摘要:目的" 應(yīng)用定量CT評(píng)估腹部?jī)?nèi)臟脂肪(VAT)及皮下脂肪(SAT),探討腹部脂肪分布與結(jié)直腸腺瘤的相關(guān)性。方法" 回顧性收集佛山市第一人民醫(yī)院2022年1月~2023年7月經(jīng)病理確診的100例結(jié)直腸腺瘤患者作為腺瘤組,又將腺瘤分為早期腺瘤(n=36)和進(jìn)展型腺瘤(n=64),之后收集我院同期的無腺瘤健康人群158例作為正常組,收集基本臨床資料并運(yùn)用定量CT測(cè)量腹部L2/3椎間隙水平的VAT及SAT面積。分別比較腺瘤組與正常組、不同病理類型腺瘤組的脂肪分布情況,采用Logistic回歸分析評(píng)估VAT、SAT與結(jié)直腸腺瘤發(fā)病風(fēng)險(xiǎn)的相關(guān)性。結(jié)果" 腺瘤組的VAT面積高于正常組(P=0.015),而SAT的差異無統(tǒng)計(jì)學(xué)意義(Pgt;0.05);進(jìn)展型腺瘤組VAT面積高于早期腺瘤(P=0.021)。Logistic回歸分析顯示,年齡、高血脂、BMI、VAT及VAT肥胖為結(jié)直腸腺瘤發(fā)生的獨(dú)立危險(xiǎn)因素(OR=2.044、1.325、1.147、1.895、2.185,Plt;0.05)。結(jié)論" VAT與結(jié)直腸腺瘤的發(fā)病存在一定聯(lián)系,VAT越高,發(fā)生腺瘤的風(fēng)險(xiǎn)可能也越高,也更有可能演變成進(jìn)展期腺瘤,而SAT與腺瘤的發(fā)生則無必然聯(lián)系。
關(guān)鍵詞:定量CT;結(jié)直腸腺瘤;內(nèi)臟脂肪;皮下脂肪
Correlation between visceral adipose tissue and colorectal adenoma assessed by quantitative CT
WANG Chengming, XU Zhifeng, XIONG Weixiang, YANG Yunjun
Department of Medical Imaging, the First People's Hospital of Foshan, Foshan 528000, China
Abstract: Objective To evaluate abdominal visceral fat (VAT) and subcutaneous fat (SAT) by quantitative CT, and to explore the correlation between abdominal fat distribution and colorectal adenoma. Methods A total of 100 patients with colorectal adenoma diagnosed by pathology in Foshan First People's Hospital from January 2022 to July 2023 were retrospectively collected as the adenoma group. The adenomas were divided into early adenomas (n=36) and advanced adenomas (n=64). Then, 158 healthy people without adenoma in our hospital during the same period were collected as the normal group. Basic clinical data were collected, and quantitative CT was used to measure the VAT and SAT areas at the L2/3 intervertebral space level in the abdomen. The fat distribution of the adenoma group was compared with the normal group and the adenoma groups of different pathological types. Logistic regression analysis was used to evaluate the correlation between VAT, SAT and the risk of colorectal adenoma. Results The VAT area of the adenoma group was higher than that of the normal group (P=0.015), while the difference in SAT was not statistically significant (Pgt;0.05),the VAT area of the advanced adenoma group was higher than that of" the early adenoma (P=0.021). Logistic regression analysis showed. Age, hyperlipidemia, BMI, VAT and VAT obesity were independent risk factors for colorectal adenoma (OR=2.044, 1.325, 1.147, 1.895, 2.185, Plt;0.05). Conclusion VAT is associated with the incidence of colorectal adenoma. The higher VAT, the higher risk of adenoma and more likely it is to develop into advanced adenoma. However, SAT is not necessarily associated with the occurrence of adenoma.
