Bariatric Surgery at the Sachsenhausen Clinic, Germany, Frankfurt

What is Bariatric Surgery?

Plamen Staikov has been the chief physician at Klinikum Sachsenhausen for 5 years. He is undergoing a gastric reduction in patients and wants to expand this focus of the hospital even further. It's just a small incision, maybe an inch long, in the abdominal area, which can help patients with severe obesity. The new chief physician and head of the obesity center at the Sachsenhausen hospital, Plamen Staikov (50), masters the minimally invasive bariatric surgery with perfection.

The reduction of the stomach works better than medication or nutritional therapy, said Staikov on Thursday at a press conference. Because the reality is that only five percent of obesity patients manage to reduce their weight on their own.

His concern is that in the public, but also in the medical profession obesity is perceived not as a flaw, but "as a disease", so Staikov. Every overweight person has the right to health. Often "bariatric surgery is the only way to get well". One could not ask an overweight mother with two children to go to the fitness studio in the evening. "Our body is designed to store energy." Due to "the excess of calories, lifestyle and genetic predisposition," the number of people suffering from high levels of obesity is increasing. With the help of bariatric surgery, it is possible to permanently reduce weight. A 1.80-meter-tall man who weighed 150 kilograms before the operation will, according to experience, weigh about 90 kilos after one and a half years.

The sooner the better

This effect occurs because patients with a smaller stomach would fill up faster. "You limit the amount of food" and eat in the restaurant only half a pizza. However, the patients would have to be accompanied by a doctor for life. Frequently, in addition to the diet vitamins and minerals should be administered. Sometimes it is also necessary to remove skin flaps. Patients are usually very satisfied after gastric reduction. About 500 to 550 times such an intervention is made in the obesity center.

An example of an emerging obesity is, for example, if you bring each year five kilos more on the scales. Then you should go to the doctor.

Prof. Staikov regretted that many patients only come to the center when they are already seriously ill. Sometimes diabetes acquired as a sequelae has already impaired vision or artificial joints have been used. The sooner a patient logs in, the greater the chance of avoiding surgery. The 50-year-old acted as successor to Professor Rudolf Weiner, who has developed the focus on obesity surgery at the Sachsenhausen Hospital. Before coming to Frankfurt, Prof. Staikov headed the center for abdominal surgery at the Hirslanden Clinic in Zurich.

When conservative treatment strategies do not bring the desired effect, surgery is the only option in most cases.

At the Frankfurt Sachsenhausen Bariatric Surgery Center, we use a wide variety of different surgical techniques. Whether it is sleeve gastroplasty, gastric bypass, gastric banding or very complex BPB surgery (biliopancreatic bypass), in any case they are used to meet the patient's individual needs.

Below you will find information about the different surgical techniques and their advantages and disadvantages. We also offer techniques, such as an intragastric balloon, which, without surgery and general anaesthesia, can help to reduce weight significantly.

Bariatric Surgery: Chances and Risks

For people with an abnormal overweight (BMI of over 40), bariatric surgery is usually the ultimate opportunity to reduce their weight steadily and sufficiently. As with any surgery, it poses a specific burden on the body and is likely to have chances and risks.

Chances

Bariatric surgery is an effective remedy for people who are particularly overweight as it provides a lasting effect of weight loss. In addition, the resulting weight loss contributes to the improvement of your overall health. This is also true for other co-existing problems such as diabetes type 2 and hypertension, as well as sleep apnoea or musculoskeletal disorders and problems. Weight loss results in an increase in life expectancy. Gastric bypass surgery or sleeve gastroplasty can also very often weaken or completely cure depression. Practically all patients report a significant increase in their activity and a considerable improvement in their quality of life.

Bariatric interventions can also have a positive effect on women's fertility. The underlying reasons are not yet fully understood. However, it is known that bariatric surgery can change hormone metabolism. Therefore, women who are planning bariatric surgery and do not want to have children should consult their gynecologist. We will tell you about it in a private conversation.

Risks

First of all, it is necessary to mention the general operational risks here. It has been proven that in large centers, where more than a hundred surgeries are performed every year, patients' risks are significantly lower than those of surgeons who perform such surgeries on a rare basis. We will give you detailed information about this during the first consultation and before the possible surgery.

