| Background:Obesity has been associated with an increased hazard ratio for many chronic diseases(type 2 diabetes mellitus,cardiovascular and cerebrovascular events and many cancers)and all-cause mortality.The first-line therapy is the modification of dietary habits and physical activity but this strategy has limited success in the mid/long term.Nonsurgical management can effectively induce 5%-10%weight loss and improve health.However,bariatric surgery(BS)is the only therapy associated with sustainable weight loss and with prevention of obesity-related complications in severe obese patients.The increasing amount of evidence on the benefits of BS has contributed to increased popularity of the procedure over the last decade.However,for an obese patient,the risks of BS can be significant and need to be considered.Some of these risks include long-term nutritional,surgical,and psychological complications,the risk of weight regain,and the recurrence of associated comorbidities.The potential severity of these conditions justifies an adequate life-long medical follow-up.In 2008?Peking Union Medical College Hospital took the lead in establishing a multi-disciplinary team(MDT)to manage patients undergoing BS.However,the management of BS in China is still in the exploratory stage.There is a lack of knowledge on the more adequate protocols for perioperative management and long-term follow-up after BS,which has led to a very high rate of loss to follow-up.The incidence of long-term complications after BS are high and serious,which seriously affects the quality of life of patients.Objective:To study the multidisciplinary comprehensive diagnosis and treatment model of obesity and the feasibility of implementation in medical institutions;to explore the key points of successful implementation of medical institutions based on retrospective cohort study and improve the comprehensive diagnosis and treatment model;to construct a comprehensive nutritional management system for the whole process of BS for severe obese patients,and to preliminarily evaluate the effectiveness.Methods:Part I.The WeChat group of experts in the multidisciplinary team of weight loss of Peking Union Medical College Hospital was established,and a green channel for preoperative MDT assessment and perioperative management was constructed.A mutual help group for patients with BS was built,and a postoperative network remote+outpatient face-to-face follow-up system was established.The first expert consensus on nutrition and multidisciplinary management in China was formed.The multidisciplinary comprehensive diagnosis and treatment model of obesity was tried out in outpatient clinic of our hospital,and the obesity patients were analyzed and evaluated,and the feasibility of the system in medical institutions was evaluated.We conducted a multidisciplinary comprehensive diagnosis and treatment model for obesity in outpatient clinic,and analyzed and evaluated the obeses patients who were diagnosed and treated,and evaluated the feasibility of implementing the system in medical institutions.Part Ⅱ.A retrospective cohort study was conducted to investigate the long-term effectiveness of laparoscopic adjustable gastric band(LAGB)and laparoscopic Sleeve Gastrectomy(LSG)for weight loss and remission rate of obesity-related comorbidities in our hospital from September 2009 to August 2016.At the same time,the occurrence of perioperative and postoperative long-term complications were evaluated,and the key points affecting the effect of weight loss after operation were analyzed.Measures that could be revised or corrected were explored to improve the workflow of the model.Part Ⅲ.All patients receiving LSG in our hospital from September 2016 to now were prospectively and continuously enrolled.Patient management was carried out according to the model:strict outpatient multidisciplinary evaluation and intervention,perioperative management and education,regular online and offline follow-up after operation.The efficiency of follow-up and weight loss of patients after operation under the new management model was evaluated,the common problems were summarized and the workflow was optimized,and the advantages of this model in the management of patients undergoing BS were explored.Results:A multidisciplinary management pathway and a patient-centered long-term follow-up system for obese and BS patients in our hospital were established.A total of 1441 overweight/obese patients were assessed and treated in outpatient clinics for the first time.439 patients(30.5%)were assessed as moderately and severely at risk.Among them,364 patients