Hristo Nikolaev Kolev is a highly qualified specialist in general surgery with a clear focus on bariatric surgery. At his private practice Adipositas Chirurgie Westend in Frankfurt am Main, he supports individuals with severe obesity on their journey toward better health, quality of life, and autonomy. With over 300 successful bariatric procedures and more than 600 endoscopic gastroscopies, including gastric balloon placements, Hristo Kolev ranks among the most experienced and skilled specialists in his field.
His range of services includes advanced procedures such as sleeve gastrectomy, mini gastric bypass, and Roux-en-Y gastric bypass. Hristo Kolev also performs complex revisional surgeries — for instance, after previous sleeve or bypass procedures — with great precision and using gentle, minimally invasive techniques. He consistently follows a holistic approach based on the latest scientific findings. His goal is not only to reduce body weight but also to alleviate associated comorbidities such as type 2 diabetes, high blood pressure, or joint pain — thereby sustainably improving his patients' quality of life.
Hristo Kolev places great value on personal, respectful care. From the initial consultation through the surgical treatment to long-term follow-up care, he supports his patients with empathy and professional diligence. Each treatment is individually tailored to the patient's medical conditions and personal needs. His additional qualification as a hygiene officer further underscores his commitment to the highest standards of safety and quality in surgical care. Anyone considering bariatric surgery or seeking trustworthy medical support after being denied coverage by their health insurance provider will find a competent and experienced partner in Hristo Kolev.
Appointments for a free initial consultation can be easily scheduled via the website www.adipositas-chirurgie-westend.de — the first step toward a lighter, healthier life. However, applying for a bariatric procedure through health insurance in Germany can often be challenging, as the surgery is considered a last resort — only approved once all conservative measures have been exhausted. Some patients then turn to treatment abroad.
Why this can be problematic was discussed by the editorial team of Leading Medicine Guide in an interview with bariatric specialist Hristo Kolev.
Obesity, commonly referred to as severe overweight, has become one of the most pressing health challenges of our time. It affects not only physical appearance but is primarily a chronic disease with far-reaching consequences for the entire body. Individuals with morbid obesity have a significantly increased risk of cardiovascular disease, type 2 diabetes, joint issues, certain types of cancer, and mental health conditions such as depression or social isolation.
The causes of obesity are complex and range from genetic and hormonal factors to metabolic disorders, emotional eating habits, and an unhealthy lifestyle. While conservative measures such as dieting, physical activity, and behavioral therapy often fail to achieve sustainable weight loss, bariatric surgery — involving procedures to reduce stomach size or reroute the digestive tract — has been proven to offer long-term success. In Germany, access to such procedures is strictly regulated: those seeking bariatric surgery must first submit an application for approval to their health insurance provider.
Before a bariatric procedure can be approved by health insurance in Germany, patients must demonstrate that several conservative treatments have failed over an extended period.
“Bariatric surgery is currently a particularly relevant topic, especially as more and more patients are traveling abroad for such procedures. In Germany, access to bariatric surgery is clearly regulated and subject to specific requirements. At the core is a structured, step-by-step plan that prioritizes conservative treatments before surgery can be approved by insurance. A key component of this process is the so-called multimodal concept (MMC), which typically must be carried out over a period of six to twelve months.
The goal is to bring about lasting lifestyle changes. The MMC includes nutritional therapy conducted by qualified professionals, aiming for a structured dietary change, physical therapy overseen by physiotherapists or exercise scientists, and, if necessary, behavioral therapy and psychological support. These measures must not only be completed but also thoroughly documented — including proof, stamps, and signatures — so the insurance provider can review the application,” explains Hristo Kolev at the beginning of our conversation.
According to current guidelines (e.g., the S3 Guidelines on Bariatric Surgery), the multimodal concept (MMC) is generally mandatory before any bariatric procedure, including:
- for a BMI ≥ 40 kg/m² (Obesity Class III), or
- for a BMI ≥ 35 kg/m² with severe comorbidities (e.g., type 2 diabetes, sleep apnea).
An exception to the MMC is only possible in rare cases, for example when a life‑threatening condition exists or the patient has demonstrably exhausted all conservative measures and these cannot be repeated within the MMC – but these are case‑by‑case decisions.
A bariatric surgery is typically medically indicated when a Body Mass Index (BMI) exceeds 40 kg/m², corresponding to Obesity Grade III. Surgery may also be considered for a BMI of 35 kg/m² or higher if severe comorbidities exist – for instance type 2 diabetes mellitus or obstructive sleep apnea – clearly confirmed by a sleep laboratory and specialist diagnosis.
In both cases, however, the implementation of a conservative multimodal therapy concept (MMC) is fundamentally required before surgery. This primarily includes nutritional, exercise, and behavioral therapy over a defined period. Only in well‑justified exceptional circumstances can MMC be waived, such as when a contraindication to conservative therapy exists or there is an urgent surgical indication. In most cases, however, the conservative treatment attempt is mandatory.
