疗应因人而异，选择保守治疗或手术治疗。吻合口狭窄主要与术者操作技术有关，LSG术后的狭窄常发生在胃角，治疗方法包括球囊扩张、支架置入，必要时手术治疗。LRYGB术后吻合口溃疡是发生在接近胃空肠结合处小肠黏膜的消化性溃疡，LSG术后残胃也会发生溃疡，发生部位多在胃窦切缘；术前抗幽门螺旋杆菌治疗，术后连续服用6个月质子泵阻滞剂（PPI）是预防和治疗吻合口溃疡的主要手段，对保守治疗无效者则应考虑内镜下修复或外科修正手术。不同的手术方式具有不同的手术相关并发症，通过多学科合作，充分了解并有效处理各种手术方式的相关并发症是手术成功的保障。

Surgical operation in treating obesity and type 2 diabetes is popularizing rapidly in China. Correct prevention and recognition of perioperation-related operative complications is the premise of ensuring surgical safety. Familiar complications of the operation include deep venous thrombosis, pulmonary artery embolism, anastomotic bleeding, anastomotic fistula and marginal ulcer. The prevention of deep venous thrombosis is better than treatment. The concrete measures contain physical prophylaxis （graduated compression stocking and intermittent pneumatic compression leg sleeves） and drug prophylaxis （unfractionated heparin and low molecular heparin）, and the treatment is mainly thrombolysis or operative thrombectomy. The treatment of pulmonary artery embolism includes remittance of pulmonary arterial hypertension, anticoagulation, thrombolysis, operative thrombectomy, interventional therapy and extracorporeal membrane oxygenation （ECMO）. Hemorrhage is a rarely occurred but relatively serious complication after bariatric surgery. The primary cause of auastomotic bleeding after laparoscopic gastric bypass is incomplete hemostasis or weak laparoscopic repair. The common bleeding site in laparoscopic sleeve gastrectomy is gastric stump and close to partes pylorica, and the bleeding may be induced by malformation and weak repair technique. Patients with hemodynamic instability caused by active bleeding or excessive bleedingshould timely received surgical treatment. Anastomotic fistula in gastric bypass can be divided into gastrointestinal anastomotic fistula and jejunum-jejunum anastomotic fistula. The treatment of postoperative anastomotic fistula should vary with each individual, and conservative treatment or operative treatment should be adopted. Anastomotic stenosis is mainly related to the operative techniques. Stenosis after sleeve gastrectomy often occurs in gastric angle, and the treatment methods include balloon dilatation and stent implantation, and surgical treatment should be performed when necessary. Marginal ulcer after gastric bypass is a kind of peptic ulcer occurring close to small intestine mucosa in the junction point of stomach and jejunum. Ulcer will also occur in the vestige stomach after laparoscopic sleeve gastrectomy, and the occurrence site locates mostly in the gastric antrum incisal margin. Preoperative anti-HP （helicobacter pylorus） therapy and postoperative continuous administration of proton pump inhibitor （PPI） for six months is the main means to prevent and treat marginal ulcer. For patients on whom conservative treatment is invalid, endoscopic repair or surgical repair should be considered. Different surgical procedures will generate different related operative complications. Fully understanding and effectively dealing with the complications of various surgical procedures through multidisciplinary cooperation is a guarantee for successful operation.