MEDICINE

Clinical Practice Guideline

Obesity Surgery and the Treatment of

Metabolic Diseases
Arne Dietrich, Jens Aberle, Alfred Wirth, Beat Müller-Stich, Tatjana Schütz, and Harald Tigges
for the S3 Guideline Group on the Surgical Treatment of Obesity and Metabolic Diseases*

T
he increased prevalence of obesity in Germany, par-
Summary ticularly among young adults, presents a challenge
to the healthcare system with major socioeconomic
Background: 3.9% of men and 5.2% of women in Germany suffer from second-
effects both now and in the future. According to the
degree obesity (body mass index [BMI] ≥ 35 to <40 kg/m2), and 6.5 million persons
DEGS1 study (2013), 5.2% of women and 3.9% of men
suffer from diabetes. Obesity surgery has become established as a further treat-
ment option alongside lifestyle changes and pharmacotherapy. in Germany suffer from second-degree obesity (body
mass index [BMI] ≥ 35 to < 40 kg/m2); 2.8% of women
Methods: The guideline was created by a multidisciplinary panel of experts on the and 1.2% of men suffer from third-degree obesity (BMI
basis of publications retrieved by a systematic literature search. It was subjected to ≥ 40 kg/m²) (1). It is stated in the German Health Report
a formal consensus process and tested in public consultation. on Diabetes for the year 2017 that 6.5 million persons in
the country now suffer from diabetes, 95% of whom have
Results: The therapeutic aims of surgery for obesity and/or metabolic disease are to
type 2 diabetes (2).
improve the quality of life and to prolong life by countering the life-shortening effect
Surgery for obesity and metabolic disease is less
of obesity and its comorbidities. These interventions are superior to conservative
treatments and are indicated when optimal non-surgical multimodal treatment has common in Germany than in the neighboring Western
been tried without benefit, in patients with BMI ≥ 40 kg/m², or else in patients with European countries (Germany, 10.5 procedures per
BMI ≥ 35 kg/m² who also have one or more of the accompanying illnesses that are 100 000 persons per year; Benelux countries, 99.3
associated with obesity. A primary indication without any prior trial of conservative procedures per 100 000 per year), and there are also
treatment exists if the patient has a BMI ≥ 50 kg/m², if conservative treatment is differences across the individual German federal
considered unlikely to help, or if especially severe comorbidities and sequelae of states (Länder) (3).
obesity are present that make any delay of surgical treatment inadvisable. Metabolic The currently available nonsurgical treatments for
surgery for type 2 diabetes is indicated (with varying recommendation grades) for weight reduction bring about sustained weight loss in
patients with BMI ≥ 30 kg/m², and as a primary indication for patients with BMI ≥ 40 only a small fraction of the persons treated and do not
kg/m². The currently established standard operations are gastric banding, sleeve lower mortality (4). The controversial designation of
gastrectomy, proximal Roux-en-Y gastric bypass, omega-loop gastric bypass, and surgical procedures as a “last resort” no longer ap-
biliopancreatic diversion. pears in the new guideline. Moreover, the expression
“bariatric surgery” has been replaced by “obesity sur-
Conclusion: No single standard technique can be recommended in all cases. In the
gery” in order to make it clear that such procedures
presence of an appropriate indication, the various surgical treatment options for
are a treatment for the disease called “obesity.”
obesity and/or metabolic disease should be discussed with the patient.
Readers are referred to the full guideline text for a
Cite this as: discussion of special aspects such as surgery in ado-
Dietrich A, Aberle J, Wirth A, Müller-Stich B, Schütz T, Tigges H: lescence or old age, pregnancy, perioperative man-
Clinical practice guideline: Obesity surgery and the treatment of metabolic diseases. agement, and details of the surgical techniques, and to
Dtsch Arztebl Int 2018; 115: 705–11. DOI: 10.3238/arztebl.2018.0705 the guideline report for methodological aspects (5).

Methods
The guideline was created in accordance with the S3
Integrated Research and Treatment Center (IFB) AdiposityDiseases, University Hospital Leipzig:
Prof. Dr. med. Arne Dietrich, Dr. rer. nat. Tatjana Schütz guideline specifications of the Association of Scien-
Department of Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital Leipzig: tific Medical Societies in Germany (Arbeitsgemein-
Prof. Dr. med. Arne Dietrich schaft der Wissenschaftlichen Medizinischen Fach-
III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg: PD Dr. med. gesellschaften e. V., AWMF) under the aegis of the
Jens Aberle Surgical Working Group for the Treatment of Obe-
Bad Rothenfelde: Prof. Dr. med. Alfred Wirth sity (Chirurgische Arbeitsgemeinschaft für Adipo-
Department of General, Visceral and Transplantation Surgery, University of Heidelberg: sitastherapie, CAADIP) of the German Society of
Prof. Dr. med. Beat Müller-Stich
General and Visceral Surgery (Deutsche Gesellschaft
Department of General, Visceral and Vascular Surgery, Klinikum Landsberg am Lech:
Dr. med. Harald Tigges für Allgemein und Viszeralchirurgie, DGAV). The
* See eTable 1 for a comprehensive list of societies, associations, authors and collaborators involved guideline was issued by the CAADIP. The German
in the development of the S3 guideline Obesity Society (Deutsche Adipositas-Gesellschaft),