Keywords: quantitative computer tomography; colorectal adenoma; visceral adipose tissue; subcutaneous adipose tissue
結(jié)直腸癌是我國(guó)最常見的惡性腫瘤之一,其發(fā)病率及死亡率均呈上升趨勢(shì)[1-2]。結(jié)直腸腺瘤是最常見的腸癌癌前病變,經(jīng)由經(jīng)典的“腺瘤-腺癌”途徑發(fā)生癌變[3-4],雖然大部分腺瘤發(fā)展成為腺癌是一個(gè)漫長(zhǎng)的過程,但早預(yù)防及早診早治仍是降低結(jié)直腸癌發(fā)病率的重要手段。目前,結(jié)腸鏡檢查和息肉切除術(shù)是腸癌篩查和預(yù)防的最重要手段[5],但腸鏡檢查在我國(guó)人群受檢率較低,遠(yuǎn)遠(yuǎn)低于西方國(guó)家。流行病學(xué)研究顯示,高齡、肥胖、長(zhǎng)期吸煙飲酒、糖尿病、長(zhǎng)期攝入紅肉或加工肉類等是結(jié)直腸癌的危險(xiǎn)因素[6],而針對(duì)具有這些危險(xiǎn)因素的患者進(jìn)行篩查或干預(yù)將有助于減少結(jié)直腸癌和腺瘤的發(fā)生。
既往研究雖然已證實(shí)肥胖與結(jié)直腸腺瘤的發(fā)生密切相關(guān),但研究大多是基于BMI、腰圍、臀圍等傳統(tǒng)肥胖指標(biāo)來探討[7-8];且與西方人群相比,亞洲人群的體質(zhì)量中心分布普遍較低,體型較小[9]。因此,更準(zhǔn)確的測(cè)量腹部脂肪分布,特別是腹腔內(nèi)臟脂肪(VAT)的評(píng)估是有必要的。CT、超聲及MRI均能用于脂肪的評(píng)估,但后兩者存在準(zhǔn)確性差、檢查時(shí)間長(zhǎng)的問題,而CT則被認(rèn)為是目前腹部脂肪最準(zhǔn)確的測(cè)量方法[10]。目前,國(guó)內(nèi)運(yùn)用CT技術(shù)來探討VAT與結(jié)直腸腺瘤發(fā)生的相關(guān)研究較少[11-12],結(jié)果存在一定差異,且未重點(diǎn)討論腺瘤的發(fā)展與VAT的關(guān)系,仍需進(jìn)一步探討。本研究將運(yùn)用目前一種可靠的腹部脂肪測(cè)量工具即定量CT(QCT)來測(cè)量腹部VAT及皮下脂肪(SAT),從而探討腹部不同脂肪分布與結(jié)直腸腺瘤發(fā)生及發(fā)展的相關(guān)性。本研究將重點(diǎn)探討肥胖與結(jié)直腸腺瘤發(fā)生的關(guān)系,以期揭示二者之間更多的關(guān)聯(lián)性。
1" 資料與方法
1.1" 一般資料
回顧性收集2022年1月~2023年7月在佛山市第一人民醫(yī)院行腸鏡檢查發(fā)現(xiàn)結(jié)直腸腺瘤,同時(shí)因臨床需求在我院行全腹部CT檢查的患者,CT與腸鏡檢查間隔不超過1月。納入標(biāo)準(zhǔn):年齡18~80歲;無幼年性息肉病、家族性結(jié)腸息肉病、惡性腫瘤、炎癥性腸病、腹腔積液及腹膜炎患者;既往未接受腹部手術(shù);排除臨床資料不足或圖像質(zhì)量差。最終共100例結(jié)直腸腺瘤患者納入研究作為腺瘤組,其中男性53例,女性47例,年齡60.3±11.8歲。納入我院同期的158例無結(jié)直腸腺瘤健康人群作為正常組,其中男性95例,女性63例,年齡50.3±14.6歲。收集受檢者的基本信息及臨床資料,包括年齡、性別、體質(zhì)量、身高、血壓、血脂、血糖、既往史及吸煙飲酒史。本研究已通過佛山市第一人民醫(yī)院倫理委員會(huì)批準(zhǔn)[審批號(hào):倫審研(2021)第175號(hào)]。
1.2" 檢查設(shè)備與測(cè)量方法
1.2.1" 結(jié)腸鏡檢查" "研究對(duì)象于術(shù)前1 d行腸道準(zhǔn)備,晚8點(diǎn)后禁食并服用和爽及溫水清潔腸道,第2天上午由具有10年以上工作經(jīng)驗(yàn)的消化內(nèi)科醫(yī)生行結(jié)腸鏡檢查,檢查者及被檢查者均對(duì)腹部脂肪測(cè)量結(jié)果不知情。檢查范圍由直腸至回盲部,檢查者對(duì)腸鏡下觀察到的病灶均進(jìn)行活檢,之后送病理檢查,同時(shí)記錄腺瘤的大小、位置、數(shù)量。本研究將腺瘤分組為早期腺瘤組(n=36)和進(jìn)展型腺瘤組(n=64)。進(jìn)展型腺瘤的定義如下:息肉直徑≥10 mm;絨毛狀息肉或混合性息肉中絨毛樣結(jié)構(gòu)超過25%;伴高級(jí)別上皮內(nèi)瘤變,只要滿足上述條件之一則定義為進(jìn)展型腺瘤[11]。多發(fā)腺瘤指腺瘤個(gè)數(shù)≥2個(gè)。
