不同体重指数的T2DM“腹腔镜胃旁路术”临床疗效研究

发布时间：2018-05-17 05:00

本文选题：体重指数 + 腹腔镜胃旁路术　；参考：《南方医科大学》2015年硕士论文

【摘要】：背景糖尿病是一组常见的以葡萄糖和脂肪代谢紊乱、血浆葡萄糖水平增高为特征的代谢内分泌疾病：其中,T2DM(2型糖尿病)主要由于胰岛素抵抗合并有相对性胰岛素分泌不足所致。表现为碳水化合物、脂肪、蛋白质、维生素、水及电解质等代谢紊乱。糖尿病在世界范围内的发病率正逐年增加,据报道：2010年全球年龄在20岁～79岁的成年人糖尿病发病率为6.4%,影响2.85亿成年人。WHO调查显示：到2030年糖尿病人数将增加一倍,且新发病例主要集中在中国等发展中国家。2008年中华医学会糖尿病学分会的一项研究显示,在我国20岁以上的成年人患病率为9.7%,患病总人数超过9000万,其中T2DM占90%。糖尿病的治疗,长期以来一直沿用包括：健康教育、医学营养治疗、体育锻炼、病情监测、口服药物治疗、胰岛素治疗、GLP-1类似物及DPP Ⅳ抑制剂等传统的治疗方法。尽管上述治疗方法的阶梯性治疗或强化性治疗,仍有许多患者难以达到其预期的治疗目标。血糖的控制与糖尿病并发症的减少密切相关,糖尿病的并发症对身体健康危害极大。糖尿病的危害不在于高血糖本身,而在于糖尿病可继发各种急、慢性并发症,严重威胁着人类的身体健康。糖尿病的急性并发症包括：糖尿病酮症酸中毒、高血糖高渗状态。糖尿病酮症酸中毒、高血糖高渗状态两者皆因胰岛素相对缺乏,合并严重的以高血糖为特征的两种不同的代谢紊乱。高血糖高渗状态因胰岛素不足,血糖升高,引起身体脱水,导致严重的脱水状态。糖尿病酮症酸中毒除胰岛素严重缺乏、严重高血糖及脱水外,同时,合并有酮体和酸的生成。糖尿病酮症酸中毒、高血糖高渗状态如得不到合理的救治可致患者的死亡。在发现胰岛素以前,糖尿病酮症酸中毒的死亡率几乎为100%。研究表明糖尿病酮症酸中毒是青少年糖尿病患者的主要死亡原因。糖尿病的慢性并发症是对人体危害最为严重,是糖尿病致残、致死的主要原因。糖尿病大血管病变可引起冠心病、心肌病变、充血性心力衰竭,心肌梗死、猝死、缺血性或出血性脑血管病、脑萎缩、脑动脉硬化、肾动脉硬化、肢体动脉硬化等。糖尿病微血管病变是糖尿病的特异性并发症,典型改变是微循环障碍和微血管基底膜增厚,可致糖尿病视网膜病变和糖尿病肾病等。患糖尿病20年后,几乎100%的1型糖尿病患者和60%的2型糖尿病患者会出现不同程度的视网膜病变。糖尿病视网膜病变在美国是成人失明的主要病因。糖尿病肾病会缩短患者的寿命,影响患者的生活方式和工作,在绝大多数国家糖尿病肾病是进展为晚期肾病的主要原因,糖尿病肾病发展到晚期,需透析或肾移植,加重患者和国家经济负担,是糖尿病致死的重要原因。糖尿病神经病变可累及全身神经的任意部分,可引起感觉异常、疼痛、感觉迟钝、感觉消失、神经反射消失、肌肉麻痹、肌肉萎缩、瞳孔改变、胃排空延迟、腹泻、便秘、光反射消失、排汗异常、直立性低血压、持续心动过速、心搏间距延长,以及残尿量增加、尿失禁、尿潴留、性功能障碍等。糖尿病足为常见的糖尿病慢性并发症,是与下肢神经病变和周围血管病变相关的下肢溃疡、感染和(或)深层组织损伤。轻者表现为足部畸形、皮肤干燥和发凉等；重者可表现为足部溃疡、坏疽。文献报道约15%的糖尿病患者将在其一生中某一阶段发生足部溃疡或坏疽,2型糖尿病患者的截肢率是非糖尿病患者的17以上倍,糖尿病足是截肢、致残主要原因。糖尿病患者容易并发感染,感染率高,且较常人感染更严重,治疗更困难。如患者可常发生疖、痈,迁延不愈或反复发生。皮肤真菌感染如足癣等也常可发生,女性患者可出现真菌性阴道炎和巴氏腺炎。糖尿病患者还可出现如毛霉菌病、恶性外耳炎、气肿性胆囊炎、气肿性肾盂肾炎等不常见感染。糖尿病患者的肺结核的发生率也较非糖尿病者高2.0-3.6倍,且疾病发展更快。此外,糖尿病还可引起各种骨关节病变、皮肤病变、影响创伤的愈合等。糖尿病极大地威胁着人类的身体健康和社会发展,糖尿病已成为严重的全球公共卫生问题之一,对社会和经济带来了沉重的负担。1995年,Pories医生首先报道,合并T2DM的肥胖症患者,在实施了减重的“胃旁路术”后,不仅获得了显著地“减重”效果,同时也取得了对糖尿病“血糖控制”的神奇疗效。从此,人们对T2DM的治疗看到了新的希望。以“胃旁路术”为代表的减重手术在T2DM的治疗方面的应用也蓬勃发展起来,方兴未艾。减重手术因其对T2DM卓越的治疗效果,而被专家及各种指南推荐作为T2DM标准的治疗措施之一。然而,目前各种指南及共识主要将BMI做为选择病人的主要指标,对于BMI≥35kg/m2的T2DM患者可考虑代谢外科手术治疗,已基本达成共识；但是,对于BMI35kg/m2的这部分患者是否能采取相同的治疗,仍然存在争议。1991年,NIH制定指南,在临床证据不是很充足的情况下,首次推荐以病人的BMI作为选择减重手术的病人的主要指标,建议：对BMI40 kg/m2的肥胖患者可以选择减重手术；对BMI在35 kg/m2～40 kg/m2的肥胖患者,如果合并高风险的心肺问题、严重的糖尿病,或合并影响生活的身体问题,如肥胖相关的关节问题或影响患者职业、家庭功能、运动等,此类患者可考虑减重手术治疗。此后,各指南和卫生机构声明的制定均参照NIH指南的标准,将BMI作为选择病人的主要标准。2009年,ADA(美国糖尿病协会)首次推荐减重手术可用于T2DM的治疗,它指出对BMI≥35kg/m2的T2DM患者可考虑减重手术治疗,尤其是那些通过改变生活方式和药物治疗不满意的患者。2011年,IDF(国际糖尿病联盟)发表声明,对BMI≥35kg/m2的T2DM患者,减重手术可以作为一种治疗措施；对BMI在30kg/m2～35kg/m2的T2DM患者,在最佳的药物治疗效果不佳时,尤其在合并其他心血管危险因素的同时,手术可以作为一种选择的治疗方式。在我国,《手术治疗糖尿病专家共识》和《中国2型糖尿病防治指南(2010年版)》指出：(1)BMI≥35 kg/m2的有或无合并症的T2DM人群,可考虑行减重代谢手术；(2)BMI 30 kg/m2～35 kg/m2合并T2DM的人群,在生活方式和药物治疗难以控制血糖或合并症时,尤其具有心血管风险因素时,手术应是治疗选择之一；(3)BMI 28.0kg/m2～29.9kg/m2的人群中,如果其合并T2DM,并有向心性肥胖(女性腰围85cm,男性90cm)且至少额外的符合两条代谢综合征标准(高甘油三酯,低高密度脂蛋白胆固醇,高血压),减重手术应也可考虑为治疗选择之一；(4)BMI25.0kg/m2～27.9kg/m2的T2DM病人,手术应该被视为试验研究,而不应广泛推广。《中国糖尿病外科治疗专家指导意见(2010)》指出：BMI≥27.5kg/m2的T2DM患者经规范的非手术治疗后效果不好或不能耐受时,可考虑手术手术治疗：对BMI27.5 kg/m2的T2DM患者手术仅作为临床研究,不宜推广。