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the German Diabetes Society (Deutsche Diabetes
Gesellschaft), and seven other medical specialty so-
cieties and associations were represented on the
guideline commission, which also included a patient
representative (for a list of delegates, see eTable 1).
A search for relevant publications (April 2009 to
March 2016) was conducted in the Medline, Coch-
rane Library, and Scopus databases. Systematic re-
views, meta-analyses, and randomized controlled
trials (RCTs) were sought.
The literature search yielded 9099 hits (after the
elimination of duplicates); after multilevel screening,
261 were chosen for further evaluation. Priority was
given to systematic reviews and meta-analyses. Evi-
dence tables to be used as a foundation for the cre-
ation of the guideline were prepared for 56 systematic
reviews and meta-analyses, one RCT, and five cohort
studies; these tables were then evaluated by the SIGN
procedure (6). Details are given in the guideline re-
port (5) and in the eMethods.
Major elements of the guideline and changes
since the preceding version
Treatment objectives
In older guidelines, weight loss was often said to be the
therapeutic objective of obesity surgery. Nonetheless,
empirical data on weight loss in kilograms, BMI points,
or percentage excess weight loss (%EWL) do not ad-
equately reflect whether the treatment has really
achieved its objective.
The newly formulated objective of obesity surgery
and metabolic procedures is to bring about a sustained
loss of weight and, through the beneficial effects of
weight loss, to achieve the following:
● Better quality of life
● Remission, improvement, and/or prevention of the
comorbidities and sequelae of obesity
● Longer survival
● Continued participation in work and in social and
cultural activities.
The goals of treatment should always be individ-
ually defined and adapted to any changes that take
place. This formulation met with a strong consensus
among the experts.
Definition of centers
Centers were defined in accordance with the certifi-
cation rules of the DGAV (7) and the Swiss guideline
on the surgical treatment of obesity (8).
The Barmer Health Report (9) and current German
registry data (10) reveal that perioperative morbidity
and mortality are lower in certified centers (e.g.,
30-day mortality after Roux-en-Y gastric bypass:
0.2% in certified centers, 0.5% in uncertified centers,
p = 0.002). There are also differences between the
various types of certified center. For example, mor-
bidity was lower in reference and excellence centers
than in competence centers (10). To take due account
of these data (even though their evidential quality is
not high), the guideline commission decided to intro-
706
duce the new category of “centers with special exper-
tise.” Such centers are supposed to be certified by a
specialty society, and the experience of the respon-
sible surgeon should comprise at least 300 obesity
operations.
There was a strong consensus among the experts
that the following types of patients should undergo
surgery only in a center with special expertise, and
that the specified techniques should only be per-
formed in such centers (however, this is not evidence
based):
● Patients under age 18, or aged 65 and above
● Patients at elevated risk with severe comorbidities
(American Society of Anesthesiologists [ASA]
score >3)
● Patients with BMI ≥ 60 kg/m²
● Distal bypass operations, conversion operations,
and redo operations
● Procedures that are primarily for the treatment of
metabolic disease (in patients with BMI <40 kg/m²,
in collaboration with a physician who is an expert in
the treatment of diabetes/a diabetologist).
Surgical indications
The treating team that establishes the indication for sur-
gery should consist of the following members:
● A surgeon with competence in the surgical treat-
ment of obesity and metabolic disorders
● An internist/general practitioner/physician with
special expertise in nutrition who has competence
in the surgical treatment of obesity and metabolic
disorders
● A mental health professional with experience in
obesity surgery
● A nutritionist or physician with special expertise in
nutrition who has experience in obesity surgery
● A physician who is an expert in the treatment of
diabetes/a diabetologist, if surgery for metabolic
indications (type 2 diabetes) is to be performed.
The term “obesity surgery” refers to any operation
(e.g., sleeve gastrectomy) that is intended to bring
about sustained weight loss and thereby prevent or
improve obesity-associated comorbidities and im-
prove the patient’s quality of life. The recommen-
dations of the current guideline of the German Obe-
sity Society (Deutsche Adipositas-Gesellschaft) (11)
and of the American guideline (12) have been
adopted.
Obesity surgery is indicated in the following situ-
ations:
● In patients with BMI ≥ 40 kg/m2 without any co-
morbidities or contraindications, when conser-
vative treatment options have been exhausted and
after the patient has been thoroughly informed.
● In patients with BMI ≥ 35 kg/m2, after the exhaus-
tion of conservative treatment options, in the pres-
ence of one or more obesity-associated comorbid-
ities, such as: type 2 diabetes, coronary heart
disease, congestive heart failure, hyperlipidemia,
arterial hypertension, nephropathy, obstructive
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sleep apnea syndrome (OSAS), obesity-hypo- TABLE 1

