腹腔镜袖状胃切除术对男性重度肥胖患者性激素水平的影响及机制探讨

Effect of laparoscopic sleeve gastrectomy on sex hormone in male severe obesity

目的探讨腹腔镜袖状胃切除术（LSG）对男性重度肥胖患者性激素水平的影响。方法回顾性收集2012年12月至2016年5月期间同济大学附属第十人民医院收治的行LSG手术的31例男性肥胖患者[体质指数（BMI）≥28kg／m^2]的临床资料（肥胖组）及其术前和术后1、3、6月患者的人体测量学指标（体质量、BMI、腰围、臀围、腰臀比及体脂比例）、糖代谢指标[空腹血糖（FPG）、空腹胰岛素（FINS）、糖化血红蛋白（HbAlc）、稳态模型评估的胰岛素抵抗指数（HOMA-IR）]以及性激素指标[雌二醇（E2）、总睾酮（TT）、卵泡刺激素（FSH）、黄体生成素（LH）]。同时选取BMI正常的31名健康男性志愿者（对照组）检测上述相同指标，比较肥胖组上述指标的变化。采用Pearson相关系数分析法来分析手术前后TT变化值与人体测量学指标以及糖代谢指标变化值的相关性（变化值以△表示）。本研究临床注册号为ChiCTROCS12002381。结果肥胖组患者年龄18-56（32．9±9．7）岁，对照组年龄为18-49（30．7±8．9）岁。术前肥胖组的人体测量学指标和糖代谢指标均明显高于对照组（均P〈0．05）。肥胖组术后1-6月的人体测量学及糖代谢指标均明显低于术前水平（均P〈0．05）。术后1月，肥胖组患者的人体测量学及糖代谢指标明显高于对照组（均P〈0．05）：至术后3-6月，肥胖组患者糖代谢指标水平与对照组患者的差异无统计学意义（均P〉0．05），但人体测量学指标仍明显高于对照组（均P〈0．05）。对照组和术前肥胖组的性激素指标：E2水平分别为（100．2±23．5）pmol／L和（129．2±81．9）pmol／L，TT水平分别为（18．0±4．9）nmol／L和（8．4±4．5）nmol／L，FSH水平分别为（4．5±3．1）IU／L和（4.3±2．5）IU／L，LH水平分别为（4．4±1．7）IU／L和（5．3±2．6）IU／L；仅术前肥胖组的TT水平明显低于对照组（P=0．000），两组E2、FSH及LH的比较，差异无统计学意义（均P〉0．05）。与术前相比，肥胖患者的TT水平在术后1、3、6月显著增加[TT水平分别为（13．1±7．0）nmol／L、（13．6±5．7）nmol／L和（21．0±19.3）nmol／L，均P〈0．05]，E2水平在术后6月显著下降[（91．4±44．9）pmol／L，P〈0．05]，而在术后1月及3月差异无统计学意义（均P〉0．05）。此外，与术前相比，肥胖组患者术后1、3、6月的FSH和LH水平的差异无统计学意义（均P〉0．05）。术后1月△TT与△BMI、△FPG、△FINS、△HOMAIR及△E2无显著相关性（均P〉0．05）。术后3月患者的△TT水平与△BMI（r=-0．441．P=0．015）、△FINS（r=-0．375，P=0．041）及△HOMAIR（r=0．397，P=0．030）均呈显著负相关，而与△FPG和△E2无显著相关性（均P〉0．05）。术后6月患者的△TT水平与ABMI（r=-0．510．P=0．018）及△HOMAIR（r=-0．435，P=0．049）呈显著负相关，而与△FPG、△FINS及△E2无显著相关性（均P〉0．05）。结论男性重度肥胖患者常伴有性激素水平异常，LSG不仅减重及降糖作用显著．还可能通过改善胰岛素抵抗来改善男性肥胖患者的性激素失衡状态。

