實(shí)施減肥手術(shù)后，肥胖癥病人在獲得體重大幅度降低的同時(shí)又將面臨皮膚松弛、下墜等新的問題，這在胸、腹、腰、臀甚至四肢組織部分都表現(xiàn)得十分突出，因此許多肥胖癥病人又將需要通過去脂整形手術(shù)解決這方面問題，本章我們重點(diǎn)介紹在胃腸減肥手術(shù)同時(shí)或后續(xù)進(jìn)行的去脂整形手術(shù)治療。

去脂整形術(shù)可分為脂肪切除術(shù)與吸脂整形術(shù)兩類，前者是將過多的脂肪皮膚組織切除，后者是將多余的脂肪吸出，可根據(jù)患者的情況選擇不同的手術(shù)方法，亦可將兩種方法結(jié)合起來運(yùn)用。隨著科學(xué)的進(jìn)步，人們對體型美觀要求的不斷提高，整形外科在去脂整形術(shù)方面也取得了理論和技術(shù)方面的進(jìn)展。

一、相關(guān)概念

1.腹部的淺筋膜　腹部淺筋膜較厚，由疏松結(jié)締組織和脂肪組織構(gòu)成。在臍以下，淺筋膜分為兩層，淺層為脂肪層，厚而富于脂肪，稱Camper筋膜，深層稱Scarpa筋膜，較致密，含彈性纖維，在中線處附著于腹白線。Illouz[273]認(rèn)為局部脂肪堆積主要是深層脂肪細(xì)胞肥大的結(jié)果；而Gasperoni等[274]則認(rèn)為深淺層脂肪細(xì)胞均有肥大。傳統(tǒng)上認(rèn)為吸脂手術(shù)應(yīng)主要去除深層脂肪[275]。現(xiàn)在認(rèn)為，深層脂肪在局部脂肪堆積和增加體重方面起著重要作用，而淺筋膜脂肪則在體型重塑方面起著重要作用。吸脂術(shù)要去除的是深層脂肪和淺層深部脂肪，保留淺層淺部的脂肪，這樣既可以去除皮下的大部分脂肪，又可使術(shù)后皮膚保持比較柔軟而有彈性。操作時(shí)將抽吸管插入淺層深部脂肪層“品”字孔向下吸取淺層深部脂肪同時(shí)通過淺層抽吸深層脂肪，一個(gè)部位抽吸完后再用手指捏皮膚檢查深層是否留有脂肪，如仍有脂肪，再將吸取管插入深層吸取深層深部的殘留脂肪。

2.腹壁的血供　隨著腹壁成形術(shù)的發(fā)展，學(xué)者們對腹部血供進(jìn)行了解剖學(xué)方面的深入研究，Huger將腹部血供分成3個(gè)區(qū)，l區(qū)由腹壁上動脈供應(yīng)，2區(qū)由下腹壁深、淺動脈供應(yīng)，3區(qū)由節(jié)段性的肋間血管供應(yīng)。基于這種對腹壁血供解剖研究方面的認(rèn)識，Alan Matarasso提出與手術(shù)聯(lián)合運(yùn)用時(shí)，將吸脂的程度和安全性分為4個(gè)分區(qū)，即可抽吸區(qū)、限制區(qū)、小心抽吸區(qū)、無限制區(qū)。周興亮等[276]于1991年首次提出吸脂相對禁區(qū)的概念，即在腹、臀、股三個(gè)部位，將各主要皮支血管的穿出點(diǎn)及其周圍區(qū)域劃為相對禁區(qū)，位于腹部正中線的兩側(cè)，相當(dāng)于腹直肌前鞘的縱行區(qū)域?yàn)楦共课南鄬麉^(qū)。

3.腹部美學(xué)標(biāo)準(zhǔn)　理想的腹部形態(tài)為扁平型，即腹部略微后收，下腹微隆，正中凹陷，腹直肌輪廓可見，臍周區(qū)亦略凹陷的形態(tài)。

4.腹部肥胖分型和治療方案　為了更好地塑造體形，減少并發(fā)癥，Bozo1a等[277]提出了以下腹部肥胖分型和治療方法（表10-1）。

二、去脂整形術(shù)的發(fā)展

1.皮膚脂肪切除術(shù)　最早的手術(shù)方法是僅切除腹壁皮膚和脂肪，包括以下兩種手術(shù)方式：

表10-1　腹部肥胖分型和治療方案

（1）多余脂肪皮膚切除術(shù)：女性肥胖癥往往表現(xiàn)在腹部、上臂、臀部、大腿等處的脂肪堆積過多，同時(shí)常會伴有不同程度的皮膚松垂。自20世紀(jì)初開始，國外許多醫(yī)生便設(shè)計(jì)各種形式的切口來切除多余的脂肪和收緊松垂的皮膚。進(jìn)入20世紀(jì)80年代，國內(nèi)也有醫(yī)生報(bào)道切除多余脂肪皮膚的減肥術(shù)，一直沿用至今。但因術(shù)中創(chuàng)傷大、出血量多及術(shù)后可能會出現(xiàn)切口愈合不良、皮膚部分壞死等問題，另外術(shù)后長期遺留較長和多條手術(shù)切口瘢痕影響美觀的問題，需要慎重選擇適應(yīng)證。

手術(shù)操作：沿設(shè)計(jì)切口切開皮膚達(dá)皮下脂肪層，一般在深筋膜上方，向兩側(cè)潛行分離，注意血管神經(jīng)走形方向，避免誤傷，必要時(shí)用電刀水平切開脂肪，有明顯出血點(diǎn)時(shí)電凝或結(jié)扎，掀起較多脂肪的一側(cè)皮膚形成皮瓣，保留皮下0.5～1.0cm脂肪層后切除多余脂肪，防止誤傷真皮下血管網(wǎng)，向?qū)?cè)牽拉皮瓣，切除多余皮膚部分后，對攏縫合皮下脂肪層、真皮下層，使皮膚在無過大張力下嚴(yán)密間斷縫合。

術(shù)后注意事項(xiàng)：皮瓣下留置負(fù)壓引流管1～3d，術(shù)區(qū)外敷棉墊彈力繃帶或腹帶確實(shí)地加壓包扎，不宜太緊（易造成壓迫血液循環(huán)或遠(yuǎn)端水腫），也不易太松（易造成淤血或皮下血腫），手術(shù)部位制動1周。

（2）腹部脂肪皮膚切除及腹壁肌筋膜緊縮術(shù)：中老年肥胖者，腹部脂肪堆積、皮膚松垂同時(shí)常伴有一定程度的腹壁腹直肌和筋膜松弛使腹腔內(nèi)容物易突出。所以在腹部臍下或臍略上以下做垂直形切口，若原有剖宮產(chǎn)刀瘢痕者更適宜此方法。在切開皮膚、切除兩側(cè)過多皮下脂肪和松弛皮膚的同時(shí)，將腹直肌前鞘暴露，在前鞘筋膜垂直切開，兩側(cè)略作游離后作縱向的橫行褥式折疊縫合，腹壁肌肉輕度松弛者可僅作部分腹直肌前鞘“8”字位攏縫合，以此可收緊腹壁肌肉層，達(dá)到更有效的收腹作用，也可更有效緩解皮瓣縫合后的皮膚張力。術(shù)后除進(jìn)行有效的彈力腹帶加壓包扎外，還需在兩周內(nèi)避免咳嗽和用力解大便，以防止腹直肌前鞘縫合線崩開。

（3）腹壁整形術(shù)：源于1890年法國的Demars和Mars進(jìn)行的腹壁整形術(shù)，其最早的方法是僅切除腹壁皮膚和脂肪，隨著整形外科醫(yī)生對手術(shù)方法的不斷改進(jìn)，逐漸形成了現(xiàn)代的腹壁整形術(shù)，主要包括以下步驟[278]：①皮膚切除，去除多余的脂肪和皮膚；②折襞術(shù)（plicate），將松弛的腹直肌前鞘折疊；③臍移位，將臍移到新的位置。這些方法有著明顯的缺點(diǎn)如：較長的手術(shù)瘢痕，皮膚感覺減退等。目前這種傳統(tǒng)的腹壁整形術(shù)的應(yīng)用已受到限制[279]。僅適用于皮膚重度松垂的患者，其主要并發(fā)癥有切口較大，遺留手術(shù)瘢痕、皮膚壞死、血腫、血清腫等。

20世紀(jì)80年代后期，皮膚脂肪切除術(shù)方面又有了新的發(fā)展：①迷你（mini）的概念：國外學(xué)者Wilkinson、Swartz和Greminger提出了迷你腹部成形術(shù)的概念，它與傳統(tǒng)腹部成形術(shù)的區(qū)別主要在于重點(diǎn)放在糾正下腹部的缺陷，適用于下腹部有多余的脂肪和皮膚，伴有臍下腹直肌的松弛，即可采用此法，此術(shù)式的優(yōu)點(diǎn)是創(chuàng)傷小，較短而隱蔽的切口，以“W”形，“U-M”形常用。切口位置一般在腹股溝上延伸到骸前上嵴內(nèi)2cm左右。②內(nèi)鏡：女性往往是腹膜外脂肪堆積，腹直肌松弛常與懷孕、肥胖和年齡相關(guān)；三四十歲的男性腹直肌松弛而皮膚卻不松弛，對于這種類型的腹部缺陷，是行內(nèi)鏡下腹部整形的主要指征。③并發(fā)癥的預(yù)防：術(shù)后血清腫，常見于腹部下方，表現(xiàn)為局部脹滿感，站立時(shí)局部膨隆明顯，或可觸及液體震蕩感。為使其發(fā)生率降至最低，術(shù)后患者均應(yīng)放置引流管，并在引流量<15ml后拔除。漸進(jìn)性張力縫合，不放置引流管，也可減少局部并發(fā)癥。

2.吸脂整形術(shù)　吸脂整形術(shù)到目前為止，共經(jīng)歷了單純機(jī)械性抽吸技術(shù)、腫脹技術(shù)、體內(nèi)超聲技術(shù)和體外超聲技術(shù)四個(gè)發(fā)展時(shí)期。

（1）單純機(jī)械性負(fù)壓吸脂術(shù)：最早可追溯到20世紀(jì)70年代初Schrud de用刮宮器借助負(fù)壓進(jìn)行脂肪刮吸術(shù)，此后意大利的兩兄弟Arped和Geoge Fisoher進(jìn)行了脂肪抽吸術(shù)，這些單純負(fù)壓吸脂手術(shù)機(jī)械性損傷大，術(shù)后出血、血腫及血清腫的發(fā)生率高，皮膚壞死的情況也時(shí)有發(fā)生。

