中国代谢病手术介绍及并发症处理.pptx

Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,Click to edit Master title style,Company Logo,中国代谢病手术介绍及并发症处理,世界减重代谢外科的历史沿革,减重外科的发展史,代谢外科的发展史,2,1954,年首次报道：,Kremen AJ,，,jejunoileal bypass(JIB),单纯限制吸收手术,严重营养不良,已被淘汰,减重外科的发展史,3,Mason EE,Ito C:Surg Clin North Am 1967;47:1345-1351,真正意义减重手术,沿用至今,金标准手术,减重外科的发展史,4,Belachew M,（,1993,）,LAGB,Wittgrove AC,（,1994,）,LRYGB,减重外科之父,减重外科的发展史,5,1.Resuts of BPD with SG,DS and 100cm common channel.Picard Marcean.1998 ASMBS Annual.,2.Laparoscopic reversal of jejuno-ileal bypass with conversion to sleeve gastrectomy,Michel Gagner,2002 ASMBS Annual.,减重外科的发展史,LSG,作为独立术式始于,2000,年以后,6,代谢外科的发展史,Buchwald,等对,1990-2003,年间发表的,136,篇文献共计,22094,例患者进行分析，,2,型糖尿病有,76.8%,可完全治愈，,86%,显著改善。,1980,年发现减重手术具有血糖控制作用,7,Based on the data in China 2008,Morbidity of diabetes was 9.7%,92 millions in China,90%Type 2 diabetes mellitus,Morbidity 18.5%in obese Cohort(BMI30kg/m,2,),Data in 2013should be much higher than 2008,Yang W,Lu J,Weng J,et al.Prevalence of diabetes among men and women in China.,N Engl J Med.2010;362(12):1090-101.,Epidemics of T2D in China,8,中国糖尿病排名世界第一，肥胖人群排名世界第二，均达到,1,亿左右。,患者需要安全有效的治疗手段，规范化尤为重要,Top 10 countries by Obese Population,1.United States,2.China,3.India,4.Russia,5.Brazil,6.Mexico,7.Egypt,8.German,9.Pakistan,10.Indonesia,肥胖症及糖尿病流行病学分布,9,Lancet April 5,2016,10,美国减重外科的发展现状,11,空回肠转流术,胃旁路转流术,袖状胃切除术,可调节绑带术,胆胰分流术,胆胰分流,+,十二指肠转流术,美国减重外科的术式发展,12,2015,年公布数据显示：减重手术治疗糖尿病位列,21,世纪前十年世界医疗创新第三位,美国减重外科的术式发展,13,中国减重代谢外科发展历程,1982first modified Payne surgery,Yang Zhongkui,杨忠魁,Payne,改良法治疗肥胖病,1,例中华外科杂志，,1984,，,22,：,143,1998first laparoscopic surgery in Asia,Lee Weijie,2000first lap banding in China,Zheng Chengzhu,2004first RYGB in China,Wang Cunchuan,2006first sleeve gastrectomy in China,Liu Jingang,14,2014,版指南,代谢疾病人群,单纯性肥胖,2,型糖尿病,27.5,BMI,32.5,32.5BMI,BMI2,7,.5,内科治疗,无效,有效,继续治疗,27.5,BMI25,内科治疗,无效,有效,充分告知，试行外科治疗,继续治疗,BMI,25,内科治疗,胰岛功能、心肺功能、术前告知、MDT、患者准备,术前评估,手术,术式选择、设备准备、围手术期处理,术后随访,3个月、6个月、12个月、24个月,合并症处理,内分泌相关、营养相关、运动医学,15,Sleeve+DJB,Lap Band,Gastric Bypass,Sleeve