石宏斌 戴勇 李曉峰 楊夢凡 高建麗 董晉
摘要:Roux-en-Y胃旁路術(shù)和腹腔鏡胃袖狀切除術(shù)相對(duì)其他減重術(shù)不僅操作簡單,且術(shù)后并發(fā)癥較少,逐漸成為目前臨床上常用的兩種減重術(shù)式。減重術(shù)后常常引起一系列的并發(fā)癥,如膽石癥、營養(yǎng)不良、胃食管反流病、腎結(jié)石以及育齡女性后代出生缺陷等,但國內(nèi)外對(duì)其發(fā)病原因和處理對(duì)策的研究結(jié)論仍存有爭議。本文主要對(duì)術(shù)后并發(fā)癥如胃食管反流病、膽囊結(jié)石、貧血、營養(yǎng)缺乏癥及相關(guān)病變、育齡女性后代出生缺陷以及腎結(jié)石的危險(xiǎn)因素和處理對(duì)策進(jìn)行綜述。
關(guān)鍵詞:減重術(shù);胃食管反流病;膽囊結(jié)石;營養(yǎng)缺乏癥;腎結(jié)石
中圖分類號(hào): R619.9? 文獻(xiàn)標(biāo)志碼: A? 文章編號(hào):1000-503X(2023)05-0833-07
DOI:10.3881/j.issn.1000-503X.15351
Causes and Countermeasures of Complications After Bariatric Surgery
SHI Hongbin1,2,DAI Yong2,LI Xiaofeng2,YANG Mengfan1,GAO Jianli1,DONG Jin2
1Graduate School,Qinghai University,Xining 810000,China
2Department of General Surgery,Qinghai University Affiliated Hospital,Xining 810000,China
Corresponding authors:DONG Jin? Tel:13997075081,E-mail:qhdongjin@163.com;
GAO Jianli? Tel:15081553228,E-mail:gaojianli3228@163.com
ABSTRACT:Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy characterized by simple operation and few postoperative complications have gradually become the two most commonly used surgical methods in clinical practice.A series of complications often occur after bariatric surgery,including gallstone disease,anemia,malnutrition,gastroesophageal reflux disease,kidney stones,and birth defects in offspring of women of childbearing age.There are controversies regarding the causes and countermeasures of these complications.This article mainly reviews the risk factors and countermeasures for the complications after bariatric surgery.
Key words:bariatric surgery;gastroesophageal reflux disease;gallbladder stones;nutritional deficiency;kidney stones
Acta Acad Med Sin,2023,45(5):833-839
在過去20年中,全球范圍內(nèi)減重代謝外科快速發(fā)展,越來越多肥胖患者接受減重術(shù),減重術(shù)在糾正肥胖癥及其合并癥方面有顯著的療效,但術(shù)后的并發(fā)癥也是影響臨床效果的重要因素,本文主要對(duì)Roux-en-Y胃旁路術(shù)(Roux-en-Y gastric bypass,RYGB)和腹腔鏡胃袖狀切除術(shù)(laparoscopic sleeve gastrectomy,LSG)兩種術(shù)式術(shù)后并發(fā)癥的數(shù)據(jù)進(jìn)行分析,為減重代謝外科臨床醫(yī)師提供參考。
減重術(shù)
減重術(shù)是通過外科手段,改變消化道的容積和消化道的路徑,進(jìn)而改變患者的食物攝入量和食物吸收方式,改善肥胖癥患者的全身癥狀如:體重超標(biāo)、高血壓、血脂高、糖尿病等,主要的減重術(shù)式有RYGB、LSG、腹腔鏡可調(diào)節(jié)胃束帶術(shù)以及膽胰分流-十二指腸轉(zhuǎn)位術(shù)等。
