胃转流手术的认知（The cognition of gastric bypass surgery）

胃转流手术的认知（The cognition of gastric bypass surgery） 胃转流手术的认知(The cognition of gastric bypass surgery) The basic introduction of editing gastric bypass surgery was first used in bariatric surgery, Westerners long-term intake of high fat and high calories, weight increasing, many people in the pursuit of beauty, to regain their health to accept this kind of bariatric surgery, after several years of clinical practice, doctors found that surgery can be effective in the treatment of diabetes. In order to gastric bypass surgery, has brought the new gospel for the patients with diabetes. A comprehensive analysis of 22094 patients showed that 84% of type 2 diabetes was completely reversed after surgery, and most patients stopped taking oral medications or insulin before they were discharged. According to the Italy Catholic University of Rome, the Francisco Rubino report, in Mexico, Peru, Dominica and India, did not reach the morbidly obese patients with diabetes in the gastric bypass surgery, also obtained similar results. Other countries, such as China, Japan, Italy and Belgium, have also conducted some clinical trials. In 2005, it was clear what people should do for this kind of surgery. The rupee and some other doctors have been submitted to the American Association of Clinical Endocrinologists (AACE) a proposal put forward by gastric bypass surgery for the treatment of type 2 diabetes mellitus. Richard Hermann, chairman of the AACE, said: "the association is working on evidence and has yet to reach a decision.". He added that the existing treatments for diabetes may be safer and cost less, but few existing therapies can cure diabetes completely. 2, the current situation of the editor, choose obesity coexist, patients with type 2 diabetes, gastric bypass surgery is a clear indication of surgery. Non obese patients with type 2 diabetes can also undergo gastric bypass surgery. Preoperative examination should make it clear that the patient's serum insulin and C peptide values increase or are normal, and gastric bypass surgery is appropriate. If we reduce these 2 indicators, often suggesting that islet dysfunction or failure, should be a diagnosis of type 1 diabetes or type 2 diabetes become late changes in type 1 diabetes, this is a contraindication to gastric bypass surgery for the treatment of diabetes. Overall, the risk of the operation is small and the cost is not high. The results of surgical risks and benefits are obvious. Early surgical treatment should be a wise option for obese patients with type 2 diabetes who may have complications. Otherwise, if complications occur, the consequences will be severe and difficult to cure. After more than 20 years of painstaking research and clinical practice in the field of diabetes medicine, gastric bypass surgery has developed into a mature method of diabetes treatment, and is the only way to cure type 2 diabetes mellitus. ? in the United States, the American Diabetes Association (ADA), an authority on diabetes worldwide, formally introduced the gastric bypass surgery (GBP) into the guidelines for the prevention of diabetes and identified it as a routine treatment for diabetes. ? in Europe, in September 29, 2009, the annual meeting of the forty-fifth Diabetes Society of Europe confirmed that diabetes has become a curable gastrointestinal disease. In China, Chinese Medical Doctor Association, China Medical Association, China Medical Continuing Education Center and other authoritative institutions have taken the gastric bypass operation for 3 consecutive years as the key promotion project. By 2010, more than 1 million of diabetics in Europe and America had benefited. In our country, Surgical treatment of diabetes has been carried out for more than 5 years, the number of surgical cases has reached more than 8000 cases, the cure rate has reached more than 92.6%. 3 treatment mechanism editing diabetes causes: first, the distribution of K cells in the gastrointestinal tract stimulated by food secretion of insulin resistance factor, so that the body produces insulin resistance. Two, pancreatic islet cells are impaired by insulin resistance. The unique feature of gastric bypass surgery is that it changes the physiological flow of food through the stomach blocking, gastrointestinal anastomosis, intestinal anastomosis and other steps. After surgery, the patient's body to eliminate the phenomenon of insulin resistance, and after surgery through the way of food can promote insulin secretion of patients, reduce islet cell apoptosis and proliferation, islet function recovery, diabetes cure. In addition to normal blood glucose, a series of complications associated with the patient were well restored. For example, retinopathy, diabetic nephropathy, diabetic dermatitis, diabetes, sexual dysfunction, hypertension, hyperlipidemia and so on are gradually healed. The occurrence of severe complications is avoided, and the occurrence of disability and fatality is avoided. Gastric bypass surgery (GBP), small trauma, quick recovery, low risk, no recurrence after operation; most patients are discharged before blood glucose returned to normal, disabled hypoglycemic drugs and insulin; a small part of the rehabilitation of the patients for a long time, this is mainly to see the islet dysfunction in patients with preoperative degree. Early treatment of the patient, recovery will be faster and more thorough. 