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-intestinal Metabolic surgery)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,生命不可承受之重Unbearable weight in life,BMI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%Malignancy,Lancet.2009 March 28;373(9669):1083-1096,JAMA 1999,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 Subjects,Lars 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Effect of Bariatric Surgery on Mortality in Swedish Obese Subjects,Lars Sjostrom et al.N Engl J Med 2007:357:741-52,Unadjusted 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Long-term mortality 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 suicide,Adams TD et al.NEJM 2007;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-intestinal Metabolic surgery)病人的选择,Who would have thought it?An operation proves to be the most effective therapy for adult-onset diabetes mellitus,Pories WJ,Swanson MS,MacDonald KG,et al.Ann Surg 1995;222:339-350,在肥胖病人，减重手术可长期根治糖尿病,Bariatric SurgeryA Systematic Review and Meta-analysis,Buchwald H.et al.JAMA 2004:292:1724-1737,Conclusion effective weight loss was achieved in morbidly obese patients after 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,Health Outcomes of Severely Obese Type 2 Diabetic Subjects 1 Year After Laparoscopic Adjustable Gastric Banding,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 duration of DMImprovement of DM associated with increased insulin resistance and B-cell function,Dixon JB et al.Diabetes Care 2002;25:358-63,可调节式胃束带手术,胃绕道手术,R-Y Bypass,Lee WJ et al.Obesity surgery resulted in significant and sustained weight loss with a cure rate of T2DM up to 80%in morbidly obese 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;33:1895-1903,Effects of Obesity Surgery on Type 2 Diabetes Mellitus Asian Patients,胆胰绕道手术 十二指肠转位,312 patientsBMI 50.1 32.0 at 10 years.Diabetes resolution 98%.,胃缩小手术(袖状切除)Laparoscopic Sleeve Gastrectomy,Stage operation for duodenal switch in high risk patientProposed operation for moderate obese patientsThe hole of ghrelin reductionLong-term efficacy,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-intestinal Metabolic surgery)病人的选择,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 worry that this radical operation can also cause dangerously low blood sugar.,25 APRIL 2008 VOL 320 SCIENCE,Nature 444,854-859(14 December 2006),Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes,60 0bese patients(BMI 30 and 40)with recently diagnosed(2 years)type 2 diabetesRandomized to two armsRemission of T2DM was 73%in the surgical group and 13%in the conventional-therapy groupWeight loss in surgical group and conventional-therapy groups were 20.7%(8.6%)and 1.7%(5.2%)respectively,Dixon JB et al.JAMA 2008;299:316-23,可调节式胃束带手术,胃缩小手术(LSG)Laparoscopic Sleeve Gastrectomy,20 patients(BMI 25 and 6 ng/ml and 14.3%in 3 ng/ml),Dixon JB et al.JAMA 2008;299:316-23,胃绕道手术,Lee WJ et al.J Gastrointst Surg 2008;12:945-52,Laparoscopic 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.,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-Ileal interposition,19 patientsBMI 40.2Weight loss 38.4%5 DM patients resolution,新的手术-Duodenaljejunal Bypass DJB,12 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-Duodenaljejunal Bypass DJB,新的方法-Duodenal-jejunal bypass sleeve,12 patients for 12 weeks.HbA1C 0.5%,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-intestinal Metabolic surgery)病人的选择,BMI 35 1.85%BMI 30-35 8.58%BMI 27-30 16.87%,2555 cases,影响糖尿病人手术效果的原因,Older peopleA longer history of T2DMSevere disease,high dose of insulin usage Poorly control DM may accelerates B-cell failureBariatric surgical procedure should be performed before irreversible B-cell failure,Dixon JB,et al.Surgery as an effective early intervention for diabesity.Diabetes Care 2005:28:472-4,Lee WJ et al.J Gastrointst Surg 2008;12:945-52,Laparoscopic 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Consensus in Asia-Pacific,2005 APBSG consensus meeting modified the indications for bariatric surgery for Asian people to:Obese patients with their BMI 37Obese patients with their BMI 32 in the presence of diabetes or two significant obesity related co-morbidities.Have been unable to lose or maintain weight loss by dietary or medical measures.Age of patient 18 years and 65 years.Under special circumstance and in consideration with a pediatrician,bariatric surgery may be used in children under age 18.,Lee WJ.Obes Surg 2005;15:751-7,ACMOMS 2008Asian consensus meeting on metabolic surgeryTrivandrum,India,Patients with Body Mass Index=30 kg/m2 with type II diabetes mellitus Research base:Metabolic surgery for patients with BMI30,亚太对减重及糖尿病手术的共识,2010 APMBSS modified the indications for bariatric and metabolic surgery for Asian people to:Obese patients with their BMI 37Obese patients with their BMI 32 in the presence of co-morbidities.Diabetic patients with their BMI 32 in the presence of central obesity and metabolic syndrome.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,