ventilation syndrome, Pickwick syndrome, non-
alcoholic fatty liver disease (NAFLD) or non- Advantages and disadvantages of various types of primary obesity surgery
and of primary surgery for metabolic indications
alcoholic steatohepatitis (NASH), pseudotumor
cerebri, gastro-esophageal reflux disease (GERD), Technique Advantages Disadvantages
asthma, chronic venous insufficiency, urinary in- Sleeve gastrectomy Good risk–benefit profile, can Inferior to RYGB with respect
continence, immobilizing joint disease, impaired (SG) be performed even in patients to long-term weight control,
fertility, or polycystic ovarian syndrome. with very high BMI (two-step reflux control, and diabetes
approach) remission
● A primary indication for obesity surgery (i.e.,
without any requirement for prior exhaustion of Proximal Roux-en-Y Good control of reflux dis- Same mortality as SG with
conservative treatment modalities) exists if one of gastric bypass (RYGB) ease, superior to SG in its higher morbidity
metabolic effect Risk of dumping syndrome,
the following conditions is present:
ulcers, and internal hernias
– BMI ≥ 50 kg/m2,
Risk of malabsorption
– Whenever, in a specific case, the multidisciplin-
ary team considers a trial of conservative treat- Omega-loop gastric Lower perioperative Elevated risk of malabsorp-
bypass (MGB) morbidity than RYGB, tion with long biliopancreatic
ment to have little or no chance of success, and because there is only a loop
– Whenever especially severe comorbidities and single anastomosis Risk of dumping syndrome
sequelae of obesity are present that make any and internal hernias
further delay before surgery inadvisable. Unclear effects of potential
Points 1 and (in part) 2 in the above list of obesity reflux of bile into the gastric
surgery indications are supported by evidence of the pouch
highest level (point 2 with respect to the therapeutic
objective of weight control and improvement in bio-
chemical markers of cardiovascular risk) and corre-
spondingly, recommendations of the highest grade are
given. A strong consensus supported all of the other Diabetes Association’s Standards of Medical Care in
points. Diabetes—2017 (13) and of the “Joint Statement by
The exhaustion of conservative treatment is de- International Diabetes Organizations” (14).
fined as follows, for the purpose of determining the The existing evidence is inadequate to support an
indication for obesity surgery: if the patient has been indication for the surgical treatment of other “meta-
unable to achieve a loss of >15% of the initial weight bolic” disturbances associated with obesity (e.g., dys-
(BMI 35.0–39.9 kg/m²), or >20% of the initial weight lipidemias, hypertension).
(BMI ≥ 40 kg/m²), despite having undergone a com- Surgery is indicated to treat a metabolic distur-
prehensive lifestyle intervention for at least 6 months bance in the following situations:
within the past two years, then conservative treatment ● Metabolic surgery should be recommended as a
is considered to have been exhausted. primarily indicated treatment option, as defined
An indication is also present if this degree of above, to patients with type 2 diabetes who also
weight loss has indeed been reached, but obesity- have a BMI ≥ 40 kg/m², as such patients stand to
associated illnesses persist that could be improved by benefit both from the antidiabetic effect and from
obesity surgery, or by surgery for a metabolic indi- the weight-reducing effect of the intervention.
cation (i.e., type 2 diabetes). Likewise, if initially suc- ● Metabolic surgery should be recommended as a
cessful weight reduction has been followed by weight potential treatment option to patients with type 2
gain of more than 10%, then conservative treatment is diabetes whose BMI lies in the range of
considered to have been exhausted. ≥ 35 kg/m² to <40 kg/m² if their individual target
If a primary indication is present, then the patient’s values, as determined from the National Disease
adherence to treatment regimens should be consid- Management Guideline on the Treatment of Type 2
ered before any procedure is carried out. The patient Diabetes, have not been achieved.
should change his/her nutrition and eating habits in a ● Metabolic surgery can be considered for patients
manner appropriate to the coming operation for the with type 2 diabetes whose BMI lies in the range
treatment of obesity. of ≥ 30 kg/m² to <35 kg/m² if their individual
The expression “surgery for a metabolic indi- target values, as determined from the National Dis-
cation” or “metabolic surgery” refers to the same ease Management Guideline on the Treatment of
surgical procedures that are performed to treat obesity Type 2 Diabetes, have not been achieved.
when they are performed primarily in order to The first two points above are supported by
improve glycemic metabolism in patients with pre- evidence of the highest level, and there was a strong
existing type 2 diabetes. consensus for all recommendations.
In its recommendations on the indications for the The background for these recommendations is
surgical treatment of type 2 diabetes mellitus the fact that patients with type 2 diabetes stand to
(“metabolic surgery”), the guideline commission benefit doubly from the intervention, i.e., both by
adopted the recommendations of the American losing weight and by experiencing an improvement

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TABLE 2

Evidence profile of surgical procedures (long-term results) (5)