（2）腫脹技術(shù)下的負(fù)壓吸脂術(shù)：現(xiàn)代吸脂的轉(zhuǎn)折點(diǎn)是1987年Klein[280]和Toledo[281]提出了在腫脹技術(shù)下行閉式吸脂術(shù)，即在抽吸區(qū)注入少量腎上腺素，大量低濃度的利多卡因，15～30min后再進(jìn)行脂肪抽吸，以使吸脂出血量和并發(fā)癥降至最低。腫脹技術(shù)由于低滲液的局部注射，壓迫血管使之閉合，吸脂術(shù)后滲血、出血的并發(fā)癥明顯減少，同時(shí)使該手術(shù)可以在門診局麻條件下操作，是較為安全的方法，但是存在費(fèi)時(shí)費(fèi)力的缺點(diǎn)。

1987年，Reployle[282]發(fā)明了皮下超量灌注濕性吸脂術(shù)，使吸脂術(shù)進(jìn)入了“低創(chuàng)去脂”時(shí)代。超量灌注鈍性吸脂是由腫脹技術(shù)衍生而來，根據(jù)患者情況、吸脂部位，在腫脹麻醉的基礎(chǔ)上聯(lián)合應(yīng)用硬膜外麻醉或全身麻醉。但應(yīng)注意把握“超量”的含義，即使用的利多卡因總量可超過我國藥典規(guī)定的安全范圍，最大可達(dá)35mg/kg，腫脹灌注液內(nèi)利多卡因濃度＜0.1g/L，腫脹吸脂術(shù)安全、有效而徹底[283-285]。但這是以低濃度配合使用腎上腺素及碳酸氫鈉為前提的。生理鹽水中加入碳酸氫鈉（每1 000ml灌注液加5～10ml），以減少注射時(shí)的刺激及疼痛，并且減少細(xì)胞外存留的離子化的利多卡因[286]，如果用乳酸林格液則不需用碳酸氫鈉。目前，對最大抽吸量達(dá)多少為安全尚未確定，但只要不盲目增加抽吸部位，控制利多卡因用量，注意觀察失血量，在一定范圍內(nèi)適當(dāng)增加抽吸量仍屬可行。此外，還應(yīng)注意體液平衡，以免發(fā)生水中毒和電解質(zhì)紊亂。三通連續(xù)注射器、彈簧加壓泵等器械的運(yùn)用縮短了腫脹液灌注的時(shí)間[287]。注液量與抽吸量比例一般在1.51∶～21∶，這將使失血量降至最低，占吸出總量的1%～5%[288]。

1992年Fischer設(shè)計(jì)出了站立位吸脂手術(shù)臺，并對站立位吸脂技術(shù)作了報(bào)道，對吸脂手術(shù)臺亦更新了三代。1996年，Botti描述了站立位檢查和手術(shù)的步驟。1999年Shuter[289]提出站立位吸脂才是真正的體型雕塑。此后國內(nèi)也有人嘗試坐位、屈膝半臥位吸脂，以提高吸脂效果。同時(shí)運(yùn)用細(xì)管吸脂使全身各處的抽吸成為可能，面頰、頭頸、手臂、腿部等部位的抽吸都起到了令人驚奇的效果。身體周緣的抽吸，如肋兩側(cè)、臀部等部位的抽吸更使腰圍縮小，體形更加令人滿意。

（3）超聲輔助負(fù)壓吸脂術(shù)：1992年，意大利的Zocchi[290]，首先報(bào)告了超聲輔助吸脂術(shù)，使吸脂術(shù)進(jìn)入了“微創(chuàng)去脂”的時(shí)代。超聲波是一種每分鐘振動2萬次以上的機(jī)械振動波，其在液體介質(zhì)中傳導(dǎo)可產(chǎn)生以下作用[291,292]。

①微機(jī)械作用：通過機(jī)械振動作用，使液體充分?jǐn)U散。

②熱作用：超聲波傳導(dǎo)過程中在通過不同的組織界面能量逐漸衰減，當(dāng)腫脹液被灌注于脂肪層后，脂肪層對超聲波能量的吸收增加，使超聲波達(dá)到更深組織的能量衰減，部分轉(zhuǎn)化為熱能。

③空泡效應(yīng)：超聲波在液體內(nèi)的傳導(dǎo)過程中，由于超聲的聲壓差可在瞬間“牽拉”水分子，產(chǎn)生“空泡”，然后瞬間再消失。足夠強(qiáng)度的超聲波能使脂肪細(xì)胞內(nèi)產(chǎn)生微腔，隨著超聲波的持續(xù)作用，微腔內(nèi)的氣體不斷膨脹，氣泡呈現(xiàn)一種機(jī)械共振，同時(shí)伴有小范圍液體流動，一方面產(chǎn)生剪切力破壞亞細(xì)胞結(jié)構(gòu)，另一方面細(xì)胞間的腫脹液發(fā)生振蕩使脂肪細(xì)胞連接疏松組織黏附力減弱。

超聲通過以上三種作用使注入到皮下的腫脹液均勻地?cái)U(kuò)散到皮下脂肪組織中，使脂肪組織腫脹疏松，組織間隙（脂肪與脂肪、脂肪與血管神經(jīng)組織間隙）增寬。脂肪組織變得疏松后，吸脂時(shí)小塊脂肪組織易于吸出。組織間隙增寬則可減少血管、神經(jīng)纖維的損傷，減少出血。超聲使得腫脹液均勻地?cái)U(kuò)散到脂肪組織中，充分達(dá)到了腫脹脂肪組織的目的。

由于體內(nèi)超聲技術(shù)中超聲頭需置于皮下，熱效應(yīng)不易控制，相對容易形成熱損傷的副作用，并且乳化作用較慢，操作時(shí)間過長，因此臨床應(yīng)用受到了限制。1998年體外吸脂開始應(yīng)用于臨床。體外超聲使用的超聲頻率比體內(nèi)超聲高1萬倍以上，使能量在腫脹組織中順利傳導(dǎo)，作用至離皮下數(shù)厘米范圍內(nèi)，故超聲作用更快更有效，皮溫升高不明顯，因此發(fā)生皮膚燒傷、皮下脂肪液化等并發(fā)癥的概率大大減少[293]；同時(shí)，體外超聲與體內(nèi)超聲[294]相比，吸出的脂肪量較大，效果更為明顯。而且體外超聲具有其獨(dú)特的皮膚收縮作用，使術(shù)后皮膚彈性回縮快，皮膚術(shù)后的皺折不明顯。目前廣泛認(rèn)為體外超聲吸脂安全、有效、損傷小。體外超聲可以最快速度使脂肪乳化，又術(shù)后并發(fā)癥出現(xiàn)最少，體內(nèi)超聲次之、單純法則最多[294-297]。

總之，超聲吸脂技術(shù)與傳統(tǒng)吸脂術(shù)相比有更多優(yōu)點(diǎn)[295]：①選擇性破壞脂肪細(xì)胞，而細(xì)胞周圍的血管、神經(jīng)、淋巴管可以完整的保留；②僅去除脂肪細(xì)胞的液體成分，而高密度的固體成分留在原位，吸后皮膚十分平坦；③超聲波特有的皮膚收縮效應(yīng)，特別適用于皮膚較松弛的患者；④由于其選擇性作用，從而避免了傳統(tǒng)吸脂造成的出血、休克、脂肪栓塞，增加了手術(shù)安全性；⑤對于醫(yī)師來說省時(shí)、省力，對于患者來說創(chuàng)傷小、出血少、恢復(fù)快、皮膚平坦，患者易于接受。

（4）吸脂術(shù)與切脂術(shù)的結(jié)合：對于各種不同類型的腹壁缺陷可選擇不同的治療方法，對于Ⅱ、Ⅲ、Ⅳ、Ⅴ型缺陷的患者均可使用吸脂術(shù)與切脂術(shù)兩種方法相結(jié)合，進(jìn)一步提高治療效果，即所謂的“marriage”法[298,299]。

三、吸脂整形術(shù)的相關(guān)問題

1.吸脂整形術(shù)的適應(yīng)證和禁忌證

（1）適應(yīng)證：如果僅從整形外科體型重塑的角度來看，吸脂術(shù)并不能治療肥胖癥，因此手術(shù)的對象一般是健康者，普遍認(rèn)為是體重超出標(biāo)準(zhǔn)體重<30%。但如果我們從外科肥胖癥綜合治療的角度去考慮問題時(shí)，吸脂整形術(shù)或去脂整形術(shù)完全可以用作胃腸外科肥胖癥治療的輔助治療或后續(xù)治療的重要組成部分。因此我們不必將體重超出標(biāo)準(zhǔn)體重30%的肥胖癥患者排除在外。

（2）禁忌證：重大疾?。ㄈ缏宰枞苑渭膊?、缺血性心臟病、高血壓控制不良等），嚴(yán)重的全身性疾病等。對于體重超過標(biāo)準(zhǔn)體重30%、輕度糖尿病及皮膚松垂者，手術(shù)應(yīng)慎用。此外，患者應(yīng)有一種合理的期望值，并通過改變生活方式，包括飲食習(xí)慣和鍛煉來鞏固減肥手術(shù)及塑形手術(shù)的治療效果。

美國整形外科醫(yī)師協(xié)會為吸脂術(shù)制定了以下安全原則：①適應(yīng)證選擇恰當(dāng)：健康、超重＜30%標(biāo)準(zhǔn)體重；②使用腫脹技術(shù)；③密切監(jiān)測出入量（尿量、血壓、心電監(jiān)護(hù)），與麻醉師交流補(bǔ)液情況；④維持體液平衡：吸出量＜5L時(shí)，僅需輸入維持液體量；吸出量＞5L時(shí)，每超過1ml補(bǔ)充0.25ml晶體液；⑤吸出量＞5L時(shí)需留院觀察過夜；⑥全麻患者需使用正壓通氣裝置或術(shù)后持續(xù)延長全麻1h；⑦利多卡因劑量＜35mg/kg[301,302]。

2.吸脂整形術(shù)的并發(fā)癥　吸脂手術(shù)的并發(fā)癥由于缺乏統(tǒng)一的標(biāo)準(zhǔn)，故文獻(xiàn)報(bào)道差異較大，從不到0.1%到9.3%[300,303,304]，死亡率為0.002 6%～0.02%[301,304,305]，美國整形外科醫(yī)師協(xié)會于1998年統(tǒng)計(jì)了全美24 295個(gè)吸脂者并發(fā)癥發(fā)生率為0.66%[301]，其中較常見的并發(fā)癥為0.37%，重大并發(fā)癥的發(fā)生0.29%，其中死亡5例（0.02%），手術(shù)風(fēng)險(xiǎn)的增加與液體過量、超量脂肪吸出及手術(shù)操作不當(dāng)、本身健康不良有關(guān)。Teimourian[304]調(diào)查了美國皮膚科醫(yī)師協(xié)會自2001年8月～2002年10月共66 570例吸脂手術(shù)，嚴(yán)重并發(fā)癥為0.68%，經(jīng)分析，門診手術(shù)與住院手術(shù)相比并不增加并發(fā)癥的發(fā)生率。單純腫脹法吸脂較聯(lián)合靜脈麻醉或肌內(nèi)注射麻醉發(fā)生并發(fā)癥的概率低。國內(nèi)對吸脂術(shù)的并發(fā)癥報(bào)道極少，幾乎未見有嚴(yán)重并發(fā)癥的報(bào)道，而且國內(nèi)對吸脂術(shù)也缺乏嚴(yán)格的管理，難以作出客觀的統(tǒng)計(jì)。應(yīng)注意以下若干并發(fā)癥。

