【作者】 张建军；

【导师】 吴毅平；

【作者基本信息】 华中科技大学 ， 外科学， 2013， 博士

【摘要】 目的：建立Wistar大鼠袖状胃切除术附加改良空回肠旁路术模型并观察其安全性。方法：（1）实验动物分组40只SPF级Wistar大鼠被随机分成以下5组：袖状胃切除术附加改良肠旁路组(SGMJIB)8只；SGMJIB术的假手术组（Sham-SGMJIB）8只，MJIB组8只，MJIB术的假手术组（Sham-MJIB）8只，空白对照组（Control）8只。（2）手术模型的建立SGMJIB组的手术方法：游离胃底及胃大弯侧，距离幽门约5mm处起，用2把无损伤血管钳沿胃大弯侧相向钳夹，确定切除线，沿大弯侧切除包括大部分胃底在内的约70~80%的胃组织，断端消毒后连续全层内翻缝合。在Treitz韧带下25cm处的空肠近端选择与距离回盲部25cm空肠行端侧吻合。MJIB组的手术方法：在Treitz韧带下25cm处切开，近端选择与距离回盲部25cm空肠行端侧吻合。假手术组分别为：Sham-SGMJIB组、Sham-MJIB组，其手术方法为：于各手术组相应的解剖位点做原位胃肠切开缝合术。必要时，延长手术时间，以产生与手术组同等程度的麻醉及手术影响。（3）一般情况的观察记录手术成功率、术后成活率、每周的体质量变化及大鼠术后的一般情况、并发症。（4）血液标本的检测术前及术后4周、12周采取血液标本用全自动生化分析仪测定谷丙转氨酶(ALT)、谷草转氨酶(AST)、肌酐(Cr)、尿素(Urea)、白蛋白(Alb)、总蛋白(TP)等血生化指标。（5）组织标本的采取和处理术后12周采血后处死大鼠，取其肝脏、胃、手术后肠道进行大体的形态学观察，肝脏湿重称量（用于计算肝脏脏器系数），然后部分取材立即放入-80度冰箱冻存，另取部分肝脏标本浸入4%的多聚甲醛溶液中，分别采取皮胃、腺胃组织及肠道手术吻合口近端5cm（近段）、远端5cm（远段）、旷置端5cm（旷置段）肠管各1cm浸入甲醛固定，对胃、肠、肝脏组织标本进行石蜡包埋后切片，常规HE染色。（6）胃肠道的组织的镜下观察和显微测量在显微镜下对SGMJIB组、Sham-SGMJIB组与Control组皮胃、腺胃、近段、远段、旷置段的肠管黏膜HE染色切片进行观察，对皮胃的黏膜及黏膜下层厚度、肠道黏膜近段、远段、旷置段的的绒毛高度、腺窝深度、黏膜厚度进行显微测量，对测量数据分别进行统计学处理，比较其形态的显微计量学变化；（7）肝脏组织的Masson染色及CYP2E1的表达情况石蜡包埋后的肝脏组织切片行Masson染色，CYP2E1抗体免疫组化染色；冻存肝脏组织制作冰冻切片CYP2E1抗体免疫荧光染色；另取部分冻存肝脏组织行CYP2E1抗体的Western Blot检测。结果：（1） SGMJIB组和MJIB组的平均手术时间分别为72.2±9.64min、42.3±7.54min。SGMJIB手术模型的成功率为100%，术后Sham-MJIB组因采血中麻醉意外死亡1只，至实验结束大鼠存活率97.5%。SGMJIB组术后2只大鼠术后3天内有腹泻，自行恢复，各组大鼠除禁食、采血、手术干预时的时间外，其精神反应、行为活动、皮毛的色泽及粪便均未发现明确异常。SGMJIB组大鼠术后12周内体质量增长较慢，术后4周才恢复术前体质量，在各术后时间点的体质量均明显低于Sham-SGMJIB组与Control组，差异具有显著的统计学意义（P<0.01）；同时术后3周起以后的各时间点体质量均低于MJIB组，差异具有统计学意义（P <0.05）。（2）各组大鼠手术前与术后4周、12周采集血标本检测发现，ALT、AST、Cr、Urea、TP、Alb在SGMJIB组和MJIB组与其对应的Sham组、Control组之间虽存在着不同程度的差异，但其差异无统计学意义（P>0.05）；（3）术后肝脏大体形态学观察，与其对应的Sham组和Control组比较，SGMJIB组和MJIB组肝脏大体形态除颜色略深外无明显差异，肝脏脏器系数与对应Sham组Control组差异无统计学意义（P>0.05）；胃组织大体观察SGMJIB组大鼠大体显示的残留皮胃的弹性下降，皱襞变浅，镜下形态皮胃黏膜、黏膜肌层较Sham-SGMJIB组与Control组变薄（P <0.05），黏膜肌层下组织较疏松。SGMJIB组和Sham-SGMJIB组腺胃的镜下可见局部黏膜下有炎性细胞浸润，SGMJIB组腺胃胃小凹的加深和延长、固有层内腺体扩张，部分可见胃内黏膜下炎症灶（淋巴细胞、浆细胞、嗜中性粒细胞），黏膜肌层厚度与正常组和假手术组接近，无肠道化生的改变。SGMJIB组的吻合口近段和远段的肠绒毛高度、腺窝深度及黏膜厚度均较Sham组和Control组明显增加（P<0.01），而旷置段的组织学改变则相反，呈萎缩性变化，与近段、远段差异明显（P<0.01）。SGMJIB组内比较显示：远段和近段的肠绒毛高度、腺窝深度及黏膜厚度较旷置段明显增加（P<0.01），且远段的增加较近段更加明显（P<0.01）。（4）肝脏切片镜下HE及Masson染色观察，SGMJIB组和MJIB组除偶见点状坏死灶，少量炎性细胞浸润外，无明显局灶性坏死，无肝细胞脂肪变性，胶原纤维显色无明显增加，无明显的纤维化改变，而在Sham-SGMJIB组、Sham-MJIB组和Control组未发现明显的病理形态学变化。肝脏组织切片CYP2E1抗体免疫组化结果显示：SGMJIB组和MJIB组与其对应Sham组、Control组比较，均可见中央静脉（腺泡III区）周围2~3层细胞少量表达，腺泡Ⅱ区及Ⅰ区无明显表达；在不同的肝组织内，CYP2E1表达强度及分布略有差异，各组之间CYP2E1抗体的组化表达按照Tsutsumi方法和常用的评分标准进行计分后比较，组间差异无统计学意义（P>0.05）；CYP2E1抗体在冰冻肝脏组织切片中的免疫荧光染色结果提示：肝脏细胞的CYP2E1抗体主要表达于肝细胞胞浆中，胞核内未见其表达，表达主要集中在腺泡III区，各组之间荧光强度灰度值之间比较差异无统计学意义（P>0.05）。CYP2E1抗体肝脏Western Blot检测发现，SGMJIB组较Control组表达量增多，但其表达量与Sham组、Control组差异均无统计学意义（P>0.05），各组CYP2E1的相对表达量之间亦无显著性差异（P>0.05）。结论：Wistar大鼠SGMJIB模型简单经济，相对稳定安全；对大鼠模型的观察和检测发现，术后大鼠虽然体重降低，但能通过胃肠道的代偿性调节保证其营养和电解质的稳定，术后肝脏无明显的功能及组织学损害的表现，SGMJIB大鼠模型在术后12周的观察期内安全性较好。目的：探讨袖状切除附加改良空回肠旁路术（Sleeve Gastrectomy and ModifiedJejunoileal Bypass，SGMJIB）对病态性肥胖症患者术后的减重和对其伴发病的疗效，并了解手术的安全性。方法：对2009年3月至2011年7月对华中科技大学同济医学院附属同济医院整形美容外科行SGMJIB治疗的7例病态性肥胖症伴有多种合并症的患者进行随访评估。收集所有病例的一般资料、手术时间、住院时间、体重评估相关指标（体重、身高、BMI、EWL%）、空腹血糖、血清甘油三脂、总胆固醇、尿酸值、伴发病的手术前后检查结果、术后并发症等相关资料和数据。计数资料以百分率表示。计量资料以x±s表示，组间比较采用SPSS20.0统计软件进行配对t检验。结果：7例患者常规开腹行SGMJIB手术，手术时间为280.29±80.59min，术后住院时间18.57±4.69d。