“Another topic is the use of pharmacological alternatives such as GLP‑1 receptor agonists (for example, Wegovy®). These are currently covered by health insurance only under certain conditions, such as for diabetic patients. For other patients with a BMI between approximately 30 and 39, this therapy is an option—however, exclusively as a self‑paid service.
Even here applies: only if no improvement occurs despite these measures can an application for surgery have a chance of success. The rationale of allowing surgery earlier is medically quite understandable, since severe overweight is directly linked to numerous secondary conditions such as high blood pressure, joint complaints, fatty liver, diabetes, or even reduced life expectancy.
Studies show that long‑term obesity can reduce life expectancy by up to ten years. Still, in Germany surgery remains the last resort, partly due to the high costs involved. Health insurers therefore place great emphasis on the exhaustion of all non‑invasive and less costly options beforehand,” explains Hristo Kolev and adds:
“In practice, the requirements of different health insurers may vary in detail. While the medical guidelines are largely uniform—such as those from the German Obesity Society or the German Society for General and Visceral Surgery—insurers may, for example, impose different requirements for the duration of the multimodal concept or the level of detail in the documentation.
Some require twelve months instead of six; others demand very precise information on therapy content, counseling frequency, or exercise documentation. The Medical Service (Medizinischer Dienst) also plays a central role in the approval process. Based on all submitted documents, it produces an independent expert opinion in which medical necessity, the results of the multimodal concept, and the psychological evaluation are reviewed. Special attention is paid to whether the patient is motivated and ‘compliant,’ meaning willing and able to commit to the necessary long‑term behavioral changes. Possible contraindications for the procedure are also evaluated.”
The German healthcare system relies heavily on the principle of proportionality: invasive measures should only be performed when less risky therapies have not succeeded. There remains a certain reluctance toward operative obesity therapy, partly stemming from outdated notions of “lack of discipline” in overweight individuals, and partly from efforts toward cost efficiency in healthcare. Access to bariatric surgery therefore remains a carefully regulated process in which long‑term benefit and the patient's individual suitability are at the forefront.
Bariatric procedures performed abroad without adequate preparation and aftercare can carry a high risk of unwanted complications and long‑term health problems. Meticulous planning, comprehensive information, and a structured aftercare plan are indispensable to secure treatment success and sustainably improve quality of life. That is why great importance is placed in Germany on interdisciplinary care that systematically addresses these aspects.
“Let us imagine that a patient has a BMI of 30, no comorbidities, and the application for bariatric surgery is rejected. The patient does not want to wait and decides instead to travel to Turkey to have a sleeve gastrectomy. The patient would usually have to pay the costs themselves, as a German health insurer does not cover such treatments abroad.
These cases do occur and are usually self‑financed by patients. The surgical costs abroad are, to my knowledge, significantly below those in Germany—typically between €3,000 and €6,000. That naturally raises questions regarding the quality and safety of these procedures, since in Germany material, instrument, and disposable costs are very high, which is also reflected in the high quality of care.
Quality among clinics abroad varies widely. There are certainly highly qualified clinics and surgeons, but also others that do not meet German standards. It is crucial that both the clinic and surgeon possess international accreditation and specialize in the specific surgical method. Experience with the technique is also essential. Hygiene standards can vary considerably between clinics, and inadequate hygiene increases the risk of infection and serious postoperative complications.
A major problem with surgeries abroad is aftercare. Patients are often discharged within a few days after the operation and travel back to Germany. Language barriers can cause misunderstandings during preoperative consent or postoperative instructions, which may compromise patient safety. Many patients do not fully understand what aftercare is necessary. Aftercare is essential, since a lack thereof can lead to long‑term medical complications.
Patients after bariatric surgery absolutely require lifelong medical follow‑up, nutritional counseling, and often psychological support. Some patients mistakenly believe that nothing further is necessary after surgery—they will lose weight and everything will be fine. But that is not the case. These procedures frequently lead to nutritional deficiencies—for example, in vitamins or iron—that must be carefully corrected to prevent sequelae,” points out Hristo Kolev.
For German physicians, treating complications from bariatric surgeries performed abroad poses a significant challenge, especially when medical documentation is incomplete or inadequate. This not only complicates the assessment of the cause but can also delay or even prevent necessary treatment measures.
“Many patients actually do not know precisely which type of operation they received abroad. Some only say they had a ‘stomach operation’ or ‘stomach reduction.’ However, there are various procedures: a sleeve gastrectomy is different from, for example, an Omega‑Loop bypass, where part of the small intestine is also connected to the stomach and the digestive tract is entirely rerouted.
