袖状胃切除术治疗肥胖型2型糖尿病的营养管理

Nutrition management in obese patients with type 2 diabetes mellitus after laparoscopic sleeve gastrectomy

目的探讨营养管理在腹腔镜袖状胃切除手术（LSC）治疗肥胖合并2型糖尿病（T2DM）中的应用价值。方法收集2013年3月至2015年7月在上海复旦大学附属浦东医院接受LSG的22例肥胖型T2DM患者临床资料。所有患者均严格接受临床专职营养师全程营养指导，包括术前予以3347．2-5020．8kJ（800-1200kcal）／d的低热能糖尿病称重饮食，术前1d予以2510．4kJ（600kcal）低热能流质饮食以促进胃排空：LSG术后胃肠道通气之前禁食，通气后予以1673．6-2510．4kJ（400-600kcal）／d清流质饮食，保证〉2000ml以上每日液体量，术后第2周开始2928．8-3765．6kJ（700-900kcal）／d（蛋白质至少达到60g／d）低脂低糖流质饮食，术后1月开始半流质饮食，直至恢复正常饮食。全组患者按期完成术前和术后1周、1月、3月以及6月的临床随访，观察5个时间点患者体质量、腰围、臀围、体质指数（BMI）、空腹血糖和血脂等指标的变化。结果22例患者中男10例，女12例，平均年龄38．6（18-66）岁，T2DM病史1月至15年，共患疾病包括高血压12例、脂肪肝14例、冠心病1例、痛风1例和慢性甲状腺炎1例，月经紊乱1例。全组患者均手术顺利，无中转开腹和严重并发症。与术前相比，术后6月患者体质量从（103．9±20．2）kg下降至（80．9±12．6）kg（t=6．294，P=0．000）、腰围从（118．6±13．8）cm下降至（96．4±8．0）cm（t=6．331，P=0．000）、臀围从（116．9±12．6）cm下降至（104．0±7．7）cm（t=3．854，P=0．000），BMI从（36．2±5．9）kg／cm下降至（27．9±3．5）kg／m^2（t=5．630，P=0．000）。随访6月，无患者出现体质量过低现象。与术前相比，术后6月患者空腹血糖从（7．4±1．4）mmol／L下降至（6．0±0．9）mmol／L（t=3．172，P=0．003）、餐后2h血糖从（14．1±4．9）mmol／L下降至（7．5±2．2）mmol／L（t=7．026，P=0．000）、空腹胰岛素从（160．0±71．9）mIU／L下降至（43．8±20．8）mIU／L（t=7．259，P=0．000）、餐后2h胰岛素从（437．6±261．4）mIU／L下降至（140．5±104．6）mIU／L（t=5．858，P=0．000）、空腹C肽从（1．1±0．6）μg／L下降至（0．7±0．3）μg／L（t=3．560，P=0．001）、餐后2hC肽从（2．5±0．9）μg／L下降至（1．5±0．7）μg／L（t=3．865，P=0．000），糖化血红蛋白水平从（8．0±1．6）％下降至（5．9±0．6）％（t=5．953，P=0．000），且除空腹血糖、餐后2hC肽和糖化血红蛋白水平以外，其他指标随时间的延长继续均呈下降趋势（均P〈0．05），差异有统计学意义；术后3月已有16例患者血糖恢复正常。术后6月甘油三酯和血压也较术前明显降低，差异有统计学意义（均P〈0．05）。术后6月8例（8／12，66．7％）共患高血压患者血压降至正常水平，4例（4／12，33．3％）较术前改善；11例（11／14，78．6％）共患脂肪肝患者复查B超未提示脂肪肝，3例（3／14，15．4％）脂肪肝较术前改善；1例痛风患者3个月后尿酸恢复正常；1例月经紊乱患者，于术后1月恢复正常月经。结论通过实行合理的营养管理，有助于LSG术后患者的体质量控制、并使血糖和血脂水平获得更为理想的改善。

