Parikh Manish S, Shen Roy, Weiner Matt, Siegel Niccole, Ren Christine J
Program for Surgical Weight Loss, Department of Surgery, New York University School of Medicine, New York, NY, USA.
Obes Surg. 2005 Jun-Jul;15(6):858-63. doi: 10.1381/0960892054222632.
Bariatric surgery in super-obese patients (BMI >50 kg/m(2)) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities.
A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30 day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations.
From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m(2). Patients were aged 42 years (13-72), and 75% were female. When categorized by operation (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3+/-12.6, 45.8+/-19.4, and 49.5+/-18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7+/-15.4, 54.7+/-21.2, and 56.8+/-21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6+/-15.9, 69.4+/-13.0 and 77.4+/-11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths.
Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.
超级肥胖患者（体重指数>50kg/m²）的减肥手术颇具挑战性，这是因为暴露内脏脂肪困难、牵拉脂肪肝、器械需承受强大扭矩，以及存在并存疾病。
对接受腹腔镜可调节胃束带术（LAGB，n = 192）、Roux - Y胃旁路术（RYGBP，n = 97）和胆胰转流术（伴或不伴十二指肠转位，BPD，n = 43）的超级肥胖患者进行回顾性研究。评估围手术期30天的发病率和死亡率，以确定这三种手术的相对安全性。
从2000年10月至2004年6月，331例超级肥胖患者接受了腹腔镜减肥手术，平均体重指数为55.3kg/m²。患者年龄为42岁（13 - 72岁），75%为女性。按手术方式（LAGB、RYGBP、BPD）分类时，平均年龄、体重指数和性别具有可比性。6例患者转为开腹手术（1.8%）。LAGB的转换率为0.5%，RYGBP为2.1%，BPD为7.0%（P = 0.02，所有组）。LAGB的中位手术时间为60分钟，RYGBP为130分钟，BPD为255分钟（P<0.001，所有组）。LAGB的中位住院时间为24小时，RYGBP为72小时，BPD为96小时（P<0.001）。LAGB术后1年、2年和3年的平均超重减少百分比（%EWL）分别为35.3±12.6、45.8±19.4和49.5±18.6，随访率分别为87%、76%和72%。RYGBP术后1年、2年和3年的平均%EWL分别为57.7±15.4、54.7±21.2和56.8±21.1，随访率分别为76%、33%和54%。BPD术后1年、2年和3年的平均%EWL分别为60.6±15.9、69.4±13.0和77.4±11.9，随访率分别为79%、43%和47%。LAGB与BPD在所有时间间隔的%EWL差异均有统计学意义（P<0.004）。然而，LAGB与RYGBP在2年和3年时的%EWL差异无统计学意义。总体围手术期发病率为27例患者（8.1%）。LAGB的发病率为4.7%，RYGBP为11.3%，BPD为16.3%（P = 0.02，所有组）。无死亡病例。
腹腔镜减肥手术在超级肥胖患者中是安全的。LAGB作为侵入性最小的手术，在这一高危患者群体中手术时间最短、转换率最低、住院时间最短且发病率最低。所研究的所有参数的发生率均随手术复杂性增加而升高。然而，RYGBP与LAGB在2年和3年时的%EWL差异无统计学意义。
