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1、国外糖尿病手术发展现况国外糖尿病手术发展现况由减重手术到糖尿病手术由减重手术到糖尿病手术以减重手术治疗糖尿病以减重手术治疗糖尿病胃肠道代谢手术胃肠道代谢手术 (Gastro-intestinal Metabolic(Gastro-intestinal Metabolic surgery)surgery)病人的选择病人的选择Nature 2000;404,635-43减重手术在美国已是最常见的胃肠道手术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生命不可承受之重Unbearable weight in lifeUnbearable weight in lifeObesity Co-mor
2、biditiesObesity Co-morbiditiesMechanicalMetabolic.Obstructive Sleep Apnea.Hypoventilation Syndrome.Osteoarthritis.Stasis Dermatitis.Heart Failure.Incontinence.Quality of Life.Diabetes.Cardiovascular.Gall stone.NASH.Gout.Cancer.PCOSPsycho-Social.Psychologic：Loss self-confidenceSocial:FreindMarriageJo
3、b,PromotionBMIBMI与死亡率的关系与死亡率的关系Mortality lowest at 22.5-2530%higher at each 5 BMI higher40%vascular60-120%DM,renal and hepatic10%MalignancyLancet.2009 March 28;373(9669):1083-1096JAMA 1999减重手术是严重肥胖最有效的治疗方法减重手术是严重肥胖最有效的治疗方法Effect of Bariatric Surgery on Mortality in Swedish Obese SubjectsEffect of Ba
4、riatric Surgery on Mortality in Swedish Obese SubjectsLars Sjostrom et al.N Engl J Med 2007:357:741-52减重手术对瑞典病人死亡率的影响减重手术对瑞典病人死亡率的影响Effect of Bariatric Surgery on Mortality in Swedish Obese SubjectsEffect of Bariatric Surgery on Mortality in Swedish Obese SubjectsLars Sjostrom et al.N Engl J Med 200
5、7:357:741-52Unadjusted overall mortality was reduced by 24.6%(p=0.0346)Adjusted risk reduction was 31.6%(p=0.00083)Mortality difference was mainly attributable to reductions in coronary events and cancers.胃绕道手术对长期死亡率的影响胃绕道手术对长期死亡率的影响Long-term mortality after gastric bypass surgeryLong-term mortality
6、 after gastric bypass surgery 7925 surgical vs.7925 matched control,follow-up 7.1 yA decrease of 40%mortality56%for coronary artery disease92%for diabetes60%for cancerA increase of 58%of death not caused by disease,such as accidents and suicideAdams TD et al.NEJM 2007;357:753-61由减重手术到糖尿病手术由减重手术到糖尿病手
7、术以减重手术治疗糖尿病以减重手术治疗糖尿病胃肠道代谢手术胃肠道代谢手术 (Gastro-intestinal Metabolic surgery)(Gastro-intestinal Metabolic surgery)病人的选择病人的选择Who would have thought it?An operation proves to be the most effective therapy for adult-onset diabetes mellitusPories WJ,Swanson MS,MacDonald KG,et al.Ann Surg 1995;222:339-350在肥胖
8、病人，减重手术可长期根治糖尿病在肥胖病人，减重手术可长期根治糖尿病Bariatric SurgeryBariatric SurgeryA Systematic Review and Meta-analysisA Systematic Review and Meta-analysisBuchwald H.et al.JAMA 2004:292:1724-1737Buchwald H.et al.JAMA 2004:292:1724-1737Conclusion effective weight loss was achieved in morbidly obese patients after
9、undergoing bariatric surgery.A substantial majority of with Diabetes,Hyperlipidemia,Hypertension and Obstructive sleep apnea experienced complete resolution or improvement.不同减重手术对糖尿病的治疗效果不同减重手术对糖尿病的治疗效果Health Outcomes of Severely Obese Type 2 Diabetic Health Outcomes of Severely Obese Type 2 Diabeti
10、c Subjects 1 Year After Laparoscopic Adjustable Gastric Subjects 1 Year After Laparoscopic Adjustable Gastric BandingBanding 50 0bese patients(BMI 48.2+8 Kg/M2)with type 2 diabetesRemission of T2DM was 64%and HbA1c decreased 1.6(from 7.8 to 6.2)Remission of diabetes predicted by weight loss%and dura
11、tion of DMImprovement of DM associated with increased insulin resistance and B-cell functionDixon JB et al.Diabetes Care 2002;25:358-63可调节式胃束带手术可调节式胃束带手术胃绕道手术胃绕道手术R-Y BypassLee WJ et al.Obesity surgery resulted in significant and sustained weight loss with a cure rate of T2DM up to 80%in morbidly ob
12、ese Asian patients.Gastric bypass surgery had a better result in T2DM cure rate than LVBG and LAGB because of better weight reduction.World Journal of Surgery 2009;33:1895-1903Effects of Obesity Surgery on Type 2 Effects of Obesity Surgery on Type 2 Diabetes Mellitus Asian PatientsDiabetes Mellitus
