胃旁路术的效果可持续至术后6年

《JAMA》9月19日发表的一项前瞻性研究表明，在418例接受了Roux-en-Y胃旁路术的重度肥胖患者中，大部分患者的减重效果及相关的心血管和代谢改善效益一直持续至术后6年。

美国犹他大学内科学系的Ted D. Adams博士及其同事以体重指数(BMI)≥35 kg/m²(平均BMI 45.9 kg/m²⁾的重度肥胖患者为研究对象，其中女性占82%，白人占96%。干预组的418例患者接受开腹或腹腔镜下胃旁路术；第一对照组的417例患者与干预组同时接受术前评估，但并没有接受手术；第二对照组的321例患者则随机选取自犹他州居民的一个基于人群的样本。
 


接受了胃旁路术的患者术后6年仍能维持平均减重28%的效果，并且糖尿病、高脂血症和高血压的缓解率也都明显改善。

虽然对照组患者无需接受该研究提出的减重干预措施，但可以自行采取各种减重措施。随着时间的推移，两个对照组共有101例受试者最终决定接受减重手术。

在干预组中，术后2年和6年平均减重35%和28%，期间体重只反弹了7%。相比之下，两个对照组的体重无显著增加或减少。

此外，术后2年干预组有75%的糖尿病患者都获得了缓解，术后6年减少至62%。虽然部分患者的糖尿病复发，但长期缓解率仍大大高于两个对照组的缓解率(分别为8%和6%)。同样，干预组在随访期间新发糖尿病的患者比例(2%)也明显低于两个对照组(分别为17%和15%)。

干预组术后6年的高血压缓解率(42%)也高于两个对照组(分别为18%和9%)。在高LDL胆固醇和甘油三酯的缓解率方面也得到了相同的结果(JAMA 2012;308:1122-31)。

不过，体重下降及其相关的心血管和代谢危险因素改善效益并没能降低患者的死亡率。随访期间共出现了29例死亡：干预组12例(3%)、第一对照组14例(3%)、第二对照组3例(1%)。

值得注意的是，干预组患者的自杀率显著高于对照组。该试验共出现了“不明原因”的4例自杀和3例中毒事件，在这7例事件中有6例都发生在干预组中。目前尚不清楚干预组自杀率高的原因，但这一结果与SF-36问卷心理评估部分的结果相一致，即接受了胃旁路术的患者在随访期间生理健康方面明显改善，但心理健康方面却没能改善。

Adams博士及其同事分析称，其他研究者曾经推测减重手术会引起一些深远的变化，而这些变化“可能会令患者紧张，带来特殊的社会、心理和生活方式上的挑战。因此可能有必要在术前和术后评估患者的社会和情绪状态，这与患者的术后期望有关，还需要评估患者出现自残行为的潜在风险。”

干预组的围手术期并发症发生率为3%，共有38例患者因与胃旁路术相关的并发症而住院。

研究者总结道，虽然胃旁路术后患者体重有一定程度的反弹，但术后6年仍能维持平均减重28%的效果，并且糖尿病、高脂血症和高血压的缓解率也都高于两个对照组。“鉴于以生活方式调整和药物治疗为主的积极减重方案实施1年后只能减重5%~9%，4年后只能减重2%~6%，这项研究中胃旁路术所维持的28%的减重效果是非常突出的。”

该研究由美国国立卫生研究院、国家糖尿病、消化病和肾病研究所以及国家研究资源中心共同资助。Adams博士的同事声明与Vivus、Orexigen、葛兰素史克、Health Outcome Solutions和爱惜康内镜外科公司之间存在利益关系。

随刊述评：胃旁路术效果持久

美国匹兹堡大学医学中心微创减重手术与普外科的Anita P. Courcoulas 博士评论道，上述研究表明，虽然重度肥胖患者在接受胃旁路术后体重可能出现一定程度的反弹，也出现了一些糖尿病复发的情况，但术后多年“合并症的控制情况仍然非常好”。

Courcoulas 博士指出，减重研究大多因为退出率太高而存在局限性，而在这项研究中干预组完成了随访的患者比例达到了96%。“该研究结果具有很重要的意义，因为它表明在对Roux-en-Y队列和对照组几乎所有的患者完成了6年的随访之后，减重效果及其相关的健康效益仍然持续存在。”

Courcoulas 博士声明与Ethicon、Endogastric Solutions、辉瑞、Allergan、Stryker Endoscopy、Covidien和Nutrisystem公司之间存在利益关系。上述文字摘自这份研究报告的随刊述评 (JAMA 2012;308:1160-1)。

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By: MARY ANN MOON, Clinical Endocrinology News Digital Network

Both weight loss and its associated improvements in cardiovascular and metabolic risk factors persisted for 6 years in most of the 418 severely obese adults who underwent Roux-en-Y gastric bypass surgery in a prospective study published in the Sept. 19 JAMA.

