袖带胃切除手术和Roux-en-y胃分流手术治疗病态性肥胖性糖尿病的疗效对比研究
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摘要
背景
肥胖外科是外科学一个迅速发展的分支。其目的是对由于肥胖而严重影响健康的人群进行减重治疗。随着对肥胖相关并发症危险性的重视,肥胖外科已不仅仅着眼于减重治疗。长海医院中国肥胖治疗中心率先在全国提出减肥手术的新概念:将肥胖伴发病的改善治疗作为整个治疗关注的焦点。中国现有糖尿病患者达5000万,其中90%以上为2型DM。而肥胖与糖尿病关系密切。在病态性肥胖患者中发生糖尿病的相对风险在男性＞5%,女性8-20%。适合手术治疗的病态性肥胖患者中30%发现有2型糖尿病。在有名的SOS研究中糖尿病术前发生率为10.8%,术后8年保持10.5%比例。同期对比对照组糖尿病发生率从7.8%上升到24.9%。在Greenville文献中有13%的患者术前有糖耐量异常,已证实这类病人如果没有手术干预发展成糖尿病的风险很高。减肥手术对防止糖耐量异常发展成糖尿病效果明显。
袖带胃切除手术作为一种限制性手术,近来在西方国家正日渐受到推广。但有关袖带胃切除手术对病态性肥胖的糖尿病治疗疗效评估研究较少,同时也未有袖带胃切除手术与Roux-en-y胃分流手术治疗病态性肥胖性糖尿病对比研究。
目的
本研究目的评估袖带胃切除手术(SG)对病态性肥胖性糖尿病治疗疗效,同时与Roux-en-y胃分流手术(RYGB)进行对比研究,探讨这两种术式治疗糖尿病的可能机制。同时根据糖尿病不同的病程(5年为界),探讨手术治疗糖尿病的时机选择。
方法
经克利夫兰医院伦理委员会同意,从2007年4月到2007年7月期间,先后对60名合并糖尿病的病态性肥胖的患者志愿随机抽号,抽到1号行袖带胃切除手术,抽到2号行Roux-en-y胃分流手术。所有病例术后均至少随访6个月。资料收集项目包括术前患者基本情况(年龄、性别、糖尿病类型、糖尿病治疗方式、发病时间),体重变化指标(BMI、EWL%)、血糖变化指标(FPG、HbA1C)、血Ghrelin。
主要指标的数据均以均数±标准表示,采用SPSS11.5统计软件进行统计学处理。RYGB和SG的BMI、HbA1C、FPG术前和术后2月、6月比较采用重复测量数据的方差分析;RYGB和SG术后不同病程糖尿病患者临床治愈情况比较分别采用卡方检验和Fisher精确概率法;RYGB和SG术后2月、6月不同病程糖尿病患者HbA1C比较采用成组t检验,RYGB和SG术后2月、6月不同疗效的糖尿病患者%EWL比较采用成组t检验。Ghrelin术前与术后1、3、7天和术后2、6月变化比较采用配对t检验进行分析。
结果
RYGB组BMI(Kg/M~2)从术前46.37±3.47降至术后2月37.70±2.26、术后6月33.30±1.75;SG组BMI(Kg/M~2)从术前46.83±4.97降至术后2月37.87±4.61、术后6月34.13±3.92;F=0.288,P=0.594,随访6个月RYGB和SG两种术式对降低BMI方面疗效相当。
RYGB组FPG(mg/dl)从术前150.37±11.76降至术后2月111.60±15.86、术后6月98.70±11.92;SG组FPG(mg/dl)从术前149.60±15.63降至术后2月128.13±19.10、术后6月112.03±15.51;F=8.145,P=0.006,随访6个月RYGB对降低血浆空腹血糖疗效好于SG,有统计学差异。
RYGB组HbA1C%从术前7.19±0.63降至术后2月6.09±0.74、术后6月5.51±0.26;SG组HbA1C%从术前7.18±0.81降至术后2月6.38±0.55、术后6月5.81±0.37;F=4.753,P=0.033,随访6个月RYGB对降低HbA1C疗效好于SG,有统计学差异。RYGB手术中糖尿病病程＜5年的治愈率与病程＞5年无明显差别(P=0.054);SG手术中糖尿病病程＜5年的治愈率高于病程＞5年(X~2=8.623,P=0.005)。
RYGB在术后2个月与6个月时,糖尿病病程＜5年组与＞5年组的%HbA1C成组t检验分别为t=5.854,P=0.000和t=3.531,P=0.001;SG在术后2个月与6个月时,糖尿病病程＜5年组与＞5年组的%HbA1C成组t检验分别为t=6.390,P=0.000和t=4.984,P=0.000。差别均有统计学意义。提示无论是SG还是RYGB,糖尿病病程＜5年的患者比＞5年的患者的%HbA1C降低程度更大。
RYGB在术后2个月与6个月时,疗效改善组与疗效治愈组的%EWL成组t检验分别为t=5.755,P=0.000和t=7.081,P=0.010;SG在术后2个月与6个月时,疗效改善组与疗效治愈组的%EWL成组t检验分别为t=22.438,P=0.000和t=11.231,P=0.000。差别均有统计学意义。显示无论何种术式体重下降程度与糖尿病治疗疗效有关,体重下降越多糖尿病治愈可能性就越高。
RYGB术后3天内血Ghrelin的平均水平下降明显,其后开始回升,术后6月高过术前水平。而SG术后Ghrelin下降明显,术后6月内都保持相对稳定的下降状态。
结论
RYGB和SG术后6个月减重效果无明显差异。RYGB和SG对病态性肥胖性糖尿病治疗疗效明显。两种手术治疗糖尿病与以下因素有关:糖尿病病程越长(5年),治愈的机率也越低;体重下降程度与糖尿病治疗疗效有关,体重下降越多糖尿病治愈可能性就越高。Ghrelin在SG术后糖尿病治愈中发挥重要作用。RYGB对病态性肥胖性糖尿病治疗疗效优于SG,提示在手术治疗糖尿病的机制中胃肠-胰岛轴激素的改变可能发挥主要的作用。
BACKGROUND
