本文選題：2型糖尿病 + 袖狀胃切除術(shù)��； 參考：《第二軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：我國(guó)20歲以上的人群糖尿病總體患病率為9.7%,患病總數(shù)高達(dá)9240萬(wàn),位居世界第一,其中 2 型糖尿病(Type2diabeticmellitus,T2DM)占 90%。T2DM 作為一種傳統(tǒng)的內(nèi)科疾病,近年來(lái)最引入注目的治療進(jìn)展就是納入了外科手術(shù),美國(guó)糖尿病協(xié)會(huì)達(dá)成共識(shí),將胃旁路手術(shù)(Roux-en-Y gastric bypass, RYGB)作為T(mén)2DM的治療選擇之一。袖狀胃切除術(shù)(sleeve gastrectomy, SG)作為一種新型獨(dú)立的減重手術(shù),因其手術(shù)難度低,并發(fā)癥少,在世界范圍內(nèi)得到了越來(lái)越多的應(yīng)用。然而隨著SG數(shù)量的增加,越來(lái)越多的外科醫(yī)生關(guān)注SG的視角由減重轉(zhuǎn)向其作為“代謝手術(shù)”的效果并對(duì)比其與“金標(biāo)準(zhǔn)”的RYGB在緩解T2DM療效的差異,SG的效果并不完美。因此越來(lái)越多的外科醫(yī)生選在一期手術(shù)時(shí)即對(duì)SG附加旁路成分。單吻合口袖狀胃切除結(jié)合十二指腸-空腸旁路手術(shù)(Single-Anastomosis Duodenal-Jejunal Bypass with Sleeve Gastrectomy,SADJB-SG )在 2013 年首次由亞洲的外科醫(yī)生所提出,SADJB-SG在短期的隨訪(fǎng)中,減重和緩解糖尿病的效果穩(wěn)定,并且具有以下優(yōu)點(diǎn):(1)與RYGB相比,SADJB-SG避免了殘胃癌的發(fā)生。(2) SADJB-SG可以認(rèn)為是一種簡(jiǎn)化了的膽胰分流/十二指腸轉(zhuǎn)位(biliopancreatic diversion with duodenal switch, BPD/DS),同時(shí)兼顧了袖狀胃切除的優(yōu)勢(shì)和“前腸理論”和“后腸理論”。(3)RYGB和BPD/DS的不過(guò)術(shù)式均有兩個(gè)吻合口,而SADJB-SG在保證基本原理不便的情況下減少了一個(gè)吻合口,這對(duì)手術(shù)操作難度、術(shù)后恢復(fù)以及并發(fā)癥的發(fā)生均有提高。本研究擬建立一個(gè)安全可靠的SADJB-SG大鼠模型,并且在次模型的基礎(chǔ)上進(jìn)一步觀(guān)察其減重及緩解T2DM的效果,初步探索SADJB-SG術(shù)后ghrelin和GLP-1等胃腸道激素的變化。第一部分單吻合口袖狀胃切除聯(lián)合十二指腸空腸旁路術(shù)在肥胖型T2DM大鼠模型中的建立研究目的在SG大鼠模型的基礎(chǔ)上建立一個(gè)安全可靠的SADJB-SG大鼠模型,并且選擇屈氏韌帶下l0cm、20cm和30cm處行十二指腸空腸吻合。材料和方法100只6周齡清潔級(jí)Sqrague-Dawley大鼠(SD大鼠),體重150-180g,平均體質(zhì)量173.66±13.73g,隨機(jī)分為普通飼料組20只(NF組),平均體質(zhì)量174.98±14.36g,高脂高糖飼料組80只(HF組),平均體質(zhì)量173.33±13.164g,兩組無(wú)統(tǒng)計(jì)學(xué)差異(p0.05)。所有大鼠飼養(yǎng)8周,HF組中體重大于NF組體重20%者定義為肥胖大鼠,最終HF組共70只達(dá)到體質(zhì)量要求。達(dá)到體質(zhì)量要求的HF組大鼠經(jīng)腹腔一次性注射鏈脲佐菌素溶液(STZ) 45mg/kg,注射3天后經(jīng)尾靜脈測(cè)定血糖,連續(xù)三天內(nèi)平均血糖大于16.70mmol/L者為造模成功者,最終共61只大鼠達(dá)到模型要求,造模成功率76.25%。排除手術(shù)死亡大鼠后共分為以下5組:空白對(duì)照組(SO組)10只,SG組10只,SADJB-SG組30只,后根據(jù)十二指腸的吻合位置又分為SA10組(吻合口位于屈氏韌帶下10cm) 10只,SA20組10只,SA30組l0只。結(jié)果SG組大鼠共行手術(shù)12只,死亡2只,存活率為83.33%。SADJB-SG手術(shù)大鼠39只,死亡9只大鼠,手術(shù)存活率為76.92%。SG組、SA10組、SA20組和SA30組的手術(shù)時(shí)間分為別52.4±5.44分鐘,69.2±5.41分鐘,68.7±5.74分鐘和68.2±5.55分鐘,SG組的手術(shù)時(shí)間小于SADJB-SG各組的手術(shù)時(shí)間,具有統(tǒng)計(jì)學(xué)意義(p 0.05)。結(jié)論本研究成功建立了肥胖型T2DM大鼠模型和SADJB-SG大鼠模型,并且可以在次基礎(chǔ)上進(jìn)一步研究相關(guān)術(shù)式緩解肥胖和T2DM的效果。第二部分單吻合口袖狀胃切除聯(lián)合十二指腸空腸旁路術(shù)緩解肥胖型2型糖尿病大鼠的研究研究目的探索SADJB-SG緩解肥胖型T2DM大鼠的效果。材料和方法6周齡清潔級(jí)Sqrague-Dawley大鼠(SD大鼠),經(jīng)過(guò)高脂高糖飼料喂養(yǎng)8周+一次性腹腔注射STZ溶液(45mg/kg)誘導(dǎo)為T(mén)2DM大鼠后共分為以下5組:空白對(duì)照組(S0組)10只,SG組10只,SADJB-SG組30只,后根據(jù)十二指腸的吻合位置又分為SA10組(吻合口位于屈氏韌帶下10cm) 10只,SA20組10只,SA30組10只。通過(guò)OGTT檢測(cè)大鼠空腹及餐后血糖和胰島素,判斷糖尿病緩解情況。通過(guò)高葡萄糖鉗夾技術(shù)和正葡萄糖高胰島素鉗夾技術(shù)判斷大鼠胰島β細(xì)胞的功能和胰島素敏感性。結(jié)果SG和SADJB-SG均可有效降低大鼠的空腹血糖和空腹胰島素,以及OGTT血糖和胰島素的曲線(xiàn)下面積。兩者均可有效增加大鼠第一時(shí)相胰島素分泌和第二時(shí)相胰島素分泌,增加葡萄糖輸注率,胰島素敏感性指數(shù)明顯增加,但SG和SADJB-SG之間差異不大。結(jié)論SG和SADJB-SG都可以顯著降低T2DM大鼠的空腹血糖和空腹胰島素水平,降低血糖和胰島素的曲線(xiàn)下面積,改善胰島素抵抗和胰島素敏感性,增加第一時(shí)相和第二時(shí)相的胰島素分泌。第三部分單吻合口袖狀胃切除聯(lián)合十二指腸空腸旁路術(shù)緩解肥胖和2型糖尿病機(jī)制的研究研究目的通過(guò)檢測(cè)SADJB-SG術(shù)后血清ghrelin和GLP-1的變化,研究SADJB-SG緩解肥胖型T2DM可能的機(jī)制。