Gastrectomy,中国开展代谢病术式,16,中国的肥胖及糖尿病外科现状,17,65%,35%,35%,64%,15%,80%,5%,10%,80%,10%,57%,34%,9%,2010,2014,中国的肥胖及糖尿病外科现状,LSG,RYGB,LAGB,18,中国的肥胖及糖尿病外科现状,2014,年,24,个省市自治区开展减重手术，以东部沿海地区为主,19,美国代谢外科的发展模式,保险公司是核心、法律是底线,代谢外科医生是执行者、网络及家庭医生,根据公司契约决定利益分配,行业协会推动法律制订、争取医生利益,1960,1980,摸索阶段,1980,2000,推广阶段,2000,2007,规范阶段,2007,至今,完善阶段,网络宣传,家庭医生,代谢外科医生,保险公司,20,中国代谢病治疗模式,中国模式,内科主导,各自为战,外科主导,中国正在探索不同于发达国家的发展模式,21,BPD:,是从水平方向切割胃，保留,100,150ml,的胃容量，将空肠横断后，近端空肠与末端回肠在距回盲瓣,50cm,处吻合。,主流术式介绍,BPD,22,BPD-DS:,则先行袖状胃切除，保留幽门，在十二指肠处横断，近端十二指肠与远侧空肠吻合，远端吻合口与,BPD,一样。,BPD-DS,距离幽门,2-6,cm,游离胃大弯网膜,32-36,Fr,管子内支撑,(,纤微胃镜,),直线切割闭合器重建消化道,建立容量,60ml,左右胃状胃,Sleeve gastrectomy,建立,15-30,毫升胃小囊,旷置全部胃底,食物袢,100cm,胆胰袢,100-120cm,胃肠吻合口直径,1.1-1.2cm,关闭各腹膜裂孔,RYGB,LAGB,DJB,Sleeve+DJB,Gastric plication,Banding plication,Others,垂直胃束带手术,空肠回肠间置手术,十二指肠回肠间置术,安全,效果,并发症处理,32,Which one is the best?,T2D,注射胰岛素,口服降糖药,体育锻炼,控制饮食,33,肥胖的病理生理改变,呼吸系统,循环系统,运动系统,内分泌系统,消化系统,34,肥胖病人的常见营养问题,一般认为，肥胖是因为营养过剩,实际上恰恰相反，胖人是脂肪过剩，营养不良,大多数胖人糖代谢障碍糖耐量异常或胰岛素抵抗,糖的代谢需要消耗掉维生素,B,族、维生素,C,、多种矿物质（如铁，钒，硒，锌，铬等）以及辅酶,Q,没有燃烧的糖转化成脂肪,胖人比普通人消耗更多的营养素，营养不良,35,Which one is the best?,36,New Clinical Evidence:STAMPEDE,Surgical treatment and medications achieved glycemic control in more patients than medical therapy alone,Which one is the best?,37,手术,30,天死亡率,:,0.1%,调节捆扎带,0.15%,胃旁路术,1.1%,胆胰分流术,手术的风险：正确看待,短期,并发症,恶心,和呕吐,吻合渗漏,便秘,倾倒综合症,吻合口,狭窄,腹泻,肺栓塞或呼吸衰竭,与,LC,大致相等,What is short-term surgical risk?,38,新英格兰医学杂志报导,15,年长期随访,胃转流手术可降低病人死亡率,50%,手术围手术期死亡率仅,0.2%,What is short-term surgical risk?,在美国，它是成年人新发的失明、终末期肾病和非外伤性截肢首要因素。,1.,糖尿病视网膜病变所致的失明占,新发失明的,20%,；,2.,糖尿病造成的,终末期肾病（,ESRD,）占新发病例的,43%,；,3.60%,的非外伤性截肢,为糖尿病所致。,每年糖尿病及其并发症的,治疗费用超过,1320,亿美元,，占美国,国家医疗财政支出的,15%,。,与非糖尿病患者比较,死亡率 高,2-3,倍,心脑血管疾病 高,2-3,倍,失明 高,10,倍,下肢溃疡及截肢 高,20,倍,糖尿病已成为发达国家,中继心血管疾病和肿瘤之后的第三大非传染病,，是严重威胁人类健康的世界性公共卫生问题！,What is long-term surgical risk?,40,贫血,切口疝,及内疝,B12,维生素,缺乏,肠梗阻,胃溃疡,What is long-term surgical risk?,长期疗效是硬道理,41,40%,12%,内科治疗,40%,胃绑带术,15%,胃转流术,6%,Long term evidences in 15 years8,2012,What is long-term surgical risk?,42,Anatomy of Stomach,43,Building-up of anastomasis,44,SG in Chinese guideline2014,45,Abdominal pain,Drainage change,tachycardia,Body temperature increase,WBC,count increase,Clinical