中国减重代谢外科主流手术方式的科学评价

Rational assessment of mainstream bariatric and metabolic surgical procedures performed in China

减重代谢外科经过半个多世纪的发展,各种手术方式不断出现,设计理念包括缩短有效小肠长度减少营养吸收、缩小有效胃容积减少摄食量以及缩短有效小肠长度联合缩小有效胃容积。绝大多数的手术方式由于设计不合理或者临床结局不佳而被淘汰,尤其是单纯缩短小肠有效长度的手术方式。一种新手术方式可否成为推荐的标准手术方式,需要经过临床前论证和动物实验、临床研究试验、临床推广和正式推荐4个阶段,并在各阶段不断收集实验和临床结局资料,以客观、科学地评价该手术。目前所有的手术方式中,经过这4个阶段评价并获得多数国家级专业学会推荐的减重代谢手术方式包括腹腔镜可调节胃绑带术、袖状胃切除术(SG)、Roux⁃en⁃Y胃旁路术(RYGB)、胆胰分流并十二指肠转位术(BPD⁃DS)、单吻合口十二指肠转位术(SADI⁃S/SIPS)和胃内球囊治疗技术。此外,单吻合口胃旁路术(MGB/OAGB)也获得国际肥胖及相关疾病外科联合会(IFSO)的认可。根据我国实际情况、西方国家专业学会立场及现有临床证据,笔者建议:我国可将SG和RYGB作为重点推荐、SADI⁃S/SIPS作为一般性推荐、MGB/OAGB和BPD⁃DS作为谨慎推荐的手术方式。国内尚无胃内球囊产品及胃镜下缝合产品,因而对胃内球囊治疗技术及胃镜下手术方式不进行评价。其他的手术方式或者因已遭淘汰,或者临床证据依然不足,也不进行评价。

Along with over half a century′s evolution of bariatric and metabolic surgery in the world,a variety of surgical procedures have emerged.The design concepts of bariatric and metabolic surgical procedure include shortening the effective length of small intestine to reduce nutrient absorption,reducing gastric volume to limit food intake,or the combination of shortening the length of small intestine and reducing gastric volume.However,majority of historic surgical procedures have become obsolete due to irrational design or poor clinical outcomes,for instance,procedures that simply shorten the length of small intestine.In order to become a standard surgical procedure,the assessment of a new surgical procedure usually need four phases including preclinical validation with animal experiments,clinical research and trial,clinical promotion,as well as official recommendation.During each phase,it is vital to collect the experimental and clinical data in order to establish an objective evaluation.Of all available bariatric and metabolic surgical procedures,laparoscopic adjustable gastric banding,sleeve gastrectomy(SG),Roux⁃en⁃Y gastric bypass(RYGB),biliopancreatic diversion with duodenal switch(BPD⁃DS),single⁃anastomosis duodenoileal bypass with sleeve gastrectomy(SADI⁃S/SIPS)and intragastric balloon have satisfied all four phases mentioned above and therefore were recommended by most national professional associations in the world.In addition,mini gastric bypass/one anastomosis gastric bypass(MGB/OAGB)has also been recognized by the International Federation for the Surgery of Obesity and Metabolic Disorders(IFSO).According to the actual situation in China,the views of professional associations in western countries and the existing clinical evidences,the authors suggest that the SG and RYGB should be classified as strongly recommended surgical procedures,SADI⁃S/SIPS be moderately recommended,and MGB/OAGB,sleeve gastrectomy and BPD⁃DS be recommended with caution in China.Currently,intragastric balloon products and endoscopic suture products have not been approved in China yet,and the other unmentioned bariatric and metabolic surgical procedures are either obsolete or with limited clinical evidences,therefore,they are not evaluated in this article.