代谢手术术前内科管理进展

doi:10.3969/j.issn.1674-8115.2023.10.016

摘要/Abstract

摘要：

肥胖是一种慢性代谢性疾病，其人数日益增多，已成为包括中国在内的许多国家的重要公共卫生问题和流行病。肥胖及其合并症如2型糖尿病（type 2 diabetes mellitus，T2DM）、非酒精性脂肪肝、高血压和心血管疾病等严重危害生命健康。随着代谢手术的不断发展和完善，其作为一种安全、有效的治疗肥胖及其合并症的方法，已被广泛应用于肥胖患者的临床治疗中。代谢手术可以帮助患者显著减轻体质量，改善代谢指标，降低糖尿病、高血压等慢性病的风险，改善患者的生活质量，为患者带来全面的健康益处。然而，目前临床上缺乏规范的代谢手术术前内科管理，可能导致患者出现代谢紊乱、营养缺乏等并发症，从而增加手术风险和术后并发症发生率，影响减重的效果，对患者的预后造成不良影响。该文回顾了代谢手术术前减重、血糖控制、血压和血脂控制、微量营养素补充、心理和行为调节等方面的相关文献，对代谢手术术前内科管理进行综述，旨在为有效提高代谢手术的安全性和治疗效果，以及改善患者的预后提供参考。

关键词: 代谢手术, 肥胖, 糖尿病, 内科管理

Abstract:

Obesity is a chronic metabolic disease that is increasing in prevalence and has become a major public health problem and epidemic in many countries, including China. Obesity and its associated complications, such as type 2 diabetes (T2DM), non-alcoholic fatty liver disease, hypertension, and cardiovascular disease, seriously damage health. With the continuous development of metabolic surgery, it has become a widely used, safe and effective method for treating obesity and its associated complications. Metabolic surgery can significantly lose weight, improve metabolic indicators, reduce the risk of chronic diseases such as diabetes and hypertension, improve the quality of life of patients, and bring comprehensive health benefits to patients. However, there is currently a lack of standardized preoperative medical management for metabolic surgery, which may lead to metabolic disorders, nutrient deficiencies, and other complications, increasing the risk of surgery and postoperative complications, and affecting the efficacy of weight loss and the prognosis of patients. Through the systematic review of literature related to preoperative weight loss, glycemic control, blood pressure and lipid control, micronutrient supplementation, and psychological and behavioral modifications, this paper reviews preoperative medical management of metabolic surgery with the aim of providing reference for effectively improving the safety and efficacy of metabolic surgery and improving the prognosis of patients.

Key words: metabolic surgery, obesity, diabetes, medical management

中图分类号:

R589.2

单颖仪, 于浩泳. 代谢手术术前内科管理进展[J]. 上海交通大学学报（医学版）, 2023, 43(10): 1332-1338.

SHAN Yingyi, YU Haoyong. Advances in preoperative medical management of metabolic surgery[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(10): 1332-1338.

图/表 2

参考文献 55

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Treatment	Preoperative treatment	Note
Metformin	To discontinue on the day of surgery	Gastrointestinal discomfort and lactic acidosis should be avoided; Patients with stage 4 severe chronic kidney disease (CKD) [estimated glomerular filtration rate 30 mL·min^-1·(1.73 m²)^-1] are contraindicated
Sulfonylureas and meglitinides	To discontinue at the start of preoperative diet (i.e., 2‒4 weeks before surgery)	Hypoglycemia and weight gain should be avoided
Thiazolidinediones	To discontinue on the day of surgery	Weight gain, fluid retention, and edema should all be avoided
ɑ-glucosidase inhibitors	To discontinue on the day before metabolic surgery	Gastrointestinal side effects should be avoided
Dipeptidyl peptidase-4 (DPP-4) inhibitors	To discontinue on the day of surgery	Patients with heart failure, arthralgia, skin conditions, allergic reactions and acute pancreatitis should use it with caution
Sodium-glucose cotransporter-2 (SGLT2) inhibitors	To discontinue 3 d prior to surgery (2 weeks prior to surgery for those on a low-calorie ketogenic diet)	Genitourinary tract infections, hypotension, fractures, acute kidney injury, ketoacidosis, and rare cases of Fournier's gangrene should all be taken seriously
Glucagon-like peptide 1 (GLP-1) receptor agonists	To discontinue on the day of surgery	Gastrointestinal side effects should be avoided; Patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 are contraindicated