材料和方法6周齡清潔級(jí)Sqrague-Dawley大鼠(SD大鼠),經(jīng)過(guò)高脂高糖飼料喂養(yǎng)8周+一次性腹腔注射STZ溶液(45mg/kg)誘導(dǎo)為T(mén)2DM大鼠后共分為以下5組:空白對(duì)照組(SO組)10只,SG組10只,SADJB-SG組30只,后根據(jù)十二指腸的吻合位置又分為SA10組(吻合口位于屈氏韌帶下10cm) 10只,SA20組10只,SA30組10只。在實(shí)驗(yàn)第一天(大鼠6周齡)、術(shù)前3天和術(shù)后8周檢測(cè)空腹血清total ghrelin (TG)和Acylated ghrelin (AG),在術(shù)前3天和術(shù)后8周檢測(cè)空腹、灌胃30分鐘、60分鐘和90分鐘的血清GLP-1值。結(jié)果肥胖大鼠具有更低的血清TG值,但AG不變,AG/TG增高,SG和SADJB-SG可以進(jìn)一步降低血清TG值,AG仍不變,AG/TG進(jìn)一步增高。SADJB-SG可增加空腹和灌胃后的GLP-1濃度,尤其是灌胃后30分鐘,SA30組具有最高的30分鐘GLP-1濃度。結(jié)論SG和SADJB-SG均可以有效降低大鼠血清空腹TG濃度,但并不改變AG濃度,而AG/TG的比例進(jìn)一步增高。SADJB-SG可以增加血清空腹GLP-1濃度,SG和SADJB-SG都可以明顯增高灌胃30分鐘后的GLP-1濃度,但后者增加幅度更大,且隨著吻合口位置的增加,SADJB-SG對(duì)GLP-1的影響更大。
[Abstract]:The overall prevalence rate of diabetes in the population over 20 years old is 9.7%, the total number of diseases is 92 million 400 thousand and the world is the first. Among them, type 2 diabetes mellitus (Type2diabeticmellitus, T2DM) accounts for 90%.T2DM as a traditional medical disease. In recent years, the most notable progress of treatment is surgery. The American Diabetes Association has reached consensus. Roux-en-Y gastric bypass (RYGB) is one of the options for the treatment of T2DM. Sleeve gastrectomy (sleeve gastrectomy, SG), as a new type of independent weight reduction operation, has been used more and more in the world because of its low difficulty and less complications. However, as the number of SG increases, more and more out of the world. Doctors are concerned about the SG perspective from weight reduction to its effect as "metabolic surgery" and to compare its differences with the "gold standard" RYGB in alleviating T2DM efficacy. The effect of SG is not perfect. Therefore, more and more surgeons choose to add the accessory pathway to SG during the first phase of the operation. Single-Anastomosis Duodenal-Jejunal Bypass with Sleeve Gastrectomy, SADJB-SG) was first proposed by Asian surgeons in 2013. SADJB-SG has a stable effect on reducing and alleviating diabetes during short-term follow-up, and has the following advantages: (1) SADJB-SG avoids the occurrence of gastric stump cancer compared with RYGB. (2) SA DJB-SG can be considered a simplified biliary pancreatic shunt / duodenal transposition (biliopancreatic diversion with duodenal switch, BPD/DS), with both the advantages of sleeve gastrectomy and the "foregut theory" and "posterior gut theory". (3) there are two anastomotic stoma in RYGB and BPD/DS, while SADJB-SG ensures the basic principle. The difficulty of operation, postoperative recovery and complications were improved. A safe and reliable SADJB-SG rat model was established in this study. On the basis of the secondary model, the weight reduction and relieving effect of T2DM were further observed, and ghrelin and GLP-1 stomach after SADJB-SG were preliminarily explored. Changes in intestinal hormone. The first part of the single anastomotic sleeve gastrectomy combined with duodenal jejunostomy in the obese T2DM rat model, a safe and reliable SADJB-SG rat model was established on the basis of the SG rat model, and the duodenal jejunostomy was selected under the SG ligamentum ligamentum ligamentum, 20cm and 30cm. Materials and methods 100 6 week old clean Sqrague-Dawley rats (SD rats), weight 150-180g, average