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1、内镜治疗2型糖尿病-医学奇迹？,三门县人民医院 黎宏章,一、概况,发病率：全球1.7亿 2025年预计3.24亿 我国20 成人：11.66% 男性13.31%，女性10.59%患病率、致残率和病死率居慢性非传染性疾病的第3位,并发症：致死致残的主要因素糖尿病性心脏病糖尿病性血管病变糖尿病性肾性病变 眼部病变神经病变皮肤、肌肉关节病变经济：个人及家庭：沉重包袱社会：严重负担,治疗现状 1.传统方法：饮食治疗运动与生活方式调节口服各种降糖药物注射胰岛素 2. 特点：基本无创伤不能根治易致生活质量下降,二、手术治疗2型糖尿病天方夜谭？,意外发现：某些减肥手术（胃肠旁路术等）治愈或减轻2型糖尿病,P
2、ories 608 GBP(肥胖症)146 2型糖尿病 83152 糖耐量异常 98.7 术后血糖 血清胰岛素 糖化血红蛋白 均恢复正常随访14年，上述指标长期正常Pories，Who would have thought it？ An operation proves to be the most effective therapy for adult-onset diabetes mellitusJ.AnnSurg,1995,222(3):339-350.,Cummings 3568 胃肠转流手术（肥胖症） 2型糖尿病 完全缓解率：82%98% 糖耐量减低者的完全缓解率：100%Cummi
3、ngs . Gastric bypass for obesity: mechanisms of weight loss and diabetes resolutionJ.J Clin EndocMetab,2004,89(6):2608-2615.,代谢手术治疗糖尿病的发展历程,糖尿病手术治疗现状,全球热点国外均用腹腔镜实施国内开腹手术较多，腹腔镜鲜有报道机制研究较少报道,可能机制,前肠假说(foregut hypothesis) ： 食物不经过十二指肠和上段空肠，导致某种抗-肠降血糖素(anti-incretin)分泌减少，从而解除了对胰岛素的抵抗，血糖恢复正常,可能机制,后肠假说(hind
4、gut hypothesis) ： 未充分消化的食物过快达到末段回肠，导致某种肠降血糖素( incretin)分泌增多，使血糖下降。 已鉴定出两种肠降血糖素：GIP， GLP-1,2型糖尿病代谢手术常用术式,Annals of the New York Academy of Sciences Volume 1212, Issue 1, pages E37-E45, 25 MAR 2011 DOI: 10.1111/j.1749-6632.2011.05984.x,可调节胃束带术,胃旁路术,胆胰分流术,垂直加帶胃隔间手术,十二指肠转位术,代谢手术临床应用与禁忌,适应症：BMI35kg/m2，伴2
5、 型糖尿病；BMI32-34.9kg/m2，伴2 型糖尿病，经过口服药物联合胰岛素治疗6 个月以上A1c7%；年龄在18-60 岁之间；2 型糖尿病病程5 年；胰岛自身免疫抗体测定阴性，C 肽水平不低于0.3g/L；无其他腹部手术的禁忌症。,禁忌症：1型糖尿病，GDM，特殊类型糖尿病，细胞功能丧失的T2DM，BMI 28 kg/m2且血糖控制良好的T2DM；不能耐受手术者。,T2DM代谢手术的获益风险比,糖尿病手术治疗到底是什么原理？,糖尿病手术治疗有哪些手术方法？,糖尿病手术治疗的方法起源于减肥手术，减肥手术的方法很多，包括胃束带、胃绕道、袖状胃、胆胰转流术、十二指肠隔离等方法，但是并不是所
6、有的减肥手术都能用来治疗糖尿病。目前适合糖尿病患者的手术主要是三种：胃束带手术、胃绕道手术和袖状胃手术。,1. 减少胃容积术式,胃束带手术： 全称腹腔镜可调节胃束带手术。是指通过腹腔镜手术将一条硅胶制束缚带束缚在胃上部，可以通过注水调节束带松紧来起到调节饮食的目的。,袖状胃手术： 又名袖状胃切除、“香蕉胃”或“管状胃”，它的原理就是把原本袋状的胃部修整成如肠道般的管状，如此便可减少食量而达到减重的效果。,垂直束带胃成形术 在贲门下靠近小弯处贯穿胃前后壁切开，经此“窗口”垂直钉合胃前后壁至His 角，将胃底部与贲门流入道分开，并经“窗口”将流入道用聚乙烯网片缝合约束，形成了一个近端小胃囊，从而达
7、到限制进食量的目的。,经胃镜向胃腔置入球囊的胃减容术 球囊容积400 700 ml，多采用装有0.9 %氯化钠溶液的硅胶软球。,2. 消化道转流手术,腹腔镜Roux-en-Y 胃旁路术 是指通过开腹或腹腔镜下通过将胃肠道进行重组，通过Roux-en-Y吻合使患者胃缩小，并且绕过部分肠道减少吸收。目前是糖尿病手术的主要方法。,腹腔镜迷你胃旁路术 靠近胃小弯自胃窦至His 角切割闭合胃体，形成管状小胃囊，旷置其余大部分胃体，将小胃囊与空肠吻合。治疗效果满意，其术后并发症主要是边缘性溃疡和反流性食管炎。,胆胰转流术： 行远端胃大部切除术，在距回盲瓣250 cm 处切断小肠，远端与保留胃囊吻合，近端在
8、距回盲瓣50 cm 处与回肠端侧吻合。 这一术式使胆汁、胰液和食物加快进入回结肠，明显减少了营养物质的消化和吸收。,回肠转位术 在距回盲瓣5-15 cm 处截取一段10-15 cm 的回肠，将距Treitz 韧带5-10 cm 处空肠切断，将远端回肠段插入吻合。保留了完整的肠道，术后少有营养不良发生。,三种常用糖尿病手术大PK,腹腔镜胃旁路手术 “腹腔镜下胃旁路”减肥手术是一种肠胃手术，即将患者的胃分成两部分，用于容纳食物的只有原来胃部的1/6-1/10，然后在小胃的切口处开一条“岔路”，接上截取的一段小肠，使得患者食量大幅度减少从而达到减肥的目的。据介绍，全身“胃旁路减肥术”在欧美国家实行了
9、40-50年，实际上国内很多医院的外科水平已经有能力开展这类减肥手术，随着手术的熟练，术后配套措施条件的逐渐完善，在国内通过胃旁路手术治疗肥胖症、糖尿病的前景会越来越好。,2008亚洲肥胖及2型糖尿病患者减重或胃肠代谢手术治疗指南,指南认为亚洲人群具备以下情况可以考虑减重/胃肠代谢手术：1. BMI大于35kg/m2的肥胖患者；2. BMI大于32kg/m2并有合并症的肥胖患者；3. BMI大于30kg/m2并有中心型肥胖（男腰围大于90cm，女性腰围大于80cm）及至少2项满足代谢综合征诊断标准（甘油三酯升高、HDL降低、高血压、空腹血糖升高）的肥胖患者；4. BMI小于30 kg/m2的糖
