Bariatric Surgery – Specialists and Information

The goal of bariatric surgery is significant weight loss for patients, which can be achieved through two fundamental principles:

• One component of bariatric surgery is reducing the size of the stomach so that less food can be consumed.
• Another key component is shortening the intestinal tract. This reduces the amount of nutrients and calories absorbed by the body.

Important: Bariatric surgery is performed only when other curative methods and diets have proven unsuccessful. As such, these procedures generally represent the last and most drastic option for weight loss.

In obesity, body fat is so excessive that it has a wide range of health consequences for those affected. The basis for calculating weight is the body mass index, also known as BMI. A normal BMI for adults ranges from 18.5 to 24.9 kg/m². A BMI between 25 and 29.9 kg/m² indicates being overweight, while a BMI of 30 kg/m² or higher indicates obesity.

The prevalence of overweight and obesity has been steadily increasing in this country for many years. Both being overweight and, in particular, obesity are associated with an increased risk of related diseases, such as diabetes mellitus and cardiovascular diseases—the risk of health complications rises significantly, especially when the BMI reaches 25 or higher.

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Conservative treatment should always be initiated when the BMI exceeds 30 kg/m² or when it falls between 25 and 29.9 kg/m² in conjunction with weight-related health problems. These include, among others, symptoms such as shortness of breath, reduced physical performance, joint problems, and metabolic disorders (e.g., diabetes, metabolic syndrome, etc.).

An important aspect of obesity treatment is achieving long-term weight stabilization in addition to weight loss itself. The foundation of any treatment should therefore be a basic program consisting of a combination of

• dietary changes,
• exercise therapy, and
• behavioral therapy

. In cases of severe obesity where these conservative methods do not result in sufficient weight loss, medication or—as a last resort—surgery should also be considered.

However, the latter treatment should only be performed in cases where a 24-month course of conservative (non-surgical) therapy has not yielded sufficient results. Furthermore, patients must have a BMI over 35 kg/m² with or without severe weight-related comorbidities (e.g., diabetes, osteoarthritis, cardiovascular diseases) to be eligible for surgery. This is in accordance with the specialist medical guidelines in Germany.

Surgery is always a procedure associated with certain risks, so the decision must be carefully considered. The decision is always made jointly by the physician and the team at the bariatric center—which often includes gastroenterologists and dietitians—together with the patient. Typically, the first point of contact is the primary care physician, who refers the patient to a specialized bariatric center.

After surgery, follow-up care is also provided by the bariatric experts. This is particularly important when it comes to maintaining the weight loss achieved through surgery over the long term. It is crucial that, even with bariatric surgery, the patient always plays the primary role in the success of the treatment by making lasting lifestyle changes.

Since the stomach is significantly reduced in size after bariatric surgery, experts recommend spreading meals over six smaller, nutritious meals during the first few months. In addition, after bariatric surgery, eating and drinking should be done separately, as there is usually not enough room in the reduced stomach to accommodate both at the same time. Sugar and fat should also be consumed only in moderation. Gastric reduction also means that important minerals and vitamins can no longer be absorbed in sufficient quantities from food alone. Therefore, supplementation with vitamin tablets is necessary.

It is absolutely essential that you, as the patient, are motivated and fully informed about bariatric surgery—including its benefits, risks, and potential long-term consequences. This usually requires multiple consultations, allowing sufficient time to make a well-considered decision.

Bariatric procedures should always be performed at specialized clinics—such as a bariatric center—that offer the full range of procedures whenever possible. Which bariatric surgery procedure is appropriate in each individual case depends, among other things, on the following factors:

• The patient’s BMI
• The patient’s personal risk
• Additional medical conditions
• The patient’s wishes

Other physical causes of excess weight, such as an underactive thyroid (hypothyroidism), must be ruled out before bariatric surgery. In addition, the BMI and body fat distribution should be accurately documented.

Prior to bariatric surgery, a detailed review of the patient’s medical history (anamnesis) is necessary, in addition to a comprehensive consultation and informed consent discussion. A thorough physical examination, which includes an abdominal ultrasound, is also essential. As a rule, a gastroscopy is also performed, during which the esophagus and duodenum can be examined as well (esophagogastroduodenoscopy). 

It has proven beneficial to reduce weight as much as possible before bariatric surgery through dietary changes and regular exercise, as this leads to better and more sustainable surgical outcomes. A thorough examination of the cardiovascular system should also be conducted, as surgery always places a strain on the body and long-standing obesity can also be associated with such conditions. Additionally, an examination by a pulmonologist may be performed.

Laboratory tests are also part of the routine preparation for bariatric surgery. Furthermore, prior to bariatric surgery, a consultation with a psychologist—or even a thorough evaluation by a psychiatrist—is required, as obesity can be associated with certain mental health conditions or illnesses. Furthermore, approximately one in four patients who decide to undergo the procedure suffers from what is known as binge-eating disorder, which leads to excessive, uncontrolled, and episodic food intake.

Possible bariatric surgery procedures are based on two fundamental principles.

• One principle is limiting the amount of food that can be consumed, which is why procedures that follow this principle are also referred to as restrictive procedures.
• The second principle is based on the idea of limiting intake by ensuring that less food is digested. These procedures are known collectively as malabsorption.

The goal of the first principle—restriction—is to significantly limit the intake of solid foods, regardless of their quality or type. In malabsorption, the following mechanisms are at work:

• a reduction in the intestinal surface area available for nutrient absorption,
• acceleration of gastrointestinal transit, also with the aim of reducing the amount of food absorbed while the chyme is passing through the tract, and
• incomplete digestion due to the exclusion of digestive juices.

Among the most commonly used restrictive procedures in bariatric surgery are

• gastric banding and
• sleeve gastrectomy.