body mass of 173.66 + 13.73g, were randomly divided into 20 (NF) group of ordinary feed group (group NF), the average body mass was 174.98 + 14.36g, high fat high sugar diet group 80 (HF group), the average body mass was 173.33 + 13.164g, two groups had no statistical difference (P0.05). All rats were fed 8. The body weight of group HF in group HF was more than that of group NF, and the weight of group NF was defined as obese rats. In the final HF group, a total of 70 had body mass requirements. The group of rats reached the body mass requirement by intraperitoneal injection of streptozotocin solution (STZ) 45mg/kg, and 3 days after the injection, the blood glucose was measured by the tail vein, and the average blood sugar was greater than 16.70mmol/L within three days for the successful model success. A total of 61 rats reached the model requirements, and the success rate of the model was divided into 5 groups: 10 in the blank control group (group SO), 10 in group SG and 30 in group SADJB-SG, and then in SA10 group (10cm of the anastomotic mouth under the flexor ligament) according to the duodenal anastomosis position, 10 in SA20 group and l0 in SA30 group. The result SG was SG. In the group of rats, 12 rats were operated and 2 died. The survival rate was 39 83.33%.SADJB-SG rats, 9 rats died and the survival rate was 76.92%.SG. The operation time of group SA10, group SA20 and SA30 group was divided into 52.4 + 5.44 minutes, 69.2 + 5.41 minutes, 68.7 + 5.74 minutes and 68.2 + 5.55 minutes. The operation time of group SG was less than the operation of SADJB-SG groups. Time was statistically significant (P 0.05). Conclusion the obese T2DM rat model and SADJB-SG rat model were successfully established in this study, and the effect of related surgical treatment on obesity and T2DM could be further studied on the basis of this study. The second partial anastomotic sleeve gastrectomy combined with twelve finger jejunum bypass to alleviate Obesity Type 2 diabetes mellitus. The purpose of the study was to explore the effect of SADJB-SG on the release of obese T2DM rats. Materials and methods 6 weeks old clean Sqrague-Dawley rats (SD rats) were divided into 5 groups after 8 weeks of high fat and high glucose feed and STZ solution induced by intraperitoneal injection of STZ (45mg/kg) were divided into the following 5 groups: the blank control group (S0 group), and the SG group 10, SADJB-. Group SG 30, then according to the location of duodenal anastomosis, divided into group SA10 (10cm under the flexor ligamentum ligamentum), 10 in group SA20 and 10 in group SA30, to determine diabetic remission by OGTT test of fasting and postprandial blood glucose and insulin in rats. The rats were judged by hyperdextrose clamp technique and glucose high insulin clamp technique. The function of islet beta cells and insulin sensitivity. Results SG and SADJB-SG can effectively reduce the fasting blood glucose and fasting insulin in rats, as well as the area under the curve of OGTT blood glucose and insulin. Both can effectively increase the first phase insulin secretion and the second phase insulin secretion, increase the glucose infusion rate