During last 10 years we have had an experience with the data of more than 45000 patients from all over the world. The choice of the treatment depends on the individual case. There is no standart. Germany is one of the leading countries in a quality of as obesity treatments as well as a diabetis type 2. The quantity of bariatric surgeries, in relation to the population, is definitly lower than in the neighbouring contries. Nowadays the frequency of bariatric surgeries in case of morbid obesity is currently 10.5 per 100 000 adults, what is much higher as in the other European countries (Sweden: 114.8, France: 86.0, Switzerland: 51.9). It is many times higher in other European countries (Sweden: 114.8, France: 86.0, Switzerland: 51.9).
There is no special standard for any bariatric interventions. The choice of the bariatric surgery is always strictly individual and depends on the very special case of the patient.
The German Bariatric Surgery Register (GBSR) follows the analytical situation in bariatric surgery branch since 2005. This observational study, also known as "Quality Assurance Study of Adiposity Operative Surgery", provides comprehensive information based on diagnostics, surgical therapy, postoperative course and long-term outcome of metabolic-surgical interventions of more than 45 121 patients.
The average age of the patients is about 42.7 years, with 71.5% (n = 28 395) significantly more women than men (28.5%, n = 11 316). The obesity-associated co morbidities, increase steadily during the observation period, with 90.26% of men and 85.05% of women, having, at least, one of co morbidity to their surgery time. At 50.67 kg / m2 Usually men have a significantly higher BMI than women ( 50.67 kg / m2 in comparison to 48.69 kg / m2).
The number of obese people is increasing dramatically worldwide. You can even say that the disease is spreading like an epidemic or even a pandemic. According to the current WHO data, approximately 21.3% of German citizens are obese, i.e. they have a BMI of more than 30 kg/m².
BMI of 35 kg/m² is considered the Obesity Grade II, BMI of more than 40 kg/m² is the Obesity Grade III. The health implications are dramatic: obesity causes numerous secondary diseases, mostly diabetes mellitus and cardiovascular diseases. Moreover different types of cancer are more common by obese people than by people with normal weight.
In addition, the obese person is impacted economically because of high health costs and trying to lead the healthy mode of life without a previous therapy.
Because of morbid obesity individuals usually experienced a significant reduction of quality of life, they are also often confronted with social exclusion and prejudice. Surely every obese person has heard the well-intentioned advice: "Eat less and move more", even though this advice certainly is a good way to prevent obesity, it does not provide an effective therapy. Overweight patients who in addition to exertional dyspnea also have severe pain or degeneration, will only be able to follow this recommendation partially.
At the same time, modern people are moving less, hard physical work has become much rare, cheap high energy food is everywhere and is aggressively advertised. All these factors have contributed to the sudden increase in obesity, seen since the 1970s in almost all industrial and newly industrializing countries.
Since conservative therapy has a rather low efficiency and therefore cannot solve the problem for the majority of patients, surgical procedures have been developed that can change the anatomy and physiology of food intake to make the rapid and sustainable weight loss possible.
The United States of America is obviously ahead of Germany in the development of obesity. The number of surgical interventions to treat morbid obesity has increased in such a way that they have already overtaken the two most frequent interventions: gallbladder removal and hernia operation. These interventions are being carried out more and more often in Europe, too.
Prerequisites for treatment
An operative reduction of pathological excess weight always represents a considerable intervention in the body anatomy and physiology and sometimes influences a critically on food digestion and metabolism. In addition, there are always risks associated with a major surgical procedure. Therefore, a surgical treatment should never be the first option, it can be chosen only if all other therapy methods have failed or promise no success.
At present, these kind of surgeries are not reimbursed by health insurance companies by default, each intervention must be applied for and motivated individually. A health insurance company will take over the costs of such an op, taking into account not only medical criteria of its usefulness, a patient should also complies with further conditions. The following criteria should be met:
- Patients should be between 18 and 65 years old.
- Their BMI should be greater than 40 kg/m² or if the BMI is over 35 and patients suffer from health problems that are associated with severe excess weight, e.g. diabetes, joint diseases, heart problems or snoring with regular suspending of respiration (sleep apnea).
- The patient has been overweight for more than 5 years.
- A multimodal conservative therapy has been conducted for more than 6 months and had no effect.
- Patients have no other diseases that could cause the overweight.
- Sufficient compliance.
- No excessive consumption of alcohol or drug abuse.
