Skip to main content
SpringerLink
Log in

Blutungskomplikationen in der Adipositaschirurgie

Prophylaxe und Therapie

Bleeding complications in bariatric surgery

Prophylaxis and therapy

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Bariatrische Operationen sind Elektiveingriffe, die auch bei Patienten mit zusätzlichen Risiken (z. B. Alter > 65 Jahre, relevante Begleiterkrankungen, BMI von über 60 kg/m2) vorgenommen werden. Zur Risikominimierung müssen Begleiterkrankungen optimal eingestellt werden. Die Komplikationsraten bariatrischer oder metabolischer Eingriffe liegen in selektionierten Kollektiven unter 1 %. Neben Leaks stellen Blutungen die häufigsten perioperativen chirurgischen Probleme bei bariatrischen Eingriffen dar. Blutungskomplikationen werden in bis zu 4 % angegeben, bei ReDo-Eingriffen ist die Rate deutlich höher. Bei der Therapie der Blutung gelten die allgemeinen viszeralchirurgischen Grundsätze, zum Operationsende muss Bluttrockenheit bestehen. Zur Prophylaxe von Blutungen bzw. zur Minimierung derselben bietet die Industrie versiegelnde Systeme zur Präparation und Gewebsdurchtrennung an, die außer beim Magenband faktisch immer Anwendung finden. Das häufigste Blutungsproblem sind Blutungen aus der Klammernahtreihe. Durch Klammernahtverstärker oder spezielle Klammernahtmagazine können Blutungen oder Nachblutungen aus der Klammernaht reduziert werden. Beides ist mit relevant höheren Kosten verbunden. Sie sollten in der Klinik zumindest vorgehalten werden und bei Risikopatienten oder bei verstärkter intraoperativer Blutungsneigung Anwendung finden.

Abstract

Bariatric surgery is an elective intervention, which is also performed in patients with additional risk factors, e.g. elderly patients over 65 years old, in patients suffering from relevant comorbidities and in patients with a body mass index (BMI) greater than 60 kg/m2. To reduce the perioperative risks comorbidities require optimal adjustment. Specialized centers have reported complication rates below 1 %. Besides leakage, bleeding is the most common surgical complication in bariatric interventions. Bleeding complications occur in up to 4 % of cases but are much more common in redo surgery. For the management of bleeding, the same general rules apply as those for abdominal surgery and at the end of an operation, all bleeding must be under control. To avoid bleeding, sealing devices are widely used during tissue dissection. Stapler line bleeding is the most common form of intraoperative and postoperative bleeding. Special stapler magazines and stapler line reinforcement materials are available to minimize stapler line bleeding. Such devices result in relevant extra costs; however, they should always be generally available and used in patients with an increased risk of bleeding or an increased intraoperative tendency to bleeding.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Literatur

  1. Dumon KR, Murayama KM (2011) Bariatric surgery outcomes. Surg Clin North Am 91:1313–1338

    Article  PubMed  Google Scholar 

  2. Pories WJ (2008) Bariatric surgery: risks and rewards. J Clin Endocrinol Metab 93:S89–S96

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Thomas H, Agrawal S (2012) Systematic review of obesity surgery mortality risk score–preoperative risk stratification in bariatric surgery. Obes Surg 22:1135–1140

    Article  PubMed  Google Scholar 

  4. Azevedo JLMC, Azevedo OC, Miyahira SA et al (2009) Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc 23:1428–1432

    Article  PubMed  Google Scholar 

  5. Ahmad G, O’Flynn H, Duffy JMN et al (2012) Laparoscopic entry techniques. Cochrane database Syst Rev 2:CD006583

    PubMed  Google Scholar 

  6. Rosenthal RJ, Szomstein S, Kennedy CI et al (2007) Direct visual insertion of primary trocar and avoidance of fascial closure with laparoscopic Roux-en-Y gastric bypass. Surg Endosc 21:124–128