4 successful cases edited to 2010, Europe and the United States has more than 1 million of patients with diabetes benefit, only the United States, every year about 140 thousand of patients through gastric bypass surgery to get rehabilitation. With the scientific knowledge of doctors and patients about the operation, gastric bypass surgery will definitely restore health to more people with type 2 diabetes! 5 advantages of surgery editor, one advantage: cure diabetes, blood sugar normal, patients get rid of lifelong medication, do not control diet. There are two main causes of diabetes mellitus: insulin resistance. Two is islet failure. After the operation of gastric bypass, there is no insulin resistance, the islet function is restored, and the diabetes mellitus is gone. Advantage two: diabetes complications get rehabilitation. Internal medicine patients have irreversible complications, and gastric bypass surgery, most patients appeared numbness, retinopathy, diabetic foot, urinary protein abnormalities, hypertension and other complications of diabetes gradually recovered. Advantage three: avoid diabetes induced disability, fatal condition. The development of diabetes can cause serious threat to people's life safety. After the operation of gastric bypass, the blood sugar is normal, the complication is no longer appeared, and the harm of diabetes is gone. Advantage four: obese patients lose weight and lean patients gain weight. The operation of gastric bypass can bring some unexpected effects to the patient. The weight of the patient who is very thin will be increased, and the patient who is very fat will achieve a satisfactory weight loss effect after the operation. Advantage five: reduce the patient's financial burden. The relative cost is not high, which is an obvious advantage of gastric bypass surgery. According to the survey, the majority of diabetic patients who have been ill for more than 5 years will suffer from various complications, and the treatment costs of these complications are very high. For diabetics, an operation is no longer a complication, Reduce the economic burden. Advantage six: the risk of gastric bypass surgery is low and postoperative recovery is fast. The operation is simple and quick, with little trauma, quick recovery, no recurrence, and can be eaten 3 days after surgery, and can be discharged in a week. Postoperative diet and nutrition absorption were not affected. 6 preoperative preparation, editing 1, diabetes antibody test 2. Evaluation of insulin secretion function Oral glucose tolerance test, insulin release test and C- peptide release test were included. Oral glucose tolerance test: normal people take a certain amount of glucose, blood sugar first rise, but after a certain period of time, the body is about to glucose synthesis glycogen storage, blood sugar is restored to an empty stomach level. If you take a certain amount of glucose after certain time interval to measure blood glucose and urine glucose, to observe the changes of blood sugar concentration and sugar, in order to infer the insulin secretion, this determination is called glucose tolerance test. Specific methods, results, judgments and precautions are as follows. (1) oral test to test the day before the dinner after fasting in the morning; the test day fasting venous blood 2 ml, 100 grams of glucose immediately submitted; (dissolved in 200 ~ 300 ml of water); the sugar service half hour and 1 hours, 2 hours and 3 hours respectively. Venous blood 2 ml immediately. The best in every blood and urine (glycosuria). (2) intravenous injection of 50% glucose, 50 ml, leaving the sample by oral method. (3) the judgment of normal for sugar after 1/2 ~ 1 hours blood glucose concentration increased rapidly after 2 hours of recovery to the fasting level, if not 2 hours after oral glucose to normal levels, and positive urine, namely for impaired glucose tolerance. (4) note the test a few days before the patient can enter the normal diet, such as eating fewer patients in the test, 3 days ago, eating carbohydrates (i.e. rice, pasta) not less than 250 ~ 300 grams; the test before discontinuation of insulin and adrenal cortex hormone; the test of the day should be in bed, fasting blood. At the same time, urine specimens. Insulin release test: is to make oral glucose or Steamed Buns meal to patients with elevated blood glucose stimulated insulin secretion of islet beta cells, the plasma insulin levels in 1 hours, 2 hours, 3 hours of fasting and postprandial understanding of pancreatic islet beta cell reserve function, which contributes to the early diagnosis and classification of diabetes mellitus guidance and treatment. 