nach oben

09.04.2024 | Original Article

Revisional one-anastomosis gastric bypass for failed laparoscopic sleeve gastrectomy

verfasst von: Artur Binda, Joanna Żurkowska, Agnieszka Gonciarska, Emilia Kudlicka, Krzysztof Barski, Paweł Jaworski, Piotr Jankowski, Michał Wąsowski, Wiesław Tarnowski

Erschienen in: Updates in Surgery

Einloggen, um Zugang zu erhalten

Abstract

The study aimed to evaluate the mid-term weight loss outcomes and complications of revisional one-anastomosis gastric bypass (OAGB) following failed laparoscopic sleeve gastrectomy (LSG). A total of 586 patients underwent LSG from January 2010 to February 2018. Revisional OAGB (rOAGB) was performed in 22 (3.8%) patients. A retrospective analysis of prospectively collected data from 20 patients with at least 12 months of follow-up after the revisional OAGB was carried out. The indications for revisional surgery were as follows: insufficient weight loss—4 (20%), weight regain—13 (65%), weight regain and symptoms of gastroesophageal reflux disease (GERD)—2 (10%), and dysphagia with gastroesophageal reflux—1 (5%). The mean interval between the LSG and rOAGB was 35.3 ± 15.4 months (range 4–64). The mean follow-up time after rOAGB was 45.5 ± 17.1 months (range 12–54). At the end of the follow-up after rOAGB, %TWL was 26.4 ± 8.9%, and %EWL was 58.5 ± 21.6%, based on pre-LSG body weight. In all three patients with intractable GERD, the clinical symptoms of reflux retreated after revisional OAGB. The overall complication rate was 20%. In conclusion, the main indications for revision after LSG are weight regain, insufficient weight loss, and intractable GERD. Revisional OAGB emerges as a viable surgical alternative for unsuccessful LSG, presenting notable weight loss outcomes; however, it may be linked to an increased incidence of complications.

Graphical abstract

Nur mit Berechtigung zugänglich

Angrisani L, Santonicola A, Iovino P, Ramos A, Shikora S, Kow L (2021) Bariatric surgery survey 2018: similarities and disparities among the 5 IFSO chapters. Obes Surg 31:1937–1948. https://doi.org/10.1007/s11695-020-05207-7CrossRefPubMedPubMedCentral

Yilmaz H, Ece I, Sahin M (2017) Revisional surgery after failed laparoscopic sleeve gastrectomy: retrospective analysis of causes, results, and technical considerations. Obes Surg 27:2855–2860. https://doi.org/10.1007/s11695-017-2712-8CrossRefPubMed

Kowalewski PK, Olszewski R, Walędziak MS, Janik MR, Kwiatkowski A, Gałązka-Świderek N, Cichoń K, Brągoszewski J, Paśnik K (2018) Long-term outcomes of laparoscopic sleeve gastrectomy: a single-center, retrospective study. Obes Surg 28:130–134. https://doi.org/10.1007/s11695-017-2795-2CrossRefPubMed

Chierici A, Chevalier N, Iannelli A (2022) Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: a systematic review and network meta-analysis. Int J Surg 102:106677. https://doi.org/10.1016/j.ijsu.2022.106677CrossRef

Velotti N, Vitiello A, Berardi G, Di Lauro K, Musella M (2021) Roux-en-Y gastric bypass versus one anastomosis-mini gastric bypass as a rescue procedure following failed restrictive bariatric surgery. A systematic review of literature with metanalysis. Updates Surg 73:639–647. https://doi.org/10.1007/s13304-020-00938-9CrossRefPubMed

Mahawar KK, Nimeri A, Adamo M, Borg CM, Singhal R, Khan O, Small PK (2018) Practices concerning revisional bariatric surgery: a survey of 460 surgeons. Obes Surg 28:2650–2660. https://doi.org/10.1007/s11695-018-3226-8CrossRefPubMed

Zappa, MA, Iossa A, Busetto L, Chiappetta S, Greco F, Lucchese M, Micanti F, Mingrone G, Navarra G, Raffaelli, M, Delphi Expert Panel, & De Luca M (2023) SICOB-endorsed national Delphi consensus on obesity treatment optimization: focus on diagnosis, pre-operative management, and weight regain/insufficient weight loss approach. EWD 28:5. https://doi.org/10.1007/s40519-023-01537-4CrossRef

Iossa A, Coluzzi I, Giannetta IB, Silecchia G (2020) Weight loss and eating pattern 7 years after sleeve gastrectomy: experience of a bariatric center of excellence. Obes Surg 30:3747–3752. https://doi.org/10.1007/s11695-020-04699-7CrossRefPubMed

