修回日期: 2010-06-29
接受日期: 2010-07-12
在线出版日期: 2010-08-18
随着社会发展和生活方式的转变, 肥胖症和2型糖尿病以及由此发展而来的代谢综合征, 成为一类威胁人类健康的重要疾病. 因传统的非手术治疗收效甚微, 既往此类疾病被认为无法治愈. 但是现在手术治疗效果显著, 形成了标准的治疗方式, 使此类疾病的治疗方式发生革命性的转变. 本文就手术治疗肥胖症和2型糖尿病的现状和机制进行综述, 并对从开放手术、腹腔镜手术到内镜手术的发展过程进行回顾和展望.
引文著录: 付唆林, 朱惠明. 手术治疗肥胖症和2型糖尿病的现状分析及前景展望. 世界华人消化杂志 2010; 18(23): 2453-2459
Revised: June 29, 2010
Accepted: July 12, 2010
Published online: August 18, 2010
Along with social progress and life style transformation, morbid obesity, type 2 diabetes mellitus, and metabolic syndrome are increasingly becoming a great threat to human health. Because conventional conservative treatment has little effect on these diseases, they were considered incurable before. However, surgery shows good results in the treatment of these diseases and has therefore revolutionized their treatment. This review aims to elucidate the therapeutic mechanisms of surgery for morbid obesity and 2 diabetes mellitus and to discuss the current situation and future prospects of surgical treatment of these diseases.
- Citation: Fu SL, Zhu HM. Surgical treatment of morbid obesity and type 2 diabetes mellitus: current situation and future prospects. Shijie Huaren Xiaohua Zazhi 2010; 18(23): 2453-2459
- URL: https://www.wjgnet.com/1009-3079/full/v18/i23/2453.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v18.i23.2453
当人体质量增加到一定程度, 容易并发糖尿病、高血压、高脂血症、冠心病等一系列疾病, 称为肥胖症(obesity)或病态肥胖(morbid obesity). 判断肥胖程度的常用指标是体质量指数(body mass index, BMI). 因为人种、文化和环境等的差异, 世界各地诊断肥胖症的标准不尽一致[1,2], 但出现并发症被视为核心要素. 国人的BMI≥28时, 检出高血压、糖尿病、冠心病的危险因素的特异度就高达90%以上[3,4]. 现代社会肥胖症正在成为全球流行的疾病. 我国肥胖症发病率也在逐年上升, 2005年的研究显示我国超重和肥胖者共2.8亿人, 肥胖者6 844万人[5]. 肥胖症给患者造成的危害显而易见, 除了引发失业、离婚、自卑, 甚至自杀等许多社会和心理问题外, 其本身并发的糖尿病、高血压、脂肪肝、胆石症、脑梗、心血管疾病、阻塞性睡眠呼吸暂停综合征等一系列疾病, 常常给患者造成致命危害. 世界卫生组织已将肥胖列为影响健康的第5大危险因素. 有研究显示, 与肥胖症相关的疾病负担占到总体医疗费用的3%-6%[6], 肥胖引起的后果比吸烟和酗酒更严重[7], 而重度肥胖症患者的实际寿命可能比预期寿命少20年[8]. 肥胖症和糖尿病密切相关, 是2型糖尿病(type 2 diabetes mellitus, T2DM)患者中最常见的危险因素[9]. 约90%的T2DM是肥胖症或体质量超重者, 研究显示肥胖症患者比正常体质量者发展为糖尿病的风险增加10倍[10]. T2DM发病的核心机制是胰岛素抵抗(insulin resistance, IR). 2004年Wild等[11]研究提示, 全球有糖尿病患者约1.7亿人, 到2030年预计将达到3.66亿, 其中85%-90%为T2DM. 糖尿病正日益成为威胁人类健康的重大疾病. 长期血糖控制不佳者, 可伴发各种器官, 尤其是眼、心、血管、肾、神经等损害, 病情严重或应激时可发生酮症酸中毒和高渗性昏迷等急性并发症, 导致残废或者早亡. 而肥胖症和T2DM发展到一定阶段便可出现代谢综合征(metabolic syndrome, MS)[10]. MS是指在个体中多种代谢异常情况集结存在的现象[9], 是一组代谢紊乱性疾病的总称, 以中心性肥胖、IR、高血压、高三酰甘油血症、高密度脂蛋白胆固醇降低、糖耐量下降或T2DM为主要表现的症候群. 其中肥胖症和T2DM可能是MS的始动和中心环节, 而IR是MS各种代谢异常集结出现的共同发病机制. MS患者常具有多重心血管危险因素, 是心血管疾病的高危人群[12,13]. MS患病率像肥胖症和糖尿病一样逐年上升, 美国的资料显示MS已累及24%的成人[14,15]. 而中国成人(35-74岁)男性MS发病率为9.8%, 女性为17.8%[16]. 可以认为肥胖症-T2DM-MS-心脑血管疾病是目前和未来除恶性肿瘤外最危害人类健康的问题, 世界许多学者和机构都呼吁予以重视, 及早预防和干预.