术后随访10～39(27.13±11.33)个月，多余体重减少百分比（PercentExcess Weight Loss，%EWL）为53.15±19.18％；术后4例患者的血压或血糖异常恢复了正常，缓解率100%；7例患者中高脂血症2例恢复正常，4例有改善，1例变化不明显，总有效率85.7%；脂肪肝4例好转，3例术后变化不明显，有效率57.1%；高尿酸血症术后2例恢复正常，1例明显好转，总有效率100%；术后4例睡眠呼吸综合症患者中3例症状消失，1例明显减轻，睡眠质量明显改善；1例女性患者术后月经趋于正常，顺利怀孕产子；1例男性患者术后性生活质量得到明显改善。本组病例未发生出血、吻合口瘘、吻合口狭窄等手术相关并发症。其中1例患者切口局部脂肪液化、切口局部裂开，经换药后缝合。3例患者手术1年后体重轻微反弹，部分患者自诉术后排气增加，早期患者进食过快会诱发呕吐，无明显腹泻的发生，随访期内无严重并发症发生。结论： SGMJIB手术1年后患者的EWL%为53.15±19.18％，达到了良好的减重的疗效，减重效果较满意，SGMJIB手术对肥胖合并症的有效率多在85%以上，疗效较好；SGMJIB术后未出现贫血、严重的低蛋白血症等营养不良和肝肾功能不全的情况，切口裂开1例，并发症轻，无腹泻等肠道菌群紊乱的表现，随访期内安全性较好，但目前病例偏少，值得进一步研究。更多还原

【Abstract】 Objectives: To establish the Sleeve Gastrectomy plus Modified Jejunoileal Bypass inWistar rat model and to explore its safety.Methods:（1） Groups:40Specific pathogen Free (SPF)Wistar rats were randomly divided into5groups: the Sleeve Gastrectomy plus Modified Jejunoileal Bypass group(SGMJIB,n=8); Sham group of SGMJIB (Sham-SGMJIB, n=8), MJIB group(MJIB, n=8);Sham group of MJIB (Sham-MJIB, n=8), control group (Control, n=8).（2） Operative model:The procedures of SGMJIB: The tissue from5mm above thepyloric to the gastric fundus was freed, the2microvascular clamp along the greatercurvature of stomach side opposite clamp to determine the resection line, about70%~80%volume of the stomach was resected, including most of the fundalportion. The incision was disinfected and then Continuous full-thickness incisioninverting suture, and end to side anastomosis of the part of jejunum (25cm from theligament of Treitz) to the ileum25cm proximal to the cecum was thenimplemented. The procedure of MJIB: only end to side anastomosis of the part of jejunum (25cmfrom the ligament of Treitz) to the ileum25cm proximal to the cecum.The procedures of Sham-SGMJIB, Sham-MJIB: Sham operations involved thesame abdominal incisions, transections and re-anastomosis of the gastrointetinaltract at corresponding sites were performed in SGMJIB and MJIB Groups. andSham operation durations were prolonged to achieve similar operating timesanesthetic influence as those casted on SGMJIB and MJIB.（3） Post-operative observation：The success rate, survival rate, weekly changes of thebody weight, general condition of the rats and postoperative complications wererecorded.（4） Analysis of blood samples：Blood samples were collected from Ophthalmic veinat the time points of preoperative and postoperative4,12weeks and then wereanalyzed by the Automatic biochemical analyzer and the parameters include thelevels of the blood biochemistry included alanine aminotransferase(ALT), aspartateaminotransferase(AST), creatinine(Cr), urea, albumin(ALB) and total protein(TP).（5） Tissue samples collection：the rats were sacrificed after blood collection in12weeks, morphology of the liver, stomach, post-operative intestinal were observedand then tissue samples were taken, after liver wet weighing, liver organ coefficientwas calculated, then one piece of every liver samples was frozen immediately inthe-80degrees refrigerator, another piece of the liver samples were immersed in4%paraformaldehyde solution, The forestomach, glandular stomach tissue,Anastomosis proximal5cm (nearly segments), remote5cm (distal segments),exclusion side5cm (exclusion segments) bowel1cm of SGMJIB group,Sham-SGMJIB group and Control group were taken respectively and fixed informalin-solution, stomach, intestines, liver tissue samples were embedded inparaffin and sliced, followed by conventional HE staining.