OBESITY TREATMENT AND BARIATRIC SURGERY

Concepts of Bariatric Surgery for the treatment of morbit obesity

Obesity is a medical condition in which there is excess accumulation of fat in our body leading to adverse effect on health. Obesity is increasingly viewed as public health problem(1) and may lead to a decrease life expectancy or an increase of other health problems. Excessive body weight increases the risk of various other diseases such as cardiovascular diseases, sleep apnoea, type 2 diabetes mellitus, osteoarthritis etc.
The Body mass index (BMI) is a widely used rough tool for measurement of body fat based on an individual’s weight and height.

The BMI is calculated by the individual’s body weight divided by the square of the individual’s body height. The resulting unit of measure is kg/m2 e.g.:  BMI = weight in kg : (height in m)2

Current definitions are as follows: (2)

• BMI between 16 and 18.5 - Underweight
• BMI between 18.5 and 25- Normal weight
• BMI between 25 and 30 – Overweight
• BMI between 30 and 35 – Class I Obesity
• BMI between 35 and 40 – Class II Obesity
• BMI over 40 – Class III Obesity

Causes of Obesity

• Multiple factors can lead to obesity. Most common causes are as follows: (3)
• Lack of activity
• Hormonal problems
• Genetic / familial reasons
• Lifestyle / behavioral problems ( e.g. over eating etc.)
• Psychological problems (eating disorders)

The Management of Obesity

The first line treatment for obesity consists of dietary restriction and increase of physical activity. Diet restriction may produce weight loss over the short term, but maintenance of weight loss is often difficult. Success rates associated with lifestyle changes are ranging from 2–20%.(4) Drugs available to treat obesity are associated with a high incidence of adverse effects. The most effective treatment for obesity is bariatric surgery.

Bariatric Surgery for the Management of Obesity

As the worldwide obesity epidemic increases, bariatric surgery, as a tool to help individuals who are morbidly obese lose weight and keep it off, has become increasingly common. Surgery in cases of severe obesity is associated with high success rates and decreased overall mortality. Surgery depends on clinical evaluation and existing treatment modalities of the individual. All patients undergoing surgery require counseling regarding outcome of surgery and importance of compliance with better lifestyle.
Bariatric surgery is a term that includes all of the surgical treatments for morbid obesity. For example: gastric bypass surgeries are one class of such operations.
Weight loss is achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery). Studies show the procedures result in significant loss of weight, recovery from diabetes, improvement in cardiovascular risk factors and decreased mortality.

Beneficial effect of Surgery on overall Health

Weight loss
Bariatric surgery, the most effective treatment for severe obesity, produces dramatic and durable weight loss. Weight loss is most easily expressed in pounds or kilograms. Most patients reach their maximum weight loss by 2 years and experience some increase of weight, perhaps 5–7%, by the fifth year with a gradual decrease again over the following years.(7) Weight loss after the insertion of adjustable bands is generally less and slower than after gastric bypass and the duodenal switch, although there is early evidence that weight loss after banding may continue into the fifth year.(7) In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures but they also have a higher risk profile.
Two studies are notable as well-designed prospective, observational studies of bariatric surgery patients and matched morbidly obese controls groups with long-term follow-up (>10 years). These are the Swedish Obese Subjects (SOS) Study and a 2-cohort study conducted at the McGill University Health Center. The SOS authors report that at the 10-year follow-up, weight loss was 25% (+/- 11%) of total body weight for gastric bypass patients, and 13.2% (+/- 13%) in the gastric banding subgroup, while the matched controls experienced a 1% ± 6% weight gain.(8)

Decreased morbidity and mortality
Several recent studies report decrease in mortality and severity of medical conditions after bariatric surgery. Laparoscopic bariatric surgery requires a hospital stay of only a few days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery.

Others
The medically more significant effects are a dramatic reduction in co-morbid conditions:

• Hyperlipidemia is corrected .
• Essential hypertension is relieved and need for medication is usually reduced
• Obstructive sleep apnoea is markedly improved or may be curative for sleep apnoea. Snoring also improves in most patients.
• Diabetes mellitus type 2 is reversed leading to a normal blood sugar without medication, sometimes within days of surgery.
• Gastroesophageal reflux disease is relieved from the time of surgery in almost all patients.
• Signs of venous thromboembolism such as swelling of legs are improved.
• Low back pain and joint pain are relieved or improved in nearly all patients.

Who are candidates for Bariatric Surgery?