肥胖症和T2DM传统的治疗方法包括饮食控制、体力锻炼、药物治疗, 如药物减肥、口服降糖药或注射胰岛素等, 由于难以坚持, 或造成生活质量下降, 如节食引起饥饿感等, 效果不佳, 极易反弹, 或血糖无法完全控制正常, 都不可避免进一步加重或发展成MS. 特别是T2DM在以往由于要终身治疗, 被认为是一种不可治愈的疾病.
1.2.1 历史: 手术治疗肥胖症和T2DM开始于20世纪50-60年代, Kremen等[17]1954年首先报道了空回肠旁路手术, 迄今已有半个多世纪. 减肥手术(bariatric surgery)发展至今已开发出数十种术式, 根据作用机制可分成3大类: 限制摄入型、减少吸收型和联合型手术. 限制摄入型作用机制为缩减胃容积, 减少进食量, 主要有胃垂直绑扎成形术(vertical banded gastroplasty, VBG)[18]、可调节胃束带术(adjustable gastric banding, AGB)[19]和胃袖状切除术(sleeve gastrotomy, SG)[20]等. 减少吸收型作用机制为将胃流出道改道缩短, 减少十二指肠和上段空肠的吸收面积, 主要有可控空回肠旁路术(controlled jejunocolic bypass)[21]、胆胰转流术(biliopancreatic diversion, BPD)[22]和改良的胆胰转流十二指肠转位术(biliopancreatic diversion with duodenal switch, BPD-DS)[23]等. 联合型即联合进行胃减容和转流的术式, 主要有胃旁路术(gastric bypass, GP)[24]和改良的Roux-en-Y胃旁路术(Roux-en-Y gastric bypass, RYGB)[25]等. BPD-DS一般都联合了SG, 也可归为联合型手术. 许多术式因为减质量效果较差或不良反应严重, 逐渐被淘汰. 最早减肥手术都是开腹手术, 自从腹腔镜外科发展起来后, 大部分减肥手术都转为腹腔镜操作, 实现了微创化的转变. 如Wittgrove等[26]1994年就开展了腹腔镜RYGB.
1.2.2 疗效: 虽然各种术式效果不一, 综合多数研究报道, 均显示减肥手术可显著减轻患者的超重体质量. 如van Gemer等[27]报道21例VBG患者多余体质量可减少50%-60%, 显著改善生活质量, 并可延长寿命, 而且费用较低. Fielding等[28]认为AGB减质量效果较慢, 但腹腔镜可调节胃束带术(laparoscopic adjustable gastric banding, LAGB)安全易行, 可取除回复, 并报道一组41例青少年LABG患者随访发现减质量达到70%并保持了5年[29]. Arias等[30]报道腹腔镜胃袖状切除术(laparoscopic sleeve gastrotomy, LSG)术后两年平均减质量达67.9%. SG常作为联合BPD-DS和RYGB治疗极度肥胖患者的一期手术[20], 但研究显示SG单独应用减质量效果也很明显[31]. BPD的效果似乎更好, Scopinaro等[22]报道1976年以来1 968例BPD患者随访18年, 减质量持续到达70%以上. Marceau等[23]发现联合SG的BPD-DS的效果还要优于远端胃切除的BPD, 且手术风险及并发症均较老式BPD少. 此类术式虽然效果明显, 但创伤大, 操作复杂, 死亡率高, 术后并发症多见, 且腹腔镜下操作难度更大, 因而较少应用. GB因为反流、吻合口溃疡等并发症基本上被RYGB取代. Higa等[32]则报道腹腔镜RYGB术后两年可减质量69%, 3年仍达62%. Weinel等[33]认为RYGB的减质量效果与Roux臂的长短有关. 最近的一项研究比较了腹腔镜RYGB(laparoscopic Roux-en-Y gastric bypass, LRYGB)和腹腔镜BPD-DS(laparoscopic biliopancreatic diversion with duodenal switch, LDS)两种方法, 结果LRYGB手术时间为91 min而LDS是206 min(P<0.001), 1例LDS转成开放手术; 早期并发症LRYGB 4例, LDS为7例(P = 0.327); 住院天数LRYGB为2 d而LDS是4 d(P<0.001); 远期并发症分别是4例和9例(P = 0.121); 但术后1年的减质量效果则是LDS优于LRYGB(74.8% vs 54.4%, P<0.001)[34].
