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123
Jürgen Ordemann
Ulf Elbelt Editors
Obesity and
Metabolic Surgery
Obesity and Metabolic Surgery
Jürgen Ordemann • Ulf Elbelt
Editors
Obesity
and Metabolic
Surgery
Editors
Jürgen Ordemann
Center for Obesity and
Metabolic Surgery
Vivantes Klinikum Spandau
Berlin, Germany
Ulf Elbelt
Division of Medicine B
University Hospital Ruppin-
Brandenburg
Brandenburg Medical School
Neuruppin, Germany
Endokrinologikum Berlin MVZ
Berlin, Germany
Medical Department
Division of Psychosomatic Medicine
Campus Benjamin Franklin
Charité- Universitätsmedizin Berlin
Corporate Member of Freie
Universität Berlin and Humboldt-
Universität zu Berlin
Berlin, Germany
This book is a translation of the original German edition „Adipositas- und metabolische
Chirurgie“ by Ordemann, Jürgen, published by Springer-Verlag GmbH, DE in 2017. The
translation was done with the help of articial intelligence (machine translation by the
service DeepL.com). A subsequent human revision was done primarily in terms of con-
tent, so that the book will read stylistically differently from a conventional translation.
Springer Nature works continuously to further the development of tools for the produc-
tion of books and on the related technologies to support the authors.
ISBN 978-3-662-63226-0 ISBN 978-3-662-63227-7 (eBook)
https://doi.org/10.1007/978-3-662-63227-7
© Springer-Verlag GmbH Germany, part of Springer Nature 2022
This work is subject to copyright. All rights are reserved by the Publisher, whether the
whole or part of the material is concerned, specically the rights of translation, reprint-
ing, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic
adaptation, computer software, or by similar or dissimilar methodology now known or
hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in
this publication does not imply, even in the absence of a specic statement, that such
names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors and the editors are safe to assume that the advice and informa-
tion in this book are believed to be true and accurate at the date of publication. Neither
the publisher nor the authors or the editors give a warranty, expressed or implied, with
respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published
maps and institutional afliations.
This Springer imprint is published by the registered company Springer-Verlag GmbH,
DE, part of Springer Nature.
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
V
Preface
Isolated cases of pronounced obesity have been found since the early
stages of human history. However, obesity has emerged to be a signicant
health problem over the last 100 years—with unforeseeable consequences
for the development of mankind. Obesity is a chronic disease that can
shorten life span and lead to various complications such as metabolic syn-
drome, sleep-related breathing disorders, neoplasm and reduced fertility.
The effect of conservative treatment is usually low and of limited dura-
tion. Conservative therapies such as nutritional therapy, physical exercise
therapy and behavioural therapy are associated with major challenges for
the person concerned. In the case of drug therapy, undesirable effects can
also occur. To date, the underlying pathophysiology and genetic predispo-
sition of the affected persons cannot be adequately addressed by conserva-
tive therapies and the dramatic environmental changes leading to obesity
are also difcult to inuence at an individual level.
In contrast, surgical measures can signicantly improve the course of
obesity. Mortality and morbidity are signicantly reduced compared to
conservative therapy. In the meantime, obesity surgery and metabolic sur-
gery have become established forms of therapy for obesity and its compli-
cations. Due to insufcient information, however, patients who are affected
and their therapists still have considerable concern. In addition, health
insurance companies also have strong reservations. In comparison to other
countries, obesity surgery is still very rarely performed in Germany.
Our practice-oriented textbook is mainly for surgeons who would
like to familiarize themselves with the indications, surgical procedures,
metabolic interventions, risks and aftercare of obesity surgery. An inter-
disciplinary approach in the treatment of people with obesity and asso-
ciated secondary diseases is of particular importance. For this reason,
nutritional medicine, internal medicine and psychosomatic issues are
featured in this textbook in detail. Our textbook is also intended to help
guide nutritional physicians, internists, general practitioners and mem-
bers of the professional groups involved in the treatment of obesity. We
intend to provide practical knowledge for the care of obese patients and
to improve the understanding of prevention, complications and after-
care of bariatric surgery for these different professional groups.
Many people contributed their expertise to the development of this
textbook. First, our thanks go to the authors of the different chapters.
We would also like to thank Dr. Fritz Kraemer and the team at Springer.
