什么样的“胖子”需要进行减重手术？来看最新指南推荐

欧洲儿科胃肠病学、肝病学和营养学协会（ESPGHAN）在一份最新的立场声明中推荐，对于体重指数（BMI）≥35kg/m2、且合并某些严重合并症的青少年肥胖患者，以及那些BMI≥40kg/m2、合并某些轻度合并症的青少年肥胖患者而言，应考虑减重手术治疗。

这份声明由ESPGHAN和北美儿科胃肠病学、肝病学及营养协会（NASPGHAN）于本月联合发布。在这份声明中，青少年减重手术的适应症与那些在成年人所使用的标准极为接近。

美国费城儿童医院青少年肥胖治疗计划医学顾问Elizabeth P. Prout教授指出，这份新指南比现行成年人减重手术指南更为保守，现行指南中，BMI≥30kg/m2、且合并严重合并症的成年肥胖患者就可起始减重手术治疗。但这份指南对于青少年减重手术走入正轨具有重要意义。

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当前，随着时间的推移，减重手术的指征在逐渐放宽，但是，关于青少年肥胖患者中进行减重手术治疗的建议远未能达成一致。美国代谢与减肥手术协会2012年指南和国际小儿内镜外科组织2009年指南中，均建议BMI≥35kg/m2、且合并严重合并症的青少年肥胖患者考虑手术治疗，但是，这两家协会在2004年发布的指南中，却建议仅在BMI≥40kg/m2青少年患者中考虑减重手术治疗。

为此，意大利罗马市班比诺·杰苏儿童医院Valerio Nobili教授领导12位专家小组成员制定了一份新的青少年减重手术指导建议，并于2015年01月19日发表在儿科胃肠病学与营养学杂志上（The Journal of Pediatric Gastroenterology and Nutrition）。在这份新的指南中，Nobili教授及其同事写到，“对于儿科患者而言，减重手术的确切指征及其疗效仍有争议。”从伦理学角度考虑，青少年肥胖患者长期预后方面的资料有限。

Nobili教授及其同事注意到，“目前，关于非酒精性脂肪性肝炎（NASH）是否应被视为青少年减重手术的一个主要或次要标准方面仍有分歧。而这部新的指南提出，合并明显肝纤维化的NASH可被视为BMI≥35kg/m2青少年肥胖患者减重手术的指征。

其他需要考虑的严重合并症还包括糖尿病、中重度睡眠呼吸暂停和假性脑瘤。而轻度合并症则包括高血压、胰岛素抵抗、糖耐量异常、生活质量受损、心理痛苦、以及轻度度睡眠呼吸暂停。

这部新指南还提出，作为减重手术候选人的青少年患者，应有记录证明通过其他方法减重失败。特纳分期应在4期或以上，提示患者已进入青春后期，骨架发育成熟度达到95％。此外，患者还应承诺能够改变生活方式，并具有稳定社会心理环境。但这部指南未描述具体的减重手术最低年龄限制。

这部指南建议，合并有智力低下的青少年患者也可以考虑减重手术治疗，但同时也指出，这些患者应该根据具体病情考虑个体化减重手术治疗，且术前评估中应有伦理学家参与。

这部指南强调，减重手术治疗前后，应给予青少年肥胖患者多学科综合诊疗，尤其应给予患者营养和心理咨询。

 

Nobili教授及其同事透露道，最新的系统性回顾研究显示，上述方法有助于获得最佳的减重手术疗效，且可降低术后患者罹患心理疾病的风险。

美国约翰霍普金斯大学医学院Raquel G. Hernandez教授评论称，对于评估一例青少年患者是否适合减重手术治疗，一个有经验的多学科团队显得尤为重要。

这部指南建议青少年肥胖患者首选 Roux-en-Y胃旁路手术治疗，并在术后给予长期随访治疗。对于其他术式，包括可调节胃束带手术和袖状胃切除手术，这部指南认为在青少年患者中应谨慎考虑。并指出，虽然临时固定设备具有可逆性的优点，而且似乎也能安全用于儿科患者，但是，很少有研究推荐青少年患者接受可调节胃束带手术治疗。

美国菲尼克斯市亚利桑那大学外科学教授Dennis P. Lund博士评论道，这部指南的作者强调，各种新术式在青少年患者都没有足够的使用经验，因此不推荐使用，不可否认，这一观点是极为正确的。但是，对青少年患者而言，Roux-en-Y胃旁路手术是一种非常激进的治疗方法，随着时间的推移，有可能会导致各种代谢并发症。

Lund博士透露道，对成年患者而言，可调节胃束带术减肥持久性和最终减肥疗效方面多少有些令人失望，但是，袖状胃切除术已被证实具有更好的治疗前景。

Lund博士指出，就像指南中所叙述的那样，当前需要一项良好匹配的对照研究，在患有肥胖相关合并症、且BMI＞35kg/m2和＞40kg/m2的青少年患者中对药物治疗与袖状胃切除术进行比较。考虑到儿童专科医院有能力进行优良的多中心临床试验研究。我认为，这对于那些对减重手术感兴趣，并从事肥胖症外科治疗的医师而言，可能是一项有价值的研究。

这部指南由ESPGHAN和NASPGHAN赞助。Nobili博士和其他11位合著者均无利益冲突。

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Bariatric surgery be considered in adolescents with a body mass index of 35 kg/m2 or higher with certain severe comorbidities and for those with BMI of 40 kg/m2 or higher with milder comorbidities, according to recommendations in a new position paper from the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition.