1.2.3 减肥手术治疗T2DM和MS: 很早人们就发现了减肥手术除减质量外在代谢方面的作用[21]. 后来许多研究显示减肥手术治疗T2DM的惊人效果. 1992年Pories等[35]首次报道515例行RYGB的肥胖患者中, 发现288例伴T2DM或糖耐量损害(impaired glucose tolerance, IGT)术后仅30例(5.8%)仍有糖尿病, 后来又报道RYGB术后146例伴T2DM和152例IGT受损患者分别有121例(82.9%)和150例(98.7%)血糖、糖化血红蛋白和胰岛素水平都保持在正常范围, 并得到完全控制; 353例伴发高血压者86%血压恢复到正常水平, 其他MS相关表现均到达不同程度改善[36]. 有专门研究显示GB可改善患者的大动脉弹性和左室功能[37]. Papadia等[38]报道了一组平均年龄16.8岁的青少年肥胖患者接受BPD治疗, 平均随访11年发现, 除了减质量外, 伴发的高血压、高血糖和血脂紊乱等均大大改善. 一般认为联合术式比单纯限制型手术效果更好, 但创伤和并发症也相当较多. 但Vidal等[39]比较分析SG(39例)和RYGB(52例)治疗肥胖症伴T2DM和MS的结果, 显示术后1年两者减质量效果相似(63.00% vs 66.06%, P = 0.413); 而T2DM治愈率相同, 均为84.6%(P = 0.618), MS的治愈率也相当(62.2% vs 67.3%, P = 0.392). 研究还显示减质量与T2DM治愈无关, 而与MS治愈有关, 并认为手术可以控制MS患者各种心血管危险因素. 另有报道显示AGB对肥胖症并T2DM、IGT和MS都有益处, 可以阻止IGT发展为T2DM[40], 可见限制型手术也有相当疗效. 2004年Buchwald等[41]荟萃分析了136篇共22 094例患者行AGB、GP、胃成形术、BPD或DS减肥手术的资料, 76.8%的糖尿病完全治愈, 86.0%得到改善, 高脂血症70%以上得到改善, 高血压61.7%治愈, 78.5%有改善, 85.7%的呼吸睡眠暂停消失. 认为减肥手术可使大多数糖尿病、高脂血症、高血压和呼吸睡眠暂停获得治愈或好转. 近年来研究发现相关手术对非肥胖症的T2DM也有优异疗效. DePaula等[42,43]用腹腔镜SG联合节段回肠插入近端空肠手术治疗BMI<35和BMI为21-29的T2DM均取得显著疗效, 绝大部分患者血糖恢复正常, 不再需要胰岛素治疗, 甚至高血脂、高血压和微蛋白尿都得到有效控制. 而相关动物实验也证实了手术对非肥胖糖尿病的效果[44]. 可以推测及早行手术治疗有可能阻止T2DM向MS发展的趋势.
1.2.4 手术治疗的优缺点: 相比传统治疗, 手术治疗肥胖症、T2DM和MS的疗效非常显著, 使人们对此类疾病的认识正在发生深刻变化. 肥胖者可能获得长期减质量, 而T2DM和MS及相关并发症均可得到长期的改善. 特别是T2DM有可能从以往认为的需要终身用药不可治愈的慢性内科疾病变成一种通过一次手术可以彻底治愈的外科疾病. 这是减质量手术的最大优点. 但手术治疗毕竟也增加了手术相关的许多风险和并发症. 手术涉及麻醉、身体的创伤、器官的毁损、生理结构的破坏以及一定的死亡率, 术后还要较多的并发症. Buchwald等[41]统计显示手术死亡率单纯限制型手术为0.1%, GB是0.5%, 而BPD或DS达到1.1%. 而且除了AGB外, 其他术式可调控性和可恢复性都很差. 德国一篇报道SG术后两年总并发症达14.1%, 手术并发症为9.4%, 术后死亡率1.4%[45]. Kellogg等[46]分析了RYGB患者短期再入院和再手术率, 分别为7.01%和2.57%, 常见的原因有恶心、呕吐、脱水、腹痛、切开疼痛等, 而开放手术高于腹腔镜手术. REGB最常见的远期并发症是胃肠吻合口溃疡, Hata等[47]报道一组患者RYGB术后10.4%怀疑溃疡而行治疗, 其中115例行胃镜82例证实溃疡, 15例再次手术治疗. 减肥手术还有减质量不足、反弹, 以及腹泻、倾倒综合征、营养不良、维生素和微量元素缺乏、慢性腹痛、肠粘连、肠梗阻, 甚至胆石症、结肠癌[48,49]等并发症. 毁损性、创伤大、破坏性强、可控可复性差和一系列的并发症, 这些都是手术治疗的缺点.