We would like to particularly thank our editor Heidrun Schoeler for her
cooperation and commitment.
We hope that this textbook will be helpful to professionals who are
involved in the treatment of obesity and that it will encourage them to
provide an interdisciplinary approach to their patients.
JürgenOrdemann
Berlin, Germany
UlfElbelt
Berlin, Germany
January 2021
VII
Contents
1 Obesity .................................................................................................................... 1
J. Ordemann, U. Elbelt, A. Stengel, and T. Hofmann
1.1 Classication of Obesity ....................................................................................... 3
1.2 “Globesity”: The Current Pandemic.................................................................. 3
1.3 Why Are We Getting More and More Obese? Etiology
and Pathophysiology ............................................................................................ 5
1.4 Regulation of Hunger and Satiety in Obesity ............................................... 9
1.5 Secondary Diseases of Obesity.......................................................................... 14
1.6 Psychosocial Aspects of Obesity ....................................................................... 18
References....................................................................................................................... 22
2 Conservative Treatment of Obesity ..................................................... 25
U. Elbelt, H. Berger, and T. Hofmann
2.1 Therapeutic Goals .................................................................................................. 26
2.2 Nutrition Therapy ................................................................................................... 26
2.3 Physical Exercise ..................................................................................................... 28
2.4 Lifestyle Change: Psychotherapy and Psychoeducation .......................... 29
2.5 Drug Therapy ........................................................................................................... 30
2.6 Multimodal Therapy Programmes .................................................................... 31
References....................................................................................................................... 32
3 Surgical Therapy of Obesity ...................................................................... 35
J. Ordemann and A. Stengel
3.1 Frequency of Obesity Surgery ........................................................................... 36
3.2 Therapeutic Goals and Evaluation Criteria .................................................... 37
3.3 Indications for Surgical Treatment of Obesity .............................................. 38
3.4 Obesity Surgical Procedures ............................................................................... 38
3.5 Mechanisms of Action .......................................................................................... 42
References....................................................................................................................... 49
4 Metabolic Surgery ........................................................................................... 51
J. Ordemann and U. Elbelt
4.1 Prospective Studies ............................................................................................... 52
4.2 Meta-Analyses ......................................................................................................... 53
4.3 Postoperative Incidence of Diabetes, Micro- and Macrovascular
Complications, Life Expectancy......................................................................... 53
References....................................................................................................................... 54
5 Preoperative Evaluation of the Patient ............................................. 57
J. Ordemann, U. Elbelt, and T. Hofmann
5.1 Surgical Evaluation ................................................................................................ 58
5.2 Internal Evaluation ................................................................................................ 59
5.3 Psychosomatic Evaluation................................................................................... 62
5.4 Choice of Procedure .............................................................................................. 64
5.5 Informing the Patient............................................................................................ 65
References....................................................................................................................... 66
VIII
6 Operation Preparation in Bariatric Surgery ................................... 69
J. Mall
6.1 Operating Room ..................................................................................................... 70
6.2 Instruments .............................................................................................................. 70
6.3 Positioning the Patient ......................................................................................... 70
6.4 Position of the Surgical Team ............................................................................. 72
6.5 Antibiotic Treatment ............................................................................................. 73
6.6 Anticoagulation ...................................................................................................... 73
6.7 Team Time Out ........................................................................................................ 75
6.8 Structure of the Pneumoperitoneum .............................................................. 75
References....................................................................................................................... 77
7 Anaesthesiology for Bariatric Surgery .............................................. 79
J. Birnbaum
7.1 Pathophysiological Aspects ................................................................................ 80
7.2 Organisational Aspects ........................................................................................ 84
7.3 Pre-medication Rounds ....................................................................................... 85
7.4 Preparation of the Anaesthesia ......................................................................... 86
7.5 Induction and Maintenance of Anaesthesia ................................................. 88
7.6 Postoperative Phase .............................................................................................. 89
Further Readings .......................................................................................................... 89
8 Laparoscopic, Adjustable Gastric Banding ..................................... 91
H. Köhler
8.1 Trocar Placement .................................................................................................... 92