RYGB? 手術(shù)將患者的胃分成上下兩部分,用于容納食物的只有原來胃部的1/6~1/10,然后在小胃的切口處開一條“岔路”,接上截取的一段小腸,重新排列小腸的位置,改變食物經(jīng)過消化道的途徑,減緩胃排空速度,縮短小腸,降低吸收,從而達(dá)到減重的目的。RYGB對(duì)2型糖尿病、高血壓、血脂異常和異常低密度脂蛋白治療方面優(yōu)于LSG,但是RYGB操作相對(duì)LSG較復(fù)雜,且并發(fā)癥較多[1]。
LSG? 手術(shù)操作難度小,且保留原有消化道,術(shù)后并發(fā)癥少。適用于青年肥胖患者以及多囊卵巢綜合征患者,但也有缺點(diǎn)如容易誘發(fā)膽囊結(jié)石以及胃食管反流病等[2]。
腹腔鏡可調(diào)節(jié)胃束帶術(shù)? 通過腹腔鏡手術(shù)束縛在胃上部,可以通過注水調(diào)節(jié)松緊的硅膠制束縛帶。但減重效果較慢,術(shù)后隨訪繁瑣,且并發(fā)癥多,逐漸被淘汰[3]。
膽胰分流-十二指腸轉(zhuǎn)位術(shù)? 手術(shù)切除了胃大彎,保留胃小彎,胃底幾乎被全部切除,仍用幽門及十二指腸首段作為出口與遠(yuǎn)端回腸的消化支吻合,保留了賁門、幽門、極短的一段十二指腸以及迷走神經(jīng),并且用胃小彎構(gòu)成的100~150 ml的管腔。膽胰分流-十二指腸轉(zhuǎn)位術(shù)比RYGB、LSG或腹腔鏡可調(diào)節(jié)胃束帶術(shù)具有更好的減重效果,也是治療糖尿病最有效的方法,但死亡風(fēng)險(xiǎn)更高,也逐漸被淘汰[4]。
目前臨床上LSG和RYGB因其操作相對(duì)簡單,且術(shù)后并發(fā)癥相對(duì)較少,已經(jīng)成為主流的術(shù)式,臨床上很少用其余幾種術(shù)式。
胃食管反流病
肥胖患者更易患胃食管反流?。╣astroesophageal reflux disease,GERD),但GERD的病理生理學(xué)機(jī)制尚未完全清楚。研究表明LSG術(shù)后47%的肥胖患者出現(xiàn)了GERD癥狀[5]。LSG手術(shù)主要是破壞了胃食管角附近的纖維,導(dǎo)致殘胃擴(kuò)張發(fā)生胃潴留,術(shù)后食管下括約肌張力減低,殘胃移位至胸腔,進(jìn)一步降低了膈肌、食管下括約肌的抗反流作用[6]。減重術(shù)后GERD的治療和預(yù)防主要包括改變生活方式、藥物治療、手術(shù)治療和內(nèi)鏡治療等:(1)改變生活方式如避免吸煙,進(jìn)食高油高脂食物以及咖啡、濃茶,患者術(shù)后出現(xiàn)GERD的癥狀可以明顯緩解。(2)當(dāng)改變生活方式無效時(shí),口服質(zhì)子泵抑制劑類藥物和促胃動(dòng)力藥物等,大多數(shù)患者的GERD癥狀可以明顯緩解[7]。(3)當(dāng)改變生活習(xí)慣和口服藥物無效時(shí),考慮手術(shù)治療,LSG+抗反流手術(shù)對(duì)GRED有明顯的治療效果,但安全性尚不確定[8];RYGB術(shù)減肥效果明顯,又有顯著抗反流功能,自然成為治療肥胖癥合并GERD的首選,但RYGB也有一定的缺陷如對(duì)胃腸道解剖結(jié)構(gòu)上改變及創(chuàng)傷大、手術(shù)操作較復(fù)雜、術(shù)后并發(fā)癥較多,患者不易接受等[9]。(4)內(nèi)鏡治療GERD效果顯著,但長期的效果有待進(jìn)一步證實(shí)[10]。
膽囊結(jié)石
減重術(shù)會(huì)增加有癥狀的膽結(jié)石病和膽囊切除術(shù)的風(fēng)險(xiǎn),Alsaif等[11]通過回顧性隊(duì)列研究發(fā)現(xiàn)有癥狀膽結(jié)石患者在6個(gè)月和12個(gè)月時(shí)的體重減輕率分別為(28.94±4.89%)和(38.51±6.84%)(P=0.002),顯著高于同期無癥狀膽結(jié)石患者的體重減輕率(24.41±6.6%)和(32.29±10.28%)(P=0.012)。Manatsathit等[12]對(duì)接受LSG的患者進(jìn)行了回顧性隊(duì)列研究,符合納入標(biāo)準(zhǔn)并接受了評(píng)估的96例患者膽囊結(jié)石形成的發(fā)生率為47.9%,有癥狀的膽囊結(jié)石發(fā)生率為22.9%,術(shù)后出現(xiàn)膽結(jié)石的患者和沒有出現(xiàn)膽結(jié)石患者的體重減輕參數(shù)沒有顯著差異,推測可能是樣本量太少的原因。Alimogullar等[13]的研究比較各組的人口統(tǒng)計(jì)學(xué)特征、合并癥、術(shù)前血脂以及早期和晚期體重減輕率,發(fā)現(xiàn)術(shù)前血脂異常是膽囊結(jié)石的一個(gè)危險(xiǎn)因素,在隨訪期間,36.9%(n=41)的患者觀察到膽結(jié)石形成,13例患者(31.8%)有癥狀性膽石癥,通過腹腔鏡膽囊切除術(shù)得到解決,多變量分析表明,血脂異常與膽結(jié)石形成有顯著的獨(dú)立相關(guān)性。