（1）感染：感染在吸脂術(shù)中并不多見，嚴(yán)格的手術(shù)器械消毒非常重要，Meyers等[306]曾報(bào)道了由于手術(shù)器械消毒不徹底，污染手術(shù)，致6個(gè)月內(nèi)的82例吸脂者中的34例（41%）出現(xiàn)皮膚脹腫，經(jīng)培養(yǎng)證實(shí)為分枝桿菌。在常規(guī)吸脂術(shù)時(shí)，一般只需口服廣譜抗生素3～5d，在大量吸脂或合并其他開放性手術(shù)時(shí)應(yīng)在術(shù)中術(shù)后預(yù)防性應(yīng)用頭孢類抗生素。感染發(fā)生時(shí)，須根據(jù)細(xì)菌培養(yǎng)及藥敏試驗(yàn)結(jié)果選擇抗生素，大部分致病菌為金黃色葡萄球菌。壞死性筋膜炎是外科急癥，致病菌為多種厭氧菌或溶血性鏈球菌，典型癥狀是體檢時(shí)發(fā)現(xiàn)術(shù)區(qū)的異常疼痛，必須在癥狀發(fā)現(xiàn)后的24～36h內(nèi)及時(shí)治療，可行外科擴(kuò)大清創(chuàng)，應(yīng)用大劑量抗生素及高壓氧治療[307]。

（2）血腫及血清腫：應(yīng)用腫脹技術(shù)，一般損傷大血管的可能性較小。曾有報(bào)道1例腰部吸脂術(shù)后出現(xiàn)低血容量性休克，經(jīng)血管造影證實(shí)雙側(cè)腰動脈損傷，行栓塞治療[303]。血清腫是最常見的并發(fā)癥，大部分發(fā)生在腹部，尤其是大量吸脂時(shí)，以超聲吸脂多見。術(shù)中控制超聲的使用時(shí)間及強(qiáng)度，應(yīng)用較細(xì)的抽吸管以及術(shù)后不要過早解除彈力加壓包扎，以避免血清腫的發(fā)生。治療采用多次抽吸或放置引流管，局部應(yīng)用海綿墊彈力加壓[303,307]。

（3）皮膚壞死：原因主要為抽吸平面過于淺表，皮下血管過度受損。應(yīng)用超聲時(shí)，要注意超聲的熱灼傷和對血管的損傷。熱損傷僅發(fā)生于超聲吸脂，應(yīng)注意兩個(gè)原則：①必須在皮下灌注后的濕潤環(huán)境下使用超聲；②超聲探頭不能固定于一個(gè)部位[307]。

（4）脂肪栓塞綜合征：大量脂肪栓塞于肺血管的最小分支，從而增加肺的灌注壓，導(dǎo)致右心衰竭，在單純吸脂術(shù)中并不多見，大部分發(fā)生在合并腹壁整形術(shù)及其他開放性手術(shù)時(shí)[307]。

（5）液體失衡：吸脂術(shù)最初采用的干性法由于創(chuàng)傷大，失血量大，已很少使用。Illouz采用的濕性法是指在治療部位先注射配制的低滲液體（1 000ml生理鹽水＋200ml蒸餾水＋10 000U透明質(zhì)酸酶＋60mg利多卡因），如為局麻，可加入1mg腎上腺素，在全麻下因應(yīng)用氟烷，禁用腎上腺素。Illouz稱之為水剝離法，水剝離使出血減少，更好地掌握組織層次，一般注入量與吸出量為11∶。Illouz認(rèn)為采用濕性法吸脂，避免一次抽吸過量脂肪，皮下灌注液適量，不易發(fā)生液體失衡[308,309]。20世紀(jì)80年代，Klein[310,311]的腫脹技術(shù)吸脂法和Fodor[301,312]等的超灌注法相繼在臨床應(yīng)用，在皮下注入含利多卡因和腎上腺素的等滲液體，使抽吸部位水腫堅(jiān)硬，然后進(jìn)行抽吸，不需全麻、硬膜外或者靜脈麻醉。腫脹法的皮下灌注量與吸出物的比例為31∶甚至更高，超灌注法為（1～2）1∶，皮下注射的大量等滲液體，防止了大量的血管內(nèi)外液體交換，同時(shí)稀釋的腎上腺素溶液大量浸潤，彌散到整個(gè)手術(shù)部位，產(chǎn)生完全的血管收縮，使出血量很少，一般失血量為吸出總量的1%[313]。手術(shù)方法及技術(shù)的改進(jìn)，使一次手術(shù)吸出大量皮下脂肪成為可能。腫脹法及超灌注法吸脂對吸出量的限制尚無報(bào)道，一般認(rèn)為吸出量>4～5L[311,303,307,313]時(shí)為大量脂肪抽吸，應(yīng)視為中等或較大手術(shù)，伴有較大程度的體液變動和心血管方面的諸多問題。Klein[310]認(rèn)為腫脹法吸脂時(shí)，大量灌注液會進(jìn)入血管內(nèi)，不需要靜脈補(bǔ)液，但維持靜脈通道還是必要的。研究表明大約70%的灌注液存留體內(nèi)，除了手術(shù)后滲出外，大量的液體經(jīng)血管吸收[301,313-315]。術(shù)中補(bǔ)液根據(jù)以下幾方面來決定：①補(bǔ)充術(shù)前缺水量，根據(jù)禁食時(shí)間長短而定；②維持液量：吸脂為中等創(chuàng)傷手術(shù)，輸液為每小時(shí)5～6ml/kg，可根據(jù)術(shù)中監(jiān)測血壓、心率、呼吸及尿量調(diào)整；③術(shù)中丟失：Trott認(rèn)為應(yīng)用超灌注技術(shù)時(shí)，在吸出總量超過4L時(shí)需補(bǔ)液，每超過1ml補(bǔ)充1ml晶體液[313]，而在美國整形外科醫(yī)師協(xié)會，認(rèn)為應(yīng)用腫脹技術(shù)，抽吸量＞5L時(shí)才需補(bǔ)充晶體液，每超過1ml補(bǔ)充0.25ml[301]。

（6）利多卡因及腎上腺素中毒：大量吸脂術(shù)中（吸出物＞5L時(shí)）伴有大量利多卡因的應(yīng)用。利多卡因做皮下浸潤麻醉時(shí)，總量＜400mg（7mg/kg體重），這并不適用于腫脹麻醉，Klein連續(xù)測定血漿濃度，發(fā)現(xiàn)吸脂時(shí)可降低利多卡因全身吸收的10%～30%，即相同比例的利多卡因通過吸脂排出體外，血清中利多卡因的峰值出現(xiàn)于皮下灌注后的12h，應(yīng)用劑量為35mg/kg時(shí)，患者血清中利多卡因濃度低于中毒劑量5μg/ml。腫脹麻醉效果持續(xù)18h[310,311]。Ostad[316]報(bào)道術(shù)中僅有1%～10%的利多卡因被吸出，使用利多卡因的安全劑量為76.7mg/kg。一般認(rèn)為，吸脂手術(shù)利多卡因的應(yīng)用總量應(yīng)限制在35mg/kg內(nèi)[301]。中毒早期表現(xiàn)包括：頭暈、倦怠、譫妄、口苦、口舌無味，這時(shí)血漿濃度為3～6μg/ml；達(dá)5～9μg/ml時(shí)，出現(xiàn)顫抖，肌肉顫動；當(dāng)＞10μg/ml時(shí)，出現(xiàn)抽搐，中樞神經(jīng)系統(tǒng)抑制及昏迷，最終導(dǎo)致呼吸抑制和心跳驟停。早期發(fā)現(xiàn)癥狀后，可采取保持氣道通暢增大肺通氣量，加強(qiáng)心肺支持，應(yīng)用地西泮提高中樞的耐受性[305]。

（7）腎上腺素和碳酸氫鈉：腎上腺素是腫脹液配方中的主要成分之一，它可使注射部位血管收縮，手術(shù)失血量大為減少，還可減緩利多卡因吸收，延長效應(yīng)，避免中毒反應(yīng)。這種延緩吸收的作用使更多的利多卡因通過吸脂同時(shí)被吸出[305]。Burk[317]認(rèn)為在利多卡因安全劑量的前提下，腎上腺素的安全劑量為10mg。但Matarasso[286]建議腎上腺素使用劑量為0.07mg/kg，一般濃度為11∶ 000 000到18∶ 000 000均有效。腎上腺素的血清峰值大約在注射后3h，可達(dá)生理值的4倍，到12h后恢復(fù)正常。在嗜鉻細(xì)胞瘤、甲狀腺功能亢進(jìn)癥、嚴(yán)重高血壓、心臟病或周圍血管疾病患者，腎上腺素要慎用。據(jù)統(tǒng)計(jì)大約10%女性有二尖瓣脫垂，對腎上腺素很敏感。腎上腺素使用劑量為0.07mg/kg，以4mg為限。中毒時(shí)會出現(xiàn)高血壓及心律失常。

（8）深靜脈血栓形成及肺栓塞：深靜脈血栓形成的癥狀包括疼痛、小腿背側(cè)緊壓感，很少能觸摸到條索狀物。可通過Doppler超聲檢查等確診。肺栓塞的癥狀、體征包括：胸痛、呼吸困難、咯血、精神狀態(tài)不穩(wěn)定、心動過速、呼吸急促、發(fā)熱、肺啰音，可做胸片、通氣-灌注掃描來確診。危險(xiǎn)因素有：高齡（＞40歲），口服避孕藥，肥胖，長時(shí)間麻醉及同時(shí)施行開放性外科手術(shù)。預(yù)防的方法有早期活動及抬高下肢（超過心臟），應(yīng)用肺的正壓通氣裝置及低劑量皮下肝素應(yīng)用（對于高危者尤其是肥胖者）。治療應(yīng)盡早使用抗凝藥物，包括靜脈使用肝素[307]。

（9）腹壁穿孔：文獻(xiàn)中至少曾有過9例該類報(bào)道，其中4例死亡。危險(xiǎn)因素有：腹壁疝（包括臍疝），以前曾有多次腹壁手術(shù)史（導(dǎo)致腹壁粘連），以前曾行吸脂術(shù)，由于瘢痕及皮下層的不規(guī)則亦可增加危險(xiǎn)。術(shù)前要詳細(xì)了解腹部手術(shù)史，檢查腹部瘢痕及腹壁疝的存在，必要時(shí)作CT掃描及超聲檢查[307]。

