Kugwiritsa ntchito maopaleshoni a mtima kwa matenda a shuga 2: kuthandiza dokotala wothandiza.Malemba a nkhani yasayansi mwapadera - Mankhwala ndi Zosamalira Zaumoyo

Malinga ndi WHO, chiwerengero cha anthu padziko lapansi omwe ali onenepa kwambiri mu 2014 aposa 600 miliyoni, ndipo onenepa - 1.9 biliyoni. Kuchuluka kwa T2DM padziko lonse lapansi kukuyerekeza 9% mwa akulu kuposa zaka 18 ndipo akunenedweratu ndi WHO kuti matenda ashuga ndi omwe azatsogolera anthu 7 kufa mu 2030 (* www.who.int /). Takudziwitsani malingaliro olakwika khumi okhudzana ndi chithandizo cha kunenepa kwambiri komanso matenda a shuga.

Kunenepa kwambiri ndi vuto la mayiko otukuka kwambiri, osati Russia

Osati kwenikweni monga choncho. Inde, kunenepa kwambiri m'maiko otukuka pakali pano ndi vuto lalikulu kwambiri. Koma pali chinthu chimodzi. Kunenepa kwambiri m'maiko otukuka kumakhudza gawo lalikulu la anthu omwe amapeza ndalama zochepa. Panthawi yakusowa kwa zinthu, anthu amadya zakudya zochepa zomanga thupi komanso ambiri otchipa otchedwa chakudya. Tsoka ilo, lero Russia ikugwira ntchito ndi mayiko otukuka malinga ndi kuchuluka kwa kunenepa kwambiri, motero, T2DM.

Masiku ano, owerengeka okha amawona kunenepa ngati vuto la zamankhwala.

Ambiri mwa anthu ndipo, mwatsoka, madokotala amawona kunenepa kwambiri komanso kunenepa kwambiri ngati zokongoletsa, zodzikongoletsera, zanyumba, zocheza, koma osati zovuta zaumoyo. Komanso malingaliro olakwika achikhalidwe omwe amayanjanitsa anthu "akuluakulu" komanso "abwino" omwe amakhala ndi thanzi, makamaka paubwana, adakali ambiri. Masiku ano, kuzindikira ndi ntchito zamankhwala, makamaka "oyambira", sikokwanira.

Ngakhale kuti opareshoni ya kunenepa kwambiri kwa zaka zopitilira 60, zambiri zokhudzana ndi chithandizo chamtunduwu mwatsoka zimapezekabe ndi gawo laling'ono kwambiri la akatswiri.

Komabe, chifukwa chogwira ntchito kwambiri pothana ndi kunenepa kwambiri, mtundu wa 2 matenda a shuga, dyslipidemia, opaleshoni ya bariatric ndi gawo lomwe likukula kwambiri, koma kukambirana pazotsatira ndi zomwe zikukhalabe chidziwitso cha kulumikizana kwa akatswiri "akatswiri" komanso ngati lamulo silimapitilira malire a misonkhano ya sayansi. Anthu omwe ali ndi matenda onenepa kwambiri nthawi zambiri samapangitsa kuti azimvera ena chisoni komanso azikhala ndi chidwi chofuna kuthandiza. M'malo mwake, nthawi zambiri anthuwa amakhala amanyoza kapena okwiyitsa. Tiyenera kudziwa kuti pakuwonjezeka kwa kuchuluka kwa kunenepa kwambiri, kuchuluka kwa matenda ashuga kumakulanso.

Ndikofunikanso kunena kuti, malinga ndi akatswiri, opitilira theka la odwala omwe ali ndi T2DM ndi anthu omwe sanawatulukirebe.

Ndiye kuti, gululi, lomwe silikudziwa za matendawa, koma motsutsana ndi kufooka kwa kagayidwe kazakudya, kuwonongeka kwa mtima kumachitika, zomwe zimapangitsa kuti pakhale chiwopsezo cha matenda ashuga komanso kuwonongeka kwa ziwiya zamtima, bongo, malekezero, impso, ndi retina.

Matenda a 2 a shuga ndi matenda osachiritsika

Inde, T2DM yakhala ikutchulidwa ngati matenda osachiritsika omwe amapita patsogolo. Izi ndizovomerezeka pang'ono. Mwakutero, kwa odwala omwe amalandira chithandizo choyenera.

Poyerekeza ndi maziko a chithandizo chokhazikika, chithandizo chokwanira ndicho kubwezera T2DM - ndiko kuti, kukwaniritsa mkhalidwe momwe kungathekere kubweretsa kuchuluka kwa glucose kuyamika kwawoko chifukwa cha njira zingapo zochiritsira, makamaka kudya mankhwala ochepetsa shuga komanso kudya.

Titha kunena kuti zotsatira za zaka 14 za odwala omwe ali ndi matenda a shuga a 2, omwe adasindikizidwa mu 1995, adasinthika pochiza matenda a shuga 2, zomwe zimapangitsa kuti pakhale mtundu wambiri wa matenda ashuga a mtundu wa 2, omwe amatanthauza kuti matenda a glycemia azikhala nthawi yayitali osagwiritsa ntchito mankhwala ochepetsa shuga. Zambiri kuchokera pazowonera masauzande ambiri zikuwonetsa kuti pambuyo poti ntchito yayitali ya chikhululukiro chautali, oposa 76% odwala omwe ali ndi T2DM afika.

Munthu aliyense atha kuchepetsa kunenepa kwambiri, ndikokwanira kudzipatula pakudya ndikuwonjezera zolimbitsa thupi!

Kulemera kwenikweni kumatha kulamulidwa kudzera mu zakudya komanso moyo. Koma lamuloli limangogwira ntchito kufikira mfundo ina. Vutoli ndikuti mfundo yoyenera yochepetsera kunenepa kwambiri kwa thupi "idyani pang'ono, yendani pang'ono" ndi kunenepa kwambiri mwambiri nthawi zambiri sizikugwiranso ntchito, popeza kudalira chakudya kwakhala kukuchitika kwa zaka zambiri ndipo odwala ambiri satha kudziimira pawokha kuti mugonjetse.

Momwe kuchuluka kwa thupi kumachulukira, kagayidwe kamasokonezedwa, minofu ya adipose yophatikizika imatulutsa mahomoni ake angapo ndipo potero imayamba kuwongolera zosowa ndikuwongolera machitidwe a anthu.

Zotsatira zakuwunikira kwakutali kwa odwala akuluakulu zikuwonetsa kuti odwala osaneneka oposa 10% sangakwaniritse chithandizo chamankhwala choyambirira. Ngakhale kugwiritsa ntchito mapulogalamu osiyanasiyana ochepetsa thupi, kuphatikiza mankhwala othandizira kudya, kupangira mankhwala osokoneza bongo komanso kuchita masewera olimbitsa thupi, pazaka 10 zapitazi sipangokhala kuchepa kwa thupi, koma kuwonjezeka kwa 1.6-2%.

Opaleshoni ya Bariatric ndi opaleshoni yokongoletsa (zodzikongoletsa) ndipo cholinga chake ndikuwongolera mawonekedwe ake

Lingaliro la kuthekera kwa njira zopangira opaleshoni zochizira kunenepa m'malingaliro a odwala ndipo mwatsoka madokotala ambiri amagwirizana ndi opaleshoni ya pulasitiki kuti achotse mafuta osaneneka monga liposuction, abdominoplasty. Izi siziri choncho. Mafuta ochulukirapo osakanikirana amayamba chifukwa cha kusokonekera kwa kagayidwe kenakake ndipo kuchotsedwa kwina sikumathetsa komwe kumayambitsa vuto.

Mosiyana ndi maopaleshoni azodzikongoletsa, zomwe zimachitika chifukwa cha opaleshoni yodwala sizimayang'aniridwa kuti zimayambitsa, koma zimayambitsa. Komanso, izi sizingokhala ndi kuchepa kwa kuchuluka kwa mafuta ochulukirapo.

