[Management of complications in bariatric surgery]

[Metabolic surgery or conservative measures as therapy of obese type 2 diabetics?]

After bariatric surgery there are some favourable effects on comorbidities of obesity as glucose and lipid metabolism besides weight loss. Therefore surgical measures targeting at improvement of such metabolic disorders especially diabetes type 2 has been called "metabolic surgery". The complexity of its underlying metabolic mechanisms is not yet clear, but restriction of energy and weight loss (maintenance) seem to be the cornerstones.Risks of these procedures which are drawn of the established methods of bariatric surgery are reported to be relatively low in qualified centers. Being an elective operation special focus has to be set on mortality and morbidity, numbers of therapeutic failure and redo-surgery. Multiple irreversible and not seldom severe, potentially life-threatening consequences of bariatric surgery require consequent interdisciplinary postsurgery care and therapy throughout the whole life, especially substitution therapy of deficiencies due to post-operative malassimilation, if necessary. Little is known about long term consequences of modified anatomy and function of digestive system caused by surgery, and there may be a delay of (many) years until manifestation of clinical problems.Obese diabetics (BMI ≥ 35 kg/m²) should primarily be treated conservatively in an "individualized" way. Metabolic surgery should not be considered earlier than failure of the conservative approach has to be stated (in this case as an "ultima ratio" in well defined trials). A broader use of metabolic surgery beyond this narrow frame is not yet supported by long-term evidence-based data showing its value and safety.

[Anastomosis and suture insufficiency after interventions for bariatric and metabolic surgery]

BACKROUND

Metabolic surgery is internationally well-established for the treatment of obesity and its comorbidities. The numbers of procedures performed is steadily increasing. The results of surgery are superior in comparison to conservative treatment options regarding weight loss and resolution of comorbidities. The insufficiency of suture lines is a well-known and feared complication in the stapling procedures and is associated with an increased morbidity as well as mortality, especially in super obese patients.

MATERIAL AND METHODS

The current literature was reviewed and the results are reported within the context of own experience.

RESULTS

The most severe complications are staple line leakage after sleeve gastrectomy, leakage of anastomoses after bypass procedures and duodenal stump insufficiency. For the treatment of sleeve leakage various endoscopic procedures, such as over the scope (OTS) clips, stents and endoluminal vacuum therapy are available. Surgical revision, such as oversuturing, drainage and redo surgery are well-established. The management of all other complications is mainly by surgical intervention. Intraoperative standardization of procedures and knowledge of the physical foundations are essential for the prevention of leakage. Several preventive methods are available but randomized controlled trials are missing.

CONCLUSION

The therapy of leakages in the field of bariatric surgery is an interdisciplinary approach and dependent on the available resources in the treating hospital. The data reported show good results but the different reports published are inconsistent. Leakages often do not occur in the immediate postoperative period but in the sense of a long-term complication; therefore standardization of procedures and follow-up as well as complication management is mandatory. Randomized controlled studies must be promoted.