National Institutes of Health’ guidelines state that individuals with a body mass index (BMI) of 40 or greater may be candidates for bariatric surgery. Individuals with a BMI of 35 to 40 and a co-morbidity such as hypertension (increased blood pressure), diabetes (increased blood sugar), sleep apnea (breathing problems during sleep), or dyslipidemia (altered blood cholesterol level) also may be candidates (U.S. Department of Health and Human Services, 2008).(5)
While determining the eligibility for bariatric surgery of morbidly obese patients, psychological screening is critical. It is also important for determining postoperative success.

Procedures for Bariatric Surgery

Below you will find a list of common surgical approaches to weight loss.
Each of them links to more information about the procedure, the advantages, disadvantages, potential risks as well as their weight loss potential.

Should you not find your medical condition, please use our contact form or call back service.

Should you not find your medical condition, please use our contact form or call back service.

Diet and Nutrition

Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free gelatin desserts. This diet is continued until the gastrointestinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of skimmed milk, cream of wheat, a small serving of margarine, protein drinks, cream soup, pureed fruit and mashed potatoes with gravy.
During the post-surgical period, patients avoid overeating as the capacity of the stomach is limited and excess food causes nausea and vomiting. Diet restrictions after recovery from surgery depend on the type of surgery performed: Many patients may need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients. As patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and simple sugars.
In the first month of the post-surgical period, it not uncommon for patients to drink too little and as a result experience volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adjust to their new stomach volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are factors that contribute to dehydration. In order to prevent fluid volume depletion and dehydration, small quantities of liquids should be consumed by repetitive small sips throughout the day.

How to select the right Medical Center for Obesity Surgery

Before selecting a centre for surgery, you should be aware of the following phases of a surgical procedures:

• Pre-admission psychological counseling
• Admission to the hospital
• Pre-operative examination 
• Surgery 
• Recovery (2-8 days depending on the procedure)
• Rehabilitation
• Follow-up

All these factors are of paramount and equal importance. Careful pre-operative  assessment and counseling for the selection of proper surgical procedure, early post-operative recovery, proper regimen for rehabilitation and follow-up are important aspects to consider before selection of the centre.
When searching for the ideal bariatric centre, a tertiary care super-specialty hospital is what to look for. Professional obesity surgery requires a multi-disciplinary approach. Ideally, these centers have different super specialty departments like cardiology, internal medicine, endocrinology, psychology and a dietician. Inter-disciplinary coordination between these departments is essential as obese patients often suffer from additional diseases such as hypertension, diabetes, or heart problems. These centers also have well equipped intensive care unit to take care of any emergency conditions which may arise out of surgical procedures. For quick recovery and rehabilitation trained dieticians, psychologists and physiotherapists are also available. Centre should have more than one experienced and accredited surgeon who is an expert in bariatric surgery. They should have a large case load, long standing experience, and good success rates. They must also be proficient in managing complications. Paramedical staff should also be well trained to ensure early recovery and rehabilitation.
Bariatric surgery is a team approach. All the above stakeholders are crucial in delivering high quality bariatric surgery.

Bariatric surgery is not plastic surgery even though many patients perceive it as such. Bariatric surgery is a significant operation on patients that are considered to be high risk patients. Therefore, a patient seeking a bariatric center should spent some time in assessing the quality, experience and success rate of the center.

When assessing a bariatric center, here are some questions to ask:

• How many years have they been practicing bariatric surgery? (look for at least ten)
• How many surgeons are trained bariatric surgeons?
• Are they supported by other specialty departments such as internal medicine, diabetology, cardiology, psychology and nutritional experts?
• What is the case load? (at least one procedure a week is a minimum)
• Are they accredited by any local or international professional and scientific associations for bariatric surgery?
• Do they have dedicated equipment for the severely obese patients, such as larger beds, large blood pressure cuffs, large OR-tables?
• Have the published any scientific work on the subject?
• Do they conduct bariatric revision surgery?
• Does the center have a quality system in place (ISO, KTQ, JCO or similar)
• Do you feel comfortable in the interaction with them?

Here are some things to avoid:

• Flashy web pages with tempting promises of successes
• Dumping prices that seem too good to be true.
• Only one surgeon doing the operation
• The surgeon operating at several hospitals (no or little chance for an expert support team to develop)
• No information about number of procedures performed in a year.
• No evident quality system of the hospital
• No scientific publications by the surgeon team
• No published data on success rates and complications
• No membership in a professional and scientific bariatric surgery society

The International Asklepios Center for the Treatment of Obesity (IACTO) in Hamburg

Asklepios is by far the largest hospital group in Germany and Europe. They have coined the term “future hospital” because they try to always stay on top of the latest medical technologies. With close to 100 hospitals in Germany they play a major role in delivering quality healthcare to the German public.