Zambiri kuchokera ku kafukufuku wa nthawi yayitali wopitilira ma cohorts ambiri odwala akuwonetsa kuti pambuyo panjira zosiyanasiyana za bariatric, chikhululukiro cha T2DM, ndiye kuti, kukwaniritsa kuchuluka kwa glucose popanda chithandizo chotsitsa shuga, zimadziwika mu milandu ya 78.8%, hyperlipidemia mu 83%, ndi matenda oopsa m'magazi a 97%. Malinga ndi zotsatira za ofufuza a ku Sweden, ndi nthawi yotsatila ya gulu la odwala (anthu 10,000) pazaka 12, anthu omwe anamwalira atachitidwa opaleshoni anali 50% kutsika poyerekeza ndi odwala omwe anali ndi chithandizo chamankhwala.

Zotsatira za opaleshoni ya bariatric pa matenda a shuga a 2 zimayenderana ndi kuchepa kwa kunenepa kwambiri

M'malo mwake, kusintha kwa matenda a shuga kumachitika kale kuchokera masiku oyamba pambuyo pa opaleshoni, kale kwambiri kuposa kuchepa kwakukulu kwa thupi. amachepetsa thupi. Pali zinthu zingapo zomwe zimakhudza matenda ashuga.

Opaleshoniyo imayambitsa mikhalidwe yatsopano kusintha kosinthika kwa zakudya zopatsa mphamvu zochepa, motsutsana ndi komwe gawo la shuga m'magazi limachepetsedwa kapena kufalikira. Kuphatikiza apo, pansi pazinthu zatsopano, thupi limapanga mahomoni ake omwe ali ndi zotsatira zabwino zambiri.

Zomwe zimaphunziridwa kwambiri ndi kukondoweza kwa kupanga insulin komwe kumalumikizidwa ndi chakudya komanso kubwezeretsa kwa ma cell a pancreatic beta. Pharmacological analogues mwa ena mwa mahomoniwa pano akuphatikizidwa m'malamulo amakono azomwe amathandizira kuti asadwale matenda a shuga 2.

Opaleshoni ya Bariatric ndi opareshoni yokhala ndi zovuta zambiri.

Osati odwala okha, komanso madokotala omwe ali ndi malingaliro olakwika okhudza kuchuluka kwa zovuta, zokhudzana kwambiri ndi mbiri ya opaleshoni ya kunenepa kwambiri. Chowonadi ndi chakuti ntchito zoyesa zakale zinachitidwa zaka zoposa 60 zapitazo, ndipo pambuyo pawo panali zovuta zambiri. Koma kuyambira pomwe ntchito yoyamba idamalizidwa, ntchito zambiri zakhala zikuchitika mpaka pano.

Mbadwo uliwonse watsopano waogwirapo udathetsa zoperewera zomwe udachita kale ndikuwalimbikitsa. Ziyenera kunenedwa kuti kukhazikitsidwa kwa matekinoloje a laparoscopic kunathandizira kuchepetsa kwakukulu kwa kuchuluka kwa zovuta. Komanso, madokotala ochita opaleshoni komanso opaleshoni yoyambitsa matenda anayambitsa njira yatsopano, yobwereka kuchokera ku opaleshoni ya odwala okalamba omwe ali ndi khansa.

Chomwe chimatanthauzanso lingaliro labwino ndikubwezeretsa wodwalayo mwachangu. Mpaka pano, chitetezo cha opaleshoni ya bariatric chikufanana ndi mulingo wa chitetezo chamachitidwe opaleshoni yozunza.

Opaleshoni ya Bariatric ndikuchita opaleshoni yama ziwalo “zathanzi”

Njira ina yolakwika ndi kuti opaleshoni ya bariatric imayambitsa kusokonezeka kwazomwe zimachitika mwanjira yamatumbo. Izi sizili choncho. Poyamba, momwe thupi limagwirira ntchito kwa odwala omwe ali ndi kunenepa kwambiri limakhala lodzikakamiza ndipo limakambirana, chifukwa kusintha kwamunthu wolumikizana ndi 1.5-2 nthawi sikungatchulidwe kuti ndi komwe.

Kachiwiri, muzochitika pakuchitidwa opaleshoni yodwala, ndi ntchito yomwe idaphwanyidwa kale kapena kutayika, yomwe ilibe mwayi wodzipulumutsa.

Chifukwa chake, opaleshoni ya kunenepa kwambiri, ndikupanga kusintha kwa thupi ndi ntchito yolumikizidwa kale, imapanga zinthu zatsopano zomwe thupi limabwereranso kwazomwe zimagwira ntchito.

Ndiye kuti, kulowererapo kwa bariatric, monga kuchitidwa opaleshoni iliyonse, sikukulira, koma kumabwezeretsa ntchito yomwe idatayika kale chifukwa cha kusintha kwakukulu kwambiri kwa anatomiki.

Opaleshoni ya Bariatric ndi mankhwala okwera mtengo

Malinga ndi kafukufuku yemwe wachitika ku India, dziko lomwe lili ndi malo otsogola padziko lonse lapansi chifukwa cha T2DM, mtengo wapakati wothira wodwala T2DM popanda zovuta ndi pafupifupi $ 650 pachaka.

Kuwonjezera vuto limodzi kumawonjezera ndalama ndi 2,5 $ - mpaka $ 1692, ndikuwonjezera zovuta zazikulu kuposa nthawi 10 - mpaka $ 6940. M'malo mwake, ntchito ya bariatric imachepetsa mtengo wochiritsa wodwala nthawi 10 - mpaka $ 65 pachaka.

Singangowonetsera gawo lazachuma la kuchepa kwakukulu kwa chakudya pambuyo pa opaleshoni, yomwe ndi imodzi mwazinthu zomwe zimakambirana kwambiri pamagulu a odwala omwe akuchitidwa opaleshoni ya bariatric.

Opaleshoni ya Bariatric ndi panacea - atamuchita opaleshoni, wodwalayo amachepetsa thupi popanda kuchita khama ndipo adzapeza zotsatira zabwino

Pali malingaliro olakwika mbali ina, omwe amayanjanitsidwa ndi kuyembekezera kwakukulu kuchokera ku opaleshoni ya bariatric. Lingaliro ili ndilolumikizana ndi lingaliro labodza loti opaleshoniyo idzathetsa mavuto onse a wodwala, ndipo mtsogolomu safunika kuyesetsa. Izi siziri choncho.

Opaleshoniyo ndi njira yongopangidwira kumene kuti abwezeretsenso ndi kusintha kwa magwiridwe antchito kale, kwa wodwala - chiyambi cha njira yatsopano osati yovuta nthawi zonse.

Wodwala aliyense amene akuganiza zopanga opaleshoni ya bariatric ayenera kudziwa kuti masiku ano 10-20% ya odwala amabwerera kulemera kwakuthupi kwakanthawi. Ambiri mwa odwalawa ndi omwe sanawonedwe kwa nthawi yayitali ndi dokotala wothandizira wazachipatala.

Aliyense amene angaganize zochita opaleshoni ya bariatric ayenera kumvetsetsa kuti pambuyo pa opaleshoni, kusinthika kwa moyo wonse, kutsatira njira yoyenera yodyera komanso kuyamikiridwa pazakudya, kuonetsetsa kuyenera koyenera kwa zochitika zolimbitsa thupi, ndipo, kuyang'aniridwa kwachipatala kuyenera kuchitika.