1.2.5 国内外现状: 手术治疗肥胖症和T2DM在欧美国家已被普遍接受并广泛开展. 仅在美国每年接受此类手术的患者就超过10万例. 各机构纷纷制订相关诊治标准和共识指南, 美国的医保政策也将其纳入补偿范围. 减肥手术的概念在逐渐向代谢手术(metabolic surgery)过渡. 手术方式也逐渐集中到几种经典术式, 其中RYGB经过数十年的实践和完善, 一直是欧美的主流术式, 并成为治疗T2DM和MS的标准术式, 有学者认为其在治疗效果、手术风险和术后生活质量三者之间达到了较好的平衡[50]. 而国内开展较晚, 21世纪开始郑成竹等学者陆续开展了相关临床和基层研究工作[51,52], 并在2007年制订了国内首部相关指南[53]. 由于国人接受度较低, 国内开展得还很不充分, 与国外差距较大.
目前对手术治疗T2DM和MS研究还不够深入, 确切机制尚不清楚. 起初认为胃缩容后进食减少可能与血糖下降有关[54], 但后来的许多研究发现AGB等单纯限制摄入手术效果不明显[55], 而RYGB降血糖作用独立于进食减少和体质量减轻[56]. 另外多项研究显示, RYGB术后血糖可很快降至正常, 而此时体质量还未有明显下降, 提示其降血糖作用与体质量减轻无关[57,58], 而主要与胃流出道改变有关. 目前的研究多集中在改道手术影响肠-胰岛轴上, 认为手术改变了食物的流向, 影响胃肠激素分泌, 通过肠-胰岛轴调节胰岛内分泌功能[59]. 相关的调节机制目前有两种假说.
十二指肠空肠旷置后, 食物成分减少或停止了对近端小肠的刺激, K细胞释放抑胃肽(gastric inhibitory polypeptide, GIP)减少, 从而解除了IR, 使T2DM得到长期治愈. 研究显示, 十二指肠空肠旁路术的大鼠糖耐量显著改善, 而胃空肠吻合术则无此作用, 认为近端小肠被绕过是关键[56], 后来又发现RYGB仅降低糖尿病患者的GIP, 而不降低无糖尿病者的GIP[57], 这一结果得到了动物实验的证实[44], 对非T2DM的G-K大鼠行BPD或GBP后, 近端空肠释放的GIP明显减少.
RYGB或BPD术后, 食物更快达到远端小肠, 刺激远端小肠的L细胞分泌胰高糖素样肽-1(glucagon-like peptide-1, GLP-1), GLP-1可增加胰岛素分泌, 还可促进胰岛细胞增殖和再生, 减少凋亡, 进一步导致胰岛素分泌增加, 从而使血糖降低[60]. 多项研究观察到BPD术后GLP-1分泌大量增加[61-63].
还有许多胃肠激素参与控制T2DM的机制也在研究中. 饥饿素(ghrelin)是目前已知唯一可在外周刺激食欲的胃肠激素, 通过增强下丘脑神经肽Y的分泌表达来发挥作用, 促进摄食、减少脂肪利用和能量消耗, 从而增加体质量[64]. 有多项研究提示GBP术后饥饿素水平下降[65,66], 从而减少了对食欲的刺激, 并抑制生长抑素释放, 升高胰岛素水平, 降低血糖. 多肽YY3-36(peptide YY3-36)是一种主要由回肠L细胞在餐后释放的后肠激素, 作用于下丘脑弓状核抑制神经肽Y的释放, 产生饱胀感, 抑制胃的排空及胃肠蠕动, 从而抑制食欲[67]. 有研究观察到GBP术后对照节食治疗多肽YY3-36显著升高[68]. 另外, 改道手术后瘦素(leptin)水平升高和脂连素(adiponectin)水平升高可能参与增高胰岛素敏感性并维持血糖长期正常[69]. 动物实验也显示, 十二指肠空肠旷置术后血清瘦素水平明显下降后, 糖代谢恢复正常[70]. 总之, 参与手术治疗T2DM作用的胃肠激素很多, 推测手术改变了原有胃肠道结构甚至功能, 导致原代谢内分泌状态被破坏, 从而恢复了正常的糖代谢, 但各种术式的详细机制还有待进一步深入研究.
