MEDICINE

Continuing Medical Education

Obesity Surgery
Weight Loss, Metabolic Changes, Oncological Effects, and Follow-Up

Jodok Fink, Gabriel Seifert, Matthias Blüher, Stefan Fichtner-Feigl, and Goran Marjanovic

Department of Gen-
eral and Visceral Sur-
gery, Center for Summary
Obesity and Meta-
bolic Surgery, Medi- Background: In 2017, the prevalence of obesity (BMI ≥= 30 kg/m2) in Germany was approximately 16%. Obesity increases an
cal Center, University individual’s risk of developing type 2 diabetes (T2DM) and arterial hypertension; it also increases overall mortality. Conse-
of Freiburg: quently, effective treatment is a necessity. Approximately 20 000 bariatric operations are performed in Germany each year.
Prof. Dr. Jodok Fink,
PD Dr. Gabriel
Seifert, Prof. Dr.
Methods: This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane databases
Stefan Fichtner-Feigl, and on current German clinical practice guidelines.
Prof. Dr. Goran
Marjanovic Results: The types of obesity surgery most commonly performed in Germany, Roux-en-Y gastric bypass and sleeve gastrec-
Helmholtz-Institute tomy, lead to an excess weight loss of 27–69% ≥= 10 years after the procedure. In obese patients with T2DM, the diabetes
for Metabolic, Obesity remission rate ≥= 10 years after these procedures ranges from 25% to 62%. Adjusted regression analyses of data from large
and Vascular
Research, (HI-MAG), registries have shown that the incidence of malignancies is 33% lower in persons who have undergone obesity surgery com-
Helmholtz Zentrum pared to control subjects with obesity (unadjusted incidence 5.6 versus 9.0 cases per 1000 person-years). The operation can
München cause vitamin deficiency, surgical complications, gastroesophageal reflux, and dumping syndrome. Therefore, lifelong follow-up
at the University of
Leipzig and the Medi- is necessary.
cal Faculty of Leipzig
AöR: Conclusion: In view of an increasing number of patients undergoing bariatric surgery, it will probably not be feasible in the future
Prof. Dr. Matthias for lifelong follow-up to be provided exclusively in specialized centers.
Blüher
Cite this as:
Fink J, Seifert G, Blüher M, Fichtner-Feigl S, Marjanovic G:
Obesity surgery—weight loss, metabolic changes, oncological effects, and follow-up.
Dtsch Arztebl Int 2022; 119: 70–80. DOI: 10.3238/arztebl.m2021.0359

T
he prevalence of obesity (body-mass index [BMI]
≥ 30kg/m2) has risen in the last 40 years in all
countries for which epidemiologic data are avail-
able (1). In Germany, 16.3% of the population was
obese in 2017 (e1). Obesity has a clear effect on overall
mortality, which rises by 29% with every 5 kg/m2
increase in BMI (hazard ratio [HR]: 1.29; 95% confi-
dence interval: [1.27; 1.32]). The life expectancy of per-
sons with a BMI in the range of 40–45 kg/m2 is reduced
by eight to ten years. This effect is comparable to that of
cigarette smoking (2). 25.6% of persons with
BMI ≥ 40 kg/m2 suffer from type 2 diabetes (T2DM),
and 50.9% from arterial hypertension. This corresponds
to a 7.4-fold increase of the risk of T2DM and a 6.4-fold
increase of the risk of arterial hypertension compared to
persons of normal weight (e2). Among persons with
BMI ≥ 30 kg/m2, 14.9% have T2DM and 40.9% have
arterial hypertension (e2). In western Europe, 3.3% [3.0;
3.6] of all cancers in men and 7.8% [7.1; 8.5] of all
cancers in women can be attributed to obesity (3). Table
1 contains a description of five tumor entities for which
a strong epidemiologic association with obesity has
been shown in a global meta-analysis (4). 13% of the
overall healthcare costs of obesity associated diseases
(such as T2DM) in Germany, amounting to 5.2 billion
euros per year, are attributable to obesity (e3). These
data highlight the urgency of effective treatment and
improved secondary prevention.
Obesity surgery, with appropriate preoperative
care and lifelong follow-up, leads to sustained
weight loss (45.9–80.9% loss of excess body weight
[EWL] at 10–25 years) (e4) as well as to

