The aim of bariatric surgery is to significantly reduce the weight of those affected, which can be achieved using two basic principles:
- One component of bariatric surgery is to reduce the size of the stomach so that less food can be absorbed.
- Another component of bariatric surgery is the shortening of the intestinal tract. This means that fewer nutrients and calories are supplied to the body.
Important: Bariatric surgery is only used if other curative methods and diets have been unsuccessful. Bariatric surgery is therefore generally thelast and most radical option for weight reduction.
In the case ofobesity, body fat is increased to such an extent that it has a variety of health consequences for those affected. The basis for calculating weight is the body mass index, also known as the body mass index (BMI ). The normal BMI for adults is between 18.5 and 24.9 kg/m2. A BMI between 25 and 29.9 kg/m2 is overweight, and a BMI of 30 kg/m2 or more is obesity.
The incidence of overweight and obesity has been rising steadily in Germany for many years. Both overweight and obesity in particular are associated with an increased risk of secondary diseases, such asdiabetes mellitus and cardiovascular diseases - the risk of health consequences increases above a BMI of 25.
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Conservative treatment should always be carried out if the BMI is over 30 kg/m2 or if it is between 25 and 29.9 kg/m2 in conjunction with weight-related health problems. These include shortness of breath, reduced performance, joint problems and metabolic disorders (e.g. diabetes, metabolic syndrome, etc.).
When treating obesity, it is important that long-term weight stabilization is achieved in addition to pure weight loss. The basis of any treatment should therefore be a basic program consisting of a combination of
- Change of diet,
- exercise therapy and
- behavioral therapy
consists of. In severe forms of obesity, where these conservative methods do not achieve sufficient weight reduction, additional medication or even surgery (bariatric surgery) should be considered.
However, this therapy, also known as bariatric surgery, should only be carried out in cases where 24 months of conservative (non-surgical) therapy has not been sufficiently successful. In addition, patients must have a BMI of over 35 kg/m2 with or without serious weight-related secondary diseases (e.g. diabetes,joint wear and tear, cardiovascular disease) in order to undergo surgery. This corresponds to the specialist medical guidelines in Germany.
An operation is always an intervention that is associated with certain risks, so the decision must be carefully weighed up. The decision is always made by the doctor and the obesity center team, which often includes gastroenterologists and nutritionists, together with the patient. As a rule, the first point of contact is the family doctor, who refers the patient to a surgical obesity center specializing in obesity surgery.
After the obesity surgery and the immediate follow-up treatment, the continuing, long-term treatment will continue to be carried out by the obesity specialists in charge. This is particularly important when it comes to maintaining the weight reduction achieved through the operation in the long term. It is crucial that even with bariatric surgery, the patient always has to play the main part in the success of the treatment by making lasting changes to their lifestyle.
As the stomach is greatly reduced in size after bariatric surgery, experts recommend dividing the diet into six smaller, wholesome meals for the first few months. In addition, after bariatric surgery, eating and drinking should be separated, as there is usually no room for both at the same time in the reduced stomach. Sugar and fat should also be used sparingly. The stomach reduction also means that important minerals and vitamins can no longer be absorbed in sufficient quantities from food. It is therefore necessary to take vitamin tablets.
It is absolutely essential that you as a patient are motivated and fully informed about bariatric surgery, its opportunities, but also its risks and the possible long-term consequences. This usually requires multiple consultations that allow enough time to make a well-considered decision.
Bariatric surgery should always be performed in specialized clinics - e.g. in a bariatric center - where the entire spectrum of bariatric surgery is offered wherever possible. Which bariatric surgery procedure is suitable in each individual case depends on the following factors, among others
- BMI of the person affected
- Personal risk of the person affected
- additional diseases
- the patient's wishes
Other physical causes of obesity, such as an underactive thyroid gland (hypothyroidism), should definitely be ruled out before bariatric surgery. In addition, the BMI and body fat distribution should be precisely documented.
Before bariatric surgery, a detailed medical history (anamnesis) must be taken in addition to a detailed consultation and information session. A thorough physical examination, including an ultrasound of the abdomen, is also essential. As a rule, a gastroscopy is also performed, during which the oesophagus and duodenum can also be examined (oesophago-gastro-duodenoscopy).
It has been shown to be beneficial to reduce weight as much as possible before bariatric surgery by changing your diet and exercising regularly, as this is associated with better and more sustainable surgical results. A thorough examination of the cardiovascular system should also be carried out, as an operation always places a strain on the cardiovascular system and a long history of obesity can also be associated with such conditions. An examination by a lung specialist can also be carried out.
Laboratory tests are also part of the routine before an operation as part of bariatric surgery. In addition, a consultation with a psychologist or even an in-depth examination by a psychiatrist is required prior to obesity surgery, as obesity can be associated with a number of psychological conditions or illnesses. In addition, around one in four people who decide to have bariatric surgery are affected by a so-called binge-eating disorder, which leads to excessive, uncontrolled and binge-like food intake.
Possible bariatric surgery procedures are based on two fundamental principles.
- The first principle is the limitation of possible food intake, which is why procedures that follow this principle are also referred to as restriction procedures.
- The second principle is based on the idea of limiting intake by digesting less food. These methods are known as malabsorption (malabsorption).
