1. Journal Club 埼玉医科大学 総合医療センター 内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田 昌文 Matsuda, Masafumi 2009 年８月６日 8:30-8:55 ８階 医局 Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, King WC, Wahed AS, Berk P, Chapman W, Pories W, Courcoulas A, McCloskey C, Mitchell J, Patterson E, Pomp A, Staten MA, Yanovski SZ, Thirlby R, Wolfe B. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009 Jul 30;361(5):445-54. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009 Jul;91(7):1621-9.

2. 減量手術 245 件 （内訳） 腹腔鏡下胃バイパス手 術 143 件 腹腔鏡下袖状胃切除術 58 件 ラップバンド手術 17 件 腹腔鏡下 BPD/DS 27 件 その他 胃内バルーン挿入術 7件7件 Laparoscopic Roux en Y Gastric Bypass: LRYGB Laparoscopic Gastric Banding BIB Before After Dr. Kasama

3. 胃バイパス術バンディング術減量手術全体 超過体重減少率 1 ） 61.60%47.50%61.20% 平均体重減少ｋｇ 1 ） 43.5kg28.6kg39.7kg 術死率 1 ） 0.50%0.10% 術後合併症率 2 ） 7.90%7.20% 再手術率 2 ） 1.10%5.30% 満足しない減量の率 2 ） 1.00%13.00% 糖尿病治癒率／改善率 1 ） 83.7% / 93.2%47.9% / 80.8%76.8% / 86.0% 高血圧治癒率／改善率 1 ） 67.5% / 87.2%43.2% / 70.8%61.7% / 78.5% 高脂血症改善率 1 ） 96.90%58.90%79.30% 睡眠時無呼吸改善率 1 ） 94.80%68%83.60% 1) Bariatric surgery: a systematic review and meta-analysis. Buchwald H, Avidor Y, Braunwald E et al: JAMA. 2004 14:1724-37 2) Brazil Sao Paulo Gastro Obeso Center での同一スタッフによる腹腔鏡下胃バイパス 術 :2012 人、腹腔鏡下バンディング術 1174 人の検討（ 2005 年 IFSO 発表）

4. The LABS writing group assumes responsibility for the content of this article. Members of the LABS writing group are listed in the Appendix. Address reprint requests to Dr. David R. Flum at the Surgical Outcomes Research Center, Department of Surgery, University of Washington N Engl J Med 2009;361:445-54.

5. BACKGROUND To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization.

6. METHODS We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery.

12. RESULTS There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body- mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not.

13. CONCLUSIONS The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)

14. bariatric surgery is no more dangerous than "having a gall bladder out, a hip replaced, or most other major operations. Last year, at least 220,000 obesity surgeries were done in the US it is a sobering fact that some obese young adults may lose up to 20 years of life expectancy if they do not reduce their weight. the weight of the evidence indicates that bariatric surgery is safe, effective, and affordable VIEW

15. Message １．肥満度の指標である BMI （＝体重 kg÷ 身長 m の２ 乗）が 32 以上で、糖尿病またはそれ以外の 2 つ合 併症をもつ方（身長 160cm で 82kg 以上） ２． BMI が 37 以上の方（身長 160cm で 95kg 以上） ※ 上記の適応を満たす方で、内科的治療が効果がな かった方 楽をしてやせるための手術ではなく、患者様の命を守 るための手術であることを十分に理解することで す ■ 四谷メディカルキューブ 減量外科 笠間和典先生 http://wwwmcube.jp/ 〒 102-0084 東京都千代田区二番町 7 番 7 http://wwwmcube.jp/

17. Investigation performed at Duke University Medical Center, Durham, North Carolina

18. Background As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital perioperative complications following lower extremity total joint arthroplasty.

19. METHODS From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-1 and Type-2 diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities.

24. RESULTS Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001).

25. CONCLUSIONS Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.

26. Message 病棟血糖管理マニュアルを活用しよう