Guidelines for the surgical treatment of obesity

Obesity is a multifactorial, chronic disease. Genetic, epigenetic, and acquired factors determine the phenotype of obesity in question, which can often vary wildly. The overwhelmingly polygenetic dispositions that have arisen over decades ensure the survival and reproduction of humanity, which is shaped by deficiencies. In the last decades of the late 2nd millennium, epigenetic, external, and acquired factors have changed fundamentally and, what’s more, globally. Obesity thus developed into a disease of pandemic proportions.

Disproportional proliferation of adipose tissue is the ultimate hallmark of obesity. Distribution patterns and metabolic influences of adipose tissue, as well as the timing and severity of sometimes fatal sequelae, are controlled by genetics and epigenetics. Obesity is not a globally uniform disease but an ethnically shaped phenotype of many primary genetic forms. The more volatile exogenous obesity factors (including reduced movement and excess food supply) and the epigenetically active exogenous factors are globally more uniform.

As a chronic disease with a genetic background, obesity is not curable, according to current knowledge, but treatable. The efforts of state and private health organizations aim at the early prevention of excess weight and obesity.

We focus on several levels of society and prevention endeavors to modify exogenous factors with a tremendous economic outlay. Our efforts to treat those already affected by obesity do not contradict or replace prevention.

The burden of the underlying disease and its sequelae (Tab. 1) restricts the body, mind, and soul to a large extent so long as no treatment is provided. The form and expense of obesity treatment are subject to a variety of ethical questions for society, for those affected, for the solidarity of those not affected, and for all actors in the environment of this disease.

Most non-surgical treatment programs can neither sufficiently nor sustainably reduce fat mass. Often, discontinuation of therapy is followed by excessive adipose tissue accumulation (rebound) and can impair later efforts at fat reduction (metabolic scar).

Surgical alteration of the gastrointestinal anatomy and function for obesity treatment began in the mid-20th century. However, the size and metabolic consequences of the extensive soft tissue trauma to the open abdomen were fraught with high morbidity and mortality. It was not until the less traumatizing laparoscopic surgery at the start of the last decade of the 20th century that bariatric surgery became the most effective, practical, and economical form of treatment for obesity itself, as well as two of its most essential sequelae: type II diabetes mellitus and dyslipidemia. Bariatric metabolic surgery is currently the most sustainable form of treatment in bariatrics.

Complete, integral bariatric treatment includes not only abdominal and endocrine surgical procedures but also reconstructive surgical interventions as time progresses.

However, optimal success and the long-term maintenance of results in total health are only possible through nutrition- and exercise-based, psychotherapeutic, and socio-therapeutic treatment within long-term, lifelong care.

The complete guidelines are available here as a PDF to download in German, Italian and French: