Bariatric surgery: traversing the CROSSROADS into mainstream diabetes care.
Bariatric surgery: traversing the CROSSROADS into mainstream diabetes care.
复制标题
减肥手术：穿越十字路口进入主流糖尿病护理。
DOI：
10.1007/s00125-016-3928-1
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发表时间：
2016
期刊：
影响因子：
8.2
通讯作者：
leRoux,CarelW
中科院分区：
文献类型：
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作者：
Neff,KarlJ;leRoux,CarelW
在过去的十年中，减肥手术已经被公认为其效果超出了减肥。瑞典肥胖受试者（SOS）研究的长期结果表明，肥胖对疾病风险、发病率和死亡率有影响[1]。重要的是，在预防肥胖人群中糖尿病的发作和在术前糖尿病患者中产生葡萄糖稳态的实质性改善方面也有明显的效果。这种显著的效果有助于糖尿病患者用较少的药物达到治疗目标[2-5]。可以理解的是，人们越来越关注减肥手术在2型糖尿病管理中的作用。以前的讨论集中在糖尿病的缓解和“糖尿病治愈”的诱人前景。然而，我们现在知道，虽然术后2年糖尿病的部分缓解率可能非常高，但在随机对照试验（RCT）中，没有任何手术显示糖尿病患者在5年时达到完全缓解[2-5]。因此，重点已经正确地转移到手术的概念，作为一种针对那些不能单独使用非手术治疗达到治疗目标的患者的预防性治疗，以及如何使用多模式医学治疗来优化手术后的长期结局。在过去的4年中，几项主要的RCT已经确定了减肥手术的疗效，特别是Roux-en-Y胃旁路术（RYGB），袖状胃切除术和胆胰分流术在实现2型糖尿病血糖控制中的作用[2-5]。在这一期的糖尿病学[6]中，热量减少或手术的发现：寻求减少肥胖和糖尿病研究（CROSSROADS）研究，比较最好的非手术治疗与RYGB，现在增加了这些结果。在所有先前的研究中，在实现血糖控制方面，医疗护理结合减肥手术比单独的药物治疗更有效。与血液控制的改善相关，手术接受者表现出血压和血脂的改善。这些改善是更大的，并实现了更少的药物，比那些单独使用药物。最初研究中的大多数有益效果在手术后长达5年。在CROSSROADS研究中，使用了强化的生活方式干预，包括规定的运动和饮食计划。该研究在实现体重减轻和降低代谢功能障碍的标志物方面非常成功，包括两组的HbA 1c和空腹胰岛素浓度。然而，与先前关于强化生活方式干预对糖尿病代谢控制和减肥效果的研究一致，如果不增加手术，最初的改善是不可持续的。6个月后，在强化生活方式中实现了初步改善
Over the last decade, bariatric surgery has come to be recognised for its effects beyond weight loss. The long-term results of the Swedish Obese Subjects (SOS) study have shown an effect on disease risk, morbidity and mortality [1]. Importantly, there are also clear effects on both preventing the onset of diabetes in obese cohorts, and in producing substantial improvements in glucose homeostasis in those with pre-operative diabetes. This considerable effect facilitates the achievement of treatment targets by diabetic individuals with less medication [2–5]. Understandably, there is increasing interest in the role of bariatric surgery in the management of type 2 diabetes. Previous discussions focused on remission of diabetes and the tantalising prospect of a ‘diabetes cure’. However, we know now that while partial remission rates of diabetes 2 years post-operatively can be impressively high, no procedure has been shown to achieve complete remission in patients with diabetes at 5 years within the setting of a randomised controlled trial (RCT)[2–5]. Therefore, the focus has rightly shifted towards the concept of surgery as an adjunctive glycaemic therapy for those who cannot meet their treatment targets with non-surgical therapy alone, and how multimodal medical therapies can be used to optimise the long-term outcomes after surgery.Over the last 4 years, several major RCTs have established the efficacy of bariatric surgery, and specifically Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy and biliopancreatic diversion, in achieving glycaemic control in type 2 diabetes [2–5]. In this issue of Diabetologia [6], the findings of the Calorie Reduction Or Surgery: Seeking to Reduce Obesity And Diabetes Study (CROSSROADS) study, comparing the very best non-surgical care with RYGB, now add to these results. In all of the previous studies, medical care in combination with bariatric surgery was more effective than medical therapy alone at achieving glycaemic control. In association with the improvements in glycaemic control, surgical recipients demonstrated improvements in blood pressure and serum lipids. These improvements were greater, and achieved with fewer drugs, than those achieved with medication alone. Most of the beneficial effects in the initial studies were durable for up to 5 years after surgery. In the CROSSROADS study, intensive lifestyle interventions, including prescribed exercise and dietary plans, were used. The study was very successful in achieving weight loss and reducing markers of metabolic dysfunction, including HbA1c and fasting insulin concentrations in both arms. However, in keeping with previous studies on the effect of intensive lifestyle interventions on metabolic control in diabetes, and on weight loss, the initial improvements were not sustainable without the addition of surgery. After 6 months the initial improvements achieved in the intensive lifestyle