Major P, Zarzycki P, Rymarowicz J, Wysocki M, Łabul M, Hady HR, Głuszyńska P, Myśliwiec P, Kowalski G, Orłowski M, Szeliga J, Kupczyk W, Tarnowski W, Lech P, Dowgiałło-Gornowicz N, Proczko-Stepaniak M, Walędziak M, Szymański P, Stefura T, Pędziwiatr M (2022) Revisional operations among patients after surgical treatment of obesity: a multicenter polish revision obesity surgery study (PROSS). Wideochir Inne Tech Maloinwazyjne 17:372–379. https://doi.org/10.5114/wiitm.2022.114525CrossRefPubMedPubMedCentral

10.

Mahawar KK, Himpens JM, Shikora SA, Ramos AC, Torres A, Somers S, Dillemans B, Angrisani L, Greve JWM, Chevallier JM, Chowbey P, De Luca M, Weiner R, Prager G, Vilallonga R, Adamo M, Sakran N, Kow L, Lakdawala M, Dargent J, Small PK (2020) The first consensus statement on revisional bariatric surgery using a modified Delphi approach. Surg Endosc 34:1648–1657. https://doi.org/10.1007/s00464-019-06937-1CrossRefPubMed

11.

Franken RJ, Sluiter NR, Franken J, de Vries R, Souverein D, Gerdes VEA, de Brauw M (2022) Treatment options for weight regain or insufficient weight loss after sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg 32:2035–2046. https://doi.org/10.1007/s11695-022-06020-0CrossRefPubMed

12.

De Luca M, Piatto G, Merola G, Himpens J, Chevallier JM, Carbajo MA, Mahawar K, Sartori A, Clemente N, Herrera M, Higa K, Brown WA, Shikora S (2021) IFSO update position statement on one anastomosis gastric bypass (OAGB). Obes Surg 31:3251–3278. https://doi.org/10.1007/s11695-021-05413-xCrossRefPubMed

13.

Bruzzi M, Voron T, Zinzindohoue F, Berger A, Douard R, Chevallier JM (2016) Revisional single-anastomosis gastric bypass for a failed restrictive procedure: 5-year results. Surg Obes Relat Dis 12:240–245. https://doi.org/10.1016/j.soard.2015.08.521CrossRefPubMed

14.

Kermansaravi M, Karami R, Valizadeh R, Rokhgireh S, Kabir A, Pakaneh M, Kassir R, Pazouki A (2022) Five-year outcomes of one anastomosis gastric bypass as conversional surgery following sleeve gastrectomy for weight loss failure. Sci Rep 12:10304. https://doi.org/10.1038/s41598-022-14633-9CrossRefPubMedPubMedCentral

15.

Yeo C, Ho G, Syn N, Mak M, Ahmed S, Oo AM, Koura A, Kaushal S, Yeo D (2021) Revisional one-anastomosis gastric bypass after restrictive index surgery-a metaanalysis and comparison with revisional Roux-en-Y gastric bypass. Obes Surg 31:949–964. https://doi.org/10.1007/s11695-020-05094-yCrossRefPubMed

16.

Rheinwalt KP, Schipper S, Plamper A, Alizai PH, Trebicka J, Brol MJ, Kroh A, Schmitz S, Parmar C, Neumann UP, Ulmer TF (2022) Roux-en-Y versus one anastomosis gastric bypass as redo-operations following sleeve gastrectomy: a retrospective study. World J Surg 46:855–864. https://doi.org/10.1007/s00268-021-06424-6CrossRefPubMed

17.

El Ansari W, Elhag W (2021) Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps—a scoping review. Obes Surg 31:1755–1766. https://doi.org/10.1007/s11695-020-05160-5CrossRefPubMedPubMedCentral

18.

Sakran N, Soifer K, Hod K, Sherf-Dagan S, Soued S, Kessler Y, Adelson D, Biton R, Buchwald JN, Goitein D, Raziel A (2022) Long-term reported outcomes following primary laparoscopic sleeve gastrectomy. Obes Surg 33:117–128. https://doi.org/10.1007/s11695-022-06365-6CrossRefPubMedPubMedCentral

19.

Clapp B, Wynn M, Martyn C, Foster C, O’Dell M, Tyroch A (2018) Long term (7 or more years) outcomes of the sleeve gastrectomy: a meta-analysis. Surg Obes Relat Dis 14:741–747. https://doi.org/10.1016/j.soard.2018.02.027CrossRefPubMed

20.