Sometimes there are cases in which surgery does not have the desired effect. In such a case, it is necessary to examine in detail the current diet and metabolism and to analyze possible reasons for the failure. Sometimes a second surgery may be required. You can learn more about this in the article "Repeated or Revision Interventions". The surgery has been very successfully performed on patients with diabetes mellitus, which has given rise to the concept of "diabetes surgery".

Repeated or Revision Interventions

Bariatric surgery is a common practice in the world. For many people who are very overweight, it is the only successful way to improve their health. However, in some cases it may be so that after one bariatric surgery the patient needs to undergo an additional one. The reasons for this are different. Along with a too little weight loss or with its re-increase, such revision interventions may become necessary under certain conditions after a sleeve gastrectomy. In such a situation, if there is a severe heartburn, it may be advisable to have the sleeve gastroplasty converted into gastric bypass. The reason for the undesirable increase in weight may be the expansion of the stomach sleeve, or in the case of gastric bypass, the expansion of the stomach pouch (small stomach) or of the loop of the small intestine attached to the surgically created small stomach. Also, the expansion of the connection (anastomosis) between the main part of the stomach and the duodenum several years after the operation may cause the scale arrow to move upwards again. A serious, though very rare problem after gastric bypass surgery can be a low level of glucose in the blood (hypoglycemia), which is also treated by our clinic.

At our Obesity Treatment Center, we also specialize in these often very complicated revision interventions. First of all, it is always important to find the cause of any health problems or inadequate weight loss. Doctors of different specialties help us with this. The main objective is to accurately diagnose patients' current state of health and then work out and implement effective treatment strategies.

Operative Techniques

People with severe obesity or other conditions, such as diabetes, may need to have an operation, such as a stomach reduction, in order to lose a lot of weight in a short time. These interventions are called bariatric surgeries (from the Greek "baros" – heaviness) or surgical interventions to treat obesity. Pumping fatty tissue is not an option for treating obesity, as it does not interfere with calorie intake and consumption and is associated with risk. In addition, there is no evidence that it is beneficial to health.

According to the current recommendations of the medical communities, surgery is considered if

  • the BMI is more than 40 (grade III overweight) or
  • if the BMI is between 35 and 40 (grade II overweight) and there are other associated conditions, such as diabetes, cardiovascular disease or sleep apnoea.

The intervention is usually planned only if other attempts to lose weight have not been successful, for example, if the weight loss programme involving nutrition counseling and physical exercise has not resulted in a sufficient weight loss. For some people, surgery may be worthwhile, even without prior attempts to lose weight, for example, in cases of BMI of more than 50 or serious concomitant diseases.

It is important to consider the pros and cons of the intervention when deciding for or against it. Bariatric surgery can lead to a considerable weight loss, which improves health and the quality of life. It also has a positive effect on other related diseases, especially diabetes, sleep apnoea and hypertension. But bariatric surgery can cause various complications and have long-term consequences. Moreover, it is necessary to take into account that gallstones form when weight is reduced very quickly.

Long-term changes in lifestyle, such as the eating habits, and regular health checks are required after the intervention. Many people, several years after bariatric surgery, can easily put on weight again.

How Can Surgery Help With Obesity?

The treatment of obesity involves various operations on the stomach. The most common techniques used are:

  • Gastric banding. The stomach is tightened with an elastic bandage, so you can't eat a lot anymore and the feeling of saturation comes faster. This intervention is reversible.
  • Sleeve gastroplasty (stomach reduction). In this case, the stomach is surgically reduced in order to decrease its capacity.
  • Gastric bypass. In this case, in addition to reducing the stomach, the digestive tract is shortened, so the human body can get less nutrients and calories from food.

Besides, gastric bypass and sleeve gastroplasty lead to hormonal changes that suppress appetite and have a positive effect on metabolism, which in its turn has a positive effect on diabetes.

Many people feel better when they lose weight after the intervention. Moving and exercising become easier and enjoyable again. After the operation, many people get appraisal from others. Some people report that they feel more professionally enduring and sexually active again after the surgery.

What are the Advantages and Disadvantages of Gastric Banding?

