Welche Rolle spielt die Chirurgie bei der Therapie des Diabetes mellitus Typ 2?

Zusammenfassung

Der Diabetes mellitus Typ 2 (T2DM) ist eine chronisch progrediente Erkrankung mit hoher Inzidenz. Bei Patienten mit einem T2DM findet sich überdurchschnittlich häufig eine Adipositas, die eine wichtige Rolle bei der Entwicklung der Insulinresistenz spielt. Die Basistherapie des T2DM umfasst eine Ernährungstherapie, eine Erhöhung der körperlichen Aktivität und eine Lebensstiländerung, meist in Kombination mit einer Pharmakotherapie. Insbesondere bei adipösen Patienten mit T2DM werden jedoch die metabolischen Therapieziele durch eine fehlende signifikante Gewichtsreduktion oft nicht erreicht.

Die Pankreastransplantation spielt derzeit bei der Behandlung des T2DM nur eine untergeordnete Rolle. Die bariatrische Chirurgie gewährleistet bei der Mehrzahl der Adipösen eine langfristige signifikante Gewichtsreduktion. Bei einem hohen Prozentsatz zeigt sich im kurz- bis mittelfristigen Verlauf nach dem operativen Eingriff eine komplette Remission des T2DM. Als Ursachen werden Gewichtsverlust mit einer Erhöhung der Insulinsensitivität und die Beeinflussung verschiedener gastrointestinaler Hormone durch die Operationen diskutiert. Problematisch für die abschließende Beurteilung sind die wenigen derzeit verfügbaren Langzeitergebnisse. Die Durchführung eines bariatrischen Verfahrens sollte vor allem bei adipösen Patienten mit einem T2DM, einem BMI > 35 kg/m² und schwer kontrollierbarer diabetischer Stoffwechsellage erwogen werden. Eine Ausweitung der Indikationsstellung auf normal- bzw. nur leicht übergewichtige Patienten mit T2DM kann trotz der positiven Ergebnisse nicht uneingeschränkt empfohlen werden.

Die Erforschung der Wirkmechanismen bariatrischer Eingriffe hat zu einem tieferen Verständnis der Pathophysiologie des T2DM beigetragen. Diese Erkenntnisse könnten zukünftig als Basis für die Entwicklung weniger invasiver und pharmakologischer Therapiemöglichkeiten dienen, um somit die Behandlung des T2DM individueller gestalten und weiter verbessern zu können.

Abstract

Typ 2 diabetes mellitus (T2DM) can be regarded as a chronic and progressive disease which is rapidly increasing worldwide. There is a significant coincidence of T2DM and obesity, the latter playing a major role in the development of insulin resistance. Medical treatment comprises lifestyle counseling, weight management and an increased physical activity, frequently in combination with pharmacotherapy. However, especially in obese patients, metabolic aims are frequently not achieved which can be attributed to the lack of significant weight reduction.

Currently, pancreas transplantation plays only a minor role in the treatment of patients with T2DM. Bariatric surgery has been proven to be a safe and effective therapeutic option in obese patients that leads to a significant weight loss. Moreover, in the majority of obese diabetics, a complete or partial remission of T2DM is observed. The significant weight loss is associated with improved insulin sensitivity. There is some evidence that alterations of gut hormones play an additional role in the amelioration of T2DM. However, little is known about the long-term effect of bariatric surgery on diabetes remission. Bariatric procedures should be considered in obese patients with T2DM (BMI > 35 kg/m²) and poorly controlled metabolic status. Despite the encouraging results in normal weight or overweight patients with T2DM, surgery can not yet be recommended in these patients. Intensive research about the impact of bariatric surgery on diabetes remission offers a unique opportunity to understand pathophysiology of T2DM. Furthermore, it may help to develop less invasive interventions and to identify new therapeutic targets for the treatment of T2DM.

Schlüsselwörter

Diabetes mellitus Typ 2 - Adipositas - Transplantation - bariatrische Chirurgie

Keywords

type 2 diabetes - obesity - transplantation - bariatric surgery

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