随着腹腔镜减肥手术的广泛开展和逐渐成熟, 内镜手术治疗代谢疾病也开始进入各国学者的视野. 已在临床使用的有内镜胃内放置水囊及十二指肠套管减肥法. 而经自然腔道内镜手术(natural orifice transluminal endoscopic surgery, NOTES)问世和初步应用[71], 使参照外科原理采用内镜治疗肥胖症成为可能. Ellsmere等[72]综述了仅有的36篇涉及内镜应用于减肥手术的初步研究文献, 认为内镜治疗相关疾病将大有可为. 而基于内镜技术的经口胃成形术(transoral gastroplasty, TOGA)已经开始在临床应用[73,74]. 随着技术的发展和器械的改进, 内镜治疗代谢病, 将可以达到外科手术相似的原理和效果, 并且更安全微创, 可控可复性更好. 随着经济发展和老龄化社会的到来, 肥胖及代谢相关疾病越来越流行, 严重危害人类健康. 而此类疾病内科治疗困难, 减肥手术或代谢外科的创立和发展为其提供了一种有效手段, 使其得到普遍治愈成为可能. 而随着代谢手术作用机制的深入研究, 胃肠激素参与肠-胰岛轴调节糖代谢的机制逐渐阐明, 一种基于激素水平调节机制的药物治疗有可能诞生, 使代谢病从有创的手术治疗又回到无创的药物治疗.
现代社会肥胖症患者越来越多, 肥胖症容易引发2型糖尿病和代谢综合征, 此类慢性代谢疾病对人类健康危害极大, 传统治疗收效甚微, 而手术治疗效果显著, 使此类疾病有可能获得治愈.
范建高, 教授, 上海交通大学医学院附属新华医院消化内科
国外十分普及手术治疗代谢疾病. 但因手术方式多种多样, 各种术式的详细机制还未阐明, 对其正在深入研究中. 此外手术方式也在向微创化方向快速发展. 而国内开展得较慢, 有必要加强研究.
Chiellini等评价了9例经口胃成形术(TOGA)患者胰岛素敏感性的变化, 发现3 mo后在体质量减轻的同时胰岛素敏感性显著改善, 显示仅用内镜完成的TOGA达到了传统减肥手术同样的效果, 而创伤大大减轻.
本文重点分析了各种减肥手术方式的可能机制, 特别是其影响胃肠激素及肠-胰岛轴调节胰岛内分泌从而降低血糖的机制, 有助于今后开展此类研究进行试验设计.
经自然腔道内镜手术(NOTES): 是指通过胃、肠、子宫等自然腔道用普通内镜进入腹腔进行手术的新技术, 目前已能完成胆囊摘除术、阑尾切除术等多种术式, 将来有可能完成各种经典的减肥术式.
本文行文简洁, 文献引用合理, 能较好地反映目前该领域的研究现状, 可读性好.
编辑:李军亮 电编:吴鹏朕
| 1. | Sauerland S, Angrisani L, Belachew M, Chevallier JM, Favretti F, Finer N, Fingerhut A, Garcia Caballero M, Guisado Macias JA, Mittermair R. Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc. 2005;19:200-221. [PubMed] [DOI] |
| 2. | Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, Joshi SR, Sadikot S, Gupta R, Gulati S. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India. 2009;57:163-170. [PubMed] |
| 6. | Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529. [PubMed] |
| 7. | Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003;289:187-193. [PubMed] |
| 8. | Sturm R. The effects of obesity, smoking, and drinking on medical problems and costs. Health Aff (Millwood). 2002;21:245-253. [PubMed] [DOI] |
| 9. | 卫生部疾病控制司, 中华医学会糖尿病学分会. 《中国糖尿病防治指南》(试行本)(节选). 中国慢性病预防与控制. 2004;12:283-285. |
| 10. | Koopman RJ, Swofford SJ, Beard MN, Meadows SE. Obesity and metabolic disease. Prim Care. 2009;36:257-270. [PubMed] [DOI] |
| 11. | Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047-1053. [PubMed] [DOI] |
| 12. | Gupta S, Gupta BM. Metabolic syndrome: diabetes and cardiovascular disease. Indian Heart J. 2006;58:149-152. [PubMed] |
| 13. | Guize L, Pannier B, Thomas F, Bean K, Jégo B, Benetos A. Recent advances in metabolic syndrome and cardiovascular disease. Arch Cardiovasc Dis. 2008;101:577-583. [PubMed] [DOI] |
| 14. | Grundy SM. Obesity, metabolic syndrome, and cardiovascular disease. J Clin Endocrinol Metab. 2004;89:2595-2600. [PubMed] [DOI] |
| 15. | Mensah GA, Mokdad AH, Ford E, Narayan KM, Giles WH, Vinicor F, Deedwania PC. Obesity, metabolic syndrome, and type 2 diabetes: emerging epidemics and their cardiovascular implications. Cardiol Clin. 2004;22:485-504. [PubMed] [DOI] |
| 16. | Gu D, Reynolds K, Wu X, Chen J, Duan X, Reynolds RF, Whelton PK, He J. Prevalence of the metabolic syndrome and overweight among adults in China. Lancet. 2005;365:1398-1405. [PubMed] [DOI] |
| 17. | Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg. 1954;140:439-448. [PubMed] [DOI] |
| 19. | Kuzmak LI, Thelmo W, Abramson DL, Kral JG. Reversible adjustable gastric banding. Surgical technique. Eur J Surg. 1994;160:569-571. [PubMed] |
| 20. | Gumbs AA, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity. Obes Surg. 2007;17:962-969. [PubMed] [DOI] |
| 21. | Shibata HR, MacKenzie JR, Long RC. Metabolic effects of controlled jejunocolic bypass. Arch Surg. 1967;95:413-428. [PubMed] |