The gastric band tightens the stomach and thus artificially reduces it. It is made of silicone and, like a ring, is placed around the cardiac region of the stomach. This creates a small stomach that can no longer hold much food, so that a feeling of saturation is achieved more quickly.

The gastric band is filled with a salt solution, so it can be made wider or narrower after the operation. The liquid can be pumped out or added through the hose via a syringe. The access (port) is fixed under the skin. It is approximately the size of a coin. If, for example, a burping occurs because the stomach bandage is too narrow, it can be made wider.

Gastric banding is a surgical procedure with minimal invasion into the body. Since the stomach and digestive tract are not changed, there are fewer problems with the absorption of nutrients. It is also possible to remove the bandage, i.e. the intervention is reversible. It is therefore a reasonable alternative for young women who plan to have children. However, adhesions can sometimes make it difficult to remove the stomach bandage.

As a rule, the body weight is reduced by about 10-25% after placing the gastric band within a year. A man who is 1.80 meters tall and weighs 130 kilograms can easily lose from 10 to 30 kilograms of body weight. During the second and third years after the intervention, the weight may still be slightly reduced.

According to some comparison studies, gastric banding was less effective than sleeve gastrolasty or gastric bypass. Sometimes the weight loss is insignificant. In such cases, the gastric band can be removed and stomach reduction surgery can be considered.

Possible side effects of gastric banding may include heartburn and regurgitation, for example if the band is too tight. In some cases, the gastric band may move, grow into the stomach or break. Therefore, it may sometimes be necessary to replace or remove it. According to the research, approximately 8 people out of 100 who have had a gastric band installed have had complications. Approximately 45 people out of 100 had to undergo a second surgery at some point in time because, for example, the resulting weight loss was insufficient or the band caused problems.

What are the Advantages and Disadvantages of Sleeve Gastroplasty?

During stomach reduction surgery, approximately three quarters of the stomach is surgically excised. Since the shape of the stomach after this looks like a sleeve, this intervention is sometimes called sleeve gastroplasty.

Within the first year after the stomach reduction, overweight people usually lose approximately 15-25% of their body weight. For a man who is 1.80 meters tall and weighs 130 kilograms, it means that he can expect to lose 20-30 kilograms of body weight after surgery.

Stomach reduction can lead to various side effects. If you eat too much, you may get heartburn or regurgitation. There may be complications during or after surgery. For example, surgical sutures can become leaky and require repeated intervention. According to studies, about 9 patients out of 100 have had complications during or after surgery, 3 patients out of 100 have had to be operated on again. Less than one out of 100 people have died during the operation or because of complications.

Stomach reduction cannot be reversed. If a patient with obesity has not lost enough weight after sleeve gastroplasty, another intervention, such as gastric bypass, is still possible later.

What are the Advantages and Disadvantages of Gastric Bypass?

Gastric bypass or shunting is a more time-consuming and complicated operation than gastric banding or sleeve gastroplasty. The name comes from the English word "shunt" (bypass), because food no longer moves through the entire stomach and small intestine, but mostly passes by.

During the operation, a small part of the stomach (approximately 20 mm) is separated. Then a small stomach is created out of it, which is then attached to the small intestine. The rest of the stomach (large stomach) is stitched up and is no longer connected to the esophagus. The food is taken directly from the small stomach to the small intestine.

So that the digestive juices from the gall bladder, pancreas and large stomach can continue to get into the intestine, the upper part of the small intestine together with the gatekeeper to the stomach is attached to the small intestine in another place.

As in the case of stomach reduction, studies show that overweight people usually lose about 15-25% of their body weight during the first year after gastric bypass. This happens relatively quickly. Weight usually becomes stable 1-2 years after the intervention.

According to recent studies, gastric bypass surgery has the potential to reduce weight more than other techniques. Gastric bypass has a positive effect, particularly on concomitant diseases such as diabetes.

The most common long-term effects of gastric bypass surgery are early and late dumping syndromes. In early dumping syndromes, large amounts of undigested food enter the small intestine. The body tries to "dilute" unusual amounts of nutrients and sends an unexpectedly large amount of water from the blood vessels to the small intestine. As a result, there is a lack of this fluid in the circulatory system, and the blood pressure falls. This can lead to fainting consciousness, nausea, abdominal pain and sweating. Early dumping syndrome occurs mainly after eating very sweet food, in most cases within 30 minutes.

