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Konversionseingriffe und endoskopische Revisionsverfahren nach erfolgter bariatrischer Chirurgie

Conversional and endoscopic procedures following bariatric surgery

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Zusammenfassung

Der Roux-en-Y-Magenbypass (RYGB) ist der Goldstandard zur chirurgischen Behandlung der morbiden Adipositas. Unter den Patienten, welche mittels Schlauchmagen oder Magenband behandelt werden, gibt es hingegen vermehrt Therapieversager. In diesen Fällen werden die Adipositas-assoziierten Morbiditäten und das Körpergewicht nicht ausreichend reduziert. Außerdem kann eine medikamentös-therapierefraktäre gastroösophageale Refluxkrankheit auftreten. Unter bestimmten Voraussetzungen kann daher ein Konversionseingriff mit der Anlage eines RYGB indiziert sein.

Die endoskopischen Verfahren werden zur Revision bariatrischer Eingriffe eingesetzt.

Therapieversager treten bei der Anlage eines RYGB in bis zu 20 % der Fälle auf. Die minimalinvasive Methode der Wahl ist die transorale Reduzierung des Durchmessers der gastrojejunalen Anastomose der alimentären Schlinge. Nach der Anlage eines Schlauchmagens kann der Durchmesser ebenfalls ungewollt dilatieren, der durch eine longitudinale Vollwandnaht reduziert werden kann.

Nach der Anlage eines RYGB können lebensbedrohliche Hypoglykämien auftreten. Diese Hypoglykämien müssen umfassend diagnostisch abgeklärt werden und können konservativ therapiert werden. Alternativ kann bei Non-Respondern ein laparoskopischer Konversionseingriff nach Branco-Zorron durchgeführt werden. Das Auftreten der schweren Hypoglykämien wird so verhindert, während eine Gewichtsreduktion gewährleistet werden kann.

Konversionseingriffe und endoskopische Revisionsverfahren können bei Therapieversagern nach bariatrischen Eingriffen durchgeführt werden. Wichtig ist, dass die konservativen Therapieoptionen ausgeschöpft werden, bevor ein erneuter operativer Eingriff durchgeführt wird.

Abstract

The Roux-en-Y gastric bypass (RYGB) is the therapy of choice in bariatric surgery. Sleeve gastrectomy and gastric banding are showing higher rates of treatment failure, reducing obesity-associated morbidity and body weight insufficiently. Moreover, gastroesophageal reflux disease (GERD) can occur refractory to medication. Therefore, a laparoscopic conversion to RYGB can be reasonable as long as specific conditions are fulfilled.

Endoscopic procedures are currently being applied to revise bariatric procedures. Therapy failure following RYGB occurs in up to 20 % of cases. Transoral outlet reduction is the minimally invasive method of choice to reduce gastrojejunal anastomosis of the alimentary limb. The diameter of a gastric sleeve can be unwantedly enlarged as well; that can be reduced by placement of a longitudinal full-thickness suture.

Severe hypoglycemic episodes can be present in patients following RYGB. Hypoglycemic episodes have to be diagnosed first and can be treated conventionally. Alternatively, a laparoscopic approach according to Branco-Zorron can be used for non-responders. Hypoglycemic episodes can thus be prevented and body weight reduction can be assured.

Conversional and endoscopic procedures can be used in patients with treatment failure following bariatric surgery. Note that non-invasive approaches should have been applied intensively before a revisional procedure is performed.

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  1. Zentrum für Innovative Chirurgie (ZIC), Klinik für Chirurgie, Campus Virchow-Klinikum und Campus Mitte, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, Deutschland

    R. Zorron M.D., J. Pratschke M.D., C. Benzing M.D. & F. Krenzien M.D.

  2. Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Klinikum Bremerhaven Reinkenheide, Bremerhaven, Deutschland

    C. Bothe M.D. & T. Junghans M.D.

  3. Berlin Institute of Health (BIH), Berlin, Deutschland

    F. Krenzien M.D.

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R. Zorron, C. Bothe, T. Junghans, J. Pratschke und C. Benzing geben an, dass kein Interessenkonflikt besteht. F. Krenzien ist Teilnehmer des BIH‐Charité Clinical Scientist Programms, das durch die Charité–Universitätsmedizin Berlin and das Berlin Institute of Health finanziert wird.

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Zorron, R., Bothe, C., Junghans, T. et al. Konversionseingriffe und endoskopische Revisionsverfahren nach erfolgter bariatrischer Chirurgie. Chirurg 87, 857–864 (2016). https://doi.org/10.1007/s00104-016-0277-z

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