Prevalence
In Germany, 16.3% of the population was obese in 2017.
Obesity has a clear effect on overall mortality.
Comorbidities
25.6% of persons with BMI ≥ 40 kg/m2 suffer from type 2 dia-
betes mellitus (T2DM), and 50.9% from arterial hypertension.
This corresponds to a 7.4-fold increase of the risk of T2DM
and a 6.4-fold increase of the risk of arterial hypertension com-
pared to persons of normal weight.

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TABLE 1
Cancer risk in obese persons and reduction of the risk of selected types of cancer after obesity surgery
Type of cancer Relative risk in obese persons (BMI ≥ 30 kg/m2) Risk of the type of cancer in question after obesity surgery
[95% KI] compared to persons of normal weight [95% CI]
Colon cancer 1.47 [1.35; 1.60] (e45)
Rena-cell carcinoma 1.76 [1.61; 1.91] (e46)
Hepatocellular carcinoma 1.90 [1.61; 2.24] (e47)
Endometrial carcinoma 2.54 [2.27; 2.81] (e49)
Esophageal adenocarcinoma 2.73 [2.16; 3.46] (e51)
BMI, body-mass index, CI, confidence interval.
improvement of pre-existing T2DM (5). Moreover,
in a meta-analysis of data from 174 772 persons,
mortality in the 30 years after obesity surgery was
found to be 49.2% [46.3; 51.9] lower than in control
patients with obesity (with or without any other spe-
cific treatment), with a life expectancy that was 6.1
[5.2; 6.9] years longer (6).
In this CME article, we present the indications,
basic principles, and results of obesity surgery.
Moreover, typical long-term effects of surgery are
discussed, and specific aspects of follow-up care are
described, including vitamin supplementation.
Learning objectives
Readers of this article should achieve the following
learning objectives:
● an understanding of the mechanism of action of
obesity surgery and a knowledge of its indications;
● acquaintance with the key results of obesity
surgery;
● the ability to recognize reflux and dumping syn-
drome as clinically relevant long-term conse-
quences of obesity surgery.
Methods
This article is based on a selective literature review in
the PubMed and Cochrane databases for the years
2003–2021, with the following searching terms: bariat-
ric surgery AND type 2 diabetes; vitamin supplemen-
tation; dumping syndrome; complication; cancer;
oncology. Further searching terms were endoscopy
The effects of obesity surgery
Obesity surgery, with appropriate preoperative care and life-
long follow-up care, leads to sustained weight loss
(45.9–80.9% loss of excess body weight at 10–25 years), as
well as to improvement of pre-existing T2DM.
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2022; 119: 70–80
MEDICINE
relative risk compared to obese controls
BMI ≥ 30 kg/m2: 0.64 [0.42; 0.98] (35)
hazard ratio compared to matched obese controls
BMI ≥ 35 kg/m2: 0.79 [0.51; 1.24] (27)
odds ratio compared to obese controls
BMI ≥ 30 kg/m2: 0.63 [0.53; 0.75] (e48)
relative risk compared to obese controls
BMI ≥ 30 kg/m2: 0.33 [0.21; 0.51] (e50)
hazard ratio compared to obese controls
BMI ≥ 30 kg/m2: 0.9 [0.4; 1.9] (e52)
AND dumping syndrome, as well as obesity AND dis-
ease risk; cancer. The contents of the current German
clinical practice guidelines were considered as well (7, 8).
Baseline treatment for patients desiring obesity
surgery
Patients with a potential indication for obesity surgery
should be offered preparatory and accompanying con-
servative treatment options (7). These should include a
combination of dietary counseling, exercise, and
behavioral therapy and should contain individualized
nutritional recommendations. The treatment goal is the
loss of at least 10% of initial weight within 6 to 12
months in a patient whose BMI exceeds 35 kg/m2
(7). The data show that efficient, high-intensity interval
training combined with dietary counseling in patients
with a BMI of 40.4 ± 7.2 kg/m2 resulted in 5.3 [3.3;
7.3] kg of weight loss at 12 weeks and in a significant
improvement of cardiovascular risk factors (abdominal
girth −7.5 cm [–9.8; –5.1 cm], mean blood pressure
−11 mm Hg [–14; –8 mm Hg]) (e5).
Long-term results were investigated in a meta-
analysis of 91 studies on patients with obesity (BMI
>30 kg/m2) treated with combined nutritional and
behavioral therapy. In the subgroup analysis of
patients with grade II and III obesity, the overall
weight loss at six to 24 months was 5.3% and 6.3%,
respectively (9). Accordingly, the German clinical
practice guideline summarizes that treatment goals
for obesity are “generally not achieved” by
conservative treatment (7).
Baseline treatment for patients desiring obesity surgery
Patients with a potential indication for obesity surgery should
be offered preparatory and accompanying conservative treat-
ment options.
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BOX The surgical treatment of obesity