8.2 Dissection ................................................................................................................. 93
8.3 Placement of Gastric Band .................................................................................. 93
8.4 Fixing the Gastric Band and Port ...................................................................... 94
8.5 Aftercare, Band Filling .......................................................................................... 95
8.6 Pitfalls ......................................................................................................................... 96
Further Readings .......................................................................................................... 96
9 Sleeve Gastrectomy ........................................................................................ 97
J. Ordemann
9.1 Trocar Placement .................................................................................................... 98
9.2 Exploration ............................................................................................................... 99
9.3 Dissection ................................................................................................................. 99
9.4 Gastric Tube Calibration ....................................................................................... 100
9.5 Resection ................................................................................................................... 101
9.6 Test for Staple Line Insuciency ....................................................................... 102
9.7 Removal of the Resected Specimen ................................................................. 102
9.8 Finishing the Operation ....................................................................................... 102
9.9 Pitfalls ......................................................................................................................... 103
References....................................................................................................................... 103
10 Laparoscopic, Proximal Roux-en-Y Gastric Bypass .................... 105
J. Ordemann
10.1 Trocar Placement .................................................................................................... 106
10.2 Exploration ............................................................................................................... 106
10.3 Creating the Gastric Pouch ................................................................................. 107
10.4 Measurement of the Intestine ........................................................................... 109
Contents
IX
10.5 Gastrojejunal Anastomosis ................................................................................. 109
10.6 Measuring the Alimentary Loop ....................................................................... 111
10.7 Jejunojejunostomy ................................................................................................ 111
10.8 Dividing of the Biliopancreatic Loop ............................................................... 112
10.9 Testing the Gastro-entero Anastomosis for Leaks ...................................... 112
10.10 Closing the Mesentery .......................................................................................... 112
10.11 Finishing the Operation ....................................................................................... 112
10.12 Pitfalls ......................................................................................................................... 112
Further Readings .......................................................................................................... 113
11 Omega-Loop Bypass (One- Anastomosis Bypass,
Mini-Gastric Bypass) ...................................................................................... 115
T. P. Hüttl, P. Stauch, and O. Dietl
11.1 Indication .................................................................................................................. 117
11.2 Trocar Placement .................................................................................................... 118
11.3 Dissection ................................................................................................................. 118
11.4 Pouch .......................................................................................................................... 119
11.5 Measuring the Bypass Length............................................................................ 119
11.6 Anastomosis ............................................................................................................. 119
11.7 Omega-Loop Bypass as a Redo Procedure After Sleeve
Gastrectomy ............................................................................................................. 120
11.8 Pitfalls ......................................................................................................................... 120
11.9 Peri- and Postoperative Management ............................................................ 121
11.10 Results ........................................................................................................................ 121
11.11 Complications and Complication Management .......................................... 121
References....................................................................................................................... 122
12 Biliopancreatic Diversion (Operation According
to Scopinaro) ....................................................................................................... 123
A. Dietrich
12.1 Introduction ............................................................................................................. 124
12.2 Indication and Preparation for Surgery .......................................................... 124
12.3 Surgical Technique ................................................................................................. 125
12.4 Pitfalls ......................................................................................................................... 127
12.5 Results ........................................................................................................................ 127
12.6 Morbidity and Mortality ...................................................................................... 128
References....................................................................................................................... 129
13 Biliopancreatic Diversion with Duodenal Switch ....................... 131
A. Dietrich
13.1 Specic Indications for BPD-DS ......................................................................... 132
13.2 Surgical Technique ................................................................................................. 132
13.3 Pitfalls ......................................................................................................................... 136
