Surgical treatment

An obesity or bariatric operation is a therapy option for patients, who were not able to sufficiently loose weight in non-surgical treatment programs. The University Hospital Leipzig is a certified reference center for bariatric surgery.

At the University Hospital Leipzig different bariatric operations are possible. (Photo: IFB Adiposity)
In 2017 the Section for Bariatric Surgery at the University Hospital Leipzig received the certification as reference center for adiposity surgery (Adipositaschirurgie). This underlines the special expertise and quality of treatment at this center

The Obesity or Bariatric Surgery at the University Hospital Leipzig is part of a broad network that offers the best advice and treatment for patients with obesity. In close cooperation with the IFB AdiposityDiseases conservative (non-surgical) as well as surgical treatment options are offered and scientifically accompanied by a multidisciplinary team of internists, surgeons, nutrition therapists, and psychologists. At the obesity outpatient clinic  for adults the patients go through a comprehensive program of investigations and receive an individual treatment recommendation as part of our multimodal therapeutic offer, consisting of group training sessions as well as individual consultations. If all the options of conservative treatment have not been successful in a patient, a bariatric operation may be the last therapeutic option. The surgeons and gastroenterologists offer a wide range of endoscopic and surgical procedures for weight loss at the University Hospital Leipzig (see below).

The established preperation and aftercare concept is offered by physicians, nutrition therapists and psychologists of the obesity outpatient clinic and plays a central role in the long-term care of bariatric patients with the aim of optimal and sustained weight loss. The preparation for a bariatric surgery includes the report for the cost transfer application to the insurance company, all relevant preliminary studies and detailed information about the procedure and individual nutritional consultations. After surgery, the bariatric patients are closely supervised in the obesity outpatient clinic.

Prerequisites for bariatric surgery

For the treatment of obesity with surgical procedures in Germany there are  the so-called S3 guidelines of the German Obesity Society (DAG). They help in deciding if such a therapy is necessary and promising. If certain criteria exist in a patient that makes bariatric surgery advisable, doctors speak of an indication for such a procedure. Factors that make surgery not advisable are called contra indications.

Indications

  • BMI ≥ 40 kg/sqm and exhaustion of conservative therapy
  • BMI between 35 and 40 kg/ sqm and one or more obesity-associated diseases
  • In the case of diabetes mellitus type 2 a bariatric surgery as part of a scientific study can be already considered at a BMI between 30 and 35 kg/sqm

 Contraindications

  • Unstable psychopathological conditions
  • Active alcohol or drug addiction
  • Tumors

Adiposity or bariatric operations

The type of bariatric surgery depends on the severity of adiposity and on existing accompanying diseases, as well as eating behaviors, and the cooperation of the individual patient. The weight loss occurs after the operation, since the absorbable amount of food is reduced (restriction) and / or nutrient absorption is reduced in the intestine (malabsorption). The following surgical methods are offered at the University Hospital Leipzig. The gastric bypass is applied most frequently, the subsequent operations then respectively rarer. (The graphs  used come from Johnson & Johnson Medical Inc., Ethicon-Endo Surgery.)

Roux-Y Magenbypass
Roux-en-Y gastric bypass (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Roux-en-Y gastric bypass

This procedure is considered as gold standard in bariatric surgery. It combines restriction (reduced amount of food due to sleeve gastrectomy) with malabsorption (reduced nutrient absorption). At least two thirds of the stomach are removed and the remaining stomach pouch is connected to the first loop of the small intestine. The digestive secretion (pancreatic  and bile secretion) come only at a lower section into the intestine. Thus, there is less time and surface for the digestion and absorption of nutrients. This reduces the nutrient absorption and rapid weight loss is possible. The mean weight loss after two years is about 50 to 75 percent of the overweight.

Schlauchmagen (Gastric Sleeve)
Gastric sleeve (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Gastric sleeve

A part of the stomach is being removed so that only a small tubular gastric remnant remains. Thus, the volume of the stomach is reduced to about 120 ml (restriction). Thus, the ingestible amount of food is reduced. In addition, the ghrelin-producing cells are located in the distant part of the stomach which is removed. Therefore, the feeling of hunger decreases. The gastric sleeve may be the surgical procedure of choice or be used as a first step of a two-stage procedure depending on the patients situation. Another surgery would then follow the gastric sleeve. For patients who suffer from an acid reflux disease, this gastric sleeve surgery is not suitable.

