Mikrobiom und metabolische/bariatrische Chirurgie

Zusammenfassung

Derzeit ist die metabolische/bariatrische Chirurgie die einzige evidenzbasierte Therapie, die bei einem Großteil der morbid adipösen Patienten zu einer relevanten und nachhaltigen Gewichtsabnahme und Verbesserung der Adipositas-assoziierten Morbidität führt. Das historische Konzept, dass die dominanten zugrundeliegenden Mechanismen der bariatrischen/metabolischen Chirurgie eine Nahrungsrestriktion (durch Verkleinerung des Magens) und eine Malabsorption von Makronährstoffen (durch einen intestinalen Bypass der oralen Dünndarmabschnitte) sind, ist mittlerweile widerlegt.

Grundlagenwissenschaftliche Studien konnten zeigen, dass der Darm als physiologische Schaltzentrale dient und nach anatomischer Umstellung, wie beispielsweise nach einer Magenbypass-Operation, veränderte neuronale und endokrine Signale an unterschiedliche Organsysteme aussendet.

Es existiert eine robuste, spezies-übergreifende Datenlage, dass es nach metabolischer/bariatrischer Chirurgie zu einer nachhaltigen Veränderung des Mikrobioms kommt. Insgesamt ist eine erhöhte Vielfältigkeit der Bakterienstämme mit einer häufigen Reduktion von Firmicutes und Bacteroidetes und eine Erhöhung von Proteobakterien beschrieben. Dabei scheint die Veränderung des Mikrobioms Chirurgie- und Prozeduren-spezifisch und nicht Folge der erreichten Gewichtsabnahme zu sein. Die biologische Relevanz konnte mehrfach experimentell in konzeptionellen Beweisstudien (Mikrobiomtransfer) gezeigt werden. Experimentelle Daten legen nahe, dass die Zusammensetzung des Mikrobioms nicht nur durch die Operation selbst verändert wird und damit unterschiedliche Systeme (entero-endokrin, Darmbarriere, Konjugation von Gallensäuren) maßgeblich beeinflusst, sondern auch einen Einfluss auf den Wirkungsgrad der Operation selbst zu haben scheint. Trotzdem sind die verfügbaren Daten meist nur beschreibend und zeigen Assoziationen auf. Den Einfluss des veränderten Mikrobioms auf das gesamte Metabolom und vice versa ist bisher nur unzureichend verstanden und muss in weiterführenden Studien weiter untersucht werden.

Abstract

Metabolic/bariatric surgery is presently the only evidence-based therapy that leads to clinically relevant and sustainable weight loss in individuals with morbid obesity coupled with superior improvements in metabolic health. Historically, this was largely attributed to food restriction (through shrinkage of the stomach) and malabsorption of macronutrients (through exclusion of the proximal small intestine from contact with ingested food). It is now clear however that consequential to anatomical conversion of the small intestine a myriad of neural and endocrine signals are sent out from this physiological control center to profoundly impact on the function of various different organ systems. There is also a robust and lasting cross-species change in the microbiome such as a decrease in Firmicutes and Bacteroidetes species as well as an increase in proteobacteria which appears to be procedure-specific and independent of weight loss. Such changes in the microbiome are considered to have a beneficial knock-on effect on host physiology including enhancement of entero-endocrine cell function, restoration of the gut barrier and formation of secondary bile acids although the supporting data obtained so far is mainly observational. Furthermore, the influence of the changed microbiome on the metabolome as a whole and vice-versa is poorly understood and warrants further investigation

Schlüsselwörter

Mikrobiom - metabolische Chirurgie - bariatrische Chirurgie - evidenzbasierte Therapie

Key words

Microbiome - metabolic surgery - bariatic surgery - evidence-based therapy

Publication History

Article published online:
02 December 2019

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