（6） Microscopic observation and measurement：HE staining slice of the forestomach, glandular stomach and the proximal, distal segment, the exclusion section of theintestinal mucosa in SGMJIB, Sham-SGMJIB and Control group were observedunder the microscope, the thickness of the mucosa and submucosa of theforestomach, villus height, crypt depth, mucosal thickness of intestinal mucosaproximal, distal, exclusion segment were microscopic measurement, data wascollected for statistical analysis, morphology micro-metrology change of tissuewere compaered between different groups.（7） Masson staining and CYP2E1staining of liver tissue： Masson staining andCYP2E1antibody immunohistochemical staining were performed inparaffin-embedded liver tissue; the production of antibody immunofluorescencestaining of CYP2E1was detected in frozen liver sections from the frozen tissuesamples; CYP2E1antibody was detected by Western Blot in another part of thefrozen liver tissue.Results:（1） The average operating time of SGMJIB group and MJIB group were72.2±9.64min and42.3±7.54min. Surgery success rate was100%in SGMJIB model, a rat inSham-MJIB group died of anesthesia before blood collection, The survival rate ofoperative rats was97.5%untill the end of the experiment.2rats diarrhea withinpostoperative3days in SGMJIB group which recovered by itself, except for thetimes when rats from each group in addition to the duration of fasting, bloodcollection, surgical intervention, the spirit of reaction, behavior, fur color and feceswere not found abnormal. During12weeks rats in SGMJIB group weight gainslowed down, which regained the preoperative body weight postoperative4weeks,body weight were significantly lower than Sham-SGMJIB group and Control groupin all postoperative time points, the difference was statistically significant (P<0.01); starting postoperative week3, each time point afterwards body weight werelower than MJIB group, have significant difference (P <0.05). （2） collecting blood samples from Rats in each group before surgery and after4weeks,12weeks were examined and been found that ALT, AST, Cr, Urea, TP, Alb werevarying degrees of difference between the surgery group, Sham group and Controlgroup, but there was not any statistically significance (P>0.05).（3） When compared with corresponding Sham group and Control group Postoperativeliver gross morphology comparison, SGMJIB group and MJIB group had nosignificant difference in addition to slightly daker color, the liver organ coefficienthad no significant difference (P>0.05). The residual forestomach of SGMJIB ratsdisplay with decreased elasticity, wrinkle reduction, the microscopic morphologyrevealed that compared with the Sham-SGMJIB group and Control group, mucosaand muscularis mucosa of the forestomach in SGMJIB group thinning(P <0.05),tissue became loose under the layer of