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

 

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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.

Literatur

• 1 Anthone G J, Lord R V, DeMeester T R et al. The duodenal switch operation for the treatment of morbid obesity.  Ann Surg. 2003;  238 618-627
  PubMedGoogle Scholar
• 2 Balsiger B M, Poggio J L, Mai J et al. Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity.  J Gastrointest Surg. 2000;  4 598-605
  CrossrefPubMedGoogle Scholar
• 3 Baltasar A, Bou R, Bengochea M et al. Duodenal switch: an effective therapy for morbid obesity – intermediate results.  Obes Surg. 2001;  11 54-58
  CrossrefPubMedGoogle Scholar
• 4 Baltasar A, Serra C, Pérez N et al. Laparoscopic sleeve gastrectomy: a multi-purpose bariatric operation.  Obes Surg. 2005;  15 1124-1128
  CrossrefPubMedGoogle Scholar
• 5 Baltasar A, Serra C, Pérez N et al. Re-sleeve gastrectomy.  Obes Surg. 2006;  16 1535-1538
  CrossrefPubMedGoogle Scholar
• 6 Bernante P, Foletto M, Busetto L et al. Feasibility of laparoscopic sleeve gastrectomy as a revision procedure for prior laparoscopic gastric banding.  Obes Surg. 2006;  16 1327-1330
  CrossrefPubMedGoogle Scholar
• 7 Bessler M, Daud A, DiGiorgi M F et al. Adjustable gastric banding as a ­revisional bariatric procedure after failed gastric bypass.  Obes Surg. 2005;  15 1443-1448
  CrossrefPubMedGoogle Scholar
• 8 Boschi S, Fogli L, Berta R D et al. Avoiding complications after laparoscopic esophago-gastric banding: experience with 400 consecutive ­patients.  Obes Surg. 2006;  16 1166-1170
  CrossrefPubMedGoogle Scholar
• 9 Brolin R E, Cody R P. Adding malabsorption for weight loss failure after gastric bypass.  Surg Endosc. 2007;  21 1924-1926
  CrossrefPubMedGoogle Scholar
• 10 Buchwald H, Williams S E. Bariatric surgery worldwide 2003.  Obes Surg. 2004;  14 1157-1164
  CrossrefPubMedGoogle Scholar
• 11 Camerini G, Adami G, Marinari G M et al. Thirteen years of follow-up in patients with adjustable silicone gastric banding for obesity: weight loss and constant rate of late specific complications.  Obes Surg. 2004;  14 1343-1348
  CrossrefPubMedGoogle Scholar
• 12 Dolan K, Fielding G. Bilio pancreatic diversion following failure of lap­aroscopic adjustable gastric banding.  Surg Endosc. 2004;  18 60-63
  CrossrefPubMedGoogle Scholar
• 13 Dolan K, Hatzifotis M, Newbury L et al. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch.  Ann Surg. 2004;  240 51-56
  CrossrefPubMedGoogle Scholar
• 14 Gagner M, Gentileschi P, de Csepel J et al. Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients.  Obes Surg. 2002;  12 254-260
  CrossrefPubMedGoogle Scholar
• 15 Gagner M, Rogula T. Laparoscopic reoperative sleeve gastrectomy for poor weight loss after biliopancreatic diversion with duodenal switch.  Obes Surg. 2003;  13 649-654
  CrossrefPubMedGoogle Scholar
• 16 Gavert N, Szold A, Abu-Abeid S. Laparoscopic revisional surgery for life-threatening stenosis following vertical banded gastroplasty, together with placement of an adjustable gastric band.  Obes Surg. 2003;  13 399-403
  CrossrefPubMedGoogle Scholar
• 17 Gavert N, Szold A, Abu-Abeid S. Safety and feasibility of revisional lap­aroscopic surgery for morbid obesity: conversion of open silastic vertical banded gastroplasty to laparoscopic adjustable gastric banding.  Surg Endosc. 2004;  18 203-206
  CrossrefPubMedGoogle Scholar
• 18 Genco A, Bruni T, Doldi S B et al. BioEnterics intragastric balloon: The Italian experience with 2515 patients.  Obes Surg. 2005;  15 1161-1164
  CrossrefPubMedGoogle Scholar
• 19 Gonzalez R, Gallagher S F, Haines K et al. Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass.  J Am Coll Surg. 2005;  201 366-374
  CrossrefPubMedGoogle Scholar
• 20 Gumbs A A, Pomp A, Gagner M. Revisional bariatric surgery for inadequate weight loss.  Obes Surg. 2007;  17 1137-1145
  CrossrefPubMedGoogle Scholar
• 21 Higa K D, Boone K, Nimeri A et al. Gastric bypass: increased restriction for poor weight loss.  Surg Endosc. 2007;  21 1922-1923
  CrossrefPubMedGoogle Scholar