Bariatric surgery is a rapidly evolving branch of surgical science.The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems.Shanghai Changhai Hospital put forward new concept of bariatric surgery in CHINA:focus on the treatment of obesity related disease.The amount of diabetes mellitus in China is over 50 millions,90%of it is type 2 diabetes.Obesity is so closely associated with typeⅡdiabetes that a causal role for obesity-or very closely related factors-is beyond doubt.In the morbidly obese,the relative risk of type 2 diabetes is at least 5%in men and 8-20%in women,while approximately 30%of those considered for bariatric surgery are found to have type 2 diabetes.In the surgical arm of the Swedish Obese Subjects(SOS) study the prevalence of diabetes was 10.8%at baseline and remained 10.5%8 years after surgery.In contrast,however,the prevalence of diabetes in the control group increased from 7.8%to 24.9%over the same period.In the Greenville series an additional 13%of patients had impaired glucose tolerance(IGT) pre-operatively, confirming that without intervention many severely obese patients are at high risk of progressing to diabetes.In subjects with IGT,bariatric surgery also has a powerful preventive effect on progression to diabetes.
Recently reports show Bariatric surgery is associated with a high rate of resolution of type 2 diabetes mellitus(T2DM) in morbidly obese subjects.
Sleeve Gastrectomy,a restrictive operation,has been more and more popular in western country.There is limited data evaluating the impact of Sleeve Gastrectomy on the control of diabetes mellitus.Let alone the data on the comparison of effect of Sleeve Gastrectomy(SG) and Roux-en-y Gastric Bypass(RYGB) on morbidly obese patients with diabetes mellitus.
OBJECTIVE
Evaluate the effectiveness of Sleeve Gastrectomy and Roux-en-y Gastric Bypass In improving glycemic control of morbidly obese patients with diabetes mellitus.Discuss the mechanism of both surgery on diabetes mellitus.
Research the diabetes-specific endpoints.
METHOD
The study was approved by the Hospital Ethics Committee and written informed consent was obtained from all participants,we conducted a prospective collected database of all 60 patients with diabetes mellitus,who underwent LSG and LRYGB as a final approach for the treatment of morbid obesity and who have completed at least 6 months of follow-up postoperatively at the Bariatric Institute at Cleveland Clinic Florida between April 2007 and January 2008.30 patients with diabetes mellitus randomly selected to be underwent laparoscopic sleeve gastrectomy(LSG) and 30 patients with diabetes mellitus randomly selected to be underwent laparoscopic Roux-en-y gastric bypass(LRYGB) were studied. Data collected included demographics,weight loss(BMI、EWL%)、diabetes control(FPG、HbA1C) and Ghrelin.