In the case of a less frequent late dumping syndrome, the body produces too much insulin, which can lead to hypoglycemia accompanied by typical symptoms such as dizziness, weakness and sweating. It may occur 1-3 hours after a meal, especially after eating food rich in carbohydrates.

Surgical risks include scarring in the small intestine, internal hernias and leaky sutures at the new junctions between the stomach and the intestine. All these complications may require a repeated intervention. According to studies, 12 patients out of 100 have had complications, 5 patients out of 100 have had to be operated on again.

It is rare that during surgery or within the first weeks after surgery life-threatening complications occur. For example, there may be blood poisoning if one of the new attachment points becomes leaky and the stomach contents get into the abdominal cavity. According to research, less than one patient out of 100 died during surgery or as a result of complications.

How Can You Prepare for the Operation?

It is often recommended to lose weight a week before the operation through a diet or medical treatment. This will make the operation easier because, among other things, the liver will get a little smaller and it will be easier to perform manipulations at the junction of the esophagus and the stomach.

Before the operation, various medical examinations are performed to ensure that there are no medical contraindications. These include various laboratory tests, a gastroscopy and abdominal ultrasonography. A psychological check-up can also be useful, for example, if there are eating disorders that may be of psychological nature.

What Type of Surgery Is Right for You and How is It Performed?

The choice of surgery, along with a patient's expectations and personal assessment of the pros and cons, depends, among other things, on his or her state of health, body weight and possible concomitant diseases. Professional activities can also play a role in making decisions. It makes sense to contact a doctor who has experience in such therapy. Medical centers certified by the German Society for General and Visceral Surgery (DGAV) in the field of bariatric surgery meet the specific requirements for experience and equipment for such operations.

Bariatric procedures are currently performed with endoscopic (minimally invasive) surgery. During minimally invasive surgery, special endoscopic surgical instruments are used, which are inserted into the abdominal cavity through several small incisions (laparoscopy). Open surgery is not usually used anymore.

In the case of minimally invasive surgery, the patient usually stays in the clinic for several days.

All the subsequent interventions are carried out at our clinic in a minimally invasive way. This means that the operation causes minimal damage to the skin and soft tissues. Thus, the so-called "keyhole surgery" provides patients with a significantly higher level of safety. Thanks to the minimally invasive approach, the number of complications and the duration of the intervention are also considerably reduced.

Comparative Table of the Most Frequent Surgical Techniques

Gastric Bypass Longitudinal Sleeve Gastroplasty
Surgery duration Approx. 1 hour 0.5-1.0 hours
Advantages
  • long-term weight loss
  • remission of diabetes type 2 in 78% of patients
  • a cure of hypertension in 75% of patients
  • reflux cure
  • the sleep apnea device isn't usually needed three months after surgery
  • polycystic ovary syndrome and infertility improvement
  • the most researched technique
  • for patients with a BMI over 60% is technically impossible
  • long-term weight loss
  • remission of diabetes type 2 in 65% of patients
  • a cure of hypertension in 50% of patients
  • concomitant diseases improvement
  • polycystic ovary syndrome and infertility improvement
  • improvement for patients with a BMI over 60% is technically possible
  • possibility of performing a 2nd operation and converting to billiopancreatic shunting
Disadvantages
  • risk of dumping syndrome
  • vitamin and mineral deficiency
  • is not recommended to take certain drugs
  • late expansion of the gastric sleeve
  • leaky suture
  • reflux disease after surgery
Body weight loss 1 year 70% of the excess weight 68% of the excess weight
Body weight loss 2 year 77% of the excess weight 70% of the excess weight
Body weight loss 3 year 75% of the excess weight 69% иof the excess weight
Body weight loss 4 year 68% of the excess weight 64% of the excess weight

If you have any problems in this respect, we will advise you in detail during reception hours.

Prof., Dr. med. Plamen Staikov

Prof., Dr. med. Plamen Staikov

Medical Director, Head physician

Holger Bahn

Holger Bahn

Senior physician

Dr. med. Konrad Stubbig

Dr. med. Konrad Stubbig

Head physician of Anesthesia Department

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