received medical nutrition intervention and/or medication,and 87 patients entered the BS process.Part Ⅰ.Among 364 obese patients at moderate and severe risk,the average age was(33.0±8.4)years old,males accounted for 33.2%,and the average BMI was(34.5±7.8)kg/m2.The BMI of male was significantly higher than that of female(37.8 vs 33.1,P=0.000).The most common obesity-related metabolic disorders were:hyperinsulinemia(FinS)73.2%,elevated ALT 32.4%,dyslipidemia 31.7%,hypertension(HTN)20.4%,type 2 diabetes(T2DM)18.5%.Among them,elevated ALT,HTN and T2DM were higher in males than in females.The proportion of micronutrient deficiency was higher:low serum iron(SI)and serum ferritin(SF)were 21.6%and 27.4%,respectively,and women were significantly higher than men;Vit B12 overall deficiency rate(11.8%)was higher than folic acid deficiency rate(3.2%),there is no gender difference between the two groups.The actual measured resting metabolic rate(RMR)of obese people was significantly lower than the estimated RMR,especially in men(1928.0 vs 2215.6,P=0.000)kcal/d;there was no difference in average body fat between the two groups(31.6 vs 31.9 kg,P=0.619),but the percentage of body fat in men(33.1%)was significantly lower than that in women(41.8%,p=0.000).Significantly significant linear associations with hsCRP levels in obese patients were BMI(R=0.512,P=0.000)and FMI(R=0.531,P=0.000).Part Ⅱ.There were 76 patients completed BS,31 LAGB and 45 LSG.Postoperative compliance of the two groups was poor:13 patients in LAGB group were completely lost to follow-up,16 contacted by telephone,2 patients in out-patient clinic(weight regain to pre-operation,taking out the bandage and doing LSG at the same time);6 patients in LSG group were completely lost to follow-up,31 contacted by telephone,and 8 patients in out-patient clinic were still regularly followed up.There were 10 male patients in LAGB group,mean age(29.4±7.1)years,mean BMI(44.4±7.2)kg/m2;21 male patients in LSG group,mean age(29.4±7.3)years,mean BMI(49.0±7.8)kg/m2.The maximum%EWL was 50±20.9 in 2-3 years after surgery and the success rate of weight loss(%EWL>50%)was 46.4%and 47.8%at 2 and 3 years after surgery.The median follow-up time of LSG group was 42 months(28-60 months).The maximum%EWL was 73.7±30.0 in 2 years after surgery and the success rate of weight loss was 77.3%and 74.4%in 1 and 2 years respectively.The long-term prominent problem of BS is weight regain.Only 27.8%of the patients who maintain%EWL>50%or TWL>20%in 5 years after LAGB and the recurrence rate of LSG was 11.8%5 years after operation.The independent correlative factors of weight loss failure or repetition were:preoperative OSA(OR=12.239,P＝0.019),higher hsCRP(OR=1.749,P＝0.009),poor postoperative compliance(OR=2.051,P=0.030)and lower 3 months%EWL(OR=0.165,P=0.044).Part Ⅲ.Prospective study included 61 patients with severe obesity who had undergone LSG without conversion to open surgery.The average BMI of 21 males was(45.6±5.6)kg/m2 and that of 40 females was(41.2±7.3)kg/m2.The common comorbidities were ALT abnormality,OSA and dyslipidemia,which were 39.3%(n=24),followed by T2DM(n=20,32.8%),hypertension(n=17,27.9%).The 2-year remission rates were 75.0%,58.3%,833%,75.0%and 58.3%,respectively.The average%EWL of 1 and 2 years after operation was 81.6±34.7 and 80.9±30.2,respectively.The proportion of successful weight loss(%EWL>50%)was 81.7%(n=49)and 81.0%(n=34),respectively.The levels of metabolic indicators and inflammatory factors improved significantly after operation.Micronutrients remained at a high level for a short time after operation,but with time prolonged,even with routine micronutrient supplementation,the risk of lack of micronutrients increased.The incidence of severe complications(Clavien-Dindo grade>grade Ⅱ)was 3.3%(1 male gastric leakage and 1 female gastroparesis).LSG is also effective in the treatment of obesity with BMI(>50 kg/m2),especially in the remission rate of complications.At present,the follow-up efficiency of this group is significantly higher than before,and its weight loss effect is better than that of previous LSG patients at all follow-up time points.Conclusions:It is feasible to give full play to the multidisciplinary comprehensive diagnosis and treatment model of obesity and to carry out the whole-course and long-term nutritional management of bariatric surgery,which will help to achieve better weight-loss results.HsCRP may be an important indicator for assessing the risk of obesity-related metabolic abnormalities and measuring the health benefits of weight loss. |
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