Summary statistics,including mean and standard deviation were calculated for all numeric variables.Categorical variables were summarized by N and percentage.Fisher's exact tests were used to examine the relationship between two categorical variables,such as dichotomized duration of disease and disease resolution.Average preoperative and postoperative biochemical markers for the study group were calculated and analysed by Student's t-test,and the average change in these markers within each operation group compared by Repeated Measurement Data Analysis Of Variance.Statistical analyses were carried out using SPSS 11.5 software(SPSS Inc.,Chicago,IL,USA).Statistical significance was set at a P value＜0.05.
RESULT
For the RNYGB group BMI(Kg/M~2) dropped from 46.37±3.47 preoperatively to 37.70±2.26 at 2 months and 33.30±1.75 at 6 months after surgery.For the SG group BMI(Kg/M~2) dropped from 46.83±4.97 preoperatively to 37.87±4.61 at 2 months and 34.13±3.92 at 6 months after surgery.From baseline to six months there was no significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes BMI (F=0.288,P=0.594).
For the RNYGB group FPG(mg/dl) dropped from 150.37±11.76 preoperatively to 111.60±15.86 at 2 months and 98.70±11.92 at 6 months after surgery.For the SG group FPG(mg/dl) dropped from 149.60±15.63 preoperatively to 128.13±19.10 at 2 months and 112.03±15.51 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes FPG (F=8.145,P=0.006),RYGB is better than SG.
For the RNYGB group HbA1C(%) dropped from 7.19±0.63 preoperatively to 6.09±0.74 at 2 months and 5.51±0.26 at 6 months after surgery.For the SG group HbA1C(%) dropped from 7.18±0.81 preoperatively to 6.38±0.55 at 2 months and 5.81±0.37 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes HbA1C(F=4.753, P=0.033),RYGB is better than SG.In SG group patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates (X~2=8.623,P=0.005).There was no significant difference between groups RYGB P=0.054.
Patients with the shorter duration of diabetes(＜5years) achieved lower HbA1C postoperative.In RYGB group T=5.854,P=0.000 at 2 months and T=3.531,P=0.001 at 6 months,respectively,T=6.390,P=0.000和T=4.984,P=0.000 in SG group.
Patients with the result of resolution on diabetes mellitus had better weight loss than improvement.In RYGB group T=5.755,P=0.000 at 2 months and T=7.081,P=0.010 at 6 months,respectively,T=22.438,P=0.000和T=11.231,P=0.000 in SG group.
In RYGB group ghrelin levels decreased during 3 day postoperative and then gradually increased,and rose further at 6 months.In SG group ghrelin levels kept stable decrease during 6 months postoperative.
CONCLUSIONS
This study suggests that weight loss surgery(RYGB and Sleeve Gastrectomy) are equally effective in promoting weight loss,but the RYGB is more effective in controlling glycemia.Patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates of diabetes mellitus.Ghrelin may play major role on the procedure of SG on treatment of diabetes mellitus.Better effect of RYGB indicates the changes of gastroenteritic-insular axis may play major role on the surgical treatment of diabetes mellitus.
肥胖外科是外科学一个迅速发展的分支。其目的是对由于肥胖而严重影响健康的人群进行减重治疗。随着对肥胖相关并发症危险性的重视,肥胖外科已不仅仅着眼于减重治疗。长海医院中国肥胖治疗中心率先在全国提出减肥手术的新概念:将肥胖伴发病的改善治疗作为整个治疗关注的焦点。中国现有糖尿病患者达5000万,其中90%以上为2型DM。而肥胖与糖尿病关系密切。在病态性肥胖患者中发生糖尿病的相对风险在男性＞5%,女性8-20%。适合手术治疗的病态性肥胖患者中30%发现有2型糖尿病。在有名的SOS研究中糖尿病术前发生率为10.8%,术后8年保持10.5%比例。同期对比对照组糖尿病发生率从7.8%上升到24.9%。在Greenville文献中有13%的患者术前有糖耐量异常,已证实这类病人如果没有手术干预发展成糖尿病的风险很高。减肥手术对防止糖耐量异常发展成糖尿病效果明显。
