Dr. med. Plamen Staikov is a highly respected specialist in surgery and visceral surgery and head physician at Sachsenhausen Hospital in Frankfurt am Main. His expertise in bariatric and tumor surgery has made him internationally renowned. Particularly in the field of bariatric surgery, which is a life-changing therapy for many severely overweight people, he is constantly setting new standards - whether through innovative treatment methods or his focus on minimally invasive techniques.
As head of the Obesity Center Frankfurt Sachsenhausen, one of the most renowned centers in Europe for the treatment of morbid obesity and surgical diabetes treatment, Dr. Staikov and his experienced team offer the entire spectrum of bariatric procedures. This includes procedures such as gastric bypass, mini gastric bypass, sleeve gastrectomy, biliopancreatic diversion, gastric balloon and gastric banding. His particular strength also lies in performing revision operations, which can successfully solve problems following previous bariatric surgery. Many patients from all over the world come to him to benefit from his extensive experience and precise approach.
In addition to bariatric surgery, Dr. Staikov is a specialist in tumor surgery. Almost all tumor operations are performed at Sachsenhausen Hospital using the keyhole technique. In addition, the surgical team headed by Dr. Staikov covers a broad spectrum that includes reflux surgery, proctology and endocrine surgery. The clinic's state-of-the-art equipment, including a specialized surgical wing with an intensive care and monitoring ward, guarantees maximum patient safety and optimal treatment results.
The editors of the Leading Medicine Guide were able to learn more about treatment options for obesity patients from Dr. Staikov.
Obesity is a chronic condition characterized by excessive accumulation of body fat that can lead to a variety of health problems. It is considered one of the biggest health challenges of the 21st century and is a major risk factor for numerous diseases such as cardiovascular disease, type 2 diabetes, joint problems and certain cancers. Despite the widespread recognition that a balanced diet and regular exercise are essential measures in the management of obesity, the treatment of severe obesity often requires more intensive medical intervention. In this context, bariatric treatments such as gastric bypass or sleeve gastrectomy have become increasingly important. These procedures offer patients the opportunity to lose a considerable amount of weight and thus improve their quality of life.
“A major challenge in Germany is for people suffering from obesity to gain access to treatment at all. Because as far as the indication is concerned, Germany is quite far behind other countries and lags behind internationally. A BMI of 50 is required by health insurance companies in order to guarantee coverage of costs. Conversely, this means that patients in Germany are older and sicker than those undergoing surgery in our neighboring countries. We have more than 60 years of experience in bariatric surgery - in the past it was primarily about achieving weight loss, and today the focus is on metabolic regulation, particularly with regard to type 2 diabetes. Metabolic disorders can also be treated well with bariatric surgery,” explains Dr. Staikov at the beginning of our conversation.
There are three standard methods in bariatric surgery:
“First and foremost is gastric sleeve surgery, which has now been around for two decades and is the most frequently performed procedure worldwide. By reducing the size of the stomach by around 80 %, this method has a simple mechanism of action. This reduces the amount of calories consumed, creating a calorie deficit over a period of more than a year, which leads to weight loss with few to no side effects. The second standard procedure is the Roux-en-Y gastric bypass, the oldest operation in obesity surgery, which has been in use for 60 years. This surgical procedure is particularly beneficial for patients who have suffered from diabetes for a long time. It is also recommended for patients who have a pronounced gastroesophageal reflux disease before the operation, which can lead to inflammation in the esophagus in addition to the symptom of heartburn,” explains Dr. Staikov and adds:
“In the last 10 to 15 years, a third operation has been added in Germany, which has been around for about 25 years: the single-anastomosis bypass, also known as the omega-loop bypass or mini-bypass. In this procedure, the stomach is reduced in size by forming a narrow gastric tube (pouch). This is connected directly to a loop of the small intestine, bypassing part of the small intestine. The single anastomosis means that only one suture point is required between the pouch and the small intestine, which makes the procedure technically simpler. The operation shows very good results in terms of weight loss and the treatment of secondary diseases. However, a proportion of patients have complaints after the operation, for example in the form of bile reflux. Bile enters the stomach via the connected loop of small intestine, irritates it and can lead to the formation of ulcers that need to be treated. Surgery is therefore the first step, followed by good monitoring and close cooperation between patient and doctor.