manifestation of SG complications,46,GI,vessel,infection,nutrition,Clinical manifestation of SG complications,47,leak,Tension increase,technique,ischemia,Wrong in contour,bleeding,Wrong in contour,Low pressure,Sub layer anastomasis,Complications of SG-GI,48,Complications of SG-GI,GERD,Spincter dilation,Hiatal hernia,Esophagus dysfunction,Gastric pouch enlarge,High distal pressure,Stenosis,EG stenosis,Sleeve stenosis,Pylorus stenosis,49,thrombosis,Pulmonary thrombosis,40%,mortality,Second largest cohort,Anticoagulation prevention,Complications of SG-thrombosis,50,Calvities,Protein loss,Zn deficiency,anemia,Fe,defi,Folic defi,Vitamin deficiency,Osteoporosis,Ca,defi,Protein support,Fe and folic acid,Ca and vitamin,Nutrition measurement,Complications of SG-nutrition,51,Complications of SG-cholecystitis,52,Pre-dilation,Post-dilation,Management of Complications-stenosis,Stenosis,Early dilation of cyst,10-12mm,cyst,Multiple times,Until 12mm,53,Laparoscopic seromyotomy,Gastric bypass,Management of Complications-stenosis,54,Drainage for mild leak,Severe leak,Reoperation,Stent,bypass,2012 ASMBS,Management of Complications-leak,55,Prevention of Complications,56,吻合口漏,吻合口张力过大,吻合口缝合技术,局部血运障碍,钉仓选择不当,出血,钉仓选择不当,缝合压力不足,未实现全层缝合,腹痛,引流液性状改变,心率增快,体温增加,WBC,上升,影像学证据,Complications of RYGB-GI,57,倾倒综合征,胃肠吻合口过大,吻合口狭窄,胃肠吻合口过小或水肿,盲袢综合征,candy cane,Complications of RYGB-GI,58,胃囊,容积：主流认为,15-30ml,形状：垂直胃切割,胃肠吻合口,大小：直径,1.1-1.2cm,环形、线形还是手工缝合,肠袢,长度：胆胰袢,120cm,，食物袢,100cm,结肠前,or,结肠后,没有一项技术是,100%,完美的,胃转流手术方式的争议,（,2012ASMBS,）,59,吻合口漏,充分引流,营养支持,控制感染,2012ASMBS Blackstone,FACS,术后,10,天,术后,12,天,术后,16,天,Management of Complications-leak,60,2012ASMBS Jacques Himpens,FASMBS,Management of Complications-bleeding,61,Management of Complications-obstruction,62,垂直,30ml,A,B,C,A,、,Mesocolic,B,、,Peterson,C,、,Mesenteric,其中,Peterson,裂孔发生內疝几率较高,Complications of RYGB-hernia,63,内疝,Peterson,裂孔,结肠系膜裂孔,小肠系膜裂孔,2012 ASMBS Daniel J Gagne,FACS,Complications of RYGB-hernia,64,Management of Complications-hernia,65,取束带胃袖状切除,video,66,胃袖状切除旁路术,video,67,内疝复位术,video,68,内疝复位术,video,69,SUMMARY,降糖减体重是表象,延缓合并症出现是目的,实现高质量的长期生存是目标,风险与收益并存,70,THANK YOU,