Procedure Percentage loss of excess weight [95% CI]*1

≤ 2 years Reference >2 to <5 years Reference ≥ 5 years Reference
Gastric banding 28.7–48 (23) 43.5 [38.5; 48.5] (19) 34.7 [23.5; 49.9] (19)
52.3 [48.7; 55.9] (18) 49.0 [44.0; 54.0] (21) 57.2 [47.2; 67.2] (18)
43.9 [40.3; 47.5] (21)
Sleeve gastrectomy 49–81 (23) 36.3 [33.1; 39.5] (19) 49.5 [39.3; 59.7] (19)
46.7 [42.9; 50.6] (18)
Gastric bypass*2 62.1–94.4 (23) 49.4 [10.8; 88.0] (19) 61.3 [55.2; 67.4] (19)
80.1 [65.7; 94.4] (18) 63.3 [58.4; 68.1] (21) 64.9 [44.3; 85.6] (18)
58.0 [54.3; 61.8] (21)
Biliopancreatic diversion with duodenal switch 56.0 [47.9; 64.2] (21) 73.7 [69.0; 78.4] (21) 49.3 [38.7; 59.9] (19)
3
Procedure Diabetes remission rate* in % [95% CI]
≤ 2 years Reference >2 to <5 years Reference ≥ 5 years Reference
Gastric banding 62 [46; 79] (24) 62.5 [42.2; 79.2] (19) 24.8 [10.9; 47.2] (19)
68 [50; 83] (18) 78.7 [53.8; 100.0] (21)
82.3 [71.4; 93.1] (21)
Sleeve gastrectomy 53.3 (23) 64.7 [42.2; 82.1] (19) 58.2 [30.8; 81.3] (19)
60 [51; 70] (24)
86 [73; 94] (18)
Gastric bypass*2 83 (23) 71.6 [59.9; 81.0] (19) 75.0 [63.1; 84.0] (19)
77 [72; 82] (24) 85.3 [70.9; 99.7] (21)
93 [85; 97] (18)
84.0 [72.9; 95.0] (21)
Biliopancreatic diversion 89 [83; 94] (24) – –
Biliopancreatic diversion with duodenal switch 100.0 [93.2; 100.0] (21) 98.9 [96.6; 100.0] (21) 99.2 [97.0; 99.8] (19)

*1 No data are available for percentage loss of excess weight after biliopancreatic diversion.
*2 proximaler Roux-en-Y-gastric bypass (RYGB), mini-bypass, and bypass procedures that were not further specified.
*3 High heterogeneity in definitions of diabetes remission between primary studies and systematic reviews.
Fields are left empty if no high-quality evidence on the level of a systematic review or a meta-analysis is available.
All evidence summarized here is from systematic reviews and meta-analyses with SIGN evidence level 2+/++. The evidence tables corresponding to the systematic reviews and meta-analyses
cited here are presented in the guideline report. CI, confidence interval

or even a remission of their diabetes. Many studies
of high quality (RCTs and meta-analyses) have
shown the superiority of surgery over conservative
treatment in these situations, justifying the recom-
mendations above (15).
Zhang et al., in a meta-analysis of 21 studies,
found a significant advantage of Roux-en-Y gastric
bypass (RYGB) over sleeve gastrectomy (SG) with
respect to the rate of remission of type 2 diabetes
(odds ratio [OR] = 3.29, 95% confidence interval
[CI]: [1.98; 5.49], p <0.001) (16).
Schauer et al. performed a randomized controlled
trial comparing conservative treatment versus SG or
RYGB in patients with poorly controlled type 2 dia-
betes. Five years after treatment, 45% of patients in
the RYGB group were in complete remission (normal
HbA1c without antidiabetic medication); the figure in
the SG group was only 25% (p <0.05) (17).
● If the patient is in an unstable psychopathological
state, e.g., untreated bulimia nervosa or ongoing
substance dependence
● In the presence of underlying diseases associated
with a catabolic state, malignant neoplasms, un-
treated endocrine disturbances, or other chronic
diseases that could be made worse under the cata-
bolic conditions brought about by the operation
● If the patient is pregnant or intends to become
pregnant in the near future.
These contraindications are relative, except for
pregnancy, and they are not supported by evidence.
The decision should be made on the basis of an indi-
vidualized, interdisciplinary risk–benefit analysis.
Decisions against surgery should be re-evaluated if
the disease that was considered a contraindication has
been successfully treated, or if the contraindicating
psychopathological state has been stabilized.

Contraindications Surgical procedures and results

There was also a strong consensus among the experts No procedure can be recommended as a universal stan-
regarding contraindications. Obesity surgery and/or dard; the choice of treatment is an individual one,
surgery for metabolic indications should not be per- taking due consideration of the initial weight, accom-
formed in the following situations: panying diseases if any, the patient’s wishes, etc.