    Article  CAS  PubMed  Google Scholar 

  7. Weiner RA, Stroh C, El-Sayes I et al (2015) Management of complications in bariatric surgery. Chirurg 86:56–66

    Article  CAS  PubMed  Google Scholar 

  8. Kirshtein B, Lantsberg L, Mizrahi S et al (2010) Bariatric emergencies for non-bariatric surgeons: complications of laparoscopic gastric banding. Obes Surg 20:1468–1478

    Article  PubMed  Google Scholar 

  9. Monkhouse SJW, Morgan JDT, Norton SA (2009) Complications of bariatric surgery: presentation and emergency management–a review. Ann R Coll Surg Engl 91:280–286

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Hamdan K, Somers S, Chand M (2011) Management of late postoperative complications of bariatric surgery. Br J Surg 98:1345–1355

    Article  CAS  PubMed  Google Scholar 

  11. Vrebosch L, Bel S, Vansant G et al (2012) Maternal and neonatal outcome after laparoscopic adjustable gastric banding: a systematic review. Obes Surg 22:1568–1579

    Article  CAS  PubMed  Google Scholar 

  12. Consten ECJ, Gagner M et al (2004) Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg 14:1360–1366

    Article  PubMed  Google Scholar 

  13. Podnos YD, Jimenez JC, Wilson SE et al (2003) Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 138:957–961

    Article  PubMed  Google Scholar 

  14. Iannelli A, Dainese R, Piche T et al (2008) Laparoscopic sleeve gastrectomy for morbid obesity. World J Gastroenterol 14:821–827

    Article  PubMed  PubMed Central  Google Scholar 

  15. Acquafresca PA, Palermo M, Rogula T et al (2015) Early surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig 28:74–80

    Article  PubMed  PubMed Central  Google Scholar 

  16. Heneghan HM, Meron-Eldar S, Yenumula P et al (2012) Incidence and management of bleeding complications after gastric bypass surgery in the morbidly obese. Surg Obes Relat Dis 8:729–735

    Article  PubMed  Google Scholar 

  17. Van Rutte PWJ, Smulders JF, de Zoete JP et al (2012) Indications and short-term outcomes of revisional surgery after failed or complicated sleeve gastrectomy. Obes Surg 22:1903–1908

    Article  PubMed  Google Scholar 

  18. Nguyen NT, Rivers R, Wolfe BM (2003) Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg 13:62–65

    Article  PubMed  Google Scholar 

  19. Rebibo L, Fuks D, Blot C et al (2013) Gastrointestinal bleeding complication of gastric fistula after sleeve gastrectomy: consider pseudoaneurysms. Surg Endosc 27:2849–2855

    Article  PubMed  Google Scholar 

  20. Eriksson L-G, Ljungdahl M, Sundbom M et al (2008) Transcatheter arterial embolization versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 19:1413–1418

    Article  PubMed  Google Scholar 

  21. Loffroy R, Estivalet L, Cherblanc V et al (2012) Transcatheter embolization as the new reference standard for endoscopically unmanageable upper gastrointestinal bleeding. World J Gastrointest Surg 4:223–227

    Article  PubMed  PubMed Central  Google Scholar 

  22. Sauerland S, Angrisani L, Belachew M et al (2005) Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 19:200–221

    Article  CAS  PubMed  Google Scholar 

  23. Evans JA, Muthusamy VR, Acosta RD et al (2015) The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc 81:1063–1072

    Article  PubMed  Google Scholar 

  24. Utzolino S, Karcz K (2013) Thrombosis prophylaxis in bariatric surgery: evaluation of the situation and practical recommendations. Phlebologie 42:71–76

    Article  Google Scholar 

  25. S3-Leitlinie Prophylaxe der Venösen Thromboembolie (VTE) (2010). http://www.awmf.org/uploads/tx_szleitlinien/003-001k_S3_AWMF-Leitlinie_Prophylaxe_der_venoesen_Thromboembolie_VTE