The indication criteria for obesity surgery are listed in
Indications for obesity and metabolic surgery the Box. The patient’s body weight remains the main
criterion on which the indication for obesity surgery is
Indications for obesity surgery based, even though the goals of obesity surgery now
● after the exhaustion of conservative treatment modalities extend well beyond weight loss alone (10).
– BMI ≥ 35 and < 40 kg/m2 with obesity-associated comorbidities* Metabolic surgery is indicated in patients with
– BMI ≥ 40 kg/m2 grade II obesity (BMI ≥ 35 to < 40 kg/m2) and T2DM
whenever the treatment goals for T2DM as stated in
● primary indication
the guidelines cannot be achieved with conservative
– BMI ≥ 50 kg/m2
therapy alone. For patients with T2DM and grade III
– if conservative treatment does not promise to be successful
obesity (BMI >40kg/m2), surgery is indicated inde-
– if the comorbidities are particularly severe
pendently of glycemic control, as long as potential
contraindications have been excluded (Box) (7). As
Indications based on metabolic parameters in patients with type 2
with the primary indication, the documented ineffi-
diabetes
cacy of conservative obesity therapy is not required
– if BMI ≥ 40 kg/m2, surgery is indicated independently of glycemic control
(7). Data on diabetes remission at least five years
– if BMI ≥ 35 and< 40 kg/m2, surgery is indicated if diabetes-specific target
after Roux-en-Y gastric bypass (RYGB) or sleeve
values can not be achieved
gastrectomy (SG) reveal that particularly patients
– if BMI ≥ 30 and < 35 kg/m2, metabolic surgery is an option if diabetes-
with a short history of type 2 diabetes, no insulin use,
specific target values can otherwise not be reached
a treatment regimen with a small number of antidi-
abetic drugs, and good glycemic control (HbA1c
Overview of indications for obesity surgery and metabolic surgery according to the German clinical
practice guideline on the surgical treatment of obesity and metabolic diseases (7). <7%) under conservative treatment stand to benefit
Conservative treatment is considered to be exhausted when at least six months of comprehensive from metabolic surgery (11). Moreover, diabetes
lifestyle interventions in the last two years have not resulted in the loss of at least 15% of the initial remission after metabolic surgery is independent of
weight in a patient with a BMI in the range of 35–39,9 kg/m2, or of at least 20% of the initial weight
in a patients with a BMI above 40 kg/m2 (7).
the initial BMI, as shown by a meta-analysis of data
from 94 579 patients (12). These findings may
* The following are defined to be obesity-associated comorbidities:
Type 2 diabetes (T2DM), coronary artery disease, heart failure, hyperlipidemia, arterial hyperten- prompt a reappraisal of the indications for metabolic
sion, nephropathy, obstructive sleep apnea syndrome (OSAS), obesity-hypoventilation syndrome, surgery in the near future.
Pickwick syndrome, nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis
(NASH), pseudotumor cerebri, gastroesophageal reflux disease (GERD), asthma, chronic venous
The contraindications for obesity surgery and
insufficiency, urinary incontinence, immobilizing joint disease, impaired fertility, polycystic ovary metabolic surgery are clearly presented in the German
syndrome (PCO). clinical practice guideline. These include untreated
BMI, body-mass index bulimia nervosa, active substance dependence, or
untreated endocrine causes of obesity (7).

