Bariatric Surgery

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This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

Schematic representation of a gastric band

Under bariatric surgery or bariatric surgery is meant surgical measures (metabolically-bariatric surgery) for the treatment of morbid overweight . It is a specialty of visceral surgery and deals with the surgical modification of the gastrointestinal tract. The aim is to help people with morbid obesity, for whom conventional weight reduction measures have not been successful, to lose weight. It is medically the most invasive means of combating obesity and its complications. After a bariatric surgery, the person affected has to switch to a special, balanced diet . Weight reduction can lead to a significant improvement in the general state of health, as many secondary diseases are also favorably influenced.

Procedure

There are numerous surgical procedures , of which recognized as a standard procedure in Germany four and individually are: gastric banding , sleeve gastrectomy , gastric bypass ( Roux-Y gastric bypass ) and biliopancreatic diversion with duodenal switch (BPD-DS). These recommendations come from the Medical Guideline for Surgery of Obesity (so-called S3 guideline), which is published by the German Society for General and Visceral Surgery eV (DGAV) and is regularly adapted to the state of medical knowledge.

Gastric band, gastric sleeve and gastric bypass develop their effect to a large extent by limiting the supply of food (restriction). A restriction of the absorption of nutritional ingredients by the body ( malabsorption or malabsorption ) is primarily achieved with biliopancreatic diversion with or without duodenal switch (DS), and to a lesser extent with gastric bypass. The malabsorptive techniques shorten (in addition to limiting food intake) the digestive passage, so that the food is more poorly utilized. They are technically more complex and prone to complications than the purely restrictive methods. For very overweight patients (BMI> 60), a restrictive procedure such as the sleeve stomach is recommended.

Other surgical procedures and techniques are currently (December 2011) considered outsider procedures or experimental and are only performed in exceptional cases.

A gastric balloon does not belong to bariatric surgery in the narrower sense, but is only acceptable as a preparatory procedure for a surgical procedure in special cases.

The decision about bariatric surgery and the choice of surgical procedure depends on many factors and the patient's personal wishes. The advice should be given individually and, if necessary, repeatedly in an experienced center. Since the beginning of 2010, centers for obesity and metabolic surgery have been certified by the German Society for General and Visceral Surgery (DGAV) as reference, competence and excellence centers (Frankfurt, Recklinghausen). Reference centers must demonstrate special expertise in the field of bariatric surgery, centers of excellence must also perform 350 operations per year and a. conduct scientific studies. Today, all primary interventions are performed laparoscopically (so-called keyhole surgery, surgery is performed under camera view using instruments that are inserted through small incisions into the abdominal cavity), which is gentler and less complicated for the patient (lower risk of wound healing disorders due to smaller scars). In the meantime, the first operations (sleeve stomach, gastric band) have also been carried out using the so-called NOTES or SILS technique.

Requirements for surgical therapy in accordance with the S3 guideline

  • Body mass index > 40 or BMI> 35 with concomitant diseases ( diabetes mellitus , sleep apnea , arterial hypertension , etc.).
  • The overweight has existed for more than 3 years.
  • Age between 18 and around 65 years, biological age is decisive.
  • Exhausted conservative methods in the sense of a multimodal therapy program over 6–12 months (nutritional advice / change, exercise training, behavioral therapy); alternatively: primary indication if there is no prospect of success in further conservative therapies.
  • No psychosis , depression (with the exception of reactive depression due to weight).
  • No addiction symptoms (because of the possible risk of shifting addiction; no alcohol, tablet or drug addiction).

Restrictive Techniques

Restrictive operations limit the capacity of the stomach while maintaining digestive performance. The results of such gastric reduction interventions vary widely. Even patients with severe obesity ( BMI 50 and greater) have achieved normal BMI values ​​in exceptional cases. Roughly one assumes a success rate of about 60% at the first attempt. This does not mean that the other 40% do not also see a decrease, but this often falls short of expectations. As the BMI increases, the success rate also drops significantly. The purely restrictive techniques can be outsmarted consciously or unconsciously by the patient consuming liquid or soft, high-energy foods or greatly extending meals. There is currently no reliable way of reliably verifying a patient's suitability for a restrictive technique prior to surgery.

