腹腔镜袖状胃切除对病态肥胖病人糖脂代谢的影响

doi:10.16139/j.1007-9610.2020.02.009

摘要/Abstract

摘要：

目的: 探讨腹腔镜袖状胃切除术（laparoscopic sleeve gastrectomy, LSG）手术对病态肥胖病人糖脂代谢相关指标的影响及相关作用机制。方法: 回顾性分析我院2012年1月至2017年6月82例肥胖病人行LSG手术的临床资料。其中合并2型糖尿病（type 2 diabetes mellitus,T2DM）25例,合并糖耐量异常30例,血糖和糖耐量正常27例,并选择同期体重正常健康者50例,比较术后减重效果、手术前后糖脂代谢指标、尿酸（uric acid,UA）和肿瘤坏死因子α（tumor necrosis factor α,TNF-α）水平,同时分析胰岛素抵抗的稳态模型评估（homeostasis model assess-ment of insulin resistance, HOMA-IR）与相关代谢指标间的相关性。结果: ①肥胖病人术后6个月BMI和腰围均显著低于术前（P<0.05）。合并T2DM的肥胖病人术后多余体重减少率（percentage of excess weight loss, EWL）显著高于血糖和糖耐量正常的肥胖者（P<0.05）。②肥胖病人术后6个月空腹血糖（fasting blood glucose, FBG）、餐后2 h血糖及胰岛素水平均显著低于术前（P<0.05）。肥胖病人术后6个月HOMA-IR 水平显著低于术前（P<0.05）。③肥胖病人术后6个月低密度脂蛋白胆固醇水平显著高于体重正常者（P<0.05）;肥胖病人术后6个月体脂比例显著低于术前（P<0.05）。肥胖病人术前UA和TNF-α水平均显著高于体重正常者（P<0.05）,其在术后6个月显著降低（P<0.05）。④肥胖病人术后6个月餐后120 min和180 min胰岛素水平均显著低于术前（P<0.05）;餐后30 min和60 min胰岛素水平显著高于体重正常者（P<0.05）。合并糖耐量异常和T2DM的病人术前胰岛素分泌高峰后移至餐后120 min,术后恢复至餐后60 min,胰岛素分泌节律基本正常。⑤术后6个月,肥胖病人HOMA-IR与BMI、FBG及空腹胰岛素呈显著正相关（P<0.05）。血糖和糖耐量正常的肥胖病人HOMA-IR与UA呈显著正相关（P<0.05）。合并糖耐量异常和T2DM的肥胖者HOMA-IR与三酰甘油、TNF-α呈显著正相关（P<0.05）。结论: 病态肥胖病人采用LSG手术可有效促进胰岛素分泌曲线恢复,改善高胰岛素血症,纠正胰岛素抵抗和代谢紊乱。肥胖病人胰岛素抵抗发生与BMI、UA、TNF-α及脂代谢紊乱密切相关。

关键词: 手术, 肥胖, 糖脂代谢

Abstract:

Objective: To investigate the impact of laparoscopic sleeve gastrectomy (LSG) on glycolipid metabolism of patients with morbid obesity and the associated mechanisms. Methods: Clinical data of 82 patients with morbid obesity were analyzed retrospectively including 25 cases with type 2 diabetes mellitus (T2DM), 30 cases with impaired glucose to-lerance and 27 cases with both glucose and glucose tolerance normal. Fifty healthy individuals of normal weight in the period from January 2012 to June 2017 were as control. Postoperative weight loss, index of glycolipid metabolism, Uric acid (UA) and tumor necrosis factor α (TNF-α) were compared between pre and post operation. Correlation between homeostasis model assessment of insulin resistance (HOMA-IR) and some index of metabolism was performed. Results: ①Body mass index (BMI) and waist circumference of obese patients 6 months post operation were significantly lower than pre operation (P<0.05). Higher postoperative excess weight loss (EWL) was found in the obese patients with T2DM compared with normal blood glucose and glucose tolerance (P<0.05). ②Fasting blood glucose (FBG), 2 h postprandial blood glucose and insulin of obese patients 6 months post operation were significantly lower than pre operation (P<0.05). HOMA-IR of obese patients 6 months post operation was significantly lower than pre operation (P<0.05). ③Low density lipoprotein cholesterol of obese patients 6 months post operation was significantly higher than control (P<0.05). Body fat ratio of obese patients 6 months post operation was significantly lower than pre operation (P<0.05). UA and TNF-α of obese patients pre operation, which were significantly higher than control (P<0.05), decreased at 6 months post operation significantly (P<0.05). ④The levels of insulin in 120 min and 180 min after meal at 6 months post operation of obese patients were significantly lower than pre operation (P<0.05). Insulin of obese patients 30 min and 60 min postprandial were significantly higher than control (P<0.05). The peak of insulin secretion curve of patients with impaired glucose tolerance and T2DM pre operation moved to 120 min postprandial and returned to 60 min postprandial. Insulin secretion rhythm of the patients was basically normal. ⑤There were three types of positive correlation of HOMA-IR in obese patients 6 months post operation. It was present with BMI, FBG and fasting insulin (P<0.05). It was present with UA in the obese patients of blood glucose and glucose tolerance normal(P<0.05). It was present with triglyceride and TNF-α of obesity patients of impaired glucose tolerance and T2DM(P<0.05). Conclusions: LSG in the treatment of patients with morbid obese could effectively recover abnormal insulin secretion curve, improve hyperinsulinemia, and correct insulin resistance and metabolic disorders. Insulin resistance of obese patients was closely related to BMI, UA, TNF-α and lipid metabolism disorders.