A conservative therapy attempt is considered sufficient if the treatment concept has elements from the three key pillars: movement, nutrition and behavior. The therapeutic approaches from these sub-areas must be coordinated and carried out simultaneously. Medications can be used to support them.
Restrictive and malabsorptive procedures
Commonly used restrictive procedures include gastric banding (GB) and sleeve gastrectomy (SG) or tubular stomach. While the gastric band ties up the diameter in the upper part of the stomach, the tube stomach is formed by a left-lateral gastric resection. This not only reduces the size of the stomach, but also eliminates hormone-producing components that affect satiety.
The Roux-Y Gastric Bypass (LRYGB) is a more complex intervention, not only restrictive, but also malabsorptive. There remains a small gastric pouch, which is directly connected to the jejunum, the passage through the duodenum and large portions of the jejunum is switched off. Other malabsorptive procedures, such as bileopancreatic diversion (BPD), in which only about 100 cm of passage remain in the small intestine, as well as BPD with duodenal switch (DS), play hardly any quantitative role in Germany.
Choice of procedure
After the gastric bypass (RYGB) with 17 215 operations, the Sleeve gastrektomie (SG) with 15 795 documented procedures is the second most common procedure. It also shows the highest percentage increase over the entire period. Complex malabsorptive processes are currently playing a minor role in Germany. The implantation of a gastric band (GB) has been carried out since 2005 in 4 124 cases and is therefore in third place.
There was a significant decrease in gastric band implantation throughout the study. Patients with GB were significantly younger at 40.5 years than patients with all other procedures. In addition, they had a significantly lower BMI of 44.92 kg / m2.
Patients who underwent SG had a significantly higher BMI and a higher incidence of comorbidities compared to all other procedures. In particular, the frequency of cardiac comorbidities, are diabetes and sleep apnea.
The RYGB gastric bypass has been performed since 2005 in 17 215 patients. There was a clear preference for laparoscopic access, which accounted for 98.6% of interventions. Patients with RYGB (47.92 kg / m2) had a significantly lower BMI than patients with other procedures (50.27 kg / m2).
The more complex BPD (n = 148) was performed in 17 institutions participating in the study. The patients are older (43.4 vs. 42.7 years) and have a higher BMI (52.79 vs. 49.24 kg / m2) than patients with other procedures. The DS was conducted in 16 participating institutions as a one-time operation in 168 cases. Patients with duodenal switch are on average the oldest patients (46.7 versus 42.7 years) compared with other surgical procedures.
Between 2005 and 2014, 3 371 re and 2 039 re-do operations were undertaken. The percentage distribution of revision procedures on the surgical procedures was shown in the table. Most frequent were revisions to primary GB (44.7%) for late complications such as slipping, ligament defects, or esophageal motility disorders.
Restriction means: Significantly less food can be consumed by reducing the size of the stomach. This causes weight loss. Typical restrictive procedures: gastric balloon, gastric band, tube stomach (or gastric sleeve).
The aim of these procedures is to reduce the amount of food that can be eaten at once. This way the patient starts feeling full faster and the sensation stays for a longer time. The classic example of such operation method is the Swedish adjustable gastric banding (SAGB).
A minimally invasive operation (laparoscopy) is used to place an adjustable gastric banding around the upper part of the stomach. It can be filled from the outside through a port chamber with liquid thus narrowing it. Larger food portions can cause vomiting or esophagus stretching. If this happens too often, the banding becomes ineffective.
The gastric banding is a foreign body, but it is usually well tolerated. In principle, the banding can remain in the body for a lifetime – even when the desired weight has been reached. If it gets removed, the patient usually regains weight.
Restrictive procedures, such as the gastric banding, demand the collaboration and cooperation of the patient in order for the therapy to be successful.
In case of sleeve gastrectomy or left lateral stomach resection a large part of the stomach is surgically removed from the body. Thus, a gastric tube is formed which can hold much smaller amount of food than before.
Its function is primarily restrictive, similar to the gastric banding. However, an additional effect of the "sleeve" is that the part of the stomach is resected, which produces certain hormones responsible for the sensations of hunger and satiety. This includes, for example, the ghrelin.
Thus, the sleeve gastrectomy not only limits the amount of food the stomach can hold, it also changes the hunger, saturation and taste sensations, resulting in a reliable weight loss.