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Currently established standard techniques include gas- TABLE 3

tric banding (laparoscpic adjustable gastric banding,
LAGB), sleeve gastrectomy (SG), proximal Roux-en-Y Prophylactic supplementation after surgery for obesity
or surgery for metabolic indications (5)
gastric bypass (RYGB), omega-loop gastric bypass
(MGB), and biliopancreatic diversion with or without SG RYGB BPD-DS
duodenal switch (Table 1). The evidence profile of the Protein (total per day [d]) >60 g/d >60 g/d >90 g/d
various techniques is presented in Table 2.
Folic acid MVM preparation 600 μg/d
The findings of two high-quality meta-analyses bid
regarding the more common procedures are worth
Vitamin B1 MVM preparation bid, no dose recommendation
examining in detail. Chang et al. carried out a meta-
analysis (evidence level 2 ++) using data from 37 RCTs Vitamin B12 p.o.: 1000 μg/d
IM: 1000 – 3000 μg/d every 3 to 6 months
and 127 observational studies, which were derived from
a total of 161 756 patients (18). They studied the relative Vitamin A MVM preparation MVM preparation 1–2 × 25 000
bid bid IU/d
effects of various interventions on Δ BMI (RYGB as ref-
erence; 5 years of follow-up), as revealed by 17 RCTs, in Vitamin D At least 3000 IU/d, serum concentration >30 ng/mL
a mixed-treatment meta-analysis. Nonsurgical interven- Vitamins E, K MVM preparation bid, no dose recommendation
tions led to the smallest reduction of BMI; 14 (6–22) Calcium citrate 1200 – 1500 mg/d
additional BMI points of weight loss were achievable
Iron sulfate, fumarate, MVM preparation 50 mg/d 2 x 100 mg/d
with RYGB. SG led to similar results. In the RCTs, the gluconate bid
rate of remission of pre-existing type 2 diabetes 5 years
after surgery was 92% (95% CI: [85; 97]). Magnesium citrate 200 mg/d
Yu et al. (evidence level 2 ++, meta-analysis of Zinc gluconate, sulfate, MVM preparation MVM preparation 8–15 mg/d
2 RCTs and 24 cohort studies, 2.1–20 years of fol- acetate bid bid
low-up) studied the long-term effects of obesity sur- Copper gluconate, oxide, No recom- MVM preparation bid with
gery on type 2 diabetes (19). For all procedures sulfate mendation 2 mg/d of copper
Selenium as sodium
combined, the mean weight loss on last follow-up selenite
was 50.5% EWL (95% CI: [43.8; 57.2]). The mean
BMI reduction after various procedures was: BPD/ MVM preparation, multivitamin and mineral preparation. A preparation should be chosen that is rich in
DS (biliopancreatic diversion with duodenal switch), micronutrients, in amounts that are within 100% of the RDA (recommended daily allowance).

18.8 kg/m2 (95% CI: [18.9; 18.7]); RYGB,
12.6 kg/m2 (95% CI: [20,1; 5,1]); AGB (adjustable
gastric banding), 11.3 kg/m2 (95% CI: [13.4; 9.2]);
sleeve gastrectomy, 10.4 kg/m² (95% CI: [15.0; 5.7]).
The rate of complete remission of pre-existing type
2 diabetes for all procedures combined was 64.7%,
and the rate of improvement or remission was 89.2%.
The remission rate was highest after BPD/DS
(99.2%; 95% CI: [97.0; 99.8]), followed by RYGB
(74.4%; 95% CI: [66.9; 80.6]), SG (61.3%; 95% CI:
[45.9; 74.8]), and AGB (33.0%; 95% CI: [16.1;
55.8]). Subgroup analyses revealed no statistically
significant differences across procedures with re-
spect to either weight loss or diabetes remission.
Long-term data are available, for example, from
the SOS study (a prospective interventional study)
(20). The mean weight loss among patients who
underwent surgery was 18% at 20 years after the pro-
cedure. These patients, in comparison to the conser-
vatively managed control group, had lower overall
mortality (adjusted hazard ratio [HR] 0.71, 95% CI:
[0.54; 0.92]; p = 0.01) and lower rates of myocardial
infarction and stroke (adjusted HR 0.71, p = 0.02, and
0.66, p = 0.008, respectively).
All of the standard procedures of obesity surgery
were rated as positive over the long term in a
risk–benefit analysis (18, 20, 21).
The perioperative morbidity and mortality of obe-
sity surgery are relatively low. In the large-scale
meta-analysis of Chang et al. (18), the 30-day mortal-
ity of surgery in the RCTs was 0.08 % (95% CI:
SG, sleeve gastrectomy; RYGB, proximal Roux-en-Y gastric bypass; BPD-DS, biliopancreatic diversion with
duodenal switch.
These recommendations are for the prevention of deficiency states; dose adaptation is necessary for
patients with documented deficiency or corresponding symptoms. Regardless of the procedure performed,
adequate amounts of MVM cannot be given immediately postoperatively because of the temporary restric-
tion of food intake. Patients who have undergone surgery with techniques that cause more pronounced
malabsorption (all distal bypasses with a short common channel or long alimentary and/or biliopancreatic
loops) should receive the same type of supplementation as patients who have had a BPD-DS procedure.
There are no data or recommendations on the appropriate duration of prophylactic supplementation after
LAGB (laparoscopic adjustable gastric banding) or SG. Patients who have undergone any type of bypass
should receive supplementation for life. Depending on the type of surgical procedure and the patient’s
nutritional state, adequate intake of macro- and micronutrients may be at least partly achievable.
After LAGB, an MVM preparation qd + 1200–1500 mg calcium + 3000 IU vitamin D are recommended.
[0.01; 0.24]), which is lower than that of laparoscopic
cholecystectomy. The perioperative morbidity in the
RCTs was 17% (95% CI: [11; 23]), consisting mainly
of minor complications (18). The most common com-
plications of obesity surgery (all of them rare) were
staple-line fistula, anastomosis insufficiency, abscess,
and bleeding.
Postoperative care
Meticulous postoperative care is indispensable and is
supported by a strong expert consensus. The evidence
regarding the proper extent of postoperative care is not
of high quality, but the outcome is clearly better in
patients who receive intensive postoperative care and
participate in self-help groups (22). The key elements
of postoperative care are the following:
● Checking whether the goal of treatment has been
reached