Mechanisms of action of obesity surgery

Conservative treatment has thus taken its place as a
component of the interdisciplinary preparatory phase
and the postoperative care of patients with a BMI ≥
35 kg/m2 who desire obesity surgery. Baseline treat-
ment need not necessarily be followed by obesity sur-
gery. The efficacy of this strategy has been shown in a
meta-analysis of studies on targeted interventions
including nutritional counseling, behavioral therapy,
and exercise in the 12 months before and after obesity
surgery. 12 months after surgery, the patients so
treated had lost 4.4 kg [1.69; 7.1] more than the con-
trol patients who had undergone obesity surgery
without any other targeted intervention (e6).
The main objective of obesity surgery is to restrict
energy intake. This is done by surgically decreasing
the stomach volume, so that only small portions of
food can be consumed. The surgical procedures often
involve gastric reduction combined with bypassing the
duodenum and part of the jejunum (Figure). The ones
most commonly performed in Germany, SG and
RYGB, do not cause any clinically relevant malab-
sorption of macronutrients (e7). The contribution of
malabsorption to weight loss after RYGB has been
estimated at 11% in a systematic review (e8). Though
they differ in their anatomical details, the various
obesity surgery procedures all cause complex
intestinal hormonal changes, including increased
levels of glucagon-like peptide 1 (GLP-1) and circulating

Results of accompanying treatment Indication: body weight

The data show that efficient, high-intensity interval training The patient’s body weight remains the main criterion on which
i
combined with dietary counseling in pat ents with a BMI of the indication for surgery is based, even though the goals of
40.4 ± 7.2 kg/m2 resulted in 5.3 [3.3; 7.3] kg of weight loss at obesity surgery now extend well beyond weight loss alone.
12 weeks and in a significant improvement of cardiovascular
risk factors, including mean blood pressure.

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bile acids, as well as lower ghrelin levels; clinically,

patients have a reduced appetite, decreased neural
stimulability, and lessened food reward compared to
their preoperative state (e9). The hormonal changes
after surgery are partly opposite to those induced by
conservative treatment, which can raise ghrelin and
cholecystokinin levels and increase the appetite (e10).
If the described entero-endocrine regulation did not
occur after obesity surgery, the ensuing sustained
weight loss would be unexplained, because dilation of
the stomach over the long term would again permit the
consumption of large portions of food (e11). The most
common surgical procedures are depicted in the
Figure.