7 the clinical significance of the insulin release test curve of diabetic patients can be divided into the following 3 types: (1) insulin secretion deficiency: a low level for the test curve, said islet function failure or serious damage, indicating insufficient insulin secretion absolute, in insulin dependent diabetes mellitus, need lifelong insulin treatment. (2) insulin secretion type: fasting insulin level in patients with normal or above normal, after stimulation curve rises slowly, the peak in 2 hours or 3 hours, mostly in 2 hours to reach the peak, the peak was significantly higher than normal, suggesting that the relative lack of insulin secretion, more common in obese non-insulin-dependent. Patients with this type of diet often have good control over diet, exercise, weight loss, or hypoglycemic agents. (3) insulin release disorder: fasting insulin level was slightly lower than normal or slightly higher, and delayed reaction after stimulation. The peak value was lower than normal. More common in adult onset, A lean or normal diabetic patient. This type of patient is effectively treated with sulfonylureas. C peptide release test and its clinical significance The C peptide is a secreted product of pancreatic beta cells, which has a common precursor to insulin - proinsulin. A molecule of proinsulin in special under the action of cracking into a molecular C peptide of insulin and a molecule, so in theory is equivalent to the C peptide and insulin secretion, C peptide in blood free physiological function is still not clear, but the C peptides by the liver damage, shorter half-life of insulin obviously for long, so C peptide levels were measured to reflect the synthesis and release of insulin beta cell function. The patient has been treated with insulin and insulin antibody produced in vivo can interfere with insulin determination; and the determination of insulin radioimmunoassay, could not distinguish is endogenous or exogenous insulin, difficult to understand the function of beta cells, and a stable relation between C peptide and insulin, and not affected the interference of insulin antibody, insulin injection exogenous and C containing peptides, so the determination of blood C peptide levels can reflect endogenous insulin levels, not only can understand the function of beta cells. The C peptide release test practices and considerations are the same as the glucose tolerance test and the insulin release test, and its clinical significance is: (1) the determination of C peptide is helpful for clinical classification of diabetes mellitus, and is helpful for understanding the function of patients with islet. (2) because the C peptide is not disturbed by the insulin antibody, the C peptide concentration can be measured directly in patients receiving insulin therapy to determine the beta cell function of the patients. (3) the cause of hypoglycemia can be identified. If the C peptide is more than normal, it can be thought to be caused by excessive insulin secretion, such as C peptide is lower than normal, for other reasons. (4) C peptide was helpful in islet cell tumor diagnosis and judgment of insulinoma operation effect, tumor blood insulin C peptide level is high, if the postoperative blood C peptide level is still high, the residual tumor tissue, if follow-up C peptide levels rising, tumor recurrence or transfer revealed may. 8. Edit the operation indication 1, meet the diagnostic criteria of type 2 diabetes mellitus; 2, the islet function is in the compensatory period (plasma insulin level > normal value); 3, diabetes history <15 years, age <70 years old; 4. Voluntary gastric bypass surgery and sign a consent form. 5, severe organic diseases (coronary heart disease, cerebral infarction, renal failure, heart failure, severe hypertension, etc.) can not tolerate surgery. 6, a certain islet function (determination of insulin and C peptide level evaluation); 7, gastrointestinal dysfunction, moderate and severe diabetic gastroparesis. Surgical contraindication 1, advanced diabetes mellitus, pancreatic failure; 2, severe organic diseases can not tolerate surgery 3, gastrointestinal dysfunction, moderate and severe diabetic gastroparesis; 4, diabetes history >15 years or age >70 years old, have serious complications; 5, autoimmune diabetes patients consider as appropriate. Preoperative examination of gastric bypass Except for routine preoperative routine examinations, the following examinations should be performed: 1. Detection of autoimmune diabetes antibody (LADA test). They mainly include insulin autoantibodies (IAA), islet cell antibodies (ICA), glutamate dehydrogenase antibodies (GAD-Ab), and tyrosine phosphatase antibodies (IA-2Ab); 2. Evaluation of insulin secretion function. Oral glucose tolerance test, insulin release test and C- peptide release test were included. Operative notes 1, check the night before last stop drug treatment. 2, check the morning fasting water, stop drugs. 3, before 9 a.m. to the Department of general surgery clinic registration, and pumping 3ml venous blood, go home, waiting for test results. (usually four to five days.) 4 、 the hospital informed and arranged hospitalization. 5, nonlocal patients can also be in the local tertiary hospital or conditional diabetes specialist hospital, improve the above inspection and contact the Department, in order to determine the operation. Secondly, if the patient meets the treatment criteria, surgical treatment should be carried out and lifelong personal files should be established, and later free consultation and expert advice will be provided. 