Gastric balloon

The gastric balloon is a balloon that can be inserted into the stomach through the esophagus without surgery. When the balloon is in the stomach, it is filled with water or air so that the gastric balloon cannot leave the stomach through the esophagus or the small intestine. Due to the foreign body in the stomach, the stomach is felt to be full even after a small amount of food.

The cost of the gastric balloon is between 2500 and 4000 € (depending on the clinic and the scope of services). A gastric balloon should remain in the stomach for a maximum of six months, because the material becomes brittle over time and a defect in the balloon must be expected. The unnoticed loss of remains of the gastric balloon can lead to complications such as an intestinal obstruction (ileus). Good results can be achieved if the gastric balloon is used as a supportive measure in the context of a change in diet. For these reasons, this method is mainly used in patients whose health is so poor that general anesthesia would be too risky. This group of patients can lose weight with the help of the gastric balloon in order to have obesity surgery six months later. In such cases, the health insurance company can also apply for the costs to be covered.

Gastric band

Gastric band system in SILS technology

A surgeon who has performed 50 operations is considered to be sufficiently experienced in relation to gastric banding . The main advantage of the gastric band is its practically complete reversibility, which means that it can also be removed again. On the other hand, such a foreign implant can in principle lead to technical problems (leakage of the tube system, problems caused by infections or adhesions on the outside of the stomach), slipping ( slippage ), forestomach dilation ( pouch dilation ), problems in the area of ​​the port (infections, slipping / turning of the port chamber, Tearing off the hose etc.). In the long term (10 years), the complications mentioned lead to another operation in about 30–50% of cases, which usually leads to gastric band removal and conversion into a sleeve resection. The surgical procedure itself has a very low risk of complications (<1%), and the operation can generally be performed as an outpatient procedure, provided there are no special contraindications.

Gastric sleeve resection with volume measurement

Gastroplastics

The gastroplastics according to Mason or Eckhout are considered out of date. Similar to the gastric band a small forestomach (also was at a gastroplasty Pouch ) formed by staple seams that could absorb only a limited amount of food and as quickly gives rise to a feeling of satiety. However, the staple sutures have often loosened, so that the effect of the operation was reversed in many cases. This operation should therefore no longer be performed and is therefore no longer included in the S3 guideline.

The formation of a tubular stomach (sleeve resection) is currently experiencing an enormous international boom. In terms of the frequency of the procedure, gastric sleeve surgery is now well ahead of gastric bypass (Federal Statistical Office 2012: gastric sleeve 3351 versus 3157 gastric bypass surgery). The stomach is resected along the large curvature so that a tubular part of the stomach (small curvature) remains. The resulting stomach volume is 100-150 ml. In contrast to gastric bypass, the separated part of the stomach is removed. The seams of this tube are very demanding and are made laparoscopically with clip cutting devices. In experienced centers, the complication rate is less than 1%.

The gastric tube ( sleeve ) was first as the first step of the two-step method in patients with a BMI / made greater than 60 kg-m. The second step is biliopancreatic diversion according to Scopinaro (BPD) about 1–2 years later and after appropriate weight reduction , which should then reach the target weight. The advantage of this two-step method is the reduction of the surgical risk, but the disadvantage is that it has to be operated twice. The sleeve gastrectomy is now recognized as the only bariatric surgical procedure. The weight reduction averages 70% (loss of excess weight) within the first 1 to 2 years after the operation. In contrast to the Roux-en-Y gastric bypass, the physiological pathway in the food passage is not changed and an endoscopy of the tubular stomach including the duodenum is possible. The long-term need for vitamins and minerals can only be ensured with a substitution of vitamin B12.

