Benedix F, Scheidbach H, Arend J, Lippert H, Wolff S
Klinik für Chirurgie, Universitätsklinikum, Magdeburg, Deutschland.
Zentralbl Chir. 2009 Jun;134(3):214-24; discussion 225. doi: 10.1055/s-0028-1098899. Epub 2009 Jun 17.
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 socio-economic burden.
Currently, surgery is the only avail-able 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.
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.
肥胖在全球范围内正以惊人的速度增长。特别是在西方国家，肥胖及相关问题已成为严重的医学问题和巨大的社会经济负担。
目前，手术是重度肥胖患者唯一可行的治疗方法，大多数患者术后体重持续减轻，并存疾病得以治愈。减肥手术数量的增加以及这些手术偶尔出现的失败和并发症导致了翻修手术需求的增加。总体而言，预计10% - 25%的患者因初次减肥手术失败需要进行翻修。翻修手术的主要指征是体重减轻不足、手术相关并发症以及手术急症，还有由营养不良或维生素缺乏引起的长期并发症。遗憾的是，目前尚无随机试验来回答针对不同患者应在初次手术后进行何种手术这一问题。决策往往受手术医生的专业技能和偏好以及患者偏好的影响。因此，对已发表数据就这一复杂问题进行系统综述，对日常外科手术实践似乎是有帮助且重要的。
减肥翻修手术在技术上更为复杂，术后并发症增多。这些手术原则上应在该手术领域有深厚专业知识的中心进行，并且只要可能，应采用腹腔镜手术。然而，每位腹部外科医生都应能够诊断和治疗一些急性并发症。限制性手术失败后，仅在出现并发症且失败时体重减轻充分的情况下才建议进行翻修。否则，应考虑转换为联合手术。联合手术失败后，可通过增加更多限制和/或吸收不良成分来进一步减轻体重或成功治疗并发症。后者会增加营养后遗症的风险。