Keyhole Surgery of Obesity
Overweight (Latin obesity) is a dramatically increasing problem in our society. More than 1.2 million adults in Germany suffer from pathological obesity. Overweight is calculated from the ratio of body weight to height in m² and is known as the Body Mass Index (BMI). The prolonged morbid obesity leads to numerous secondary diseases such as diabetes, high blood pressure, lipid metabolism disorders, microsleep, an increase in cancer and chronic joint diseases of the hips, knees and back with a significant reduction in the quality of life of the patient. The mortality of overweight people is significantly increased. It is estimated that the life expectancy of severely overweight people is 12-14 years shorter than that of people of the same age of normal weight.
Many patients try to lose their weight over the years with various diets under medical supervision, but this is often unsuccessful or the weight loss achieved cannot be sustained in the long term. In these cases, surgery can help permanently. Various surgical methods are used in obesity surgery. By implanting a so-called gastric band, a narrowing of the gastric entrance can be achieved with the formation of a small forestomach. With this method, a feeling of fullness is achieved earlier and the ingestion of large amounts of food is impossible. Another method that has been established in the last ten years in particular is the formation of a tubular stomach. A part of the stomach is surgically removed and the remaining part is formed into a tube. One advantage of this method is that it removes the part of the stomach where the hunger hormone ghrelin is formed. This messenger substance is decisive for the development of the feeling of hunger and therefore after this operation there is often a lack of hunger, which has a lasting positive effect on eating habits. The currently most common operation in bariatric surgery worldwide is gastric bypass. Here, the stomach is surgically divided, leaving a small forestomach and the small part is connected directly to the middle part of the small intestine. This not only leads to a significantly reduced amount of ingested food, but at the same time also to a lower digestion of the ingested food, as this only meets in the middle of the small intestine with the body's digestive juices such as bile and pancreatic secretions.
Which procedure is most suitable for the respective patient must be checked in each individual case by a careful examination by a surgeon experienced in obesity surgery. In recent years, the number of overweight operations in Germany and Europe has increased significantly. While in the 1970s and 1980s all operations were performed using large abdominal incisions, today the use of minimally invasive surgical techniques (so-called keyhole surgery) is the method of choice. Compared to open overweight operations, this results in less surgical trauma, significantly less stress on the patient, a lower need for painkillers after the operation and a shorter recovery time and shorter hospital stay than after open operations. Of course, complications can also arise after obesity surgery. However, these are not frequent and are between 2% and 4% in surgical centers that often perform these interventions. In particular, the risk of the overweight operation must be weighed against the risk of concomitant diseases of morbid obesity, as described above, which occurs in the event of the disease progressing untreated.
After a gastric tube or bypass operation, an up to 80% reduction in obesity can be expected in the first few years. Understandably, the patient's performance, resilience and self-esteem increase significantly. Fortunately, pre-existing comorbidities such as diabetes, sleep apnea or high blood pressure often regress or significantly improve. Over time, many patients require less or no medication to control their blood sugar or blood pressure.
Overall, the possibility of a keyhole operation to reduce morbid obesity is a valuable treatment option for patients who cannot reduce their weight in a permanently relevant way using other conservative methods. Of course, a decision to have such an operation is linked to a lifelong confrontation with the obesity disease. The operation is not the only step in combating the disease, but often, in the truest sense of the word, the "incisive" step for the possible change in behavior and life after the operation. With this in mind, more and more patients are choosing such a procedure as a last resort.
What is Metabolic Surgery?
Obesity is often associated with a number of metabolic disorders that form the so-called metabolic syndrome. These include severe metabolic disorders such as insulin resistance, dyslipidemia, type 2 diabetes mellitus and others. These diseases are also considered to be cardiovascular risk factors: they seem to favor the development of arteriosclerotic cardiovascular diseases directly. Myocardial infarction and cerebral infarction are the most unfavorable endpoints. In addition, dyslipidemia results in steatohepatitis (non-alcoholic fatty liver), a chronic liver disease that can dramatically convert to cirrhosis.
Metabolic surgery provides patients with excellent opportunities in achieving complete cure of type 2 diabetes mellitus, dyslipidemia and insulin resistance. The state of steatohepatitis can also be improved and cirrhosis averted.
Regarding diabetes mellitus type 2, insulin therapy after surgery is often superfluous, regardless of the amount of previously needed insulin. For example, a reduction of 300 IU insulin to zero is possible. The improvement in dyslipidemia usually occurs within a year after surgery, in parallel with weight loss.
