每年有30,000名英国人和365,000名美国人死于肥胖和缺乏运动。[1]National Audit Office. Tackling obesity in England. February 2001. http://www.nao.org.ukhttp://www.nao.org.uk/wp-content/uploads/2001/02/0001220.pdf[2]Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004 Mar 10;291(10):1238-45.http://www.ncbi.nlm.nih.gov/pubmed/15010446?tool=bestpractice.com[3]Mokdad AH, Marks JS, Stroup DF, et al. Correction: actual causes of death in the United States, 2000. JAMA. 2005;293:293-294.http://www.ncbi.nlm.nih.gov/pubmed/15657315?tool=bestpractice.com[4]Scottish Intercollegiate Guidelines Network (SIGN). Management of obesity: a national clinical guideline. February 2010. https://www.sign.ac.uk/our-guidelines.htmlhttps://www.sign.ac.uk/sign-115-management-of-obesity.html III 级肥胖（体重指数为 40 或以上）的发病率正在快速增加，全球接受减重手术的患者也越来越多。一些大规模的前瞻性试验已经表明：减重手术可以改善所有年龄段 III 级肥胖患者的生活质量，并降低死亡风险。[5]Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741-52.http://www.nejm.org/doi/full/10.1056/NEJMoa066254#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/17715408?tool=bestpractice.com[6]Inabnet WB 3rd, Belle SH, Bessler M, et al. Comparison of 30-day outcomes after non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2010;6:22-30.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836857/pdf/nihms174958.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/20129303?tool=bestpractice.com[7]Healthcare Improvement Scotland (NHS QIS). Bariatric surgery in adults: Evidence Note 28. June 2010. http://www.healthcareimprovementscotland.orghttp://www.healthcareimprovementscotland.org/programmes/clinical__cost_effectiveness/shtg_-_evidence_notes/evidence_note_28.aspx[8]Pontiroli AE, Morabito A. Long-term prevention of mortality in morbid obesity through bariatric surgery. A systematic review and meta-analysis of trials performed with gastric banding and gastric bypass. Ann Surg. 2011;253:484-487. [Erratum in Ann Surg. 2011;253:1056.]http://www.ncbi.nlm.nih.gov/pubmed/21245741?tool=bestpractice.com[9]Tayyem R, Ali A, Atkinson J, et al. Analysis of health-related quality-of-life instruments measuring the impact of bariatric surgery: systematic review of the instruments used and their content validity. Patient. 2011;4:73-87.http://www.ncbi.nlm.nih.gov/pubmed/21766897?tool=bestpractice.com[10]Flum DR, Belle SH, King WC, et al; Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445-454.http://www.nejm.org/doi/full/10.1056/NEJMoa0901836http://www.ncbi.nlm.nih.gov/pubmed/19641201?tool=bestpractice.com[11]Inge TH, Courcoulas AP, Jenkins TM, et al; Teen-LABS Consortium. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med. 2016;374:113-23.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810437/http://www.ncbi.nlm.nih.gov/pubmed/26544725?tool=bestpractice.com 研究表明，III 级肥胖的儿童和青少年患者可以从减重手术中获益。[12]NHS England. Clinical Commissioning Policy: Obesity surgery for children with severe complex obesity. April 2017. https://www.england.nhs.uk/https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e02/ II 级（体重指数为 35-39.9）至 III 级肥胖的患者应接受全面评估，并在减重手术后的近期和远期接受护理。[13]British Obesity & Metabolic Surgery Society, Royal College of Surgeons. Commissioning guide: Weight assessment and management clinics. March 2014. http://www.bomss.org.uk/http://www.bomss.org.uk/commissioning-guide-weight-assessment-and-management-clinics-tier-3/