Zinthuzi zidakonzedwa ndi wofufuza wofufuza ku Research Laboratory of upasuaji Correction of Metabolic Dis shida, dokotala wa opareshoni ku Federal State Budgetary Institution "North-West Medical Institute yotchedwa Acad. V.A. Almazova

Wotsutsa nkhani yasayansi yazachipatala ndi zaumoyo, wolemba pepala lasayansi - Yershova Ekaterina Vladimirovna, Troshina Ekaterina Anatolyevna

Kugwiritsidwa ntchito kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 shuga mellitus (T2DM) ali ndi mawonekedwe ake. Mu mutu uwu, zikuwonetsa ndikuwonetsa ma bariatric ntchito, kuphatikizapo mwachindunji pamaso pa T2DM. Mitundu yosiyanasiyana yama bariatric ntchito ndi njira zomwe zimathandizira pakachulukidwe kazakudya ndi lipid metabolism amafotokozedwa. Zotsatira za opaleshoni yoletsa komanso ya shunt bariatric mwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 wa shuga akuwonetsedwa. Zofunikira pakugwira ntchito za bariatric zimaperekedwa ndipo magawo a kuwunika momwe amapangidwira amapatsidwa, kuphatikiza chikhululukiro cha T2DM atatha kulowererapo. Zomwe zimayambitsa post-bariatric hypoglycemia, komanso olosera za postoperative prognosis ya kugwira ntchito bwino kwa bariatric mogwirizana ndi metabolic control mwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM, amawunikira.

Kugwiritsira ntchito opaleshoni yodwala kwa odwala omwe ali ndi matenda a shuga a 2: thandizirani adokotala

Kugwiritsidwa ntchito kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 shuga mellitus (T2DM) ali ndi mawonekedwe ake. M'maphunzirowa timakambirana ndi ma contraindication opangira ma bariatric, kuphatikizapo mwachindunji, i.e. kupezeka kwa matenda a shuga a mtundu wachiwiri. Mitundu yosiyanasiyana ya opaleshoni ya bariatric ndi njira zamavuto awo pa glucose ndi milomo> ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri komanso mtundu wa 2 shuga, timapereka zofunikira pakuchita opaleshoni ya bariatric ndi magawo a kuwunika kwake, kuphatikizapo kuchotsedwa kwa matenda a shuga 2 pambuyo pa opaleshoni ya bariatric . Zomwe zimapangidwira kukonzanso kwa hypoglycemia, komanso olosera zakuchita bwino kwa opaleshoni ya bariatric kwa kagayidwe kazakudya kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu 2 shuga.

Zolemba pazaka yasayansi pamutu wakuti "Kugwiritsa ntchito kwa opaleshoni yodwala matenda a shuga 2: kuthandiza katswiri"

Kunenepa kwambiri komanso kagayidwe. 2016.13 (1): 50-56 DOI: 10.14341 / OMET2016150-56

Kugwiritsa ntchito maopaleshoni oyambitsa matenda a shuga a 2: kuthandiza katswiri

Ershova E.V. *, Troshina E.A.

Federal State Budgetary Institution Endocrinological Science Science Center la Unduna wa Zaumoyo wa Russia, Moscow

(Wowongolera - Phunziro la RAS I.I. Dedov)

Kugwiritsidwa ntchito kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 shuga mellitus (T2DM) ali ndi mawonekedwe ake. Mu mutu uwu, zikuwonetsa ndikuwonetsa ma bariatric ntchito, kuphatikizapo enieni - pamaso pa T2DM. Mitundu yosiyanasiyana yama bariatric ntchito ndi njira zomwe zimathandizira pakachulukidwe kazakudya ndi lipid metabolism amafotokozedwa. Zotsatira za opaleshoni yoletsa komanso ya shunt bariatric mwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 wa shuga akuwonetsedwa. Zofunikira pakugwira ntchito za bariatric zimaperekedwa ndipo magawo a kuwunika momwe amapangidwira amapatsidwa, kuphatikiza chikhululukiro cha T2DM atatha kulowererapo. Zomwe zimayambitsa post-bariatric hypoglycemia, komanso olosera za postoperative prognosis ya kugwira ntchito bwino kwa bariatric mogwirizana ndi metabolic control mwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM, amawunikira.

Mawu osakira: kunenepa kwambiri, mtundu 2 matenda a shuga, opaleshoni ya bariatric

Kugwiritsira ntchito opaleshoni ya bariatric kwa odwala omwe ali ndi matenda a shuga a mtundu wa 2: thandizirani kwa Ershova E.V. *, Ttoshina E.A.

Center la Research la Endocrinology, Dmitriya Ulyanova St., 11, Moscow, Russia, 117036

Kugwiritsidwa ntchito kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 shuga mellitus (T2DM) ali ndi mawonekedwe ake. M'maphunzirowa timakambirana ndi ma contraindication opangira ma bariatric, kuphatikizapo mwachindunji, i.e. kupezeka kwa matenda a shuga a mtundu wachiwiri. Mitundu yosiyanasiyana ya opaleshoni ya bariatric ndi machitidwe awo pazotsatira zamagulu a glucose ndi lipid metabolism. Tikuwonetsa zotsatira za opaleshoni yoletsa komanso yodutsa odwala omwe ali ndi kunenepa kwambiri komanso mtundu wachiwiri wa matenda ashuga, timapereka zofunikira pakuchita opaleshoni ya bariatric ndi magawo a kuwunika kwake, kuphatikizapo kuchotsedwa kwa matenda a shuga a 2 pambuyo pa opaleshoni ya bariatric. Zomwe zimapangidwira kukonzanso kwa hypoglycemia, komanso olosera zakuchita bwino kwa opaleshoni ya bariatric kwa kagayidwe kazakudya kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu 2 shuga. Mawu osakira: kunenepa kwambiri, matenda a shuga a 2, opaleshoni ya bariatric.

* Wolemba wa nepenucKu / Wolemba makalata - [email protected] DOI: 10.14341 / 0MET2016150-58

Opaleshoni ya Bariatric (yochokera ku Greek Lambo - yolemetsa, yolemetsa, yolemetsa) ndi njira zopangira opaleshoni zomwe zimachitika pamimba yokumba kuti muchepetse kulemera kwa thupi (MT).

M'zaka makumi angapo zapitazi, njira zochitira opaleshoni zakhala zikugwiritsidwa ntchito padziko lonse lapansi kuchitira kunenepa kwambiri, ndipo pali malingaliro omveka bwino owonjezera kuchuluka kwa ntchito zomwe zikuchitidwa ndikuwonjezera chiwerengero cha mayiko omwe opaleshoni ya bariatric ikuchulukirachulukira.

Zolinga za opaleshoni yothandizira kunenepa kwambiri:

"Chifukwa cha kuchepa kwakukulu kwa MT, zimakhudza njira zamatenda omwe akuchulukirachulukira ngati mtundu wa MT umayamba (mtundu wa matenda ashuga 2), matenda oopsa, matenda obanika usiku, kusowa kwa ovari, ndi zina zambiri.

Kukonza moyo wa odwala omwe ali ndi kunenepa kwambiri.

Zisonyezero za opaleshoni ya bariatric

Mankhwala othandizira kunenepa kwambiri amatha kuchitika ngati njira zoyeserera kale zochepetsera MT kwa odwala azaka zapakati pa 18 ndi 60 sizothandiza.

Obes kunenepa kwambiri (body index index (BMI)> 40 kg / m2),

♦ kunenepa kwambiri ndi BMI> 35 kg / m2 kuphatikiza ndi matenda oopsa omwe amakhala osagwirizana ndi kusintha kwamakhalidwe ndi mankhwala osokoneza bongo. Cholepheretsa opaleshoni ya bariatric ndiko kukhalapo kwa wokonzekera:

♦ mowa, mankhwala osokoneza bongo,

♦ kuchuluka kwa zilonda zam'mimba kapena duodenum,

- Kusintha kosasintha kwa ziwalo zofunika (kulephera kwamtima kwa mphamvu ya III - makalasi othandizira, chiwindi kapena impso),

Stand Kusamvetsa za zoopsa zomwe zimachitika chifukwa chogwiritsa ntchito ndalama,

♦ Kusagwirizana kwa kukhazikitsidwa kwakanthawi kwa dongosolo la ma postoperative. Contraindication yapadera pakukonzekera opaleshoni ya bariatric mwa odwala omwe ali ndi kunenepa kwambiri ndi matenda a shuga:

♦ antibodies abwino ku glutamic acid decarboxylase kapena maselo a Langerhans

♦ C-peptide sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

Ntchito zonse za bariatric, kutengera mphamvu zawo pamatumbo am'mimba, zitha kugawidwa m'magulu atatu: kupumira, kusuntha (malabsorption) ndi kusakaniza. Kusankhidwa kwa maupangiri othandizira opaleshoni kumadalira kuchuluka kwa kunenepa kwambiri, kuchuluka kwa zovuta zamtundu wa metabolic komanso matenda, mawonekedwe a malingaliro a wodwalayo, mtundu wa kadyedwe kake komanso kukonzekera kwa wodwala chithandizo komanso kusintha kwa moyo. Nthawi zambiri, kusankha kwa opaleshoni yotsimikizika kumatsimikiziridwa ndi zomwe eni ake a dokotala akuchita.