Objective To explore the value of nutrition management in obese patients with type 2 diabetes melfitus （T2DM） after laparoseopic sleeve gastreetomy （LSG）. Methods Clinical data of 22 obese T2DM patients undergoing LSG from March 2013 to July 2015 in Fudan University Pudong Medical Center were collected. All the patients strictly followed the specialized instruction by nutritionists： diabetic and low calorie diet 3347.2 to 5020.8 kJ （800 to 1200 kcal） per day before the operation; low calorie liquid diet 2510.4 kJ（600 keal） per day before operation for promoting gastric emptying; fasting diet before postoperative ventilation; clear liquid diet 1673.6 to 2510.4 kJ （400 to 600 kcal） per day after postoperative ventilation （liquid intake 〉 2000 ml）; low fat liquid diet 2928.8 to 3765.6 kJ （700 to 900 keal） per day （protein 60 g per day at least, 2000 ml liquid） 2 weeks after the operation; semi-liquid diet 1 month after operation and gradually normal diet. All the 22 patients were followed up at 1 week, 1, 3, 6 months after operation on time. Changes of body weight, waist circumference, hip circumference, body mass index（BMI）, blood glucose indexes induding fasting blood glucose （FBG）, 2-hour postparandial blood glucose （PBG）, fasting C-peptide, 2-hour postprandial C-peptide, fasting serum ineulin （FINS）, 2-hour postprandial inculin （INS）, HhAle, blood pressure and blood lipid indexes were observed and analyzed before and 1 week, 1, 3, 6 months after operation. Results The average age of 22 patients （10 men and 12 women） was 38.6 years （18 to 66 years）. The duration of diabetes varied from 1 month to 15 years. Comorbidity included 12 patients of high blood pressure, 14 of fatty liver, 1 of coronary heart disease, 1 of gout, 1 of chronic thyroiditis and 1 of menstrual disorder. LSG was performed successfully in all the patients and no severe complications and transference to laparotomy occurred. As compared to pre-operation, at 6 months after operation, the average body weight decreased from （ 103.9 ± 20.2） kg to （80.9 ± 12.6） kg （t = 6.294, P = 0.000）, waist circumference from （118.6 ± 13.8） em to （96.4 ± 8.0） em （t = 6.331, P = 0.000）, hip circumference from （116.9 ± 12.6） cm to （104.0 ± 7.7） cm （t = 3.854, P= 0.000）, BMI from （36.2 ± 5.9） kg/m2 to （27.9 ± 3.5 ） kg/m2 （t = 5.630, P = 0.000）, showing a decreasing trend over time. There was no underweight patient after 6 months follow-up. As compared to we-operation, at 6 months after operation, the average FBG reduced from （7.4 ±1.4） mmol/L to （6.0 ± 0.9） mmol/L （t = 3.172, P = 0.003）, 2 h PBG from （14.1 ± 4.9） mmol/L to （7.5 ± 2.2） mmol/L （t = 7.026, P = 0.000）, FINS from （160.0 ± 71.9） mIU/L to （43.8 ± 20.8） mIU/L （t = 7.259, P = 0.000）, 2-hour postprandial INS fiom （437.6 ± 261.4） mIU/L to （140.5 ± 104.6） mlU/L （t = 5.858, P = 0.000）, fasting C-peptide from （1.1 ± 0.6） μg/L to （0.7 ± 0.3） μg/L （t =3.560, P= 0.000）, 2-hour postprandial C-peptide from （2.5 ± 0.9） μg/L to （1.5 ± 0.7） μg/L （t =3.865, P = 0.000）, HbAlc from （8.0 ± 1.6）% to （5.9 ± 0.6）% （t = 5.953, P=0.000）, showing a decreasing trend over time except FBG, 2h postprandial C-peptide and HbAlc （all P 〈 0.05）. FBG and 2-hour PBG of 16 patients returned to normal 3 months after the operation. Blood pressure and trigly ceride decreased obviously 6 months after operation compared to pre-operation with significant difference（P 〈 0.05）. At 6 months after operation, blood pressure of 8 comorbidity patients with high blood pressure became normal （8/12, 66.7%） and of 4 patients improved （4/12, 33.3%）; B ultrasound examination revealed normal in 11 comorbidity patients with fatty liver （11/14,78.6%） and improvement in 3 patients （3/14,15.4%）. Blood uric acid of the gout patient and the menstruation of the menstrual disorder patient returned to normal 3 months and 1 month after the operation respectively. Conclusion As for obese patients with T2DM undergoing LSG, reasonable nutrition management is helpful to decrease body weight, and to obtain an ideal improvement of blood glucose and blood lipid levels.