mucosal muscle layer. The glandularstomach in SGMJIB group and Sham-SGMJIB group presented inflammatory cellinfiltration in local submucosal under the microscope, the gastric pits deepened andelongated, glands in the lamina propria expanded, partially visible gastric mucosalinflammatory foci (lymphocytes, plasma cells, neutrophils)were observed inSGMJIB group, no intestinal metaplasia change. villus height, crypt depth andmucosal thickness of the anastomosis stoma proximal and distal intestinal in theSGMJIB group increased significantly (P <0.01) as oppose to those in thecorresponding Sham group and Control group, histological changes of theexclusion segment in SGMJIB group were atrophic, organizational compensatorychanged significantly (P<0.01). The comparison within SGMJIB groups: villusheight, crypt depth and mucosal thickness of the distal and proximal intestinal thanthe exclusion segment increased significantly (P<0.01), and compensatory changesin distal was more obviously than distal segment (P <0.01).（4） Liver sections were HE and Masson staining and observed under the microscopic,in addition to occasionally spotty necrosis foci, a small amount of inflammatory cell infiltration, no obvious focal necrosis, no liver steatosis, collagen fiberschromogenic increase, no significant fibrosis in SGMJIB group and MJIB group,and there was no obvious morphological changes be found in Sham-SGMJIB group,Sham-MJIB group and Control group. CYP2E1antibody immunohistochemistry inliver tissue slices and results showed that: there can be seen around the central vein(acinar zone III)2-3layers of cells positive express a small amount, there was noobvious expression in acinar zone II and zone I, meanwhile, CYP2E1expressionintensity and distribution had a slight difference in different liver tissue slices fromdifferent groups. CYP2E1antibodies were expressed among the groups accordingto Tsutsumi’s method and the common scoring criteria to quantify, the differencebetween the groups was not statistically significant (P>0.05); frozen liver sliceswere stained by CYP2E1antibody immunofluorescence which showed: CYP2E1antibody was mainly expressed in the cytoplasm of hepatocytes, no expression inthe nucleus, expressed mainly in the acinar zone III. fluorescence intensitydifference between different group were slightly, the difference was no significantstatistically(P>0.05). CYP2E1antibody detected by Western Blot in different liversections showed that expression levels in the SGMJIB group increased slightlythan the Control group, and its expression level’s difference was not significantstatistically with Sham group and Control group (P>0.05), the difference of theCYP2E1antibody’s the relative expression level between different group was nosignificant statistically (P>0.05).Conclusions: SGMJIB Wistar rats model was easy to perform and economical, relativelysafe; the results from this model showed postoperative body weight of rats in SGMJIBgroup were significantly lower, but subjects’ nutrition and relative metabolisms were notaffected.. This is due to the compensatory structural change of the gastrointestinal tract,Postoperative liver showed