最近,我国刚发布了《中国肥胖和2型糖尿病外科治疗指南(2014)》,其中指出：BMI≥32.5kg/m2的T2DM患者应积极考虑手术；BMI 27.5kg/m2～32.5 kg/m2的T2DM患者,经改变生活方式和药物治疗难以控制血糖且至少符合额外的2个代谢综合征组分或存在合并症,可考虑手术；对BMI 25.0kg/m2～27.5kg/m2的T2DM患者,应慎重开展手术。虽然,目前胃旁路术为代表的减重手术已广泛地应用于治疗T2DM,但是,在治疗T2DM的患者选择上,仍存在争议。特别是对BMI35kg/m2的T2DM患者是否能采取减重手术的治疗争议较大。我们总结了我们近几年“腹腔镜胃旁路术”治疗T2DM临床经验的基础上,对三组不同BMI患者胃旁路术后的临床疗效,进行了初步的比较研究和探讨,主要比较三组患者血糖控制率是否存在差异,探索不同BMI患者胃旁路术后降糖效果。目的不同体重指数的T2DM患者“腹腔镜胃旁路术”的临床疗效。方法在我科2010-2013年间,实施“腹腔镜胃旁路术”的206名2型糖尿病患者中,分层随机抽取25kg/m2BMI28 kg/m2、28 kg/m2≤BMI35 kg/m2、35 kg/m2≤BMI三组各20例,共60名患者,分别作为低BMI组、中BMI组和高BMI组。三组患者均采用相同的全麻下“腹腔镜胃旁路”术式。将糖化血红蛋白7%定义为血糖控制。三组患者术后12个月血糖控制率以及术后体重、腰围、臀围、BMI、空腹血糖、餐后2小时血糖、空腹C肽、餐后2小时C肽、空腹胰岛素、餐后2小时胰岛素变化情况,及术后并发症发生情况。统计方法：三组间术后12个月血糖控制率比较用x2检验比较分析；组间术前指标、术后12个月指标及术前术后指标变化值,采用多样本均数的方差分析；组内术前术后指标比较采用配对t检验。p值小于0.05为有统计学差异,采用双侧检验。所用数据分析用统计软件spss 13.0分析。结果低BMI组、中BMI组、高BMI组血糖控制率分别为75%、85%、90%,三组患者血糖控制率无统计学差异；三组患者体重、BMI、腰围、臀围、空腹血糖、餐后2小时血糖、术后12个月均较术前显著改善,空腹胰岛素、餐后2小时胰岛素也较术前较少,高BMI组的空腹C肽、餐后2小时C肽也较术前明显降低,但是低BMI和中BMI组,这两项指标较术前的变化不明显：中、高BMI组各有两例患者出现低血糖,三组各有2例出现胃肠吻合口溃疡。结论腹腔镜胃旁路术后,BMI 28-35kg/m2的T2DM患者,可能会取得与BMI35kg/m2患者大致相同的临床疗效,BMI 25-28kg/m2的T2DM患者,也可手术获益,且可取得较为满意的临床治疗效果,也不失为一种可供临床治疗选择的方案之一。三组不同BMI的T2DM患者在腹腔镜胃旁路术后均可获得较为满意的临床疗效。
[Abstract]:Background diabetes is a common group of metabolic disorders characterized by glucose and fat metabolism disorder and high plasma glucose level. Among them, T2DM (type 2 diabetes) is mainly due to insulin resistance combined with relative insulin deficiency. It is characterized by carbon hydrates, fat, protein, vitamins, water and electrolytes. Metabolic disorders. The incidence of diabetes in the world is increasing year by year. It is reported that the incidence of diabetes in adults aged 20 to 79 years old in 2010 is 6.4%. The influence of 285 million adults on.WHO survey shows that by 2030 the number of diabetes will double, and the new cases are mainly concentrated in the developing countries such as China and other developing countries in.2008 years. The prevalence rate of adults over 20 years old in China is 9.7%, and the total number of diseases is more than 90 million, of which T2DM accounts for the treatment of 90%. diabetes. It has been used for a long time, including health education, medical nutrition treatment, physical exercise, disease monitoring, oral medicine treatment, insulin treatment, GLP- 1 traditional treatments such as analogues and DPP IV inhibitors. Despite the staircase or intensive treatment of the above treatment, many patients are still difficult to achieve the desired target of treatment. The control of blood sugar is closely related to the reduction of diabetic complications. The complications of diabetes are very harmful to health. The harm of diabetes is not The acute complications of diabetes include diabetes ketoacidosis, hyperglycemic hyperosmotic state, diabetic ketoacidosis, hyperglycemic hyperosmotic state, and hyperglycemic hyperosmotic state two because of insulin relative deficiency and severe hyperemia. Two different metabolic disorders characterized by sugar. Hyperglycemic