Restrictive malabsorptive procedures

Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass is a technique in which the aim is to restrict food intake by making the stomach smaller . In addition, the intestinal passage is shortened here too, so that there is also a malabsorptive component. Relatively feared with R / Y is the so-called dumping syndrome , the nausea after consuming confectionery. The weight reduction is probably faster and greater in many patients than with gastric bands, but there are also reports of patients who, like with gastric bands, gain weight again after several years - usually 5–10% of the weight lost, this applies to everyone OP procedure with the exception of the BPD.

As with all obesity surgical measures, vitamins , trace elements and protein must be supplied for life .

Biliopancreatic Diversion with Duodenal Switch (BPD-DS)

The biliopancreatic division (English biliopancreatic diversion ) with duodenal switch supplements the stomach reduction caused by the surgical formation of a sleeve stomach with a switch-off of the small intestine. To do this, the duodenum is closed behind the gastric gate and a short part of the small intestine behind the stomach is connected to the rest of the stomach. The part of the small intestine that transports the digestive juices is connected at a more distant point with the part that transports the pulp, so that the food components are only absorbed over a short distance. After the procedure there is a foul smelling stool.

The duodenal switch (= duodenal change) is based on the principle of biliopancreatic diversion and is a further development of this effective technique. With the duodenal switch, however, the gastric gatekeeper is present, which prevents "dumping" (sudden evacuation of sugar from the remaining stomach with subsequent blood sugar regulation and side effects such as nausea and sweating). The duodenal switch is the further development of the BPD. This technique is not entirely equivalent to BPD in terms of its function, but it has the advantage that the gastric gate (pylorus) can be preserved. The sleeve stomach has a volume of about 80-120 ml. The technique was originally developed by Tom R. DeMeester for the treatment of biliary reflux. The duodenal stump is closed and the postpyloric duodenum (duodenum) is connected to the ileum (part of the small intestine). In contrast to the bilopancreatic diversion according to Scopinaro, the so-called common channel is 100 cm. In 1988 Douglas Hess (Bowling Green, Ohio) was the first surgeon to use the open technique combination with BPD for weight loss. The results in weight loss and quality of life (eating behavior) were convincing. Michael Gagner (New York, USA) was the first surgeon to perform this procedure laparoscopically in 1999.

Malabsorptive procedures

Biliopancreatic diversion according to Scopinaro

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

This so-called biliopancreatic division represents a further development of the intestinal bypass and has been developed since 1976 by Nicola Scopinaro in Genoa (Italy), who oversees a considerable number of patients (approx. 2000) over the long term. It is somewhat similar to the Roux-en-Y gastric bypass. It is a demanding and, because of the possible complications after the operation and in the long term, potentially more dangerous, but extremely effective in terms of weight loss. The principle is less based on food restriction - stomach reduction through a distal gastrectomy - similar to gastric bypass - that is, the removal of the lower part of the stomach leaving a residual stomach that has a defined volume of 200 to 250 ml - and deficient digestion. The remaining antrum has recently been left in place. The intestinal continuity is reconstructed by connecting the remaining stomach with the approx. 200 cm distal (lower) small intestine, which enables a rapid shunt into the lower small intestine (ileum).

The weight is maintained through biliopancreatic diversion (diversion of digestive juices) via permanent, selective malabsorption (reduced absorption) for fat and starch. The proximal (upper), switched off part of the small intestine, which contains all digestive enzymes from the pancreas and the bile from the liver, is in turn connected to the lower small intestine, around 50 cm before the transition to the large intestine. The so-called common channel is then 50 cm. This reduces the resorptive area of ​​the small intestine for fats and starches, which require the digestive juice from the pancreas and the bile acids from the liver, so that only a small amount can be digested and absorbed into the body. The protein uptake from the intestine, on the other hand, experiences less reduction and simple sugar compounds are absorbed unhindered.

Other procedures

Gastric pacemaker

A gastric pacemaker is a battery-powered pulse generator that delivers current pulses to the stomach muscles via an electrical probe attached to the front wall of the stomach by means of a laparoscopic approach, in order to achieve a slower or faster emptying of the stomach. The probe inserted into the stomach muscles is connected to the battery via a catheter.