Ntchito zoletsa (zopumira) zimapangidwa kuti muchepetse kukula kwa m'mimba. Pa ntchito yoletsa, m'mimba imagawika magawo awiri, ndikusiya kuchuluka kwa gawo lakumapeto kupitirira 15 ml. Izi zitha kuchitika pang'onopang'ono posunthira pamimba ndi kutuluka pang'ono kuchokera kumalo aang'ono (vertical gastroplasty (VGP), mkuyu. 1a), kapena mwa kugwiritsa ntchito silicone cuff (yosinthika gastric banding (BZ), mkuyu. 1b). Njira ina yamakono - kuyambitsanso kwam'mimba (tubular, vertical) m'mimba (PRG, mkuyu. 1c) kumakhudzanso kuchotsa kwamimba m'mimba ndi chubu chopyapyala pamalo ake ochepera 60-100 ml.

Limagwirira kagayidwe kachakudya yoletsa bariatric opaleshoni

Zomwe zimapangitsa kuti ntchito zizilepheretsa kuphatikiza kusintha kwa kagayidwe kachakudya ka matenda a shuga a 2 zimakhazikika pa:

Kukakamizidwa kusamutsa odwala kumayambiriro kwa ntchito pambuyo pa chakudya chamagulu ochepa,

♦ ndipo pokhapokha - kuchepa kwamafuta, kuphatikiza. visceral, monga gwero lamafuta acids am'madzi mu portal vein system panthawi ya lipolysis, yomwe imathandizira kuchepetsa insulin,

♦ pankhani ya khansa ya Prostate - kuchotsedwa kwa malo opanga ma ghrelin m'matumbo a m'mimba, omwe atha

Thumba lam'mimba lopumira

Chingwe cham'mimba

Pyloric gawo la m'mimba

Mkuyu. 1. Opaleshoni yovomerezeka ya bariatric: a) vertical gastroplasty, b) kuzungulira kwa m'mimba, kutalikirana kwakumbuyo kwam'mimba

kuthana ndi njala komanso kuchepetsa njala.

Kuletsa kwakanthawi kochepa komwe kumadziwika ndi chitetezo chokwanira komanso kuphedwa mosavuta, kumavomerezedwa ndi odwala, koma nthawi zambiri, makamaka ngati kunenepa kwambiri (kapena kunenepa kwambiri, komwe BMI> 50 kg / m2), zotsatira zawo zimakhala zosakhazikika. Pankhani yakutaya kwakukhazikika kwakanthawi (mwachitsanzo, ndikubwezeretsanso kwa kupendekera, kutsekeka kwa gawo laling'ono la m'mimba kapena kukomoka kwa bandeji), pamakhala kuthekera kwenikweni kwa kubwezeretsedwa konse kwa MT komanso kubwezeredwa kwa DM2.

Maziko a malabsorbent (shunting) ndi ntchito zonse ndikuphatikizidwa kwa magawo osiyanasiyana a m'matumbo aang'ono, omwe amachepetsa kuyamwa kwa chakudya. Nthawi ya gastroshunting (GSh, mkuyu. 2a), m'mimba kwambiri, duodenum ndi gawo loyambirira la matumbo ochepa limachotsedwa pakadali chakudya, komanso ndi biliopancreatic shunting (BPS, Matenda a 2b ndi 2c), pafupifupi jejunum yonse.

Ntchito zophatikizika, kuphatikiza zomwe zimapangitsa kuti zisamawonongeke komanso kusunthika, zimadziwika ndi zovuta zambiri komanso kuwopsa kwa zotsatira zosayenerera, komabe, zimapereka zotsatira zotchulidwa komanso zokhazikika zazitali, komanso zimakhudza bwino zovuta zamatenda a metabolic ndi matenda omwe amachitika chifukwa cha kunenepa, komwe kumatsimikiza zabwino.

Njira zamachitidwe a GSH pa chakudya chamafuta mu kunenepa ndi mtundu 2 shuga:

Kukakamizidwa kusinthika koyambirira kwa nthawi yoyambirira kupita ku chakudya chamafuta ochepa,

♦ kusiyidwa kwa duodenum kuti asakhudzane ndi chakudya, zomwe zimabweretsa zoletsa za diabetogenic, zomwe zimatchedwa anti-incretins (zotheka ofuna kupatsirana amadalira glucose-insulinotropic polypeptide (HIP) ndi glucagon), zotulutsidwa m'chigawo chaching'ono cha m'matumbo aang'ono poyankha kuvomereza Mmenemo mumakhala zakudya ndi zinthu zotsutsa kapena insulin,

♦ chakudya cholowa kwambiri mu gawo lachiberekero laling'ono la matumbo, zomwe zimathandizira kuti amasulidwe a glucagon ofanana ndi peptide-1 (GLP-1), omwe ali ndi insulinotropic amadalira glucose, omwe amathandizira "otchedwa" insretin "omwe amachitika pamene chyme chikufika gawo laal-L matumbo (mwayi wokhala ndi vuto la kutaya zinyalala - chiwonetsero chodabwitsa kwambiri cha kuperewera kwa mankhwala - - chimachepetsa mwayi woti wodwala azidya chakudya cham'mimba mosavuta),

♦ kuletsa kwa katulutsidwe wa glucagon mothandizidwa ndi GLP-1,

♦ kuthamanga kwa kukodzedwa chifukwa cha zotsatira za GLP-1 pazogwirizana ndi ubongo,

Decrease kuchepa pang'onopang'ono mu visceral fat misa.

Mkuyu. 2. Opaleshoni ya bariatric: a) gastroshunting,

b) HPS yolembedwa ndi Hess-Marceau ("Ad hoc m'mimba") ("Duodenal switch") 1. duodenum. 2. The hepatic duct wamba. 3. Ndulu

kuwira. 4. Wotupa m'mimba 5. Biliopancreatic loop.

6. Jugoiliac anastomosis. 7. Cecum. 8. M'mimba mwanga.

9. M'matumbo. 10. Rectum. 11. Pancreatic duct.

BPSh pakusintha kwa Scopinaro imatanthawuza kuphatikizika kwam'mimba, kusiya kuchuluka kwa chitsa cham'mimba kuchokera pa 200 mpaka 500 ml, kudutsa matumbo ang'onoang'ono mpaka 250 masentimita kuchokera pakona ya ileocecal, mapangidwe a enteroenteroanastomosis - 50 cm. Kutalika kwazungulira wamba ndi 50 cm, ndipo 200 yopatsa thanzi. masentimita (mkuyu.2b).

Ntchito yapamwamba ya BPSH mu Scopinaro kusinthidwa kwakanthawi kochepa kwa odwala kumayendetsedwa ndi kukula kwa zilonda zam'mimba, kutaya magazi, komanso kutaya matenda. Chifukwa chake, pano amagwiritsidwa ntchito nthawi zambiri.