1.2.2" 腹部CT掃描" "腹部CT檢查與腸鏡檢查間隔1月內(nèi)。檢查前1 d晚8點(diǎn)后禁食,次日空腹行CT檢查,檢查前口服約500 mL溫水。采用Philips 256iCT進(jìn)行掃描,掃描范圍需覆蓋膈頂至恥骨聯(lián)合水平。掃描參數(shù):管電流600~800 mAs/轉(zhuǎn),管電壓100~120 kV,準(zhǔn)直器128×0.625,螺距0.16~0.20,旋轉(zhuǎn)時(shí)間270~330 ms,矩陣512×512,顯示野500 mm。
1.2.3" 腹部脂肪面積測(cè)量" "將層厚1 mm、層間距1 mm的腹部平掃軸位Dicom數(shù)據(jù)傳輸至Mindways QCT軟件,運(yùn)用軟件中的Tissue Compositon模塊進(jìn)行腹部脂肪面積測(cè)量,選取L2/3椎間隙水平測(cè)量VAT及SAT面積[13]。由2位具有5年以上工作經(jīng)驗(yàn)的影像科診斷醫(yī)生分別進(jìn)行測(cè)量,若2次測(cè)量結(jié)果lt;5 cm2,結(jié)果取其平均值,若2次測(cè)量結(jié)果差異gt;5 cm2,需進(jìn)行重復(fù)測(cè)量。VAT肥胖定義為男性VAT面積gt;142 cm2、女性VAT面積gt;115 cm2。
1.2.4" 統(tǒng)計(jì)學(xué)分析" "采用SPSS22.0軟件對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差表示,計(jì)數(shù)資料以n(%)表示。計(jì)量資料的組間比較行t檢驗(yàn),計(jì)數(shù)資料的組間比較行卡方檢驗(yàn)。評(píng)估不同影響因素(自變量)對(duì)結(jié)直腸腺瘤發(fā)生(因變量)的影響采用Logistic回歸分析。以Plt;0.05為差異有統(tǒng)計(jì)學(xué)意義。
2" 結(jié)果
2.1" 臨床資料比較
與正常組對(duì)比,腺瘤組的年齡更大,高血脂發(fā)病率及吸煙者比例更高,差異有統(tǒng)計(jì)學(xué)意義(Plt;0.05,表1)。
2.2" 腺瘤組與正常組肥胖相關(guān)指標(biāo)的比較
與正常組對(duì)比,腺瘤組的VAT面積更高(圖1),VAT肥胖患病率更高,差異均有統(tǒng)計(jì)學(xué)意義(Plt;0.05);而兩組SAT面積量及BMI的差異無統(tǒng)計(jì)學(xué)意義(Pgt;0.05,表2)。
2.3" 不同腺瘤分型肥胖相關(guān)指標(biāo)的比較
與早期腺瘤組對(duì)比,進(jìn)展型腺瘤組的VAT面積更高,VAT肥胖患病率更高,差異有統(tǒng)計(jì)學(xué)意義(Plt;0.05);而SAT面積及BMI的差異無統(tǒng)計(jì)學(xué)意義(Pgt;0.05)。單發(fā)腺瘤組與多發(fā)腺瘤組VAT、SAT、VAT肥胖及BMI的差異無統(tǒng)計(jì)學(xué)意義(Pgt;0.05,表3)。
2.4" 結(jié)直腸腺瘤的獨(dú)立危險(xiǎn)因素分析
多因素Logistic回歸分析結(jié)果顯示,年齡、高血脂、BMI、VAT及VAT肥胖為結(jié)直腸腺瘤發(fā)生的獨(dú)立危險(xiǎn)因素(OR=2.044、1.325、1.147、1.895、2.185,Plt;0.05,表4)。
3" 討論
本研究運(yùn)用定量CT技術(shù)測(cè)量腹部VAT及SAT面積,并探討了腹部脂肪分布與結(jié)直腸腺瘤發(fā)生的關(guān)系,結(jié)果顯示結(jié)直腸腺瘤患者的VAT含量明顯高于非腺瘤人群,VAT肥胖發(fā)病率也更高,而SAT并沒有明顯差異;在調(diào)整了多種危險(xiǎn)因素及混雜因素進(jìn)行分析后,發(fā)現(xiàn)結(jié)直腸腺瘤的發(fā)生與VAT面積仍獨(dú)立相關(guān),與SAT面積則無相關(guān)性,這與既往部分研究結(jié)果[14-16]一致。