本文選題：肥胖癥　切入點(diǎn)：腹腔鏡　出處：《天津醫(yī)科大學(xué)》2015年碩士論文　論文類(lèi)型：學(xué)位論文

【摘要】：背景:隨著公眾生活水平的提高,肥胖癥以及與其相關(guān)的2型糖尿病已經(jīng)在全世界流行開(kāi)來(lái),大量的臨床研究證實(shí),傳統(tǒng)的2型糖尿病的治療很難達(dá)到有效且持久的減重效果和緩解2型糖尿病的目的。外科領(lǐng)域方面,Pories[1]最先發(fā)表了關(guān)于手術(shù)治療肥胖癥合并T2DM的病例報(bào)道,他們對(duì)病態(tài)肥胖的患者行“Y”形胃旁路術(shù)(RYGB),術(shù)后的結(jié)果令人驚喜,所有患者不僅體重下降,而且還意外的發(fā)現(xiàn)部分合并T2DM的病態(tài)肥胖患者中的大部分糖尿病臨床癥狀完全緩解[2]。近年來(lái)減重手術(shù)治療T2DM在全世界流行大熱,而隨著腹腔鏡技術(shù)的成熟所確立的優(yōu)勢(shì)地位,微創(chuàng)手術(shù)治療肥胖合并T2DM成為了趨勢(shì)。近年來(lái)我國(guó)開(kāi)展較多的主要是腹腔鏡胃旁路術(shù)(laparoscopic Roux-en-Y gastric bypass,LRYGB)和腹腔鏡袖狀胃切除術(shù)(laparoscopic Sleeve Gastrectomy,LSG)。其原理可分概括為①限制食物的攝入量,②減少營(yíng)養(yǎng)物質(zhì)的吸收,③通過(guò)改變胃腸道生理結(jié)構(gòu)來(lái)影響腸道內(nèi)激素。但具體作用機(jī)制尚無(wú)明確定論。此外,不同術(shù)式術(shù)后的減重效果、術(shù)后對(duì)于2型糖尿病的療效分析、不同術(shù)式手術(shù)操作的難易程度、術(shù)后并發(fā)癥的發(fā)生率等方面也存在不同,如何為肥胖癥合并2型糖尿病患者選擇合適且個(gè)體化的治療方案也需更多的臨床依據(jù)。目的:分別觀察行LRYGB以及LSG的肥胖癥合并2型糖尿病患者手術(shù)前后糖代謝、脂代謝指標(biāo)、體重及營(yíng)養(yǎng)變化情況、胰島素功能及胰島抵抗變化、T2DM的治療效果來(lái)對(duì)比2種手術(shù)方式安全性以及療效,探討2種術(shù)式治療T2DM的可能機(jī)制,為不同的肥胖合并T2DM的患者選擇合適的臨床術(shù)式提供醫(yī)學(xué)依據(jù)。方法:回顧性分析2011年2月至2012年5月在天津中西醫(yī)結(jié)合醫(yī)院66例患有肥胖癥合并2型糖尿病患者的資料,按照手術(shù)方式分為:LRYGB組(40例)和LSG組(26例)。術(shù)后隨訪至少24個(gè)月,記錄分析手術(shù)前后患者的糖脂代謝指標(biāo)(空腹血糖、餐后2小時(shí)血糖、空腹C肽、Hb A1C、總膽固醇、三酰甘油)、體重及營(yíng)養(yǎng)變化情況(BMI、腰圍、EWL%、血紅蛋白、總蛋白、白蛋白)、胰島素功能及胰島抵抗變化(Homa-IR、Homa-β)、2型糖尿病的治療效果,對(duì)比以上2種腹腔鏡術(shù)式的操作時(shí)間、術(shù)后住院天數(shù)、術(shù)后并發(fā)癥的發(fā)生率來(lái)評(píng)估2種術(shù)式的安全性。數(shù)據(jù)均以平均數(shù)±標(biāo)準(zhǔn)差來(lái)表示。采用SPSS 17.0統(tǒng)計(jì)軟件統(tǒng)計(jì)分析。結(jié)果:手術(shù)完成情況:66例患者均由同一團(tuán)隊(duì)在腹腔鏡下成功完成手術(shù),無(wú)中轉(zhuǎn)開(kāi)腹以及死亡病例,所有患者均完成24個(gè)月的術(shù)后隨訪。2組手術(shù)時(shí)間差異有統(tǒng)計(jì)學(xué)意義(P0.05),LRYGB和LSG組手術(shù)時(shí)間分別為(150.3±23)min和(127.6±34.3)min;2組術(shù)中出血量差異有統(tǒng)計(jì)學(xué)意義(P0.05),LRYGB組和LSG組術(shù)中出血量分別為(46.6±9.2)ml和(32.6±8.6)ml;2組術(shù)后排氣時(shí)間組間差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),LRYGB組和LSG組分別為(1.47±0.27)天和(1.27±0.21)天;2組術(shù)后住院天數(shù)組間差異有統(tǒng)計(jì)學(xué)意義(P0.05),LRYGB組和LSG組分別為(4.7±1.4)天和(3.7±1.3)天。