减重与代谢外科新进展

Recent advancement in bariatric and metabolic surgery

减重手术是严重肥胖症患者最有效的治疗方法,可大幅改善肥胖症引起的代谢性疾病,特别是2型糖尿病。减重与代谢外科是外科学最新且发展最快的分支,但是该学科仍然在持续演变与进步。笔者通过检索文献总结近年来减重与代谢外科中外科手术治疗病态性肥胖及2型糖尿病的进展可以分成3部分:(1)手术方法的改进及新的适应证。目前袖状胃切除术以及Roux-en-Y胃旁路术是最常见的减重手术。十二指肠转位术及其单吻合口的手术方式被医师认可但实施较少。单吻合口胃旁路术是最新被认可的减重手术,其较Roux-en-Y胃旁路术简单、安全,手术效果也优于目前大部分的减重手术。双通道手术则可能是下一个被认可的手术方法。此外,减重手术的适应证也越来越宽广,新版世界减重手术白皮书已将亚洲人手术适应证修订为体质量指数>27.5 kg/m^(2)。(2)手术效果以及机制。减重手术可以大幅降低肥胖症患者心血管疾病的发生率以及死亡率,最主要的受益人群是合并有糖尿病的患者。新的基础研究以及肠道激素药物的成功,一致显示肠道激素改变是减重手术最主要的机制。但是临床经验显示胃减容仍是减重手术组成的重要部分。(3)创新器械及其他治疗方法。近年来内镜减重治疗,在使用内镜缝合器行袖状胃缝合术已发展成一种成熟且效果良好的治疗方法。更令人瞩目的是新型肠道激素药物治疗的发展,由每周注射1次胰高糖素样肽-1可达1年减重14%的效果,进而到合并2种以及3种肠道激素药物,可达1年减重24%的效果,已经接近减重手术的成效。未来,其在肥胖症及糖尿病的治疗效果相当令人期待。随着世界肥胖症及糖尿病的日益严重,除了减重与代谢外科在近年呈现爆炸性的发展,许多新的手术方法及新的治疗方式,特别是全新且有效的肠道激素相关治疗药物都被研发出来。减重与代谢外科的成功有赖于具有丰富临床经验的多学科团队通过精确的术前策划与完善的术后管理,以及患者的了解与配合,多方配合才能达到最好的效果。

Bariatric surgery is the most effective treatment for patients with severe obesity,which can significantly improve the metabolic disorders,especially type 2 diabetes mellitus.Bariatric and metabolic surgery is the latest and fastest-growing branch of surgery,with the types of procedure and other novel treatment modalities are still evolving and in progress.The authors summarize the recent advancement related to novel bariatric and metabolic surgery in the treat-ment of morbid obesity and type 2 diabetes mellitus in recent years through literature search,which can be divided into the following three parts:(1)novel surgical procedures and new guideline of indication.Sleeve gastrectomy and Roux-en-Y gastric bypass are the most performed bariatric surgery.Duodenal switch or the variant of one anastomosis duodenal ileostomy are also accredited procedures but been less performed.One anastomosis gastric bypass is the most recently accredited bariatric surgical procedures with better safety profile and weight loss efficacy than most of the procedures.For other novel procedures,bipartition procedure may be the next accredited proce-dure.A new worldwide guideline is recently launched and the indication for bariatric surgery is lowered BMI 27.5 kg/m^(2) for Asian.(2)The effect and mechanism of bariatric surgery.Bariatric surgery can significantly reduce the incidence of cardiovascular disease and mortality in obese patients.The main beneficiary group is patients with diabetes mellitus.Along with the recent basic research and the success of new gut hormone related drugs,the mechanism of bariatric surgery can be mostly attributed to gut hormonal effect,however,gastric volume still play an important role.(3)Novel obesity treatment modalities.Endoscopic obesity treatment has a major progress in the success of endoscopic gastroplasty by endoscopic suturing designs.More noteworthy is the development of new intestinal hormone drug therapy,which can achieve a weight loss of 14%in one year by injec-ting once a week glucagon-like peptide-1 preparation,and then combining two or three intestinal hormone drugs can achieve a weight loss of 24%in one year,which is close to the effectiveness of bariatric surgery.Pharmacologic treatment of obesity is very promising and expected.With the increasing severity of obesity and diabetes mellitus in the world,in addition to the explosive develo-pment of bariatric and metabolic surgery in recent years,many new surgical methods and new treatments,especially new and effective intestinal hormone related therapeutic drugs,have been developed.The success of bariatric and metabolic surgery depends on a multidisciplinary team with rich clinical experience:precise preoperative planning and comprehensive postoperative manage-ment,as well as patient understanding and cooperation,in order to achieve the best results.