Ist Diabetes heilbar durch bariatrische Chirurgie? – Mechanismen der Verbesserung der diabetischen Stoffwechsellage durch chirurgische Adipositastherapie –

Zusammenfassung

In den letzten Jahren wurden die Ergebnisse randomisierter kontrollierter Studien publiziert, die im 5-Jahres-Verlauf die metabolischen Effekte der bariatrischen Chirurgie mit konventionellen Formen der Gewichtsreduktion vergleichen. Diese Studien zeigen unisono, dass die bariatrische Chirurgie hinsichtlich der Besserung der diabetischen Stoffwechsellage den konventionellen Behandlungsformen signifikant überlegen ist. Die Diabetesremissionsraten variieren abhängig von Ausgangsparametern, Operationsmethode und Follow-up-Dauer zwischen 95 und 23 %.

Ist Diabetes heilbar durch bariatrische Chirurgie? Die klare Antwort muss lauten: Nein, aber

1. 35 – 50 % der Patienten mit Typ-2-Diabetes, die mittels bariatrischer Chirurgie initial nach Operation eine Diabetesremission erreichen konnten, erleben im weiteren Verlauf das Wiederkehren der „Krankheit“ d. h. erneut ansteigende Blutzuckerwerte.

2. Die mittlere „krankheitsfreie Zeit“ beträgt 8,3 Jahre (Range 5 – 15 Jahre)

3. Jedes Jahr, das die Patienten mit Typ-2-Diabetes in der Remission der Erkrankung verbrachten, war mit einer Reduktion des Risikos mikrovaskulärer Komplikationen um 19 % verbunden.

Insofern ist die bariatrische Chirurgie in Form von Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) und den neueren Verfahren wie Omega Loop Bypass („Mini-Bypass“) oder biliopankreatische Diversion (BPD) eine wirkungsvolle therapeutische Option in der Behandlung des Diabetes mellitus Typ 2 und verringert offenbar auch das Risiko des Auftretens von mikrovaskulären Diabetesfolgekomplikationen. Je früher im Krankheitsverlauf die bariatrische Chirurgie SSherangezogen wird, desto effektiver scheinen diese Verfahren zu sein.

Welche der Operationen für Patienten mit Typ-2-Diabetes am besten geeignet ist, ist derzeit nicht definitiv entschieden. Der RYGB scheint etwas effektiver zu sein. Die Verfahren der bariatrischen Chirurgie gehören in das Spektrum der differenzialtherapeutischen Überlegungen insbesondere bei adipösen Patienten mit Typ-2-Diabetes mit einem BMI > 35 kg/m².

Die Mechanismen der Verbesserung der diabetischen Stoffwechsellage durch bariatrische Operationen werden anhand der aktuellen Literatur detailliert beschrieben. Die Indikationen, Kontraindikationen, Komplikationen und Therapiealgorithmen der bariatrischen Chirurgie bei Typ-2-Diabetes sind in den entsprechenden Leitlinien ausführlich dargestellt und nicht Gegenstand dieser Publikation.

Abstract

Recently, the results of long-term randomized controlled studies were published comparing the metabolic effects of bariatric surgery with conventional treatment strategies of obesity. Unanimously, these studies demonstrate that bariatric surgery improves glycemic control significantly compared to conventional medical treatment. Rates of diabetes remission range from 95 to 23 % depending on initial patients characteristics, operation method of bariatric surgery and follow-up duration.

Is diabetes curable with bariatric surgery? The clear answer is: no, but

1. 35 – 50 % of diabetic patients, achieving diabetes remission after bariatric surgery, had a recurrence of the disease in terms of increasing blood glucose values during the following years.

2. The mean “diabetes-free” time was 8.3 years (range 5 – 15 years).

3. Each year that diabetic patients were in the remission of the disease, was associated with a reduction of the risk of microvascular complications of 19 %.

Therefore, bariatric surgery with Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), biliopancreatic diversion (BPD) or newer techniques as omega loop bypass are powerful therapeutic options in the treatment of diabetes and obesity. Bariatric surgery seems to reduce the risk of microvascular diabetic complications. Therefore, bariatric surgery should be involved in the therapeutic strategies as early as possible.

It is not definitively clear which type of bariatric operation is the best option for diabetic patients. RYGB seems to have some benefits. The methods of bariatric surgery should be included into the therapeutic armamentarium of each diabetes specialist.

The mechanisms of improvement of glycemic control by bariatric surgery will be described in detail according to recent literature data.

Indications, contraindications, complications or therapeutic algorithms of bariatric surgery of type 2 diabetes are listed in detail at common guidelines and are not part of this review.

Schlüsselwörter

Diabetes mellitus Typ 2 - Adipositas - bariatrische Chirurgie

Key words

diabetes mellitus type 2 - obesity - bariatric surgery

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