9, after the operation, edit a, cure diabetes, blood sugar normal, through the stomach bypass surgery patients can get rid of lifelong medication. Two, for the complications of diabetes complication in patients with type 2 diabetes after surgery significantly alleviate the patients have been unable to reverse the medicine medical complications, and gastric bypass surgery, most patients appeared numbness, retinopathy, diabetic foot, urinary protein abnormalities, hypertension and other complications of diabetes will be significantly improved. Three, to avoid the occurrence of diabetes caused by diabetic foot disability and death in diabetes is the most common complication is one of the most harmful, diabetic foot not timely treatment will face the risk of amputation, but piecemeal, piecemeal method obviously can not fundamentally solve the problem. After the gastric bypass operation, the blood sugar is normal, the complication no longer appears, the diabetes harm also does not exist, fundamentally solves the thorough cure diabetes, is relieves the harm the basic way. Four, obese patients lose weight, thinner patients weight gain, gastric bypass surgery can bring some unexpected results. This was also the original intention of bariatric surgery. Five, reduce the economic burden of patients with long-term treatment of drug taking insulin injections compared gastricbypasssurgery relative cost is not high, a surgical therapy to cure diabetes complications, no longer appear, economic burden is in doubt. Six, gastric bypass surgery, quick recovery, easy operation, quick, small trauma, quick recovery, 3 days after surgery you can eat, you can leave the hospital in a week. Postoperative diet and nutritional absorption were not affected. It can be said that gastric bypass surgery is the best option for people with type 2 diabetes. Life in diabetics can be rewritten, and gastric bypass surgery is no longer a lifelong disease, but can be cured. 10 clinical problems editor 1, surgery to gastrointestinal tract, will not have an impact on nutrient absorption? The effect is minimal: protein absorption is limited to the middle and lower segments of the jejunum and the ileum. GBP follow-up data show that there is no serious complication of protein deficiency. Carbohydrate can not be mixed with related digestive enzymes in time, which can reduce the degradation rate of food starch and blood sugar after operation. Therefore, the peak value of the food can be avoided and the function of the islets can be restored. The lipid food promotion of bile and pancreatic juice into the gut by stimulating cholecystokinin release, lipid degradation in food, the formation of GBP delay lipid chyme, resulting in lipid fast discharged into e.. It may decrease the absorption of vitamins, iron and calcium. Although it is not serious, we should pay attention to the supplementation of a variety of vitamins and minerals in the long term after surgery. 2, endocrine experts generally believe that diabetes can not be cured, how to treat this problem? Endocrine experts generally believe that diabetes can not be carried for life, what is the reason? They believe that first, insulin resistance is a natural phenomenon that is common in nature and cannot be eliminated; and second, the decline of islet function. After this operation, the first, insulin resistance disappeared, or even disappeared; second, pancreatic islet proliferation. So the two reasons that they think are gone. And after a long period of postoperative visits, the patient recovered really well! 3, will the cure diabetes recur? The patient's condition will become better and better because of the proliferation of islets of Langerhans, the restoration of islet function, and the elimination of insulin resistance. 11 diabetic complications of diabetes editing is not terrible, terrible is the global diabetes complications! Every 10 seconds, 2 people were diagnosed with diabetes, 3 million 800 thousand people died of diabetes related diseases each year in the world, the world every 10 seconds, 1 people died of diabetes related diseases, estimated 2030 global diabetes population will reach 366 million. Brain: hardening of the arteries that can cause strokes. Eye lesions: 1. retinopathy 2. retinal vascular injuries cause cataracts 3. increased intraocular pressure may damage optic nerve and cause blindness. Periodontal disease: The deterioration of the human immune system and the worsening of periodontal disease will be faster. Cardiovascular disease: 1. atherosclerosis can cause angina pectoris and myocardial infarction 2. nerve pathological change is easy to cause palpitation. Gastrointestinal symptoms: autonomic or peripheral nerve damage, causing abdominal distension, constipation, diarrhea, incontinence, dysuria, postural hypotension. Skin: 1. microvascular lesions, wounds are difficult to heal. 2., poor resistance, easy local infection. Acute complication: 1. hypoglycemia 2. ketoacidosis 3. high osmotic pressure hyperglycemia nonketotic syndrome. Renal disease: 1., cause edema, proteinuria, blood pressure rise and other symptoms 2. renal failure caused by uremia, dialysis is required for life. Sexual dysfunction: Microvascular lesions may lead to erectile dysfunction, such as impotence. Diabetic foot: 1. make the foot blood reduce arteriosclerosis, easily lead to intermittent claudication. 