13、Asian Patients胆胰绕道手术胆胰绕道手术 十二指肠转位十二指肠转位312 patientsBMI 50.1 32.0 at 10 years.Diabetes resolution 98%.胃缩小手术胃缩小手术 (袖状切除袖状切除)Laparoscopic Sleeve GastrectomyStage operation for duodenal switch in high risk patientProposed operation for moderate obese patientsThe hole of ghrelin reductionLong-term effica
14、cy 由减重手术到糖尿病手术由减重手术到糖尿病手术以减重手术治疗糖尿病以减重手术治疗糖尿病胃肠道代谢手术胃肠道代谢手术 (Gastro-intestinal Metabolic surgery)(Gastro-intestinal Metabolic surgery)病人的选择病人的选择胃肠道手术会带来肠道激素的巨大改变胃肠道手术会带来肠道激素的巨大改变By altering the guts production of hormones,gastric bypass surgery may be able to eliminate type 2 diabetes.But scientists
15、 worry that this radical operation can also cause dangerously low blood sugar.25 APRIL 2008 VOL 320 SCIENCE Gut Hormone IncretinStomach GhrelinDuodenum Glucagon VIP .Ileum GLP-1 PYY .Nature 444,854-859(14 December 2006)Adjustable Gastric Banding and Conventional Adjustable Gastric Banding and Conven
16、tional Therapy for Type 2 DiabetesTherapy for Type 2 Diabetes 60 0bese patients(BMI 30 and 40)with recently diagnosed(25 and 6 ng/ml and 14.3%in 45 onT2DM treatment.胆胰绕道手术胆胰绕道手术5 patientsBMI 30.9(27-33)One year later,BMI 25.4 at 10 years.Hba1C from 8.5 to 5.6新的手术新的手术-Ileal interposition19 patientsBM
17、I 40.2Weight loss 38.4%5 DM patients resolution 新的手术新的手术-Duodenaljejunal Bypass DJB12 patientsAge 49.8;BMI 25.6 HbA1c 8.9%,duration 9yAt 6m,BMI 24.2,HbA1C 7.8%Better than control G 新的手术新的手术-Duodenaljejunal Bypass DJB新的方法新的方法新的方法新的方法-Duodenal-jejunal bypass sleeve-Duodenal-jejunal bypass sleeve12 pat
18、ients for 12 weeks.HbA1C 0.5%由减重手术到糖尿病手术由减重手术到糖尿病手术以减重手术治疗糖尿病以减重手术治疗糖尿病胃肠道代谢手术胃肠道代谢手术 (Gastro-intestinal Metabolic(Gastro-intestinal Metabolic surgery)surgery)病人的选择病人的选择BMI 35 1.85%BMI 30-35 8.58%BMI 27-30 16.87%2555 cases2555 cases影响糖尿病人手术效果的原因影响糖尿病人手术效果的原因Older peopleA longer history of T2DMSevere
19、 disease,high dose of insulin usage Poorly control DM may accelerates B-cell failureBariatric surgical procedure should be performed before irreversible B-cell failureDixon JB,et al.Surgery as an effective early intervention for diabesity.Diabetes Care 2005:28:472-4Lee WJ et al.J Gastrointst Surg 20
20、08;12:945-52Laparoscopic minigastric bypass resulted in significant and sustained weight loss with successful treatment of T2DM up to 87.1%in 201patients.Patients with BMI35 had a slightly lower response rate of 78%than the 93%in patients with BMI 45 onT2DM treatment.在低在低BMIBMI的病人，手术效果会较差的病人，手术效果会较差
21、预测糖尿病手术效果的指针预测糖尿病手术效果的指针亚太减重手术的共识亚太减重手术的共识Consensus in Asia-PacificConsensus in Asia-Pacific2005 APBSG consensus meeting modified the indications for bariatric surgery for Asian people to:1.Obese patients with their BMI 372.Obese patients with their BMI 32 in the presence of diabetes or two signific
22、ant obesity related co-morbidities.3.Have been unable to lose or maintain weight loss by dietary or medical measures.4.Age of patient 18 years and=30 kg/m2 with Patients with Body Mass Index=30 kg/m2 with type II diabetes mellitus type II diabetes mellitus Research base:Research base:Metabolic surge
23、ry for patients with BMI30 Metabolic surgery for patients with BMI 372.Obese patients with their BMI 32 in the presence of co-morbidities.3.Diabetic patients with their BMI 32 in the presence of central obesity and metabolic syndrome.4.Patients with their BMI 30 or any new procedure required IRB approval and patients consent.Evaluation of B-cell function and duration of diabetes are indicated.APMBSS Consensus Meeting