hyperosmotic state, due to insufficient insulin and high blood sugar, causes dehydration to cause severe dehydration. Diabetic ketoacidosis is a serious deficiency of insulin, severe hyperglycemia and dehydration, combined with the formation of ketone body and acid. Diabetes ketoacidosis, hyperglycemic hyperglycemia The death rate of diabetic ketoacidosis is almost 100%. before the discovery of insulin. Diabetes ketoacidosis is the main cause of death in adolescents with diabetes. The chronic complications of diabetes are the most serious harm to the human body, the disability and death of diabetes. The main causes of diabetes are coronary heart disease, cardiomyopathy, congestive heart failure, myocardial infarction, sudden death, ischemic or hemorrhagic cerebrovascular disease, cerebral atrophy, cerebral arteriosclerosis, renal arteriosclerosis, arteriosclerosis of limbs, and so on. Diabetic microvascular disease is a specific complication of diabetes and a typical change is microcirculation barrier Diabetic retinopathy and diabetic nephropathy can be caused by hindering and thickening of the microvascular basement membrane. After 20 years of diabetes, almost 100% of type 1 diabetes and 60% of type 2 diabetic patients have different degrees of retinopathy. Diabetic retinopathy is the main cause of loss of blindness in the United States. Diabetic nephropathy will shorten the patient's disease. Life expectancy affects patients' lifestyle and work. In most countries, diabetic nephropathy is the main cause of advanced kidney disease, the development of diabetic nephropathy to late stage, dialysis or renal transplantation, aggravating the patient and national economic burden, is an important cause of death in diabetes. Diabetic neuropathy can involve any part of the whole body nerve. It can cause abnormal sensation, pain, dull sensation, disappearance of feeling, disappearance of nerve reflex, muscle paralysis, muscle atrophy, changes of pupil, delayed gastric emptying, diarrhea, constipation, disappearance of light reflex, abnormal perspiration, erect hypotension, prolonged cardiac tachycardia, increased residual urine volume, urinary incontinence, urinary retention, sexual dysfunction, and so on. Urinary foot is a common chronic diabetic complication, which is associated with lower extremity neuropathy and peripheral vascular disease, infection and (or) deep tissue injury. The light is characterized by foot deformity, skin drying and hair cooling, and the weight of foot ulcers and gangrene. The article reports about 15% of diabetic patients in their lifetime. The stage of foot ulcer or gangrene, the amputation rate of type 2 diabetic patients is more than 17 times of non diabetic patients, diabetic foot is amputation, the main cause of disability. Diabetes patients are prone to infection, high infection rate, more serious infection and more difficult treatment. For example, patients can often have furuncle, carbuncle, immigrant or