The choice of the appropriate procedure depends on individual factors such as the degree of obesity, concomitant diseases and the patient's lifestyle. At the same time, careful preparation is crucial for the success of the operation. Comprehensive medical diagnostics are carried out in advance to rule out possible contraindications such as untreated eating disorders or serious illnesses. Psychological counseling ensures that patients are emotionally stable and aware of the lifelong changes that the procedure will require. Nutritional counseling also plays a central role, as patients must learn to adapt their eating habits before the operation, for example by eating smaller portions and a high-protein diet. In addition, a pre-operative diet is often recommended to reduce the size of the liver and make the operation easier. During this preparatory phase, doctors, psychologists, nutritionists and other specialists work together on an interdisciplinary basis to determine the most suitable surgical method for the individual patient. Patients must also be informed in detail about the risks, benefits and necessary adjustments to everyday life after the operation. Bariatric surgery is therefore not just a surgical procedure, but part of a comprehensive treatment approach that requires careful preparation, the choice of the right method and lifelong aftercare to ensure long-term success.
Medical tourism has increased in recent years.
For cost reasons, some patients from Germany have surgery abroad. “Having an operation performed abroad almost always causes problems. This is because the necessary follow-up checks cannot usually be carried out, as it is difficult for the patient to see the attending doctor regularly. Nowadays, some check-ups can be carried out online, but if problems arise, patients in Germany go to the doctor. Here in the Rhine-Main region, we have many of these patients who have had surgery in Turkey, for example, but come to us for revision or follow-up surgery - sometimes as emergency patients, sometimes planned. This then leads to justified problems with the health insurance company, as the initial treatment took place abroad. Patients must not forget that all operations can also have late effects that only occur years after the procedure. This can lead to lifelong problems, particularly in the form of deficiency symptoms (iron/vitamins), which can be avoided with regular check-ups. In addition, there are possible mechanical problems that can lead to secondary operations, for example reflux with heartburn as a symptom. This is a relatively common problem after gastric sleeve surgery. If conservative measures do not help, the sleeve gastrectomy must be surgically revised. It is therefore always better to make arrangements so that the attending physician can be consulted again,” advises Dr. Staikov.
There is a measurable increase in obesity among adults in Germany - over 65% among men and over 40% among women. This means that over a quarter of adults are morbidly obese.
“The rise in childhood obesity is actually the worst in all industrialized countries. Basically, there are few concepts for obesity patients in Germany that are effective across the board. Of course, there are conservative and surgical approaches, but it is always difficult for the patient to find a customized solution for this disease that is easily accessible. It is not enough to tell the patient to eat less and exercise more. It is necessary to introduce the patient to a therapy that has proven long-term benefits. For this, patients need partners in therapy in the form of nutritionists and sports physicians, psychologists, behavioral therapists, physiotherapists and surgeons. Unfortunately, health insurance companies in Germany are too late in covering the costs. The countries around us - such as Switzerland, the Benelux countries and Scandinavia - act much earlier. It is a considerable advantage for patients if they are operated on earlier. This is because the timing of the operation always comes first in order to get the most out of it for the patient. Of course, all the necessary measures must be implemented before an operation, for example in the form of preliminary consultations and pre-treatment by various specialists (psychology, endocrinology, etc.). However, the waiting times for the necessary appointments are currently getting longer and longer in Germany, and unfortunately there is no prospect of this improving in any way over the next ten years, as our healthcare system has become so badly out of kilter. In addition to the structural problems, the main issue is the lack of staff in all areas. Germany was also the last country to define obesity as a disease in 2022 - that is shameful,” states Dr. Staikov.
Of course, the aim is to help every patient to get well again.