袖带胃切除手术作为一种限制性手术,近来在西方国家正日渐受到推广。但有关袖带胃切除手术对病态性肥胖的糖尿病治疗疗效评估研究较少,同时也未有袖带胃切除手术与Roux-en-y胃分流手术治疗病态性肥胖性糖尿病对比研究。
目的
本研究目的评估袖带胃切除手术(SG)对病态性肥胖性糖尿病治疗疗效,同时与Roux-en-y胃分流手术(RYGB)进行对比研究,探讨这两种术式治疗糖尿病的可能机制。同时根据糖尿病不同的病程(5年为界),探讨手术治疗糖尿病的时机选择。
方法
经克利夫兰医院伦理委员会同意,从2007年4月到2007年7月期间,先后对60名合并糖尿病的病态性肥胖的患者志愿随机抽号,抽到1号行袖带胃切除手术,抽到2号行Roux-en-y胃分流手术。所有病例术后均至少随访6个月。资料收集项目包括术前患者基本情况(年龄、性别、糖尿病类型、糖尿病治疗方式、发病时间),体重变化指标(BMI、EWL%)、血糖变化指标(FPG、HbA1C)、血Ghrelin。
主要指标的数据均以均数±标准表示,采用SPSS11.5统计软件进行统计学处理。RYGB和SG的BMI、HbA1C、FPG术前和术后2月、6月比较采用重复测量数据的方差分析;RYGB和SG术后不同病程糖尿病患者临床治愈情况比较分别采用卡方检验和Fisher精确概率法;RYGB和SG术后2月、6月不同病程糖尿病患者HbA1C比较采用成组t检验,RYGB和SG术后2月、6月不同疗效的糖尿病患者%EWL比较采用成组t检验。Ghrelin术前与术后1、3、7天和术后2、6月变化比较采用配对t检验进行分析。
结果
RYGB组BMI(Kg/M~2)从术前46.37±3.47降至术后2月37.70±2.26、术后6月33.30±1.75;SG组BMI(Kg/M~2)从术前46.83±4.97降至术后2月37.87±4.61、术后6月34.13±3.92;F=0.288,P=0.594,随访6个月RYGB和SG两种术式对降低BMI方面疗效相当。
RYGB组FPG(mg/dl)从术前150.37±11.76降至术后2月111.60±15.86、术后6月98.70±11.92;SG组FPG(mg/dl)从术前149.60±15.63降至术后2月128.13±19.10、术后6月112.03±15.51;F=8.145,P=0.006,随访6个月RYGB对降低血浆空腹血糖疗效好于SG,有统计学差异。
RYGB组HbA1C%从术前7.19±0.63降至术后2月6.09±0.74、术后6月5.51±0.26;SG组HbA1C%从术前7.18±0.81降至术后2月6.38±0.55、术后6月5.81±0.37;F=4.753,P=0.033,随访6个月RYGB对降低HbA1C疗效好于SG,有统计学差异。RYGB手术中糖尿病病程＜5年的治愈率与病程＞5年无明显差别(P=0.054);SG手术中糖尿病病程＜5年的治愈率高于病程＞5年(X~2=8.623,P=0.005)。
RYGB在术后2个月与6个月时,糖尿病病程＜5年组与＞5年组的%HbA1C成组t检验分别为t=5.854,P=0.000和t=3.531,P=0.001;SG在术后2个月与6个月时,糖尿病病程＜5年组与＞5年组的%HbA1C成组t检验分别为t=6.390,P=0.000和t=4.984,P=0.000。差别均有统计学意义。提示无论是SG还是RYGB,糖尿病病程＜5年的患者比＞5年的患者的%HbA1C降低程度更大。
RYGB在术后2个月与6个月时,疗效改善组与疗效治愈组的%EWL成组t检验分别为t=5.755,P=0.000和t=7.081,P=0.010;SG在术后2个月与6个月时,疗效改善组与疗效治愈组的%EWL成组t检验分别为t=22.438,P=0.000和t=11.231,P=0.000。差别均有统计学意义。显示无论何种术式体重下降程度与糖尿病治疗疗效有关,体重下降越多糖尿病治愈可能性就越高。
RYGB术后3天内血Ghrelin的平均水平下降明显,其后开始回升,术后6月高过术前水平。而SG术后Ghrelin下降明显,术后6月内都保持相对稳定的下降状态。
结论
RYGB和SG术后6个月减重效果无明显差异。RYGB和SG对病态性肥胖性糖尿病治疗疗效明显。两种手术治疗糖尿病与以下因素有关:糖尿病病程越长(5年),治愈的机率也越低;体重下降程度与糖尿病治疗疗效有关,体重下降越多糖尿病治愈可能性就越高。Ghrelin在SG术后糖尿病治愈中发挥重要作用。RYGB对病态性肥胖性糖尿病治疗疗效优于SG,提示在手术治疗糖尿病的机制中胃肠-胰岛轴激素的改变可能发挥主要的作用。
BACKGROUND
Bariatric surgery is a rapidly evolving branch of surgical science.The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems.Shanghai Changhai Hospital put forward new concept of bariatric surgery in CHINA:focus on the treatment of obesity related disease.The amount of diabetes mellitus in China is over 50 millions,90%of it is type 2 diabetes.Obesity is so closely associated with typeⅡdiabetes that a causal role for obesity-or very closely related factors-is beyond doubt.In the morbidly obese,the relative risk of type 2 diabetes is at least 5%in men and 8-20%in women,while approximately 30%of those considered for bariatric surgery are found to have type 2 diabetes.In the surgical arm of the Swedish Obese Subjects(SOS) study the prevalence of diabetes was 10.8%at baseline and remained 10.5%8 years after surgery.In contrast,however,the prevalence of diabetes in the control group increased from 7.8%to 24.9%over the same period.In the Greenville series an additional 13%of patients had impaired glucose tolerance(IGT) pre-operatively, confirming that without intervention many severely obese patients are at high risk of progressing to diabetes.In subjects with IGT,bariatric surgery also has a powerful preventive effect on progression to diabetes.
