腹腔镜袖状胃切除术与Roux-en-Y胃旁路术对肥胖合并阻塞性睡眠呼吸暂停患者术后代谢及胃食管反流病影响的研究进展

doi:10.3877/cma.j.issn.2095-8765.2026.01.007

本文系统比较腹腔镜袖状胃切除术（LSG）与Roux-en-Y胃旁路术（RYGB）对肥胖合并阻塞性睡眠呼吸暂停（OSAS）患者术后代谢影响的多种机制。胃食管反流病（GERD）作为OSAS的重要共病，二者存在双向加重的病理关系，术式对GERD的不同影响直接关乎OSAS的术后缓解效果。两种术式除通过体质量依赖机制减轻上气道脂肪沉积、缓解间歇性低氧与系统性炎症外，还通过胃肠激素重塑、胆汁酸信号激活与肠道菌群调控等非体质量依赖机制直接调节糖脂代谢。其中，RYGB在肠源性激素与胆汁酸调控方面更具优势，且兼具明确的抗反流作用；而LSG则通过强力抑制Ghrelin与增强GLP-1/PYY应答发挥代谢效益，还可通过调节GLP-1/DPP-4通路抑制氧化应激诱导的脂肪炎症，却存在诱发或加重GERD的风险。本文旨在为肥胖合并OSAS患者，尤其是合并GERD者，提供个体化术式选择的综合机制依据。

关键词: 腹腔镜袖状胃切除术, 胃旁路术, 肥胖症, 阻塞性睡眠呼吸暂停, 代谢, 胃食管反流病

This article systematically compares the multiple mechanisms by which laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) affect postoperative metabolism in obese patients with obstructive sleep apnea (OSAS). As a key comorbidity of OSAS, gastroesophageal reflux disease (GERD) has a bidirectional pathological exacerbation relationship with OSAS, and the different effects of these two procedures on GERD are directly related to the postoperative remission of OSAS. In addition to reducing upper airway fat deposition and alleviating intermittent hypoxia and systemic inflammation through weight-dependent mechanisms, both procedures directly regulate glucose and lipid metabolism via non-weight-dependent mechanisms such as gastrointestinal hormone remodeling, bile acid signal activation, and gut microbiota regulation. Among them, RYGB shows superior advantages in the regulation of enteric hormones and bile acids, and has a definite anti-reflux effect; while LSG exerts metabolic benefits by strongly inhibiting ghrelin and enhancing GLP-1/PYY responses, and can also inhibit oxidative stress-induced adipose inflammation through regulating the GLP-1/DPP-4 pathway, but carries the risk of inducing or exacerbating GERD. This review aims to provide a comprehensive mechanistic basis for the individualized selection of surgical procedures for obese patients with OSAS, especially those with concomitant GERD.

Key words: Laparoscopic sleeve gastrectomy, Roux-en-Y gastric bypass, Obesity, Obstructive sleep apnea, Metabolism, Gastroesophageal reflux disease

图1 肥胖合并OSAS患者GERD的个体化术式决策流程注：OSAS为阻塞性睡眠呼吸暂停；GERD为胃食管反流病；LES：为食管下括约肌；RYGB为Roux-en-Y胃旁路术。

表2 RYGB与LSG的机制比较

减重术式	RYGB	LSG
起效速度	极快，对血糖的改善常在术后数日内发生，远早于显著体质量下降	快，对血糖的改善迅速，前驱期略长于RYGB。
核心作用权重	强效的体质量非依赖机制与体质量依赖机制并重。肠源性机制作用尤为突出。	以体质量依赖机制为主，兼具重要的非体质量依赖机制。
主要效应激素	GLP-1\PYY餐后水平急剧、持久升高，效应强于LSG。胃泌素餐后反应较弱。	Ghrelin水平极度被抑制，是其核心作用。GLP-1\PYY餐后水平显著升高。
核心机制路径	食物快速抵达远端肠道，产生强效促胰液素效应，通过胆汁绕行强力激活远端肠道。	因切除胃底，极度抑制食物Ghrelin，同时促进食物与肠道接触，增强促胰液素的效应，限制食物摄入。
胆汁酸代谢	胆汁酸总量显著增加，成分发生改变，胆汁酸绕行十二指肠接触强力激活FXR和TGR5受体。	胆汁酸同样增加，但程度弱于RYGB，主要通过胃排空加速间接影响肠肝循环。
临床应用	对2型糖尿病、严重胰岛素抵抗患者效果更佳，缺点在于手术操作较复杂，长期营养风险较高，需严格随访。	对2型糖尿病有高缓解率，手术操作简单，营养并发症风险较低，但存在胃食管反流风险。
对OSAS缓解及间接效应	通过高效减重大幅度改善上呼吸道结构，缓解间歇性低氧和睡眠紊乱，从而减少氧化应激与系统性炎症间接改善胰岛素抵抗。	通过减重改善上气道解剖结构，有效缓解间歇性低氧和睡眠紊乱，间接促进代谢改善。

表2 RYGB与LSG的机制比较

减重术式	RYGB	LSG
起效速度	极快，对血糖的改善常在术后数日内发生，远早于显著体质量下降	快，对血糖的改善迅速，前驱期略长于RYGB。
核心作用权重	强效的体质量非依赖机制与体质量依赖机制并重。肠源性机制作用尤为突出。	以体质量依赖机制为主，兼具重要的非体质量依赖机制。
主要效应激素	GLP-1\PYY餐后水平急剧、持久升高，效应强于LSG。胃泌素餐后反应较弱。	Ghrelin水平极度被抑制，是其核心作用。GLP-1\PYY餐后水平显著升高。
核心机制路径	食物快速抵达远端肠道，产生强效促胰液素效应，通过胆汁绕行强力激活远端肠道。	因切除胃底，极度抑制食物Ghrelin，同时促进食物与肠道接触，增强促胰液素的效应，限制食物摄入。
胆汁酸代谢	胆汁酸总量显著增加，成分发生改变，胆汁酸绕行十二指肠接触强力激活FXR和TGR5受体。	胆汁酸同样增加，但程度弱于RYGB，主要通过胃排空加速间接影响肠肝循环。
临床应用	对2型糖尿病、严重胰岛素抵抗患者效果更佳，缺点在于手术操作较复杂，长期营养风险较高，需严格随访。	对2型糖尿病有高缓解率，手术操作简单，营养并发症风险较低，但存在胃食管反流风险。
对OSAS缓解及间接效应	通过高效减重大幅度改善上呼吸道结构，缓解间歇性低氧和睡眠紊乱，从而减少氧化应激与系统性炎症间接改善胰岛素抵抗。	通过减重改善上气道解剖结构，有效缓解间歇性低氧和睡眠紊乱，间接促进代谢改善。

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Laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: research progress on the mechanisms underlying postoperative metabolic changes and gastroesophageal reflux disease in obese patients with obstructive sleep apnea

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Laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: research progress on the mechanisms underlying postoperative metabolic changes and gastroesophageal reflux disease in obese patients with obstructive sleep apnea