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MEDICINE

CLINICAL PRACTICE GUIDELINE

Bariatric Surgery
by Norbert Runkel, Mario Colombo-Benkmann, Thomas P. Hüttl, Harald Tigges, Oliver Mann, and Stephan Sauerland

SUMMARY
Background: Bariatric surgery has increased in numbers, but the treatment of morbid obesity in Germany still needs improvement. The new interdisciplinary S3-guideline provides information on the appropriateindications, procedures, techniques, and follow-up care. Methods: Systematic review of the literature, classification of the evidence, graded recommendations, and interdisciplinary consensus-building. Results: Bariatric surgery is a component of the multimodal treatment of obesity, which consists of multidisciplinary evaluation and diagnosis, conservative and surgical treatments, and lifelong follow-upcare. The current guideline extends the BMI-based spectrum of indications that was previously proposed (BMI greater than 40 kg/m2, or greater than 35 kg/m2 with secondary diseases) by eliminating age limits, as well as most of the contraindications. A prerequisite for surgery is that a structured, conservative weight-loss program has failed or is considered to be futile. Type 2 diabetes is nowconsidered an independent indication under clinical study conditions for patients whose BMI is less than 35 kg/m2 (metabolic surgery). The standard laparoscopic techniques are gastric banding, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion. The choice of procedure is based on knowledge of the results, long-term effects, complications, and individual circumstances. Structured lifelongfollow-up should be provided and should, in particular, prevent metabolic deficiencies. Conclusion: The guideline contains recommendations based on the scientific evidence and on a consensus of experts from multiple disciplines about the indications for bariatric surgery, the choice of procedure, techniques, and follow-up care. It should be broadly implemented to improve patient care in thisfield. ►Cite this as: Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Sauerland S: Clinical practice guideline: Bariatric surgery. Dtsch Arztebl Int 2011; 108(20): 341–6. DOI: 10.3238/arztebl.2011.0341

besity is a growing medical and socioeconomic problem (e1, e2). Every second adult in Germany is overweight (Body Mass Index [BMI] ≥ 25 kg/m²), and every fifth one is obese (BMI ≥ 30 kg/m²)(e3–e5). Obesity is associated with many different illnesses, chief among them type 2 diabetes mellitus, high blood pressure (metabolic syndrome), gallstones, certain types of cancer, gastroesophageal reflux disease (GERD), fatty liver, degenerative joint diseaeses, obstructive sleep apnea syndrome, and psychiatric diseases. It lowers life expectancy by 5 to 20 years (e6). The efficacy of surgeryfor obesity (bariatric surgery) has been demonstrated by extensive meta-analyses, with evidence level (EL) 1a (1–3). Surgery is markedly superior to conservative treatment with respect to weight reduction and alleviation of illnesses caused by obesity (EL 2b) (4, 5). It can lower the long-term lethality of obesity by as much as 40% (EL 2b) (5, 6). In a prospective, controlled study from Sweden,the absolute risk reduction (ARR) was found to be 1.3%; in an American retrospectve cohort study, in which patients were observed for seven years, the ARR was 1.4%. These two figures correspond to an NNT (number needed to treat) of 76.5 and 73, respectively (EL 2b) (5, 6). Surgery for obesity is not yet available everywhere in Germany. This interdisciplinary S3 guideline is intended to providepractical aid in decision-making for the purpose of quality assurance.

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Methods
The methods used here were in accordance with the recommendations of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlich-medizinischen Fachgesellschaften, AWMF). This guideline was developed on the basis of the existing evidence-based guideline of the European...