胃間隔手術對肥胖青少年是安全的


  July 7, 2006 (舊金山) — 根據第23屆美國胃間隔手術學會年會所發表的兩個研究資料,胃間隔手術對肥胖青少年是安全且有效的。
  
  胃間隔手術用於治療成人病態肥胖,但迄今對於青少年族群的危險和好處的資料很少;儘管兩項研究都是相對回溯性、單一中心研究,其資料認為青少年病患面對此手術的風險和成人一樣。
  
  義大利Genoa大學醫學院的Francesco S. Papadia醫師和其同事,評估了在1976年5月到2005年12月間、68位於18歲生日前進行膽胰分流術的長期效益;這些人之中有52% 是女性,手術時平均年紀是16.8歲(範圍從14 - 18 歲),平均體重是125 kg (範圍從70 - 198 kg),平均身體質量指數(BMI) 是46 kg/m2 (範圍從26 - 71 kg/m2)。
  
  沒有因手術導致的死亡,長期死亡率是3%,包括1位發生急性胰臟炎的;有14位進行其他19次的附加手術,包括7次修正手術。
  
  平均追蹤期間為11年 (範圍從2 - 23 年),病患平均減輕78% 體重;開始時的共同疾病大多在術後解決且體重減輕;有33位在開始時有高血壓,有6位 (18%)在最長追蹤期後仍有高血壓 ;此外,有11位有脂肪酸代謝異常,3位是高血糖,2位有第二型糖尿病,這些都在治療後消失。
  
  在術後1到10年有12位發生蛋白質營養不良,包括2位女性懷孕時發生嚴重營養不良而死亡;Papadia醫師指出這兩位女性未在懷孕時在他的門診回診,因而未在懷孕期間獲得應有的密切追蹤;另一方面,在術後4到23年有18位女性產下28位健康小孩,有一個寶寶是心智遲緩。
  
  進一步分析這些發生蛋白質營養不良的病患,他們的原始體重比其他56位沒有類似問題者高(143相較於 121 kg; P = .01),他們也有較高的BMI (53相較於44 kg/m2;P < .01) ,至於胃容量則沒有顯著較小 (253相較於315;P = .07),平均年紀(16.9相較於16.4歲, p=0.34)、性別比率 (73%相較於92% 女性; P = .17),或消化道長度 (204相較於208;P = .37) 均無差異。
  
  Papadia醫師表示,在我們逐年的系列研究中可以發現,蛋白質營養不良的發生率從30%降至目前的2.1%;參考Genoa大學醫學院1976年以來2637位接受胃間隔手術病患的不計年齡追蹤資料,胃間隔區域越大則體重減少越多,但是也增加了蛋白質營養不良的比率;基於此觀察,該團隊目前極少在手術中納入胃間隔術。
  
  Papadia醫師在發表時結論指出,年紀似乎對[膽胰分流術]的結果與併發症不會有影響,而懷孕婦女必須要有仔細的追蹤。
  
  加拿大Laval醫院Simon Biron 醫師指出一個醫師和病患都必須警覺的事實,就是此研究告訴大家胃間隔手術是一輩子的事情。
  
  另一個研究中,巴西Sao Camilo醫院Jose L. Pinheiro醫師和同事回顧49位平均16歲(範圍從13 - 18歲) 在他們醫院接受腹腔鏡Roux-en-Y 胃繞道術的病患;研究者指出,90%的肥胖青少年變成肥胖成年人,而增加了致病率和死亡率;但是對此族群進行胃間隔手術存在有偏見,更缺乏這會造成問題的資料。
  
  這些病患在接受手術前進行心理評估且獲得父母親支持,其中有35位男性,開始時的平均 BMI是45 kg/m2,範圍從41到50 kg/m2,術前共同疾病有16位有高血壓、6位接受憂鬱症治療、3位糖尿病患、3位血清中胰島素過高、3位膽結石、3位有關節病、2位有氣喘、1 位有胃食道逆流疾病。
  
  沒有手術間併發症,沒有轉化,沒有術後併發症,沒有死亡,平均留院時間為30小時。
  
  平均追蹤期48 個月(範圍從3 - 60個月),平均 BMI是23.5 kg/m2 (未提供範圍);Pinheiro醫師表示,我們的每個病患都進行體能運動,減少許多過重的體重,效果比其他年齡層好。
  
  開始時的共同疾病大多在術後解決,且病患的生理心理健康在追蹤期間也維持良好。
  
  他總結指出,胃繞道手術應可提供作為肥胖青少年的治療。
  
  Dalton手術團隊的Jaime Ponce 醫師表示,這些資料遠比成人進行胃繞道手術者為佳;不過,他提問說最後是否有病患後悔進行手術,應給青少年有改變心意的機會。
  
  Pinheiro醫師對此回應表示,這是非常重要的,當我們開始進行此研究時,我們也不確定會發生什麼事情,因為有關於此的文獻著實太少,我們相當盡力的對這些病患密切追蹤,目前為止我們看到比40、50歲病患的治療效果為佳,而青少年們對此治療感到滿意,因為他們變瘦且活動力變好。
  
  該團隊的正式生活品質測量正在進行中,而未包括在此次報告。
  
  

Bariatric Surgery Safe for Obe

By
Medscape Medical News

July 7, 2006 (San Francisco) — Bariatric surgery is safe and effective for adolescents, according to data from 2 studies presented here at the 23rd annual meeting of the American Society of Bariatric Surgery.

