ASMBS 2009:術前狀態會影響糖尿病患胃繞道手術的長期結果


  June 25, 2009 (德州達拉斯) — 根據發表於美國代謝與減重手術協會(ASMBS)第26屆年會的研究,及早轉診進行胃繞道手術,比較可以長時間緩解那些疾病初期之第2型糖尿病患者的症狀。
  
  作者之一、維吉尼亞Commonwealth大學外科教授James Maher醫師表示,有許多胃繞道手術對糖尿病患有利的資訊。
  
  報告指出,80%至90%病患的糖尿病獲得解決,但是有關糖尿病長期緩解的資訊有限。
  
  研究者著眼於在1993至2003年間接受Roux-en-Y胃繞道手術之177名病患的結果;最短追蹤期間為至少5年,有些病患追蹤長達16年。病患根據他們術前的糖尿病狀態分成三類:59名屬於胰島素依賴型、83人服用口服藥物、35人單用飲食控制他們的狀況。
  
  研究者發現,這177名病患手術之後有157人(89.0%)的第2型糖尿病完全緩解。平均身體質量指數從術前的50.2 kg/m2 降低到術後的31.3 kg/m2,平均減輕過量體重70.0%。20名病患(11.3%)平均減輕過量體重58.2% (P< 0.0009),但是他們的第2型糖尿病並未緩解。157人中有68人(43.1%)的糖尿病再度出現,與體重復胖有關。
  
  Maher醫師在Medscape General Surgery的訪問中表示,胃繞道手術顯然是有效的。對於大多數病患而言,緩解是持久的。如果比喻成癌症,你可以說他們已經被治癒。
  
  糖尿病緩解持久的定義是無症狀5年以上,術前屬於非胰島素依賴型之病患的此一比率較高:服用口服降血糖藥物者為66%、僅以飲食控制者為76%。
  
  Maher醫師表示,病患和第一線照護醫師需要知道的是,病患越早轉診進行手術治療,長期結果會越好。如果他們在以飲食控制或以口服藥物時即轉診,他們有治癒糖尿病的良機。
  
  Maher醫師表示,研究認為,罹患糖尿病的期間越長,病患胃繞道手術的長期成功率降低。
  
  Maher醫師推論,產生胰島素的細胞自己會消耗殆盡。重點在於,你沒有足夠的儲量來永久治癒此病。
  
  ASMBS前總裁Philip Schauer醫師表示,本研究之所以重要,在於其探究胃繞道手術對糖尿病之影響的追蹤期間夠長。
  
  俄亥俄州克里夫蘭診所減重與代謝研究中心主任、微創一般外科主任、克里夫蘭診所Lerner醫學院外科教授Schauer醫師表示,我們已經知道,胃繞道手術對於緩解糖尿病有立即的強力效果,有80%至85%的病患緩解。本研究顯示,他們在術後至少5年依舊沒有糖尿病。顯示這具有長期效果。
  
  Schauer醫師指出,本分析確認其他研究的發現,胃繞道手術的時機會影響糖尿病患的長期緩解狀態。
  
  Schauer醫師表示,如果病患手術時疾病惡化,他們可以從手術中獲益,但是可能無法有持久的緩解。在他們成為胰島素依賴型之前進行介入是重要的,本研究也支持此論點。非屬胰島素依賴型的病患,有較佳與較久的緩解。許多病患的疾病可以解決。
  
  本研究為獨立進行。Maher醫師宣告沒有相關財務關係。Schauer醫師接受Ethicon Inc和Covidien Inc兩家公司的資金。
  
  美國代謝與減重手術協會第26屆年會:摘要PL-101。發表於2009年6月24日。
  

ASMBS 2009: Preoperative Status Affects Long-Term Outcome of Gastric Bypass Surgery in Diabetics

By Louise Gagnon
Medscape Medical News

June 25, 2009 (Dallas, Texas) — Early referral for gastric bypass surgery is more likely to resolve symptoms of type?2 diabetes mellitus over the long haul in patients in the early stages of the disease, according to research presented here at the American Society for Metabolic and Bariatric Surgery (ASMBS) 26th Annual Meeting.