Mu HPS, pakusinthidwa kwa Hess - Marceau (Bilio-pancreatic Diversion ndi Duodenal switch, ndiye HPS (kutulutsa) ndi duodenum yazimitsa), pyloric yosungitsa khansa ya Prostate imapangidwa, ndipo ileamuyo siyabwino ndi chitsa chamimba, koma ndi gawo loyambirira la duodenum . Kutalika kwa matumbo omwe amatenga gawo la chakudya ndi pafupifupi 310-350 cm, pomwe masentimita 80-100 amapatsidwa gawo lodziwika, 230-250 masentimita kwa alimentary (mkuyu. 2c). Ubwino wa ntchitoyi ndi kuphatikiza kusungidwa kwa pylorous ndi kuchepetsedwa chifukwa cha mwayi wokhala ndi vuto lotaya kutaya ndi peptic

Zilonda m'dera la duodenoeleanastomosis, zomwe zimathandizidwanso ndi kuchepa kwakukulu kwa chiwerengero cha maselo a parietal nthawi ya PRG.

Kuphatikiza pa njira zomwe zafotokozedwera poyambitsa matenda a metabolic kunenepa kwambiri komanso T2DM mwa odwala omwe ali ndi BPS,

♦ kusankha malabsorption wamafuta ndi chakudya chovuta chifukwa chakumapeto kwakanthawi kwa bile ndi ma pancreatic enzymes mu chimbudzi, zomwe zimapangitsa kuchepa kwa kuchuluka kwamafuta acids mu portal vein system ndipo, chifukwa chake, kutsika kwa insulin, ndiye chinthu chofunikira kwambiri chotsimikizira kusintha kwa njira ya T2DM,

Reduction kusankha kuchepetsa kwa ectopic lipid deposition mu chigoba minofu ndi chiwindi, zomwe zimapangitsa kuti insulini imveke bwino (popeza chiwindi chodzaza ndi lipids mu kunenepa kwambiri chimagwirizanitsidwa ndi mphamvu yochepa ya adipose minofu yodzikundikira lipids ndikuwonjezera kuchuluka kwake, zomwe zimapangitsa kuti pakhale kuchuluka kwa mafupa ndi lipotoxicity , yomwe imapanga maziko a dyslipidemia ndi insulin kukana mu T2DM). Zomwe zinachitika pochita opaleshoni ya bariatric kwa odwala onenepa kuphatikizika ndi zovuta za metabolic ndi matenda zidalola Buchwald H. ndi Varco R. kubwerera mu 1978 kuti apange lingaliro la opaleshoni ya "metabolic" ngati gawo la opaleshoni ya bariatric "ngati opaleshoni yoyendetsa chiwalo kapena dongosolo lanthenda ndi cholinga kukwaniritsa zotsalira za thanzi labwino. " Mtsogolomo, chizolowezi chogwiritsa ntchito kwa nthawi yayitali kugwiritsa ntchito opaleshoni ya bariatric kwa odwala omwe ali ndi kunenepa kwambiri ndikugwirizananso ndi T2DM, cholinga chomwe poyambira kuchepetsa MT, chikuwonetsa mwayi waukulu wa opaleshoni kuti akwaniritse kulipidwa kwa T2DM, yomwe idayamba motsutsana ndi maziko onenepa kwambiri.

Posachedwa, zikhulupiliro zakukhazikika ndi malingaliro okhudzana ndi matenda a shuga a 2 awunikiranso.

onenepa. Makamaka, zonena kuti kutayika kwakukulu kwa MT ndikofunikira pakuwongolera glycemic control ku T2DM, yomwe idayamba motsutsana ndi maziko a kunenepa kwambiri atachitidwa opaleshoni ya bariatric, idatsimikiziridwa ndikuti kutsika kwa glycemia kumawonedwa kuyambira milungu yoyamba atachitidwa opaleshoni, i.e. kale kwambiri kuchepa kwamankhwala ku MT. Ndi kutengera kwa mitundu yambiri ya maopaleshoni amtundu wa bariatric (GSH, BPSH) machitidwe, zinaonekeratu kuti kuchepa kwa MT ndikamodzi, koma osati chinthu chokhacho chomwe chikuwonetsa kusintha kwa kagayidwe kazachilengedwe kwa anthu onenepa omwe ali ndi T2DM.

Kugwira Bariatric

ndi matenda a shuga a 2

Popeza chithandizo cha T2DM chimaphatikizapo kusamalira osati glycemic control, komanso mtima wamavuto, opaleshoni ya bariatric ingalimbikitsidwe kwa odwala omwe ali ndi kunenepa kwambiri ndi T2DM omwe samakwaniritsa zolinga zamankhwala othandizira mankhwala Amawongolera kwambiri njira ya matenda oopsa, kukomoka, matenda obanika kugona, etc., Kuphatikiza apo, amachepetsa kufa kwathunthu.

Ntchito zopumira zimathandizira kulipidwa kwa T2DM: kusintha kwa kagayidwe kazakudya m'masabata oyamba atachitidwa opaleshoni chifukwa cha kusamutsidwa kwa odwala kupita ku chakudya chopatsa mphamvu cha calorie, ndipo pambuyo pake, chifukwa malo ochulukirapo amafuta, kuyambiranso kwa T2DM kumakhala kotheka, koma mulingo wake umakhala wofanana ndi kuchuluka kwa kuchepa kwa MT, mosiyana ndi magwiridwe antchito Pambuyo pake mayendedwe a glycemia amadzionetsa ngakhale asanafike kuchepa kwakukulu kwa MT chifukwa cha zomwe zimadziwika kuti "mphamvu yatsopano ya mahomoni."

Pakufufuza kwake, a Buchwald H. et al. adapereka zotsatira za maphunziro onse ofalitsidwa pa opaleshoni yama bariatric kuyambira 1990 mpaka 2006. Mphamvu ya zotsatira zawo pa kagayidwe kazakudya kwa odwala omwe ali ndi kunenepa kwambiri

Zotsatira zamitundu yosiyanasiyana ya opaleshoni ya bariatric pa kutayika kwa MT ndi maphunziro a T2DM Table 1

Zizindikiro Zonse BZ VGP GSH BPSH

% yotayika MT 55.9 46.2 55.5 59.7 63.6

% ya odwala omwe ali ndi matendawa a magawo a matenda ndi ma labotale mu T2DM 78.1 47.9 71 83.7 98.9

Maphunziro a tebulo lachiwiri akuwonetsa kuwongolera kwa glycemic kwa nthawi yayitali atatha opaleshoni ya bariatric mwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM

Odwala, n Nthawi yowunikira, miyezi. Zotsatira

Herbst S. et al., 1984 23 20 AHbA, c = - 3.9%

Pories W. et al., 1992 52 12 AHbA, c = - 4.4%

Pories W. et al., 1995 146 168 91% b-x yokhala ndi Normoglycemia 91% b-x yokhala ndi HbA1c yabwinobwino

Sugerman H. et al., 2003 137 24 83% b-s ndi Normoglycemia 83% b-s ndi HbA1c yachilendo

Scopinaro N. et al., 2008 312 120 97% yogwiritsidwa ntchito ndi HbA1c yachibadwa

Scheen A. et al., 1998 24 28 AHbA1c = - 2.7%

Pontiroli A. et al., 2002 19 36 AHbA1c = - 2.4%

Sjostsrom L. et al., 2004 82 24 72% b-x ndi Normoglycemia

Ponce J. et al., 2004 53 24 80% b-x ndi Normoglycemia AHbA1c = - 1.7%

Dixon J. et al., 2008 30 24 AHbA1c = - 1.8%

za sindikutha kupeza zomwe mukufuna? Yeserani ntchito yosankha mabuku.

ndipo DM2 idayesedwa ndi kuchuluka kwa odwala omwe ali ndi mawonekedwe osintha kapena kuwongolera pakuwonetsedwa kwachipatala ndi ma labotale a DM2 (maphunziro a 621 okhudzana ndi odwala 135,246 adaphatikizidwa pakuwunikira kwa meta) (Mat. 1, 2).