Key words: Operation, Obesity, Glycolipid metabolism

中图分类号:

R589.2

张怀波, 马荣龙, 张德景. 腹腔镜袖状胃切除对病态肥胖病人糖脂代谢的影响[J]. 外科理论与实践, 2020, 25(02): 129-133.

ZHANG Huaibo, MA Ronglong, ZHANG Dejing. Impact of laparoscopic sleeve gastrectomy on glycolipid metabolism of patients with morbid obesity[J]. Journal of Surgery Concepts & Practice, 2020, 25(02): 129-133.

图/表 3

表1

3组围术期临床指标水平比较

指标	体重正常（n=50）	血糖和糖耐量正常（n=27）		糖耐量异常（n=30）		T2DM（n=25）
指标	体重正常（n=50）	术前	术后6个月	术前	术后6个月	术前	术后6个月
体重（kg）	69.26±6.30	121.40±25.60^b）	90.96±22.30^a）b）	108.93±14.97^b）	76.99±13.42^a）b）	109.54±21.60^b）	79.67±15.75^a）b）
BMI	23.70±1.52	41.52±5.84^b）	31.70±7.52^a）b）	38.56±3.73^b）	27.54±4.35^a）b）	37.81±6.72^b）	27.10±4.34^a）b）
EWL（%）	-	-	61.92±7.70	-	76.47±20.31	-	77.85±27.14
腰围（cm）	60.85±5.51	121.02±14.80^b）	102.12±12.90^a）b）	116.93±8.42^b）	91.83±9.77^a）b）	122.91±13.50^b）	101.92±9.81^a）b）
体脂比例（%）	21.93±4.55	41.17±2.52^b）	31.20±3.94^a）b）	40.03±3.27^b）	32.01±5.83^a）b）	38.20±4.31^b）	28.84±5.78^a）b）
HbA1c（%）	5.23±0.74	5.64±0.43	5.34±1.06^a）	6.15±0.93^b）	5.16±0.30^a）	8.08±1.76^b）	5.64±1.26^a）
FBG（mmol/L）	5.28±0.85	5.02±0.60	4.51±0.57^a）	5.61±0.57	4.63±0.37^a）	8.72±2.32^b）	5.29±1.48^a）
2 hPG（mmol/L）	6.86±0.64	6.64±0.96	4.15±0.52^a）	9.25±1.32^b）	4.17±1.02^a）	15.30±4.56^b）	6.23±2.02^a）
空腹胰岛素（mU/L）	12.52±5.20	33.51±17.10^b）	11.48±4.60^a）	35.30±16.39^b）	14.71±5.60^a）	35.74±19.18^b）	11.28±4.14^a）
餐后2 h胰岛素（mU/L）	54.76±16.80	161.39±73.80^b）	37.61±19.58^a）	217.69±89.71^b）	33.53±14.57^a）	125.50±70.62^b）	46.69±17.34^a）
HOMA-IR	1.82±1.16	7.52±3.77^b）	2.40±0.39^a）	9.77±3.80^b）	2.07±1.35^a）	13.58±5.67^b）	2.17±0.86^a）
TC（mmol/L）	4.23±0.74	4.34±1.31	4.16±0.92	4.80±1.37^b）	4.42±0.86^b）	4.94±1.35^b）	4.36±0.84^a）
HDL-C（mmol/L）	1.53±0.36	1.10±0.53^b）	1.33±0.45^a）	1.08±0.20^b）	1.29±0.20^a）	0.91±0.24^b）	1.44±0.32^a）
LDL-C（mmol/L）	2.19±0.76	2.56±1.04^b）	2.64±0.91^b）	3.16±1.20^b）	3.00±1.04^b）	2.97±1.09^b）	2.62±0.78^b）
TG（mmol/L）	0.90±0.13	1.50±0.89^b）	0.97±0.35^a）	1.89±1.06^b）	1.06±0.41^a）	2.84±1.04^b）	1.37±0.40^a）
UA（μmol/L）	267.94±63.59	435.60±94.46^b）	398.92±98.00^a）b）	410.17±121.80^b）	355.70±82.58^a）b）	400.62±101.26^b）	363.74±71.42^a）b）
TNF-α（pg/ml）	6.20±2.33	10.75±4.11^b）	7.68±3.02^a）b）	14.88±4.52^b）	8.62±2.55^a）b）	10.25±3.81^b）	8.68±2.69^a）b）

表1

表2

表3

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胰岛素（mU/L）	体重正常（n=50）	血糖和糖耐量正常（n=27）	糖耐量异常（n=30）	T2DM（n=25）
术前
餐后30 min	42.28±6.85	175.02±29.60	128.51±21.57	73.61±7.57
餐后60 min	52.86±8.64	218.64±31.96	188.15±34.52	126.25±12.32
餐后120 min	39.52±4.20	162.51±25.10	219.48±45.60	138.30±16.39
餐后180 min	24.76±3.80	70.39±12.80	114.61±19.58	77.69±10.71
术后6个月
餐后30 min	38.53±4.36	115.10±13.53^b)	112.33±12.45^b)	140.08±18.20^b)
餐后60 min	54.19±7.76	110.56±11.04^b)	136.64±16.91^b)	197.16±21.20^b)
餐后120 min	47.90±6.13	51.50±5.89	50.97±6.35	55.89±9.06^a)
餐后180 min	17.94±2.59	20.60±3.46	21.92±3.00	24.17±4.80^a)