Objective To investigate the effect of laparoscopic sleeve gastrectomy （LSG） on sex hormone in male patients with severe obesity. Methods Retrospective analysis was performed in 31 male patient with severe obese [body mass index （BMI）≥28 kg/m2, obesity group] who underwent LSG in Shanghai Tenth People＇s Hospital of Tongji University from December 2012 to May 2016. The anthropometric parameters（weight, BMI, waist circumference, hip circumference, waist-hip ratio, body fat percentage）, glucose metabolic indices [fasting plasma glucose（FPG）, fasting insulin （FINS）, glycosylatcd hemoglobin （HbAlc）, homeostasis model assessment-insulin resistance index （HOMA-IR）], and sex hormone parameters [estradiol （E2）, total testosterone （TT）, follicle-stimulating hormone （FSH） and luteinizing hormone （LH） ] were collected preoperatively and 1, 3, 6 months postoperatively. In addition, 31 healthy male volunteers with normal BMI were consecutively recruited in this study as control group. The above-mentioned parameters were also determined in control group. Changes of these variables before and after surgery were analyzed. Pearson method was used to analyze the correlation of TT with anthropometric parameters and glucose metabolic indices before and after surgery. Results The average age of patients in obesity and control group was （32.9 ±_ 9.7） （18 to 56） years and （30.7 ± 8.9） （18 to 49） years. Compared to the control group, obesity group had significantly higher anthropometric parameters and glucose metabolic indices before surgery （all P〈0.05）. In obesity group, the anthropometrie and glucose metabolic indices significantly decreased at 1 to 6 months after surgery compared to those before smgery （all P 〈 0.05）. At 1 month after surgery, the anthropometric parameters and glucose metabolic indices in obesity group were significantly higher than those in control group （all P 〈 0.05）. At 3, and 6 months after surgery, there were no significant differences in glucose metabolic indices between obesity and control group （all P 〉 0.05）, while the anthropometric parameters in obesity group were still significantly higher than those in control group（all P 〈 0.05）. The sex hormone parameters in control and obesity group before surgery were as follows： E2：（100.2 ± 23.5） pmol/L and （129.2 ± 81.9） pmol/L; TT （18.0 ± 4.9） nmol/L and （8.4 ± 4.5） nmol/L; FSH： （4.5 ± 3.1） IU/L and （4.3 ± 2.5） IU/L; LH： （4.4 ± 1.7） IU/L and （5.3 ± 2.6） IU/L. Compared to control group, the TT level of obese patients before surgery significantly decreased （P = 0.000）, while no significant differences were observed in the levels of E2, FSH, and LH （all P 〉 0,05）. The TT levels were significantly increased at 1, 3, 6 months after surgery[（13.1 ± 7.0）, （13.6 ± 5.7）, （21.0 ± 19.3） nmol/L, respectively, all P〈0.05] and the E2 level was significantly decreased at 6 months after surgery [ （91.4 ± 44.9） pmol/L, P〈0.05], while no significant differences were observed at 1 and 3 months after surgery （all P 〉 0.05）. Furthermore, the FSH and LH levels did not exhibit significant change at 1, 3, and 6 months after surgery compared to those before surgery （all P 〉 0.05）. At 1 month after surgery, no significant correlations were examined in the change value of TT levels （ATT） with the changes of BMI （△BMI）, FPG（△FPG）, FINS（△FINS）, HOMA-IR（△HOMA-IR）, and E2（△E2） （all P 〉 0.05）. At 3 months after surgery, △TT was negatively correlated with △BMI （r = -0.441, P = 0.015）, △FINS （r = -0.375, P = 0.041）, and △HOMA-IR （r = -0.397, P = 0.030）, but not correlated with AFPG and△E2 （all P 〉 0.05）. At 6 months after surgery, △TT was negatively correlated with △BMI （r = -0.510, P = 0.018） and △HOMA-IR （r = -0.435, P = 0.049）, but not correlated with △FPG, △FINS and△E2 （all P 〉 0.05）. Conclusions Male severe obese patients are accompanied with abnormal sex hormone levels. LSG has a significant effect on weight loss and blood glucose improvement, and may ameliorate the sex hormone unbalance by improving the insulin resistance in men with severe obesity.