Recently reports show Bariatric surgery is associated with a high rate of resolution of type 2 diabetes mellitus(T2DM) in morbidly obese subjects.
Sleeve Gastrectomy,a restrictive operation,has been more and more popular in western country.There is limited data evaluating the impact of Sleeve Gastrectomy on the control of diabetes mellitus.Let alone the data on the comparison of effect of Sleeve Gastrectomy(SG) and Roux-en-y Gastric Bypass(RYGB) on morbidly obese patients with diabetes mellitus.
OBJECTIVE
Evaluate the effectiveness of Sleeve Gastrectomy and Roux-en-y Gastric Bypass In improving glycemic control of morbidly obese patients with diabetes mellitus.Discuss the mechanism of both surgery on diabetes mellitus.
Research the diabetes-specific endpoints.
METHOD
The study was approved by the Hospital Ethics Committee and written informed consent was obtained from all participants,we conducted a prospective collected database of all 60 patients with diabetes mellitus,who underwent LSG and LRYGB as a final approach for the treatment of morbid obesity and who have completed at least 6 months of follow-up postoperatively at the Bariatric Institute at Cleveland Clinic Florida between April 2007 and January 2008.30 patients with diabetes mellitus randomly selected to be underwent laparoscopic sleeve gastrectomy(LSG) and 30 patients with diabetes mellitus randomly selected to be underwent laparoscopic Roux-en-y gastric bypass(LRYGB) were studied. Data collected included demographics,weight loss(BMI、EWL%)、diabetes control(FPG、HbA1C) and Ghrelin.
Summary statistics,including mean and standard deviation were calculated for all numeric variables.Categorical variables were summarized by N and percentage.Fisher's exact tests were used to examine the relationship between two categorical variables,such as dichotomized duration of disease and disease resolution.Average preoperative and postoperative biochemical markers for the study group were calculated and analysed by Student's t-test,and the average change in these markers within each operation group compared by Repeated Measurement Data Analysis Of Variance.Statistical analyses were carried out using SPSS 11.5 software(SPSS Inc.,Chicago,IL,USA).Statistical significance was set at a P value＜0.05.
RESULT
For the RNYGB group BMI(Kg/M~2) dropped from 46.37±3.47 preoperatively to 37.70±2.26 at 2 months and 33.30±1.75 at 6 months after surgery.For the SG group BMI(Kg/M~2) dropped from 46.83±4.97 preoperatively to 37.87±4.61 at 2 months and 34.13±3.92 at 6 months after surgery.From baseline to six months there was no significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes BMI (F=0.288,P=0.594).
For the RNYGB group FPG(mg/dl) dropped from 150.37±11.76 preoperatively to 111.60±15.86 at 2 months and 98.70±11.92 at 6 months after surgery.For the SG group FPG(mg/dl) dropped from 149.60±15.63 preoperatively to 128.13±19.10 at 2 months and 112.03±15.51 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes FPG (F=8.145,P=0.006),RYGB is better than SG.
For the RNYGB group HbA1C(%) dropped from 7.19±0.63 preoperatively to 6.09±0.74 at 2 months and 5.51±0.26 at 6 months after surgery.For the SG group HbA1C(%) dropped from 7.18±0.81 preoperatively to 6.38±0.55 at 2 months and 5.81±0.37 at 6 months after surgery.From baseline to six months there was significant difference between groups RYGB and Sleeve Gastrectomy in the clinical outcomes HbA1C(F=4.753, P=0.033),RYGB is better than SG.In SG group patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates (X~2=8.623,P=0.005).There was no significant difference between groups RYGB P=0.054.