Makulidwe a magawo azachipatala ndi a labotale a T2DM amatanthauza kusapezeka kwa matenda a T2DM ndi kufunika kotenga mankhwala a hypoglycemic, ndikukwaniritsa glycemia yachangu sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

Kuwunika kwa odwala onse omwe akugwira ntchito: mogwirizana ndi pulogalamu ya European SoE - osachepera 75% odwala akuyenera kutsatiridwa osachepera zaka 5,

♦ malinga ndi mayeso okonzanso: osachepera 1 m'miyezi itatu chaka chatha chitatha opareshoni, osachepera nthawi imodzi m'miyezi 6 chaka chachiwiri pambuyo pa opaleshoni, ndiye - chaka chilichonse,

Odwala T2DM, kuti muchepetse chiopsezo cha hypoglycemia, kugwiritsa ntchito mankhwala ochepetsa shuga kapena mkaka wa m'magazi kuyenera kusintha posachedwa ntchito.

Kuwunika kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi T2DM

International Diabetes Federation (IDF) yalimbikitsa izi:

♦ kutayika kwa MT kuposa 15% yazoyambira,

Kukwaniritsa HbA1c mulingo sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

Kukwaniritsa mulingo wa LDL-C sindingapeze zomwe mukufuna? Yeserani ntchito yosankha mabuku.

Milandu ya chitukuko cha malo a hypoglycemic ofotokozedwa pambuyo pa zolemba pambuyo pakuchita opaleshoni ya bariatric imapereka chiwopsezo pamlingo wina panthawi yoyang'anira odwala pakatha nthawi yothandizira.

Pali njira zingapo zomwe zimatsogolera kukukula kwa malo a hypoglycemic atachitidwa opaleshoni ya bariatric bypass:

1) kukhalapo kwa hypertrophy ndi hyperplasia ya b-cell, komwe kunachitika opareshoniyo ndipo anali ovomerezeka kuti athane ndi insulin, ndipo atachitidwa opaleshoni ya bariatric, monga kukana kwa insulin kunachepa, adathandizira mikhalidwe ya hypoglycemic,

2) zotsatira za GLP-1 (mulingo womwe umawonjezeka kwambiri pambuyo povutikira ntchito ya bariatric) pakuchulukana kwa ma cell a B ndikuchepa kwa apoptosis awo

3) momwe mphamvu ya ISU (kachitidwe ka chikoka sichinawonekere),

4) mphamvu ya ghrelin (amene mlingo wake umatsika kwambiri atachotsa fundus yam'mimba), visfatin, leptin, YY peptide (imawonjezera mphamvu ya incretin) ndi mahomoni ena.

Kutalika kwambiri kwa hypoglycemia kumawonedwa pambuyo pa opareshoni ya GSH (mu 0,2% ya odwala omwe akuchita opaleshoni), yomwe imalumikizidwa ndi kukwaniritsidwa mwachangu ndi kuchuluka kwa chakudya cha gawo lachiberekero, komwe ma L-maselo omwe amapanga GLP-1 amapezeka makamaka, mosiyana ndi BPS, momwe matumbo onse ang'onoang'ono ayenera kuzimitsidwa kuti asakumba. Komabe, zomwe zimafotokozeredwa za genesis zomwe zikubwera pambuyo pa bariatric hypoglycemia ndizosemphana kwambiri, ndipo maphunziro enanso amafunikira kuti aphunzire pamwambapa ndi njira zina zomwe zingakhalire kuti zikule.

Mavuto obwera pambuyo pa anthu komanso kuchuluka kwa anthu omwalira

Kuchepa kwa zovuta zoyambirira (mkati mwa masiku 30 atachitidwa opaleshoni) pambuyo panjira zosiyanasiyana zama bariatric sizidutsa 5-10%.

Chiwopsezo cha kufa motsutsana ndi maziko a njira zopangira opaleshoni ya bariatric ndi ochepa kwambiri, ali mulingo wa 0-1-1.1% ndipo amafananizidwa ndi chisonyezo chomwecho cha zochitika zowukira pang'ono, monga, mwachitsanzo, laparoscopic cholecystectomy. Pafupifupi 75% ya anthu omwe amafa kumayambiriro kwa ntchito pambuyo pake amaphatikizidwa ndi chitukuko cha peritonitis chifukwa chodukiza pazinthu kuchokera ku anastomosis mpaka m'mimba ndipo 25% ndizotsatira zoyipa zomwe zimagwirizanitsidwa ndi pulmonary embolism.

Malinga ndi kusanthula kwa manambala, anthu wamba omwe amafa kumayambiriro kwa ntchito ndi 0,28%, makamaka, atatha kulumikizana kwa m'mimba sichidutsa 0.1%, pambuyo pa GSH - 0.3-0.5%, pambuyo pa HPS - 0.1-0 , 3%. Chiwerengero cha anthu omwalira chikuwonjezeka kuyambira tsiku la 30 kufika chaka chachiwiri atachitidwa opaleshoni mpaka 0.35%. Odwala opitirira zaka 60, amafa kwambiri, makamaka ndi matenda amtima. Mwambiri, poyerekeza ndi chithandizo chosasinthika cha kunenepa kwambiri, opaleshoni ya bariatric imachepetsa kufa kwa opaleshoni yayitali.

Ndikofunika kukumbukira kuti anthu ochepa omwalira pambuyo pochita opareshoni ya kunenepa kwambiri, kuphatikizapo odwala omwe ali ndi T2DM, amatha kuchitika pokhapokha ngati zonse zofunika kuchitidwa opaleshoni ya bariatric zikutsatiridwa mosamala mukuwonetsa kuwunikira komanso kuwonetsa zolakwika, komanso kukonzekera koyenera.

Okulosera za postoperative prognosis ya kubwezeretsanso kobwezeretsanso kwa chakudya cham'madzi ndi lipid metabolism mwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu 2 shuga

Amaganiza kuti zinthu zomwe zafotokozedwera m'munsimu zitha kupangitsa kuti matendawa athe kuchotsedwa kwa T2DM pambuyo pochita opaleshoni ya bariatric:

♦ Kutalika kwa T2DM,

Oper kwambiri ogwira ntchito HbA1c,

♦ kusowa kwa hyperinsulinemia ndi insulin kukana,

Therapy mankhwala a insulin a shuga.

Izi zimachitika makamaka chifukwa chakuti odwala omwe ali ndi matenda a shuga a 2, kuchuluka kwa maselo a β-amachepetsa pakapita nthawi chifukwa chovuta pakati pa apoptosis ndi neogeneis, kuthekera kwa maselo β maselo kukana insulin komwe kumayambitsa kukula kwa matenda a shuga a 2 kumachepa, komanso wachibale kapena Mtheradi insulinopenia. Chifukwa chake, zitha kuganiziridwa kuti m'magulu omwe ali pamwambawa odwala, kudalirika kwa kukwaniritsa malipiro a carbohydrate metabolism kumatsimikiziridwa ndi kuchuluka kwa ap-aposis ya b-cell, komanso zidziwitso zomwe zimakhala ndi chinsinsi cha magwiridwe antchito a b-cell (mulingo woyambira komanso wolimbikitsa C-peptide).

Pafupifupi, zambiri zowonetsedwa pamabuku zimafotokoza kuti, posankha mosamala anthu omwe akufuna kuchitidwa opaleshoni ya bariatric molingana ndi chizindikiritso chovomerezedwa ndi zotsutsana, kutalika kwa matendawa kuli mpaka zaka 10-15, koyambirira kusawongolera glycemic, zaka zopitilira 50, ndipo BMI yoyambirira siyikhudza pa kupita patsogolo kwa kusintha kwa kagayidwe kazakudya kwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM atachitidwa opaleshoni ya bariatric, malinga ngati ntchito yopanga insulin ya b-cell imasungidwa, motsimikizika d kutengera muyeso woyambirira ndi wolimbikitsidwa wa C-peptide.

