肥胖减重手术后遗症

​在美国，超重每年导致约 500,000 例死亡。[1]Ward ZJ, Willett WC, Hu FB, et al. Excess mortality associated with elevated body weight in the USA by state and demographic subgroup: a modelling study. EClinicalMedicine. 2022 Jun;48:101429. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00159-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/35516446?tool=bestpractice.com 在英格兰和苏格兰，估计有 23% 的死亡归因于超重或肥胖。[2]Ho FK, Celis-Morales C, Petermann-Rocha F, et al. Changes over 15 years in the contribution of adiposity and smoking to deaths in England and Scotland. BMC Public Health. 2021 Feb 11;21(1):169. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10167-3 http://www.ncbi.nlm.nih.gov/pubmed/33568116?tool=bestpractice.com Ⅲ 级肥胖（体重指数 [body mass index, BMI] 为 40 或以上）的发病率正在快速增加，导致全球接受减重手术的患者也越来越多。与非手术方法治疗肥胖相比，减重手术（也称为代谢手术）可显著降低肥胖成人的全因死亡率。[3]Syn NL, Cummings DE, Wang LZ, et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet. 2021 May 15;397(10287):1830-41. http://www.ncbi.nlm.nih.gov/pubmed/33965067?tool=bestpractice.com 研究表明，III 级肥胖的儿童和青少年患者可以从减重手术中获益。[4]NHS England. Clinical Commissioning Policy: Obesity surgery for children with severe complex obesity. April 2017. https://www.england.nhs.uk https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e02 减重手术治疗肥胖的作用机制尚不完全明确，但目前认为可能与胃容量限制、吸收不良和激素改变有关。​[5]Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc. 2010 Apr;110(4):571-84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4284064 http://www.ncbi.nlm.nih.gov/pubmed/20338283?tool=bestpractice.com ​​[6]Balsiger BM, Poggio JL, Mai J, et al. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. J Gastrointest Surg. 2000 Nov-Dec;4(6):598-605. http://www.ncbi.nlm.nih.gov/pubmed/11307094?tool=bestpractice.com

不同指南对开展减重手术的 BMI 阈值建议不同。[7]National Institute for Health and Care Excellence (NICE). Obesity: identification, assessment and management. Jul 2023​ [internet publication]. https://www.nice.org.uk/guidance/cg189 [8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com [9]Welbourn R, Hopkins J, Dixon JB, et al. Commissioning guidance for weight assessment and management in adults and children with severe complex obesity. Obes Rev. 2018 Jan;19(1):14-27. https://onlinelibrary.wiley.com/doi/10.1111/obr.12601 http://www.ncbi.nlm.nih.gov/pubmed/29024367?tool=bestpractice.com [10]Di Lorenzo N, Antoniou SA, Batterham RL, et al. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc. 2020 Jun;34(6):2332-58. https://link.springer.com/article/10.1007/s00464-020-07555-y http://www.ncbi.nlm.nih.gov/pubmed/32328827?tool=bestpractice.com ​​ 美国代谢与减重手术学会、国际肥胖与代谢疾病外科联盟建议，对 BMI≥35 kg/m²（无论是否存在合并症）或 BMI 在 30.0-34.9 kg/m² 之间且采用最佳非手术治疗后仍无法实现持久减重和合并症管理的患者进行减重手术。[8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com 对于 2 型糖尿病患者，如果 BMI＞30 kg/m²，且采用最佳非手术疗法后仍无法实现持久的减重和合并症管理，也可选择进行减重手术。[11]American Diabetes Association Professional Practice Committee; 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes–2024. Diabetes Care. 2024 January 1; 47 (Suppl 1): S145–57. https://diabetesjournals.org/care/article/47/Supplement_1/S145/153942/8-Obesity-and-Weight-Management-for-the-Prevention [8]Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14. https://link.springer.com/article/10.1007/s11695-022-06332-1 http://www.ncbi.nlm.nih.gov/pubmed/36336720?tool=bestpractice.com 由于身体成分和心脏代谢风险存在差异，亚洲人实施减重手术的 BMI 阈值较低。[11]American Diabetes Association Professional Practice Committee; 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes–2024. Diabetes Care. 2024 January 1; 47 (Suppl 1): S145–57. https://diabetesjournals.org/care/article/47/Supplement_1/S145/153942/8-Obesity-and-Weight-Management-for-the-Prevention

患者在行减重手术后，可能到门诊、急诊科或行手术所在医院之外的其他医院就诊。因此，需要了解常见的并发症。[12]Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010 Mar 4;6(2):115-7. http://www.ncbi.nlm.nih.gov/pubmed/20189469?tool=bestpractice.com ​ 可能难以检查中心性肥胖患者的腹部，并且中心性肥胖可掩盖脓毒症的典型体征。因此，密切注意生命体征、实验室检查结果以及一切偏离预期的术后病程十分重要。