腹腔镜2种术式治疗肥胖症合并2型糖尿病的临床研究

发布时间：2018-03-10 09:08

  本文选题：肥胖症　切入点：腹腔镜　出处：《天津医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：背景:随着公众生活水平的提高,肥胖症以及与其相关的2型糖尿病已经在全世界流行开来,大量的临床研究证实,传统的2型糖尿病的治疗很难达到有效且持久的减重效果和缓解2型糖尿病的目的。外科领域方面,Pories[1]最先发表了关于手术治疗肥胖症合并T2DM的病例报道,他们对病态肥胖的患者行“Y”形胃旁路术(RYGB),术后的结果令人惊喜,所有患者不仅体重下降,而且还意外的发现部分合并T2DM的病态肥胖患者中的大部分糖尿病临床症状完全缓解[2]。近年来减重手术治疗T2DM在全世界流行大热,而随着腹腔镜技术的成熟所确立的优势地位,微创手术治疗肥胖合并T2DM成为了趋势。近年来我国开展较多的主要是腹腔镜胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)和腹腔镜袖状胃切除术(laparoscopic Sleeve Gastrectomy,LSG)。其原理可分概括为①限制食物的摄入量,②减少营养物质的吸收,③通过改变胃肠道生理结构来影响肠道内激素。但具体作用机制尚无明确定论。此外,不同术式术后的减重效果、术后对于2型糖尿病的疗效分析、不同术式手术操作的难易程度、术后并发症的发生率等方面也存在不同,如何为肥胖症合并2型糖尿病患者选择合适且个体化的治疗方案也需更多的临床依据。目的:分别观察行LRYGB以及LSG的肥胖症合并2型糖尿病患者手术前后糖代谢、脂代谢指标、体重及营养变化情况、胰岛素功能及胰岛抵抗变化、T2DM的治疗效果来对比2种手术方式安全性以及疗效,探讨2种术式治疗T2DM的可能机制,为不同的肥胖合并T2DM的患者选择合适的临床术式提供医学依据。方法:回顾性分析2011年2月至2012年5月在天津中西医结合医院66例患有肥胖症合并2型糖尿病患者的资料,按照手术方式分为:LRYGB组(40例)和LSG组(26例)。术后随访至少24个月,记录分析手术前后患者的糖脂代谢指标(空腹血糖、餐后2小时血糖、空腹C肽、Hb A1C、总胆固醇、三酰甘油)、体重及营养变化情况(BMI、腰围、EWL%、血红蛋白、总蛋白、白蛋白)、胰岛素功能及胰岛抵抗变化(Homa-IR、Homa-β)、2型糖尿病的治疗效果,对比以上2种腹腔镜术式的操作时间、术后住院天数、术后并发症的发生率来评估2种术式的安全性。数据均以平均数±标准差来表示。采用SPSS 17.0统计软件统计分析。结果:手术完成情况:66例患者均由同一团队在腹腔镜下成功完成手术,无中转开腹以及死亡病例,所有患者均完成24个月的术后随访。2组手术时间差异有统计学意义(P0.05),LRYGB和LSG组手术时间分别为(150.3±23)min和(127.6±34.3)min;2组术中出血量差异有统计学意义(P0.05),LRYGB组和LSG组术中出血量分别为(46.6±9.2)ml和(32.6±8.6)ml;2组术后排气时间组间差异无统计学意义(P0.05),LRYGB组和LSG组分别为(1.47±0.27)天和(1.27±0.21)天;2组术后住院天数组间差异有统计学意义(P0.05),LRYGB组和LSG组分别为(4.7±1.4)天和(3.7±1.3)天。在术后24个月内LRYGB组出现术后并发症6例而LSG组为4例。术后并发症总的发生率组间差异无统计学意义(χ2=0.742,P=0.867)。脂代谢改善情况:糖代谢:与术前相比,LRYGB组和LSG组空腹血糖、餐后2 h血糖、Hb A1c在术后1、3个月均有明显下降(P0.01),术后6、12、18个月下降平稳(P0.05),而组间比较差异无统计学意义(P0.05);脂代谢:两组病人术后血脂水平均较术前明显降低(P0.05);LRYGB组和LSG组在术后1、3、6、12个月平稳下降,其余时间组间差异无统计学意义(P0.05)。体重及营养变化情况:与术前相比,LRYGB组和LSG组在术后1、3、6、12个月BMI有明显降低(P0.05)、术后12个月后至24个月,患者BMI趋于稳定,差异无统计学意义。而总蛋白和白蛋白水平变化不明显,仅总蛋白在术后6个月时与术前相比差异有统计学意义(P0.05),但仍在正常参考值范围内;术后1个月至6个月,两组病人血红蛋白水平较术前均降低(P0.05),6个月后血红蛋白水平趋于稳定,正常参考值范围,未出现明显贫血。胰岛素抵抗及胰岛功能变化情况:LRYGB组和LSG组术后的胰岛素抵抗(Homa-IR)均较术前明显改善(P0.05)。LRYGB组术后1个月时胰岛功能(Homa-β)即较术前明显改善(P0.05),而LSG组改善不明显(P0.05);在术后6、12、18、24个月LSG组与术前相比明显改善(P0.05),而与LRYGB组组间相比差异有统计学意义(P0.05)。⑤2型糖尿病治疗效果:LRYGB组40例患者,术后24个月,完全缓解27例(67.5%),部分缓解7例(17.5%),临床改善6例(15%),40例治疗全部有效。34例(85%)停用胰岛素或降糖药,6例(15%)口服降糖药且均停用胰岛素,其中5例(12.5%)口服药物减半,1例(2.5%)仅口服阿卡波糖。40例患者均无复发,至术后24个月时治疗效果仍保持稳定;LSG组17例患者术后24个月时完全缓解(65.4%),4例部分缓解(15.4%),5例患者停用胰岛素且口服药物减半(19.2%),而有效率亦为100%,术后2年时仍保持稳定。采用Fisher确切概率法比较两组病人术后2型糖尿病缓解率,二者差异无统计学意义(P=1.0000.05)。结论:①LRYGB和LSG是两种有效的治疗肥胖合并2型糖尿病的术式,对2型糖尿病有较高的缓解率。②LRYGB对于治疗肥胖合并糖尿病的治疗效果可能要优于LSG,尤其是2型糖尿病病史时间长、使用降糖药量、用药比率高的患者。但LSG相对简单,不改变胃肠道生理状态,安全性较高。③LSG更适用于以肥胖症状为主、糖尿病较轻、年龄较小、术前胰岛功能受损较轻的病人。同时,如果LSG术后效果不佳,须改行LRYGB或胆胰转流术(DBP)