| 22. | Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, Cuneo S, Vitale B, Ballari F, Colombini M. Biliopancreatic diversion for obesity at eighteen years. Surgery. 1996;119:261-268. [PubMed] [DOI] |
| 23. | Marceau P, Hould FS, Simard S, Lebel S, Bourque RA, Potvin M, Biron S. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947-954. [PubMed] [DOI] |
| 24. | Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967;47:1345-1351. [PubMed] |
| 25. | Alden JF. Gastric and jejunoileal bypass. A comparison in the treatment of morbid obesity. Arch Surg. 1977;112:799-806. [PubMed] |
| 26. | Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic Gastric Bypass, Roux-en-Y: Preliminary Report of Five Cases. Obes Surg. 1994;4:353-357. [PubMed] [DOI] |
| 27. | van Gemert WG, Adang EM, Kop M, Vos G, Greve JW, Soeters PB. A prospective cost-effectiveness analysis of vertical banded gastroplasty for the treatment of morbid obesity. Obes Surg. 1999;9:484-491. [PubMed] [DOI] |
| 28. | Fielding GA, Ren CJ. Laparoscopic adjustable gastric band. Surg Clin North Am. 2005;85:129-140, x. [PubMed] [DOI] |
| 29. | Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surg Obes Relat Dis. 2005;1:399-405; discussion 405-407. [PubMed] [DOI] |
| 30. | Arias E, Martínez PR, Ka Ming Li V, Szomstein S, Rosenthal RJ. Mid-term follow-up after sleeve gastrectomy as a final approach for morbid obesity. Obes Surg. 2009;19:544-548. [PubMed] [DOI] |
| 31. | Bernante P, Foletto M, Busetto L, Pomerri F, Pesenti FF, Pelizzo MR, Nitti D. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding. Obes Surg. 2006;16:1327-1330. [PubMed] [DOI] |
| 32. | Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech A. 2001;11:377-382. [PubMed] [DOI] |
| 33. | Weinel RJ, Neuhaus C, Stapp J, Klotter HJ, Trautmann ME, Joseph K, Arnold R, Rothmund M. Preoperative localization of gastrointestinal endocrine tumors using somatostatin-receptor scintigraphy. Ann Surg. 1993;218:640-645. [PubMed] [DOI] |
| 34. | Søvik TT, Taha O, Aasheim ET, Engström M, Kristinsson J, Björkman S, Schou CF, Lönroth H, Mala T, Olbers T. Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity. Br J Surg. 2010;97:160-166. [PubMed] [DOI] |
| 35. | Pories WJ, MacDonald KG Jr, Flickinger EG, Dohm GL, Sinha MK, Barakat HA, May HJ, Khazanie P, Swanson MS, Morgan E. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg. 1992;215:633-642; discussion 643. [PubMed] [DOI] |
| 36. | Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, Barakat HA, deRamon RA, Israel G, Dolezal JM. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339-350; discussion 350-352. [PubMed] [DOI] |
| 37. | Ikonomidis I, Mazarakis A, Papadopoulos C, Patsouras N, Kalfarentzos F, Lekakis J, Kremastinos DT, Alexopoulos D. Weight loss after bariatric surgery improves aortic elastic properties and left ventricular function in individuals with morbid obesity: a 3-year follow-up study. J Hypertens. 2007;25:439-447. [PubMed] [DOI] |
| 38. | Papadia FS, Adami GF, Marinari GM, Camerini G, Scopinaro N. Bariatric surgery in adolescents: a long-term follow-up study. Surg Obes Relat Dis. 2007;3:465-468. [PubMed] [DOI] |
| 39. | Vidal J, Ibarzabal A, Romero F, Delgado S, Momblán D, Flores L, Lacy A. Type 2 diabetes mellitus and the metabolic syndrome following sleeve gastrectomy in severely obese subjects. Obes Surg. 2008;18:1077-1082. [PubMed] [DOI] |