Roux‑en‑Y bypass is another complex operation in which two intestinal loops are connected in different ways—one to the stomach and one between two sections of bowel. If a patient only reports that they had a ‘stomach operation’ or ‘stomach reduction,’ it becomes very difficult for us to determine which procedure was actually performed without detailed surgical reports—often absent or written in a foreign language we cannot readily understand. Nonetheless, we in Germany must treat and resolve resulting complications. Legally speaking, we are obligated to provide the best possible care to the patient—even if we did not perform the original surgery,” says Hristo Kolev and outlines the most common challenges:
The most frequent complication in patients who had a sleeve gastrectomy abroad is a leak in the suture line. This is a serious complication and constitutes a surgical emergency that must be treated immediately. Patients often present with peritonitis and severe pain. Such cases often require another operation, during which the abdominal cavity is thoroughly irrigated and cleaned. Additional treatment may include placing a special stent in the stomach to bridge the leak. This stent typically remains in place for six weeks until the area heals.
However, there are cases in which healing does not fully occur. Then advanced therapy is required, in which a special sponge is endoscopically placed into a resulting cavity containing inflammation. This sponge is very expensive and must be replaced every three days—Monday, Wednesday, and Friday—over a period of approximately two to three weeks until healing is complete. This treatment is highly costly and represents a considerable burden for health insurers.”
If patients choose a bariatric procedure abroad that was not approved in Germany, various legal and insurance challenges may arise, particularly if postoperative complications occur.
Hristo Kolev comments: “If a patient undergoes surgery abroad and then develops complications that need to be treated in Germany, the question arises how insurance coverage is handled. In principle, German health insurers cover the costs of treating such complications regardless of where the original surgery took place. German physicians are morally and ethically obliged to treat every patient, irrespective of the location of the initial surgery. However, coverage by the insurer in some cases can be contentious.
If a patient consciously opts for surgery abroad against the insurer’s advice or without medical justification, theoretically regressive claims could be made. Such claims are, however, rare and difficult to enforce, as treatment in the home country is usually viewed as a humanitarian obligation.”
The most popular countries for such operations are particularly Turkey, Poland, or the Czech Republic. In Turkey, operations are often the least expensive, which attracts many patients.
Germany has strict standards for both clinics and the materials used. These high‑quality materials used in Germany are often very expensive, whereas abroad cheaper—but potentially substandard—products may be used. One cannot always know how high quality the instruments and materials employed actually are. Even though there are very good doctors in Turkey, this is not universally the case. That is why a clear warning is appropriate.
For one’s own health, it is better to ensure the operation is carried out by experienced specialists using high‑quality materials. Another major problem is aftercare. In Germany, aftercare is often only partially covered by health insurance—particularly long‑term follow‑up is not. Many obesity centers attempt to cover the initial follow‑up using the flat rates paid by insurers, but further follow‑up appointments and supportive measures often must be paid privately. This issue is even more difficult with procedures abroad, because aftercare is often not available or only minimally possible,” states Hristo Kolev.
Follow‑up after an obesity operation is absolutely crucial for patients—for life. Many patients return after surgery to an obesity center and report that they have regained weight or no longer adhere to the nutritional plan.
“Some know how they should eat but still occasionally indulge in sweets. At that point, patients must take action again: resume nutritional counseling, exercise more, or keep a food diary to identify exactly where the problem lies. Often, many receive only one nutritional counseling session post‑operation and then do not return for follow‑up—though these appointments should occur regularly. If weight loss stagnates, one must carefully examine the cause and take targeted corrective action.
Another very important point is the lifelong intake of supplements, meaning vitamins and minerals. General practitioners play a decisive role here, as they continue to care for patients and should regularly, ideally once or twice a year, monitor levels of essential nutrients such as iron, ferritin, transferrin, vitamin B12, and other B vitamins. If these values fall too low, serious deficiencies may arise—with neurological effects or blood loss.
GPs are also responsible for supplementing missing nutrients. In cases of iron deficiency, it is not enough to give a patient a pill—especially in bypass patients, an iron infusion is often necessary, which is costly. This leads many GPs to not administer such treatments, which again places patients in a vicious cycle,” emphasizes Hristo Kolev and concludes our conversation:
Moreover, many obesity centers in hospitals do not hold statutory physician seats and therefore lab tests cannot simply be billed through health insurance. This means patients are often dissatisfied, as they do not receive all necessary aftercare services, and then switch doctors, which does not improve the situation. Ideally, aftercare should be taken over by the GP, but if they refuse or do not cooperate, patients have to bear the costs themselves. Unfortunately, that is the reality—health insurers do not adequately cover many of these necessary aftercare services.
It is a difficult topic because health insurers are often primarily cost‑oriented and place less emphasis on the patient. Every treatment is strictly billed by code, and often the funds allocated for comprehensive care are insufficient. Moreover, favorable offers abroad have led to a lot of medical tourism, for example in plastic surgery—even though these come with high risks.
Thank you very much, Mr. Kolev, for these important cautionary words regarding bariatric procedures abroad!
