胃间隔手术可能对儿童族群有益


  【24drs.com】根据一篇在线发表在3月3日临床肥胖学期刊的系统性综论结果,胃间隔手术对于肥胖儿童与青少年可能是有效的,但是需要以较谨慎的方法进行。
  
  来自英国伦敦国际肥胖研究组织的Andrea Aikenhead在一篇新闻稿中表示,肥胖流行现在同时影响儿童与成人,且肥胖及其共病,还有医疗花费不断地上升,建立有效治疗儿童肥胖的方法,不仅能降低儿童肥胖的盛行率以及相关的不健康状态,同时可以抑制肥胖儿童长大成人的比例,这是对抗这个流行一个关键步骤。
  
  研究人员查找2010年9月6日前的PubMed、ISI网络科学、EMBASE以及考科蓝图书馆,也针对找出文章的参考文献进行手动查找;收纳条件包括英文摘要的文章,收纳19岁以下受试者,且在术后至少测量体重一次以上,以及至少一年的术后追踪。
  
  收纳的37项研究中,共有831位儿童或青少年,横跨了36年。在13项以胃束带进行的研究中,身体质量指数(BMI)平均从8.5下降到4.3 kg/m2,其中1项病例研究报告体重不降反增。8项以Roux-en-Y胃绕道(RYGB)手术进行的研究,BMI平均介于9到25 kg/m2。
  
  另外14项研究使用其它形式的胃间隔手术,包括袖状胃切除术、垂直加带胃隔间手术、胰绕道手术,或是合并术式。这些术式可以降低BMI 9到24 kg/m2,许多病例术后复胖,且发生3件与手术有关的死亡事件。
  
  大部分研究报告共病消除或改善。许多外科术式与一连串术后并发症有关,包括溃疡、小肠渗漏、伤口感染、吻合口狭窄、营养缺乏、肠阻塞、肺栓塞、钉线中断、间隔滑动、精神后遗症、以及反覆呕吐。
  
  仅有一澳洲模拟研究分析经济效益,且研究结果显示腹腔镜可调整胃间隔(LAGB)手术对青少年是符合经济效益的。
  
  研究作者们写到,现存的证据显示,虽然大部分是根据统计力量不足、回溯性的研究,代表较大儿童接受胃间隔手术可以显著减重且改善共病与生活质量。
  
  然而,青少年的术后并发症、顺应性以及后续追踪比成人麻烦,且安全性的长期数据、效果与经济效益大部分仍然未知。目前可获得的证据还有进步的空间,对于儿童与青少年进行胃间隔手术应该更谨慎,且建议采取可回复的术式,而非永久改变解剖构造的方法。
  
  这项研究的限制包括大部分研究是回溯性或观察性设计、统计力量不足、样本数目太少、整体结果并非可比较的、以及低发生率的预后,例如死亡率与并发症資訊有限。除此之外,不容易确认青少年复胖的程度,部分是因为患者失去后续追踪的误差。
  
  作者们的结论是,不应忘记生活型态改变与预防的功效:前者对胃间隔手术的长期成功是关键的。现在需要赶快发展出手术外的治疗方法,例如实际的生活型态计画,可以有效适用于中度肥胖、过重以及肥胖儿童。公共卫生专家们必须继续致力于预防准则,让政府了解执行健康促进公共卫生政策,以支持预防性计画以及足够的治疗性长期研究。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=6480&x_classno=0&x_chkdelpoint=Y
  

Bariatric Surgery May Be Helpful in Pediatric Population

By Laurie Barclay, MD
Medscape Medical News

March 15, 2011 — Bariatric surgery may be effective in obese children and adolescents, but a cautious approach is warranted, according to the results of a systematic review reported online March 3 in Clinical Obesity.

"The obesity epidemic now affects children as well as adults, with obesity and its associated morbidities and costs increasing in scale," said lead author Andrea Aikenhead, from the International Association for the Study of Obesity in London, United Kingdom, in a news release. "Establishing effective methods for treating severe obesity in children will not only reduce the prevalence of childhood obesity and related ill health, but inhibit the progression of obese children to obese adults, a crucial step in combating the epidemic."

The investigators searched PubMed, ISI Web of Science, EMBASE, and the Cochrane Library to September 6, 2010, and also did a manual search of reference lists of retrieved articles. Inclusion criteria were articles with English-language abstracts reporting on participants not older than 19 years, with 1 or more measurements of postoperative weight loss and at least 1 year of postoperative follow-up.

The 37 included studies enrolled a total of 831 children or adolescents, spanning 36 years. Among 13 studies of gastric banding, mean decreases in body mass index (BMI) ranged from 8.5 to 43 kg/m2, with weight gain reported in 1 case study. Mean BMI reductions ranged from 9 to 25 kg/m2 in 8 studies of Roux-en-Y gastric bypass (RYGB).

Other forms of bariatric surgery, including sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion, or a combination of procedures, were reported in 14 articles. These procedures resulted in mean BMI decreases ranging from 9 to 24 kg/m2, weight regain in several cases, and 3 deaths related to surgery.

Most studies reported resolution or improvement of comorbid conditions. Various surgical procedures were associated with a range of postoperative complications including ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological sequelae, and repeated vomiting.

Only 1 Australian modeling project studied cost-effectiveness, and results of this study suggested that laparoscopic adjustable gastric banding (LAGB) is cost effective for adolescents.

"Existing evidence — although based generally on underpowered, retrospective studies — suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life," the study authors write.

"However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy."

Limitations of this study include retrospective or observational design in most studies, insufficient power, generally small sample sizes, results not broadly comparable, and limited information for low-frequency outcomes such as mortality and complications. In addition, it was difficult to determine the degree of weight regain in adolescents, in part because of the bias introduced by patients lost to follow-up.

"Lifestyle modification and prevention should not be de-emphasized: the former is crucial to the long-term success of bariatric procedures," the study authors conclude. "There is an urgent need to develop alternatives to surgery, such as practical lifestyle programmes that are effective, even modestly, for overweight and obese children. Public health experts must continue to employ the precautionary principle to convince governments of the importance of implementing health-promoting public policies to support prevention programmes and adequate long-term research for treatment."

The project that led to this study was funded by the WHO Health Evidence Network of the World Health Organization. The study authors have disclosed no relevant financial relationships.

Clin Obesity. Published online March 3, 2011.

    
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