Weight loss a b
A meta-analysis of eleven randomized controlled trials
(RCTs) revealed that obesity surgery leads to a mean
amount of weight loss at two years that is 26 kg [31; 21
kg] greater than that resulting from conservative treat-
ment alone (-38.5 to -14.4 kg, versus -7.9 to +1.0 kg)
(13). The only Cochrane review to date on weight loss
after obesity surgery revealed a similar difference of 21.3
kg [18.9; 23.6 kg] at 12–24 months (14). Long-term data
from one of the included studies have become available
in the meantime and show a large sustained difference in
weight loss between RYGB and conservative treatment
at 10 years (RYGB, -37.3 kg; conservative treatment, c d e
-6.5 kg; difference, 30.8 kg [16.7; 44.8 kg]) (15). In the Figure: Surgical procedures in obesity and metabolic surgery (Dr. Leven Efe, courtesy of
prospective Swedish Obese Subjects (SOS) cohort trial, the International Federation for the Surgery of Obesity and Metabolic Disorders [IFSO]). (e44)
which involved 4047 patients, the overall weight loss at
a) Sleeve gastrectomy (SG) with the removal of 80–90% of the stomach along an inserted cali-
15 years was 27% after RYGB, versus 0% in the control
bration tube (diameter 1.2–1.5 cm). The resected stomach part is removed. Sleeve Gastrec-
patients (some of whom received no specific treatment tomy is the most commonly performed type of obesity surgery in Germany (approximately 50%
for obesity) (16). of operations for obesity).
Table 2 contains a detailed overview of weight loss
after different obesity surgery procedures. It has been b) Roux-en-Y gastric bypass (RYGB): A small, elongated gastric pouch (20–30 mL) is created
and directly connected to the small intestine via Roux-en-Y reconstruction. The lengths of the
found in multiple RCTs that the two most common
resulting biliopancreatic (green) and alimentary (yellow) limbs are variable; typically, the alimen-
surgical procedures, SG and RYGB, lead to similar
tary limb is 150 cm long, and the biliopancreatic limb 50 cm long. This results in hypoabsorption,
degrees of weight loss (14). Pooled data from the two but not malabsorption. Gastric bypass is the second most common type of obesity surgery in
largest randomized trials of SG versus RYGB, both of Germany (circa 32% of all procedures for obesity). It is surgically reversible, as it does not
them published in 2021, imply that RYGB leads to involve the resection of any part of the bowel or stomach.
significantly more weight loss at five years (EWL
67.7% versus 55.5%) (17). An advantage for RYGB c) One-anastomosis gastric bypass (OAGB): a gastric pouch is formed that is similar to the
one made in RYGB, but slightly longer. The small intestine is then anastomosed to the stom-
over SG has likewise been found in three more recent
ach as an omega loop. The biliopancreatic (green) limb is typically 150–250 cm long, although
meta-analyses, as well as in one RCT with 7-year numerous variations have been described. OAGB accounts for approximately 15% of the sur-
follow-up data (18, 19, e12, e13). These newer find- gical procedures for obesity that are performed in Germany.
ings remain to be confirmed.
A meta-analysis of data from 12 445 patients d) Gastric banding (LAGB): The gastric band is placed just below the gastroesophageal junc-
revealed that weight loss one, two, and five years tion and connected to a subcutaneously implanted port. With this port, the degree of filling of
the inner cushion of the gastric band, and thus the inner diameter of the band, can be regu-
after one-anastomosis gastric bypass (OAGB) was
lated from the outside. Because of its many complications, and its lesser effect on weight than
greater than after RYGB: the difference in EWL at other types of obesity surgery, gastric banding is now only used in special situations (ca. 1% of
procedures in Germany).

Contraindications of obesity surgery and metabolic
surgery
These include untreated bulimia nervosa, active substance
dependence, or untreated endocrine causes of obesity
e) Duodenal switch (BPD-DS): In this operation, sleeve gastrectomy is combined with duo-
denum division distal to the pylorus. Reconstruction of the passage is basically analogous to
RYGB, although the loop lengths are markedly different: the alimentary limb is approx. 250 cm
long, and the common distal segment (common channel) is 75–100 cm long. The biliopancreatic
loop, which is usually not measured, is several meters long. Because the common channel is so
short, the duodenal switch leads to marked hypoabsorption, in turn necessitating parenteral
vitamin supplementation and leading to frequent, mushy stools. Few procedures of this type are
performed in Germany (about 0.5% of all operations).

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TABLE 2

The outcomes of obesity surgery and metabolic surgery

Type of Loss of excess weight (EWL) Type 2 diabetes 30-day mortality

procedure
1–2 years 5–7 years ≥ 10 years Remission Remission Partial remission Remission
2–3 years 5 years 5 years ≥ 10 years
LSG 51–79% 54–57% 53–62% 50–67% 28–59% 74% 58% 0.03–0.33%
(36) (e53, 18) (e4) (24, 21) (18, e53) (18) (e54) (e55, e56)
RYGB 63–72% 66–72% 27–69% 75% 37–76% 77.5% 25–62% 0.07%
(36) (18, e53) (e4) (37) (18, e53) (38) (15, e54) (e55, e56)
OAGB 31–89% 30–73% 70–84% 60% 67–94% 85% 67% 0–0.26%
(20) (20) (e4) (e14) (e53, e57) (e58) (e57) (e53, e56)
BPD-DS/BPD 73% 75% 61–94% 98% 88–99% 63% 50–68% 0.6–0.8%
(e59) (e59) (e4) (39) (38) (39) (15, e60) (38)
LAGB 33–34% 42–57% 27–66% 20% 16% 23% 18% 0–0.1%
(36) (36) (e4) (e61) (e61) (e61) (e62) (40, 36)