同時(shí),研究中將腺瘤分為進(jìn)展期腺瘤及早期腺瘤進(jìn)行探討,結(jié)果發(fā)現(xiàn)進(jìn)展期腺瘤的VAT面積遠(yuǎn)遠(yuǎn)高于早期腺瘤患者,這與既往一些研究[15-18]有所不同,提示VAT的堆積可能誘發(fā)腺瘤的發(fā)生,同時(shí)也可能會(huì)導(dǎo)致部分早期腺瘤向進(jìn)展期腺瘤的演變。雖然確切的機(jī)制尚未完全知曉,但這可能與VAT內(nèi)的一些腫瘤相關(guān)因子是一直存在并可能發(fā)揮作用。脂肪組織其實(shí)是具有高代謝活性的內(nèi)分泌組織,國(guó)外學(xué)者通過18F-FDG PET/CT檢測(cè)發(fā)現(xiàn)VAT內(nèi)的葡萄糖代謝比SAT旺盛,這說明VAT的代謝活性高于SAT[18-19]。脂肪組織能分泌許多細(xì)胞因子和激素,它們共同被稱為“脂肪因子”,如瘦素具有致瘤性,其通過多種途徑調(diào)節(jié)血管生成或凋亡,可能促進(jìn)結(jié)直腸腫瘤的發(fā)生與發(fā)展[20-21]。同時(shí),部分研究發(fā)現(xiàn)VAT堆積在肥胖誘導(dǎo)的胰島素抵抗和全身慢性炎性反應(yīng)狀態(tài)中發(fā)揮著關(guān)鍵作用,不僅是代謝性疾病、心腦血管疾病等肥胖相關(guān)疾病的病理生理基礎(chǔ),也同時(shí)增加多種惡性腫瘤的發(fā)生和死亡風(fēng)險(xiǎn),特別是胃腸道腫瘤的發(fā)生及發(fā)展[22-26]。
本研究通過VAT面積對(duì)男女性VAT肥胖進(jìn)行了分組,同時(shí)將內(nèi)臟脂肪肥胖作為其中的影響因素進(jìn)行探討,發(fā)現(xiàn)腺瘤組中VAT肥胖人群明顯高于非腺瘤組。同時(shí),VAT肥胖也是腺瘤發(fā)生的獨(dú)立危險(xiǎn)因素。該結(jié)果提示當(dāng)患者被納入VAT肥胖人群,則需高度警惕腺瘤的發(fā)生,定期的腸鏡檢查對(duì)這部分人群將更有必要,這將有助于早期腺瘤的發(fā)現(xiàn)及治療。國(guó)外有研究以L4/5椎間隙水平為測(cè)量基線,結(jié)果顯示當(dāng)腹部?jī)?nèi)臟脂肪面積大于200 cm2時(shí),結(jié)直腸腺瘤的發(fā)生風(fēng)險(xiǎn)將提高3倍以上[27]。另外,雖然既往多數(shù)研究均證明BMI與結(jié)直腸腺瘤的發(fā)生無相關(guān)性[28-30],但是本研究結(jié)果提示這種相關(guān)性是存在的,不過其危險(xiǎn)性明顯低于VAT(ORVATgt;ORBMI)。我們分析可能是BMI也能反應(yīng)肥胖程度,包括機(jī)體肌肉及脂肪分布特征,且與VAT分布存在一定正相關(guān)性。需要指出的是,對(duì)比西方國(guó)家的一些研究[31-32],我國(guó)人群BMI往往偏低,本研究BMI約22 kg/cm2,而西方國(guó)家人群為24~26 kg/cm2。很多看似體型標(biāo)準(zhǔn)同時(shí)BMI正常者卻是內(nèi)臟脂肪肥胖患者,這部分人群反而容易被忽視,需得到更多的關(guān)注。雖然常規(guī)使用CT測(cè)量VAT并未得到廣泛運(yùn)用,且輻射問題無法繞開且一直被質(zhì)疑。但針對(duì)有CT檢查臨床需求的患者,推薦常規(guī)開展,腹部脂肪的測(cè)量并未增加患者的輻射劑量及經(jīng)濟(jì)負(fù)擔(dān),同時(shí)其準(zhǔn)確性及可重復(fù)性佳。
本研究的局限性:本研究為單中心研究,且結(jié)直腸腺瘤樣本不夠大;由于本研究的橫斷面設(shè)計(jì),內(nèi)臟脂肪與結(jié)直腸腺瘤的發(fā)展之間的時(shí)間關(guān)系尚不清楚;脂肪代謝也是新陳代謝的一部分,影響脂肪含量及分布的因素眾多,如體育鍛煉、飲食方式等,本研究未完全納入分析。后續(xù)研究希望納入更多結(jié)直腸腺瘤的病例進(jìn)行研究,同時(shí)進(jìn)行長(zhǎng)期隨訪,觀察VAT與腺瘤復(fù)發(fā)及癌變的關(guān)系。
綜上,通過定量CT測(cè)量的VAT面積與結(jié)直腸腺瘤的發(fā)病存在一定聯(lián)系,VAT含量越高,發(fā)生結(jié)直腸腺瘤的風(fēng)險(xiǎn)可能也越高,而皮下脂肪與腺瘤的發(fā)生則無必然聯(lián)系;同時(shí),隨著VAT的進(jìn)一步堆積,將可能促進(jìn)早期腺瘤向進(jìn)展期腺瘤的轉(zhuǎn)變。