The paper, released jointly this month by the ESPGHAN and its North American counterpart, NASPGHAN, aligns criteria for bariatric surgery in adolescents more closely to those used in adults, clinicians say.

The new guidelines “are still more conservative than what is currently recommended for adults, which begin with severe comorbidities at a BMI of 30 or higher, but this is a great paper to move things in the right direction for adolescents,” said Dr. Elizabeth P. Prout, medical director of the adolescent bariatrics program at the Children’s Hospital of Philadelphia.

Recommendations on bariatric surgery in this patient group are far from standardized, though they have become less conservative over time. Guidelines issued be theAmerican Society for Metabolic and Bariatric Surgery in 2012 and the International Pediatric Endosurgery Group in 2009 both say surgery can be considered in adolescent patients with a BMI of 35 and severe comorbidities, while those published in 2004 by the advise that bariatric surgery be considered only for adolescents with BMI of 40 or higher.

Dr. Valerio Nobili of Bambino Gesù Children’s Hospital in Rome led the 12-author team in developing the new recommendations, which were published online Jan. 19 in the Journal of Pediatric Gastroenterology and Nutrition (doi:10.1097/MPG.0000000000000715). Dr. Nobili and his colleagues wrote that “the exact indications and the role of bariatric surgery in the pediatric patient are still controversial,” citing ethical considerations along with limited information on long-term outcomes in younger patients.

Dr. Nobili and his colleagues noted that there is still disagreement as to whether nonalcoholic steatohepatitis (NASH) should be a considered a major or minor criterion for bariatric intervention in adolescents. The guidelines state that NASH with significant fibrosis can be considered an indication along with BMI of 35 kg/m2 or higher.

Additional serious comorbidities to consider include diabetes, moderate to severe sleep apnea, and pseudotumor cerebri. Milder comorbidities include hypertension, insulin resistance, glucose intolerance, impaired quality of life, psychological distress, and mild sleep apnea.

Adolescents who are candidates for bariatric surgery should have a documented failure to lose weight by other means, a Tanner stage of 4 or greater, indicating advanced puberty, 95% skeletal maturity, a “demonstrated commitment” to lifestyle change, and a stable psychosocial environment, the guidelines say. No specific minimum age is described.

The guidelines do not exclude adolescents who have mental retardation from being considered for surgery; however, these should be considered on a case-by-case basis, and an ethicist should be part of any evaluating team.

Multidisciplinary patient management before and after surgery is stressed in the guidelines, particularly nutritional and psychological counseling.

This approach has “the potential to facilitate optimal weight loss following bariatric surgery but also to reduce the risk of psychological consequences indicated by a recent systematic review,” Dr. Nobili and his colleagues wrote.

Dr. Raquel G. Hernandez, director of Healthy Steps/Fit4AllKids at All Children’s Hospital Johns Hopkins Medicine, St. Petersburg, FL, commented that a trained multidisciplinary team is “essential” to consider an adolescent patient’s overall fit for bariatric surgery.

The guidelines support Roux-en-Y gastric bypass with long-term follow-up care. Other procedures, including adjustable gastric banding and sleeve gastrectomy, should be considered investigational in this patient group, the guidelines caution, while temporary devices, which have the advantage of reversibility and appear promising for pediatric patients, are yet too little studied to recommend.

Dr. Dennis P. Lund, professor of child health and surgery at the University of Arizona, Phoenix, commented that while that while the guideline authors are correct to emphasize that newer procedures do not have enough of a track record in adolescent patients to recommend, “the Roux-en-Y seems a very aggressive option for an adolescent and can be fraught with metabolic complications long term.”

Dr. Lund said that in adults, adjustable gastric banding has been “somewhat disappointing in durability and in ultimate weight loss,” while sleeve gastrectomy has shown more promise.

 “What is required is a good matched, controlled study comparing medical treatment vs. sleeve gastrectomy for adolescent patients with BMI > 35 and 40 with the associated comorbidities outlined in the guidelines,” Dr. Lund said. “Given the ability of children’s hospitals to perform good multicentered trials, I would suggest that this would be a valuable study for those interested in treating obesity surgically to pursue.”

The guidelines were funded by ESPGHAN and NASPGHAN. Neither Dr. Nobili nor any of his 11 coauthors declared conflicts of interest.

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