Weight loss is presented as loss of excess body weight (EWL), and the results with regard to type 2 diabetes are presented for each surgical technique as described in the pertinent references.
BPD-DS/ BPD: biliopancreatic diversion with duodenal switch and biliopancreatic diversion are presented together; LAGB, gastric banding; LSG, sleeve gastrectomy; RYGB, Roux-en-Y gastric
bypass; OAGB, one-anastomosis gastric bypass.

five years was 12.82% [5.37; 20.27%] (20). A disad-
vantage of OAGB compared to RYGB is a higher rate
of malnutritive complications (21% versus 0%), as
shown in one randomized controlled trial (e14).
Clinically relevant weight regain (defined as an
increase of at least 25% from the nadir) occurs in
approximately 20% of patients at a median follow-
up of five years and is apparently higher after SG
than after RYGB (e15). In such cases, a reoperation
may be indicated. In order to minimize weight re-
gain, silicone rings can be implanted around the
stomach during the primary procedure. Weight
regain three to five years after RYGB or SG has
been found to be significantly less if silicone rings
are used (21, e16).
The course of diabetes after obesity surgery
In a meta-analysis of data from 1108 patients,
metabolic surgery brought about a remission of pre-
existing T2DM in 59.3% (RYGB) to 91.2% (OAGB) of
patients at five years (5). The only RCT to date with 10
years of follow-up revealed a diabetes remission rate of
37.5% after metabolic surgery and 0% after medical
management alone. In this trial, the percentage of
patients needing insulin rose from 47% to 53.3% in the
medical group and fell from 47.5% to 2.5% in the sur-
gical group. The incidence of macrovascular and
microvascular complications of T2DM at 10 years was
5.0% in the surgical group and 72.2% in the medical
group (relative risk 0.07 [0.01; 0.48] (15). Likewise, a
meta-analysis of data from 17 532 patients with T2DM
who were treated either medically or surgically reveal-
ed lower incidences of diabetic retinopathy (1.9% ver-
sus 6.6%; odds ratio [OR] 0.30) and nephropathy (5.9%
versus 22.4%; OR 0.19) in the surgical group at 1–15
years (e17). The incidence of diabetes in the prospec-
tive SOS cohort at 15 years was 6.8 per 1000 person-
years after obesity surgery and 28.4 per 1000 person-
years in the control group, corresponding to a relative
risk reduction of 78% (22).
Multiple meta-analyses have shown statistically
similar antidiabetic effects for SG and RYGB at five
years (Table 2) (23, 24). In contrast, in a cohort study
from the USA including 9710 patients with SG or
RYGB at 34 centers, RYGB resulted in better gly-
cemic control (ΔHbA1c 0.45; [0.27; 0.63]), a 10%
higher diabetes remission rate (HR 1.1 [1.04; 1.16],
and a lower diabetes recurrence rate (HR 0.75 [0.67;
0.84] than SG (25). In a study of 629 patients fol-
lowed up for a median of 4.9 years after RYGB, inde-
pendent predictive factors for diabetes recurrence
were the preoperative insulin requirement, lower
weight loss at 12 months, and greater regaining of
weight after the first year (26).

Effects of hormonal changes Weight gain

Hormonal changes after obesity surgery include reduced appe- Clinically relevant regaining of weight (defined as an increase
tite, decreased neural stimulability, and lessened food reward of at least 25% from the nadir) occurs in approximately 20% of
compared to the patients’ preoperative state patients at a median follow-up of five years and is apparently
higher after SG than after RYGB.

