新加坡国立大学卫生系统Asim Shabbir团队研究了代谢-减肥手术与成人糖尿病患者和非糖尿病患者长期生存率的相关性。2021年5月6日，该研究发表在《柳叶刀》杂志上。
代谢-减肥手术可显著减轻体重，并可使肥胖相关风险和并发症得到缓解或改善。然而，该术式对长期死亡率和预期寿命的影响仍需更为稳健的估计，尤其是根据既往糖尿病状况进行分层，以指导政策和促进患者咨询。研究组比较了接受代谢-减肥手术和常规治疗的严重肥胖患者的长期生存结局。
研究组使用前瞻性对照试验和高质量匹配队列研究重建患者生存数据，进行了一项预先指定的单阶段荟萃分析。研究组在PubMed、Scopus和MEDLINE等大型数据库中检索从建库到2021年2月3日，关于代谢减肥手术与非手术治疗肥胖后的全因死亡率的随机试验、前瞻性对照研究和配对队列研究。
在确定的1470篇文章中，16篇配对队列研究和1篇前瞻性对照试验被纳入分析。在120万患者-年中，共有7712人死亡。研究共纳入174772名受试者，与常规治疗相比，代谢-减肥手术将死亡风险降低了49.2%，平均预期寿命延长6.1年。在亚组分析中，有或无基线糖尿病且接受代谢减肥手术的患者全因死亡率较低，但对于糖尿病患者来说治疗效果更明显。
代谢-减肥手术组糖尿病患者的平均预期寿命比非手术组延长9.3年，而无糖尿病患者的平均预期寿命则延长5.1年。在10年的时间跨度内，为防止增加1例患者死亡，需要治疗8.4名糖尿病成人患者，或治疗29.8名非糖尿病患者。胃分流术、环扎术和袖状胃切除术的治疗效果似乎没有差异。根据该分析结果，研究组估计，在全球患和不患有糖尿病的代谢性肥胖病候选人群中，每增加1.0%的代谢性肥胖病手术率，可分别产生510万和660万潜在生命年。
研究结果表明，对于患有肥胖症的成年人，代谢性减肥手术与通常的肥胖症治疗相比，能显著降低全因死亡率和延长预期寿命。糖尿病患者的生存获益显著大于没有糖尿病的人群。
附：英文原文
Title: Association of metabolic–bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174772 participants
Author: Nicholas L Syn, David E Cummings, Louis Z Wang, Daryl J Lin, Joseph J Zhao, Marie Loh, Zong Jie Koh, Claire Alexandra Chew, Ying Ern Loo, Bee Choo Tai, Guowei Kim, Jimmy Bok-Yan So, Lee M Kaplan, John B Dixon, Asim Shabbir
Issue&Volume: 2021-05-06
Abstract:
Background
Metabolic–bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy—especially stratified by pre-existing diabetes status—are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic–bariatric surgery versus usual care.
Methods
We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic–bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic–bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.
Findings
Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174772 participants, metabolic–bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3–51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2–6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370–0·453, p<0·0001) or without (0·704, 0·588–0·843, p<0·0001) baseline diabetes who underwent metabolic–bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I2 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1–11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0–9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8–9·1) for adults with diabetes and 29·8 (21·2–56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I2 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic–bariatric surgery utilisation rates among the global pool of metabolic–bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.
Interpretation
Among adults with obesity, metabolic–bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.
DOI: 10.1016/S0140-6736(21)00591-2
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00591-2/fulltext
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本期文章：《柳叶刀》：Online/在线发表