A modern gastric pacemaker system consists of an implantable gastrointestinal stimulator (IGS) and a wire as well as a programmer, wand and software package intended for the doctor. The IGS is about the size of a pocket watch (60 × 54 × 10.3 mm) and weighs 55 g. The lead wire has a diameter of 3 mm and a length of 38.5 cm.

The indications are the same as those for the gastric band. An expected weight loss of a maximum of 30 percent makes its use appear questionable with a BMI> 45. The system is very expensive because there is no cash register to pay for it and the batteries have to be replaced again.

The Schwabach City Hospital reported in March 2011 that Germany's first certified gastric pacemaker had been implanted.

Small bowel bypass

The pure bypass of the small intestine , in which only the small intestine is functionally shortened and the digestion of the food supplied is to be partially prevented ( malabsorption ), is now considered obsolete. The side effects and complications, some of which were fatal, were considerable. There is the Jejuno-Ileal Bypass and the Jejuno-Colic Bypass.

Assumption of costs

Situation in Germany

Bariatric surgery is (as of 2007) not included in the standard benefit catalog of the statutory health insurance (GKV), but can be applied for as an individual case and financed by the health insurance fund.

The prerequisite for this is proof of the use of so-called conservative methods of weight loss. The current reimbursement of costs includes proof of participation in a multimodal concept, which is from the fields of psychology, internal medicine, bariatric surgery, nutritional advice and exercise therapy over a period of 6 to 12 months. However, this concept is not ready. Every patient has to find his own therapist and create a link between them. Certified obesity centers have to provide advice and mediation here, including the support of self-help groups.

Situation in Switzerland

Stomach reduction coverage infographic Switzerland

In Switzerland, the health insurance companies are obliged to provide benefits for the surgical treatment of obesity, but not for the gastric balloon.

Requirements:

  • Body mass index > 35
  • Two years of adequate overweight treatment were unsuccessful.
  • The guidelines of the SMOB (Swiss Society for the Study of Morbid Obesity and Metabolic Disorders) are observed in diagnosis and treatment.
  • The operation is carried out in a center recognized by SMOB or a professionally and technically equipped clinic.
  • If the center is not recognized by the SMOB, the medical examiner must agree.

SMOB guidelines on bariatric surgery

In the guidelines of the SMOBS, an additional requirement is considered:

  • Written commitment of the patient to lifelong follow-up care
  • In patients over 65 years of age, the risks and benefits should be carefully weighed. Age alone is not an exclusion criterion.

Various contraindications for the use of bariatric surgery are also mentioned here. In addition to physical illnesses such as cardiovascular illnesses and other internal ailments, this also includes mental illnesses and personality traits (lack of compliance , lack of judgment, etc.)

Situation in South Africa

Around 50 percent of people in South Africa are considered overweight. Private health insurances do not fully cover the operation, other health insurances are thinking about assuming costs in the future.

Aftercare

Follow-up care for patients who have undergone bariatric surgery in other European countries such as Great Britain and the Benelux countries is well established thanks to different organizational and administrative structures and facilities. In contrast, this process and the understanding of its necessity in Germany has only recently started. However, this is all the more important as it has been known for several years through various scientific studies that satisfactory weight loss through surgical or non-surgical measures under suddenly changed framework conditions such as psychological stress, loss of partners, unemployment, even after several years, can be nullified by gaining body weight can. Weight regain can become a serious problem for those affected. The therapeutic consequence is often associated with an expansion of the surgical procedure and a reduced likelihood of largely reversing the consequences of the surgical procedure (such as with gastric banding). Reliable information on the effects of the individual therapeutic procedures is required.