The International Asklepios Center for the Treatment of Obesity (IACTO) in Hamburg is part of the Asklepios Westklinikum, a hospital with over 500 beds in the western part of the city of Hamburg, Germany. The hospital is certified by the German Association for Hospital Transparency and Quality (KTQ) and was voted “exceptional” in a patient satisfaction review conducted by one of the largest German Health Insurance (The Technikerkrankenkasse).
The obesity center is a competence center as certified by the German Association for General and Visceral Surgery and has established the self help group “Big Friends”.

The ICATO has defined it as its mission to provide those affected with obesity with individual and effective help to not only lose weight, but to define a lifestyle conducive towards maintaining a healthy lifestyle and weight.
A successful therapy of obesity requires high motivation and cooperation of all involved parties. Close interaction between patients, general practitioners, auxiliary therapists, specialized centers and health insurances are key to a successful long term treatment of obesity.
The International Asklepios Center for the Treatment of Obesity (IACTO) consists of an interdisciplinary team of experts who have specialized in the treatment of obesity.
Their holistic treatment concept is established by close cooperation between an experienced team consisting of physicians and auxiliary medical staff specializing in:

•    internal medicine,
•    treatment of diabetes,
•    surgeons,
•    psychologists,
•    a team of dieticians,
•    physiotherapists,
•    and self-help groups

The IACTO also operates a large department for conservative, non-surgical obesity management.

The International Asklepios Center for the Treatment of Obesity was founded in 2004 and in 2010 was one of the first centers in Germany to be certified by the by the German association for General and Visceral Surgery.
Both the German Association and the IACTO consider it their goal to prevent and treat obesity according to the guidelines of the German Association for Obesity.
The head of the IACTO, Dr. W. Tigges, MD, has been specializing in the surgical treatment of obesity since 1997 (close to 15 years).


The involved bariatric surgeons perform all obesity procedures laparoscopically and numerous bariatric procedures are performed during a single week.
The high technical skill that these procedures require can only be established and developed with and trough an established and routine team.
The team consists of the department leader Dr. W. Tigges, MD, senior consultant Dr. Pick, MD, senior consultant Dr. Adelhelm, MD, and a selection of anesthesiologists and perioperative nurses who are all familiar with the special requirements of obesity surgery.

Since 2005 the center is part of a study on quality assurance conducted by the German Association for General and Visceral Surgery and the Germany Association for Bariatric Surgery. The IACTO is a certified member since 2010.

The department has a strongly established believe of approaching obesity surgery as an interdisciplinary task. Specialists in the area of cardiology, gastroenterology, diabetology, dietology, psychology and physical therapy are involved in the treatment of each patient.
As such, Premier Healthcare Germany considers the IACTO as their prime partner and advisor in the treatment of obesity.

The Asklepios Center for Bariatric Surgery in Hamburg is comprised of:

• Dr. med. W. Tigges, head of the department for general and bariatric surgery
• Dr. med. P. Pick, senior surgeon for general and bariatric surgery
• Dr. med. A. Adelhelm
• PD Dr. med A. Stirn, head of the psychosomatic specialty center
• Prof. Dr. med. A. Raedler, head of center for gastroenterology
• Dr. med. R. Zahorsky, head of the department for cardiology
• Prof. Dr. med. M. Dreyer, head of the center for diabetology
• Mr. Karsten Eggers, head of the department of physiotherapy
• Mrs. Smoljanowic, certified dietician

Weight management approached offered at the center include:

• Pre-operative consultations and diagnostics
• Gastric Balloon Placement
• Gastric Band Surgery
• Vertical Sleeve Gastrectomy
• Gastric Bypass surgeries
• Gastric Pacemaker Placement
• Revision Surgery
• Conservative approaches to weight management
• Post-operative management

Planning a medical trip for obesity surgery

Your medical trip will be broken down into 10 individual steps each of which Premier Healthcare will assist and guide you through, so you have the confidence that nothing is missed:

• Review of your medical case and travel requirements
• Preparation of a cost estimate
• Preparation of the travel plan
• Travel
• Admission to the hospital
• Pre-operative examination
• Surgery
• Recovery (5-8 days)
• Return home (after a minimum of 8 days or once surgeon certifies a fit to fly)
• Follow up at home by bariatric specialist

The review of your medical files as well as the preparation of a treatment plan and quote are a free service that we provide to our patients in order to convince you of our expertise. Once you have reviewed our suggestions and are ready to move forward we will start with the preparation of your medical trip to Germany. We will interact with you directly to ensure all your expectations are met.