在術(shù)后24個(gè)月內(nèi)LRYGB組出現(xiàn)術(shù)后并發(fā)癥6例而LSG組為4例。術(shù)后并發(fā)癥總的發(fā)生率組間差異無(wú)統(tǒng)計(jì)學(xué)意義(χ2=0.742,P=0.867)。脂代謝改善情況:糖代謝:與術(shù)前相比,LRYGB組和LSG組空腹血糖、餐后2 h血糖、Hb A1c在術(shù)后1、3個(gè)月均有明顯下降(P0.01),術(shù)后6、12、18個(gè)月下降平穩(wěn)(P0.05),而組間比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05);脂代謝:兩組病人術(shù)后血脂水平均較術(shù)前明顯降低(P0.05);LRYGB組和LSG組在術(shù)后1、3、6、12個(gè)月平穩(wěn)下降,其余時(shí)間組間差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。體重及營(yíng)養(yǎng)變化情況:與術(shù)前相比,LRYGB組和LSG組在術(shù)后1、3、6、12個(gè)月BMI有明顯降低(P0.05)、術(shù)后12個(gè)月后至24個(gè)月,患者BMI趨于穩(wěn)定,差異無(wú)統(tǒng)計(jì)學(xué)意義。而總蛋白和白蛋白水平變化不明顯,僅總蛋白在術(shù)后6個(gè)月時(shí)與術(shù)前相比差異有統(tǒng)計(jì)學(xué)意義(P0.05),但仍在正常參考值范圍內(nèi);術(shù)后1個(gè)月至6個(gè)月,兩組病人血紅蛋白水平較術(shù)前均降低(P0.05),6個(gè)月后血紅蛋白水平趨于穩(wěn)定,正常參考值范圍,未出現(xiàn)明顯貧血。胰島素抵抗及胰島功能變化情況:LRYGB組和LSG組術(shù)后的胰島素抵抗(Homa-IR)均較術(shù)前明顯改善(P0.05)。LRYGB組術(shù)后1個(gè)月時(shí)胰島功能(Homa-β)即較術(shù)前明顯改善(P0.05),而LSG組改善不明顯(P0.05);在術(shù)后6、12、18、24個(gè)月LSG組與術(shù)前相比明顯改善(P0.05),而與LRYGB組組間相比差異有統(tǒng)計(jì)學(xué)意義(P0.05)。⑤2型糖尿病治療效果:LRYGB組40例患者,術(shù)后24個(gè)月,完全緩解27例(67.5%),部分緩解7例(17.5%),臨床改善6例(15%),40例治療全部有效。34例(85%)停用胰島素或降糖藥,6例(15%)口服降糖藥且均停用胰島素,其中5例(12.5%)口服藥物減半,1例(2.5%)僅口服阿卡波糖。40例患者均無(wú)復(fù)發(fā),至術(shù)后24個(gè)月時(shí)治療效果仍保持穩(wěn)定;LSG組17例患者術(shù)后24個(gè)月時(shí)完全緩解(65.4%),4例部分緩解(15.4%),5例患者停用胰島素且口服藥物減半(19.2%),而有效率亦為100%,術(shù)后2年時(shí)仍保持穩(wěn)定。采用Fisher確切概率法比較兩組病人術(shù)后2型糖尿病緩解率,二者差異無(wú)統(tǒng)計(jì)學(xué)意義(P=1.0000.05)。結(jié)論:①LRYGB和LSG是兩種有效的治療肥胖合并2型糖尿病的術(shù)式,對(duì)2型糖尿病有較高的緩解率。②LRYGB對(duì)于治療肥胖合并糖尿病的治療效果可能要優(yōu)于LSG,尤其是2型糖尿病病史時(shí)間長(zhǎng)、使用降糖藥量、用藥比率高的患者。但LSG相對(duì)簡(jiǎn)單,不改變胃腸道生理狀態(tài),安全性較高。③LSG更適用于以肥胖癥狀為主、糖尿病較輕、年齡較小、術(shù)前胰島功能受損較輕的病人。同時(shí),如果LSG術(shù)后效果不佳,須改行LRYGB或膽胰轉(zhuǎn)流術(shù)(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 娌葷枟鏁堟灉,瀵規(guī)瘮浠ヤ笂2縐嶈吂鑵旈暅鏈紡鐨勬搷浣滄椂闂，

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