“You can define two groups. One group consists of patients for whom there is no alternative to surgery. If all the criteria are met here, the operation is covered by the respective health insurance company. Then there is the group of patients who are in a gray area. They are severely and morbidly overweight, for example with grade II obesity (BMI 35-40), sometimes already have relevant secondary illnesses, but do not fit into the grid for cost coverage by health insurance companies. For these patients, it is possible to obtain the necessary surgery with proof of six months of conservative treatment and a small detour. At our center, we offer everything - from nutritional counseling to behavioral therapy - to carry out the six-month conservative treatment. We treat patients from all over Germany, but this makes the logistical implementation of the therapy more difficult. The fact that digitalization is not yet sufficiently developed in Germany is an additional complication. Parts of the treatment could theoretically be implemented digitally or medially, but German laws are too complicated and data protection also prevents some things. Unfortunately, like so many things, the improvement of the parameters is failing due to funding,” criticizes Dr. Staikov and adds:
“We try to find a way and a good solution with every patient. Of course, it is always easiest if the patient can be integrated into our center, as we offer the full range of necessary measures. Many patients have serious concomitant illnesses that need to be clarified before surgical obesity treatment, and many are clearly overwhelmed by this. We can organize all the necessary steps for the patient in-house - we developed a concept for this in 2017 that enables all the necessary medical assessments to be carried out so that patients can be helped here.”
Nutrition plays a key role in long-term success.
Immediately after the operation, patients undergo a gradual transition from liquid food to pureed food to solid food. In the long term, a protein-rich, balanced diet with reduced fat and sugar content is recommended, as this supports weight loss and prevents the occurrence of dumping syndrome and other digestive problems. Maintaining small portions and mindful eating habits are crucial to prevent overeating and minimize the risk of regaining weight. Lifestyle changes are equally important. Regular physical activity supports weight loss, improves muscle mass and metabolism and contributes to long-term weight stabilization. Psychological support, for example in the form of behavioral therapy, can be helpful in overcoming emotional eating patterns and boosting motivation. Self-help groups or weight management programs offer additional support.
„Food culture is a decisive criterion. With children, for example, you still have the chance to influence whether or not they become overweight later on. It would make sense to have a comprehensive concept for schools that includes sufficient exercise on the timetable - every day! All children should be required to take part in some form of sport. Unfortunately, our children are getting fatter and fatter. School sport is being cut out far too often. We have a duty to create the best possible conditions for children,” Dr. Staikov pleads emphatically.
Weight loss injections such as those containing the active ingredients semaglutide (e.g. Wegovy) or tirzapatide (e.g. Mounjaro) offer obesity patients a way to reduce their weight pharmacologically. These drugs, which act as GLP-1 receptor agonists, promote a feeling of satiety, reduce appetite and in many cases stabilize blood sugar levels.
“Weight loss injections are playing an increasingly important role. However, anyone thinking about taking them needs to know one thing: These injections are designed to be started and not stopped. It is a lifelong therapy, as the yo-yo effect is 80 percent likely to strike if you stop. They achieve a good result - 20 percent of total body weight can be reduced. However, they are not suitable for all patients. They are best suited to people who are not yet extremely overweight and have a real chance of either reaching a normal weight or at least getting close to it with the injection. Most of these patients have a BMI of between 28 and 35. At present, the therapy often fails because health insurance companies do not cover the cost of the injections, and the costs are still very high (approx. 300 euros per month). This is likely to be regulated somewhat in the next few years, and it would be desirable if the therapy then became accessible to the general population. In the USA, the therapy is more accessible, and around 20,000 to 40,000 people start it there every week,” says Dr. Staikov, who concludes by sharing a few more thoughts:
“There needs to be a rethink in Germany - we now have over eight million diabetics, and 80 to 90 percent of them are overweight. The consequential costs of obesity are enormous and continue to rise every year. If we don't have a positive influence on the next generation right from the start, the situation will get worse and worse, because at some point no one will be able to bear the costs. There are also too few obesity specialists for the number of patients."
Thank you very much, Dr. Staikov, for your frank words on the subject of obesity and its treatment!