[Abstract]:Background: with the improvement of the living standards of the public, obesity and type 2 diabetes related has been popular in all over the world from a large number of clinical studies have confirmed that the traditional treatment of type 2 diabetes is difficult to achieve effective and lasting weight loss and remission of type 2 diabetes. The field of surgery, Pories[1] was first published on surgery the treatment of obesity with T2DM cases reported on their morbidly obese patients with "Y" type of gastric bypass surgery (RYGB), postoperative results of surprise, all the patients not only weight loss, most of the clinical symptoms of diabetes and the incidence of accidents is complicated with T2DM in morbidly obese patients in [2]. in recent years, bariatric surgery T2DM is popular in the world hit complete remission, the laparoscopic technique mature establishment of the dominant position, minimally invasive surgery in the treatment of obesity with T2DM has become a trend in recent years. To carry out more in our country mainly laparoscopic gastric bypass (laparoscopic Roux-en-Y gastric bypass, LRYGB) and laparoscopic sleeve gastrectomy (laparoscopic Sleeve, Gastrectomy, LSG). The principle can be summarized as the restriction of food intake, reduce the absorption of nutrients, and by changing the physiological structure of gastrointestinal tract to influence intestinal hormone but the specific mechanism of action. There is no clear conclusion. In addition, the effect of weight loss after different methods of surgery, after surgery for patients with type 2 diabetes of different degrees of difficulty in the surgical operation, postoperative complications rate etc are different, how to obesity patients with type 2 diabetes mellitus and select the appropriate and the individual treatment also need more clinical basis. Objective: To observe the LRYGB and LSG with obesity before and after surgery in patients with type 2 diabetes mellitus glucose metabolism, lipid metabolism, body Weight and nutritional changes, insulin function and insulin resistance in the treatment of T2DM, to compare the 2 methods of operation safety and efficacy, to explore the possible mechanism of 2 kinds of surgical treatment of T2DM, for different obese patients with T2DM clinical surgical options provide medical basis. Methods: a retrospective analysis of February 2011 May 2012 in Tianjin Hospital of traditional Chinese and Western medicine in 66 cases of obese patients with type 2 diabetes, the patients were divided into LRYGB group (40 cases) and LSG group (26 cases). All cases were followed up for at least 24 months after the operation, recording and analysis of glucose and lipid metabolism of patients before and after surgery (fasting blood glucose, postprandial 2 blood glucose, fasting C peptide, Hb A1C, total cholesterol, triglyceride, body weight three) and nutritional changes (BMI, EWL%, waist circumference, hemoglobin, total protein, albumin), insulin function and insulin resistance change (Homa-IR, Homa-), type 2 diabetes mellitus 娌荤枟鏁堟灉,瀵规瘮浠ヤ笂2绉嶈吂鑵旈暅鏈�寮忕殑鎿嶄綔鏃堕棧�

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