| 40. | Brancatisano A, Wahlroos S, Matthews S, Brancatisano R. Gastric banding for the treatment of type 2 diabetes mellitus in morbidly obese. Surg Obes Relat Dis. 2008;4:423-429. [PubMed] [DOI] |
| 41. | Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724-1737. [PubMed] |
| 42. | DePaula AL, Macedo AL, Rassi N, Machado CA, Schraibman V, Silva LQ, Halpern A. Laparoscopic treatment of type 2 diabetes mellitus for patients with a body mass index less than 35. Surg Endosc. 2008;22:706-716. [PubMed] [DOI] |
| 43. | DePaula AL, Macedo AL, Mota BR, Schraibman V. Laparoscopic ileal interposition associated to a diverted sleeve gastrectomy is an effective operation for the treatment of type 2 diabetes mellitus patients with BMI 21-29. Surg Endosc. 2009;23:1313-1320. [PubMed] [DOI] |
| 44. | Patriti A, Facchiano E, Donini A. Effect of duodenal-jejunal exclusion in a non-obese animal model of type 2 diabetes: a new perspective for an old disease. Ann Surg. 2004;240:388-389; author reply 389-391. [PubMed] [DOI] |
| 45. | Stroh C, Birk D, Flade-Kuthe R, Frenken M, Herbig B, Höhne S, Köhler H, Lange V, Ludwig K, Matkowitz R. Results of sleeve gastrectomy-data from a nationwide survey on bariatric surgery in Germany. Obes Surg. 2009;19:632-640. [PubMed] [DOI] |
| 46. | Kellogg TA, Swan T, Leslie DA, Buchwald H, Ikramuddin S. Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5:416-423. [PubMed] [DOI] |
| 47. | Hata JA, DeMaria EJ, Portenier DD, Grant J, Pryor AD. PL-52: Marginal ulcer after 1,792 laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures: Incidence, medical and surgical treatment and complications. Surg Obes Relat Dis. 2008;4:308-309. [PubMed] [DOI] |
| 48. | Adami GF, Papadia FS, Scopinaro N. Colorectal cancer after biliopancreatic diversion for obesity. Int J Obes (Lond). 2007;31:1864. [PubMed] [DOI] |
| 49. | Sainsbury A, Goodlad RA, Perry SL, Pollard SG, Robins GG, Hull MA. Increased colorectal epithelial cell proliferation and crypt fission associated with obesity and roux-en-Y gastric bypass. Cancer Epidemiol Biomarkers Prev. 2008;17:1401-1410. [PubMed] [DOI] |
| 50. | Rotellar F, Pastor C, Baixauli J, Gil A, Valetí V, Poveda I, Martí-Cruchaga P. [Laparoscopic bariatric surgery: proximal gastric bypass]. An Sist Sanit Navar. 2005;28 Suppl 3:33-40. [PubMed] [DOI] |
| 51. | 郑 成竹, 柯 重伟, 印 慨, 李 际辉, 吴 月凤, 胡 明根, 葛 小莉, 邹 大进. 腹腔镜垂直捆绑胃成形术治疗病态肥胖(附25例 报告). 中国实用外科杂志. 2002;22:591-592. |
| 52. | 郑 成竹, 胡 明根, 柯 重伟, 印 慨, 李 际辉, 胡 兵, 吴 月凤, 邹 大进. 腹腔镜可调节捆扎带胃减容术治疗单纯重度肥胖症 的临床应用. 中华胃肠外科杂志. 2004;7:368-371. |
| 53. | 中华医学会外科学分会内分泌外科学组, 中华医学会外科学分会腹腔镜与内镜外科学组, 中华医学会外科学分会胃肠 外科学组, 中华医学会外科学分会外科手术学学组. 中国肥胖病外科治疗指南(2007). 中国实用外科杂志. 2007;27:759-762. |
| 54. | Greenway SE, Greenway FL 3rd, Klein S. Effects of obesity surgery on non-insulin-dependent diabetes mellitus. Arch Surg. 2002;137:1109-1117. [PubMed] [DOI] |
| 55. | Meneghini LF. Impact of bariatric surgery on type 2 diabetes. Cell Biochem Biophys. 2007;48:97-102. [PubMed] [DOI] |
| 56. | Rubino F, Forgione A, Cummings DE, Vix M, Gnuli D, Mingrone G, Castagneto M, Marescaux J. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann Surg. 2006;244:741-749. [PubMed] [DOI] |
| 57. | Rubino F, Gagner M, Gentileschi P, Kini S, Fukuyama S, Feng J, Diamond E. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Ann Surg. 2004;240:236-242. [PubMed] [DOI] |
| 58. | Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad G, Eid GM, Mattar S, Ramanathan R, Barinas- Mitchel E. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238:467-484; discussion 484-485. [PubMed] |
