極端肥胖糖尿病青年可能因為Roux-en-Y胃繞道手術而受益


  December 30, 2008 — 根據一項發表在2009年1月號小兒科期刊上的研究結果,Roux-en-Y胃繞道手術可能使極端肥胖的糖尿病青少年體重顯著減少,降低心血管疾病危險因子,並使第二型糖尿病消退。
  
  俄亥俄州辛辛那提兒童醫院醫學中心的Thomas H. Inge醫師與其同事寫到,第二型糖尿病與肥胖、血脂異常及高血壓有關,這些都是廣為人知的心血管疾病危險因子。外科手術減重可以顯著降低成人的這些危險因子。我們假設胃繞道手術可以改善罹患第二型糖尿病青少年的代謝異常參數以及心血管疾病危險因子。
  
  11位青少年在5個醫學中心接受Roux-en-Y胃繞道手術,這些青少年都是極端肥胖的(平均身體質量指數[BMI]為50 ± 5.9 kg/m2),且有許多心血管疾病危險因子。這些病患的人體測量、血行動力學,以及生物化學評測以及手術併發症,都與67位同樣罹患第二型糖尿病且接受一年藥物治療的病患相比較。
  
  手術後,11位青少年中有10位有第二型糖尿病消退的證據。BMI(差異為-34%)、空腹血糖值(差異為-41%)、空腹胰島素值(差異為-81%)以及糖化血紅素值(7.3%-5.6%)、胰島素敏感性、脂肪,還有血壓都有顯著差異。
  
  那些接受藥物治療的第二型糖尿病青少年,體重是穩定的(試驗前BMI為35 ± 7.3 kg/m2,一年後為34.9 ± 7.2 kg/m2),且血壓與糖尿病藥物在後續追蹤一年間並沒有顯著差別。然而,他們的糖化血紅素值有顯著改善(試驗前為7.85% ± 2.3%,一年後為7.1% ± 2%)。
  
  研究作者寫到,極端肥胖的第二型糖尿病青少年,在Roux-en-Y胃繞道手術體驗到體重顯著下降與第二型糖尿病消退的經驗。胰島素抗性、貝他細胞功能,以及心血管危險因子的改善,支持了Roux-en-Y胃繞道手術作為改善這些青少年健康的一個方法。雖然Roux-en-Y的長期療效仍然未知,但這些發現顯示Roux-en-Y胃繞道手術是改善罹患第二型糖尿病極端肥胖青少年的治療選擇。
  
  這項研究的限制包括這項研究是在不同中心進行,日常病患照護下回溯性地收集病歷資料,沒有共同的病患處理計畫;有資料缺失,特別是手術組病患在後續追蹤一年時的實驗室檢驗值以及糖化血紅素值,在11位病患中僅有5位有這些資料,缺乏標準化實驗室檢驗方法;即使僅針對少數臨床特徵,但不容易找到與手術組相符的病患族群;最後,接受外科手術病患人數不多,且後續追蹤時間相對較短。
  
  試驗作者的結論是,在這些挑選過後的病例,外科手術降低體重似乎可以提供一個反轉不良健康預後的有效方法。然而,胃間隔手術在青少年的長期療效與安全性仍然需要建立。如果代謝記憶的觀念在EDIC(Epidemiology of Diabetes Interventions and Complications)研究中獲得印證,我們假設特定病患早期,而不是後期接受外科介入(這些病患主要是嚴重肥胖的糖尿病患者,且對於藥物治療無效,以及處於與第二型糖尿病有關併發症高風險),可能因為這個有效的方法而嚴格控制血糖,因而預防長期不良健康預後。
  
  研究作者們表示沒有相關資金上的往來。

Extremely Obese Diabetic Teens May Benefit From Roux-en-Y Gastric Bypass

By Laurie Barclay, MD
Medscape Medical News

December 30, 2008 — Roux-en-Y gastric bypass may allow significant weight loss, reduced cardiovascular risk factors, and remission of type 2 diabetes mellitus in extremely obese diabetic adolescents, according to the results of a study reported in the January 2009 issue of Pediatrics.

"Type 2 diabetes mellitus is associated with obesity, dyslipidemia, and hypertension, all well-known risk factors for cardiovascular disease," write Thomas H. Inge, MD, PhD, from Cincinnati Children's Hospital Medical Center in Ohio, and colleagues. "Surgical weight loss has resulted in a marked reduction of these risk factors in adults. We hypothesized that gastric bypass would improve parameters of metabolic dysfunction and cardiovascular risk in adolescents with type 2 diabetes mellitus."

At 5 centers, 11 adolescents underwent Roux-en-Y gastric bypass. These adolescents were extremely obese (mean body mass index [BMI], 50 ± 5.9 kg/m2) and had numerous cardiovascular risk factors. Anthropometric, hemodynamic, and biochemical measures and surgical complications in these patients were compared vs those of 67 adolescents with type 2 diabetes mellitus who were treated medically for 1 year.

After surgery, 10 of the 11 adolescents had evidence of remission of type 2 diabetes mellitus. There were also significant improvements in BMI (difference, –34%), fasting blood glucose levels (difference, –41%), fasting insulin concentrations (difference, –81%), hemoglobin A1c levels (7.3% - 5.6%), insulin sensitivity, serum lipid levels, and blood pressure.

In those adolescents with type 2 diabetes mellitus who were treated medically, body weight was stable (baseline BMI, 35 ± 7.3 kg/m2; 1-year BMI, 34.9 ± 7.2 kg/m2), and blood pressure level and diabetic medication use did not change significantly during 1 year follow-up. However, they had significant improvements in hemoglobin A1c levels (baseline, 7.85% ± 2.3%; 1 year, 7.1% ± 2%).

"Extremely obese diabetic adolescents experience significant weight loss and remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass," the study authors write. "Improvements in insulin resistance, beta-cell function, and cardiovascular risk factors support Roux-en-Y gastric bypass as an intervention that improves the health of these adolescents. Although the long-term efficacy of Roux-en-Y gastric bypass is not known, these findings suggest that Roux-en-Y gastric bypass is an effective option for the treatment of extremely obese adolescents with type 2 diabetes mellitus."

Limitations of this study include retrospective review of data collected during routine clinical care of patients at multiple institutions without common patient management protocols; missing data, particularly laboratory data at 1 year in the surgical cohort, and hemoglobin A1c levels available in only 5 of the 11 patients at 1 year; lack of standardization of laboratory assays; difficulty in matching cohorts on even a small number of characteristics; and small number of surgical patients with relatively short follow-up.

"In selected cases, surgical weight loss seems to provide an effective method to reverse adverse health outcomes, at least for the short-term," the study authors conclude. "However, the long-term safety and efficacy of bariatric surgery in adolescents remains to be firmly established. If the concept of metabolic memory demonstrated in the EDIC [Epidemiology of Diabetes Interventions and Complications] study applies, we hypothesize that earlier rather than later surgical intervention in selected subjects (severely obese diabetics refractory to medical therapy or at high risk for morbidities associated with T2DM [type 2 diabetes mellitus]) may be an effective method for providing tight control of hyperglycemia, and thus preventing adverse health outcomes in the long-term."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;123:214-222.

    
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