Therefore, an absolute requirement for the diagnosis and therapy of obesity is a complete documentation of the patient data during the course of the process under the most modern premises: (1) data transfer from practice or hospital information systems (PIS or HIS); (2) efficient patient management through modern software; (3) standardized, structured data entry, especially of historical data that has been repeatedly collected; (4) individual tabular and graphic data evaluations from patient groups; (5) direct data entry into or encrypted data export to the quality assurance study in Magdeburg; (6) automated reporting and writing templates for health insurance applications.

Follow-up care and long-term therapy now also include advice and planning of the operations that are often required to restore the body contour after massive weight reduction. The patients should z. For example, the often necessary follow-up operations (post-bariatric surgery) should be pointed out before obesity surgery (see guidelines).

Bariatric Surgery - Criticism

According to current studies, bariatric surgery is a successful form of therapy for pathological obesity, which, however, has not remained without criticism. Ultimately, the patient and the doctor have to weigh the risks and consequences of the bariatric intervention or of remaining in the high-risk obesity disease.

Dimension surgery

Most bariatric surgery measures are generally irreversible. Healthy organs are operated on: the healthy gastrointestinal tract is not the cause of obesity. The operation is performed on the healthy abdomen, which means that all the risks of an abdominal operation arise (intraoperatively e.g. injury to neighboring organs, postoperatively e.g. seam insufficiencies or pneumonia , long-term complications such as adhesions ). Most surgical procedures require electrolytes, vitamins, iron and trace elements to be taken in for a lifetime. It should also be borne in mind that the absorption of drugs changes.

Dimension psychology

In spite of all the psychological tests carried out before the operation for serious mental illnesses that prohibit the operation in accordance with the guidelines, the person who has developed obesity remains. This development of obesity has mostly taken place over years or even decades, and inadequate food consumption is often a compensation for felt or actual psychological and emotional impairments or injuries. This compensation for eating is taken away from the operated patient.

A special diet must be observed throughout your life, which can no longer be freely selected due to the operation.

Long-term, qualified psychological follow-up care is not guaranteed either, since health insurance companies reject such long-term therapy.

Dimension hormonal regulatory mechanisms

Ultimately, the hormonal regulatory cycles that lead to the development of obesity and the long-term consequences of the operation with the partial removal of neuronal organs and the suppression of hormonal regulatory mechanisms (e.g. hormones of the pancreatic islet cells, peptide hormones of the gastrointestinal tract) are not yet understood . .

Dimension diabetology

Many operated patients are diabetics, whose blood sugar levels improve considerably after the operation up to an apparently normal blood sugar metabolism. At least temporarily, the surgeons achieve significantly better treatment results for diabetes mellitus than diabetologists . However, studies have not shown a cure for diabetes mellitus. After years there is often a relapse in the diabetic metabolic state. Long-term studies are still lacking. Also, no studies have yet been published that included control groups.

Brain metabolism dimension

According to Achim Peters' selfish brain theory, the procedure destabilizes brain metabolism by lowering blood sugar levels. Immediately after the procedure, the brain would receive less energy than before. Either it gets by with too little energy, which leads to general exhaustion, or it permanently overloads the stress system, which suddenly sets in and sustained massive permanent stress.

See also

literature

  • Martin Büsing et al: Sleeve stomach formation in the treatment of morbid obesity study results and first experiences with the transvaginal hybrid NOTES technique. In: The surgeon . Volume 82, Number 8, pp. 675-683, 2011
  • Rudolf Weiner : New opportunities for obesity - gastric banding - gastric bypass - gastric pacemaker. Trias Verlag, 2002, ISBN 3-8304-3049-3 .
  • Rudolf Weiner among others: Obesity surgery - indication and therapy method. UNI-MED Verlag, Bremen 2006, ISBN 3-89599-958-X .
  • Emmanuel Hell, Karl Miller: Morbid Obesity. Clinic and surgical therapy. Ecomed 2002, ISBN 3-609-20181-9 .
  • Anna Maria Wolf: Surgical options for massive obesity. Obesity spectrum , edition 02/2006, ISSN  1861-7093
  • Martin Büsing et al: Initial Experience with Transvaginal Sleeve Gastrectomy for Morbid Obesity by NOTES-First Experience in Europe. In: Obesity Surgery . Volume 19, 2009, p. 1055.
  • Jörn Christian Halter among others: The laparoscopic gastric band application as an outpatient operation. In: CHAZ. Volume 11, Number 4, 2010, p. 224.
  • Tim C. Werner: Financing of bariatric surgery: application, objection and lawsuit. In: Obesity Facts. Volume 4, 2011, pp. 50-54.
  • Richard Daikeler, Götz Use, Sylke Waibel: Diabetes. Evidence-based diagnosis and therapy. 10th edition. Kitteltaschenbuch, Sinsheim 2015, ISBN 978-3-00-050903-2 , pp. 123-127 ( obesity surgery ).