Patients with the shorter duration of diabetes(＜5years) achieved lower HbA1C postoperative.In RYGB group T=5.854,P=0.000 at 2 months and T=3.531,P=0.001 at 6 months,respectively,T=6.390,P=0.000和T=4.984,P=0.000 in SG group.
Patients with the result of resolution on diabetes mellitus had better weight loss than improvement.In RYGB group T=5.755,P=0.000 at 2 months and T=7.081,P=0.010 at 6 months,respectively,T=22.438,P=0.000和T=11.231,P=0.000 in SG group.
In RYGB group ghrelin levels decreased during 3 day postoperative and then gradually increased,and rose further at 6 months.In SG group ghrelin levels kept stable decrease during 6 months postoperative.
CONCLUSIONS
This study suggests that weight loss surgery(RYGB and Sleeve Gastrectomy) are equally effective in promoting weight loss,but the RYGB is more effective in controlling glycemia.Patients with the shorter duration of diabetes(＜5years) and better weight loss after surgery achieved higher resolution rates of diabetes mellitus.Ghrelin may play major role on the procedure of SG on treatment of diabetes mellitus.Better effect of RYGB indicates the changes of gastroenteritic-insular axis may play major role on the surgical treatment of diabetes mellitus.
引文
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1.武阳平,马冠生.中国居民的超重和肥胖流行现状.中华预防医学杂志2005,9(39)第5期:316-320
2.中国肥胖问题工作组.中国学龄儿童青少年超重、肥胖筛查体重指数分类标准.中华流行病学杂志,2004,25:97-102.
3.Colditz GA,Willett WC,Rotnitzky A,Manson JE.Weight gain as a risk factor for clinical diabetes mellitus in women.Ann Intern Med 1995;122:481-486.
4.Chan JM,Stampfer MJ,Rimm EB,Willett WC,Colditz GA.Obesity,fat distribution,and weight gain as risk factors for clinical diabetes in men.Diabetes Care 1994;17:961-969.
5.Mason EE,Renquist K,Jiang D.Predictors of two obesity complications;diabetes and hypertension.Obes Surg 1992;2:231-237.
6.Kral JG.Morbidity of severe obesity.Surg Clin North Am 2001;81:1039-1061.
7.Sjostrom CD,Lissner L,Wedel H,Sjostrom L.Reduction in incidence of diabetes,hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery:the SOS intervention study.Obesity Res 1999;7:477-485.
8.Pories WJ,Swanson M,MacDonald KG,Long SD,Morris PG,Brown BM,Barakat HA,deRamon RA,Israel G,Dolezal JM,Dohm L.Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus.Ann Surg 1995;222:339-352.
9. Pories WJ, MacDonald KG, Morgan EJ, Sinha MK, Dohm GL, Swanson MS, Barakat HA, Khazanie PG, Leggett-Frazier N, Long SD. Surgical treatment of obesity and its effect on diabetes: 10-y follow-up. Am J Clin Nutr 1992; 55: 582S-585S.
10. Cowan CGM, Buffington CK. Significant changes inignifi blood pressure, glucose and lipids with gastric bypass surgery. World J Surg 1998; 22: 987-992.
11. Gleysteen JG, Barboriak JJ, Sasse EA. Sustained coronary risk factor reduction after gastric bypass for morbid obesity. Am J Clin Nutr 1990; 51: 774-778.
12. Wittgrove AC, Clark W, Schubert KR. Laparoscopic gastric bypass, Roux-en-Y: technique and results in 75 patients with 3-30 months follow-up. Obes Surg 1996; 6: 500-504.
13. Sjostrom CD, Peltonen M, Wedel H, Sjostrom L. Differentiated long-term effects of intentional weight loss on diabetes and hypertension. Hypertension 2000; 36: 20-25.
14. Pories WJ,Swanson MS,MacDonald KG,et al.Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus[J].Ann Surg,1995,222 (3) : 339-350.
15. Schauer PR,Burguera B,Ikramuddin S,et al.Effect of laparoscopic Roux-En Y gastric bypass on type 2 diabetes mellitus[J].Annals of Surgery,2003,238(4):467-485.
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20. Chan JM, Stampfer MJ, Rimm EB, Willett WC, Colditz GA. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994; 17: 961-969.
21. Mason EE, Renquist K, Jiang D. Predictors of two obesity complications; diabetes and hypertension. Obes Surg 1992; 2: 231-237.
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