四、腹部去脂的麻醉方法

目前，常采用的麻醉方法有膨脹劑（含麻藥）局部浸潤麻醉、靜脈全身麻醉、硬膜外麻醉。

局部浸潤麻醉就是在手術(shù)部位的皮下脂肪內(nèi)注入3 000～4 000ml的腫脹液，腫脹液內(nèi)含利多卡因400mg、腎上腺素1mg、5%碳酸氫鈉30～40ml，然后進(jìn)行手術(shù)吸脂。但此時(shí)患者情緒過于緊張、煩躁、血壓升高，影響手術(shù)順利進(jìn)行，甚至有患者要求停止手術(shù)。而現(xiàn)代的麻醉要求患者絕對安靜、對人體的各器官影響最小，以有利于術(shù)后患者的康復(fù)。

靜脈全麻是一種比較舒適的麻醉方法，但氯胺酮可引起夢幻和嘔吐，雖然輔用丙泊酚后，氯胺酮的副作用已經(jīng)大幅度下降，但夢幻和嘔吐還是有一定的發(fā)生率。

硬膜外阻滯只要操作成功，輔以神經(jīng)安定鎮(zhèn)靜劑可以完成下肢、下腹部、中上腹部手術(shù)，可施行控制性降壓，是減少術(shù)中大出血的有效方法。它不僅使與手術(shù)區(qū)相關(guān)的交感神經(jīng)充分阻滯，而且也使手術(shù)部位的向心傳導(dǎo)阻滯，從而降低了交感神經(jīng)緊張性，去甲腎上腺素分泌得以穩(wěn)定。降低了患者的應(yīng)激反應(yīng)，術(shù)中生命體征平穩(wěn)，鎮(zhèn)痛完全，完全能滿足手術(shù)和患者的要求[318]。

參考文獻(xiàn)

[1]章　柯. 全球通病肥胖癥[J]. 中國保健食品, 2004, 1(10):57

[2]Gary J. Anthone, Reginald V. N. Lord, Tom R. DeMeester, et al, The Duodenal Switch Operation for the Treatment of Morbid Obesity. Ann Surg, 2003, 238:618-628

[3]Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg, 2004, 240:416-424

[4]Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA, 2004, 291:1238-1264

[5]Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA. 2003, 289:187-193

[6]Hu FB, Manson JE, Stampfer MI, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women[J]. N Eng. J Med, 2001, 345:790-797

[7]Kopelman PG. Obesity as a medical problem. Nature 2000, 404:635-643

[8]Would Health Organization. Obesity:preventing and managing the global ep idemic. Report of a WHO consultation. Would Health Organ Tech Rep Ser, 2000, 894:1-253

[9]武陽平, 馬冠生. 中國居民的超重和肥胖流行現(xiàn)狀[J]. 中華預(yù)防學(xué)雜志2005, 9(5):316-320

[10]中國肥胖問題工作組. 中國學(xué)齡兒童青少年超重、肥胖篩查體重指數(shù)分類標(biāo)準(zhǔn)[J]. 中華流行病學(xué)雜志, 2004, 25(2):97-102

[11]Balsiger BM, Murr MM, Poggio JL, et al. Bariatric surgery. Surgery for weight control in patients with morbid obesity. Med Clin North Am, 2000, 84:477-489

[12]Thomusch O, Keck T, Dobschütz EV, et al. Risk factors for the intermediate outcome of morbid obesity after laparoscopically placed adjustable gastric banding. Am J Surg, 2005, 189:214-218

[13]Borao FJ, Thomas TA, Steichen FM. Alternative operative techniques in laparoscopic Roux-en-Y gastric bypass for morbid obesity[J]. JSLS, 2001, 5(2):123

[14]封蘇琴, 郝　超, 沈洪兵, 等. 肥胖與糖尿病、高血壓關(guān)系的流行病學(xué)研究[J]. 江蘇預(yù)防醫(yī)學(xué), 2000, 11(4):3-5

[15]Zhang Y, Proenca R, Maffei M, et al. Positional cloning of the mouse obese gene and its human homologue. Nature, 1994, 372:425-432

[16]Antipatis VJ, Gill TP. Obesity as a Global Problem. [M]//Bjorntorp P. International textbook of obesity. Wiley:Chichester, 2001:3-22

[17]Black DW, Goldstein RB, Mason EE. Psychiatric diagnosis and weight loss following gastric surgery for obesity[J]. Obes Surg, 2003, 13(55):746-751

[18]Nehoda H, Weiss H, Labeck B, et al. Results and complications after adjustable gastric banding in a series of 250 patients[J]. Am J Surg, 2001, 181(1):12

[19]Quételet AJ. Sur l’homme et le Développement de ses Facultés, ou Essai de Physique Sociale, Paris, Bachelier, 1835

[20]Kuczmarski RJ, Flegal KM, Campbell SM, et al. Increasing prevalence of overweight among US adults. The National Health and Nutrition Examination Surverys. 1960-1991(see comments)[J]. JAMA, 1994, 272(3):205-211

[21]張延齡. 病態(tài)性肥胖癥的手術(shù)治療. [J]. 國外醫(yī)學(xué)外科學(xué)冊, 2002, 29(6):324-326

[22]鄭成竹. 腹腔鏡外科減肥的幾點(diǎn)經(jīng)驗(yàn). 外科理論與實(shí)踐, 2004, 9(6):446-447

[23]中國肥胖問題工作組聯(lián)合數(shù)據(jù)匯總分析協(xié)作組. 中國成人體質(zhì)指數(shù)分類的推薦意見簡介. 中華預(yù)防醫(yī)學(xué)雜志, 2001, 35(5):349-350

[24]中國肥胖問題工作組數(shù)據(jù)匯總分析協(xié)作組. 我國成人體重指數(shù)和腰圍對相關(guān)疾病危險(xiǎn)因素異常的預(yù)測價(jià)值:適宜體重指數(shù)和腰圍切點(diǎn)的研究.中華流行病學(xué)雜志, 2002, 23(1):5-10

[25]徐明彤, 傅祖植. 正確選用減肥藥[J]. 新醫(yī)學(xué), 2002, 33(11):645-647

[26]陳鷺穎. 藥物治療肥胖癥的研究進(jìn)展[J]. 中國藥學(xué), 2002, 37(11): 812-814

[27]王　豫, 郭　銳, 張　波. 合理選用減肥藥[J]. 河南診斷與治療, 1996, 10(2):103

[28]王建平, 顏　湘, 朱旭萍, 等. 鹽酸西布曲明治療單純性肥胖的療效與安全性[J]. 湖南醫(yī)科大學(xué)學(xué)報(bào), 2003, 28(5):527-530

[29]李　泉, 張　敏. 新型減肥藥鹽酸西布曲明的藥理學(xué)研究[J]. 山東醫(yī)藥工業(yè), 1999, 18(5):50-52

[30]周詠明, 鄧　文, 鄒大進(jìn). 新型減肥藥β3-腎上腺素受體激動劑[J]. 中國新藥雜志, 2001, 10(7):496-499

[31]李文波, 仲伯華. 甲狀腺激素β受體選擇性激動劑:減肥和降脂藥涉及的新策略[J]. 國外醫(yī)學(xué)藥學(xué)分冊, 2004, 31(3):166-168

[32]李慧敏. 生長素研究進(jìn)展[J]. 國際病理科學(xué)與臨床雜志, 2003, 274:410-413

[33]馬衛(wèi)東. 減肥藥奧利司他[J]. 國外醫(yī)藥·合成藥生化藥、制劑分冊, 1999, 20(5):84-286

[34]魏桂林, 朱　珠. 減肥新藥－奧利司他[J]. 中國醫(yī)藥導(dǎo)刊, 2000, 2(3):53-55

[35]梁茂本, 沈雪峰. 減肥藥奧利司他和西布曲明臨床的合理應(yīng)用[J]. 齊齊哈爾醫(yī)學(xué)院學(xué)報(bào), 2002, 23(11):1250

[36]劉志峰, 李春梅, 李　敏, 等. α-糖苷酶抑制劑阿卡波糖的臨床藥理作用[J]. 中國藥理學(xué)通報(bào), 2004, 21(9):965-968

[37]Prince D M, Welschenbath MA. Olestra:A food additives[J]. J Am Diet Assoc, 1998, 98(5):565-569

[38]魏經(jīng)銓. 肥胖與減肥藥研究的新動向[J]. 國外醫(yī)藥·合成藥、生化藥、制劑分冊, 2002, 23(3):142-146

[39]范　鳴. 減肥藥開發(fā)動態(tài)[J]. 藥學(xué)進(jìn)展, 2003, (2):113

[40]郭　澄, 魏道智, 陳海華, 等. 中醫(yī)藥減肥療法的研究概況[J]. 中藥材, 2002, 25(7):534-537

[41]毓　芩. 肥胖癥的手術(shù)治療[J]. Foreign Medical Information. 2002, 23(4):426

[42]National Institutes of Health Consensus Development Conference Statement. Gast rointestinal Surgery for Severe Obesity[J]. Am J Clin Nutr, 1992, 55(suppl 2):6158

[43]Bouchard C et al. N Engl J Med, 1990, 322:1477-1482

[44]鄭成竹, 柯重偉, 印　慨, 等. 腹腔鏡垂直捆綁胃成形術(shù)治療病態(tài)肥胖(附25例報(bào)告)[J]. 中國實(shí)用外科雜志, 2002, 22(10):591-592

[45]中國肥胖癥外科治療指南(2007). 中國實(shí)用外科雜志, 2007, 27(10): 759-762

[46]The National Institutes of Health. Gastrointestinal surgery for severe obesity[J]. Consens Statement, 1991, 25, 9(1):1-20

[47]Lee WJ, Wang W. Bariatric surgery:Asia2Pacific perspective[J]. Obes Surg, 2005, 15(6):751-757

[48]鄭成竹, 李心翔, 胡　兵. 中國肥胖癥現(xiàn)狀及減肥手術(shù)的新概念——腹腔鏡手術(shù)治療肥胖癥的手術(shù)指征及療效評判新標(biāo)準(zhǔn)[J]. 中國實(shí)用外科雜志, 2007, 27(2):134-135

[49]周建平. 外科手術(shù)治療肥胖癥的歷史演變[J]. 中國現(xiàn)代手術(shù)學(xué)雜志, 2000, 4(3):235-237

[50]Payne J H, De Wind L T. Surgical Treatment of Obesity[J]. Am J Surg, 1969, 118:141

[51]Scott H W Jr, Dean R et al. Considerations in the use of jejuno-ileal bypass in patients with morbid obesity[J]. Ann Surg, 1973, 177(6):323-335

[52]Hocking MP et al. Am J Surg, 1991;141:159-163

[53]Scopinaro NE, Gianetta, et al. Biliopancreatic Diversion for Obesity at Eighteen Years[J]. Surgery, 1996, 119(3):261-268

[54]Mason EE, C. Ito. Gastric bypass in obesity[J]. Surg Clin North Am, 1967, 47(6):1345-1351

[55]Printen KJ, Mason EE. Gastric surgery for relief of morbid obesity[J]. Arch Surg, 1973, 106(4):428-431

[56]Deitel M. Overview of operations for morbid obesity[J]. Word J Surg, 1998, 22(9):913-918

