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비만/대사 수술이 체중 감소와 당뇨병 관해를 일으키는 기전

Mechanism of Weight Loss and Diabetes Remission after Bariatric/Metabolic Surgery

조영민
대한내과학회 (The Korean Association Of Internal Medicine)|2013.05|대한내과학회지 (The Korean Journal of Medicine)|제84권 제5호|pp. 629-639|DOI http://dx.doi.org/10.3904/kjm.2013.84.5.629

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비만당뇨병ObesityType 2 diabetesBariatric surgeryMetabolic surgeryGastrointestinal hormones비만 수술신진 대사 수술위장 호르몬
주제분류내과학

초록

본 종설에서 살펴본 것처럼 비만/대사 수술을 통해 체중 감소가 일어나고 대사 이상이 개선되는 것은 매우 다양한 기전의 복합적인 상호작용에 의해서 일어난다. 각각의 기전에 대해서는 좀더 연구가 필요하며, 이러한 기전을 밝힘으로써 수술을 하지 않고 내과적 치료만으로 비슷한 효과를 얻을 수 있는 시대가 곧 다가 올 것으로 믿어 의심치 않는다. 그러나 수술과는 달리 평생 약을 복용해야 할 가능성이 있기 때문에 일회성의 치료로 식행동까지 바꾸어 놓는 비만/대사수술은 여전히 유용한 치료 수단으로 남을 것으로 전망된다. 무수한 미해결 과제가 산재해 있지만, 대한민국의 의사로서 가장 궁금한 점은 “과연 우리나라 환자들에게도 비만대사 수술이 유용할 것인가?”라는 질문일 것이다. 최근 한 연구에서 22명의 체질량지수 32 kg/m2 정도인 비만한 제2형 당뇨병 환자를 대상으로 루와이 위우회술을 시행한 결과 16명(73%)에서 수술 후 1년째 검사에서 당뇨병의 관해가 확인되었으며(공복혈당 < 126 mg/dL이면서 HbA1c < 6.5%를 기준으로 함), 수술 전 내장지방이 많은 경우 관해가 잘 일어나지 않았고 관해가 일어난 환자들은 수술 후 1년째 인슐린 분비능에는 차이가 없었으나 인슐린 감수성이 우수한 특징을 보였다[67]. 전국적으로 이루어진 연구에서 2008년부터 2011년까지 비만/대사 수술(27.6%가 위밴드술, 28.0%가 루와이 위우회술, 44.4%가 위소매 절제술)을 받은 261명의 환자와 생활습관교정과 약물 치료 등의 내과적 치료를 받은 224명을 후향적으로 분석한 결과, 치료 후 18개월 경과 시점에 치료 시작 시점 대비 수술군에서 22.6% 대조군에서 6.7%의 체중 감소가 있었고, 당뇨병, 고혈압, 이상지혈증으로부터 각각 57%, 47%, 84%에서 회복이 되어 대조군의 10%, 20%, 24% 보다 유의하게 우수한 성적을 보임을 알 수 있었다[68]. 체중 감소는 큰 차이는 없었으나 루와이 위우회술에서 수술전 체중 대비 26.6%의 감소가 있었고, 위밴드술에서 20.8%, 위소매 절제술에서 22.3%의 체중 감소를 보였다[68]. 수술군에서 1명이 30일 이내에 흡인성 폐렴으로 사망하여 수술 관련 사망률은 0.38%이었으며, 위소매 절제술의 경우 수술 직후 및 그 이후의 합병증이 가장 낮았다[68]. 그러나 수술군이 대조군에 비해 유의하게 체질량지수가 높았고(39.0 ± 6.2 kg/m2 vs. 34.3 ± 3.8 kg/m2) 당뇨병 유병률도 수술군이 대조군에 비해 유의하게 높은(39.1% vs. 12.9%) 등, 두 그룹 간의 차이가 있었기 때문에 정확한 비교가 이루어졌다고 볼 수 없다. 그럼에도 불구하고 수술군에서 현저한 체중 감소와 대사 합병증의 호전이 있었으므로 국내 비만 환자에게도 비만/대사수술은 중요한 치료 방법의 하나이며 어쩌면 가장 우수한 치료법이라고 할 수 있을 것이다. 이러한 점에서 대사 합병증을 동반한 비만 환자의 경우 비만/대사수술이 하루 빨리 건강보험의 혜택을 받아야 할 것이다. 앞으로 여러 진료과의 의사들이 협력하여 비만대사수술을 받는 환자를 관리해야 할 것이며, 또한 이 분야의 미해결 과제를 풀기 위해 함께 노력해야 할 것이다.

Abstract

The greatest achievement in the treatment of obesity and diabetes would be the development of bariatric/metabolic surgery. At the beginning, bariatric surgeries were developed to simply reduce body weight in morbidly obese subjects. Before long, it was discovered that diabetes and other metabolic complications of obesity could be placed in remission. The remission rate of diabetes after bariatric surgery is strikingly high and, in the case of Roux-en-Y gastric bypass surgery, diabetes remission commonly occurs immediately after the surgery, when significant weight loss does not take place. Therefore, the concept of bariatric surgery has evolved into metabolic surgery. Physiologic changes in gastrointestinal endocrine system following the anatomical changes made by bariatric/metabolic surgery are regarded as the major mechanisms of weight loss and diabetes remission. In this regard, the foregut and hindgut hypotheses were suggested as the mechanisms associated with diabetes remission. With the advent of sleeve gastrectomy, which does not bypass the foregut (duodenum and proximal jejunum) but increases the secretion of glucagon-like peptide-1, the foregut hypothesis is currently under attack. However, a single mechanism is not enough to explain the metabolic effect of bariatric/metabolic surgery. Further studies are warranted to elucidate the mechanisms of metabolic improvements after bariatric/metabolic surgery.

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