胃間隔手術可能對兒童族群有益


  【24drs.com】根據一篇線上發表在3月3日臨床肥胖學期刊的系統性綜論結果,胃間隔手術對於肥胖兒童與青少年可能是有效的,但是需要以較謹慎的方法進行。
  
  來自英國倫敦國際肥胖研究組織的Andrea Aikenhead在一篇新聞稿中表示,肥胖流行現在同時影響兒童與成人,且肥胖及其共病,還有醫療花費不斷地上升,建立有效治療兒童肥胖的方法,不僅能降低兒童肥胖的盛行率以及相關的不健康狀態,同時可以抑制肥胖兒童長大成人的比例,這是對抗這個流行一個關鍵步驟。
  
  研究人員搜尋2010年9月6日前的PubMed、ISI網路科學、EMBASE以及考科藍圖書館,也針對找出文章的參考文獻進行手動搜尋;收納條件包括英文摘要的文章,收納19歲以下受試者,且在術後至少測量體重一次以上,以及至少一年的術後追蹤。
  
  收納的37項研究中,共有831位兒童或青少年,橫跨了36年。在13項以胃束帶進行的研究中,身體質量指數(BMI)平均從8.5下降到4.3 kg/m2,其中1項病例研究報告體重不降反增。8項以Roux-en-Y胃繞道(RYGB)手術進行的研究,BMI平均介於9到25 kg/m2。
  
  另外14項研究使用其他形式的胃間隔手術,包括袖狀胃切除術、垂直加帶胃隔間手術、胰繞道手術,或是合併術式。這些術式可以降低BMI 9到24 kg/m2,許多病例術後復胖,且發生3件與手術有關的死亡事件。
  
  大部分研究報告共病消除或改善。許多外科術式與一連串術後併發症有關,包括潰瘍、小腸滲漏、傷口感染、吻合口狹窄、營養缺乏、腸阻塞、肺栓塞、釘線中斷、間隔滑動、精神後遺症、以及反覆嘔吐。
  
  僅有一澳洲模擬研究分析經濟效益,且研究結果顯示腹腔鏡可調整胃間隔(LAGB)手術對青少年是符合經濟效益的。
  
  研究作者們寫到,現存的證據顯示,雖然大部分是根據統計力量不足、回溯性的研究,代表較大兒童接受胃間隔手術可以顯著減重且改善共病與生活品質。
  
  然而,青少年的術後併發症、順應性以及後續追蹤比成人麻煩,且安全性的長期數據、效果與經濟效益大部分仍然未知。目前可獲得的證據還有進步的空間,對於兒童與青少年進行胃間隔手術應該更謹慎,且建議採取可回復的術式,而非永久改變解剖構造的方法。
  
  這項研究的限制包括大部分研究是回溯性或觀察性設計、統計力量不足、樣本數目太少、整體結果並非可比較的、以及低發生率的預後,例如死亡率與併發症資訊有限。除此之外,不容易確認青少年復胖的程度,部分是因為患者失去後續追蹤的誤差。
  
  作者們的結論是,不應忘記生活型態改變與預防的功效:前者對胃間隔手術的長期成功是關鍵的。現在需要趕快發展出手術外的治療方法,例如實際的生活型態計畫,可以有效適用於中度肥胖、過重以及肥胖兒童。公共衛生專家們必須繼續致力於預防準則,讓政府了解執行健康促進公共衛生政策,以支持預防性計畫以及足夠的治療性長期研究。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6480&x_classno=0&x_chkdelpoint=Y
  

Bariatric Surgery May Be Helpful in Pediatric Population

By Laurie Barclay, MD
Medscape Medical News

March 15, 2011 — Bariatric surgery may be effective in obese children and adolescents, but a cautious approach is warranted, according to the results of a systematic review reported online March 3 in Clinical Obesity.

"The obesity epidemic now affects children as well as adults, with obesity and its associated morbidities and costs increasing in scale," said lead author Andrea Aikenhead, from the International Association for the Study of Obesity in London, United Kingdom, in a news release. "Establishing effective methods for treating severe obesity in children will not only reduce the prevalence of childhood obesity and related ill health, but inhibit the progression of obese children to obese adults, a crucial step in combating the epidemic."

The investigators searched PubMed, ISI Web of Science, EMBASE, and the Cochrane Library to September 6, 2010, and also did a manual search of reference lists of retrieved articles. Inclusion criteria were articles with English-language abstracts reporting on participants not older than 19 years, with 1 or more measurements of postoperative weight loss and at least 1 year of postoperative follow-up.

The 37 included studies enrolled a total of 831 children or adolescents, spanning 36 years. Among 13 studies of gastric banding, mean decreases in body mass index (BMI) ranged from 8.5 to 43 kg/m2, with weight gain reported in 1 case study. Mean BMI reductions ranged from 9 to 25 kg/m2 in 8 studies of Roux-en-Y gastric bypass (RYGB).

Other forms of bariatric surgery, including sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion, or a combination of procedures, were reported in 14 articles. These procedures resulted in mean BMI decreases ranging from 9 to 24 kg/m2, weight regain in several cases, and 3 deaths related to surgery.

Most studies reported resolution or improvement of comorbid conditions. Various surgical procedures were associated with a range of postoperative complications including ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological sequelae, and repeated vomiting.

Only 1 Australian modeling project studied cost-effectiveness, and results of this study suggested that laparoscopic adjustable gastric banding (LAGB) is cost effective for adolescents.

"Existing evidence — although based generally on underpowered, retrospective studies — suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life," the study authors write.

"However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy."

Limitations of this study include retrospective or observational design in most studies, insufficient power, generally small sample sizes, results not broadly comparable, and limited information for low-frequency outcomes such as mortality and complications. In addition, it was difficult to determine the degree of weight regain in adolescents, in part because of the bias introduced by patients lost to follow-up.

"Lifestyle modification and prevention should not be de-emphasized: the former is crucial to the long-term success of bariatric procedures," the study authors conclude. "There is an urgent need to develop alternatives to surgery, such as practical lifestyle programmes that are effective, even modestly, for overweight and obese children. Public health experts must continue to employ the precautionary principle to convince governments of the importance of implementing health-promoting public policies to support prevention programmes and adequate long-term research for treatment."

The project that led to this study was funded by the WHO Health Evidence Network of the World Health Organization. The study authors have disclosed no relevant financial relationships.

Clin Obesity. Published online March 3, 2011.

    
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