  26. Stroh C, Luderer D, Weiner R et al (2012) Actual situation of thromboembolic prophylaxis in obesity surgery: data of quality assurance in bariatric surgery in Germany. Thrombosis 2012:1–6

    Article  Google Scholar 

  27. Nice (2010) Obesity: NICE guideline. NICE Clin Guidel 43:1–84

    Google Scholar 

  28. Birkmeyer NJO, Finks JF, Carlin AM et al (2012) Comparative effectiveness of unfractionated and low-molecular-weight heparin for prevention of venous thromboembolism following bariatric surgery. Arch Surg 147:994–998

    Article  PubMed  Google Scholar 

  29. Ikesaka R, Delluc A, Le Gal G et al (2014) Efficacy and safety of weight-adjusted heparin prophylaxis for the prevention of acute venous thromboembolism among obese patients undergoing bariatric surgery: a systematic review and meta-analysis. Thromb Res 133:682–687

    Article  CAS  PubMed  Google Scholar 

  30. Frederiksen SG, Hedenbro JL, Norgren L (2003) Enoxaparin effect depends on body-weight and current doses may be inadequate in obese patients. Br J Surg 90:547–548

    Article  CAS  PubMed  Google Scholar 

  31. Harold KL, Pollinger H, Matthews BD et al (2003) Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc Other Interv Tech 17:1228–1230

    Article  CAS  Google Scholar 

  32. Harrell AG, Kercher KW, Heniford BT (2004) Energy sources in laparoscopy. Semin Laparosc Surg 11:201–209

    PubMed  Google Scholar 

  33. Noble EJ, Smart NJ, Challand C et al (2011) Experimental comparison of mesenteric vessel sealing and thermal damage between one bipolar and two ultrasonic shears devices. Br J Surg 98:797–800

    Article  CAS  PubMed  Google Scholar 

  34. Kennedy JS, Stranahan PL, Taylor KD et al (1998) High-burst-strength, feedback-controlled bipolar vessel sealing. Surg Endosc 12:876–878

    Article  CAS  PubMed  Google Scholar 

  35. Landman J, Kerbl K, Rehman J et al (2003) Evaluation of a vessel sealing system, bipolar electrosurgery, harmonic scalpel, titanium clips, endoscopic gastrointestinal anastomosis vascular staples and sutures for arterial and venous ligation in a porcine model. J Urol 169:697–700

    Article  PubMed  Google Scholar 

  36. Tsamis D, Natoudi M, Arapaki A et al (2014) Using LigasureTM or Harmonic Ace® in Laparoscopic Sleeve Gastrectomies? A Prospective Randomized Study. Obes Surg 1–4

  37. Gill RS, Switzer N, Driedger M et al (2012) Laparoscopic sleeve gastrectomy with staple line buttress reinforcement in 116 consecutive morbidly obese patients. Obes Surg 22:560–564

    Article  PubMed  Google Scholar 

  38. Barreto TW, Kemmeter PR, Paletta MP et al (2015) A comparison of a single center’s experience with three staple line reinforcement techniques in 1,502 laparoscopic sleeve gastrectomy patients. Obes Surg 25:418–422

    Article  PubMed  Google Scholar 

  39. Rosenthal RJ, Diaz AA, Arvidsson D et al (o J) International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of > 12,000 cases. Surg Obes Relat Dis 8:8–19

Download references

Author information

Authors and Affiliations

  1. Bereich Bariatrische Chirurgie, Klinik u. Poliklinik für Viszeral-, Transplantations-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland

    H. Spieker &  A. Dietrich

Authors
  1. H. Spieker
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Dietrich
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. Dietrich.

Ethics declarations

Interessenkonflikt

A. Dietrich gibt an, dass kein Interessenkonflikt besteht.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Spieker, H., Dietrich, A. Blutungskomplikationen in der Adipositaschirurgie. Chirurg 86, 833–840 (2015). https://doi.org/10.1007/s00104-015-0038-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-015-0038-4

Schlüsselwörter

Keywords

Search

Navigation