Ziyembekezero zopitiliza kuphunzira za kagwiridwe kabwino ndi kagwiridwe ka ntchito zoyambira, zolembedwa ndi IDF

Monga gawo lofufuzira momwe zotsatira za opaleshoni ya bariatric panjira zosiyanasiyana zamankhwala ndi chithandizo cha T2DM kwa odwala omwe ali ndi kunenepa kosiyanasiyana, ndikofunikira:

♦ kutsimikiza kwa njira zodalirika zowonongera kugwiririra ntchito kwachilengedwe poyerekeza chakudya, lipid, purine ndi mitundu ina ya kagayidwe.

Kuchititsa maphunziro kuti athe kuwunika momwe opaleshoni yodwala yodwala imayendera odwala omwe ali ndi matenda ashuga a 2 komanso kunenepa kwambiri ndi BMI yotsika 35 kg / m2,

♦ kudziwa zomwe zimapangitsa opaleshoni ya bariatric popewa kapena kuchepa kwa kutayika kwa ntchito ya insulin yopanga ma b-cell, a T2DM,

♦ kuwunika kwa zotsatira za opaleshoni ya bariatric pazovuta za T2DM,

♦ mayeso osasankhidwa kuti afananize zotsatira za mitundu yosiyanasiyana ya opaleshoni yamatumbo pa T2DM.

DOI: 10.14341 / OMET2016150-56 Zolemba

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Wofufuza wa Ershova Ekaterina Vladimirovna, Dipatimenti Yachithandizo

Federal State Budgetary Institution Endocrinology Science Science Center of the Ministry of Health of Russia E-mail: [email protected] Troshina Ekaterina Anatolyevna MD, pulofesa, wamkulu wa dipatimenti yamankhwala ochizira odwala ndi onenepa kwambiri

Federal State Budgetary Institution "Endocrinological Science Science Center" ya Unduna wa Zaumoyo ku Russia

Kugwiritsa ntchito maopaleshoni oyambitsa matenda a shuga a 2: kuthandiza katswiri

Kugwiritsidwa ntchito kwa ma bariatric opaleshoni kwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 shuga mellitus (T2DM) ali ndi mawonekedwe ake. Mu mutu uwu, zikuwonetsa ndikuwonetsa ma bariatric ntchito, kuphatikizapo enieni - pamaso pa T2DM. Mitundu yosiyanasiyana yama bariatric ntchito ndi njira zomwe zimathandizira pakachulukidwe kazakudya ndi lipid metabolism amafotokozedwa. Zotsatira za opaleshoni yoletsa komanso ya shunt bariatric mwa odwala omwe ali ndi kunenepa kwambiri ndi mtundu wa 2 wa shuga akuwonetsedwa. Zofunikira pakugwira ntchito za bariatric zimaperekedwa ndipo magawo a kuwunika momwe amapangidwira amapatsidwa, kuphatikiza chikhululukiro cha T2DM atatha kulowererapo. Zomwe zimayambitsa post-bariatric hypoglycemia, komanso olosera za postoperative prognosis ya kugwira ntchito bwino kwa bariatric mogwirizana ndi metabolic control mwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM, amawunikira.

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Mawu osakira

Opaleshoni ya Bariatric (yochokera ku baros yachi Greek - yolemetsa, yolemetsa, yolemetsa) ndi njira zochitidwa opaleshoni zomwe zimachitika pamimba yokumba pofuna kuchepetsa thupi (MT).

M'zaka makumi angapo zapitazi, njira zochitira opaleshoni zakhala zikugwiritsidwa ntchito padziko lonse lapansi kuchitira kunenepa kwambiri, ndipo pali malingaliro omveka bwino owonjezera kuchuluka kwa ntchito zomwe zikuchitidwa ndikuwonjezera chiwerengero cha mayiko omwe opaleshoni ya bariatric ikuchulukirachulukira.

Zolinga za opaleshoni yothandizira kunenepa kwambiri:

• chifukwa cha kuchepa kwakukulu kwa MT, kukhudza njira yamatenda omwe amayamba pamene MT akuwonjezeka (mtundu wachiwiri wa matenda ashuga mellitus (T2DM), matenda oopsa, matenda apnea usiku, kusowa kwa ovarian, ndi zina zambiri.
• khalani ndi moyo wa odwala onenepa kwambiri.

Zisonyezero za opaleshoni ya bariatric

Mankhwala othandizira kunenepa kwambiri amatha kuchitika ngati njira zoyeserera kale zochepetsera MT kwa odwala azaka zapakati pa 18 ndi 60 sizothandiza.

• kunenepa kwambiri (thupi misa index (BMI) ≥40 kg / m2),
• kunenepa kwambiri ndi BMI ≥35 kg / m2 kuphatikiza ndimatenda akulu ogwirizana omwe samakhutitsidwa ndi kusintha kwa moyo komanso mankhwala osokoneza bongo.

Contraindication chifukwa cha opaleshoni yovomerezeka ndi kukhalapo kwa wokonzekera:

• mowa, mankhwala osokoneza bongo kapena vuto lililonse,
• matenda amisala
• kuchuluka kwa zilonda zam'mimba kapena duodenum,
• mimba
• matenda oncological
• kusintha kosasintha kwa ziwalo zofunika (kulephera kwamtima kwa mtima kwa III - magawo olimbitsa thupi a IV, chiwindi kapena kulephera kwa aimpso),
• kusamvetsa za zoopsa zomwe zimachitika chifukwa chogwiritsa ntchito ndalama,
• Kusagwirizana ndi kukhazikitsidwa kwakanthawi kwa dongosolo la ma postoperative.

Molakwika mwapadera pokonzekera bariatric opaleshoni mwa odwala omwe ali ndi kunenepa kwambiri ndi matenda a shuga:

• matenda ashuga
• antibodies abwino ku glutamic acid decarboxylase kapena maselo a Langerhans
• C-peptide 50 kg / m2), mphamvu zawo zimakhala zosakhazikika. Pankhani yakutaya kwakukhazikika kwakanthawi (mwachitsanzo, ndikubwezeretsanso,

Maziko a malabsorbent (shunting) ndi ntchito zonse ndikuphatikizidwa kwa magawo osiyanasiyana a m'matumbo aang'ono, omwe amachepetsa kuyamwa kwa chakudya. Nthawi ya gastroshunting (GSh, mkuyu. 2a), m'mimba kwambiri, duodenum ndi gawo loyambirira la matumbo ochepa limachotsedwa pakadali chakudya, komanso ndi biliopancreatic shunting (BPS, Matenda a 2b ndi 2c), pafupifupi jejunum yonse.

Ntchito zophatikizika, kuphatikiza zomwe zimapangitsa kuti zisamawonongeke komanso kusunthika, zimadziwika ndi zovuta zambiri komanso kuwopsa kwa zotsatira zosayenerera, komabe, zimapereka zotsatira zotchulidwa komanso zokhazikika zazitali, komanso zimakhudza bwino zovuta zamatenda a metabolic ndi matenda omwe amachitika chifukwa cha kunenepa, komwe kumatsimikiza zabwino.

Njira zamachitidwe a GSH pa chakudya chamafuta mu kunenepa ndi mtundu 2 shuga:

• kukakamizidwa kusintha koyambirira kwa nthawi yoyambirira kupita ku chakudya chamafuta ochepa,
• kusiyanitsidwa kwa duodenum kuti asakhudzane ndi chakudya, zomwe zimapangitsa kuti pakhale zovuta za matenda ashuga, omwe amatchedwa anti-insretins (omwe angathe kukhala osokoneza bongo amadalira insulinotropic polypeptide (HIP) ndi glucagon, yotulutsidwa gawo lachiberekero laling'ono lamatumbo poyankha kulowetsedwa kwa chakudya ndi zinthu zotsutsana kapena insulin kanthu
• imathandizira kudya kwakanthawi kwamatumbo aang'ono, komwe kumathandizira kuti magazi amasuke ngati glucagon-1 (GLP-1), omwe ali ndi insulinotropic yomwe imadalira shuga, zomwe zimapangitsa kuti "chidziwitso" cha "insretin" "chichitike pamene chyme ifika ku leum L-cell koyambirira (kuthekera) chitukuko cha kutaya matenda - mawonekedwe ochititsa chidwi kwambiri azakudya zamatenda - amachepetsa mwayi wa odwala omwe amataya chakudya cham'mimba mosavuta,
• kuletsa kwa secretion wa glucagon mothandizidwa ndi GLP-1,
• mathamangitsidwe a machulukitsidwe chifukwa cha zotsatira za GLP-1 pazogwirizana ndi ubongo
• kuchepa kwapang'onopang'ono kwa visceral mafuta misa.