Treatment	Preoperative treatment	Note
Metformin	To discontinue on the day of surgery	Gastrointestinal discomfort and lactic acidosis should be avoided; Patients with stage 4 severe chronic kidney disease (CKD) [estimated glomerular filtration rate 30 mL·min^-1·(1.73 m²)^-1] are contraindicated
Sulfonylureas and meglitinides	To discontinue at the start of preoperative diet (i.e., 2‒4 weeks before surgery)	Hypoglycemia and weight gain should be avoided
Thiazolidinediones	To discontinue on the day of surgery	Weight gain, fluid retention, and edema should all be avoided
ɑ-glucosidase inhibitors	To discontinue on the day before metabolic surgery	Gastrointestinal side effects should be avoided
Dipeptidyl peptidase-4 (DPP-4) inhibitors	To discontinue on the day of surgery	Patients with heart failure, arthralgia, skin conditions, allergic reactions and acute pancreatitis should use it with caution
Sodium-glucose cotransporter-2 (SGLT2) inhibitors	To discontinue 3 d prior to surgery (2 weeks prior to surgery for those on a low-calorie ketogenic diet)	Genitourinary tract infections, hypotension, fractures, acute kidney injury, ketoacidosis, and rare cases of Fournier's gangrene should all be taken seriously
Glucagon-like peptide 1 (GLP-1) receptor agonists	To discontinue on the day of surgery	Gastrointestinal side effects should be avoided; Patients with a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 are contraindicated

Micronutrient	Prevention	Treatment
Iron	45‒60 mg/d by oral administration	150‒200 mg/d by oral administration
Zinc	15 mg/d by oral administration	60 mg twice a day by oral administration
Copper	2 mg/d by oral administration (≥1 mg Cu per 8‒15 mg Zn to prevent copper deficiency is recommended)	Severe deficiency: 2‒4 mg/d by intravenous injection for 6 d
Vitamin A	6 000 IU/d by oral administration	Without corneal changes: 10 000‒25 000 IU/d by oral administration. With corneal changes: 50 000‒100 000 IU by intramuscular injection for 3 d, followed by 50 000 IU/d by intramuscular injection for 2 weeks to achieve clinical improvement
Vitamin B₁	12 mg/d by oral administration	500 mg/d by intravenous injection for 3‒5 d, followed by 250 mg/d by intravenous injection for 3‒5 d or until symptoms disappear. If further treatment is required, 100 mg/d is taken by oral administration
Vitamin B₆	400 μg/d by oral administration	1 000 μg/d by oral administration
Vitamin B₁₂	250‒350 μg/d or 1 000 μg/wk by sublingual administration	1 000‒2 000 μg/d by sublingual administration
Vitamin D₂or D₃	Vitamin D₂ or D₃ 3 000 IU/d by oral administration to reach normal concentrations of 30 ng/mL	Vitamin D₂ or D₃ 50 000 IU/week for 8 weeks, followed by maintenance therapy of 1 500‒2 000 IU/d by oral administration to achieve normal concentrations
Vitamin E	400 IU/d by oral administration	800‒1 200 IU/d by oral administration
Vitamin K	300 μg/d by oral administration	10 mg by intramuscular injection, followed by 1‒2 mg/week by oral administration

Micronutrient	Prevention	Treatment
Iron	45‒60 mg/d by oral administration	150‒200 mg/d by oral administration
Zinc	15 mg/d by oral administration	60 mg twice a day by oral administration
Copper	2 mg/d by oral administration (≥1 mg Cu per 8‒15 mg Zn to prevent copper deficiency is recommended)	Severe deficiency: 2‒4 mg/d by intravenous injection for 6 d
Vitamin A	6 000 IU/d by oral administration	Without corneal changes: 10 000‒25 000 IU/d by oral administration. With corneal changes: 50 000‒100 000 IU by intramuscular injection for 3 d, followed by 50 000 IU/d by intramuscular injection for 2 weeks to achieve clinical improvement
Vitamin B₁	12 mg/d by oral administration	500 mg/d by intravenous injection for 3‒5 d, followed by 250 mg/d by intravenous injection for 3‒5 d or until symptoms disappear. If further treatment is required, 100 mg/d is taken by oral administration
Vitamin B₆	400 μg/d by oral administration	1 000 μg/d by oral administration
Vitamin B₁₂	250‒350 μg/d or 1 000 μg/wk by sublingual administration	1 000‒2 000 μg/d by sublingual administration
Vitamin D₂or D₃	Vitamin D₂ or D₃ 3 000 IU/d by oral administration to reach normal concentrations of 30 ng/mL	Vitamin D₂ or D₃ 50 000 IU/week for 8 weeks, followed by maintenance therapy of 1 500‒2 000 IU/d by oral administration to achieve normal concentrations
Vitamin E	400 IU/d by oral administration	800‒1 200 IU/d by oral administration
Vitamin K	300 μg/d by oral administration	10 mg by intramuscular injection, followed by 1‒2 mg/week by oral administration

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