Further Readings

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177

Inge TH, Courcoulas AP, Jenkins TM etal (2016) Weight

loss and health status 3 years after bariatric surgery

in adolescents. N Engl J Med 374:113–123

Kromeyer-Hauschild WM, Kunze D et al (2001) Per-

zentile für den Body Mass Index für das Kindes-

und Jugendalter unter Heranziehung verschiedener

deutscher Stichproben. Monatsschr Kinderheilk

8:807–818

Musella M, Milone M, Maietta P et al (2014) Bar-

iatric surgery in elderly patients. A comparison

between gastric banding and sleeve gastrectomy

with ve years of follow up. Int J Surg 12(Suppl. 2):

S69–S72

Nijhawan S, Martinez T, Wittgrove AC (2012) Laparo-

scopic gastric bypass for the adolescent patient: long-

term results. Obes Surg 22:1445–1449

Paulus GF et al (2015) Bariatric surgery in morbidly

obese adolescents: a systematic review and metaanal-

ysis. Obes Surg 25:860–878

Qin C, Luo B (2014) Advanced age as an independent

predictor of perioperative risk after laparoscopic

sleeve gastrectomy. Obes Surg 25:406–412

Sugerman HJ, DeMaria EJ, Kellum JM, et al (2004)

Effects of bariatric surgery in older patients. Ann

Surg. 240:243–247

Treadwell JR, Sun F, Schoelles K (2008) Systematic

review and metaanalysis of bariatric surgery for pedi-

atric obesity. Ann Surg 248:763–776

Wabitsch M (2014) Adipositas. In: Hoffmann GF, Lentze

MJ, Spranger J (Hrsg) Pädiatrie. Springer, Heidelberg

Obesity Centre

R.Weise

Contents

17.1 Establishment andCertication 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

J. Ordemann, U. Elbelt (eds.), Obesity and Metabolic Surgery,

https://doi.org/10.1007/978-3-662-63227-7_17

180

Adiposity centres at large municipal hospitals

or university clinics usually have all the nec-

essary disciplines under one roof. In contrast,

obesity centres in smaller, partly rural hospi-

tals often have to rely on external cooperation

partners. In these centres with a large catch-

ment area, aftercare can also be organised

close to home at external locations. Both con-

cepts are possible and can show comparably

good long-term results

17.1 Establishment

andCertication ofan

Obesity Centre

The establishment of an obesity centre must

be very well prepared. It has been proved

to be a good idea to present and discuss the

topic of adiposity, metabolic disorders and

treatment methods in detail at the so-called

round table. Employees from as many hospi-

tal departments as possible should participate

(7 Overview: “Recommended Employees

and Departments”). This is the only way to

reduce frequent prejudices against the future

patients. In addition, such a round table is

best suited for brainstorming, listing equip-

ment deciencies and constructional decits

and later eliminating those.

Recommended Employees and Depart-

ments for an Internal Round Table

5 Surgery with the involvement of nurs-

ing and operating personnel

5 Internal medicine with the involvement

of nursing staff

5 Psychosomatics with the involvement

of nursing staff

5 Medical and nursing staff of the inten-

sive care unit

5 Nursing service management

5 Administration

5 Physiotherapy

5 Case manager

5 Controlling

5 Nutrition/kitchen

5 Building services

Since in Germany the performance of meta-

bolic interventions is not yet part of the

service obligation of the statutory health

insurances (Gesetzlichen Krankenversi-

cherungen, GKV), prior information of the

most important cost units and the responsi-

ble medical service can help to reduce time-

consuming inquiries. Of course, the extension

of the range of services offered by the clinic

should be mentioned and negotiated with the

cost bearers as part of budget negotiations.

The German Society for General and

Visceral Surgery (Deutsche Gesellschaft für

Allgemein- und Viszeralchirurgie, DGAV)

has dened the personal requirements for

surgeons and the structures in the hospital

to obtain certication as a centre for obesity

surgery. According to these certication regu-

lations, it is possible to apply for certication

as a centre of competence, reference or excel-

lence. The individual certication levels differ

to a large extent regarding the numbers of

operations and the increasing demand to pub-

lish scientic papers.

The currently valid version of the cer-

tication regulations can be viewed and

downloaded from the DGAV website

(7 www. dgav. de).