• 22 Himpens J, Dapri G, Cadière G B. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years.  Obes Surg. 2006;  16 1450-1456
  CrossrefPubMedGoogle Scholar
• 23 Ikramuddin S, Kellogg T A, Leslie D B. Laparoscopic conversion of vertical banded gastroplasty to a Roux-en-Y gastric bypass.  Surg Endosc. 2007;  21 1927-1930
  CrossrefPubMedGoogle Scholar
• 24 Imaz I, Martínez-Cervell C, García-Alvarez E E et al. Safety and effectiveness of the intragastric balloon for obesity. A meta-analysis.  Obes Surg. 2008;  18 841-846
  CrossrefPubMedGoogle Scholar
• 25 Johnson W H, Fernanadez A Z, Farrell T M et al. Surgical revision of loop (“mini”) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass.  Surg Obes Relat Dis. 2007;  3 37-41
  CrossrefPubMedGoogle Scholar
• 26 Keshishian A, Zahriya K, Hartoonian T et al. Duodenal switch is a safe operation for patients who have failed other bariatric operations.  Obes Surg. 2004;  14 1187-1192
  CrossrefPubMedGoogle Scholar
• 27 Khaitan L, Van Sickle K, Gonzalez R et al. Laparoscopic revision of bar­iatric procedures: is it feasible?.  Am Surg. 2005;  71 6-10
  PubMedGoogle Scholar
• 28 Lanthaler M, Mittermair R, Erne B et al. Laparoscopic gastric re-banding versus laparoscopic gastric bypass as a rescue operation for patients with pouch dilatation.  Obes Surg. 2006;  16 484-487
  CrossrefPubMedGoogle Scholar
• 29 Lattuada E, Zappa M A, Mozzi E et al. Band erosion following gastric banding: how to treat it.  Obes Surg. 2007;  17 329-333
  CrossrefPubMedGoogle Scholar
• 30 Lee W J, Yu P J, Wang W et al. Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial.  Ann Surg. 2005;  242 20-28
  CrossrefPubMedGoogle Scholar
• 31 Lyass S, Cunneen S A, Hagiike M et al. Device-related reoperations after laparoscopic adjustable gastric banding.  Am Surg. 2005;  71 738-743
  PubMedGoogle Scholar
• 32 Marceau P, Hould F S, Simard S et al. Biliopancreatic diversion with duodenal switch.  World J Surg. 1998;  22 947-954
  CrossrefPubMedGoogle Scholar
• 33 Melissas J, Koukouraki S, Askoxylakis J et al. Sleeve gastrectomy: a restrictive procedure?.  Obes Surg. 2007;  17 57-62
  CrossrefPubMedGoogle Scholar
• 34 Menon T, Quaddus S, Cohen L. Revision of failed vertical banded gastroplasty to non-resectional Scopinaro biliopancreatic diversion: early experience.  Obes Surg. 2006;  16 1420-1424
  CrossrefPubMedGoogle Scholar
• 35 Müller M K, Wildi S, Scholz T et al. Laparoscopic pouch resizing and redo of gastro-jejunal anastomosis for pouch dilatation following gastric bypass.  Obes Surg. 2005;  15 1089-1095
  CrossrefPubMedGoogle Scholar
• 36 Nguyen N T, Hinojosa M W, Gray J et al. Reoperation for marginal ulceration.  Surg Endosc. 2007;  21 1919-1921
  CrossrefPubMedGoogle Scholar
• 37 Noun R, Zeidan S, Riachi E et al. Mini-gastric bypass for revision of failed primary restrictive procedures: a valuable option.  Obes Surg. 2007;  17 684-688
  CrossrefPubMedGoogle Scholar
• 38 Ortega J, Sala C, Flor B et al. Vertical banded gastroplasty converted to Roux-en-Y gastric bypass: little impact on nutritional status after 5-year follow-up.  Obes Surg. 2004;  14 638-643
  CrossrefPubMedGoogle Scholar
• 39 Peterli R, Wölnerhanssen B K, Peters T et al. Prospective study of a two-stage operative concept in the treatment of morbid obesity: primary lap-band followed if needed by sleeve gastrectomy with duodenal switch.  Obes Surg. 2007;  17 334-340
  CrossrefPubMedGoogle Scholar
• 40 Rogula T, Yenumula P R, Schauer P R. A complication of Roux-en-Y gastric bypass: intestinal obstruction.  Surg Endosc. 2007;  21 1914-1918
  CrossrefPubMedGoogle Scholar
• 41 Roller J E, Provost D A. Revision of failed gastric restrictive operations to Roux-en-Y gastric bypass: impact of multiple prior bariatric operations on outcome.  Obes Surg. 2006;  16 865-869
  CrossrefPubMedGoogle Scholar
• 42 Rutledge R. The mini-gastric bypass: experience with the first 1274 cases.  Obes Surg. 2001;  11 276-280
  CrossrefPubMedGoogle Scholar
• 43 Rutledge R. Revision of failed gastric banding to mini-gastric bypass.  Obes Surg. 2006;  16 521-523
  CrossrefPubMedGoogle Scholar