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Key messages
● Various surgical methods can be used, depending on the specific indication and the
wishes of the patient: gastric banding, sleeve gastrectomy, proximal Roux-en-Y
gastric bypass, omega-loop gastric bypass, and biliopancreatic diversion.
● The most commonly performed procedures are sleeve gastrectomy and proximal
Roux-en-Y gastric bypass. These can be expected to lead to a loss of 50–65% of
excess weight over the intermediate term, and to the remission of pre-existing type
2 diabetes in 60–75% of the patients who have it.
● In a meta-analysis, the 30-day mortality of such procedures was 0.08%, and the
morbidity was 17%. The most common (but still rare) postoperative complications of
obesity surgery are staple-line fistula, anastomosis insufficiency, abscess, and
bleeding.
● Structured postoperative care with frequent appointments is indispensable.
● Depending on the type of procedure, the patient may need prophylactic supple-
mentation of protein, vitamins, and trace elements.
● Monitoring comorbidities and changing medi-
cations as indicated
● Encouraging the patient to exercise and follow a
proper diet
● Early recognition of complications, etc.
There was expert consensus concerning the timing
of follow-up examinations and laboratory checks:
after surgery for obesity and/or metabolic indications
(except gastric banding), follow-up examinations
should take place at 1, 3, 6, 12, 18, and 24 months,
and then annually. Laboratory values should be
checked at 6 and 12 months, and thereafter at inter-
vals depending on the particular surgical procedure
and on the patient’s comorbidities. At least the follow-
ing should be checked:
● Complete blood count, electrolytes, hepatic and
renal function tests, blood glucose and HbA
1c
(only in diabetics), vitamins B and B , albumin,
1 12
calcium, folic acid, ferritin
● After any type of bypass procedure: 25(OH)D3,
parathormone, vitamin A
● After distal bypasses: zinc, copper, selenium, mag-
nesium.
Patients with preoperatively recognized mental ill-
ness and/or self-injurious behavior should be actively
questioned postoperatively about the presence, recur-
rence, or worsening of their mental problems, and
about suicidality.
Successful weight loss may necessitate skin-
removal surgery, particularly from the abdomen and
the thighs, but sometimes even from the arms and
chest. Consultation with a plastic surgeon should be
made available to the patient.
Prophylactic dietary supplementation is indicated
after any type of surgery for obesity or a metabolic in-
dication. Dosage recommendations for the individual
micronutrients are given in Table 3.
710
Conflict of interest statement
Prof. Dietrich has served as a paid consultant for BOWA and has received
reimbursement of meeting participation fees and of travel and accom-
modation costs from Medtronic, Johnson & Johnson, Bowa, and Novo
Nordisc. He has received lecture honoraria from Bauerfeind, Johnson &
Johnson, and BOWA.
Dr. Schütz has received reimbursement of meeting participation fees and
of travel and accommodation costs from ETHICON and Johnson &
Johnson.
Dr. Aberle, Prof. Wirth, Prof. Müller-Stich, and Dr. Tigges state that they
have no conflict of interests.
Manuscript submitted on 12 July 2018, revised version accepted on
12 July 2018.
Translated from the original German by Ethan Taub, M.D.
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Correspondence address
Prof. Dr. med. Arne Dietrich
Klinik für Viszeral-, Transplantation-, Thorax- und Gefässchirurgie
Universitätsklinikum Leipzig
Liebigstr. 20, 04103 Leipzig, Germany
arne.dietrich@medizin.uni-leipzig.de
►Supplementary material
eMethods, eTables and eFigure:
www.aerzteblatt-international.de/18m0705