[57]Mason EE. Vertical banded gastroplasty for obesity[J]. Arch Surg, 1982, 117(5):701-706

[58]Suter M, Jayet C, Jayet A. Vertical banded gastroplasty:long-term results comparing three different techniques[J]. Obes Surg, 2000 Feb;10(1):41-6; discussion 471

[59]Kuzmak LI, Thelmo W, Abramson DL, et al. Reversible adjustable gastric banding, surgical technique[J]. Eur J Surg, 1994, 160(10):569-571

[60]Greenstein RJ. Invited commentary:laparoscopic adjustable gastric bandingaviable option in bariatric surgery[J]. Surgery 2000, 127(5):491-492

[61]Gasbarrini G, Mingrone G, Greco AV, et al. An 18-year-old woman with familial chylomicronaemia who would not stick to a diet. Lancet 1996, 348:794

[62]Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J. Surg. 1998, 22:936-946

[63]Guidelines for laparoscopic and open surgical treatment of morbid obesity. American Society for Bariatric Surgery and Society of American Gastrointestinal Endoscopic Surgeons. Obes. Surg. 2000, 10:378-379

[64]Guidelines for Patient Selection and Postoperative Follow-up Care in Surgical Treatment of Obesity. The American Society for Bariatric Surgery, 5-94

[65]Scheen A, Luyckx F, Desaive C, et al. Severe/extreme obesity:a medical disease requiring a surgical treatment?Acta Clin. Belg. 1999, 54:154-161

[66]Gastrointestinal surgery for severe obesity:consensus development conference panel. Ann. Intern. Med. 1991, 115:956-961

[67]Deitel M, Shahi B. Morbid obesity:selection of patients for surgery. J. Am. Coll. Nutr. 1992, 11:457-462

[68]Johnson B, Bjorvell H, Levander S, et al. Personality traits predicting weight loss outcome in obese patients. Acta Psychiatr. Scand. 1986, 74:384-387

[69]Stunkard AJ, Stinnet JL, Smoller JW. Psychological and social aspects of the surgical treatment of obesity. Am.　J. Psychiatry 1986, 143:417-429

[70]Guisado JA, Vaz FJ. Personality profiles of the morbidly obese after vertical banded gastroplasty. Obes. Surg. 2003, 13:394-398

[71]Fox SR. The use of biliopancreatic diversion as a treatment for failed gastric partitioning in the morbidly obese. Obes. Surg. 1991, 1:89-93

[72]Buchwald H. A bariatric surgery algorithm. Obes. Surg. 2002, 12:733-746

[73]Brolin RE. Gastric restrictive operations. In Schein M, Wise L, editors, Controversies in Surgery, vol. 4, New York, Springer, 2001, 343-352

[74]Scopinaro N, Gianetta E, Civalleri D, et al. Biliopancreatic by-pass for obesity. I. An experimental study in dogs. Br. J. Surg. 1979, 66:613-617

[75]Scopinaro N, Gianetta E, Civalleri D, et al. Biliopancreatic by-pass for obesity. II. Initial experience in man. Br. J. Surg. 1979, 66:618-620

[76]Scopinaro N, Gianetta E, Civalleri D, et al. Two years of clinical experience with biliopancreatic bypass for obesity. Am. J. Clin. Nutr. 1980, 33:506-514

[77]Miller K, Rettenbacher L, Hell E. Adjustments and leak detection of the adjustable silicone gastric band (ASGB) and Lap-band adjustable gastric band (LAGB) system. Obes. Surg. 1996, 6:406-411

[78]Eckhout GV, Willbanks OL, Moore JT. Vertical ring gastroplasty for obesity:five year experience with 1463 patients. Am. J. Surg. 1986, 152: 713-716

[79]Mason EE, Maher JW, Doherty C, et al. Ten years of vertical banded gastroplasty for severe obesity. Probl. Gen. Surg. 1992, 9:280-289

[80]Linner JH. Gastric operations. In Linner JH, editors, Surgery for Morbid Obesity, New York, Springer, 1984, 65-107

[81]Scopinaro N, Papadia F. Malabsorptive procedures. In Schein M, Wise L, editors, Controversies in Surgery, vol. 4, New York, Springer, 2001, 353-360

[82]Marceau P, Hould FS, Lebel S, et al. Malabsorptive obesity surgery. Surg. Clin. North Am. 2001, 81:1113-1127

[83]Noya G, Cossu ML, Coppola M, et al. Biliopancreatic diversion for treatment of morbid obesity:experience in 50 cases. Obes. Surg. 1998, 8:61-66

[84]Marceau P, Biron S, Bourque R-A, et al. Biliopancreatic diversion with a new type of gastrectomy. Obes. Surg. 1993, 3:29-35

[85]Lagacé M, Marceau P, Marceau S, et al. Biliopancreatic diversion witha new type of gastrectomy:some previous conclusions revisited. Obes. Surg. 1995, 5:411-418

[86]Hess DS. Biliopancreatic diversion with a duodenal switch procedure. Obes. Surg. 1994, 4:106

[87]Baltasar A, Bou R, Cipagantu LA, et al. Hybrid bariatric surgery: biliopancreatic diversion and duodenal switch;preliminary experience. Obes. Surg. 1995, 5:419-423

[88]Rabkin RA. Distal gastric bypass/duodenal switch procedure, Rouxen-Y gastric bypass and biliopancreatic diversion in a community practice. Obes. Surg.　1998, 8:53-59

[89]Anthone GJ. Surgical treatment of morbid obesity. American College of Surgeons postgraduate course, October 1997

[90]Vassallo C, Negri L, Della Valle A, et al. Biliopancreatic diversion with transitory gastroplasty preserving duodenal bulb:3 years experience. Obes. Surg. 1997, 7:30-33

[91]Mittempergher F, Bruni T, Bruni O, et al. Biliopancreatic diversion with preservation of the duodenal bulb and transitory gastroplasty in the treatment of morbid obesity:our experience. Ann. Ital. Chir. 2002, 73: 137-142

[92]Yashkov YI, Oppel TA, Shishlo LA, et al. Improvement of weight loss and metabolic effects of vertical banded gastroplasty by an added duodenal switch procedure.　Obes. Surg. 2001, 11:635-639

[93]Totté E, Hendrickx L, Van Hee R. Biliopancreatic diversion for treatment of morbid obesity:experience in 180 consecutive cases. Obes. Surg. 1999, 9:161-165

[94]Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996, 119:261-268

[95]Torres JC, Oca CF, Garrison RN. Gastric bypass:Roux-en-Y gastrojejunostomy from the lesser curvature. South. Med. J. 1983, 76: 1217-1221 [96]Torres J, Oca C. Gastric bypass lesser curvature with distal Roux-en-Y. Bariatric Surg. 1987, 5:10-15

[97]Torres J. Why I prefer gastric bypass distal Roux-en-Y gastroileostomy. Obes. Surg. 1991, 1:189-194

[98]Fobi MAL. Distal Roux-en-Y-gastric bypass, a revision operation for failed gastric bypass procedures. In Proceedings, Fourth Annual Symposium Surgical Treatment of Obesity, Anaheim, March 1986

[99]Brolin RE, Kenler HA, Gorman JH, et al. Long limb gastric bypass in the super-obese:a prospective randomized study. Ann. Surg. 1992, 215:387-395

[100]Gianetta E, Friedman D, Adami GF, et al. Present status of biliopancreatic diversion(BPD). In Proceedings of the Third International Symposium on Obesity Surgery, Genoa, September 1987, 11-13

[101]Pavia D, Bernardes L, Suretti L. Laparoscopic biliopancreatic diversion for the treatment of morbid obesity:initial experience. Obes. Surg. 2001, 11:619-622

[102]Scopinaro N, Marinari GM, Camerini G. Laparoscopic standard biliopancreatic diversion:technique and preliminary results. Obes. Surg. 2002, 12:362-365

[103]De Csepel J, Burpee S, Jossart G, et al. Laparoscopic biliopancreatic diversion with a duodenal switch for morbid obesity:a feasibility study in pigs. J. Laparoendosc. Adv. Surg. Tech. A 2001, 11:79-83

[104]Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch:a case series of 40 consecutive patients. Obes. Surg. 2000, 10:514-523

[105]De Csepel J, Quinn T, Pomp A, et al. Conversion to a laparoscopic biliopancreatic diversion with a duodenal switch for failed laparoscopic adjustable silicone gastric banding. J. Laparoendosc. Adv. Surg. Tech. A 2002, 12:237-240

[106]Gagner M, Steffen R, Biertho L, et al. Laparoscopic adjustable gastric banding with duodenal switch for morbid obesity:technique and preliminary results. Obes. Surg. 2003, 13:444-449

[107]Rabkin RA, Rabkin JM, Metcalf B, et al. Laparoscopic technique for performing duodenal switch with gastric reduction. Obes. Surg. 2003, 13:263-268

[108]Lemmens L. Biliopancreatic diversion:170 patients in a 7-years follow-up. Obes. Surg. 1993, 3:179-180

[109]Holian DK, ClareMW. Biliopancreatic bypass for morbid obesity:late results and complications. Clin. Nutr. 1986, 5:133-136

[110]Marceau P, Biron S, St. Georges R, et al. Biliopancreatic diversion with gastrectomy as surgical treatment of morbid obesity. Obes. Surg. 1991, 1:381-386

[111]Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion:two decades of experience. In Deitel M. , Cowan Jr. GSM, editors, Update: Surgery for the Morbidly Obese Patient, Toronto, FD-Communications, 2000, 227-258

[112]Sugerman HJ, Kellum JM, Reines D, et al. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am. J. Surg. 1996, 171:80-81

[113]Gianetta E, Friedman D, Traverso E, et al. Small bowel obstruction after biliopancreatic diversion. Probl. Gen. Surg. 1992, 9:386

[114]Schein M. Acute pancreatitis following pancreaticobiliary bypass (Scopinaro operation). Arch. Surg. 1987, 122:1088

[115]Michielsen D, Van Hee R, Hendrickx L. Complications of biliopancreatic diversion surgery as proposed by Scopinaro in the treatment of morbid obesity. Obes. Surg. 1996, 6:416-420

[116]Marceau P, Hould F-S, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J. Surg. 1998, 22:947-954

[117]Compston JE, Vedi S, Gianetta E, et al. Bone histomorphometry and vitamin D status after biliopancreatic bypass for obesity. Gastroenterology 1984, 87:350-356

[118]Compston JE, Vedi S, Watson GJ, et al. Metabolic bone disease in patients with biliopancreatic bypass. Clin. Nutr. 1986, 5:221-224

[119]Chapin BL, Le Mar HJ Jr, Knodel DH, et al. Secondary hyperparathyroidism following biliopancreatic diversion. Arch. Surg. 1996, 131:1048-1053

[120]Bonalumi U, Cafiero F, Caponnetto A, et al. Protein absorption studies in biliopancreatic bypass patients. Int. J. Obes. 1981, 5:543