repeated occurrence. Real skin. Bacterial infection, such as tinea pedis, can also occur often, female patients can have fungal vaginitis and barbatitis. Patients with diabetes can also appear as Trichoderma, malignant otitis externa, emphysematous cholecystitis, emphysematous pyelonephritis and other uncommon infections. The incidence of tuberculosis in diabetic patients is 2.0-3.6 times higher than that of non diabetic patients, and the development of the disease is more than that of the non diabetic patients. In addition, diabetes can also cause various bone and joint lesions, skin lesions, and wound healing. Diabetes greatly threatens the health and social development of human beings. Diabetes has become one of the serious global public health problems. It has brought a heavy burden to the society and the economy for.1995 years, doctor Pories first reported and merged. T2DM obesity patients, after the implementation of the weight reduction "gastric bypass", not only achieved a significant "weight loss" effect, but also achieved a magical effect on diabetes "blood glucose control". From then on, people have seen new hopes for the treatment of T2DM. The treatment of T2DM, represented by "gastric bypass", should be done in the treatment of the disease. It is also flourishing and flourishing. Because of its excellent therapeutic effect on T2DM, weight reduction surgery has been recommended by experts and various guidelines as one of the treatment measures of T2DM standard. However, the current guidelines and consensus are mainly to use BMI as the main index for selecting patients and to consider the metabolic surgical treatment for T2DM patients with BMI > 35kg/m2. There is a basic consensus for treatment; however, there is still a dispute over the same treatment for this part of the BMI35kg/m2, but there is still a dispute.1991, NIH guidelines, and the first recommendation of the patient's BMI as the main indicator of the disease in the weight reduction operation under the condition that the clinical evidence is not sufficient. It is suggested that the obese patients with BMI40 kg/m2 are obese. People can choose weight reduction surgery; for patients with BMI in 35 kg/m2 to 40 kg/m2, if combined with high risk of cardiopulmonary problems, severe diabetes, or combined with physical problems affecting life, such as obesity related joint problems or the impact of occupational, family function, exercise, and so on, such patients may consider weight reduction surgery. Thereafter, guidelines And the formulation of the health agency statement is based on the standards of the NIH guide, and BMI is the primary standard for selecting patients.2009. ADA (American Diabetes Association) recommends that weight reduction surgery can be used for the treatment of T2DM for the first time. It points out that weight reduction treatment for T2DM patients with BMI > 35kg/m2 can be considered, especially those by changing lifestyle and drug treatment. Dissatisfied