參考文獻(xiàn):
[1]" Jideh B, Bourke MJ. Colorectal cancer screening reduces incidence, mortality and morbidity[J]. Med J Aust, 2018, 208(11): 483-4.
[2]" Angenete E. Reducing morbidity and mortality in the elderly population with colorectal cancer[J]. Colorectal Dis, 2020, 22(4): 362-3.
[3]" Cui GL, Wang ZQ, Liu HZ, et al. Cytokine-mediated crosstalk between cancer stem cells and their inflammatory niche from the colorectal precancerous adenoma stage to the cancerous stage: mechanisms and clinical implications[J]. Front Immunol, 2022, 13: 1057181.
[4]" " 吳靜怡, 曹海龍, 王邦茂. 重視結(jié)直腸腺瘤癌變的精準(zhǔn)防治[J]. 中國(guó)實(shí)用內(nèi)科雜志, 2018, 38(9): 784-7.
[5]" Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths[J]. N Engl J Med, 2012, 366(8): 687-96.
[6]" "中華醫(yī)學(xué)會(huì)消化內(nèi)鏡學(xué)分會(huì)結(jié)直腸學(xué)組. 中國(guó)結(jié)直腸癌及癌前病變內(nèi)鏡診治共識(shí)(2023,廣州)[J]. 中華消化內(nèi)鏡雜志, 2023, 40(7): 505-20.
[7]" "Nagata N, Sakamoto K, Arai T, et al. Effect of body mass index and intra-abdominal fat measured by computed tomography on the risk of bowel symptoms[J]. PLoS One, 2015, 10(4): e0123993.
[8]" "Huang BZ, Tsilidis KK, Smith MW, et al. Polymorphisms in genes related to inflammation and obesity and colorectal adenoma risk[J]. Mol Carcinog, 2018, 57(10): 1278-88.
[9]" "Wells JCK, Treleaven P, Charoensiriwath S. Body shape by 3-D photonic scanning in Thai and UK adults: comparison of national sizing surveys[J]. Int J Obes, 2012, 36(1): 148-54.
[10] Maurovich-Horvat P, Massaro J, Fox CS, et al. Comparison of anthropometric, area-and volume-based assessment of abdominal subcutaneous and visceral adipose tissue volumes using multi-detector computed tomography[J]. Int J Obes (Lond), 2007, 31(3): 500-6.
[11]" 葉驊駿, 徐含煙, 蔣學(xué)佩, 等. 腹部脂肪分布與結(jié)直腸息肉的相關(guān)性[J]. 溫州醫(yī)科大學(xué)學(xué)報(bào), 2018, 48(7): 490-4.
[12]nbsp; 吳海武, 賴衛(wèi)國(guó), 劉國(guó)焰, 等. 腹部?jī)?nèi)臟脂肪厚度與結(jié)直腸腺瘤發(fā)病的關(guān)系[J]. 中國(guó)老年學(xué)雜志, 2016, 36(23): 5882-4.