減重術(shù)后患者腸道菌群會(huì)發(fā)生明顯的改變,腸道菌群失衡會(huì)影響膽汁酸和膽固醇代謝,從而導(dǎo)致膽結(jié)石[14]。減重術(shù)前患有疼痛綜合征或無癥狀膽結(jié)石的患者減重術(shù)后出現(xiàn)膽結(jié)石疼痛癥狀的風(fēng)險(xiǎn)明顯增加[15]。幽門螺桿菌感染也與膽結(jié)石病明顯相關(guān),Cen等[16]的回顧性隊(duì)列研究發(fā)現(xiàn)膽結(jié)石組與無膽結(jié)石組的幽門螺桿菌感染事件的風(fēng)險(xiǎn)比(95%可信區(qū)間)為1.84(1.19,2.85),將幽門螺桿菌陽性受試者與幽門螺桿菌陰性受試者進(jìn)行比較的膽結(jié)石事件的年齡和性別調(diào)整發(fā)生幽門螺桿菌感染的風(fēng)險(xiǎn)比為1.74(1.01,2.98),表明幽門螺桿菌感染與膽結(jié)石之間存在潛在的雙向關(guān)聯(lián)。很多研究表明熊去氧膽酸(ursodesoxycholic acid,UDCA)對(duì)減重術(shù)后預(yù)防膽囊結(jié)石的發(fā)生有很好的療效。Magouliotis等[17]的研究顯示LSG術(shù)后,治療組(術(shù)后口服6個(gè)月UDCA)與非治療組(術(shù)后口服6個(gè)月安慰劑)比較,新發(fā)膽囊結(jié)石的發(fā)病風(fēng)險(xiǎn)下降61%~95%;RYGB術(shù)后,治療組與非治療組比較,新發(fā)膽囊結(jié)石的發(fā)病風(fēng)險(xiǎn)下降56%~85%;垂直胃帶狀減容術(shù)后,治療組與非治療組比較,新發(fā)膽囊結(jié)石發(fā)病風(fēng)險(xiǎn)無明顯變化;可調(diào)節(jié)胃綁帶術(shù)后,治療組與非治療組比較,新發(fā)膽囊結(jié)石發(fā)病風(fēng)險(xiǎn)下降62%~83%;研究結(jié)果表明除垂直胃帶狀減容術(shù)外,其余手術(shù)方式術(shù)后口服UDCA可以大幅度降低新發(fā)膽囊結(jié)石發(fā)生率。Machado等[18]研究數(shù)據(jù)顯示RYGB術(shù)后,未使用UDCA的患者膽石癥發(fā)病風(fēng)險(xiǎn)是使用UDCA患者的24.4倍 。Han等[19]研究發(fā)現(xiàn)益生菌和消化酶在減重術(shù)后預(yù)防膽囊疾病效果更佳。此外,他汀類藥物也可以降低減重術(shù)后膽囊結(jié)石的發(fā)病率[15]。減重術(shù)同時(shí)行腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy,LC)是可行的預(yù)防措施,Dakour-Aridi等[20]對(duì)21 137例患者(2.0%接受了LSG+LC,98%僅接受了LSG)隊(duì)列分析顯示:LSG+LC組相對(duì)LSG組,新發(fā)膽囊結(jié)石發(fā)生率大幅度降低,平均手術(shù)時(shí)間增加了33 min。兩組在30 d總死亡率和住院時(shí)間方面沒有顯著差異,可見LSG同時(shí)行LC是可行的預(yù)防措施,且相對(duì)安全。
貧? 血
貧血常見于RYGB術(shù)后,且發(fā)病率遠(yuǎn)高于其他術(shù)式。RYGB術(shù)后2~3年內(nèi)患者存在多種微量營養(yǎng)素缺乏癥,尤其是鐵和維生素B12的缺乏[21]。減重術(shù)后為避免鐵缺乏的發(fā)生,需定期監(jiān)測患者的血清鐵離子、鐵蛋白、總鐵結(jié)合力等生化指標(biāo)。Sandvik等[22-23]研究表明RYGB術(shù)后5年左右患者會(huì)出現(xiàn)鐵儲(chǔ)備不足或耗盡,術(shù)后鐵儲(chǔ)備耗盡的患者須常規(guī)進(jìn)行靜脈補(bǔ)鐵治療,才能保持血紅蛋白水平?;颊甙l(fā)生缺鐵性貧血時(shí)可口服硫酸亞鐵、富馬酸亞鐵或葡萄糖酸鐵,同時(shí)補(bǔ)充維生素C以促進(jìn)鐵的吸收,對(duì)于無法耐受口服補(bǔ)鐵或嚴(yán)重鐵吸收不良的患者可選擇靜脈補(bǔ)鐵[24]。目前缺乏減重術(shù)后鐵、維生素B12、葉酸或銅缺乏與貧血關(guān)系的高質(zhì)量數(shù)據(jù),為了讓臨床醫(yī)師進(jìn)一步了解到接受減重術(shù)患者的術(shù)后和未來營養(yǎng)需求,還需要進(jìn)一步探究[25]??傊瑴p重術(shù)后缺鐵和貧血是常見的,個(gè)體化的鐵補(bǔ)充劑治療和靜脈注射鐵治療可以降低貧血的發(fā)生率,但不能預(yù)防缺鐵,患者需要終身接受個(gè)體化鐵補(bǔ)充劑治療。
營養(yǎng)缺乏癥及相關(guān)病變