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TABLE 3

Prevalences of micronutrient deficiency, laboratory tests, recommendations on vitamin supplementation following obesity surgery, and recom-
mended vitamin and micronutrient intake according to the German Nutrition Society (Deutsche Gesellschaft für Ernährung) (e63)

Micro- Prevalence of micro- Symptoms of micronutrient Recommended follow-up intervals Recommended Recommended
nutrient nutrient deficiency deficiency after obesity surgery quantity of intake accord-
supplementation ing to DGE

Vitamin A
LSG 5.2% nyctalopia, Bitot spots, – 1500 RAE*2 M: 850 RAE
RYGB 7.7% hyperkeratinization of the skin at 3, 6, and 12 months, then annually 1500–3000 RAE*2 F: 700 RAE

Thiamine (vitamin B1)

LSG prevalence depending at 6 and 12 months, then annually
dry beriberi involving the nervous
on risk factors such as
RYGB system, wet beriberi with heart fail- at 3, 6, and 12 months, then annually M: 1.2 mg/day
vomiting, alcohol 12 mg/day*2
ure and edema; Wernicke’s enceph- F: 1.0 mg/day
abuse
alopathy.
< 1–49 %.
Calcium
LSG not applicable; see at 6 and 12 months, then annually
leg cramps, muscle weakness, 1200–1500 mg/day of M: 1000 mg/day
prevalence of vitamin
RYGB osteoporosis at 3, 6, and 12 months, then annually calcium citrate F: 1000 mg/day
D deficiency.
Vitamin D
LSG very high prevalence at 6 and 12 months, then annually at least 3000 IE/day, tar-
leg cramps, paresthesiae, hypocal- M: 800 IE/day
(up to 100% in some get serum concentration
RYGB cemia, osteoporosis at 3, 6, and 12 months, then annually F: 800 IE/day
collectives) > 30 mg/mL
Iron Ferritin
LSG < 18% at 6 and 12 months, then annually 50*2 mg/day in women
fatigue, prostration, microcytic ane- of childbearing age
M: 10 mg/day
mia, susceptibility to infections,
RYGB 20–55% at 3, 6, and 12 months, then annually 50 mg/d of iron sulfate, F: 15 mg/day
glossitis, koilonychia
fumarate, gluconate
Folic acid (Vitamin B9)
LSG megaloblastic anemia, neural tube at 6 and 12 months, then annually 600*2 µg/day M: 300 µg/day
up to 65% described
RYGB defects (embryo) at 3, 6, and 12 months, then annually 600 µg/day F: 300 µg/day

Vitamin B12
LSG 4–20% pernicious (megaloblastic) anemia, at 6 and 12 months, then annually oral: 1000 µg/day
M: 4 µg/day
skin pallor, glossitis, fatigue, numb- i.m.: 1000–3000 µg
RYGB < 20% at 3, 6, and 12 months, then annually F: 4 µg/day
ness/paresthesiae, ataxia, tinnitus every 3–6 months
Vitamins E and K
LSG – vitamin E:
vitamin E:
vitamin E: hyporeflexia, gait distur- M: 14 mg/day
RYGB at 3, 6, and 12 months, then annually 15*2 mg/day
bance, ophthalmoplegia F: 12 mg/day
low prevalence
vitamin K:
(no recommendation from the vitamin K:
vitamin K: bleeding tendency M: 70 µg/day
ASMBS) 90–120*2 µg/day
F: 60 µg/day

Zinc
LSG 19% rash, acne, hypogeusia, susceptibil- – M: 14 mg/day
8–11*2 mg/day
RYGB 40% ity to infections, infertility at 3, 6, and 12 months, then annually F: 8 mg/day

Copper
LSG Low prevalence hypochromic anemia, neutropenia, – 1*2 mg/day M: 1–1.5 mg/day
RYGB 10–20 % hypopigmentation annually*1 2 mg/day F: 1–1.5 mg/day