13.4 Results ........................................................................................................................ 136
13.5 Morbidity and Mortality ...................................................................................... 137
References....................................................................................................................... 137
14 Postoperative Management of Bariatric Surgery Patients .......... 139
H. Berger, J. Ordemann, U. Elbelt, T. Hofmann,
and C. Menenakos
14.1 Initial Diet Regimen After Bariatric Surgery .................................................. 141
14.2 Long-Term Nutrition After Bariatric Surgery................................................. 142
Contents
X
14.3 Supplementation ................................................................................................... 143
14.4 Surgical Aftercare ................................................................................................... 144
14.5 Internal Aftercare ................................................................................................... 145
14.6 Psychosomatic Aftercare ..................................................................................... 148
14.7 Surgical Complications ......................................................................................... 151
14.8 Internal Complications ......................................................................................... 160
References....................................................................................................................... 162
15 Revision and Redo Operations After Bariatric
Procedures ............................................................................................................ 165
T. Dziodzio and C. Denecke
15.1 Background .............................................................................................................. 166
15.2 Revision/Redo Procedure After Gastric Banding ......................................... 166
15.3 Revision/Redo Procedure After Sleeve Gastrectomy ................................. 167
15.4 Revision/Redo Procedure After Gastric Bypass Surgery ........................... 168
Further Readings .......................................................................................................... 170
16 Special Patient Groups in Bariatric Surgery ................................... 171
J. Mühlsteiner, P. Stauch, and T. P. Hüttl
16.1 Surgery at Older Age ............................................................................................. 172
16.2 Surgery in Childhood and Adolescence ......................................................... 172
16.3 High Risk Patients .................................................................................................. 176
References....................................................................................................................... 176
17 Obesity Centre ................................................................................................... 179
R. Weise
17.1 Establishment and Certication of an Obesity Centre .............................. 180
17.2 Interdisciplinary Treatment Team: Obesity Board....................................... 180
17.3 Necessary Hospital Equipment ......................................................................... 181
17.4 Multimodal Treatment Processes ..................................................................... 181
17.5 Self-Help Groups and Internet Portals ............................................................ 182
17.6 Patient Presentations and Information Material ......................................... 183
17.7 Treatment and Patient Pathways ...................................................................... 183
Further Readings .......................................................................................................... 184
18 Alternative Techniques and Methods
in Obesity Therapy .......................................................................................... 185
C. A. Jacobi
18.1 Gastric Plication ...................................................................................................... 186
18.2 POSE Procedure ...................................................................................................... 187
18.3 Endobarrier
®
............................................................................................................. 187
18.4 Gastric Sleeve with Ileum Interposition ......................................................... 188
18.5 Securing Dierent Operation Procedures with a Band or a Ring .......... 189
18.6 Gastric Stimulator .................................................................................................. 189
18.7 Gastric Balloon ........................................................................................................ 190
18.8 AspireAssist™ ........................................................................................................... 190
References....................................................................................................................... 191
Supplementary Information ..................................................................... 193
Index ................................................................................................................................. 195
Contents
XI
Contributors
H. Berger Practice for Nutritional Therapy and Counselling, Lebenswert
Essen, Berlin, Germany
J.Birnbaum Department of Anaesthesiology and Intensive Care Medicine,
Campus Charité Mitte and Campus Virchow-Klinikum, Charité—Universitäts-
medizin Berlin, Berlin, Germany
C. Denecke Department of Surgery, Campus Charité Mitte and Campus
Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
O.Dietl Dr. Lubos Kliniken, Obesity Center Munich, Klinik Bogenhausen,
Munich, Germany
A.Dietrich Clinic and Polyclinic for Visceral, Transplantation, Thoracic and
Vascular Surgery, University Hospital Leipzig AöR, Leipzig, Germany
T. Dziodzio Department of Surgery, Campus Charité Mitte and Campus
Virchow-Klinikum, Charité—Universitätsmedizin Berlin, Berlin, Germany
U.Elbelt Division of Medicine B, University Hospital Ruppin-Brandenburg,
Brandenburg Medical School, Neuruppin, Germany
T.Hofmann Department for Psychosomatic Medicine, Charité-Universitäts-
medizin Berlin, Berlin, Germany
T.P.Hüttl Dr. Lubos Kliniken, Obesity Center Munich, Klinik Bogenhausen,
Munich, Germany
C.A.Jacobi Adiposity Center Wesseling, Wesseling, Germany
H.Köhler Herzogin Elisabeth Hospital, Obesity Center, Germany
J.Mall Hospital Nordstadt KRH, Clinic for General, Visceral, Vascular and
Bariatric Surgery, Hannover, Germany
C.Menenakos Klinikum Barnim GmbH, Eberswalde, Germany
J.Mühlsteiner Clinical Department of General Surgery, University Hospital
Graz, Austria
J.Ordemann Center for Obesity and Metabolic Surgery, Vivantes Klinikum
Spandau, Berlin, Germany
P.Stauch Dr. Lubos Kliniken, Obesity Center Munich, Klinik Bogenhausen,
Munich, Germany