減重術(shù)后營養(yǎng)缺乏常見的是維生素B12、葉酸、維生素E、維生素A、銅和硫胺素等缺乏。在一項(xiàng)研究中發(fā)現(xiàn)減重術(shù)后患者微量營養(yǎng)素缺乏所占百分比分別為維生素D 7.52%、維生素B128.5%、鐵 42.6%、葉酸 28.5%[26]。術(shù)后營養(yǎng)缺乏癥的神經(jīng)學(xué)表現(xiàn)包括腦病、視神經(jīng)病、脊髓病、多發(fā)性神經(jīng)根神經(jīng)病和多發(fā)性神經(jīng)病。減重術(shù)后肥胖患者微量元素缺乏的原因主要是患者的飲食依從性不佳,存在蛋白質(zhì)、維生素、微量元素?cái)z入不足,脂肪、碳水化合物攝入過量的問題[27]。
維生素B12缺乏? 常見的神經(jīng)系統(tǒng)癥狀包括感覺異常、虛弱、反射減退、痙攣、共濟(jì)失調(diào)、位置和振動(dòng)感喪失、失禁、視神經(jīng)病變導(dǎo)致的視力喪失、癡呆、精神病和情緒改變[28]。RYGB術(shù)后維生素B12缺乏率比其他術(shù)式高,有研究表明RYGB術(shù)后高達(dá)35%患者發(fā)生維生素B12缺乏,LSG術(shù)后僅8.0%患者會(huì)出現(xiàn)維生素B12缺乏[29-30]。質(zhì)子泵抑制劑可降低胃酸度和維生素B12吸收,也是減重術(shù)后患者維生素B12缺乏癥發(fā)生的一個(gè)原因[31]。Stein等[32]建議減重術(shù)后補(bǔ)充維生素B12,可采用肌肉或皮下高劑量注射,每年至少注射2次,可以避免維生素B12吸收不良。
葉酸缺乏? 減重術(shù)后葉酸(維生素B9)的缺乏會(huì)引起一系列的神經(jīng)病變?nèi)缰車窠?jīng)病變、視神經(jīng)病變、疲勞、貧血和認(rèn)知障礙[33-34]。減重術(shù)后患者葉酸水平降低,維生素B12缺乏可能會(huì)導(dǎo)致葉酸缺乏,RYGB術(shù)后的解剖變化,葉酸的吸收受到影響,會(huì)導(dǎo)致葉酸缺乏,富含葉酸食物攝入不足和不依從服用多種維生素也會(huì)導(dǎo)致葉酸缺乏[33-36]。減重術(shù)后高達(dá)65%患者出現(xiàn)葉酸的缺乏,建議對(duì)所有患者進(jìn)行篩查,育齡女性患者必查[36]。
維生素E缺乏? 減重術(shù)后維生素E水平會(huì)受到影響,尤其是在伴有膽胰分流-十二指腸轉(zhuǎn)位術(shù)中,這會(huì)影響脂溶性維生素的吸收,導(dǎo)致維生素E的缺乏[37-38]。維生素E可保護(hù)神經(jīng)細(xì)胞免受氧化損傷,減重術(shù)后維生素E缺乏可能會(huì)引起一系列的神經(jīng)病變,表現(xiàn)為反射不足、共濟(jì)失調(diào)、眼肌麻痹、上瞼下垂、構(gòu)音障礙、脊髓病和本體感覺下降[37-38]。維生素E缺乏在臨床上比較少見,建議對(duì)有癥狀的患者進(jìn)行檢查[36]。
維生素A缺乏? 維生素A是一種脂溶性維生素,維生素A缺乏的主要表現(xiàn)是夜盲癥,還可能伴有皮膚特征:瘙癢、皮膚干燥和頭發(fā)干燥等[37]。減重術(shù)后,尤其是RYGB術(shù)后會(huì)引起維生素A的缺乏,Eckert等[39]研究顯示,64例RYBG患者中有7例發(fā)現(xiàn)維生素A水平低,18例患者出現(xiàn)眼部干燥癥,45例報(bào)告了夜視力改變。減重術(shù)后4年內(nèi)維生素A的缺乏率約70%,建議在術(shù)后第1年內(nèi)進(jìn)行復(fù)查,特別是接受胃十二指腸轉(zhuǎn)流術(shù)的患者和那些有蛋白質(zhì)熱量營養(yǎng)不良的患者復(fù)查是必要的[36]。
銅缺乏? 銅的缺乏會(huì)導(dǎo)致血液系統(tǒng)疾病如貧血、中性粒細(xì)胞減少癥等,也會(huì)導(dǎo)致骨骼和結(jié)締組織疾病、多發(fā)性神經(jīng)病、視神經(jīng)病和脊髓神經(jīng)病等。RYGB術(shù)后無癥狀的銅缺乏很常見,有癥狀的銅缺乏很少見[40]。銅的主要吸收部位減少或由于鋅攝入過多干擾銅吸收,RYGB術(shù)后易發(fā)生銅缺乏。為盡量減少缺銅的風(fēng)險(xiǎn),建議術(shù)后用葡萄糖酸銅或硫酸銅進(jìn)行補(bǔ)充,術(shù)后銅的補(bǔ)充劑量取決于手術(shù)類型[36]。Pineles等[41]報(bào)道在RYGB術(shù)后,1例女患者發(fā)生了銅缺乏的視神經(jīng)病變和脊髓病變合并病例。Naismith等[42]報(bào)道了22年前1名女性在接受胃繞道手術(shù)后,發(fā)生銅缺乏相關(guān)的視神經(jīng)病變,導(dǎo)致急性和雙側(cè)失明的病例。無癥狀的銅缺乏癥很難診斷和治療延誤也會(huì)導(dǎo)致永久性神經(jīng)功能障礙[43-44]。減重術(shù)后的最初幾年內(nèi),患者通過服用多種維生素和礦物質(zhì)補(bǔ)充劑就可以保持正常的銅濃度[45]。研究表明大約10%的患者在RYGB后會(huì)缺乏銅,但癥狀很少見,臨床表現(xiàn)出的銅缺乏癥也可以通過補(bǔ)充葡萄糖酸銅或硫酸銅進(jìn)行完全糾正,因此RYGB術(shù)后不需要常規(guī)監(jiān)測銅水平[46]。