2. neuropathy may cause cold and abnormal sensation of the foot. 3. foot infection, wound healing slow. 12 intensive care editor diabetes foot According to the WHO (WHO) definition: diabetic foot refers to diabetic patients with neuropathy and various degree of peripheral vascular disease of the lower limbs caused by infection, ulcer formation and (or) the destruction of deep tissue. Clinically, patients with diabetes because of the long-term influence of hyperglycemia due to lower extremity vascular sclerosis, vascular wall thickening, vascular elasticity, easy to form thrombus, and assembled into a plaque, caused by vascular occlusion of the lower limbs, end nerve injury, resulting in lower limb tissue disease. And the foot is the farthest from the heart, The most serious occlusion phenomenon, causing edema, black, rotten, necrosis, gangrene formation. Diabetic eye diseases The biggest danger of diabetes is that it can cause many chronic complications. Eye disease is one of the most common chronic complications of diabetes. Almost all eye diseases can occur in people with diabetes. Such as fundus hemangioma, fundus hemorrhage, dacryocystitis, glaucoma, cataract, vitreous opacity, optic atrophy, macular degeneration, retinal detachment. Moreover, the chances of developing these eyes are higher in diabetics than in non-diabetic people. diabetic nephropathy Diabetic nephropathy, diabetic nephropathy (DN) is a particularly common and troublesome complication of diabetes. In other words, diabetic nephropathy is one of the most serious complications of diabetes and the leading cause of end-stage renal disease. Diabetic nephropathy is the main microvascular complication of diabetes mellitus. It mainly refers to diabetic glomerulosclerosis, a kind of glomerular lesion with vascular damage. Early, more asymptomatic, blood pressure can be normal or high. Its incidence increases with the course of diabetes. Early diabetic renal volume, glomerular filtration rate increased, a high filtration state, after the gradual emergence of gap proteinuria or albuminuria, with the extension of duration of persistent proteinuria, edema, hypertension, reduced glomerular filtration rate and renal insufficiency, uremia, is one of the main causes of death in diabetes mellitus. According to experts, gastric bypass surgery requires rigorous testing, and not all patients are suitable. The following conditions were not suitable for gastric bypass surgery: diabetes, islet function failure; severe organic disease can not tolerate surgery; gastrointestinal dysfunction, severe diabetic gastroparesis; diabetes for more than 15 years or older than 65 years old, suffering from serious complications; these patients do not suitable for surgery. Gastric bypass surgery requires rigorous medical testing before surgery can be performed. 13 Chinese modified operation editor in 2004 and the first to introduce "gastric bypass surgery", but in the long-term clinical treatment, the gastric bypass surgery treatment effect is good, but it is for the small part of the population will appear rejection, the treatment effect is difficult to improve. Due to the different east west race constitution (Westerners tall, fat, short, thin Asians), differences in diet (western main high fat and high calorie diet) and other factors in diabetic patients with symptoms, surgical tolerance etc. are different, if copying the western "gastric bypass surgery" treatment, is bound to The climate does not suit one. cause "". The Asian human quality, especially the incidence and disease characteristics of patients with diabetes China, multidisciplinary diabetes center hospital of Hunan provincial military region a comprehensive upgrade of improved design of the gastric bypass surgery, modified the gastric bypass surgery (also known as the China type "gastric bypass") was born. Operation principle Gastrointestinal tract -- the largest endocrine organ in the human body". The physiological function of the gastrointestinal tract, except for the digestion and absorption function, gastrointestinal function is also the exercise of endocrine organs, gut hormones involved in the regulation of blood glucose levels in steady state, dynamic balance of physiological function is regulating islet hyperplasia, proliferation, regeneration from apoptosis. Our previous study showed that gastrointestinal hormone regulation of islet dysfunction is one of the pathogenesis of diabetes, that is to say the patient first appeared gastrointestinal hormone regulation disorder, leading to pancreatic islet cells decreased, apoptosis increased, culminating in elevated blood glucose levels, the diagnosis of diabetes was established. On the contrary, after operation, the mechanism of islet regulation was improved, and the mechanism of islet cell proliferation, proliferation and regeneration was initiated. Finally, the islet function was improved and diabetes was cured. Based on the above background, taking into account the operation of the negative effects on the intake and absorption of nutrition, we design China gastric bypass surgery, Chinese gastric bypass surgery to adapt to the crowd is non obesity diabetes patients, instead of simple obesity patients, treatment objective in pathological disorders to improve intestinal hormone regulation of islet function. Rather than lose weight, this is for surgical treatment of China non obese diabetic patients. After the "Chinese style" improvement: Ji'nan Diabetes Hospital 1, increase the proximal gastric volume to 30% of the total gastric volume 2, increase the effective absorption area of gastrointestinal tract, and design the individual nutrition length of the small intestine 3, take into account the improvement of pancreatic function and avoid malnutrition complications 4, the elimination of the original surgery caused by human rejection 5 is equally effective for nonobese diabetics 6, postoperative diet and nutritional absorption were not affected, no adverse reactions 7, at the same time to cure diabetes complications, the effective rate reached 100%, the cure rate increased to 92.6%.