JAMA：糖尿病非病态性肥胖成年患者的外科手术治疗

　　芝加哥 – 据6月5日发表在《美国医学会杂志》上的一则研究披露，通过对超过50项研究进行回顾后发现，只有有限的证据支持用减肥手术来治疗患有糖尿病或葡萄糖耐受性受损的非病态性肥胖的成年人（身体质量指数[BMI]30-35）。就这组病人的有限数据而言，与诸如药物、饮食及行为改变等非手术干预相比，减肥手术与短期体重减轻、中级的血糖浓度、血压及高胆固醇水平的较大改善有关。

　　根据文章的背景资料：“减肥手术常常被用于促进体重的减轻以及被用于处理病态性肥胖患者（身体质量指数[BMI；35或以上]）的与肥胖症有关的并存疾病[同时存在的疾病]。在这一人群中，诸如腹腔镜可调式胃束带术及鲁氏Y形分流术等手术，与非手术治疗相比，可在治疗后1或2年时使血糖得到更好的控制并且可以减去更多的体重。减肥手术被倡导作为治疗不甚肥胖的糖尿病患者（BMI，30-35）的一种治疗。然而，这种做法仍然存在争议。2006年，医疗保险与医疗补助服务中心不同意为BMI较低的糖尿病患者提供保费覆盖，而联邦食品及药品管理局却已经批准了对患有肥胖相关性并存疾病的BMI在30-35的人施行胃束带术。”

　　加利福尼亚圣莫尼卡Rand Health的Melinda Maggard-Gibbons, M.D., M.S.H.S.及其同事就BMI在30-35的患有糖尿病或葡萄糖耐受受损的患者在接受手术治疗和非手术治疗时所面对的与这些治疗有关的相对裨益和风险进行了一项系统性的回顾。文章的作者对医疗文献进行了搜索并发现了32项手术研究、11项对非手术治疗的系统性综述，以及在那些综述之后发表的符合这项分析标准的11项大型非外科研究。

　　研究人员只在3项随机化临床试验（RCTs; n=290）中发现，与非手术治疗相比，减肥手术与在1-2年的跟踪随访中观察到的体重更大幅度的减轻（范围：32-53磅）和更好的血糖控制有关。这些试验中没有一项具有数目众多的符合本研究标准的患者： 一项试验包含了150名患有II型糖尿病的且其BMI的平均值为37的患者； 一项试验包含了80名没有糖尿病但其BMI为30-35的患者；还有一项试验包含了60名患有糖尿病且其BMI为30-40 [13名患者的BMI <35]的患者。

　　文章的作者得出结论：“在这一特定患者人群中，来自临床试验的数据有限，因此无法得知所观察到的裨益是否会长期持久，而且这些发现是否能转而减少糖尿病的微血管及大血管并发症也是未知的。在可以获得这样的数据之前，还没有足够证据就恰当地在这一患者人群中施行减肥手术得出结论，针对这一目标人群中施行的这类手术应该得到仔细的科学审查，而且有必要做更多的检查来比较这些疗法。”

Bariatric Surgery for Weight Loss and Glycemic Control in Nonmorbidly Obese Adults With Diabetes: A Systematic Review
ABSTRACT
Importance  Bariatric surgery is beneficial in persons with a body mass index (BMI) of 35 or greater with obesity-related comorbidities. There is interest in using these procedures in persons with lower BMI and diabetes.
Objective  To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35.
Evidence Review  PubMed, EMBASE, and Cochrane Library databases were searched from January 1985 through September 2012. Of 1291 screened articles, we included 32 surgical studies, 11 systematic reviews on nonsurgical treatments, and 11 large nonsurgical studies published after those reviews. Weight loss, metabolic outcomes, and adverse events were abstracted by 2 independent reviewers.
Findings  Three randomized clinical trials (RCTs) (N = 290; including 1 trial of 150 patients with type 2 diabetes and mean BMI of 37, 1 trial of 80 patients without diabetes [38% with metabolic syndrome] and BMI of 30 to 35, and 1 trial of 60 patients with diabetes and BMI of 30 to 40 [13 patients with BMI <35]) found that surgery was associated with greater weight loss (range, 14.4-24 kg) and glycemic control (range, 0.9-1.43 point improvements in hemoglobin A1c levels) during 1 to 2 years of follow-up than nonsurgical treatment. Indirect comparisons of evidence from observational studies of bariatric procedures (n ≈ 600 patients) and meta-analyses of nonsurgical therapies (containing more than 300 RCTs) support this finding at 1 or 2 years of follow-up. However, there are no robust surgical data beyond 5 years of follow-up on outcomes of diabetes, glucose control, or macrovascular and microvascular outcomes. In contrast, some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more. Surgeon-reported adverse events were low (eg, hospital deaths of 0.3%-1.0%), but data were from select centers and surgeons. Long-term adverse events are unknown.
Conclusions and Relevance  Current evidence suggests that, when compared with nonsurgical treatments, bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes. Evidence is insufficient to reach conclusions about the appropriate use of bariatric surgery in this population until more data are available about long-term outcomes and complications of surgery.