国外糖尿病手术的发展现况.ppt

国外糖尿病手术发展现况,由减重手术到糖尿病手术以减重手术治疗糖尿病胃肠道代谢手术(Gastro-intestinalMetabolicsurgery)病人的选择,Nature2000;404,635-43,减重手术在美国已是最常见的胃肠道手术,生命不可承受之重Unbearableweightinlife,BMI与死亡率的关系,Mortalitylowestat22.5-2530%higherateach5BMIhigher40%vascular60-120%DM,renalandhepatic10%Malignancy,Lancet.2009March28;373(9669):1083-1096,JAMA1999,减重手术是严重肥胖最有效的治疗方法EffectofBariatricSurgeryonMortalityinSwedishObeseSubjects,LarsSjostrometal.NEnglJMed2007:357:741-52,减重手术对瑞典病人死亡率的影响EffectofBariatricSurgeryonMortalityinSwedishObeseSubjects,LarsSjostrometal.NEnglJMed2007:357:741-52,Unadjustedoverallmortalitywasreducedby24.6%(p=0.0346)Adjustedriskreductionwas31.6%(p=0.00083)Mortalitydifferencewasmainlyattributabletoreductionsincoronaryeventsandcancers.,胃绕道手术对长期死亡率的影响Long-termmortalityaftergastricbypasssurgery,7925surgicalvs.7925matchedcontrol,follow-up7.1yAdecreaseof40%mortality56%forcoronaryarterydisease92%fordiabetes60%forcancerAincreaseof58%ofdeathnotcausedbydisease,suchasaccidentsandsuicide,AdamsTDetal.NEJM2007;357:753-61,由减重手术到糖尿病手术以减重手术治疗糖尿病胃肠道代谢手术(Gastro-intestinalMetabolicsurgery)病人的选择,Whowouldhavethoughtit?Anoperationprovestobethemosteffectivetherapyforadult-onsetdiabetesmellitus,PoriesWJ,SwansonMS,MacDonaldKG,etal.AnnSurg1995;222:339-350,在肥胖病人，减重手术可长期根治糖尿病,BariatricSurgeryASystematicReviewandMeta-analysis,BuchwaldH.etal.JAMA2004:292:1724-1737,Conclusioneffectiveweightlosswasachievedinmorbidlyobesepatientsafterundergoingbariatricsurgery.AsubstantialmajorityofwithDiabetes,Hyperlipidemia,HypertensionandObstructivesleepapneaexperiencedcompleteresolutionorimprovement.,不同减重手术对糖尿病的治疗效果,HealthOutcomesofSeverelyObeseType2DiabeticSubjects1YearAfterLaparoscopicAdjustableGastricBanding,500besepatients(BMI48.2+8Kg/M2)withtype2diabetesRemissionofT2DMwas64%andHbA1cdecreased1.6(from7.8to6.2)Remissionofdiabetespredictedbyweightloss%anddurationofDMImprovementofDMassociatedwithincreasedinsulinresistanceandB-cellfunction,DixonJBetal.DiabetesCare2002;25:358-63,可调节式胃束带手术,胃绕道手术,R-YBypass,LeeWJetal.ObesitysurgeryresultedinsignificantandsustainedweightlosswithacurerateofT2DMupto80%inmorbidlyobeseAsianpatients.GastricbypasssurgeryhadabetterresultinT2DMcureratethanLVBGandLAGBbecauseofbetterweightreduction.,WorldJournalofSurgery2009;33:1895-1903,EffectsofObesitySurgeryonType2DiabetesMellitusAsianPatients,胆胰绕道手术十二指肠转位,312patientsBMI50.132.0at10years.Diabetesresolution98%.,胃缩小手术(袖状切除)LaparoscopicSleeveGastrectomy,StageoperationforduodenalswitchinhighriskpatientProposedoperationformoderateobesepatientsTheholeofghrelinreductionLong-termefficacy,由减重手术到糖尿病手术以减重手术治疗糖尿病胃肠道代谢手术(Gastro-intestinalMetabolicsurgery)病人的选择,胃肠道手术会带来肠道激素的巨大改变,Byalteringthegutsproductionofhormones,gastricbypasssurgerymaybeabletoeliminatetype2diabetes.Butscientistsworrythatthisradicaloperationcanalsocausedangerouslylowbloodsugar.,25APRIL2008VOL320SCIENCE,Nature444,854-859(14December2006),AdjustableGastricBandingandConventionalTherapyforType2Diabetes,600besepatients(BMI30and351.85%BMI30-358.58%BMI27-3016.87%,2555cases,影响糖尿病人手术效果的原因,OlderpeopleAlongerhistoryofT2DMSeveredisease,highdoseofinsulinusagePoorlycontrolDMmayacceleratesB-cellfailureBariatricsurgicalprocedureshouldbeperformedbeforeirreversibleB-cellfailure,DixonJB,etal.Surgeryasaneffectiveearlyinterventionfordiabesity.DiabetesCare2005:28:472-4,LeeWJetal.JGastrointstSurg2008;12:945-52,LaparoscopicminigastricbypassresultedinsignificantandsustainedweightlosswithsuccessfultreatmentofT2DMupto87.1%in201patients.PatientswithBMI35hadaslightlylowerresponserateof78%thanthe93%inpatientswithBMI45onT2DMtreatment.,在低BMI的病人，手术效果会较差,预测糖尿病手术效果的指针,亚太减重手术的共识ConsensusinAsia-Pacific,2005APBSGconsensusmeetingmodifiedtheindicationsforbariatricsurgeryforAsianpeopleto:ObesepatientswiththeirBMI37ObesepatientswiththeirBMI32inthepresenceofdiabetesortwosignificantobesityrelatedco-morbidities.Havebeenunabletoloseormaintainweightlossbydietaryormedicalmeasures.Ageofpatient18yearsand=30kg/m2withtypeIIdiabetesmellitusResearchbase:MetabolicsurgeryforpatientswithBMI37ObesepatientswiththeirBMI32inthepresenceofco-morbidities.DiabeticpatientswiththeirBMI3