10、尿病患者实施减重/胃肠代谢手术应严格遵守研究方案并获知情同意，且这类手术应限于实验研究范畴，并通过伦理委员会审查。,“肠套管”技术治疗型糖尿病,困扰患者和医生的问题产生了： 手术毕竟是手术，手术风险怎样才能避免呢？手术后如果后悔了，也没办法复原了？基于同样的理论，通过在人体胃肠道植入“人工合成塑料套管”这一新技术，解决了以上这些问题。英国、美国的研究人员使用这种“肠套管”，将套管放置在胃与十二指肠肠段，并根据患者糖尿病病情情况来选择合适长度的“肠套管”。该项临床技术并不需要手术，更无须开刀，只需要通过胃肠镜从咽喉食道送入肠套管并与胃肠道相连，整个过程仅需1个小时，就可以将“肠套管”固定在胃部。
11、通过临床观察后研究人员发现，食物同样可以绕过十二指肠肠段，减少糖吸收，从而起到控制血糖的作用。,三、内镜治疗2型糖尿病医学奇迹？,手术治疗2型糖尿病天方夜谭？内镜治疗2型糖尿病医学奇迹？未来内镜下植入十二指肠-空场袖管(消化道支架模管)将成为消化内镜一个主要内镜治疗项目，几亿患者，千万患者啊.,EndoBarrier Gastrointestinal Liner （十二指肠-空场袖管，消化道支架模管）,由麻省的GI Dymanics公司研发，通过在在摄入的食物和胃肠壁之间建立物理屏障，它可能使超重的患者逐渐恢复正常体重。 这种体内的屏障由胃镜吞入体内无需胃旁路手术或是任何外科手术在小肠起始的两
12、英尺处放置这装置，最易吸收卡路里的一段就被阻断了（更靠后的消化道中，还是会有营养被吸收的）。,What is EndoBarrier?,The EndoBarrier Gastrointestinal Liner is a breakthrough treatment designed to help patients regain metabolic control of T2DM and to aid in weight loss. This is a new class of treatment that fits between pharmaceutical regimens and
13、surgery. It is performed easily and quickly without any incisions and just a few hours in hospital.Based on the growing body of clinical evidence, EndoBarrier has the potential to dramatically change the treatment approach for people who are obese or have T2DM. experience has found that EndoBarrier
14、can provide immediate relief from T2DM in patients with significantly elevated HbA1c. In addition, most patients experience clinically significant weight loss. This is believed to have a long term effect in managing insulin resistance as well as a positive impact on cardiovascular risk factors, incl
15、uding elevated lipid levels and high blood pressure.,The EndoBarrier advantage,EndoBarrier has demonstrated:Serum glucose levels drop significantly within the weeks immediately following implantation routinely achieving normal levels.HbA1c levels also show substantial improvement and often reach nor
16、mal levels at 3 months and beyond.Results show a sustained effect lasting beyond the period of treatment in both HbA1c levels and fasting plasma glucose.Patients lose a significant amount of weight during the treatment period, which is believed to have a long term impact on levels of insulin resista
17、nce.,Patients report appetite suppression, higher energy levels and overall improved outlook.When patients participate in a multidisciplinary support programme, including behaviour modification, nutritional counselling and exercise, weight loss increases and durability of result improves, providing
18、for a sustained control of diabetes.It has been well established that even a small amount of weight loss can have a substantial impact on long term serum glucose levels.,How the EndoBarrier Works?,The EndoBarrieris a thin, flexible, tube-shaped liner that forms a barrier between the food you eat and