Omega Loop Bypass
Omega loop bypass (Graph: Dr. Tobias Meile, Tübingen)

Omega loop bypass

With this method the passage of food through the duodenum is turned off, similarly to the above-mentioned Roux-Y gastric bypass. The stomach is reduced to a shortened gastric sleeve and is connected laterally with the small bowel at a point about two meters further down. This operation is especially suitable as a second step operation after the realisation of a  gastric sleeve if this first surgery did not lead to sufficient weight loss or if there has been a renewed weight gain. A problem in this method is a possible backflow of bile acid which normally is secreted into the duodenum. After the procedure, physicians have to pay attention to regular checks of the vitamin level and vitamin supplements.

Biliopankreatische Diversion
Biliopancreatic diversion (BDP) (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Biliopancreatic diversion (BPD)

The biliopancreatic diversion consists of a stomach reduction (pouch formation) and the separation of the first half of the small intestine from the passage of digestive secretion. Only about 100 cm of the small intestine are remaining, through which digested food and digestive secretion are passing. This short digestive passage leads to decreased digestion and absorption of nutrients. This operation method therefore combines restriction and malabsorption.

Duodenal Switch
Duodenal switch (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Duodenal switch

This method means also a reduction of the stomach (gastric sleeve). In addition, a large part of the small intestine is not supplied with digestive secretion and thus is not active in the digestion and absorption of nutrients. This surgical method also combines restriction and malabsorption of nutrients.

Magenschrittmacher
Gastric pacemaker (Grafik: IntraPace®, Inc.; abiliti)

 Gastric pacemaker

A gastric pacemaker with a built-in mini computer is a new electronical method that helps to lose weight sustainably. The device is implanted in a minimally invasive surgical procedure. It supports weight reduction by electronic impulses to the stomach, leading fasterto a felling of satiety. In addition, the device documents when and how long the patient eats and drinks by a sensor. A motion sensor furthermore documents the frequency and duration of physical activity. This information allows an insight into the eating and exercise habits of the patient. This helps to develop an individual program for permanent weight loss. The patient has to show big compliance with this surgical method and a high motivation to actively change his or her lifestyle so as to permanently lose weight and respectively keep the lower weight. (Link zu Studie Dietrich)

Magenband
Adjustable gastric band (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Adjustable gastric band

The University Hospital Leipzig does not offer this intervention because it often leads to complications, such as shifting or ingrowth of the gastric band. Thus, the success of this treatment method is not convincing in the long term.

Nevertheless, gastric band surgery is offered by various hospitals. The gastric band is wrapped around the upper part of the stomach so that a gastric pouch with only a 15-20 ml capacity emerges. Due to this restriction the amount that the patient  can eat is strongly reduced. The total gastric volume and the area of the stomach in which the appetite-boosting hormone ghrelin is produced (ghrelin center), remain untouched in this procedure.

More information about bariatric surgery methods is available on the website of the University Hospital Leipzig.

Endoscopic treatment methods of obesity

In certain cases the obesity therapy can also be possible via a gastric balloon or a special intestinal tube. Both are placed in the stomach or intestine by an endoscope, a flexible hose which is usually used for an inspection (endoskopy) of the inner digestive organs. The above mentioned indications and contraindications do not apply to endoscopic procedures but only to surgical ones.

Magenballon
Gastric balloon (Graph: Johnson & Johnson Medical GmbH, Ethicon-Endo Surgery)

Gastric balloon

The insertion of a gastric balloon is an endoscopic procedure. The patient receives a tranquilizer before hand. During a gastroscopy a special balloon is inserted into the stomach and filled with about 500 ml of water. Thus, the largest part of the stomach is filled and the patient reaches a feeling of satiety faster and for a longer period of time. The amount of food the patient can consume is smaller (restriction). The gastric balloon must be removed after six months at the latest.

Darmschlauch EndoBarrier
Intestinal tube - EndoBarrier (Photo: GID-Germany GmbH)

Intestinal tube (EndoBarrier TM)

The EndoBarrier is placed by a flexible tubular device (endoscope) through the mouth in the top section of the small intestine. This requires a narcosis, but there are no surgical incisions and no surgical changes in the digestive system, as described above. Therefore, the physical strains caused by surgery is omitted. The upper part of the intestine is lined by the EndoBarrier intestinal tube. The resulting barrier between food and the intestinal wall means, that in this area no nutrients can be absorbed. The digestive secretion can only be active in a later and overall shorter segment of the intestine. In addition, the EndoBarrier can restrain appetite stimulating hormones and thus contribute to a weight loss. The EndoBarrier can remain in the intestine for a maximum of one year. The weight loss by this method can also be used in preparation for a surgical procedure. The EndoBarrier is primarily used in obese patients with type 2 diabetes.