单吻合口十二指肠回肠旁路联合袖状胃切除术治疗肥胖症患者的疗效和营养评价

Comprehensive evaluation of single-anastomosis duodenal-ileal bypass with sleeve gastrecto‐my in obese patients based on efficacy and nutrition

目的评价单吻合口十二指肠回肠旁路联合袖状胃切除术(SADI⁃S)治疗肥胖患者术后1年的疗效和营养学指标。方法采用回顾性观察性研究方法。纳入无论是否合并其他相关代谢病的体质指数(BMI)≥40 kg/m^(2)患者以及合并严重2型糖尿病并且27.5 kg/m^(2)<BMI<40 kg/m^(2)的患者。收集2018年11月至2022年5月期间于吉林大学中日联谊医院减重与代谢外科接受SADI⁃S治疗的66例肥胖患者临床资料,包括达芬奇机器人手术53例、腹腔镜手术13例。其中男性38例,女性28例,中位年龄35(18~61)岁,术前BMI为(42.93±6.82)kg/m^(2),38例患者合并2型糖尿病,46例患者合并高尿酸血症,45例患者合并高血压,35例患者合并高脂血症,12例患者合并高胆固醇血症,12例患者合并高低密度脂蛋白(LDL)血症。主要观察指标:(1)术中和术后情况;(2)减重效果:术后3、6和12个月的体质量、BMI、多余体质量减少率(%EWL)以及总体质量减少率(%TWL)等指标变化情况;(3)代谢性疾病治疗效果;(4)营养素指标变化情况。结果(1)术中和术后情况:所有患者均顺利完成SADI⁃S手术,无一例中转开腹或死亡。出现术后并发症4例(6.1%),均通过保守治疗或手术治疗后痊愈出院。(2)减重效果:术后3、6和12个月%EWL分别为62.07±26.56、85.93±27.92、106.65±29.65,%TWL分别为22.67±4.94、32.10±5.18、40.56±7.89。术后3~12个月的体质量和BMI均较术前明显降低,差异均有统计学意义(均P<0.001)。(3)代谢性疾病治疗效果:术后3~12个月,空腹血糖、HbA1c、尿酸、收缩压、舒张压、甘油三酯、总胆固醇、LDL等指标较术前均显著下降,差异均有统计学意义(均P<0.05)。术后12个月,糖尿病、高尿酸血症、高血压、高甘油三酯症、高胆固醇血症以及高LDL血症缓解率分别为100%(38/38)、65.2%(30/46)、62.2%(28/45)、94.3%(33/35)、12/12及12/12。(4)营养素指标变化:与术前营养素水平比较,术后3~12个月患者的血红蛋白和红细胞压积有所降低,术后6~12个月的总蛋白水平、术后6个月的白蛋白水平以及术后3个月的铁蛋白水平均有降低;差异均有统计学意义(均P<0.05)。贫血发生率为6.1%(4/66),低蛋白血症发生率为4.5%(3/66),铁蛋白缺乏发生率为4.5%(3/66),均通过保守治疗改善或正常。术后12个月,共检测维生素A缺乏30例(45.5%),维生素E缺乏17例(25.8%),叶酸缺乏11例(16.7%),钾离子缺乏2例(3.0%),钙离子缺乏3例(4.5%),镁离子缺乏2例(3.0%),铁离子缺乏9例(13.6%),锌离子缺16例(24.2%)。但均未出现相关临床症状。结论SADI⁃S具有非常显著的减重及代谢病缓解效果。SADI⁃S术后营养素缺乏主要发生在维生素A、维生素E、锌离子及叶酸,其长期疗效及安全性仍有待进一步随访观察。

Objective To evaluate the 1-year postoperative efficacy and nutritional indicators of single-anastomosis duodeno-ileal bypass with sleeve gastrectomy(SADI-S)in obese patients.Methods This retrospective observational study included patients with a body mass index(BMI)of≥40.0 kg/m^(2) regardless of other related metabolic diseases and patients with severe type 2 diabetes and a BMI between 27.5 and 40.0 kg/m^(2).The clinical data of 66 obese patients who underwent SADI-S at the Bariatric and Metabolic Surgery Department of China-Japan Union Hospital of Jilin University from November 2018 to May 2022 were collected,including 53 cases of da Vinci robotic surgery and 13 cases of laparoscopic surgery.The patients comprised 38 men and 28 women with a median age of 35(18–61)years and a mean preoperative BMI of 42.93±6.82 kg/m^(2).A total of 38 patients had type 2 diabetes,and 46 had hyperuricemia,45 had hypertension,35 had hyperlipidemia,12 had hypercholesterolemia,and 12 had a high low-density lipoprotein(LDL)level.The main observation indicators were(1)intraoperative and postoperative conditions;(2)weight loss outcomes,including body weight,BMI,excess body weight loss(%EWL),and total body weight loss(%TWL)at 3,6,and 12 months after surgery;(3)effects of treatment on metabolic disease;and(4)changes in nutrient indicators.Results(1)Intraoperative and postoperative conditions:All patients successfully underwent SADI-S with neither conversion to laparotomy nor death.Four(6.1%)patients developed postoperative complications,and all of them recovered and were discharged after conservative or surgical treatment.(2)Weight loss outcomes:%EWL at 3,6,and 12 months after surgery was 62.07±26.56,85.93±27.92,and 106.65±29.65,respectively,and%TWL was 22.67±4.94,32.10±5.18,and 40.56±7.89,respectively.Body weight and BMI 3 to 12 months after surgery were significantly lower than those before surgery(all P<0.001).(3)Effect of treatment on metabolic disease:3 to 12 months after surgery,fasting blood sugar,HbA1c,uric acid,systolic blood pressure,diastolic blood pressure,triglycerides,total cholesterol,LDL,and other indicators were significantly lower than those before surgery(all P<0.05).Twelve months after surgery,the remission rates of diabetes,hyperuricemia,hypertension,hypertriglyceridemia,hypercholesterolemia,and high LDL were 100%(38/38),65.2%(30/46),62.2%(28/45),94.3%(33/35),100%(12/12),and 100%(12/12),respectively.(4)Changes in nutrient indicators:Compared with the preoperative nutrient levels,the hemoglobin and hematocrit levels were lower at 3 to 12 months after surgery,the total protein level was lower at 6 to 12 months after surgery,the albumin level was lower at 6 months after surgery,and the ferritin level was lower at 3 months after surgery.The differences were statistically significant(all P<0.05).The incidence of anemia was 6.1%(4/66),hypoalbuminemia was 4.5%(3/66),and ferritin deficiency was 4.5%(3/66),all of which were improved or normalized through conservative treatment.Twelve months after surgery,30(45.5%)patients had vitamin A deficiency,17(25.8%)had vitamin E deficiency,11(16.7%)had folic acid deficiency,2 had potassium deficiency(3.0%),3(4.5%)had calcium deficiency,2(3.0%)had magnesium deficiency,9(13.6%)had iron deficiency,and 16(24.2%)had zinc deficiency.However,no relevant clinical symptoms occurred.Conclusions SADI-S has a very significant effect on weight loss and alleviation of metabolic diseases.Nutrient deficiencies after SADI-S mainly involve vitamin A,vitamin E,zinc,and folic acid.The long-term efficacy and safety of SADI-S still need further follow-up observation.