[13]" 康海鋒, 李海燕, 朱凌音, 等. 結(jié)腸進(jìn)展期腺瘤的內(nèi)鏡下檢出特點(diǎn)[J]. 中華消化內(nèi)鏡雜志, 2014, 31(9): 542-4.
[14] Riondino S, Roselli M, Palmirotta R, et al. Obesity and colorectal cancer: role of adipokines in tumor initiation and progression[J]. World J Gastroenterol, 2014, 20(18): 5177-90.
[15]" Kim B, Kim BC, Nam SY, et al. Visceral adipose tissue volume and the occurrence of colorectal adenoma in follow-up colonoscopy for screening and surveillance[J]. Nutr Cancer, 2017, 69(5): 739-45.
[16] Nagata N, Sakamoto K, Arai T, et al. Visceral abdominal fat measured by computed tomography is associated with an increased risk of colorectal adenoma[J]. Int J Cancer, 2014, 135(10): 2273-81.
[17] Cheng X, Zhang Y, Wang C, et al. The optimal anatomic site for a single slice to estimate the total volume of visceral adipose tissue by using the quantitative computed tomography (QCT) in Chinese population[J]. Eur J Clin Nutr, 2018, 72(11): 1567-75.
[18] Yoon HJ, Kim BS, Lee KE, et al. Glucose metabolism of visceral adipose tissue measured by 18F-FDG PET/CT is related to the presence of colonic adenoma[J]. Medicine, 2017, 96(25): e7156.
[19]Oliveira AL, Azevedo DC, Bredella MA, et al. Visceral and subcutaneous adipose tissue FDG uptake by PET/CT in metabolically healthy obese subjects[J]. Obesity, 2015, 23(2): 286-9.
[20] Mathis D. Immunological goings-on in visceral adipose tissue[J]. Cell Metab, 2013, 17(6): 851-9.
[21] Palau?Rodriguez M, Marco?Ramell A, Casas-Agustench P, et al. Visceral adipose tissue phospholipid signature of insulin sensitivity and obesity[J]. J Proteome Res, 2021, 20(5): 2410-9.
[22] Liu JT, Yao HY, Yu SC, et al. Joint association of metabolic health and obesity with ten?year risk of cardiovascular disease among Chinese adults[J]. Biomed Environ Sci, 2022, 35(1): 13-21.
[23] Elangovan A, Skeans J, Landsman M, et al. Colorectal cancer, age, and obesity-related comorbidities: a large database study[J]. Dig Dis Sci, 2021, 66(9): 3156-63.
[24] Djiogue S, Nwabo Kamdje AH, Vecchio L, et al. Insulin resistance and cancer: the role of insulin and IGFs[J]. Endocr Relat Cancer, 2013, 20(1): R1-R17.
[25]" Chiefari E, Mirabelli M, La Vignera S, et al. Insulin resistance and cancer: in search for a causal link[J]. Int J Mol Sci, 2021, 22(20): 11137.
[26]" Jung IS, Shin CM, Park SJ, et al. Association of visceral adiposity and insulin resistance with colorectal adenoma and colorectal cancer[J]. Intest Res, 2019, 17(3): 404-12.
[27] Ng ZQ, Wijesuriya R, Misur P, et al. Opportunistic use of radiological measures of visceral adiposity for assessment of risk of colorectal adenoma[J]. ANZ J Surg, 2020, 90(11): 2298-303.
[28] Moon JM, Im JP, Kim D, et al. Increasing changes in visceral adiposity is associated with higher risk for colorectal adenoma: Multilevel analysis in a prospective cohort[J]. J Gastroenterol Hepatol, 2021, 36(7): 1836-42.
[29] Liu ZH, Zhang GX, Zhang H, et al. Association of body fat distribution and metabolic syndrome with the occurrence of colorectal adenoma: a case-control study[J]. J Dig Dis, 2021, 22(4): 222-9.
[30] Seo JY, Han YM, Chung SJ, et al. Visceral obesity is a more important factor for colorectal adenomas than skeletal muscle or body fat[J]. Cancers, 2022, 14(21): 5256.
[31]" Morris K, Tuorto S, G?nen M, et al. Simple measurement of intra-abdominal fat for abdominal surgery outcome prediction[J]. Arch Surg, 2010, 145(11): 1069-73.
[32]" Im JP, Kim D, Chung SJ, et al. Visceral obesity as a risk factor for colorectal adenoma occurrence in surveillance colonoscopy[J]. Gastrointest Endosc, 2018, 88(1): 119-27.e4.
(編輯:郎" 朗)