BPSh pakusintha kwa Scopinaro imatanthawuza kuphatikizika kwam'mimba, kusiya kuchuluka kwa chitsa cham'mimba kuchokera pa 200 mpaka 500 ml, kudutsa m'matumbo ang'onoang'ono mpaka 250 cm kuchokera pakona ya ileocecal, mapangidwe a enteroenteroanastomosis - 50 cm. Kutalika kwofala kulikonse ndi 50 cm, ndipo 200 yopatsa thanzi. masentimita (mkuyu.2b).

Ntchito yapamwamba ya BPSH mu Scopinaro kusinthidwa kwakanthawi kochepa kwa odwala kumayendetsedwa ndi kukula kwa zilonda zam'mimba, kutaya magazi, komanso kutaya matenda. Chifukwa chake, pano amagwiritsidwa ntchito nthawi zambiri.

Mu HPS pakusinthidwa kwa Hess - Marceau ("Biliopancreatic diversion ndi Duodenal switch", mwachitsanzo, HPS (kutulutsa) ndi duodenum yazimitsa), khansa yokhazikika ya piroric imachitidwa, ndipo ileamu siinaphatikizidwe ndi chitsa cha m'mimba, koma ndi gawo loyambirira la duodenum. Kutalika kwa matumbo omwe amatenga gawo la chakudya ndi pafupifupi 310-350 masentimita, pomwe masentimita 80-100 amapatsidwa gawo lodziwika, 230-250 masentimita kwa alimentary (mkuyu. 2c). Ubwino wakugwiritsira ntchito ndikuphatikiza kusungidwa kwa pylorous ndikuchepetsa mwayi wokhala ndi zotupa zotayika komanso zilonda zam'mimba m'dera la duodenoelanastomosis chifukwa cha izi, zomwe zimathandizanso kuchepa kwakukulu kwa chiwerengero cha maselo a parietal panthawi ya khansa ya prostate.

Kuphatikiza pa njira zomwe zafotokozedwera poyambitsa matenda a metabolic kunenepa kwambiri komanso T2DM mwa odwala omwe ali ndi BPS,

• kusankha malabsorption wamafuta ndi zovuta ma carbohydrate chifukwa chakuphatikiza kwa ndulu ndi ma pancreatic enzymes mu chimbudzi, zomwe zimapangitsa kuchepa kwa kuchuluka kwamafuta acids mu dongosolo lamitsempha yam'mimba ndipo, chifukwa chake, kutsika kwa insulin, ndiye chinthu chofunikira kwambiri chotsimikizira kusintha kwa njira ya T2DM,
• kusankha kuchepa kwa ectopic lipid deposition mu chigoba minofu ndi chiwindi, zomwe zimapangitsa insulin kumva (chifukwa chiwindi chochuluka ndi lipids mu kunenepa kwambiri imalumikizidwa ndi kuchepa kwa mphamvu ya adipose minofu yodziunjikira lipids ndikuwonjezera kuchuluka kwake, komwe kumapangitsa kuti pakhale kuchuluka kwa mafupa ndi lipotoxicity, kupanga maziko a dyslipidemia ndi insulin kukana mu T2DM).

Zochitika zakugwiritsira ntchito opaleshoni ya bariatric kwa odwala onenepa kuphatikiza zovuta zama metabolic komanso matenda adalola Buchwald H. ndi Varco R. kubwerera mu 1978 kuti apange lingaliro la opaleshoni ya "metabolic" ngati gawo la opaleshoni ya bariatric "ngati opaleshoni yoyendetsa ziwalo wamba kapena dongosolo kuti akwaniritse kwachilengedwa zotsatira zaumoyo. ”Mtsogolomo, chizolowezi chogwiritsa ntchito kwa nthawi yayitali kugwiritsa ntchito maopaleshoni achilendo kwa odwala omwe ali ndi kunenepa kwambiri ndikugwirizananso ndi T2DM, cholinga chomwe poyambira kuchepetsa MT, chikuwonetsa mwayi waukulu wa opaleshoni kuti akwaniritse kulipidwa kwa T2DM, yopangidwa motsutsana ndi maziko a kunenepa kwambiri.

Posachedwa, zikhulupiriro zoyambira ndi malingaliro olakwika okhudza T2DM mwa odwala onenepa kwambiri awunikiranso. Makamaka, zonena kuti kutayika kwakukulu kwa MT ndikofunikira pakuwongolera glycemic control ku T2DM, yomwe idayamba motsutsana ndi maziko a kunenepa kwambiri atachitidwa opaleshoni ya bariatric, idatsimikiziridwa ndikuti kutsika kwa glycemia kumawonedwa kuyambira milungu yoyamba atachitidwa opaleshoni, i.e. kale kwambiri kuchepa kwamankhwala ku MT. Ndi kutengera kwa mitundu yambiri ya maopaleshoni amtundu wa bariatric (GSH, BPSH) machitidwe, zinaonekeratu kuti kuchepa kwa MT ndikamodzi, koma osati chinthu chokhacho chomwe chikuwonetsa kusintha kwa kagayidwe kazachilengedwe kwa anthu onenepa omwe ali ndi T2DM.

Kuchita bwino kwa opaleshoni yodwala matenda a shuga 2

Popeza chithandizo cha T2DM chimaphatikizapo kusamalira osati glycemic control, komanso mtima wamavuto, opaleshoni ya bariatric ingalimbikitsidwe kwa odwala omwe ali ndi kunenepa kwambiri ndi T2DM omwe samakwaniritsa zolinga zamankhwala othandizira mankhwala Amawongolera kwambiri njira ya matenda oopsa, kukomoka, matenda obanika kugona, etc., Kuphatikiza apo, amachepetsa kufa kwathunthu.

Ntchito zopumira zimathandizira kulipidwa kwa T2DM: kusintha kwa kagayidwe kazakudya m'masabata oyambilira atachitidwa opaleshoni chifukwa cha kusamutsidwa kwa odwala kupita ku chakudya chowonjezera cha calorie, ndipo pambuyo pake, chifukwa malo ochulukirapo amafuta, kuyambiranso kwa T2DM kumakhala kotheka, koma mulingo wake umakhala wofanana ndi kuchuluka kwa kuchepa kwa MT, mosiyana ndi magwiridwe antchito Pambuyo pake mayendedwe a glycemia amadzionetsa ngakhale asanafike kuchepa kwakukulu kwa MT chifukwa cha zomwe amadziwika kuti "incretin athari."

Pakufufuza kwake, a Buchwald H. et al. adapereka zotsatira za maphunziro onse ofalitsidwa pa opaleshoni yama bariatric kuyambira 1990 mpaka 2006. Kuchita bwino kwa zotsatira zawo pa carbohydrate metabolism mwa odwala omwe ali ndi kunenepa kwambiri komanso T2DM idawunikidwa ndi kuchuluka kwa odwala omwe ali ndi normalization kapena kusintha kwa mawonetsedwe azachipatala ndi a labotale a T2DM (maphunziro a 621 okhudzana ndi odwala 135,246 adaphatikizidwa pakuwunikira kwa meta) (Mathebulo 1, 2).

Gome 1. Zotsatira zamitundu yosiyanasiyana yochita opaleshoni ya bariatric pa kutayika kwa MT ndi maphunziro a T2DM