Obesity surgery

Over 20 years ago, obesity surgery (bariatric surgery from Baros = Greek “heavy” compare also barometer) sought me out. You read correctly, it was not me who was looking for this speciality, merely known from my jobs in the USA and Germany, but a family doctor in Bern who approached me in 1992 because of an unhappy young patient weighing 130 kg. That’s how it started!

Bariatric surgery at the Beausite Clinic

Today, the Beausite Clinic is the leader in Switzerland with around 500 bariatric procedures. I have built around me a team of seven surgeons accredited for these procedures by the SMOB (Swiss Group for Morbid Obesity). Together with the team, the hospital service has grown.
For example, the clinic has an emergency unit that is freely accessible around the clock, regardless of a patient’s insurance class. “Anyone who has had an operation with us will not be turned away in an emergency”!

We rarely use the intensive care units, but they have been upgraded for such situations. For example, structurally complex patient lifts were installed in the ceiling of the IPS bunks. Imagine caring for a 150kg ventilated person who is incapable of assisting, re-covering the bed or “transferring” him from one side to the other without this help!

All areas of the clinic have grown from the high number of cases in obesity surgery. All necessary medical and technical areas are always available in routine but also with on-call service.

Severely overweight patients are no longer exotic in our clinic. Their acceptance has become natural, be it in the cafeteria, in X-ray, in nursing or wherever.
The individual surgeons are independent but we work together in friendship and respect. This ensures a high professional quality even in the absence of the person in charge.

Comprehensive care and aftercare

My personal service for bariatric patients is comprehensive with integral assessment and follow-up care (www.zfbc.ch) and thus meets the special circumstances of these patients. Morbid obesity is incurable and lifelong. Also bariatric surgery does not cure and strictly speaking we are changing a healthy (except for the gut hormones) digestive system. So it’s not healthy after the operation.

This is the real pro-or-con dilemma of obesity surgery for many sufferers. It is always a question of the risk/benefit ratio, and with this in mind (and not from the point of view of a non-obese person), the choice may be easier with the well-documented effectiveness with regard to the “deadly quartet” (obesity, diabetes II, lipometabolic disorders, hypertension). This is precisely why the same importance must be attached to aftercare as to the operation itself: Professional, structured, long-term and in cooperation with the family doctors. In my aftercare (www.zfbc.ch) at Seilerstrasse 8 in City West Bern, all this is available and has a modern orientation far beyond my time. My successor Dr.med.J.Zehetner Prof. UC USA is also already integrated in the team.

Gastric bypass, sleeve, gastric banding or others

I do not want to comment on the details of the operations here. Thousands of their descriptions can be found on the internet. Just to what seems important to me in my long experience:
Since we do not heal and since new generations of surgeons and new technical possibilities always appear, new things are always propagated. The new products often come with great fanfare only to lose significant momentum over the long term.

Money plays a certain role here, whether in Switzerland because of the DRGs (for every operation – tubular stomach, gastric bypass, gastric plication, gastric banding, scopinaro operation, Marceau operation – there is exactly the same amount of money for the hospital from the health insurance company) or whether abroad, where patients very often pay for the operation from their own funds. Profit optimisation goes along the cost differential. In Switzerland, a tube stomach is around a thousand francs cheaper than a gastric bypass. However, for me in individual evaluation, cost is not an important topic!

Tube stomach or gastric bypass?

After all, it is the long-term course that is of most interest, along with the risks in the treatment of an incurable disease. In the USA, more gastrostomy tube operations than gastric bypasses were performed for the first time in 2015. I have a lot of experience with both operations and personally the following differences count for me:

Advantages and disadvantages of the tube stomach

There is no going back with the tube stomach! 85% of a healthy stomach is at the pathologist. There is no way back. I give younger patients in particular cause for concern.
The subject of surgical risk with the tube stomach: leaks at the sutures we make on the stomach or intestine are really dangerous. However, during the three days that the patients are in hospital with me and have been operated on by me, I have not had to treat a leak during initial operations for years. In the range of 1%, patients come back with a late leak between the sixth and tenth day after gastric surgery. Gastric bypass leaks are easily treatable, whereas tube stomach leaks can be very difficult to heal. An escalation of complications is what I fear (and have experienced) the most.

Advantages and disadvantages of gastric bypass

With gastric bypass, everything is still there, i.e. it can be reversed. The main disadvantage of the gastric bypass compared to the tube stomach results from the direct connection to the intestine. This can give rise to emergency situations in the long term (internal hernia, intestinal obstruction). In addition, there is the rapid passage of food into the intestine and thus the main disadvantage (personal opinion) after gastric bypass: hypoglycaemia (dumping). This affects many bypass patients but only very few require invasive treatment. Most patients cope well by adjusting their diet. Long-term success, reoperation rates, oesophageal stress, deficiency symptoms are of secondary importance to me in counselling; there is no consistent, guiding data on this.

Mortality after bariatric surgery

In the international literature, death rates due to obesity surgery are ten times lower than those due to obesity. In centres with a lot of experience, it is less than one percent, which is quite amazing considering how sick these people often are and how difficult it is to operate because of the weight.

Since the era of laparoscopic surgery, I have not lost a single patient in a first procedure and, unfortunately, one after a second procedure. I could never report this certainty if the environment at the Beausite Clinic were not right. It is therefore more an expression of team success than the success of a one-man show.

Second interventions after bariatric surgery

It follows inevitably from the above that second interventions are unavoidable. On the one hand, the surgical change may lose its effect over time (long-term results!) and on the other hand, complications may give rise to follow-up indications. Secondary interventions are associated with higher risks and require interdisciplinary assessment. In Switzerland, these must be carried out in certified centres – such as ours.

The gastric band

What actually happened to the gastric band? The miracle implant that helped the whole specialty of bariatric surgery out of the cradle in the first place?
It now only ekes out a marginal existence and is only rarely offered.

From my point of view, with 25 years of experience, even with the fixed bands (vertical gastroplasty), I can still see indications for a gastric band. Keep in mind that there is no surgery yet that definitively controls weight. There will always be technical failures and, as a result, reoperations after bariatric surgery. The gastric band is very safe and does not change the anatomy. In the long term, the oesophagus unfortunately “leaches out” in most people and can no longer be used. However, you can definitely gain 10-15 years, considering how little influence the gastric band has on vitamins and trace elements. There are no surgical complications to worry about and in hundreds of conversion surgeries from gastric banding to gastric bypass or gastric sleeve, I have no additional risks to report. In my opinion, this still makes gastric banding an option, especially for young patients. At present, we still have over 300 gastric band patients under our care, some of whom have been “wearing” the band for almost 20 years.