[121]Scopinaro N, Marinari GM, Gianetta E, et al. The respective importance of the alimentary limb(AL)and the common limb(CL)in protein absorption (PA) after BPD. Obes. Surg. 1997, 7:168

[122]Primavera A, Brusa G, Novello P, et al. Wernicke Korsakoff encephalopathy following biliopancreatic diversion. Obes. Surg. 1993, 3:175-177

[123]Quaranta L, Nascimbeni G, Semeraro F, et al. Severe corneoconjunctival xerosis after biliopancreatic bypass for obesity(Scopinaro’s operation). Am. J. Ophthalmol. 1994, 118:817-818

[124]Cantatore FP, Carrozzo M, Loperfido MC. Post biliopancreatic bypass arthritis:dermatitis syndrome. Clin. Rheumatol. 1991, 10:449-451

[125]Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am. J. Gastroenterol. 1992, 87: 774-779

[126]Biron S, Marceau S, Dejoie C, et al. Effects of weight loss after biliopancreatic diversion on liver morphology. Obes. Surg. 1996, 6:121

[127]Del Gaudio A, Boschi L, Del Gaudio GA, et al. Liver damage in obese patients. Obes. Surg. 2002, 12:802-804

[128]Gholam PM, Kotler DP, Flancbaum LJ. Liver pathology in morbidly obese patients undergoing Roux-en-Y gastric bypass surgery. Obes. Surg. 2002, 12:49-51

[129]Spaulding L, Trainer T, Janiec D. Prevalence of non-alcoholic steatohepatitis in morbidly obese subjects undergoing gastric bypass. Obes. Surg. 2003, 13:347-349

[130]Allison DB, Fontaine KR, Manson JE, et al. Annual deaths attributable to obesity in the United States. JAMA 1999, 282:1530-1538

[131]Calle EE, Rodriguez C, Walker-Thurmond K, et al. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U. S. adults. N. Engl. J. Med. 2003, 348:1625-1638

[132]Sjo¨stro¨m LV. Mortality of severely obese subjects. Am. J. Clin. Nutr. 1992, 55:S516-S523

[133]To TB, Deitel M, Stone E, et al. Sex hormonal changes after loss of massive excess weight. Surg. Forum 1987, 38:465-467

[134]Deitel M, To TB, Stone E, et al. Sex hormonal changes accompanying loss of massive excess weight. Gastroenterol. Clin. North Am. 1987, 16:511-515

[135]Pasquali R, Vicennati V, Scopinaro N, et al. Achievement of nearnormal body weight as the prerequisite to normalise sex hormonebinding globulin concentration in morbidly obese men. Int. J. Obes. 1997, 21:1-5

[136]Gerrits EG, Ceulemans R, Van Hee R, et al. Contraceptive treatment after biliopancreatic diversion needs consensus. Obes. Surg. 2003, 13:378-382

[137]Richards DS, Miller DK, Goodman GN. Pregnancy after gastric bypass for morbid obesity. J. Reprod. Med. 1987, 32:172-176

[138]Treadwell L, Mason EE, Scott DA, et al. Pregnancy outcome after vertical banded gastroplasty. Obes. Surg. 1993, 3:143

[139]Wittgrove AC, Jester L, Wittgrove P, et al. Pregnancy following gastric bypass for morbid obesity. Obes. Surg. 1998, 8:461-464

[140]Deitel M, Ternamian AM. Gynecologic-obstetric features of morbid obesity and the effect of weight loss. In Deitel M, Cowan Jr. GSM, editors, Update:Surgery for the morbidly obese patient, Toronto, FDCommunications, 2000, 481-485

[141]Friedman D, Cuneo S, Valenzano M, et al. Pregnancies in an 18-year follow-up after biliopancreatic diversion. Obes. Surg. 1995, 5:308-313

[142]Adami GF, Friedman D, Cuneo S, et al. Intravenous nutritional support in pregnancy:experience following biliopancreatic diversion. Clin. Nutr. 1992, 11:106-109

[143]Amaral JF, Thompson WR, Caldwell MD, et al. Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity. Ann. Surg. 1985, 201:186-193

[144]Simon SR, Zemel R, Betancourt S, et al. Hematologic complications of gastric bypass for morbid obesity. South. Med.　J. 1989, 82:1108-1110

[145]Hess DW, Hess DS. Biliopancreatic diversion with a duodenal switch. Obes. Surg. 1998, 8:267-282

[146]Rhode BM, McLean LD. Vitamin and mineral supplementation after gastric bypass. In Deitel M, Cowan Jr. GSM, editor, Update:Surgery for the Morbidly Obese Patients, Toronto, FD-communications, 2000, 161-170

[147]Brolin RE, Leung M. Survey of vitamin and mineral supplementation after gastric bypass and biliopancreatic diversion for morbid obesity. Obes. Surg. 1999, 9:150-154

[148]Byrne TK. Complications of surgery for obesity. Surg. Clin. North Am. 2001, 81:1181-1194

[149]Favretti F, Cadie`re GB, Segato G, et al. Laparoscopic banding:selection and technique in 830 patients. Obes. Surg. 2002, 12:385-390

[150]Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes. Surg. 2002, 12:564-568

[151]Vertruyen M.　Experience with Lap-Band System up to 7 years. Obes. Surg. 2002, 12:569-572

[152]O’Brien PE, Nixon JB, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band?):a prospective study of medium-term effectson weight, health and quality of life. Obes. Surg. 2002, 12:652-660

[153]Misset M, Fabry H, Van Hee R, et al. Laparoscopic adjustable gastric banding with up to 6-year follow-up:is it really safe and affective?Acta Chir. Belg. in press

[154]Chelala E, Cadie`re GB, Favretti F, et al. Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases. Surg. Endosc. 1997, 11:268-271

[155]Meir E, Van Baden M. Adjustable silicone gastric banding and band erosion: personal experience and hypotheses. Obes. Surg. 1999, 9:191-193

[156]Hell E, Miller KA. Comparison of vertical banded gastroplasty and adjustable silicone gastric banding. In Deitel M, Cowan Jr. GSM, editor, Update:Surgery for the Morbidly Obese Patient, Toronto, FD Communications, 2000, 379-386

[157]DeMaria EJ, Sugerman HJ, Meador JG, et al. High failure rate after laparoscopic adjustable silicon gastric banding for treatment of morbid obesity. Ann. Surg. 2001, 233:809-818

[158]Niville E, Dams A. Late pouch dilation after laparoscopic adjustable gastric and esophagogastric banding: incidence, treatment and outcome. Obes. Surg. 1999, 9:381-384

[159]Morino M, Toppino M, Garrone C. Disappointing long-term results of laparoscopic adjustable silicone gastric banding. Br. J. Surg. 1997, 84:868-869

[160]Westling A, Bjurling K, Ohrvall M, et al. Silicone-adjustable gastric banding:disappointing results. Obes. Surg. 1998, 8:467-474

[161]Van Hee R. Bariatric surgery:a view on the future. G. Chir. 1999, 20:73-79

[162]Sugerman HJ, Londrey GL, Kellum JM, et al. Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment. Am. J. Surg. 1989, 157:93-100

[163]Larsen F. Psychological function before and after gastric banding surgery for morbid obesity:a prospective psychiatric study. Acta Psychiatr. Scand. 1990, 82:S1-S57

[164]Savage RC. Abdominoplasty following gastrointestinal bypass surgery. Plast. Reconstr.　Surg. 1983, 71:500-507

[165]Fuente del Campo A, Rojas Allegretti E, Fernandes Filho JA, et al. Regional dermolipectomy as treatment for sequelae of massive weight loss. World J. Surg. 1998, 22:974-980

[166]Floros C, Davis KB. Complications and long-term results following abdominoplasty:a retrospective study. Br. J. Plast. Surg. 1991, 44:190-194

[167]Soundarajan V, Hart NB, Royston CMS. Abdominoplasty following vertical banded gastroplasty for morbid obesity. Br. J. Plast.　Surg. 1995, 48:423-427

[168]Pitanguy I. Surgical reduction of the abdomen, thigh and buttocks. Surg. Clin. North Am. 1971, 51:479-489

[169]Grazer FM. Abdominoplasty. Plast.　Reconstr. Surg. 1973, 51:617-623

[170]Lowis S, Van Hee R, Peeters R, et al. Abdominoplasty after biliopancreatic diversion for morbid obesity. Br. J. Plast. Surg. in press

[171]Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with emphasis on complications. Plast.　Reconstr. Surg. 1977, 59:513-517

[172]Van Uchelen JH, Werker PNM, Kon M. Complications of abdominoplasty in 86 patients. Plast. Reconstr. Surg. 2001, 107:1869-1873

[173]Hensel JM, Lehman JA, Tantri MP, et al. An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties. Ann. Plast. Surg. 2001, 46:357-363

[174]Cottam D, Qureshi FG,　Mattar SG, et al. Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity[J]. Surg Endosc, 2006, 20(6):859-863

[175]Lee WJ, Lai IR, Huang MT, et al. Laparoscopic versus open vertical banded gastroplasty for the treatment of morbid obesity[J]. Surg Laparosc Endosc Percutan Tech, 2001, 11(1):9-13

[176]Davila Cervantes A, Ganci Cerrud G, Gamino R, et al. Open vs. laparoscopic vertical banded gastroplasty:a case control study with a 1-year follow-up[J]. Obes Surg, 2000, 10(5):409-412

[177]王晨曦, 王存川. 腹腔鏡Roux-en-Y分流胃旁路手術(shù)的現(xiàn)狀及進(jìn)展. 國外醫(yī)學(xué)外科學(xué)分冊, 2004, 31(5):288-290

[178]Kelvin D, et al. J Laparoendoscopic Advanced Surg Tech 2001, 11(6):377-382

[179]Ninh TN, et a1. J Am Coll Surg 2000, 191:149-157

[180]Reinhold RB. J Am Coll Nutr 1994, 13(4):326-331

[181]Nguyen NT, et al. J Am Coll Surg 2001, 192(4):469-476

[182]Dresel A, et al. Am J Surg 2002, 184(6):617-620

[183]Papasavas PK, et al. Surg Endosc 2002, 16(12):1653-1657

[184]Christopher G. Andrew, Wael Hanna, Didier Look, Early results after laparoscopic Roux-en-Y gastric bypass:effect of the learning curve[J]. Can J Surg, 2006, 12(49), 417-421

[185]Alan A. Saber, MD, Facs MS, et al. A Simple Technique for Reinforcement of the Gastro-jejunostomy during Roux-en-Y Gastric Bypass [J]. Obes Surg, 2007, 17(1):5-18

[186]Royd Fukumoto, Jeraldine Orlina, JamesMcGinty. Use of Polyflex stents in treatment of acute esophageal and gastric leaks after bariatric surgery[J]. Surg Obes Relat, 2007, 3:68-72

[187]Ken FujioKa. Follow-up of nutritional and metabolic problems after bariatric surgery[J]. Diabetes Care, 2005, 28(2):481-484

[188]Finnell W, Atul KM. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass christopher[J]. Obes Surg, 2007, 17(1):145-148