Felsenreich DM, Langer FB, Kefurt R, Panhofer P, Schermann M, Beckerhinn P, Sperker C, Prager G (2016) Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 12:1655–1662. https://doi.org/10.1016/j.soard.2016.02.021CrossRefPubMed

21.

Kehagias I, Bellou A, Kehagias D, Markopoulos G, Amanatidis T, Alexandrou A, Albanopoulos K, Lampropoulos C (2022) Long-term (11+ years) efficacy of sleeve gastrectomy as a stand-alone bariatric procedure: a single-center retrospective observational study. Langenbecks Arch Surg 408:4. https://doi.org/10.1007/s00423-022-02734-yCrossRefPubMed

22.

Chiappetta S, Lainas P, Kassir R, Valizadeh R, Bosco A, Kermansaravi M (2022) Gastroesophageal reflux disease as an indication of revisional bariatric surgery-indication and results-a systematic review and metanalysis. Obes Surg 32:3156–3171. https://doi.org/10.1007/s11695-022-06183-wCrossRefPubMed

23.

Binda A, Jaworski P, Kudlicka E, Ciesielski A, Cabaj H, Tarnowski W (2016) The impact of selected factors on parameters of weight loss after sleeve gastrectomy. Wideochir Inne Tech Maloinwazyjne 11:288–294. https://doi.org/10.5114/wiitm.2016.64999CrossRefPubMedPubMedCentral

24.

Athanasiadis DI, Martin A, Kapsampelis P, Monfared S, Stefanidis D (2021) Factors associated with weight regain post-bariatric surgery: a systematic review. Surg Endosc 35:4069–4084. https://doi.org/10.1007/s00464-021-08329-wCrossRefPubMed

25.

Migaczewski M, Czerwińska A, Rubinkiewicz M, Zarzycki P, Pisarska M, Rymarowicz J, Pędziwiatr M, Major P (2021) The prevalence of, and risk factors for, Barrett’s oesophagus after sleeve gastrectomy. Wideochir Inne Tech Maloinwazyjne 16:710–714. https://doi.org/10.5114/wiitm.2021.107776CrossRefPubMedPubMedCentral

26.

Bevilacqua LA, Obeid NR, Yang J, Zhu C, Altieri MS, Spaniolas K, Pryor AD (2020) Incidence of GERD, esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma after bariatric surgery. Surg Obes Relat Dis 16:1828–1836. https://doi.org/10.1016/j.soard.2020.06.016CrossRefPubMed

27.

Levy JL, Levine MS, Rubesin SE, Williams NN, Dumon KR (2018) Stenosis of gastric sleeve after laparoscopic sleeve gastrectomy: clinical, radiographic and endoscopic findings. Br J Radiol 91(1089):20170702. https://doi.org/10.1259/bjr.20170702CrossRefPubMedPubMedCentral

28.

Rebibo L, Hakim S, Dhahri A, Yzet T, Delcenserie R, Regimbeau JM (2016) Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management. Obes Surg 26:995–1001. https://doi.org/10.1007/s11695-015-1883-4CrossRefPubMed

29.

Binda A, Jaworski P, Tarnowski W (2013) Stenosis after sleeve gastrectomy—cause, diagnosis and management strategy. Pol Przegl Chir 85:730–736. https://doi.org/10.2478/pjs-2013-0112CrossRefPubMed

30.

Sillén L, Andersson E, Olbers T, Edholm D (2021) Obstruction after sleeve gastrectomy, prevalence, and interventions: a cohort study of 9726 patients with data from the Scandinavian obesity surgery registry (SOReg). Obes Surg 31:4701–4707. https://doi.org/10.1007/s11695-021-05574-9CrossRefPubMedPubMedCentral

31.

Parmar CD, Gan J, Stier C, Dong Z, Chiappetta S, El-Kadre L, Bashah MM, Wang C, Sakran N (2020) One anastomosis/mini gastric bypass (OAGB-MGB) as revisional bariatric surgery after failed primary adjustable gastric band (LAGB) and sleeve gastrectomy (SG): a systematic review of 1075 patients. Int J Surg 81:32–38. https://doi.org/10.1016/j.ijsu.2020.07.007CrossRefPubMed

32.

Rutledge R (2001) The mini-gastric bypass: experience with the first 1274 cases. Obes Surg 11:276–280. https://doi.org/10.1381/096089201321336584CrossRefPubMed

33.