patients,.2011, IDF (International Diabetes Association) issued a statement that a weight-loss operation can be used as a treatment for T2DM patients with BMI > 35kg/m2; for BMI in 30kg/m2 to 35kg/m2 patients, the operation may be a kind of operation, especially when the best treatment effect is poor, especially in the combination of his cardiovascular risk factors. The choice of treatment. In our country, < surgical treatment for diabetes experts' consensus > and China's type 2 diabetes prevention guide (2010 Edition) > points out: (1) T2DM people with or without complications of BMI > 35 kg/m2 may consider weight reduction surgery; (2) people with BMI 30 kg/m2 to 35 kg/m2 and T2DM are difficult to control in lifestyle and drug treatment. When blood sugar or complication, especially with cardiovascular risk factors, surgery should be one of the options for treatment; (3) among people with BMI 28.0kg/m2 to 29.9kg/m2, if they merge with T2DM and have centripetal obesity (female waistline 85CM, male 90cm) and at least additional compliance with the standard of two metabolic syndrome (high triglyceride, low density lipoprotein bile solid) Alcohol, hypertension), weight loss surgery should also be considered as one of the choice of treatment; (4) BMI25.0kg/m2 ~ 27.9kg/m2 T2DM patients, the operation should be considered as an experimental study, and should not be widely popularized. < < Chinese Diabetes surgical treatment expert guidance (2010) > > point out: BMI > 27.5kg /m2 T2DM patients after standardized non-surgical treatment results are not good or In the case of intolerance, surgical treatment can be considered: the operation of T2DM patients with BMI27.5 kg/m2 is not suitable for clinical study. Recently, China has just published the guidelines for surgical treatment for obesity and type 2 diabetes in China (2014). It is pointed out that the T2DM patients with BMI > 32.5kg/m2 should consider the operation actively; BMI 27.5kg/m2 ~ 32.5 kg/m2 T2DM patients Patients who are difficult to control blood glucose by changing lifestyle and medications are difficult to control blood sugar and at least 2 additional metabolic syndrome components or concomitant symptoms. Surgery should be considered; surgery for BMI 25.0kg/m2 to 27.5kg/m2 T2DM patients should be carefully operated. Although the weight reduction surgery represented by gastric bypass has been widely used in the treatment of T2DM, however, however, There is still controversy in the choice of patients with T2DM, especially whether the T2DM patients in BMI35kg/m2 can take the treatment of weight reduction surgery. We summarized the clinical experience of laparoscopic gastric bypass for the treatment of T2DM in recent years, and made a preliminary comparison of the clinical efficacy of three groups of different BMI patients after the parastastal bypass. Compared with the study and discussion, the difference of blood glucose control rate between the three groups was compared, and the effect of hypoglycemic effect of different BMI patients after gastric bypass surgery was explored. The clinical efficacy of "laparoscopic gastric bypass" in T2DM patients with different body mass index (BMI) was performed in 206 cases of type 2 diabetic patients undergoing "abdominal endoscopic gastric bypass" in 2010-2013 years of our department. 