Preparation for travel includes assistance in obtaining visa for a medical visit to Germany where required, obtaining health travel insurance, arranging flights, accommodation for accompanying family members, and ground transportation. It also includes preparing the hospital for your special requirement, such as insuring that translators are available (if required), and the medical staff is informed of cultural requirements of the patient. Our in-house travel department will manage this part with you.
Visa assistance includes obtaining and creating the various documents required for the applications including: invitation letters, confirmation of partial payment, copies of travel documents, etc.

Travel: You will most likely be flying directly to Hamburg where a member of Premier-Healthcare will be expecting you at the airport.
The first night will be spent at a hotel to wind down from the travel. We arrange for special assistance at the departing airport as well as at the arriving airport if this should be required.  Our cooperation with Lufthansa ensures special fare conditions and ticket flexibility.

Admission to the hospital: We will assist the admission process personally. Even in Hospitals with a lot of experience with international patients, we have seen that it is helpful when a Premier Healthcare Germany representative is present to facilitate and speed up the process.

Pre-operative examinations will include the review of your condition based on files you bring, but very likely also on additional examinations that will be conducted at the hospital. Standard pre-operative examination such as EKG, chest X-ray and blood values will be conducted before the procedure to determine the health status of the patient.

Surgery: The night before surgery you will receive a mild sedative if desired to calm any potential anxieties. You will also receive a mild sedative before you are taken to the operating room. This is optional, but many patients tell us that it helped them to be less anxious. The surgery itself commonly lasts 90 minutes in a routine team. After the surgery, the patient will spend 2-3 hours in the recovery room before being brought back to the room.
Recovery: A good recovery is as important as a good surgery. During the following days after surgery you will have time to recover, and your food intake will gradually be increased. Your Premier-Healthcare Germany Representative will visit you to check your progress and to assist with any requirements during your stay.

Rehabilitation: Local patients are usually dismissed from the hospital after 4-6 days. However, as you have to do some travelling, we recommend staying in Germany at least 8-10 days. During this time, you will meet with a certified dietician who will explain the food regimen that you are required to adhere to during the next weeks.

Return home: We will most likely have arranged a flexible return flight, so if there are unexpected changes to the return date, you are flexible to do this. At the point of return you will be handed over all your medical data for follow up visit. You will also be given the contact details of your surgeon and of your Premier-Healthcare Germany case agent. We will assist you with any questions or concerns, even after your return home.

Follow up: Depending on your case you may want to visit a doctor back at home for a follow up visit. Sometimes, patients want to have the approval of the surgery by a doctor at home or someone to go to if there are problems. For this reason and if required we will research a qualified doctor in your home town/region and contact him or her to brief him about your case. By the time you visit the doctor, he will already know about you and your situation.

Conclusion

Bariatric Surgery can be a life saving step for many morbidly obese individuals. However, medical travel for obesity surgery is complex and requires specialist centers and a medical travel consultant experienced in medical travel for obesity treatmenty.

We (at Premier Healthcare Germany) believe that through our network of medical experts and auxillary service providers the delivery of an exceptional cost/value ratio  in obesity treatment is entirely possible for any patient.

International patients can schedule an appointment here.

References:

1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults. 1999–2002. JAMA 2004;291:2847–50.
2. Torpy J, Lynm C, Glass RM. Bariatric Surgery. JAMA 2002; 288: 2918
3. Haslam DW, James WP. Obesity. Lancet 2005; 366:1197–209
4. Strychar I. Diet in the management of weight loss. CMAJ 2006 ;174 (1): 56-63
5. Dugan S. Part I. Bariatric surgery. AAOHN Journal
6. Schauer PR, Burguera B, Ikramuddin S, Cottam D, Gourash W, Hamad Get al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003; 238:467–84.
7. Pories WJ. Bariatric Surgery: risks and rewards. J Clin Endocrinol Metab 2008; 93(11):S89–S96
8. Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, Dahlgren S, Larsson B, Narbro K, Sjöström CD, Sullivan M, Wedel H. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:2683–93.
9. Buchwald H.  International symposium on gastric banding. Supplement to Surgery for Obesity and Related Diseases.2008. Cambridge, MA: Elsevier; 4:35;pp 71
10. Himpens J, Dapri G, Cadiere GB.A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years. Obes Surg 2006;16:1450–6.
11. Kreft JS, Montebelo J, Fogaca KC, Rasere I, Oliveira MR.Gastric bypass: post-operative complications in individuals with and without preoperative dietary guidance. Journal of Evaluation in Clinical Practice2008;14:169–71