• 44 Sapala J A, Wood M H, Sapala M A et al. Marginal ulcer after gastric ­bypass: a prospective 3-year study of 173 patients.  Obes Surg. 1998;  8 505-516
  CrossrefPubMedGoogle Scholar
• 45 Sapala J A, Wood M H, Sapala M A et al. The micropouch gastric bypass: technical considerations in primary and revisionary operations.  Obes Surg. 2001;  11 3-17
  CrossrefPubMedGoogle Scholar
• 46 Sarr M G. Reoperative bariatric surgery.  Surg Endosc. 2007;  21 1909-1913
  CrossrefPubMedGoogle Scholar
• 47 Schouten R, van Dielen F M, Greve J W. Re-operation after laparoscopic adjustable gastric banding leads to a further decrease in BMI and obe­sity-related co-morbidities: results in 33 patients.  Obes Surg. 2006;  16 821-828
  CrossrefPubMedGoogle Scholar
• 48 Schouten R, van Dielen F M, van Gemert W G et al. Conversion of vertical banded gastroplasty to Roux-en-Y gastric bypass results in restoration of the positive effect on weight loss and co-morbidities: evaluation of 101 patients.  Obes Surg. 2007;  17 622-630
  CrossrefPubMedGoogle Scholar
• 49 Scopinaro N, Gianetta E, Adami G F et al. Biliopancreatic diversion for ­obesity at eighteen years.  Surgery. 1996;  119 261-268
  CrossrefPubMedGoogle Scholar
• 50 Sjöström L, Narbro K, Sjöström C D Swedish Obese Subjects Study et al.,. ­Effects of bariatric surgery on mortality in Swedish obese subjects.  N Engl J Med. 2007;  357 741-752
  CrossrefPubMedGoogle Scholar
• 51 Slater G H, Fielding G A. Combining laparoscopic adjustable gastric banding and biliopancreatic diversion after failed bariatric surgery.  Obes Surg. 2004;  14 677-682
  CrossrefPubMedGoogle Scholar
• 52 Stroh C, Hohmann U, Schramm H et al. Long-term results after gastric banding.  Zentralbl Chir. 2005;  130 410-418
  Article in Thieme ConnectPubMedGoogle Scholar
• 53 Stroh C, Birk D, Flade-Kuthe R et al. Quality assurance in bariatric surgery in Germany – results of the German multicentre trial 2005–2006.  Zentralbl Chir. 2008;  133 1-6
  PubMedGoogle Scholar
• 54 Sturm K, Parker B, Wishart J et al. Energy intake and appetite are related to antral area in healthy young and older subjects.  Am J Clin Nutr. 2004;  80 656-667
  PubMedGoogle Scholar
• 55 Sugerman H J, Kellum J M, DeMaria E J. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity.  J Gastrointest Surg. 1997;  1 517-524
  CrossrefPubMedGoogle Scholar
• 56 Suter M, Calmes J M, Paroz A et al. A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates.  Obes Surg. 2006;  16 829-835
  CrossrefPubMedGoogle Scholar
• 57 Taskin M, Zengin K, Unal E et al. Conversion of failed vertical banded gastroplasty to open adjustable gastric banding.  Obes Surg. 2001;  11 731-734
  CrossrefPubMedGoogle Scholar
• 58 van Gemert W G, van Wersch M M, Greve J W et al. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass.  Obes Surg. 1998;  8 21-28
  CrossrefPubMedGoogle Scholar
• 59 van Wageningen B, Berends F J, van Ramshorst B et al. Revision of failed laparoscopic adjustable gastric banding to Roux-en-Y gastric bypass.  Obes Surg. 2006;  16 137-141
  CrossrefPubMedGoogle Scholar
• 60 Wang W, Huang M T, Wei P L et al. Laparoscopic mini-gastric bypass for failed vertical banded gastroplasty.  Obes Surg. 2004;  14 777-782
  CrossrefPubMedGoogle Scholar
• 61 Weber M, Müller M K, Michel J M et al. Laparoscopic Roux-en-Y gastric bypass, but not rebanding, should be proposed as rescue procedure for patients with failed laparoscopic gastric banding.  Ann Surg. 2003;  238 827-833
  CrossrefPubMedGoogle Scholar
• 62 Weiner R, Blanco-Engert R, Weiner S et al. Outcome after laparoscopic adjustable gastric banding – 8 years experience.  Obes Surg. 2003;  13 427-434
  CrossrefPubMedGoogle Scholar
• 63 Weiner R A, Weiner S. Chirurgie der extremen Adipositas und metabolischer Störungen.  Allgemeine und Viszeralchirurgie up2date. 2008;  2 115-130
  PubMedGoogle Scholar
• 64 Weiner R A, Weiner S, Pomhoff I et al. Laparoscopic sleeve gastrectomy – influence of sleeve size and resected gastric volume.  Obes Surg. 2007;  17 1297-1305
  CrossrefPubMedGoogle Scholar

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