Web links

Individual evidence

  1. ↑ Guideline for Obesity Surgery . Association of the Scientific Medical Societies in Germany (AWMF). 2018. Retrieved August 7, 2019.
  2. ^ German Society for General and Visceral Surgery eV (DGAV) . German Society for General and Visceral Surgery eV. Retrieved December 25, 2011.
  3. ^ German Society for General and Visceral Surgery eV (DGAV) . Dgav.de. Retrieved August 19, 2010.
  4. ↑ Forms of bariatric surgery: gastric balloon. Retrieved October 30, 2007 .
  5. ↑ Average costs of different forms of bariatric surgery. Retrieved October 30, 2007 .
  6. ↑ Richard Daikeler et al. a .: diabetes. Evidence-based diagnosis and therapy. 2915, p. 125 f.
  7. ↑ Patient information on antidiabetic operations. In: k-plus.de. Archived from the original on June 22, 2010 ; Retrieved February 18, 2014 .
  8. ↑ Richard Daikeler, idols Use, Sylke Waibel: diabetes. Evidence-based diagnosis and therapy. 10th edition. Kitteltaschenbuch, Sinsheim 2015, ISBN 978-3-00-050903-2 , p. 126.
  9. ↑ New type of gastric pacemaker helps obese patients lose weight permanently. ( Memento from June 21, 2011 in the Internet Archive )
  10. ↑ judgment of the Federal Social Court of 19 February 2003, B 1 KR 1/02 R . Lumrix.de. February 19, 2003. Archived from the original on September 27, 2007. Retrieved on June 19, 2016.
  11. ^ Ordinance of the EDI on benefits in compulsory health insurance, Appendix 1, 1.1 General surgery . The Federal Department of Home Affairs (FDHA). August 3, 2017. Retrieved August 24, 2017.
  12. ↑ [ http://www.smob.ch/de/component/jdownloads/send/1-root/3-smob-linien-medizinisch-2013?option=com_jdownloads guidelines for the surgical treatment of obesity] . Swiss Society for the Study of Morbid Obesity and Metabolic Disorders. January 1, 2014. Retrieved August 24, 2017.
  13. ^ "The Sunday Times" author Shantini Naidoo: Bariatric Surgery in South Africa: Lean through Operations . In: Spiegel Online . October 27, 2018 ( spiegel.de [accessed October 27, 2018]).
  14. ↑ R.Singhal: Role of laparoscopic adjustable gastric banding in the treatment of obesity and related disorders; British Journal of Diabetes & Vascular Disease May / June 2009 vol. 9 no.3 131-133
  15. ↑ How surgeons become the new diabetologists, Aulinger, B., Rohrer, S., Diabetes Congress Report December 2011, Congress Report 71st Annual Meeting of the ADA 2011
  16. ↑ Surgical treatment of obesity: mortality not reduced within six years . In: Deutsches Ärzteblatt , October 21, 2011. Accessed February 25, 2012. 
  17. ↑ Achim Peters with Sebastian Junge: Myth overweight. Why fat people live longer , C. Bertelsmann Verlag, 2013, ISBN 978-3-570-10149-0 . Chapter Bariatric Operations: How an Intervention Turns a Fat Man into a Thin Man , pp. 134–148, see p. 139 and pp. 144–145.