硫胺素缺乏? 減重術(shù)后硫胺素缺乏會(huì)導(dǎo)致韋尼克腦病,LSG術(shù)后患者硫胺素缺乏癥的發(fā)病率最高[47]。硫胺素缺乏癥常見的非特異性癥狀有惡心、嘔吐和食欲減退等[48]。營養(yǎng)不良、飲酒、心力衰竭或速尿藥物,以及對(duì)維生素補(bǔ)充劑的依從性差等都是導(dǎo)致硫胺素缺乏的風(fēng)險(xiǎn)因素,常規(guī)篩查和補(bǔ)充硫胺素是非常必要的[36]。無論是腸胃外給硫胺素,還是口服硫胺素都可以完全預(yù)防韋尼克腦?。?9]。
育齡女性后代出生缺陷
減重術(shù)后懷孕的婦女后代出生缺陷的風(fēng)險(xiǎn)會(huì)增加,Savel等[50]研究顯示在空腸回腸旁路手術(shù)后受孕婦女生產(chǎn)出的57名嬰兒,4名嬰兒有嚴(yán)重的出生缺陷。Haddow等[51]研究發(fā)現(xiàn)3名RYGB術(shù)后懷孕的婦女,出生嬰兒都患有神經(jīng)管缺陷。由于術(shù)后補(bǔ)充營養(yǎng)減少,任何手術(shù)方式都可能增加出生缺陷的風(fēng)險(xiǎn),有研究發(fā)現(xiàn)出生缺陷可能與特定微量營養(yǎng)素缺乏和體重獨(dú)立效應(yīng)的影響有關(guān)[52-53]。建議接受減重術(shù)的女性在術(shù)后 12~18 個(gè)月內(nèi)應(yīng)盡量避免受孕,術(shù)后患者及時(shí)補(bǔ)充維生素和礦物質(zhì);減重術(shù)的女性懷孕前和懷孕期間必須檢查是否存在營養(yǎng)缺乏,加強(qiáng)營養(yǎng)補(bǔ)充[54-55]。然而,有關(guān)出生缺陷的研究也存在局限性,減重術(shù)和先天缺陷之間關(guān)系的明確結(jié)論還需要進(jìn)一步的證據(jù)。
腎結(jié)石
腎結(jié)石的發(fā)病率在世界范圍內(nèi)呈上升趨勢,在女性人群中發(fā)病率更高。腎結(jié)石的形成與飲食因素、遺傳背景、合并癥、體內(nèi)微生物環(huán)境、尿液調(diào)節(jié)因子等都存在重要關(guān)聯(lián)。研究表明接受RYGB術(shù)的患者和接受LSG術(shù)的患者中,術(shù)后癥狀性腎結(jié)石的發(fā)生率分別為8.1%和3.7% [56]。減重術(shù)后尿草酸鹽的增加會(huì)引起腎結(jié)石,Valezi等[57]在一項(xiàng)對(duì)151例接受RYGB手術(shù)患者的研究中,發(fā)現(xiàn)尿草酸鹽從RYGB前的24 mg/d增加到RYGB后12個(gè)月的41 mg/d。減重術(shù)后腸道產(chǎn)草酸桿菌定植的減少,也可能導(dǎo)致減重術(shù)后草尿酸增加,從而增加腎結(jié)石形成風(fēng)險(xiǎn)[58]。RYGB術(shù)后尿中的檸檬酸鹽與腎結(jié)石的形成相關(guān)[59],RYGB術(shù)后患者出現(xiàn)的低尿量也會(huì)增加腎結(jié)石的形成風(fēng)險(xiǎn),建議減重術(shù)后患者每日增加液體攝入量以預(yù)防低尿量相關(guān)腎結(jié)石的形成[60]。
總結(jié)與展望
綜上,鑒于肥胖癥的日益流行和減重術(shù)適應(yīng)證的范圍擴(kuò)大,減重術(shù)后并發(fā)癥的患者人數(shù)也正在增加。如何避免減重術(shù)后并發(fā)癥的發(fā)生是減重代謝外科醫(yī)師關(guān)注的問題。外科醫(yī)師只有對(duì)各種術(shù)式的優(yōu)缺點(diǎn)、適應(yīng)證以及禁忌證等嚴(yán)格把控,同時(shí)在手術(shù)過程中規(guī)范操作,才能降低并發(fā)癥的發(fā)生率。此外,醫(yī)師和營養(yǎng)師不能籠統(tǒng)地按照指南要求來制訂術(shù)后的營養(yǎng)補(bǔ)充方案,而應(yīng)該全方位評(píng)價(jià)患者術(shù)前術(shù)后營養(yǎng)狀況,為每個(gè)患者制訂個(gè)體化的營養(yǎng)方案,這樣才能保證患者維持良好營養(yǎng)水平,有效降低并發(fā)癥的發(fā)生。減重術(shù)后有些并發(fā)癥比較少見,其發(fā)病原因以及處理對(duì)策還需要進(jìn)一步的研究探討,完全了解這些術(shù)后并發(fā)癥的機(jī)制以及處理對(duì)策可能是外科醫(yī)師最需要攻克的難題。
參考文獻(xiàn)
[1]Zhao H,Lei J.Comparative analysis for the effect of Roux-en-Y gastric bypass vs sleeve gastrectomy in patients with morbid obesity:evidence from 11 randomized clinical trials(meta-analysis)[J].Int J Surg,2019,72:216-223.DOI:10.1016/j.ijsu.2019.11.013.