Malabsorptive procedures in bariatric surgery include

• biliopancreatic diversion (BPD), in which a reduced residual stomach is connected to a short loop of the small intestine that does not secrete digestive juices, as well as
• gastric bypass.

The methods of bariatric surgery differ significantly in

• mechanism of action,
• potential weight loss,
• risks, and
• long-term effects.

An experienced bariatric surgeon determines which procedure is appropriate for each individual case. Consultations should be personalized and conducted on multiple occasions to fully assess the patient’s wishes and any influencing factors. Today, all primary bariatric surgery procedures are performed laparoscopically. In this method, also known as the “keyhole technique,” instruments are inserted into the abdominal cavity through small incisions under camera guidance.

Gastric banding

is a surgical procedure in bariatric surgery. The specialist places a silicone band around the stomach, thereby dividing it into a small upper portion and the remainder of the stomach. When food is consumed, it first enters the upper stomach and then slowly moves into the lower portion. 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 if necessary. However, it is now used only in exceptional cases, as experience has shown that it can also lead to an increased risk of complications.

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Sleeve Gastrectomy

In a sleeve gastrectomy, the stomach is completely removed except for a tube-shaped remnant. This procedure removes the site where the hormone ghrelin is produced. Patients experience fewer bouts of intense hunger, and the feeling of fullness sets in more quickly.

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Gastric bypass

A gastric bypass is a common combination procedure in bariatric surgery. In this procedure, both the intestines and the stomach are surgically altered. The upper part of the stomach is tied off. The small upper pouch of the stomach fills quickly, and the patient feels full. After food passes through the stomach, it is not directed into the duodenum as usual, but immediately into the small intestine. It is not until the middle section of the small intestine that food and digestive juices mix. Because the small intestine is shorter, fewer calories are absorbed. After bariatric surgery, a large portion of the food is excreted by the body without being digested.

In a gastric bypass, the remaining stomach and the duodenum are not surgically removed but remain connected to the small intestine to allow digestive juices from the gallbladder and pancreas to continue flowing. Patients can achieve a weight loss of up to approximately 75% of their body weight with this method. Consequently, gastric bypass surgery is performed in bariatric surgery only on severely obese individuals. Due to poor nutrient absorption, patients must take vitamin and nutrient supplements for the rest of their lives.

Biliopancreatic Diversion

In this procedure, the stomach is reduced in size, and a large portion of the small intestine is bypassed during nutrient absorption because the necessary digestive juices from the duodenum (bile and pancreatic juice) are not delivered to it until much further down the digestive tract. Because a single digestive tract—now only 50–100 cm long—is created, fat and starch from food are no longer absorbed effectively. However, since other nutrients are also no longer absorbed in sufficient quantities, certain vitamins and trace elements must be taken as part of a lifelong supplemental regimen.

Liposuction is a procedure in plastic surgery that can be used to remove excess fat deposits in specific, localized areas. Liposuction is not suitable for treating overweight or obesity, both of which affect the entire body.

Plastic surgery procedures may be necessary, at most, after successful weight loss to remove excess skin—partly for aesthetic reasons, but more importantly to eliminate the risk of skin infections.

When safety guidelines are followed, bariatric surgery carries a relatively low risk. In contrast, untreated obesity is associated with a significantly higher mortality rate due to cardiovascular diseases. Nevertheless, bariatric surgery should only be a last resort when conservative treatments have failed.

For health insurance to cover the costs of bariatric surgery, the following conditions must be met:

• The patient must have Class 3 obesity, i.e., morbid obesity with a BMI over 40 (also known as “adiposity permagna” or “giant obesity”), or Class 2 obesity, that is, morbid obesity with a BMI over 35 in combination with other serious conditions related to obesity (e.g., high blood pressure, type 2 diabetes, sleep apnea). In cases of Grade 1 obesity—which, according to the calculator, corresponds to a BMI of 30—surgery is performed only in very rare cases. Health insurance companies are not involved in these cases.
• Prior to bariatric surgery, a 12–24-month course of conservative (non-surgical) therapy lasting 12–24 months—consisting of dietary, exercise, and behavioral therapy (and, if necessary, additional treatment with medication)—was carried out under medical supervision, and further conservative therapy was deemed unlikely to be successful.
• It is clear that bariatric surgery always carries a risk and that lifelong follow-up care (e.g., taking vitamins and trace elements) may be necessary after surgery.
• Patients are willing and motivated to change their lifestyle (particularly their dietary and exercise habits) both in conjunction with the surgical procedure and beyond.

Tips for Submitting an Application

Covering the costs of bariatric surgery is not always easy. However, if the above conditions are met, it’s worth submitting an application to your health insurance provider. They do not always approve it immediately. 

In such cases, you should not give up right away, but rather try again and file an appeal. It’s best to do this with the support of a bariatric center, which you should involve from the very beginning of your application process. Thanks to their experience, the staff there can advise you and help with further communication with your health insurance provider.

• Due to the reduced size of the stomach, the absorption of vitamins and minerals is limited. Therefore, these—such as vitamin B12—must be taken for the rest of your life.
• Sufficient exercise and physical activity are also necessary to promote weight loss and maintain a healthy weight. Studies have shown that moderate-intensity exercise lasting about 150 minutes per week is associated with better weight loss.
• To prevent weight gain after surgery, dietary adjustments must continue.
• Follow-up care is primarily provided by the bariatric clinic and the treating surgeon. After about five years, if there have been no complications, follow-up care can be transferred to the patient’s primary care physician.

Bariatric surgery is a highly successful way to lose large amounts of weight quickly after conventional therapies have proven ineffective. Depending on the procedure chosen, weight loss success rates range from 60% to 75% of the initial excess weight.