Bariatric surgery is an accepted treatment for morbidly obese adults, but until now there have been few data available on its risks and benefits in the adolescent population. Although both studies were relatively retrospective, single-institution studies, the data suggest that the risks adolescents face with the surgery are similar to those of adult bariatric patients.

Francesco S. Papadia, MD, from the University of Genoa School of Medicine in Italy, and colleagues evaluated the long-term outcomes of 68 patients who underwent biliopancreatic diversion prior to their 18th birthday between May 1976 and December 2005. Of the patients, 52% were women, mean age at the time of surgery was 16.8 years (range, 14 - 18 years), mean body weight was 125 kg (range, 70 - 198 kg), with a mean body mass index (BMI) of 46 kg/m2 (range, 26 - 71 kg/m2).

There were no deaths due to surgery in the patient population and long-term mortality was 3%, including 1 patient who developed acute pancreatitis. Fourteen patients had to have a total of 19 additional surgeries, including 7 revisions.

With a mean follow-up time of 11 years (range, 2 - 23 years), patients lost on average 78% of their initial excess weight. The majority of comorbidities present at baseline resolved after surgery and weight loss in this patient population. Of the 33 patients who were hypertensive at baseline, 6 (18%) remained hypertensive at their longest follow-up. In addition, 11 patients were dyslipidemic, 3 were hyperglycemic, and 2 had type 2 diabetes at baseline, and all of these comorbidities cleared up after treatment.

Twelve patients developed protein malnutrition 1 to 10 years after surgery, including 2 women who developed severe protein malnutrition during pregnancy and died. Dr. Papadia noted that the women were not seen at his clinic during pregnancy and, therefore, might not have been followed as closely as they should have been during pregnancy. On the other hand, 18 women patients gave birth to 28 healthy children 4 to 23 years after surgery. One baby was mentally retarded.

Closer analysis of the patients who developed protein malnutrition showed that they had a higher initial body weight compared with the 56 patients who did not have the problem (143 vs 121 kg; P = .01). They also had a higher BMI (53 vs 44 kg/m2; P < .01) and there was a nonsignificant trend toward having a smaller gastric volume (253 vs 315; P = .07). There was no difference in mean age (16.9 vs 16.4 years, p=0.34), sex ratio (73% vs 92% female; P = .17), or alimentary limb length (204 vs 208; P = .37).

"To put this into perspective, in our series throughout the years you can see a steadily decreasing incidence of protein malnutrition ranging from 30% in the initial years to 2.1% incidence recently," said Dr. Papadia, referring to follow-up data from all 2637 patients who have undergone bariatric surgery at the University of Genoa Medical School since 1976 regardless of age. "We thought back then that adding gastric restriction would increase weight loss, which it does, but it increases the rate of protein malnutrition extremely." As a result of this observation, the team now rarely includes gastric restriction in the surgery.

"Age seems to have no effect on the results and complications of [biliopancreatic diversion]," concluded Dr. Papadia during his presentation. "Pregnant patients have to be carefully followed up."

"This study shows well that bariatric surgery is a surgery for a lifetime," said Simon Biron, MD, from Laval Hospital in Quebec, Canada, a fact of which both bariatric surgeons and patients should be well aware.

In the second study, Jose L. Pinheiro, MD, and colleagues from Hospital Sao Camilo in Sao Paulo, Brazil, reviewed data from 49 patients with a mean age of 16 years (range, 13 - 18 years) who underwent laparoscopic Roux-en-Y gastric bypass at their institution. The researchers noted that 90% of obese adolescents become obese adults and have increased morbidity and mortality throughout their lifetime as a result. Yet there is an a priori bias against performing bariatric surgery in these patients, despite a lack of data indicating there is a problem.

All patients in the cohort were required to undergo psychiatric evaluation prior to the surgery and to have full parental support. Thirty-five of the patients were men. The mean BMI at baseline was 45 kg/m2, with a range of 41 to 50 kg/m2. Comorbidities prior to surgery included 16 patients with hypertension, 6 being treated for depression, 3 cases of diabetes, 3 with high serum insulin, 3 with cholelithiasis, 3 with arthropathy, 2 with asthma, and 1 with gastroesophageal reflux disease.

There were no intraoperative complications, no conversions, no postoperative complications, and no deaths. Patients' mean hospital stay was 30 hours.

With a mean follow-up of 48 months (range, 3 - 60 months), the mean BMI was 23.5 kg/m2 (no range given). "All of our patients practice physical activity," said Dr. Pinheiro. "And excess weight loss is very high, better than other age groups."

All comorbidities were resolved after the surgery and both the physical and psychological health of the patients appeared good during follow-up.

"Gastric bypass should be offered as a treatment for obese adolescents," he concluded.

These data "are much better than we have for gastric bypass in adults," said Jaime Ponce, MD, from the Dalton Surgical Group in Dalton, North Carolina. Nonetheless, he asked whether any of the patients ended up regretting their choice of surgery, given teenagers' propensity to change their mind.

"This is something that is very important, and when we started doing this study we weren't sure what was going to happen with these patients because there was not much data in the literature," responded Dr. Pinheiro. "We really tried to follow these patients closely, and what we have seen so far is that they are much more committed to the treatment than are older patients, who are 40-something or 50-something. They seem to enjoy the treatment because they are getting thinner and becoming more active."

The team's formal quality-of-life measurements are ongoing and were not included in the presentation.

ASBS 23rd Annual Meeting: Abstracts 9, 10. Presented June 29, 2006.

Reviewed by Carol Peckham

    
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