First Department of Propaedeutic Internal Medicine, Diabetes Centre, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.
Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland.
BMC Endocr Disord. 2017 Aug 10;17(1):50. doi: 10.1186/s12902-017-0202-6.
Bariatric surgery is emerging as a powerful weapon against severe obesity and type 2 diabetes mellitus (T2DM). Given its role in metabolic regulation, the gastrointestinal tract constitutes a meaningful target to treat T2DM, especially in light of accumulating evidence that surgery with gastrointestinal manipulations may result in T2DM remission (metabolic surgery). The major mechanisms mediating the weight loss-independent effects of bariatric surgery comprise effects on tissue-specific insulin sensitivity, β-cell function and incretin responses, changes in bile acid composition and flow, modifications of gut microbiota, intestinal glucose metabolism and increased brown adipose tissue metabolic activity. Shorter T2DM duration, better preoperative glycemic control and profound weight loss, have been associated with higher rates of T2DM remission and lower risk of relapse. In the short and medium term, a significant amount of weight is lost, T2DM may completely regress, and cardiometabolic risk factors are dramatically improved. In the long term, metabolic surgery may achieve durable weight loss, prevent T2DM and cancer, improve overall glycemic control while leading to significant rates of T2DM remission, and reduce total and cause-specific mortality. The gradient of efficacy for weight loss and T2DM remission comparing the four established surgical procedures is biliopancreatic diversion >Roux-en-Y gastric bypass >sleeve gastrectomy >laparoscopic adjustable gastric banding. According to recently released guidelines, bariatric surgery should be recommended in diabetic patients with class III obesity, regardless of their level of glycemic control, and patients with class II obesity with inadequately controlled T2DM despite lifestyle and optimal medical therapy. Surgery should also be considered in patients with class I obesity and inadequately controlled hyperglycemia despite optimal medical treatment.
减重手术作为治疗严重肥胖和 2 型糖尿病（T2DM）的有效手段正在兴起。鉴于其在代谢调节中的作用，胃肠道是治疗 T2DM 的一个有意义的靶点，尤其是有越来越多的证据表明，胃肠道手术可能导致 T2DM 缓解（代谢手术）。减重手术对体重减轻以外的影响的主要机制包括对组织特异性胰岛素敏感性、β细胞功能和肠促胰岛素反应的影响、胆汁酸组成和流量的变化、肠道微生物群的改变、肠道葡萄糖代谢和棕色脂肪组织代谢活性的增加。T2DM 病程较短、术前血糖控制较好和体重减轻较多与更高的 T2DM 缓解率和更低的复发风险相关。在短期和中期，体重显著减轻，T2DM 可能完全缓解，且心血管代谢危险因素明显改善。在长期，代谢手术可能实现持久的体重减轻，预防 T2DM 和癌症，改善整体血糖控制，同时导致 T2DM 缓解率显著提高，并降低总死亡率和特定原因死亡率。四种已确立的手术程序在减重和 T2DM 缓解方面的疗效梯度为胆胰分流术＞胃旁路术＞袖状胃切除术＞腹腔镜可调节胃束带术。根据最近发布的指南，无论血糖控制水平如何，对于患有 III 类肥胖的糖尿病患者，应推荐进行减重手术，对于因生活方式和最佳药物治疗而血糖控制不佳的 II 类肥胖患者也应推荐进行减重手术。对于因最佳药物治疗而血糖控制不佳的 I 类肥胖患者，也应考虑手术治疗。