17.2 Interdisciplinary Treatment

Team: Obesity Board

From the indication to the treatment of late

complications after a metabolic intervention,

the cooperation of many medical disciplines is

necessary. In addition to a close cooperation

R . Weise

181

between surgeons and internists, a close coop-

eration with specialists in psychosomatics/

psychiatry is equally important. For example,

there is a strong association between obesity

and psychopathic abnormalities (see also

7 Sect. 1.6).

Since a large proportion of the patients

affected suffer from metabolic disorders, spe-

cialists in endocrinology and diabetology are

indispensable cooperation partners in the

treatment of obesity. From initial contact

to long-term aftercare, qualied nutritional

advice plays a decisive role.

In addition, other specialist disciplines

often have to be consulted in individual cases.

In some cases, an individual treatment concept

must be agreed with pulmonologists and car-

diologists. Furthermore, the sequence of joint-

replacing and bariatric interventions must be

determined with orthopaedic surgeons.

Practical Tip

It is advisable to set up a meeting of an

interdisciplinary obesity board at regular

intervals to discuss indications and com-

plications and to establish individual treat-

ment plans. Obesity conferences are a

prerequisite for certication of the obesity

centre.

A special role is played by family doctor care

close to home. A family doctor who does

not know or accept the principles of treating

obese patients can only treat bariatric patients

inadequately. Here, the holding of regular

information events can be helpful.

17.3 Necessary Hospital Equipment

The equipment of the clinic must be consis-

tently adapted to the needs of obese patients,

starting with the sufcient size of the surgi-

cal shirts and ending with the sufcient load-

bearing capacity of the sanitary facilities.

. Table 17.1 lists the most important mini-

mum requirements that should be present in

an obesity clinic.

17.4 Multimodal Treatment

Processes

The implementation of conservative multi-

modal treatment procedures should be cov-

ered by the obesity centre. The indications and

the multimodal therapy itself are described

elsewhere (7 Sect. 2.6).

In addition to centre-specic treatment pro-

grams, supra-regional multimodal treatment

concepts are also available (. Table17.2).

. Table 17.1 Necessary equipment of an

obesity clinic

Scales Minimum load 300kg, sufcient

number

Seating

facilities

Sufciently wide, possibly

without armrests, up to 300kg

loadable chairs and benches in

the waiting areas, examination

rooms and patient rooms

Patient beds/

examination

couches

Sufcient dimensions, heavy-duty

gallows, high load capacity, easy

to move

Surgical

shirts

Oversized surgical shirts may

have to be specially made

Duvets Sufciently wide and long plumes

Patient

toilets

Minimum load 300kg, this also

applies to the mobile commode

chairs of the stations

Patient lift Occasionally a patient lift with

sufcient load capacity is

necessary

Blood

pressure

cuffs

Incorrectly dimensioned blood

pressure cuffs result in incorrect

blood pressure values, therefore

oversize must be present

Operating

tables

Sufciently loadable operating

tables, which can still be adjusted

under load

Obesity Centre

182

. Table 17.2 Examples of multimodal therapy concepts in Germany

Name of the

program

Institution responsible Contact details

Vivantes Vital Zentrum für Adipositas und Metabolische Chirurgie,

Vivantes Klinikum Spandau, Berlin, Germany

7 www.

adipositaszentrum. berlin

Obesity Balance Interdisciplinary Obesity Centre—Charité, Berlin

7 www.

adipositaszentrum-

berlin. de

MMK Multimodal therapy concept—Diakoniekrankenhaus

Henriettenstift, Hannover

7 www.

adipositaschirurgie-

hannover. de

Phoenix Program Adipositas-Zentrum Nord-West—St. Marien-Hospital,

Friesoythe

7 www.

adipositaszentrum-

nord- west. de

Adi Posi Fit Sana Adiposity Centre NRW—Remscheid

7 www. sana-

adipositas- nrw. de

DOC WEIGHT

Federal Association of German Nutritional Physicians

7 www. bdem. de

M.O.B.I.L.I.S. M.O.B.I.L.I.S.—Freiburg

7 www. mobilis-

programm. de

OPTIFAST

Nestlé HealthCare Nutrition GmbH—Frankfurt/Main

7 www. optifasthome. de

17.5 Self-Help Groups andInternet

Portals

Self-help groups (SHG) are an ideal bridge

between the patients and the specialist institu-

tions of an obesity centre. Here people with

the same problems can meet, exchange infor-

mation and help each other. For these rea-

sons, every obesity centre should endeavour to

promote the establishment and maintenance

of at least one obesity SHG in its catchment

area. However, in any support, care should be

taken to ensure that the SHG retains its inde-

pendence and autonomy toward the obesity

centre.

