Revisionseingriffe nach bariatrischen Operationen – Überblick über Komplikationsspektrum und derzeitige therapeutische Optionen

Zusammenfassung

Hintergrund: Die Adipositas nimmt weltweit in alarmierendem Ausmaß zu. Vor allem in den Ländern der westlichen Welt hat sie sich zu einem ernsthaften medizinischen und sozioökonomischen Problem entwickelt. Diskussion: Die chirurgische Therapie gilt derzeit als einzige Behandlungsoption, mit deren Hilfe bei der Mehrzahl der morbid Adipösen eine deutliche Reduktion des Körpergewichts erreicht und erhalten werden kann. Darüber hinaus werden assoziierte Komorbiditäten positiv beeinflusst. Die Akzeptanz der Chirurgie als effektivste Therapie hat in den letzten Jahren zu einer deutlichen Zunahme bariatrischer Eingriffe geführt. Damit wächst jedoch auch die Zahl der Patienten mit operationsassoziierten Früh- bzw. Langzeitkomplikationen, welche die Durchführung von Revi­sionsoperationen erfordern. 10–25 % der Patienten nach bariatrischen Eingriffen benötigen im weiteren Verlauf eine operative Revision. Hauptindikationen hierfür sind der inadäquate Gewichtsverlust, eingriffsspezifische, allgemeine chirurgische sowie nicht-chirurgische Komplikationen durch nutritive oder metabolische Störungen. Es gibt derzeit keine randomisierten Untersuchungen, welche die Frage – welche Operation bei welchem Patienten und nach welchem primären Eingriff – eindeutig beantworten können. Häufig werden Entscheidungen von den Erfahrungen und Vorzügen des behandelnden Chirurgen bzw. von Wünschen des Patienten beeinflusst. Schlussfolgerungen: Bariatrische Revisionsoperationen stellen anspruchsvolle, technisch kom­plexe Eingriffe dar, welche mit einer erhöhten Komplikationsrate assoziiert sind und grundsätzlich in Zentren mit Expertise auf diesem Gebiet, nach Möglichkeit laparoskopisch durchgeführt werden sollten. Bestimmte akute Komplikatio­nen müssen jedoch von jedem Viszeralchirurgen erkannt und entsprechend behandelt werden können. Bei Ver­sagen rein restriktiver Operationen kann die Revision ohne ­Umwandlung in ein anderes Verfahren nur bei Komplikationen mit adäquatem Gewichtsverlust und entsprechender Patientenzufriedenheit empfohlen werden. In den übrigen Fällen sollte eine Konversion zu einem kombinierten Verfahren erfolgen. Bei Versagen kombinierter Operationen können durch Verbesserung der restriktiven oder malabsorptiven Komponente in der Regel ein weiterer Gewichtsverlust erreicht oder Komplikationen erfolg­reich therapiert werden. Bei Erhöhung der Malabsorption steigt jedoch auch das Risiko metabolischer und nutritiver Störungen.

Abstract

Background: Obesity is increasing worldwide at an alarming rate. Particularly in Western countries, obesity and related problems have become a serious medical problem and an enormous socio­economic burden. Discussion: Currently, surgery is the only avail­able treatment for patients with severe obesity which leads to sustained weight loss and cure of co-morbidities in the majority of the patients. The increase in the number of bariatric opera­tions and the occasional failure and complications of these surgical procedures have resulted in an increased need for revision surgery. Overall, 10–25 % of patients are expected to need a revision for failure of the primary bariatric procedure. The main indications for revision procedures are inadequate weight loss, surgery-related complications as well as surgical emergencies and long-term complications caused by malnutrition or ­vitamin deficiencies. Unfortunately, there are currently no randomised trials to answer the ques­tion as to which operation should be performed in which patient and after which procedure. Deci­sions are often influenced by the expertise and preference of the operating surgeon as well as by patient’s preference. Thus, a systematic review of published data to this complex issue appears to be helpful and important for daily surgical prac­tise. Conclusions: Revision bariatric procedures are technically more complex and associated with increased postoperative complications. These operations should basically be performed in cen­tres with profound expertise in this field of surgery, and – whenever possible – laparoscopically. However, every abdominal surgeon should be able to diagnose and treat some acute complica­tions. After failed restrictive procedures, revision is recommended only in cases of complications but with adequate weight loss at the time of ­fail­ure. Otherwise, conversion to combined procedures should be considered. After the failure of combined procedures, further weight loss or successful treatment of complications can be achieved by adding more restriction and / or malabsorption components. The latter is associated with an increased risk of nutri­tional sequelae.

Schlüsselwörter

Revision - bariatrische Chirurgie - Komplikationen - Übersicht

Key words

revision - bariatric surgery - complications - review

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