Dillemans Bruno, Van Cauwenberge Sebastiaan, Agrawal Sanjay, Van Dessel Els, Mulier Jan-Paul
Department of General Surgery, AZ Sint-Jan Hospital AV, Brugge, Belgium.
BMC Surg. 2010 Nov 14;10:33. doi: 10.1186/1471-2482-10-33.
Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.
In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.
Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.
To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.
目前，对于超级病态肥胖（体重指数，BMI>60kg/m²）的最佳选择手术尚无共识。 Roux-en-Y胃旁路术（RYGB）在约15%的患者中存在无法实现或维持50%的超重减轻（EWL）或BMI<35的情况。此外，与肥胖程度较轻的组相比，超级肥胖组在术后1年的EWL百分比明显较低，并且在该组中，许多患者在接受RYGB手术后从技术角度仍被认为肥胖（术后最低BMI>35）。据报道，在RYGB基础上加用可调节胃束带（AGB）作为一种修正手术，但这种联合减肥手术尚未作为初次手术进行探索。
在初次腹腔镜RYGB手术中，通过胃小弯血管与胃囊之间的小开口，将AGB环绕胃囊。然后通过将胃残端缝合到束带上下的胃囊上来固定束带，以防止移位。
2009年11月至2010年3月期间，我院连续6例超级肥胖患者接受了初次腹腔镜可调节束带Roux-en-Y胃旁路手术。1例男性患者（21岁，BMI 70kg/m²）术后发生肺炎。未观察到其他术后并发症。
据我们所知，这是索引文献中首例接受腹腔镜可调节束带RYGB作为超级肥胖患者初次手术的系列病例。通过这种联合手术，有望实现减肥的序贯作用机制。RYGB的限制、吸收不良和激素作用机制将从一开始就导致体重减轻，并在12 - 18个月后达到稳定的体重平台期。届时，可以开始充盈束带，从而进一步限制胃囊并增加体重减轻。此外，除了改善总体体重减轻效果外，逐渐充盈束带还可以防止RYGB患者随着时间推移束带限制作用减弱而出现体重反弹。