New participants can inform themselves

about treatment options and the effects of a

bariatric procedure. In this way, they learn

beyond the professional consultation what

they are getting involved in and what to

expect. Many SHGs support their members in

applying for reimbursement and certify their

participation in the monthly meetings.

The SHGs always provide the obesity cen-

tre with the opportunity to inform its patients

about innovations and changes. In addition,

joint events and lectures by the various dis-

ciplines of the obesity clinic strengthen the

bond and create trust.

In addition to the self-help groups, the

internet presence of the obesity centre is an

important source of information. Many

patients and relatives of affected persons

inform themselves about the disease and treat-

ment options of obesity with the help of the

internet and often choose the clinic of their

choice based on the internet presence.

In addition, information brochures and

events can be published and, if necessary, posted

on social networks (Facebook, Twitter, etc.).

General practitioners are also increasingly

obtaining information through these media.

R . Weise

183

17.6 Patient Presentations

andInformation Material

The level of information of patients with obe-

sity is often insufcient at the time of rst pre-

sentation. Since the treatment of obesity and

its accompanying diseases can be very com-

plex on the one hand and on the other hand

due to the extreme changes in behaviour and

nutrition, detailed information and counsel-

ling measures are necessary.

Appropriate brochures can help to convey

basic knowledge and clear up misunderstand-

ings. In addition, lectures can interactively

impart the essential treatment topics and offer

the opportunity to answer and discuss ques-

tions. These measures should contain the fol-

lowing information:

5 Basic knowledge about the disease obesity

and its accompanying diseases,

5 Information on operational procedures,

including their risks, realistic prognosis

and long-term effects,

5 Alternative concepts of treatment,

5 Behavioural and nutritional concepts after

surgical interventions,

5 Education about lifelong aftercare, includ-

ing the need for lifelong substitution of

food supplements.

The “b.m.i.-circle” was developed for this pur-

pose under the auspices of the Bundesverband

Deutscher Ernährungsmediziner e. V. (Federal

Association of German Nutritionists). This

bariatric multimodal information program

(b.m.i.) consists of 7 modules that cover all

important topics concerning bariatric surgery

and its long-term effects.

Modules of the “b.m.i.-Circle”

1. Behaviour: Test of courage—self-care

2. Surgery: Under the knife

3. Nutrition: From liquid to solid

4. Nutritional medicine: Where is the

journey heading

5. Nutrition/behaviour: Training Camp

Eating Behaviour

6. Behaviour/SHG: We are not alone

7. Nutrition: Enjoy for life

The "b.m.i.-circle" provides for a training

course prior to the performance of a bariatric

intervention, in which the modules are taken

at intervals of 1–2 weeks (i.e. a total of 6–12

weeks preparation time before the operation).

The program, including the training material,

can be viewed and obtained on the internet

portal of the German Nutritional Medical

Association (7 www. bdem. de).

In addition to the regular lectures men-

tioned above, larger annual information events

have proven to be a good idea. These "open

house days" serve to exchange information

and are generally very well received. Patients,

relatives, family doctors and specialists can

get to know the entire obesity team of a cen-

tre. Additional topics can be offered by other

disciplines through lectures, presentations and

information desks, for example from

5 Plastic surgery,

5 Physical therapy,

5 Obesity SHGs,

5 Companies with auxiliary products,

5 Pharmacies.

17.7 Treatment andPatient

Pathways

Taking into account quality requirements,

necessary process optimizations and required

transparency, it is possible to map all treat-

ment steps from the initial presentation to

follow-up care in treatment paths. The cre-

ation of these pathways, in which employ-

ees from all responsible departments should

be involved, requires considerable time and

effort. However, the very creation of these

pathways usually leads to process optimiza-

tion. Checklists, which are placed at suitable

process intersections, can ll the treatment

pathways with life.