Scavone G, Caltabiano DC, Gulino F, Raciti MV, Giarrizzo A, Biondi A, Piazza L, Scavone A (2020) Laparoscopic mini/one anastomosis gastric bypass: anatomic features, imaging, efficacy and postoperative complications. Updates Surg 72:493–502. https://doi.org/10.1007/s13304-020-00743-4CrossRefPubMed

34.

Wilczyński M, Spychalski P, Proczko-Stepaniak M, Bigda J, Szymański M, Dobrzycka M, Rostkowska O, Kaska Ł (2022) Comparison of the long-term outcomes of RYGB and OAGB as conversion procedures after failed LSG—a case-control study. J Gastrointest Surg 26:2255–2265. https://doi.org/10.1007/s11605-022-05395-wCrossRefPubMedPubMedCentral

35.

Dantas ACB, Branco LT, Tustumi F, de Oliveira DRCF, Pajecki D, Santo MA (2022) One-anastomosis gastric bypass versus Roux-en-Y gastric bypass as revisional surgery after sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg 32:4082–4088. https://doi.org/10.1007/s11695-022-06326-zCrossRefPubMed

36.

Magouliotis DE, Tasiopoulou VS, Tzovaras G (2019) One anastomosis gastric bypass versus Roux-en-Y gastric bypass for morbid obesity: an updated meta-analysis. Obes Surg 29:2721–2730. https://doi.org/10.1007/s11695-019-04005-0CrossRefPubMed

37.

Musella M, Berardi G, Velotti N, Schiavone V, Manetti C, Vitiello A (2022) Safety and efficacy of OAGB/MGB during the learning curve: setting a benchmark in a bariatric center of excellence. Updates Surg 75:169–174. https://doi.org/10.1007/s13304-022-01380-9CrossRefPubMedPubMedCentral

38.

Wysocki M, Łabul M, Małczak P, Proczko-Stepaniak M, Szymański M, Hady HR, Głuszyńska P, Myśliwiec P, Walędziak M, Zarzycki P, Rymarowicz J, Pędziwiatr M, Pisarska-Adamczyk M, Major P, Polish Revision Obesity Surgery Study (PROSS) Collaborative Study Group (2023) Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter polish revision obesity surgery study. Surg Obes Relat Dis 19:68–75. https://doi.org/10.1016/j.soard.2022.08.011CrossRef

39.

Mahawar KK, Jennings N, Brown J, Gupta A, Balupuri S, Small PK (2013) “Mini” gastric bypass: systematic review of a controversial procedure. Obes Surg 23:1890–1898. https://doi.org/10.1007/s11695-013-1026-8CrossRefPubMed

40.

Genser L, Carandina S, Tabbara M, Torcivia A, Soprani A, Siksik JM, Cady J (2016) Presentation and surgical management of leaks after mini-gastric bypass for morbid obesity. Surg Obes Relat Dis 12:305–312. https://doi.org/10.1016/j.soard.2015.06.010CrossRefPubMed

41.

Liagre A, Queralto M, Juglard G, Anduze Y, Iannelli A, Martini F (2019) Multidisciplinary management of leaks after one-anastomosis gastric bypass in a single-center series of 2780 consecutive patients. Obes Surg 29:1452–1461. https://doi.org/10.1007/s11695-019-03754-2CrossRefPubMed

42.

Baker RS, Foote J, Kemmeter P, Brady R, Vroegop T, Serveld M (2004) The science of stapling and leaks. Obes Surg 14:1290–1298. https://doi.org/10.1381/0960892042583888CrossRefPubMed

43.

Miranda A, Rosato A, Costanzi A, Pisano L, Colzani S, Auricchio S, Mari G, Achilli P, Maggioni D (2020) Case report: acute kidney failure leading to permanent haemodialysis due to hyperoxaluria following one-anastomosis gastric bypass-related rapid weight loss. F1000Res 9:155. https://doi.org/10.12688/f1000research.22109.2CrossRefPubMedPubMedCentral

44.

Witting C, Langman CB, Assimos D, Baum MA, Kausz A, Milliner D, Tasian G, Worcester E, Allain M, West M, Knauf F, Lieske JC (2021) Pathophysiology and treatment of enteric hyperoxaluria. Clin J Am Soc Nephrol 16:487–495. https://doi.org/10.2215/CJN.08000520CrossRefPubMed

45.

Nazzal L, Puri S, Goldfarb DS (2016) Enteric hyperoxaluria: an important cause of end-stage kidney disease. Nephrol Dial Transplant 31:375–382. https://doi.org/10.1093/ndt/gfv005CrossRefPubMed

46.