Despite some weight regain over time, surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension, compared with the two control groups, said Ted D. Adams, Ph.D., of the department of internal medicine, University of Utah, Salt Lake City, and his associates.

 
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Gastric bypass surgery patients showed a mean weight loss of 28% at 6-year follow-up, as well as higher remission rates for diabetes, dyslipidemia, and hypertension

"Considering the 5%-9% weight loss at 1 year with only 2%-6% weight loss after 4 years of intensive lifestyle-based and medication-based therapy, the weight-loss maintenance of 28% ... in our Utah study is quite significant," they noted.

The study involved severely obese adults with a body mass index of 35 kg/m2 or higher (mean BMI 45.9 kg/m2), of whom 82% were women and 96% were white. In addition to the patients who underwent either open or laparoscopic gastric bypass, there were 417 obese subjects in the first control group who were assessed for the surgery at the same time as the intervention group but did not have the surgery, and 321 obese subjects in the second control group who were randomly selected from a population-based sample of Utah residents.

Subjects in the control groups did not receive any weight-loss intervention as part of the study but were free to pursue it on their own. Over time, 101 of the subjects from both control groups chose to have bariatric surgery.

In the surgical group, mean weight loss was 35% at 2 years and 28% at 6 years, representing a 7% regain over time. By comparison, neither control group showed any significant weight loss or regain.

Diabetes remitted in 75% of the bypass group at 2 years, decreasing to 62% at 6 years. Despite the recurrence of diabetes in some patients, this long-term remission rate was dramatically better than the remission rates in the control groups (8% and 6%, respectively).

Similarly, the proportion of bypass patients who developed index diabetes during follow-up was markedly lower in the bypass group (2%) than in either control group (17% and 15%, respectively).

Remission of hypertension also was greater 6 years after bypass surgery (42%) than in the control groups (18% and 9%, respectively). Rates of high LDL cholesterol and triglycerides followed the same pattern, Dr. Adams and his colleagues wrote (JAMA 2012;308:1122-31).

Importantly, the weight loss and the concurrent improvement in cardiovascular and metabolic risk factors did not improve mortality. There were 29 deaths: 12 in the bypass group (3%); 14 in the first control group (3%); and 3 in the second control group (1%).

Notably, suicide was significantly more common in the bypass patients than in the control subjects. There were four suicides and three poisonings "of undetermined intention" overall, and six of these seven events occurred in bypass patients. The reason for this excess in the surgery group is unknown, but it is consistent with the finding that the mental component of the SF-36 fails to improve during follow-up, even though the physical component improves markedly among gastric bypass patients.

Other investigators have postulated that bariatric surgery precipitates profound changes "that may generate tension and pose special social, psychological, and lifestyle challenges. Preoperative and postoperative psychological assessment of social and emotional status related to post–bariatric surgical expectations and the potential risk of self-destructive behavior might be warranted," Dr. Adams and his associates said.

The rate of perioperative complications was 3% in the surgery group, and there were 38 hospitalizations for bypass-related indications.

This study was supported by the National Institutes of Health, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Center for Research Resources. Dr. Adams’s associates reported ties to Vivus, Orexigen, GlaxoSmithKline, Health Outcome Solutions, and Ethicon Endo-Surgery.

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Gastric Bypass Produces Durable Results

Dr. Adams and his associates show that, despite some weight regain and some recurrence of diabetes, "the control of comorbid conditions remained very good" several years after severely obese patients underwent gastric bypass surgery, said Dr. Anita P. Courcoulas.

Most weight-loss studies are limited by very high dropout rates, so it was remarkable that follow-up was 96% in the intervention group in this study. "These findings are important because they show in a Roux-en-Y cohort and control group with nearly complete follow-up at 6 years that weight loss and associated health benefits ... are durable," she noted.

ANITA P. COURCOULAS, M.D., is in the department of minimally invasive bariatric and general surgery at the University of Pittsburgh Medical Center. She reported ties to Ethicon, Endogastric Solutions, Pfizer, Allergan, Stryker Endoscopy, Covidien, and Nutrisystem. These remarks were taken from her editorial comment accompanying the report (JAMA 2012;308:1160-1).