[189]Gorecki JP, et al. Obes Surg 2002, 12(2):289-291

[190]Schauer P, et al. Surg Endosc 2003, 17(2):212-215

[191]Oliak D, et al. Obes Surg 2002, 12(5):643-647

[192]de la Torre RA, et al. Obes Surg 1999, 9(5):492-498

[193]Wittgrove AC, et al. J Laparoendoscopic Advanced Surg Tech 1998, 8(1):53-55

[194]Willbanks OL. Long term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity[J]. Surgery, 1987, 101(5):606-610

[195]Melissas J, Christodoulakis M, Spyridakis, et al. Disorders associated with clinically severe obesity:significant improvement after surgical weight loss[J]. South Med J, 1998, 91(12):1143-1148

[196]Von Gemert WG, Adang EM, Kop M, et al. A prospective cost-effective analysis of vertical banded gastroplasty for the treatment of morbid obesity[J]. Obes Surg, 1999, 9(5):484-491

[197]Yashkov YI, Timoshin AD, Oppel TA, et al. Vertical banded gastroplasty:first experience in Russia. Obes Surg, 1997, 7(4):317

[198]Bleier J I, Krupnick AS, Kreisel D, et al. Hand-assisted laparoscopic vertical banded gastroplasty:early results. Surg Endosc, 2000, 14(10):902

[199]Fiky KA. Laparoscopic vertical banded gastroplasty:early experience. Obes Surg, 2001, 11(3):271

[200]MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity[J]. Surgery, 1990, 107(1):20-27

[201]Belachew M, Legrand M, Vincent V, et al. Laparoscopic adjustable gastric banding. World J Surg, 1998, 22:955-963

[202]鄭成竹, 胡明根, 柯重偉, 等. 腹腔鏡可調(diào)節(jié)捆扎帶胃減容術(shù)治療單純重度肥胖癥的臨床應(yīng)用. 中華胃腸外科雜志, 2004, 7(5):368-371

[203]Martin LF. Obesity surgery. The McGraw[M]. New York:Hill Companies, 2004:265

[204]寇玉彬, 鄭成竹, 印　慨, 等. 腹腔鏡可調(diào)控性胃捆扎帶減肥術(shù)術(shù)后并發(fā)癥的診治[J]. 中華外科雜志, 2006, 44(11):1473-1476

[205]Evans JD, Scott MH, Brown AS, et al. Laparoscopic adjustable gastric banding for the treatment of morbid obesity. Am J Surg, 2002, 184:97-102

[206]Boschi S, Fogli L, Berta RD. Avoiding comp lications after laparoscopic esophago-gastric banding:experience with 400 consecutive patients[J]. Obes Surg, 2006, 16(9):1166-1170

[207]Solly Mizrahi, Eliezer Avinoah. Technical tips for laparoscopic gastric banding:6years’ experience in 2800 procedures by a single surgical team[J]. Am J Surg, 2007, 193(2):160-165

[208]Ponce J, Dixon JB. Laparoscopic adjustable gastric banding[J]. Surg Obes Relat Dis, 2005, 1(2):310-316

[209]Brien PE, Dixon JB. Laparoscopic adjustable gastric banding in the treatment of morbid obesity[J]. Arch Surg, 2003, 138:376-382

[210]O’ Brien PE, Dixon JB, Brown W. Obesity is a surgical disease:overview of obesity and bariatric surgery. ANZ J Surg, 2004, 74:200-204

[211]Weiss HG, Nehoda H, Labeek B, et al. Pregnancies after adjustable gastric banding. Obes Surg, 2001, 11:303-306

[212]Regan JP, Inabmet WB, Gagner M, et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient[J]. Obes Surg, 2003, 13(6):861-864

[213]Baltasar A, Serra C, Perez N, et al. Laparoscopic sleeve gastrectomy:a multi-purpose bariatric operation[J]. Obes Surg, 2005, 15(8):1124-1128

[214]Miller K, Hell E. Lapaoscopic adjustable gastric banding:a prospective 42-year follow-up study[J]. Obes Surg, 1999, 9(2):183-187

[215]Frezza EE. Laparoscopic vertical sleeve gastrectomy for morbid obesity. The future procedure of choice?[J]. Surg Today, 2007, 37(4):275-281

[216]Kjima M, Hosoda H, Date Y, et al. Ghrelin is a growth-hormone-releasing acylated peptide from stomach[J]. Nature, 1999, 402(6762):656-660

[217]Wertz-Lutz AE, Knight TJ, Pritchard RH, et al. Circulating ghrelin concent rations fluctuate relative to nutritional status and influence feeding behavior in cattle. J Anim Sci, 2006, 84:3285-3300

[218]Trudel L, Tomasetto C, Rio MC, et al. ghrelin/motilin-related peptide is a potent prokinetic to reverse gastric postoperative ileus in rat. Am J Physiol Gast rointest Liver Physiol, 2002, 282:G948-952

[219]Kitazawa T, De Smet B, Verbeke K, et al. Gastric motor effect s of peptide and non-peptide ghrelin agonist s in mice in vivo and in vitro. Gut, 2005, 54:1078-1084

[220]Poitras P, Polvino WJ, Rocheleau B, et al. Gastrokinetic effect of ghrelin analog RC-1139 in the rat. Effect on postoperative and on morphine induced ileus. Peptides, 2005, 26:1598-1601

[221]Nakazato M, Murakami N, Date Y, et al. A role for ghrelin in the central regulation of feeding. Nature, 2001, 409:194-198

[222]Suzuki S, Ramos EJ, Goncalves CG, et al. Changes in GI hormones and their effect on gastric emptying and transit times after Roux-en-Y gastric bypass in rat model. Surgery, 2005, 138:283-290

[223]Dornonville de la Cour C, Lindst rom E, Norlen P, et al. Ghrelin stimulates gastric emptying but is without effect on acid secretion and gastric endocrine cells. Regul Pept, 2004, 120:23-32

[224]Tack J, Depoortere I, Bisschops R, et al. Influence of ghrelin on gastric emptying and meal-related symptoms in idiopathic gastroparesis. Aliment Pharmacol Ther, 2005, 22:847-853

[225]Murray CD, Martin NM, Patterson M, et al. Ghrelin enhances gastric emptying in diabetic gastroparesis:a double blind, placebo controlled, crossover study. Gut, 2005, 54:1693-1698

[226]Langer FB, Reza Hoda MA, Bohdjalian A. Sleeve gastrectomy and gastric banding:effects on plasma ghrelin levels[J]. Obes Surg，2005, 15(10):1501-1502

[227]Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy(LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005, 15:1469-1475

[228]Himpens J, Dapri G, Cadiere GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy:results after 1 and 3 years. Obes Surg 2006, 16(11):1450-1456

[229]Roa PE, Kaidar-Person O, Pinto D, Cho M, Szomstein S, Rosenthal RJ. Laparoscopic sleeve gastrectomy as treatment for morbid obesity:technique and short-term outcome. Obes Surg 2006, 16:1323-1326

[230]Silecchia G, Boru C, Pecchia A, Rizzello M, Casella G, Leonetti F, Basso N. Effectiveness of laparoscopic sleeve gastrectomy(first stage of biliopancreatic diversion with duodenal switch)on co-morbidities in super-obese high-risk patients. Obes Surg 2006, 16:1138-1144

[231]Hess DS, Hess DW, Oakley RS. The biliopancreatic diversion with the duodenal switch:results beyond 10 years. Obes Surg 2005, 15:408-416

[232]Wu JT, Kral JG. ghrelin:integrative neuroendocrine peptide in health and disease. Ann Surg 2004, 239:464-474

[233]Faraj M, Havel PJ, Phelis S, Blank D, Sniderman AD, Cianfl one K. Plasma acylation-stimulating protein, adiponectin, leptin and ghrelin before and after weight loss induced by gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2003, 88:1594-1602

[234]Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX, Zacherl J, Wenzl E, Schindler K, Luger A, Ludvik B, Prager G. Sleeve gastrectomy and gastric banding:effects on plasma ghrelin levels. Obes Surg 2005, 15:1024-1029

[235]Bernante P, Foletto M, Busetto L, et al. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding[J]. Obes Surg, 2006, 16(10):1327-1330

[236]Lopez-Pardo Martinez M, de Torres Aured ML, Diaz Gomez J. Care of patients who have undergone bariatric surgery[J]. Rev Med Univ Navarra, 2006, 50(4):15-22

[237]Elkins G, Whitfield P, Marcus J, et al. Noncompliance with behavioral recommendations following bariatric surgery[J]. Obes Surg 2005, 15(4):546-551

[238]Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol 1999, 94:2840-2844

[239]Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch. Obes Surg 2003, 13:649-654

[240]Deitel M. Surgery for morbid obesity. Overview. Eur J Gastroenterol Hepatol 1999, 11:57-61

[241]Egan TD, Hulzing AB, Gupata SK, et al. Remifentanil pha rmacokinetics in obese versus lean patients[J]. Anesthesiology, 1998, 89(3):562-573

[242]Slepchenko G, Simon N, Goubaux B, et al. Performance of target-controlled sufentani1 infusion in obese patients[J]. Anesthesiology, 2003, 98(10):65-73

[243]Leykin Y, Pellis T, Lucca M, et al. The pharmacokinetic effects of rocuronium when dosed according to real body weight or ideal body weight in morbid1y obese patients[J]. Anesth Analg, 2004, 99(4): 1086-1089

[244]Bailey Craig R. Diffcult tracheal intubation ismore common in obesity than in lean patients. Anesthesiology, 2004, 48(2):73-74

[245]Brodysky JB, et al. Morbid obesity and tracheal intubation. Anesthesia & Analgesia, 2002, 94(3):732-736

[246]Iohom G, et al. Prediction of difficult tracheal intuation. Eur J Anaes2thesiology,　2003, 20(1):31-36

[247]Rajan GR. MD. Unticipated difficult intubation due to significant chang in mobility at the neck and jaw on assuming supine position. Anesthesiology, 2004, 100(6): 1632

[248]Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 head-up position than in the supine position in severely obese patients[J].　Anesthesioloy, 2005, 102:1110-1115

[249]Coussa M, Proietti S, Schnyder P, et al. Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients[J]. Anesth Analg, 2004, 98(5):1491-1495

[250]Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy morbid obesity:a comparision of the “sniff” and “ramped” positions[J]. Obesity Surgery, 2004, 14(9):1171-1175

[251]薛富善. 困難氣管插管技術(shù). 北京:科學(xué)技術(shù)文獻(xiàn)出版社, 2002:57-58, 252-253

[252]Von Ungern-Sternberg BS, Regli A, Reber A, et al. Comparis on of perioperative spirometric data following spinal or general anaesthesia in normal-weight and overweight gynaecological patients[J]. Acta Anaesthesiol Scand, 2005, 49(7):940-948

[253]Sprung J, Whalley DG, Falcone T, et al. The effects of tidal volume and respiratory rate on oxygenation and respiratory mechanics during laparoscopy in morbidly obese patients[J]. Anesth Analg, 2003, 97(1): 268-274