[2]Kheirvari M,Dadkhah Nikroo N,Jaafarinejad H,et al.The advantages and disadvantages of sleeve gastrectomy:clinical laboratory to bedside review[J].Heliyon,2020,6(2):e03496.DOI:10.1016/j.heliyon.2020.e03496.
[3]Kuzmak LI,Thelmo W,Abramson DL,et al.Reversible adjustable gastric banding.Surgical technique[J].Eur J Surg,1994,160(10):569-571.
[4]Anderson B,Gill RS,de Gara CJ,et al.Biliopancreatic diversion:the effectiveness of duodenal switch and its limitations[J].Gastroenterol Res Pract,2013,2013:974762.DOI:10.1155/2013/974762.
[5]Popescu AL,Ionia-Radu F,Jinga M,et al.Laparoscopic sleeve gastrectomy and gastroesophageal reflux [J].Rom J Intern Med,2018,56(4):227-232.DOI:10.2478/rjim-2018-0019.
[6]Genco A,Soricelli E,Casella G,et al.Gastroesophageal reflux disease and Barretts esophagus after laparoscopic sleeve gastrectomy:a possible,underestimated long-term complication [J].Surg Obes Relat Dis,2017,13(4):568-574.DOI:10.1016/j.soard.2016.11.029.
[7]Katz PO,Gerson LB,Vela MF.Guidelines for the diagnosis and management of gastroesophageal reflux disease[J].Am J Gastroenterol,2013,108(3):308-328;quiz 329.DOI:10.1038/ajg.2012.444.
[8]Peng BQ,Zhang GX,Chen G,et al.Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy:current knowledge and surgical therapies[J].Surg Obes Relat Dis,2020,16(8):1145-1155.DOI:10.1016/j.soard.2020.04.025.
[9]Chiappetta S,Stier C,Scheffel O,et al.Mini/One anastomosis gastric bypass versus Roux-en-Y gastric bypass as a second step procedure after sleeve gastrectomy-a retrospective cohort study[J].Obes Surg,2019,29(3):819-827.DOI:10.1007/s11695-018-03629-y.
[10]閆鳴,閆文貌,白日星.減重手術(shù)術(shù)后胃食管反流病的研究進(jìn)展[J].中華胃食管反流病電子雜志,2018,5(2):77-80.
[11]Alsaif FA,Alabdullatif FS,Aldegaither MK,et al.Incidence of symptomatic cholelithiasis after laparoscopic sleeve gastrectomy and its association with rapid weight loss[J].Saudi J Gastroenterol,2020,26(2):94-98.DOI:10.4103/sjg.SJG_472_519.
[12]Manatsathit W,Leelasinjaroen P,Al-Hamid H,et al.The incidence of cholelithiasis after sleeve gastrectomy and its association with weight loss:a two-centre retrospective cohort study[J].Int J Surg,2016,30:13-18.DOI:10.1016/j.ijsu.2016.09.085.
[13]Alimogullar M,Bulu?H.Predictive factors of gallstone formation after sleeve gastrectomy:a multivariate analysis of risk factors[J].Surg Today,2020,50(9):1002-1007.DOI:10.1007/s00595-020-01971-2.
[14]Wang Q,Hao C,Yao W,et al.Intestinal flora imbalance affects bile acid metabolism and is associated with gallstone formation[J].BMC gastroenterology,2020,20(1):1-13.DOI:10.1186/s12876-020-01195-1.
[15]Haal S,Guman MSS,Bruin S,et al.Risk factors for symptomatic gallstone disease and gallstone formation after bariatric surgery[J].Obes Surg,2022,32(4):1270-1278.DOI:10.1007/s11695-022-05947-8.
[16]Cen L,Wu J,Zhu S,et al.The potential bidirectional association between Helicobacter pylori infection and gallstone disease in adults:a two-cohort study[J].Eur J Clin Invest,2023,53(2):e13879.DOI:10.1111/eci.13879.
[17]Magouliotis DE,Tasiopoulou VS,Svokos AA,et al.Ursodeoxycholic acid in the prevention of gallstone formation after bariatric surgery:an updated systematic review and meta-analysis[J].Obes Surg,2017,27(11):3021-3030.DOI:10.1007/s11695-017-2924-y.
[18]Machado FHF,Castro Filho HF,Babadopulos RFAL,et al.Ursodeoxycholic acid in the prevention of gallstones in patients subjected to Roux-en-Y gastricby pass[J].Acta Cir Bras,2019,34(1):e20190010000009.DOI:10.1590/s0102-865020190010000009.
[19]Han ML,Lee MH,Lee WJ,et al.Probiotics for gallstones prevention in bariatric surgery patients:a prospective randomized trial[J].Asian J Surg,2022,45(12):2664-2669.DOI:10.1016/j.asjsur.2022.01.120.