20 cases of 25kg/m2BMI28 kg/m2,28 kg/m2 < BMI35 kg/m2,35 kg/m2 < BMI three were selected by stratified random sampling. A total of 60 patients were used as low BMI group, middle BMI group and high BMI group respectively. The three groups were treated with the same general anesthesia "laparoscopic gastric bypass" operation. The glycated hemoglobin 7% was defined as blood sugar control. The three groups of patients had 12 months of blood glucose after 12 months. Control rate, waist circumference, hip circumference, BMI, fasting blood glucose, 2 hours postprandial blood glucose, fasting C peptide, 2 hours postprandial C peptide, fasting insulin, 2 hours postprandial insulin changes and postoperative complications. Statistical methods: comparison and analysis of blood glucose control rate in the three groups after 12 months of operation were compared with x2 test; preoperative index and operation between groups After 12 months of the index and the preoperative and postoperative index changes, using the multiple sample mean variance analysis, the preoperative and postoperative indexes compared with the paired t test.P value less than 0.05 was statistically different, the use of bilateral test. Data analysis using statistical software SPSS 13 analysis. Results low BMI group, BMI group, high BMI group blood glucose control rate respectively The blood glucose control rates of the 75%, 85%, 90% and three groups were not statistically different. The three groups of patients weight, BMI, waistline, hip circumference, fasting blood glucose, 2 hours postprandial blood glucose, 12 months after the operation were significantly improved, fasting insulin and 2 hours postprandial insulin were less than before, higher BMI group C peptide, and 2 hours postprandial C peptide was also significantly lower than before the operation, In the low BMI and middle BMI group, the two indexes were not obvious before the operation. In the high BMI group, two patients had hypoglycemia and 2 of the three groups had gastrointestinal anastomosis ulcers. Conclusion after the laparoscopic gastric bypass, the T2DM patients of BMI 28-35kg/m2 may have approximately the same clinical efficacy as BMI35kg/m2 patients, BMI 25-28kg/m2 T2D. M patients also benefit from surgery, and can achieve satisfactory clinical therapeutic effects. It is also one of the options available for clinical treatment. Three groups of T2DM patients with different BMI can obtain satisfactory clinical efficacy after laparoscopic gastric bypass surgery.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1;R656.61

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