阅读更多目前还在研究将减重手术（也称为代谢手术）作为 2 型糖尿病一种可能的主要治疗方法。随机对照临床试验以及系统评价和 meta 分析的结果显示，在肥胖的 2 型糖尿病患者中，减重手术对血糖的控制优于单用传统药物治疗。[14]Yan Y, Sha Y, Yao G, et al. Roux-en-Y gastric bypass versus medical treatment for type 2 diabetes Mellitus in obese patients: a systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2016;95:e3462.http://www.ncbi.nlm.nih.gov/pubmed/27124041?tool=bestpractice.com[15]Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med. 2017;376:641-51.http://www.nejm.org/doi/full/10.1056/NEJMoa1600869http://www.ncbi.nlm.nih.gov/pubmed/24679060?tool=bestpractice.com[16]Müller-Stich BP, Senft JD, Warschkow R, et al. Surgical versus medical treatment of type 2 diabetes mellitus in nonseverely obese patients: a systematic review and meta-analysis. Ann Surg. 2015;261:421-429.http://www.ncbi.nlm.nih.gov/pubmed/25405560?tool=bestpractice.com[17]Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet. 2015;386:964-973.http://www.ncbi.nlm.nih.gov/pubmed/26369473?tool=bestpractice.com[18]Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-256.e5.http://www.ncbi.nlm.nih.gov/pubmed/19272486?tool=bestpractice.com 此外，美国糖尿病协会 (American Diabetes Association)、英国国家卫生与临床优化研究所以及国际糖尿病基金会的指南建议，对于仅采用最佳药物治疗不足以控制血糖的肥胖合并 2 型糖尿病患者，可进行减重手术。[19]Marathe PH, Gao HX, Close KL. American Diabetes Association standards of medical care in diabetes 2017. J Diabetes. 2017;9:320-324.https://onlinelibrary.wiley.com/doi/full/10.1111/1753-0407.12524http://www.ncbi.nlm.nih.gov/pubmed/28070960?tool=bestpractice.com[20]National Institute for Health and Care Excellence (NICE). Obesity: identification, assessment and management. November 2014. http://www.nice.org.ukhttps://www.nice.org.uk/guidance/cg189/resources/obesity-identification-assessment-and-management-35109821097925[21]International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention. 2011. http://www.idf.orghttp://www.idf.org/webdata/docs/IDF-Position-Statement-Bariatric-Surgery.pdf[22]Dixon JB, Zimmet P, Alberti KG, et al; International Diabetes Federation Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese Type 2 diabetes. Diabet Med. 2011;28:628-642.http://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2011.03306.x/fullhttp://www.ncbi.nlm.nih.gov/pubmed/21480973?tool=bestpractice.com
一项小型随机试验表明，对于有高血压的肥胖患者，与给予单纯的药物治疗相比，实施减重手术减少了控制血压所需的降压药数量 (≥30%)。[23]Schiavon CA, Bersch-Ferreira AC, Santucci EV, et al. Effects of bariatric surgery in obese patients with hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension). Circulation. 2018;137:1132-1142.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865494/http://www.ncbi.nlm.nih.gov/pubmed/29133606?tool=bestpractice.com
减重手术治疗肥胖的作用机制尚不完全明确，但目前认为可能与胃容量限制、吸收不良和激素改变有关。[24]Beckman LM, Beckman TR, Earthman CP. Changes in gastrointestinal hormones and leptin after Roux-en-Y gastric bypass procedure: a review. J Am Diet Assoc. 2010;110:571-584.http://www.ncbi.nlm.nih.gov/pubmed/20338283?tool=bestpractice.com[25]Balsiger BM, Poggio JL, Mai J, et al. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity. Gastrointest Surg. 2000;4:598-605.http://www.ncbi.nlm.nih.gov/pubmed/11307094?tool=bestpractice.com
患者在行减重手术后，可能到门诊、急诊科或行手术所在医院之外的其他医院就诊。因此，需要了解常见的并发症。[26]Clinical Issues Committee of the American Society for Metabolic and Bariatric Surgery. American Society for Metabolic and Bariatric Surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010;6:115-117.http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/PositionStatement/ASMBS_Position_Statement_on_Emergency_Care_of_Ptients_with_Complications_Related_to_Bariatric_Surgery_Mar_2010.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/20189469?tool=bestpractice.com 可能难以检查中心性肥胖患者的腹部，并且中心性肥胖可掩盖脓毒症的典型体征。因此密切注意生命体征、实验室检查结果以及一切偏离预期的术后病程十分重要。
为了帮助患者维持减肥手术后的体重减轻，可能需要常规自我监测和频繁的术后随访。[27]Odom J, Zalesin KC, Washington TL, et al. Behavioral predictors of weight regain after bariatric surgery. Obes Surg. 2010;20:349-356.http://www.ncbi.nlm.nih.gov/pubmed/19554382?tool=bestpractice.com