Regarding the type of treatment, we offer a customized therapy with many options, from sleeve gastrectomy (gastric tube formation) to gastric bypass to biliopancreatic diversion with or without duodenal switch.
These procedures are aimed to alter the digestive physiology in such a way that only part of the consumed food is absorbed by the body. This naturally reduces the amount of calories ingested. However, this procedure also has disadvantages: in the same way severe vitamin deficiency symptoms can occur as well as steatorrhea and extreme flatulence. The classical representative of such surgeries is the biliopancreatic diversion (BPD), which belongs to exceptional indications.
Gastric bypass is a classic example of the combined type of procedures. A small part of the stomach, a so-called pouch is surgically separated from the rest of the stomach, still remaining in the body. A part of the small intestine is anastomosed to the upper stomach, so that the duodenum and the proximal part of the jejunum are excluded from of the food passage and the alimentary limb is separated from the biliopancreatic limb.
Only much later in the Roux-en-Y jejunum anastomosis the digestive enzymes meet the food bolus. Only from here the digestion takes place as usual. Since the alimentary limb, i.e. the part through which the food gets transported without digestive enzymes, is approximately 150 cm long, the surgery was considered to cause a certain malabsorption. However, this fact is now disputed, at least with this length of the digestive limb.
After the operation
After a gastric bypass operation, the patients first feels no or much less hunger, the sense of taste and smell changes and they lose weight very rapidly. However, this cannot be explained by restriction or malabsorption alone. Surprisingly, the total energy consumption of the body increases after the operation despite significantly reduced calorie intake. In contrast, a diet with reduced energy consumption automatically lowers the basal metabolic rate, which makes further weight loss more difficult and when the diet is over leads to a rapid weight regain.
Diabetes mellitus is also dramatically affected. Probably due to the exclusion of duodenum and the early contact of food with the distal jejunum, there is a series of humoral changes that can break the extreme insulin resistance. Many patients who required high doses of insulin before the surgery are able to significantly reduce or even eliminate its intake altogether.
This effect is so great that it is now debated whether to operate patients with normal weight or only slightly obese diabetics if the diabetes can no longer be controlled in a conventional way. This metabolic surgery will probably prevail even more in the future, even if the mechanisms behind the effects are not fully understood at the moment.
Nowadays all bariatric surgeries can be carried out minimally invasive with tolerable risk, but they should be performed in an interdisciplinary centre in which all the disciplines involved in conservative therapy, diagnostics, preparation and implementation of the operation and, above all, the life-long aftercare of the patients work together. In order to prevent deficiency symptoms, patients must also take vitamins and micronutrients for their whole life after the gastric bypass operation, as they are absorbed in the proximal gastrointestinal tract. Diagnostics and treatment of other complications requires a lot of experience and expertise.
In 2009 the German Society for General and Surgery therefore drafted special guidelines, that allow clinics to get certified as obesity centres. In addition to certain infrastructural requirements, an obesity-experienced surgeon team and a minimum number of performed bariatric interventions are required.
Although these operations are very popular and the results in many cases is stunning, yet the gastric bypass and other obesity surgeries are not miracle remedies. If the doctors believe you are a good candidate for the procedure, they will surely explain to you that the operation alone does not guarantee that you will be able overcome obesity or maintain a healthy weight for a long time. In order to achieve tangible and lasting effects, it is necessary to maintain a strict dietary plan and do exercises. A scalpel can do nothing to improve your commitment and willpower.
The cost of stomach reduction varies greatly and depends, among other things, on the following factors:
- Surgical technique and type of stomach reduction
- Doctor and clinic
Cost of a gastric balloon
The number of specialized obesity clinics in Germany is still relatively low, mostly private clinics offer the gastric balloon treatment for long-term weight loss.
The average cost is between €2,500 and €4,000.
This price usually includes:
- Consultation, preliminary examination and nutritional advice
- Insertion of the gastric balloon
- Medical follow-up and removal of the gastric balloon after about 6 months
Cost of a gastric band
Significantly more expensive is the so-called gastric band. This surgical technique is much more complicated and involves a 2-3 day hospital stay. The cost of a gastric band is about €6,500-7,000.
Also included here:
- Consultation and preliminary examination
- Specialist surgery
Cost of a gastric bypass
Gastric bypass is a relatively costly measure compared to gastric balloon and gastric banding. In this operation, the stomach is surgically reduced and the food intake is throttled. The cost of a gastric bypass for self-payers are around €8,000–8,500.