A treatment pathway (patient pathway)

should also be created specically for individ-

ual patients, informing them about the timing

of their treatment (timeline).

Obesity Centre

184

18.1 Gastric Plication

The good results after sleeve resection led

to the development of another surgical pro-

cedure that uses the principle of restriction

without resecting a large part of the stomach.

This so-called gastric plication is performed

laparoscopically, like all bariatric operations.

The stomach is rst dissected at the large

curvature as in sleeve resection and all vessels up

to the left diaphragm are cut through. In con-

trast to the sleeve, a reverse suture is then applied

(. Fig.18.1). Several rows of sutures are neces-

sary to achieve sufcient restriction. As in sleeve

gastrectomy, a gastric tube is required to calibrate

the lumen. Despite the lack of standardization

in the choice of suture material, most authors

recommend non- resorbable suture materials of

the thickness 2.0–3.0. Both single-button as well

as continuous sutures are described.

The main mechanism of action of gastric

plication is the achieved restriction. In contrast

to sleeve gastrectomy, ghrelin-producing cells

are not removed, so ghrelin production is not

affected. Furthermore, vagal nerve bres, which

are partially dissected in sleeve gastrectomy or

gastric bypass, remain unaffected. Neurohumoral

effects as a result of this partial dissection are

therefore not achieved by gastric plication.

Various authors describe this operation as

being easily performed and, with a low com-

plication rate, as safe and effective. Possible

complications are gastric perforations and

bleeding. Furthermore, insufcient weight

loss has been described.

The indication for surgery corresponds to

that of established surgical procedures. Some

authors recommend this method on the one

hand especially for patients with low morbid

obesity, but on the other hand also for patients

with very severe obesity. Prospective random-

ized studies on the long-term effectiveness of

gastric plication are still pending. The short-

term results published so far show an overall

. Fig. 18.1 Technique

of gastric replication by

surgery

C. A. Jacobi

187

signicantly lower proportion of patients who

achieve an overweight loss comparable to the

established procedures. As a possible advan-

tage for the performance of gastric surgery,

some authors mention the lower operation

costs, since no stapler devices are required.

However, the presumed higher rate of revi-

sion surgery in cases of insufcient weight loss

must be taken into account.

The possible combination with other

bariatric surgical procedures has also been

described for gastric plication. For example,

a gastric band can be implanted proximally

to the plication to prevent dilatation of the

stomach and to achieve greater effectiveness

in terms of weight loss over the long term.

A nal assessment of the value of the gas-

tric ligature can therefore not yet be made.

18.2 POSE Procedure

The POSE procedure is a complete endolumi-

nal procedure. The stomach is endoscopically

gathered intra-luminally, thus creating a restric-

tion comparable to the gastric plication. For

this demanding procedure a specially developed

equipment is required. So far, only preliminary

clinical results are available for this method. It

should be noted that a standardized calibration

by means of a gastric tube is not possible.

Possible advantages of the method are the

outpatient feasibility of the procedure, the

avoidance of skin incisions and the absence

of the need for general anaesthesia with

intubation. The duration of this procedure

in analgo-sedation is comparable to that of

established laparoscopic surgical procedures.

However, the fact that endoscopic procedures

in the stomach and the esophagus have not

been established in the therapy of reux dis-

eases and the results described in the literature

are not satisfactory remains to be criticized.

The procedure is strongly advertised by the

manufacturers of the necessary accessories,

but it remains unclear whether the method will

establish itself and for which patient groups it

will be used. In addition, the costs for the user

and the reimbursement by the health insur-

ances have not yet been claried.

18.3 Endobarrier®

The endoscopic application of the Endobar-

rier™ uses the principle of eliminating food

intake in the duodenum and the rst part of

the jejunum resulting in missing hormonal

changes. The chyme passes an endolumi-

nally placed tube system with its xation in

the area of the pylorus (. Fig.18.2), so that

the intestinal mucosa of the duodenum and

a b

. Fig. 18.2 a, b Endoscopic gastric bypass (Endobar-

rier™ with inlay). A plastic tube (inlay, b) is anchored

postpylorically and thus a functional elimination of the

duodenum is achieved. The results obtained so far are

promising, the signicance in the overall concept is still

unclear. (From Wirth and Hauner 2013)

Alternative Techniques andMethods inObesity Therapy

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