| 59. | Patriti A, Facchiano E, Sanna A, Gullà N, Donini A. The enteroinsular axis and the recovery from type 2 diabetes after bariatric surgery. Obes Surg. 2004;14:840-848. [PubMed] [DOI] |
| 60. | Cummings DE, Overduin J, Foster-Schubert KE. Gastric bypass for obesity: mechanisms of weight loss and diabetes resolution. J Clin Endocrinol Metab. 2004;89:2608-2615. [PubMed] [DOI] |
| 61. | Valverde I, Puente J, Martín-Duce A, Molina L, Lozano O, Sancho V, Malaisse WJ, Villanueva-Peñacarrillo ML. Changes in glucagon-like peptide-1 (GLP-1) secretion after biliopancreatic diversion or vertical banded gastroplasty in obese subjects. Obes Surg. 2005;15:387-397. [PubMed] [DOI] |
| 62. | Borg CM, le Roux CW, Ghatei MA, Bloom SR, Patel AG. Biliopancreatic diversion in rats is associated with intestinal hypertrophy and with increased GLP-1, GLP-2 and PYY levels. Obes Surg. 2007;17:1193-1198. [PubMed] [DOI] |
| 63. | Patriti A, Aisa MC, Annetti C, Sidoni A, Galli F, Ferri I, Gullà N, Donini A. How the hindgut can cure type 2 diabetes. Ileal transposition improves glucose metabolism and beta-cell function in Goto-kakizaki rats through an enhanced Proglucagon gene expression and L-cell number. Surgery. 2007;142:74-85. [PubMed] [DOI] |
| 64. | Nakazato M, Murakami N, Date Y, Kojima M, Matsuo H, Kangawa K, Matsukura S. A role for ghrelin in the central regulation of feeding. Nature. 2001;409:194-198. [PubMed] [DOI] |
| 65. | Tritos NA, Mun E, Bertkau A, Grayson R, Maratos-Flier E, Goldfine A. Serum ghrelin levels in response to glucose load in obese subjects post-gastric bypass surgery. Obes Res. 2003;11:919-924. [PubMed] [DOI] |
| 66. | Cummings DE, Weigle DS, Frayo RS, Breen PA, Ma MK, Dellinger EP, Purnell JQ. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346:1623-1630. [PubMed] [DOI] |
| 67. | Batterham RL, Cohen MA, Ellis SM, Le Roux CW, Withers DJ, Frost GS, Ghatei MA, Bloom SR. Inhibition of food intake in obese subjects by peptide YY3-36. N Engl J Med. 2003;349:941-948. [PubMed] [DOI] |
| 68. | Oliván B, Teixeira J, Bose M, Bawa B, Chang T, Summe H, Lee H, Laferrère B. Effect of weight loss by diet or gastric bypass surgery on peptide YY3-36 levels. Ann Surg. 2009;249:948-953. [PubMed] [DOI] |
| 69. | Vendrell J, Broch M, Vilarrasa N, Molina A, Gómez JM, Gutiérrez C, Simón I, Soler J, Richart C. Resistin, adiponectin, ghrelin, leptin, and proinflammatory cytokines: relationships in obesity. Obes Res. 2004;12:962-971. [PubMed] [DOI] |
| 70. | Pacheco D, de Luis DA, Romero A, González Sagrado M, Conde R, Izaola O, Aller R, Delgado A. The effects of duodenal- jejunal exclusion on hormonal regulation of glucose metabolism in Goto-Kakizaki rats. Am J Surg. 2007;194:221-224. [PubMed] [DOI] |
| 72. | Ellsmere JC, Thompson CC, Brugge WR, Chuttani R, J Desilets D, Rattner DW, E Tarnoff M, Kaplan LM. Endoscopic interventions for weight loss surgery. Obesity (Silver Spring). 2009;17:929-933. [PubMed] [DOI] |
| 73. | Moreno C, Closset J, Dugardeyn S, Baréa M, Mehdi A, Collignon L, Zalcman M, Baurain M, Le Moine O, Devière J. Transoral gastroplasty is safe, feasible, and induces significant weight loss in morbidly obese patients: results of the second human pilot study. Endoscopy. 2008;40:406-413. [PubMed] [DOI] |
| 74. | Chiellini C, Iaconelli A, Familiari P, Riccioni ME, Castagneto M, Nanni G, Costamagna G, Mingrone G. Study of the effects of transoral gastroplasty on insulin sensitivity and secretion in obese subjects. Nutr Metab Cardiovasc Dis. 2010;20:202-207. [PubMed] [DOI] |