Ritz E (2013) Bariatric surgery and the kidney-much benefit, but also potential harm. Clin Kidney J 6:368–372. https://doi.org/10.1093/ckj/sfs161CrossRefPubMed

47.

Upala S, Jaruvongvanich V, Sanguankeo A (2016) Risk of nephrolithiasis, hyperoxaluria, and calcium oxalate supersaturation increased after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis. Surg Obes Relat Dis 12:1513–1521. https://doi.org/10.1016/j.soard.2016.04.004CrossRefPubMed

48.

Ormanji MS, Korkes F, Meca R, Ishiy CSRA, Finotti GHC, Ferraz RRN, Heilberg IP (2017) Hyperoxaluria in a model of mini-gastric bypass surgery in rats. Obes Surg 27:3202–3208. https://doi.org/10.1007/s11695-017-2725-3CrossRefPubMed

49.

Agrawal V, Wilfong JB, Rich CE, Gibson PC (2016) Reversal of gastric bypass resolves hyperoxaluria and improves oxalate nephropathy secondary to Roux-en-Y gastric bypass. Case Rep Nephrol Dial 6:114–119. https://doi.org/10.1159/000449128CrossRefPubMedPubMedCentral

50.

Barzin M, Tasdighi E, Ebadinejad A, Khalaj A, Mahdavi M, Valizadeh M, Hosseinpanah F (2022) Anemia after sleeve gastrectomy and one-anastomosis gastric bypass: an investigation based on the Tehran obesity treatment study (TOTS). World J Surg 46:1713–1720. https://doi.org/10.1007/s00268-022-06528-7CrossRefPubMed

51.

Shirazi N, Beglaibter N, Grinbaum R, Ahmad WA, Aronis A (2022) Nutritional outcomes 1 year after one anastomosis gastric bypass compared to sleeve gastrectomy. Nutrients 14:2597. https://doi.org/10.3390/nu14132597CrossRefPubMedPubMedCentral

Titel: Revisional one-anastomosis gastric bypass for failed laparoscopic sleeve gastrectomy
verfasst von: Artur Binda
Joanna Żurkowska
Agnieszka Gonciarska
Emilia Kudlicka
Krzysztof Barski
Paweł Jaworski
Piotr Jankowski
Michał Wąsowski
Wiesław Tarnowski
Publikationsdatum: 09.04.2024
Verlag: Springer International Publishing
Erschienen in: Updates in Surgery
Print ISSN: 2038-131X
Elektronische ISSN: 2038-3312
DOI: https://doi.org/10.1007/s13304-024-01820-8

Neu im Fachgebiet Chirurgie

Vorsicht, erhöhte Blutungsgefahr nach PCI!

10.05.2024 Koronare Herzerkrankung Nachrichten

Nach PCI besteht ein erhöhtes Blutungsrisiko, wenn die Behandelten eine verminderte linksventrikuläre Ejektionsfraktion aufweisen. Das Risiko ist umso höher, je stärker die Pumpfunktion eingeschränkt ist.

Darf man die Behandlung eines Neonazis ablehnen?

08.05.2024 Gesellschaft Nachrichten

In einer Leseranfrage in der Zeitschrift Journal of the American Academy of Dermatology möchte ein anonymer Dermatologe bzw. eine anonyme Dermatologin wissen, ob er oder sie einen Patienten behandeln muss, der eine rassistische Tätowierung trägt.

Deutlich weniger Infektionen: Wundprotektoren schützen!

08.05.2024 Postoperative Wundinfektion Nachrichten

Der Einsatz von Wundprotektoren bei offenen Eingriffen am unteren Gastrointestinaltrakt schützt vor Infektionen im Op.-Gebiet – und dient darüber hinaus der besseren Sicht. Das bestätigt mit großer Robustheit eine randomisierte Studie im Fachblatt JAMA Surgery.

Chirurginnen und Chirurgen sind stark suizidgefährdet

07.05.2024 Suizid Nachrichten

Der belastende Arbeitsalltag wirkt sich negativ auf die psychische Gesundheit der Angehörigen ärztlicher Berufsgruppen aus. Chirurginnen und Chirurgen bilden da keine Ausnahme, im Gegenteil.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Aktuelle BDC Leitlinien-Webinare

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare

CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare

CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske

Dr. med. Benjamin Meyknecht

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare

CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric

Springer Medizin

Abstract

Graphical abstract

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Update Chirurgie