The aim of the first principle, restriction, is to significantly limit the intake of solid foods, regardless of their quality and type. The following mechanisms are effective in malabsorption:
- Reduction of the intestinal surface area over which food can be absorbed,
- Acceleration of the gastrointestinal passage, also with the aim that less food can be absorbed during the passage of the chyme and
- insufficient digestion by eliminating digestive juices.
The most commonly used restrictive procedures in bariatric surgery include
Malabsorptive obesity surgery procedures include
- Biliopancreatic diversion (BPD), in which a reduced residual stomach is connected to a short loop of small intestine that does not release digestive juices, and
- gastric bypass.
The methods of bariatric surgery differ significantly in
- mode of action,
- possible weight loss,
- risks and
- long-term effects.
An experienced bariatric surgeon will decide which bariatric surgery procedure to use in each individual case. The consultation should be individualized and repeated in order to fully clarify the patient's wishes and influencing factors. Today, all primary bariatric surgery procedures are performed laparoscopically. In this method, also known as the "keyhole technique", the instruments are inserted through small incisions in the abdominal cavity under camera vision.
Gastric banding
Gastric banding is a procedure used in bariatric surgery. The bariatric surgeon places a silicone band around the stomach and thus separates the stomach into a small upper part and the remaining stomach. When eating, the food first enters the upper stomach and from there slowly enters the lower stomach. After just a few bites, the stomach is full and a feeling of satiety sets in. One advantage of the gastric band is that it can be completely removed again if necessary. Nowadays, gastric banding is only used in exceptional cases, as it has been shown that it can also lead to increased complications.
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Tubular stomach
With a sleeve gastrectomy, the stomach is completely removed except for a tubular residual stomach. The production site of the hormone ghrelin is removed. Those affected have fewer food cravings and feel full more quickly.
© bilderzwerg / Fotolia
Gastric bypass
A gastric bypass is a combination procedure commonly used in bariatric surgery. Both the intestine and the stomach are surgically altered. The upper part of the stomach is tied off. The small upper stomach pouch is quickly filled and the patient feels full. After the food has passed through the stomach, it is not passed into the duodenum as usual, but immediately into the small intestine. Food and digestive juices only mix in the middle of the small intestine. Due to the shortness of the small intestine, fewer calories are absorbed. A large proportion of the food is excreted by the body unprocessed.
With a gastric bypass, the remaining stomach and duodenum are not surgically removed but remain connected to the small intestine in order to pass on digestive juices from the bile and pancreas. Patients can thus achieve a reduction of up to around 75 % of their body weight with this method. In obesity surgery, the gastric bypass is therefore only performed on severely overweight people. Due to the poor utilization of nutrients, those affected must take vitamin and nutrient supplements for the rest of their lives.
Biliopancreatic division (diversion)
In this procedure, the stomach is reduced in size and a large part of the small intestine is excluded from food intake (absorption) because the necessary digestive juices from the duodenum (bile and pancreas) are only supplied to it much further down. Due to the creation of acommon digestive tract, which is only 50-100 cm long, fat and starch from food are no longer absorbed well. However, as other food components are also no longer absorbed in sufficient quantities, certain vitamins and trace elements must be taken as lifelong supplementation therapy.
Liposuction is a plastic surgery procedure that can be used to remove excess fat deposits from specific, limited areas (locally). Liposuction is not suitable for treating overweight or obesity, both of which affect the whole body.
Plastic surgery procedures may only be necessary after successful weight loss to remove excess skin, firstly for aesthetic reasons, but more importantly to eliminate the risk of skin infections.
If safety recommendations are followed, bariatric surgery has a relatively low risk. On the other hand, untreated obesity is associated with a significantly higher mortality rate due to cardiovascular disease. Nevertheless, bariatric surgery should only be a last resort if conservative treatments are unsuccessful. Bariatric surgery, also known as bariatric surgery, should be performed in specialized clinics or centers where surgeons who are familiar with and experienced in bariatric surgery work.
For health insurance companies to cover the costs of bariatric surgery, the following conditions must be met:
- There is grade III obesity, i.e. morbid obesity with a BMI over 40, or grade II obesity, i.e. morbid obesity with a BMI over 35 in combination with other serious illnesses associated with the obesity (e.g. high blood pressure, diabetes II, breathing problems during sleep).
- A 12-24 month conservative (non-surgical) therapy consisting of nutritional, exercise and behavioral therapy (possibly also additional drug therapy) under medical supervision was carried out prior to bariatric surgery and further conservative therapy was assessed as not promising.
- It is clear that bariatric surgery always represents a risk and that lifelong follow-up care (e.g. taking vitamins and trace elements) may be necessary after bariatric surgery.
- Patients are willing and motivated to change their lifestyle (especially diet and exercise habits) during and after bariatric surgery.
- Due to the reduced stomach size, the absorption of vitamins and minerals is restricted. Therefore, these, such as vitamin B12, must be taken throughout life.
- To promote weight loss and maintain body weight, sufficient exercise and activity is also necessary. Studies have shown that moderate-intensity exercise of around 150 minutes per week is associated with better weight loss.
- To avoid weight gain after the operation, the diet must continue to be adjusted.
- Follow-up care is mainly provided by the Center for Bariatric Surgery and the treating surgeon. After around 5 years, if the operation goes smoothly, the follow-up care can be handed over to the patient's family doctor.
Bariatric surgery is a very successful way of losing large amounts of weight quickly after frustrating conventional therapy. Depending on the procedure chosen, the success rate is between 60 % and 75 % of the initial excess weight.