[20]Dakour-Aridi HN,El-Rayess HM,Abou-Abbass H,et al.Safety of concomitant cholecystectomy at the time of laparoscopic sleeve gastrectomy:analysis of the American College of Surgeons National Surgical Quality Improvement Program database[J].Surg Obes Relat Dis,2017,13(6):934-941.DOI:10.1016/j.soard.2016.12.012.
[21]Arias PM,Domeniconi EA,García M,et al.Micronutrient deficiencies after Roux-en-Y gastric bypass:long-term results[J].Obes Surg,2020,30(1):169-173.DOI:10.1007/s11695-019-04167-x.
[22]Sandvik J,Hole T,Klckner CA,et al.Intravenous iron treatment in the prevention of iron deficiency and anaemia after Roux-en-Y gastric bypass[J].Obes Surg,2020,30(5):1745-1752.DOI:10.1007/s11695-020-04396-5.
[23]Sandvik J,Bjerkan KK,Grslie H,et al.Iron deficiency and anemia 10 years after Roux-en-Y gastric bypass for severe obesity[J].Front Endocrinol (Lausanne),2021,22(12):679066.DOI:10.3389/fendo.2021.679066.
[24]中華醫(yī)學(xué)會(huì)腸外腸內(nèi)營養(yǎng)學(xué)分會(huì)營養(yǎng)與代謝協(xié)作組,北京協(xié)和醫(yī)院減重多學(xué)科協(xié)作組.減重手術(shù)的營養(yǎng)與多學(xué)科管理專家共識(shí)[J].中華外科雜志,2018,56(2):81-90.DOI:10.3760/cma.j.issn.0529-5815.2018.02.001.
[25]Lewis CA,de Jersey S,Seymour M,et al.Iron,vitamin B12,folate and copper deficiency after bariatric surgery and the impact on anaemia:a systematic review[J].Obes Surg,2020,30(11):4542-4591.DOI:10.1007/s11695-020-04872-y.
[26]Ben-Porat T,Weiss R,Sherf-Dagan S,et al.Nutritional deficiencies in patients with severe obesity before bariatric surgery:what should be the focus during the preoperative assessment[J].J Acad Nutr Diet,2020,120(5):874-884.DOI:10.1016/j.jand.2019.10.017.
[27]Hood MM,Kelly MC,F(xiàn)eig EH,et al.Measurement of adherence in bariatric surgery:a systematic review[J].Surg Obes Relat Dis,2018,14(8):1192-1201.DOI:10.1016/j.soard.2018.04.013.
[28]Roach ES,McLean WT.Neurologic disorders of vitamin B12 deficiency[J].Am Fam Physician,1982,25(1):111-115.
[29]Majumder S,Soriano J,Louie Cruz A,et al.Vitamin B12 deficiency in patients undergoing bariatric surgery:preventive strategies and key recommendations[J].Surg Obes Relat Dis,2013,9(6):1013-1019.DOI:10.1016/j.soard.2013.04.017.
[30]Van Rutte PW,Aarts EO,Smulders JF,et al.Nutrient deficiencies before and after sleeve gastrectomy[J].Obes Surg,2014,24(10):1639-1646.DOI:10.1007/s11695-014-1225-y.
[31]Long AN,Atwell CL,Yoo W,et al.Vitamin B12 deficiency associated with concomitant metformin and proton pump inhibitor use[J].Diabetes Care,2012,35(12):e84.DOI:10.2337/dc12-0980.
[32]Stein J,Stier C,Raab H,et al.Review article:the nutritional and pharmacological consequences of obesity surgery[J].Aliment Pharmacol Ther,2014,40(6):582-609.DOI:10.1111/apt.12872.
[33]Via MA,MechanickJI.Nutritional and micronutrient care of bariatric surgery patients:current evidence update[J].Curr Obes Rep,2017,6(3):286-296.DOI:10.1007/s13679-017-0271-x.
[34]Landais A.Neurological complications of bariatric surgery[J].Obes Surg,2014,24(10):1800-1807.DOI:10.1007/s11695-014-1376-x.
[35]Shane B,Stokstad EL.Vitamin B12-folate interrelationships[J].Annu Rev Nutr,1985,5:115-141.DOI:10.1146/annurev.nu.05.070185.000555.
[36]Mechanick JI,Apovian C,Brethauer S,et al.Clinical practice guidelines for the perioperative nutrition,metabolic,and nonsurgical support of patients undergoing bariatric procedures-2019 update:cosponsored by American association of clinical endocrinologists/American college of endocrinology,the obesity society,American society for metabolic & bariatric surgery,obesity medicine association,and American society of anesthesiologists[J].Surg Obes Relat Dis,2020,16(2):175-247.DOI:10.1016/j.soard.2019.10.025.
[37]Goodman JC.Neurological complications of bariatric surgery[J].Curr Neurol Neurosci Rep,2015,15(12):79.DOI:10.1007/s11910-015-0597-2.
[38]Lewis CA,de Jersey S,Hopkins G,et al.Does bariatric surgery cause vitamin A,B1,C or E deficiency? A Systematic Review[J].Obes Surg,2018,28(11):3640-3657.DOI:10.1007/s11695-018-3392-8.
[39]Eckert MJ,Perry JT,Sohn VY,et al.Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass[J].Surg Obes Relat Dis,2010,6(6):653-657.DOI:10.1016/j.soard.2010.02.044.