CLINICAL SNAPSHOT
Adhesions and Abdominal Pain: Ileal Perforation by a Sharp Ingested Foreign Body With
Mechanical Erosion at the Base of the Appendix
A 56-year old man presented to the emergency department with a Figure: Frontal recon-
2-day history of lower abdominal pain. Clinical examination struction of the contrast-
revealed pressure sensitivity in the right lower abdomen with local enhanced abdominal CT
shows a longitudinal
peritonism. Laboratory analysis showed a normal leukocyte count
radiodense foreign body
of 8790/µL but CRP elevation to 5.7 mg/dL. Sonography showed in the right lower
no clearly pathological findings. Subsequent computed tomography abdomen. This object
(CT) showed a radiodense structure (arrow). Urgent laparoscopic extends beyond the
intervention was converted to longitudinal lower abdominal lapa- bowel wall with projec-
rotomy owing to extensive adhesions. The intestinal perforation tion of the point towards
was located in the ileum, caused by a 3-cm-long fishbone; the base the cecum. In this area
of the appendix was involved. After removal of the bone, the per- there is an inflammatory
wall reaction in the
foration was repaired and the appendix resected. The patient
pericecal fatty tissue
recovered quickly and was discharged 5 days after surgery. He close to the base of the
must have accidentally swallowed the bone while eating a carp 3 appendix corresponding
days previously. Complications are described in only 1% of in- to the tubular structure
gested foreign bodies, but for sharp objects the rate rises to 35%. seen on the initial
sonogram.
Jens Strohäker, Dr. med. Robert Bachmann, Klinik für Allgemeine,
Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen,
jens.strohaeker@med.uni-tuebingen.de
Conflict of interest statement: The authors declare that no conflict of interest exists.
Translated from the original German by David Roseveare
Cite this as: Strohäker J, Bachmann R: Adhesions and abdominal pain: ileal perforation by a sharp ingested foreign body with mechanical erosion at the base of the appendix.
Dtsch Arztebl Int 2018; 115: 711. DOI: 10.3238/arztebl.2018.0711

Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 705–11 711
MEDICINE
Supplementary material to:
Obesity Surgery and the Treatment of Metabolic Diseases
Arne Dietrich, Jens Aberle, Alfred Wirth, Beat Müller-Stich, Tatjana Schütz, and Harald Tigges
for the S3 Guideline Group on the Surgical Treatment of Obesity and Metabolic Diseases
Dtsch Arztebl Int 2018; 115: 705–11. DOI: 10.3238/arztebl.2018.0705
eMETHODS: ON THE CREATION OF THE GUIDELINE
The guideline committee
As required by the Association of Scientific Medical Societies in
Germany (AWMF), other specialty societies (i.e., societies other
than the one mainly responsible for the guideline), corresponding
to the intended users of the guideline, were included in the com-
mittee; a patient representative was included as well (eTable 1).
The conflict of interest statements submitted by all committee
members, as required by the AWMF, are incorporated in the
guideline report (5).
The literature search
The guideline was created in collaboration with the User-
Group—Medizinische Leitlinienentwicklung e. V., CGS Clinical
Guideline Services, Berlin, and with the counseling and interac-
tive support of the AWMF. The literature search and evaluation
were carried out by the UserGroup—Medizinische Leitlinienent-
wicklung e. V. in collaboration with the guideline committee. On
the basis of questions formulated according to the PICO scheme,
and corresponding algorithms, a search for literature published
from April 2009 to March 2016 was carried out in the Medline,
Cochrane Library, and Scopus databases. Systematic reviews,
meta-analyses, and randomized controlled trials (RCTs) were
sought.
Results of the literature search
The literature search yielded 9099 hits (after the elimination of
duplicates), which were subjected to multilevel screening. 7920
were excluded by screening of titles and abstracts, leaving 1179
for full-text screening. 833 were excluded, leaving 353 publi-
cations that were intended to be used in the evaluation of the
literature on all key questions. After correction for publications
that were counted more than once because they were relevant to
multiple key questions, and therefore appeared in multiple lit-
erature groups, the number remaining for evaluation was 261.
Evaluation of the evidence
The evidence was evaluated by the SIGN method (eTable 2) (6).
Systematic reviews and meta-analyses were given priority. RCTs
and cohort studies that were included in systematic reviews of
I Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 705–11 | Supplementary material
good or very good quality were not individually evaluated. If two
or more reviews overlapped in more than half of the studies that
they included, only the review that was of the highest quality and
had the most recent publication date was considered. In this way,
the 261 publications chosen for analysis after full-text screening
were reduced to a set of 56 systematic reviews and meta-analyses
and, as requested by the experts, one RCT and five cohort studies.
PRISMA charts on the screening algorithm for the literature
search on each topic, including reasons for the exclusion of pub-
lications, can be seen in the guideline report (eFigure) (5). In the
next step, data were extracted from the included publications and
summarized in the form of evidence tables.
Structured consensus-finding and formulation of the
recommendations
After formulation of the guideline text and recommendations, the
latter were evaluated and commented upon online in the frame-
work of a formal consensus-finding process with two rounds of
voting, then discussed a final time in the subsequent structured
consensus conferences, where they were assigned recommen-
dation grades (eTable 3) and consensus strengths (eTable 4).
The recommendation grades were assigned on the basis of
the evidence, as well as further criteria such as the consistency
of study findings, the clinical relevance of the endpoints and ef-
fect strengths, risk–benefit ratios, the applicability of the study
findings to the target group of patients and to the healthcare
system, the implementability of the recommendations in rou-
tine care, patient preferences, and ethical and legal aspects.
Recommendations that were not study-based were desig-
nated as “expert consensus.” These recommendations represent
good clinical practice still in need of confirmation by scientific
studies, or for which such confirmation cannot be expected
because any relevant studies would be considered unethical.
The resulting guideline text was submitted to all participat-
ing specialty societies (and by some of these to their respec-
tive membership), discussed in multiple rounds, and amended
as indicated. Compromises that were acceptable to the guide-
line committee could be found on all points, so that no special
votes were necessary.
 MEDICINE