and insulin sensitivity. The sex index increased significantly, but there was little difference between SG and SADJB-SG. Conclusion both SG and SADJB-SG can significantly reduce the level of fasting blood glucose and fasting insulin in T2DM rats, reduce the area under the curve of blood glucose and insulin, improve insulin resistance and insulin sensitivity, and increase the insulin secretion in the first and second phase. The third part is increased. Study on the mechanism of obesity and type 2 diabetes by single anastomotic sleeve gastrectomy combined with duodenal jejunostomy in order to study the possible mechanism of SADJB-SG in alleviating obesity type T2DM by detecting the changes of serum ghrelin and GLP-1 after SADJB-SG. Materials and methods of high fat and high lipid level in clean grade Sqrague-Dawley rats (SD rats) at the age of 6 weeks 8 weeks and one-off intraperitoneal injection of STZ solution (45mg/kg) induced by sugar feed were divided into 5 groups: blank control group (group SO) 10, SG group 10 and SADJB-SG group 30, and then the duodenum anastomosis position was divided into SA10 group (the anastomotic mouth under the flexor ligament 10cm) 10, SA20 group 10, and SA30 group 10. In the first day of the experiment ( Total ghrelin (TG) and Acylated ghrelin (AG) of fasting serum were detected at 3 days before and 8 weeks after operation. The serum GLP-1 values were detected at 3 days before and 8 weeks after operation. The serum GLP-1 value was 30 minutes, 60 and 90 minutes. The results showed that the obese rats had lower serum TG value, but AG remained unchanged, AG/TG increased, SG and SADJB-SG could further reduce serum levels. The value of TG and AG remained unchanged, and the further increase of AG/TG in.SADJB-SG could increase the GLP-1 concentration in the fasting and after gavage, especially in the 30 minute after gavage, and the SA30 group had the highest GLP-1 concentration in 30 minutes. Conclusion SG and SADJB-SG could effectively reduce the concentration of TG in the fasting serum of rats, but did not change the AG concentration, but the proportion of AG/TG was increased. Adding serum fasting GLP-1 concentration, both SG and SADJB-SG could significantly increase the concentration of GLP-1 after 30 minutes of gastric perfusion, but the latter increased significantly, and with the increase of the location of the anastomosis, SADJB-SG had a greater impact on GLP-1.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R587.1;R-332;R656.6

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7 張馳;胡祥;;腹腔鏡下行保留幽門(mén)及迷走神經(jīng)胃切除術(shù)治療早期胃癌[A];第9屆全國(guó)胃癌學(xué)術(shù)會(huì)議暨第二屆陽(yáng)光長(zhǎng)城腫瘤學(xué)術(shù)會(huì)議論文匯編[C];2014年

8 林祖朝;董米連;王敏;;胃切除術(shù)并發(fā)急性胰腺炎13例分析[A];2005年浙江省外科學(xué)術(shù)會(huì)議論文匯編[C];2005年

9 王春榮;;胃切除圍手術(shù)期中西醫(yī)結(jié)合處理——附2001例報(bào)告[A];全國(guó)中西醫(yī)結(jié)合圍手術(shù)期研究新進(jìn)展學(xué)習(xí)班暨第三屆全國(guó)中西醫(yī)結(jié)合圍手術(shù)期醫(yī)學(xué)專(zhuān)題研討會(huì)論文集[C];2008年

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8 健康時(shí)報(bào)記者　 鄭帆影;胃切除后還會(huì)得胃癌嗎？[N];健康時(shí)報(bào);2006年

9 李蔭廷;胃切除術(shù)后綜合征[N];廣東科技報(bào);2000年

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