减肥手术进展促使三学会更新指南

根据美国临床内镜医师协会(AACE)、肥胖学会(OS)和美国代谢与减肥手术学会(ASMBS)最近更新的减肥手术指南，减肥手术患者应在补充其他维生素和矿物质的同时常规使用铜补充剂。

这3家学会提倡每日补充2 mg以抵消手术导致铜缺乏的可能性。尽管术后常规铜筛查并不必要，但对于贫血、中性粒细胞减少、脊髓神经病变和伤口愈合受损患者，确实应当评估铜水平并按需治疗。

自2008年发布前一版指南以来，这是首次提出关于铜的建议。另外73条建议则吸纳了近年来减肥手术领域的新进展和新证据。新版指南还加入了术前和术后清单，以避免犯错。另一项新建议是，初级保健医生应当根据患者的年龄和风险，对其进行随访和在术前筛查肿瘤。

关于袖状胃切除术也有了更多信息。在2008年时，这种手术还处于实验阶段，而如今它已获得批准并且正在得到越来越普遍的应用。现在关于该手术的代谢效果(而且该效应独立于减重效果)、对血糖控制和心血管风险的影响，都已经有了很好的数据。新版指南指出，袖状胃切除术已被证明具有超出其他减肥手术的获益。一个全国性风险校正数据库根据减重、消除合并症和并发症等因素，将其列于腹腔镜可调节胃束带术和腹腔镜Roux-en-Y胃旁路术之间。

指南主要作者、美国临床内分泌医师协会(AACE)候任主席Jeffrey Mechanick 博士指出：“我们还解决了2个富有争议的问题。一是采用腹腔镜胃束带术治疗轻度肥胖，二是采用针对2型糖尿病患者的减肥手术控制血糖。”

与2008年时一样，新版指南并不建议仅仅为了控制血糖而实施减肥手术。“我们还没有充分理由称它为‘糖尿病手术’，但我们确实认识到了减肥手术在血糖控制方面的有益作用。”

至于轻度肥胖患者，新版指南认为体重指数(BMI)介于30~34.9 kg/m²的糖尿病或代谢综合征患者“也可接受减肥手术，不过现有证据在受试者数量和长期数据方面均比较有限。”

这部指南将发表在《内分泌实践》3/4月刊和《肥胖及相关疾病的手术》3月刊上。

Mechanick博士披露称从雅培营养公司获得了讲课和项目发展酬金。

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By: M. ALEXANDER OTTO, Clinical Endocrinology News Digital Network

Weight loss surgery patients should get routine copper supplements along with other vitamins and minerals, according to newly updated bariatric surgery guidelines from the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

The groups call for 2 mg/day to offset the potential for surgery to cause a deficiency. Although routine copper screening isn’t necessary after the procedure, copper levels should be assessed and treated as needed in patients with anemia, neutropenia, myeloneuropathy, and impaired wound healing.

The copper recommendations are new since the guidelines were last published in 2008. Other recommendations – there are 74 in all – have been revised to incorporate new advances in weight loss surgery and an improved evidence base. Changes are pointed out where they’ve been made, and the level of evidence cited for each assertion. Pre- and postoperative bariatric surgery checklists have been added as well, to help avoid errors.

"This is actually a very unique collaboration among the internists represented by the endocrinologists and the obesity people and the surgeons. We actually agreed on all these things. The main intent is to assist with clinical decision making," including selecting patients and procedures and perioperative management, said lead author Dr. Jeffrey Mechanick, president-elect of the American Association of Clinical Endocrinologists and director of metabolic support at the Mt. Sinai School of Medicine in New York.

"We scrutinized every recommendation one by one in the context of the new data. In many cases the recommendations changed," he said in an interview.

Another new recommendation is for patients to be followed by their primary care physicians and screened for cancer prior to surgery, as appropriate for age and risk. Dr. Mechanick and his colleagues have also given more attention to consent, behavioral, and psychiatric issues as well as weight loss surgery in patients with type 2 diabetes.

There’s more information on sleeve gastrectomy, as well. Considered experimental in 2008, it’s now "approved and being done more widely. There are some very nice data about its metabolic effects, independent from just the weight loss effect, effects on glycemic control, and cardiovascular risk. It was very important to devote a fair amount of time" to the procedure, he said.

The guidelines note that "sleeve gastrectomy has demonstrated benefits comparable to other bariatric procedures. ... A national risk-adjusted database positions [it] between the laparoscopic adjustable gastric band and laparoscopic Roux-en-Y gastric bypass in terms of weight loss, co-morbidity resolution, and complications."

"We [also] addressed two issues which were quite controversial, and are still rather unsettled. The first is the use of the lap band for mild obesity. The second is the use of these weight loss procedures specifically for patients with type 2 diabetes for glycemic control. Since 2008, there’ve been a lot more data" about the issues, he said, just as there’ve been more data about the need for copper supplementation.

As in 2008, the guidelines do not recommend bariatric surgery solely for glycemic control. "We still don’t have an absolute indication for ‘diabetes surgery,’ but we do recognize the existence of the salutary effects on glycemic control when these procedures are done for weight loss. It was important for the reader to be exposed to this information," Dr. Mechanick said.

Regarding surgery in the mildly obese, the guidelines note that patients with a body mass index of 30-34.9 kg/m2 with diabetes or metabolic syndrome "may also be offered a bariatric procedure, although current evidence is limited by the number of subjects studied and lack of long-term data demonstrating net benefit."

The guidelines will be published in the March/April 2013 issue of Endocrine Practice and March 2013 issue of Surgery for Obesity and Related Diseases.

Dr. Mechanick disclosed compensation from Abbott Nutrition for lectures and program development.