no signs of compromised structural hence the safety ofSGMJIB rat model was better during the postoperative12weeks. Objectives：To investigate efficacy of the Sleeve Gastrectomy plus Modified JejunoilealBypass (SGMJIB) on weight loss, commorbidities and its safety.Methods：7morbidly obese patients associated with commorbidities admitted in the Plasticand Reconstructive Surgery of Tongji Hospital, Tongji Medical College of HuazhongUniversity of Science and Technology and underwent SGMJIB in Our department betweenMarch2009and July2011were followed-up and assessed．We collected data from all casesincluded general information, operative time, hospital-stay, Weight assessment relatedindex(weight, height, BMI and%EWL), fasting blood glucose(FBG), serumtriglycerides(TG), total cholesterol(TC), uric acid, Assessment pre-and post-operativeexamination results with the Comorbidity, postoperative complications and other relatedinformation and data. Count data expressed as a percentage. Measurement data tox±s,data processing Paired t-test and the Dunnett t-test (two-sided) using SPSS20.0statisticalsoftware.Results:7patients with conventional open SGMJIB operation, The mean operative timewas (280.29±80.59) min, Follow-up ranged from10~39（mean27.13±11.33months），the mean postoperative length of stay was(18.57±4.69)d.%EWL was53.15±19.18%;Blood pressure or abnormal blood glucose levels returned to normal in4cases, theremission rate of100%; hyperlipidemia in two cases of7patients returned to normal,4cases had improved,1cases did not change significantly, the total effective rate was85.7%;fatty liver in4cases were improved,3cases did not change significantly, the total effectiverate was57.1%; high uric acid hyperlipidemia2cases returned to normal,1case improved markedly, the total effective rate was100%; The symptoms relieved three cases among4cases with sleep apnea syndrome, sleep quality improved significantly; menstrual of1female patients become normal, uneventful pregnancy give birth; postoperative quality ofsex life of1male patient had been significantly improved. Bleeding, anastomotic leakage,anastomotic stenosis, surgery-related complications had not occured in the group ofpatients.1case of the group occurred fat liquefaction and dehiscence whica local incisionwas sutured after routine dressing. weight of3patients rebound slightly postoperative1year, Several patients complained of increased flatus and eating too fast can inducevomiting in the early postoperative. no significant occurrence of diarrhea, no seriouscomplications.Conclusions： The EWL%of the postopetive1year in the SGMJIB patients was53.15±19.18%which had been achieved a good weight loss efficacy, the effect of weightloss is more satisfactory, SGMJIB achieved better effect, efficiency of most obesitycomorbidities was more than85%. wound dehiscence in1case.complications includedpostoperative anemia,severe hypoalbuminemia, malnutrition and liver and kidneydysfunction, diarrhea and other intestinal flora disturbance syndromes were not occurred inthe follow-up period, the security of SGMJIB is better in the term, but cases in the groupwas too few, need to further study.更多还原