"There is a lot of information about the beneficial effects of gastric bypass [surgery] on patients with diabetes," said James Maher, MD, professor of surgery at Virginia Commonwealth University in Richmond, and one of the study's authors.

"It's reported that 80% to 90% of patients have resolution of their diabetes, but there is very little information about long-term resolution of diabetes."

Investigators looked at outcomes of 177 patients who underwent Roux-en-Y gastric bypass surgery between 1993 and 2003; minimum follow-up was at least 5 years, and was as long as 16 years for some patients. Patients were stratified into 3 categories on the basis of their diabetes status prior to surgery: 59 were insulin-dependent, 83 were taking oral medications, and 35 were controlling their condition with diet alone.

Researchers found that complete resolution of type?2 diabetes occurred in 157 of 177 patients (89.0%) after surgery. There was a decrease in mean body mass index from a preoperative measurement of 50.2?kg/m2 to a postoperative measurement of 31.3?kg/m2, and a mean excess weight loss of 70.0%. Twenty patients (11.3%) had a mean excess weight loss of 58.2% (P?< 0.0009), but their type?2 diabetes did not resolve despite the weight loss. Diabetes reappeared in 68 (43.1%) of 157 patients and was linked to a regaining of the weight that was lost as a result of surgery.

"It's obvious that gastric bypass is very effective," said Dr. Maher in an interview with Medscape General Surgery. "For most patients, the resolution was durable. If they had cancer, you would refer to the patients as being cured."

Durability of diabetes resolution, defined as being symptom-free for 5 or more years, was higher in patients who were not insulin-dependent prior to surgery — who were taking oral hypoglycemics (66%) or controlling the condition with diet only (76%) — than their counterparts who were insulin-dependent prior to surgery.

"The real message to patients and to primary-care physicians is that the earlier you refer patients for surgical therapy, the better the long-term results will be," said Dr. Maher. "If they are referred at the stage when they are controlled by diet alone or oral medications alone, they have a good chance of being 'cured' of their diabetes."

Dr. Maher said the study suggests that longer duration of diabetes reduces a patient's long-term success of gastric bypass surgery.

"The insulin-producing cells may be 'burning themselves out'," speculated Dr. Maher. "It may get to a point that you don't have enough reserve to be permanently cured of the disease."

The study is significant because of the length of follow-up beyond the initial impact of gastric bypass surgery on diabetes, according to Philip Schauer, MD, past president of the ASMBS.

"We have known for quite a while that gastric bypass has a powerful immediate effect in terms of remission of diabetes, with 80% to 85% of patients having remission," said Dr. Schauer, professor of surgery at the Cleveland Clinic Lerner College of Medicine, chief of Minimally Invasive General Surgery, and director of the Cleveland Clinic Bariatric and Metabolic Institute in Ohio. "This study shows that they are still free of their diabetes at least 5 years after surgery. It shows the impact in the long term."

This analysis confirms the findings of other studies, that the timing of gastric bypass surgery will affect the likelihood of long-term resolution of diabetes in patients, added Dr. Schauer.

"If patients are advanced in their disease when they have the surgery, they will benefit [from gastric bypass surgery], but may not see durable remission," said Dr. Schauer. "Intervening before they are insulin-dependent is critical, and this study supports that. The patients who were not insulin-dependent had a much better and more durable remission. We can arrest the disease for many patients."

The study was independently conducted. Dr. Maher has disclosed no relevant financial relationships. Dr. Schauer receives grant funding from Ethicon Inc and from Covidien Inc.

American Society for Metabolic and Bariatric Surgery (ASMBS) 26th Annual Meeting: Abstract PL-101. Presented June 24, 2009.

    
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