eTABLE 1

Composition of the guideline group: the participating specialty societies and associations and their delegates to the
guideline-creating committee (collaborators*)

Guideline-issuing society Representatives/experts

Surgical Working Group for the Treatment of Obesity (CAADIP)
of the German Society of General and Visceral Surgery
(DGAV)
Participating specialty societies and associations
German Obesity Society (DAG)
German Diabetes Society (DDG)
German Society of Nutritional Medicine (DGEM)
German Society of Endoscopy and Imaging Techniques (DGE-BV)
German Society of Psychosomatic Medicine and Medical Psycho-
therapy (DGPM)
German Society of Plastic, Reconstructive, and Esthetic Surgeons
(DGPRÄC)
German Collegium of Psychosomatic Medicine (DKPM)
Association of Diabetes Counseling and Educating Professions in
Germany (VDBD)
Professional Association for Ecotrophology (VDOE)
German Obesity Surgery Self-Help Association
Prof. Dr. med. Arne Dietrich*, Leipzig (chairman)
Prof. Dr. med. Lars Fischer*, Baden-Baden
Dr. med. Daniel Gärtner*, Karlsruhe
PD Dr. med. Mike Laukötter*, Münster
Prof. Dr. med. Beat Müller-Stich*, Heidelberg
Dr. med. Martin Susewind*, Berlin
Dr. med. Harald Tigges*, Landsberg am Lech
PD Dr. med. Markus Utech*, Gelsenkirchen
Prof. Dr. med. Stefanie Wolff*, Magdeburg
Representatives/experts
Prof. Dr. med. A. Wirth*, Bad Rothenfelde
PD Dr. med. Jens Aberle*, Hamburg
Prof. Dr. med. Arved Weimann*, Leipzig
Prof. Dr. med. Georg Kähler*, Mannheim
Prof. Dr. Martina de Zwaan*, Hanover
Prof. Dr. med. Adrian Dragu*, Dresden
Prof. Dr. Martina de Zwaan*, Hanover
Prof. Dr. rer. medic. Markus Masin*, Münster
Dr. rer. nat. Tatjana Schütz*, Leipzig (coordination)
Andreas Herdt*, Kelsterbach

eTABLE 2

Adapted evidence classification according to SIGN (6)

Type of study Categories Risk of systematic errors Descriptive quality

1+ Low Well-conducted
Systematic review with randomized controlled
1− High -
trials
1++ Very low High-quality
2++ Very low High-quality
Systematic review with cohort or
2+ Low Well-conducted
case–control studies
2− High -
1++ Very low High-quality
Randomized controlled trial 1+ Low Well-conducted
1− High -
2+ Low Well-conducted
Cohort or case–control study
2− High -

-, no verbal description given

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MEDICINE

eTABLE 3 eTABLE 4

Recommendation grades, according to the AWMF (25) Adapted AWMF classification of consensus strength (25)

Grade Description German verb Strong Consensus Majority No consensus

consensus agreement
A Strong Soll/soll nicht
recommendation Agreement Agreement Agreement Agreement
>90% >75 – 90% >50 – 75% <50%
B Recommendation Sollte/sollte nicht
0 Open Kann erwogen werden/
recommendation kann verzichtet werden

eFIGURE 1

Sleeve gastrectomy

PubMed Cochrane Scopus

Systematic literature search
(n = 282) (n = 194) (n = 273)

Hits after removal of duplicates

(n = 577)

Results after screening of

Screening Abstracts excluded (n = 450)
titles and abstracts (n = 127)

Results after full-text Double publication or more recent

Full texts excluded (n = 95)
screening (n = 32) publication available:
(n = 2)
Not a systematic review or
meta-analysis:
(n = 4)
Need for clarification:
(n = 8)
Wrong question being asked:
n = 48
Outcomes not relevant:
(n = 13)
Study population not according to
PICO: (n = 1)
Randomized controlled trial with only
50 or fewer patients: (n = 10)
No full text:
(n = 9)

Studies included after assessment Literature excluded Inadequate quality

Literature evaluation
of quality (n = 31) (n = 1) (n = 1)

Illustrative PRISMA chart for the literature search on sleeve gastrectomy

III Deutsches Ärzteblatt International | Dtsch Arztebl Int 2018; 115: 705–11 | Supplementary material