The State of Obesity and Bariatric Surgery in Germany
Obesity and Bariatric Surgery Trends Around the World
The state of obesity and bariatric surgery varies from country to country. In this series, authors from around the world discuss obesity and bariatrics in their country, answering questions on the most recent trends, most frequently performed procedures, access to care, health coverage, requirements, accreditation, and cultural considerations. This series is dedicated to providing updates on the global state of obesity.
This month:
An Interview with Dr. Rudolf Weiner, Head of Department of Surgery, Frankfurt Sachsenhausen Hospital, Frankfurt, Germany; President elect of the International Federation for Surgery of Obesity and Metabolic Disorders (IFSO)
FUNDING: No funding was provided.
DISCLOSURES: The author reports no relevant conflicts of interest.
Bariatric Times. 2014;11(9):10–11.
How did you become a bariatric surgeon? How many bariatric surgeons are there in Germany today?
Dr. Weiner: Between 1977 and 1980 I began an investigation into intestinal absorption with a mathematic calculation model in bariatric patients. This model was a part of my diploma and, later on, my scientific work to became a doctor of medicine at the Charité in Berlin, Germany. During the investigation, I learned the process of intestinal abdaption and also became aware of the heavy side effects of these types of surgery. I concluded that I would never do such procedures in the future. In 1992, the first laparoscopic gastric band procedure was performed by G.B. Cadiere in Brussels, Belgium, and later on in 1993 by Mitiku Belachew in Huy, Belgium. In 1944, the gastroenterologist in my hospital Krankenhaus Nordwest, Wolfgang Rösch called and asked if I could perform a laparoscopic adjustable gastric band procedure. I was a fan of the laparoscopic approach for all procedures, like Dr. Raul Rosenthal, who moved from my hospital to Los Angeles, California. Finally, I went to visit Dr. Belachew and observed his technique. After my return, I invited Peter Forsell and Dag Arvidson from Sweden to my hospital in Germany and we performed the first laparoscopic adjustable band procedure in Germany. The number of patients was increasing each month. From that time up until 2000, I placed about 980 gastric bands. In 2000, I became a professor at the University of Frankfurt. In 2001, I became Head of the Department of the Hospital Sachsenhausen in Frankfurt am Main. Since 2001, the Hospital Sachsenhausen in Frankfurt am Main has been the leading center for bariatric surgery in Germany. In the first year, more than 50 percent of all procedures in Germany were done in this department. In 2013, the hospital performed only 10 percent of all surgeries because the number of centers rapidly increased. In 2013, there were more than 130 surgeons performing bariatric procedures in Germany.
Do you need a special certification to conduct bariatric procedures in Germany?
Dr. Weiner: At the moment there is only one certification offered to bariatric surgeons in Germany. Bariatric surgeons are required to be at least a level 2 certified visceral surgeon. The Center of Excellence requires at least 3 certificated visceral surgeons. The program of certification will start in early 2015.
Are centers that perform bariatric surgery accredited by any society in Germany?
Dr. Weiner: Yes, the Society of General and Visceral Surgery gives a certification in three different stages. There is also a European certification.
What is the obesity rate in Germany? Is it increasing or decreasing? How about in children?
Dr. Weiner: Germany was one of leading nations in prevalence of overweight and obesity, but has improved. There is still an increase, but it is slower than in years past. The incidence of obesity in children is stable.
Is there anything unique about the country culture/lifestyle that may contribute to the obesity rate (e.g., extreme cold or heat, dominant occupations, access to food and drink)?
Dr. Weiner: There is no relationship to the type of food. Some might assume that the Bavarian population will be more at risk for obesity because they are consuming “Haxe” (ham hocks) and drinking a lot of beer. This is not correct. We have a strong correlation between the prevalence of obesity and unemployment, social status, and annual income per person. The leanest population we can observe in Germany is Hamburg. This area also has a lower unenployment rate and higher income and social status in contrast to the country Mecklenburg-Vorpommern. The people in both of these areas have diets that largely include fish, but their social statuses are different.
What percentage of the obese population actually undergo bariatric surgery? Are those numbers increasing or decreasing?
Dr. Weiner: Germany has a potential patient population of 82.6 million. Per year, we perform 8,000 procedures (Figure 1). This makes our surgery rate one of the lowest rates in the world. There are approximately 720,000 patients with body mass indices (BMIs) above 40kg/m2. In Germany, there are approximately 50,000 obesity-related deaths per year. France has a potential patient population of 54 million. They perform close to 40,000 procedures per year. The number of procedures in Germany is continuously increasing, but we are still treating less than one percent of the eligible population (BMI>40kg/m2).
What are the current trends in bariatric surgery in your country?
Dr. Weiner: The number of adjustable gastric band procedures is dramatically down (Figure 3). Gastric bypass is still increasing, but the increase of sleeve gastrectomy is far ahead. The sleeve gastrectomy has been the leading procedure in Germany since 2013 (Figure 4). Malabsorptive procedures make up less than two percent of all surgeries.
What procedures do you perform at your center—order from most frequent to least frequent with statistics, if available.
Dr. Weiner: In 2013, our procedure breakdown was as follows (Figure 5):
• 353 sleeve gastrectomies
• 322 Roux-en-Y gastric bypass
• 24 Omega-loop bypass
• 6 biliopancreatic diversion with duodenal switch (BPD-DS)
• 3 BPD
• 254 revisional surgeries (e.g., sleeve to Roux-en-Y for reflux, sleeve into omega or single anastomosis duodeno-ileal bypass [SADI] for failed weight loss).
What is the healthcare/ insurance system like in your country? How do patients pay for weight loss surgeries?
Dr. Weiner: The private insurances cover the cost of surgery about 95 percent of the time as long as the patients meets the guidelines. About 8 to 10 percent of Germans have private insurance. More than 90 percent of the population have a standard insurance (more than 50 insurances are available). These patients must undergo a medical control system, which was installed to lower the costs for the insurances. At the end of the process between 15 and 20 percent of patients will get an authorization. The percentage of self-paying patients is around five percent.
What is your prediction for the future of bariatric surgery in your country?
Dr. Weiner: My prediction is that there will be a four-fold increase in the number of procedures without marginal increase of number of centers. In high-volume centers we can observe the best results. The main concern in Germany is that the follow up of the patients after surgery is still not reimbursed.
If you would have to choose a bariatric procedure for yourself or a relative of yours, which one would you choose?
Dr. Weiner: I would choose sleeve gastrectomy only. There is one contraindication: Barrett-esophagus, which I do not have.
FUNDING: No funding was provided.
DISCLOSURES: The author reports no relevant conflicts of interest.
Author affiliation: Dr. Weiner is Head of Department of Surgery, Frankfurt Sachsenhausen Hospital, Frankfurt, Germany. He is also President elect of the International Federation for Surgery of Obesity and Metabolic Disorders (IFSO).
Category: International Perspective, Past Articles
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