19、 a portion of the wall of your intestine.Placing the EndoBarrieris a procedure that doesnt require any surgery or incisions. Your doctor will attach the EndoBarrierto just below your stomach (called the duodenal bulb). The EndoBarrierwill then extend approximately 60cm through parts of your digestiv
20、e system called the duodenum and proximal jejunum. Once in place, the EndoBarrierwill change the way your body responds to food and will lead to controlled diabetes and increased weight loss.,Who will benefit from EndoBarrier?,You can benefit from Endobarrier if Your BMI is over 27 and you are livin
21、g with Type 2 Diabetes.Your BMI is over 27 and you are at risk of developing Type 2 Diabetes.Your BMI is over 27 and you would like to lose weight.You meet all of the criteria and you are prepared to follow certain diet and lifestyle modifications.,A Multicenter, Randomized Efficacy Study of the End
22、oBarrier Gastrointestinal Liner for Presurgical Weight Loss Prior to Bariatric SurgeryAnn Surg. 2010 Feb;251(2):236-43. Schouten R, Rijs CS, Bouvy ND, Hameeteman W, Koek GH, Janssen IM, Greve JW. Department of Surgery, Atrium Medical Centre Parkstad, Heerlen, The Netherlands.,Methods:,A multicenter,
23、 randomized clinical trial was performed. 41 patients were included and 30 underwent sleeve implantation. Eleven patients served as a diet control group. All patients followed the same low-calorie diet during the study period. The purpose of the study was to determine the safety and efficacy of the
24、device.,RESULTS:,Twenty-six devices were successfully implanted.4 patients, implantation could not be achieved. because of：migration ；dislocation of the anchor; sleeve obstruction ； continuous epigastric pain.adverse event :mainly abdominal pain and nausea during the first week after implantation.BM
25、I :Initial BMIwas 48.9 and 47.4 kg/m2 for the device and control patients, respectively. Mean excess weight loss after 3 months was 19.0% for device patients versus 6.9% for control patients (P 0.002). Absolute change in BMI at 3 months was 5.5 and 1.9 kg/m2, respectively. Type 2 diabetes mellitus w
26、as present at baseline in 8 patients of the device group and improved in 7 patients during the study period (lower glucose levels, HbA1c, and medication requirements).,CONCLUSION:,The EndoBarrier Gastrointestinal Liner is a feasible and safe noninvasive device with excellent short-term weight loss results.The device also has a significant positive effect on type 2 diabetes mellitus. Long-term randomized and sham studies for weight loss and treatment of diabetes are necessary to determine the role of the device in the treatment of morbid obesity.,