[254]Nieben OG, Harboe H. Intragastric balloon as an artifical bezoar for treatment of obesity. Lancet, 1982, 1:198-199

[255]Doldi SB, Micheletto G, Di Prisco F, et al. Intragastric balloon in obese patients[J].　Obesity Surgery, 2000, 10(6):578

[256]Loffredo A, Cappuccio M, De Luca M, et al. Three years experience with the new intragastric balloon, and a preoperative test for success with restrictive surgery[J]. Obesity Surgery, 2001, 11(3):330

[257]秦鳴放, 王震宇, 錢　東, 等. 內(nèi)鏡腹腔鏡治療肥胖癥的初步探討[J].中華消化內(nèi)鏡雜志, 2007, 24(1):29-31

[258]Doldi SB, Micheletto G, Perrini MN, et al. Treatment of morbid obesity with intragastric balloon in association with diet[J]. Obesity Surgery, 2002, 12(4):583-587

[259]Giardiello C, Cristiano S, Cerbone MR, et al. Gastric perforation in an obese patient with an intragastric balloon, following previous fundoplication[J]. Obesity Surgery, 2003, 13(4):658

[260]Puglisi F, Capuano P, Veneziani N, et al. Tachyarrhythmia due to atrial fibrillation in an intragastric balloon carrier:coincidence or consequence? [J]. Obesity Surgery, 2005, 15(5):716

[261]Sallet JA, Marchesini JB, Komoto K, et al. Brazilian multicenter study of the intragastric balloon. Obes Surg, 2004, 14:991-998

[262]TottéE HendrickxL, Pauwels M, et al. Weight reduction by means of intragastric device:experience with the bioenterics intragastric balloon[J]. Obesity Surgery, 2001, 11(4):519

[263]Mui WL, So WY, Yau PY, et al. Intragastric balloon in ethnic obese Chinese:initial experience[J]. Obesity Surgery, 2006, 16(3):308

[264]Genco A, Bruni T, Doldi SB, et al. Bioenterics Intragastric Balloon:The Italian Experience with 2515 Patients[J]. Obesity Surgery, 2005, 15(11):1161

[265]Genco A, Cipriano M, Bacci V, et al. Bioenterics Intragastric Balloon(BIB):a short-term, double-blind, randomised, controlled, crossover study on weight reduction in morbidly obese patients[J]. International journal of obesity, 2006, 30(1):129

[266]Milone L, Strong V, Gagner M. Laparoscopic sleeve gastrectomy is superior to endoscopic intragastric balloon as a first stage procedure for super-obese patients(BMI≥50kg/m2)[J]. Obesity Surgery, 2005, 15(5):612

[267]梅力文, 吳國偉. 亞太地區(qū)引入胃內(nèi)水球治療肥胖癥[J]. 中華醫(yī)學(xué)雜志, 2005, 85(39):2748

[268]Roman S, Napoleon B, Mion F, et al. Intragastric balloon for“Non-Morbid” Obesity:a retrospective evaluation of tolerance and efficacy [J]. Obesity Surgery, 2004, 14(4):539

[269]Rydzewska G, Milewski J. Intragastric balloons—the new hope in bariatry?[J]Bibliographic Details, 2004, 17:SUPP/1

[270]Kim WY, Kirkpatrick UJ, Moody AP, et al. Large bowel impaction by the Bioenterics Intragastric Balloon(BIB) necessitating surgical intervention[J]. Ann R Coll Surg Engl, 2000, 82(3):202

[271]Vanden Eynden F, Urbain P. Small intestine gastric balloon impaction treated by laparoscopic surgery[J]. Obesity Surgery, 2001, 11(5):646

[272]Melissas J, Mouzas J, Filis D, et al. The intragastric balloon -smoothing the path to bariatric surgery[J]. Obesity Surgery, 2006, 16(7):897

[273]Illouz YG. Study of subcutaneous fat[J]. Aesthetic Plast Surg 1990, 14(3):165

[274]Gasperoni C, Salgarello M. Rationale of subdermal superficial liposuction related to the anatomy of subcutaneous fat and the superficial fascial system[J]. Aesthetic Plast Surg, 1995, 19(1):13

[275]馮傳波, 陳林峰, 時(shí)安乎. 脂肪抽吸術(shù)與解剖學(xué)相關(guān)問題[J]. 實(shí)用美容整形外科雜志, 1999, 10(1):33

[276]周興亮, 韓秉公, 張愛珍, 等. 脂肪抽吸術(shù)應(yīng)用解剖及其臨床意義[J].中華整形燒傷外科雜志, 1991, 7(4):250

[277]Bozola AR, Psillakis JM. Abdominoplasty:a new concept and clasification for treatment[J]. Plast Reconstr Surg, 1988, 82(5):983

[278]Ramirez OM. Abdominoplasty and abdominal wall rahabilitation:a comprehensive approach[J]. Plast Reconstr Surg, 2000, 105(1):425

[279]李　斌, 馬曉冰. 去脂整形術(shù)[J]. 中華整形外科雜志, 2000, 16(4):243

[280]Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic Surg, 1987, 63:263-267

[281]Toledo LS, Lewis CM. Syringe liposculpture. A 22 year experience. Aesth Plast Surg, 1991, 15:321-326

[282]Reployle S. Experience with tumescent technique in lipoplasty. Aesth Plast Surg, 1993, 17:205-208

[283]劉　洪. 超量灌注麻醉吸脂術(shù)160例[J]. 貴陽醫(yī)學(xué)院學(xué)報(bào), 2002, 27(5):451-454

[284]李薈元. 國外美容外科最新動態(tài)[J]. 中國美容醫(yī)學(xué), 2002, 11(4):399

[285]朱唯力, 李益敏, 吳　鑫. 低濃度大劑量利多卡因在吸脂術(shù)中應(yīng)用[J].中國基層醫(yī)藥, 2002, 9(10):878

[286]Matarasso A. Lidocaine in ultrasound assisted lipoplasty. Clin Plast Surg, 1999, 26:431-439

[287]童新輝, 劉海蚊, 李物華. 腫脹技術(shù)與抽脂術(shù)的進(jìn)展[J]. 中華醫(yī)學(xué)美容雜志, 2000, 6(1):50

[288]Shiffman MA. Liposuction with standing technique[J]. Plust Reconstr Surg, 2000, 105(6):2268

[289]Shuter D, Drourr NR. Liposuction with standing technique:the true liposculpture [J]. Plast Reconstr Surg, 1999, 104(5):1546

[290]Zocchi M. Ultrasonic liposculpturing. Aesth Plast Surg, 1992, 16:287-289

[291]羅致誠, 蔣大宗, 楊小彬. 中國醫(yī)學(xué)百科全書, 生物醫(yī)學(xué)工程學(xué)[M].上?？茖W(xué)技術(shù)出版社, 1989. 54

[292]Beran SJ. External ultrasound—assisted lipoplasty from our experience. Aesthet Plast Surg, 2000, 24:270-274

[293]Rohrich RJ. Comparative lipoplasty analysis of in vivo treated adipose tissue. Plast Reconstr Surg, 2000, 105:2152-2154

[294]匡瑞霞, 吳延芳, 董　觀, 等. 超聲吸脂術(shù)73例報(bào)告. 實(shí)用整形美容外科雜志, 1997, 18:254-255

[295]Rosenberg GJ, Cabrera RC. External ultrasonic lipoplasty:an effective method of fat removal and skin shrinkage[J]. Plust Reconstr Surg, 2000, 105(2):758

[296]胡志奇, 齊向東, 高建華. 3種吸脂減肥術(shù)的療效比較[J]. 廣州醫(yī)學(xué), 2001, 22(10):916

[297]張雪松, 王　野, 劉學(xué)源. 常用三種去脂術(shù)臨床效果分析[J]. 黑龍江醫(yī)藥, 2002, 25(6):31

[298]李　斌, 馬曉冰, 王曉軍, 等. 脂肪切除術(shù)大鼠體重、血糖、胰島素及ob基因表達(dá)的研究[J]. 中華醫(yī)學(xué)美容雜志, 2000, 6(2):82

[299]Shestak KC. Marriage abdominoplasty expands the mini abdominoplasty concept [J]. Plast Reconstr Surg, 1999, 103(3):1020

[300]魯開化, 艾玉峰. 臨床美容整形外科學(xué). 西安:世界圖書出版公司, 1998. 441-447

[301]Rohrich RJ, Beran SJ. Is liposuction safe?Plast Reconstr Surg, 1999, 104:819-822

[302]Coleman WP, Glogau RG, Klein JA, et al. Guidelines of care for liposuction. J Am Acad Dermatol, 2001, 45:438-447

[303]Mia Talmor, Thomas J, Fahey Ⅱ, et al. Large volume liposuction complicated by retroperitoneal hemorrhage:management principles and implications for the quality improvement process. Plast Reconstr Surg, 2000, 105:2249-2250

[304]Teimourian B, Rogers WB. A national survey of complications associated with suction lipectomy:a comparative study. Plast Reconstr Surg, 1989, 84:628-631

[305]Daane SP, Rockwell WB. Analysis of methods for reporting severe and mortal lipoplasty complications. Aesthet Plast Surg, 1999, 23:303-306

[306]Meyers H, Brown-Elliott BA, Moore D, et al. An outbreak of mycobacterium chelonae infection following liposuction. Plast Reconstr Surg, 2001, 107:608-613

[307]Gingrass MK. Lipoplasty complications and their prevention. Clin Plast Surg, 1999, 26:341-354

[308]Illouz YG. History and current concept of lipoplasty. Clin Plast Surg, 1996, 23:721-730

[309]Flynn TC, Coleman WP, Field LM, et al. History of liposuction. Dermatol Surg, 2000, 26:515-520

[310]Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg, 1993, 92:1085-1098;discussion 1099-1100

[311]Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35mg/kg for liposuction. J Dermatol Surg Oncol, 1990, 16:248-263

[312]Fodor PB. Wetting solutions in aspirative lipoplasty:a plea for safety in liposuction. Aesthet Plast Surg, 1995, 19:379-380

[313]Trott SA, Berah SJ, Rohrich RJ, et al. Safety considerations in liposuction:An analysis of 53 consecutive patients. Plast Reconstr Surg, 1998, 102:2220-2229

[314]Samdal F, Amland PF, Bugge JF. Blood loss during liposuction using the tumescent technique. Aesthet Plast Surg, 1994, 18:157-160

[315]Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction. A surgeon’s perspective. Clin Plast Surg, 1996, 23:633-641, discussion642-645

[316]Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55mg/kg is safe for liposuction. Dermatol Surg, 1996, 22:921-927

[317]Burk RW3rd, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg, 1996, 97:1379-1384

[318]鄭　笛, 顧偉平, 黃云萍. 腹部減肥吸脂術(shù)的麻醉方法比較[J]. 浙江臨床醫(yī)學(xué), 2003, 5(3):273