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中華民國泌尿科醫學會雜誌

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篇名 Urolithiasis after Intestinal Bypass for Morbid Obesity-Chinese Experience
卷期 1:2
並列篇名 小腸繞道手術後之尿路結石
作者 邱文祥陳明村李瀛輝張心湜黃榮慶單子元彭芳谷
頁次 105-110
關鍵字 urolithiasisjejunoileal bypassmorbid obesityTSCI
出刊日期 199006

中文摘要

自從Dr. Kremen 25年前首次利用空腸迴腸繞道手術(Jejunoileal bypass),來治療病態肥胖症(morbid obesity)患者後,這種手術的療效已獲肯定,但是無可諱言地,這類手術可能造成一些併發症,例如:腹瀉,肝功能異常,膽結石,尿路結石,腎小管酸血症,腎病症候群……等。根據統計尿路結石發生率約在百分之二至百分之二十三之間,其中絕大多數為草酸鈣結石,台北榮民總醫院自民國63年2月至75年2月總共為65例病態肥胖症患者施行小腸繞道手術,其手術方式及治療效果已在中華外科醫學會雜誌報告過 (P’ eng et.al., J Surg Assoc ROC 21:397 -406, 1988)。其中4例發生尿路結石(6.1%),幸皆可以以手術或體外電震波碎石術處理。取出的結石,其分析皆為草酸鈣。這4例病人由手術至結石發現之間隔平均為100個月,這與西方報告多為2年內者有很大的差距,其原因常不詳。為進一步探討結石成因,追蹤檢查者中,17例接受靜脈腎盂攝影及新陳代謝評估,發現24小時尿中草酸含量比對照組顯著增加(51.4 ± 18.7 mg/day vs. 21.1 ± 13.6 mg/day,P value <0.0001)。至於血或尿中鈣、鎂、尿酸、無機磷酸或酸鹼度皆與正常人無異。探討這類病患尿中草酸過高的原因可能為:(1)有功能小腸長度縮短後,脂肪吸收減少,多餘的魯肪與鈣離子結合,造成腸管中游離鈣變少,相對地草酸與鈣的結合亦減少,使得游離草酸的吸收增加,(2) 接受過小腸繞道手術後,大腸對草酸的通透性(permeability)增加,更助長其吸收,(3) 肝腸循環(enterohepatic circulation)的改變增加了甘膠酸(glycine)的吸收,甘膠經肝臟代謝後變成草酸而增加血中草酸的濃度,(4) 此類病患常常腹瀉,使得尿中草酸濃度因缺水而相對增加。針對以上數點可能的致病機轉,我們建議患者儘量減少攝取高草酸,高脂肪食物,並多飲水(每日至少3000cc)期能降低尿中草酸濃度,進而減少尿路結石發生率。

英文摘要

Jejunoileal bypass for decreasing morbid obesity has been advocated by Kremen for more than 25 years. Not unexpectedly, obese patients in whom an intestinal bypass had been created have had multiple metabolic problems directly related to their surgical procedure, such as diarrhea, liver insufficiency, gall stone and urolithiases. The reported incidence of urinary tract stone was form 2% to 23%, and most of these stones were composed of calcium oxalate. From February 1947 to February 1986, a total of 65 morbid obese patients received the jejunoileal bypass at Veterans General Hospital, Taipei. Four of them (6.1%) suffered from urolithiasis after an unusual average duration of 100 months postoperatively, which is much longer than the western reports. The stone analyses were all composed of calcium oxalate. Seventeen of these 65 patients were reevaluated with urine analysis and intravenous urography for detecting the urolithiasis; the urine and blood were also sampled for the measurement of calcium, uric acid, magnesium, inorganic phosphate and oxalate. There was a significant increment of 24-hour urine oxalate in morbid obese patients as compared with the control group (51.4 ± 18.7 mg/day vs. 21.1 ± 13.6 mg/day,P value <0.0005), and abnormal urine oxalate level was found in 8 patients (47%). Nevertheless, other urine or serum concentration of calcium, uric acid, magnesium or phosphate showed no statistically significant difference in these two groups. (J Urol R.O.C., 1: 105-110, 1990)

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