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Diabetes Care:糖尿病手术疗法进临床指南

2016-06-20 MedSci MedSci原创

在近期的 Diabetes Care 上,发表了新的2型糖尿病治疗临床指南,这次公布的指南近100年来最大的一次修改。国际上45个专业学会共同支持该指南的修改。指南建议胃转流等手术是适当糖尿病患者的标准治疗方法。这次修改是依据多个临床试验证明这种手术可比任何生活方式和药物干预更有效地改善血糖水平,并可以带来长期病情缓解。胃肠转流手术治疗糖尿病从偶然发现到被科学家明确认识,然后经过动物和临床试验,并

在近期的 Diabetes Care 上,发表了新的2型糖尿病治疗临床指南,这次公布的指南近100年来最大的一次修改。国际上45个专业学会共同支持该指南的修改。指南建议胃转流等手术是适当糖尿病患者的标准治疗方法。这次修改是依据多个临床试验证明这种手术可比任何生活方式和药物干预更有效地改善血糖水平,并可以带来长期病情缓解。


胃肠转流手术治疗糖尿病从偶然发现到被科学家明确认识,然后经过动物和临床试验,并经过大规模双盲临床研究证实,最后被临床医学接受并推荐为标准治疗方法。最后主动研究的历史也先后经过18年。氢气医学自从2007年被发现以来,至今尚未达到临床有效的确认,按照这样的估计,再过20年,氢气治疗能成为某疾病的标准或辅助治疗手段,也已经是相对乐观了。
        
历经全球糖尿病医学领域20多年的潜心研究和临床实践,胃转流手术已经发展为成熟的糖尿病治疗方法,也是可以实现临床治愈Ⅱ型糖尿病的唯一方法。截止2010年,美国、英国、澳等国已有超过100万糖尿病患者通过手术告别了糖尿病。我国糖尿病手术治疗开展已有5年多时间,手术例数累计已经达8000多例,治愈率已达92.6% 以上。
        
一种本来用于减肥的外科手术,偶然被发现能治疗二型糖尿病,在没有完全弄清楚具体分子机理情况下,国际上相继开展大规模临床试验证明这种手术的对糖尿病治疗的有效性,最终被接受为国际标准治疗方法。这就是一种治疗手段的标准成长史。

        
当1990年代开始有人对这种手术和糖代谢平衡之间的联系进行探讨时,最大的阻力来自许多临床学家对这一说法的偏见。其实最早发现这种手术对糖尿病的改善效果是在近100年前。这种手术对糖尿病的治疗作用,对改变过去认为糖尿病不可逆转的说法具有重要意义,这会提高人们寻找治愈糖尿病的新方法和药物的信心。当然这一征途仍然充满艰辛。
        
从1980年到2014年,全球糖尿病患者从1.08亿人增加到4.22亿人(4倍),其中90%属于二型糖尿病,这种疾病是造成肾脏衰竭、盲、神经损伤、截肢、心脏病和中风的重要原因。少于50%的二型糖尿病患者能通过药物或适当改变生活方式,如改变饮食习惯和增加体育运动,达到控制血糖的目的。或者说有超过50%的患者没有很好地控制好血糖。最新指南是对哪些其他方法控制血糖不理想的糖尿病患者,体重指数超过30(亚洲人放宽到27.5)。这和过去用于减肥手术的选择患者标准完全不同,从1950年代开始的减肥手术患者选择标准是体重指数BMI超过40。
        
1925年,《柳叶刀》杂志报道了一例治疗胃溃疡的胃肠手术后出现了“副作用”,手术当天晚上该患者尿糖症状神秘消失。此后这种手术后类似“副作用”的报道越来越多,尤其是到1950年代后,减肥手术的盛行,许多患者手术后糖尿病神奇痊愈。1980年代和90年代,减肥术可治疗糖尿病的报道越来越多,甚至最高出现有120名患者的报道。1999年,纽约西奈山医学院Francesco Rubino博士偶然发现,几乎所有2型糖尿病患者在进行胆胰分流减肥手术前一个月血糖就已经完全恢复。这些人能停止服用降糖药和低热量饮食。

Rubino博士怀疑是否胃肠手术能直接对糖尿病产生作用,如果是这样,外科手术将能治疗糖尿病,或许能帮助理解糖尿病发生的原因。看到这个文章后次日,Rubino博士就劝说导师申请这种临床试验研究。但是他们的临床研究申请没有获得医学院的批准,于是转向开展大鼠实验验证胃肠手术对血糖代谢影响的效果。动物实验结果确认了这一作用,但是随后用了2年才最终发表了研究结果。

2006年和2007年,外科手术小组也证实了这种手术对人类糖尿病患者的治疗作用。另外一些研究小组也开始对这种效应的分子机制进行探讨。在这些研究的基础上,2007年第一届糖尿病外科治疗峰会上,来自多个学科的临床和基础医学家对胃肠手术治疗糖尿病的工作机理和临床治疗效果的数据进行了回顾和分析,并明确了下一步的研究重点。

峰会提出应该用随机临床试验确认这种手术治疗糖尿病的效果。八年后,2015年9月,第二届糖尿病外科治疗峰会上,手术治疗糖尿病被参会代表正式推荐为二型糖尿病的标准治疗方法。

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    2016-09-21 1e10c84am36(暂无匿称)

    文章很好,非常有益

    0

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    2016-09-13 舒心和人

    手术治疗也是一种方式,学习了

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