[40]Ernst B,Thurnheer M,Schultes B.Copper deficiency after gastric bypass surgery[J].Obesity(Silver Spring),2009,17(11):1980-1981.DOI:10.1038/oby.2009.237.
[41]Pineles SL,Wilson CA,Balcer LJ,et al.Combined optic neuropathy and myelopathy secondary to copper deficiency[J].Surv Ophthalmol,2010,55(4):386-392.DOI:10.1016/j.survophthal.2010.02.002.
[42]Naismith RT,Shepherd JB,Weihl CC,et al.Acute and bilateral blindness due to optic neuropathy associated with copper deficiency[J].Arch Neurol,2009,66(8):1025-1027.DOI:10.1001/archneurol.2009.70.
[43]Juhasz-Pocsine K,Rudnicki SA,Archer RL,et al.Neurologic complications of gastric bypass surgery for morbid obesity[J].Neurology,2007,68(21):1843-1850.DOI:10.1212/01.wnl.0000262768.40174.33.
[44]Rounis E,Laing CM,Davenport A.Acute neurological presentation due to copper deficiency in a hemodialysis patient following gastric bypass surgery[J].Clin Nephrol,2010,74(5):389-392.
[45]Papamargaritis D,Aasheim ET,Sampson B,et al.Copper,selenium and zinc levels after bariatric surgery in patients recommended to take multivitamin-mineral supplementation[J].J Trace Elem Med Biol,2015,31:167-172.DOI:10.1016/j.jtemb.2014.09.005.
[46]Kumar P,Hamza N,Madhok B,et al.Copper deficiency after gastric bypass for morbid obesity:a systematic review[J].Obes Surg,2016,26(6):1335-1342.DOI:10.1007/s11695-016-2162-8.
[47]Tang L,Alsulaim HA,Canner JK,et al.Prevalence and predictors of postoperative thiamine deficiency after vertical sleeve gastrectomy[J].Surg Obes Relat Dis,2018,14(7):943-950.DOI:10.1016/j.soard.2018.03.024.
[48]Dihn D,Chien K,Ma L.Case Report:Wernicke encephalopathy following Roux-en-Y gastric bypass[J].Am Fam Physician,2020,102(4):197-198.
[49]Oudman E,Wijnia JW,van Dam M,et al.Preventing wernicke encephalopathy after bariatric surgery[J].Obes Surg,2018,28(7):2060-2068.DOI:10.1007/s11695-018-3262-4.
[50]Savel LE,Simon SR,Maxon WS.Pregnancy after jejunoileal bypass.A review and report of one case[J].Obstet Gynecol,1978,52(1 Suppl):58S-60S.
[51]Haddow JE,Hill LE,Kloza EM,et al.Neural tube defects after gastric bypass[J].Lancet,1986,1(8493):1330.DOI:10.1016/s0140-6736(86)91252-3.
[52]Maggard MA,Yermilov I,Li Z,et al.Pregnancy and fertility following bariatric surgery:a systematic review[J].JAMA,2008,300(19):2286-2296.DOI:10.1001/jama.2008.641.
[53]Guelinckx I,Devlieger R,Vansant G.Reproductive outcome after bariatric surgery:a critical review[J].Hum Reprod Update,2009,15(2):189-201.DOI:10.1093/humupd/dmn057.
[54]Mechanick JI,Youdim A,Jones DB,et al.Clinical practice guidelines for the perioperative nutritional,metabolic,and nonsurgical support of the bariatric surgery patient-2013 update:cosponsored by American Association of Clinical Endocrinologists,the Obesity Society,and American Society for Metabolic & Bariatric Surgery[J].Obesity(Silver Spring,Md.),2013,21Suppl1(1):S1-S27.DOI:10.1002/oby.20461.
[55]Kominiarek MA,Jungheim ES,Hoeger KM,et al.American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society[J].Surg Obes Relat Dis,2017,13(5):750-757.DOI:10.1016/j.soard.2017.02.006.
[56]Mishra T,Shapiro JB,Ramirez L,et al.Nephrolithiasis after bariatric surgery:a comparison of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy[J].Am J Surg,2020,219(6):952-957.DOI:10.1016/j.amjsurg.2019.09.010.
[57]Valezi AC,F(xiàn)uganti PE,Junior JM,et al.Urinary evaluation after RYGBP:a lithogenic profile with early postoperative increase in the incidence of urolithiasis[J].Obes Surg,2013,23(10):1575-1580.DOI:10.1007/s11695-013-0916-0.
[58]Siener R,Bangen U,Sidhu H,et al.The role of oxalobacter formigenes colonization in calcium oxalate stone disease[J].Kidney Int,2013,83(6):1144-1149.DOI:10.1038/ki.2013.104.
[59]Lieske JC,Mehta RA,Milliner DS,et al.Kidney stones are common after bariatric surgery[J].Kidney Int,2015,87(4):839-845.DOI:10.1038/ki.2014.352.
[60]Borbély YM,Osterwalder A,Krll D,et al.Diarrhea after bariatric procedures:diagnosis and therapy[J].World J Gastroenterol,2017,23(26):4689-4700.DOI:10.3748/wjg.v23.i26.4689.
(收稿日期:2022-10-21)