Figures on the prevalence of micronutrient deficiency are taken from the ASMBS guideline (e64). For vitamin A, Parrot et al. (e64) did not specify prevalence and the figures are taken from Johnson
et al. (e65). The recommended laboratory tests are as per the German clinical practice guideline (7); *1 not recommended in the German clinical practice guideline, but recommended by the
ASMBS. The ASMBS does not recommend laboratory testing for patients who have undergone RYGB because of the low prevalence of vitamin E and vitamin K deficiency. The recommended
supplementation amounts are also taken from the German clinical practice guideline and are complemented by the ASMBS recommendations when the amount to be substituted is not specified
(marked by *2). All supplementation amounts listed in bold are typically contained in specially formulated multivitamin tablets for patients who have undergone obesity surgery. ASMBS, American
Society for Metabolic and Bariatric Surgery; DGE, German Society for Nutrition; F, female; i.m., intramuscular; LSG, sleeve gastrectomy; M, male; RAE, retinol activity equivalent; RYGB, Roux-en-Y
gastric bypass.

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MEDICINE
Cancer prevention
A retrospective observational study of 22 198 patients
who underwent obesity surgery, compared to 66 427
controls who were closely matched for sex, age, BMI,
and comorbidities, determined that the incidence of
cancer in 3.5 years of follow-up was 5.6 per 1000
person-years in the surgical group, compared to 9.0 per
1000 person-years in the nonsurgical group, which cor-
responded to a 33% relative reduction (27). With regard
to individual types of cancer, a meta-analysis of data
from more than 7 million patients revealed that
endometrial cancer arose within four to 26 years in
0.4% of women who underwent obesity surgery, com-
pared to 0.6% of women in the control group. This
meta-analysis showed a 59% (OR 0.41 [0.22; 0.74])
lower risk of endometrial cancer after obesity surgery
(e18). As for colorectal cancer (CC), a population-
based, multicenter study from France involving 1.05
million persons with obesity followed up for at least 2
years revealed an absolute CC incidence of 0.6% with-
in 10 years after obesity surgery compared to 1.3% in
the control group. The risk of CC after obesity surgery
was the same as in the normal population (standard
incidence ratio [SIR] 1.0; [0.9; 1.09]), but it was 34%
higher (SIR 1.34; [1.32; 1.36]) in obese persons who
did not undergo obesity surgery (28).
Follow-up
Patients who have undergone obesity surgery benefit
from regular follow-ups. In support of this assertion,
a register based study including 46 381 patients 12
months after RYGB showed that those who adhered to
scheduled postsurgical follow-ups had better
remission rates of T2DM (OR 1.27; [1.18; 1.37]) and
arterial hypertension (OR 1.25; [1.18; 1.32]), after ad-
justment for age, sex, BMI, and other factors (e19). In
Germany, approximately 20 000 surgical procedures
for obesity are performed per year (e20). The rapidly
rising numbers of patients and operations will soon
make it impossible for lifelong follow-up to be pro-
vided in specialized centers alone (29). In the next
section, we outline what appropriate follow-up con-
sists of and discuss two potential long-term sequelae,
i.e., reflux and dumping syndrome. The necessary lab-
oratory tests and supplementation recommendations
are listed in Table 3.
Specific aspects of follow-up
In a large-scale meta-analysis, obesity surgery led to
the remission of preexisting arterial hypertension in 24
902 (50%) of 49 844 patients (e21). This implies that
The course of diabetes after obesity surgery
In a meta-analysis of data from 1108 patients, metabolic sur-
gery brought about a remission of preexisting T2DM in 59.3%
(RYGB) to 91.2% (OAGB) of patients at five years.
76
the antihypertensive medication must be continually
readjusted. The same applies to T2DM: insulin secreta-
gogues should be stopped, and the subcutaneous insulin
dose should be adjusted (30). The use of sodium-
glucose cotransporter 2 (SGLT2) inhibitors is not rec-
ommended for six to twelve months after obesity
surgery because of the increased risk of ketoacidosis
(7). A meta-analysis on the effect of exercise after obe-
sity surgery revealed that participation in an exercise
program was associated with a slightly greater degree
of weight loss (–1.8 kg [–3.2; –0.4]) and improved
physical performance (VO2max and muscle strength)
(e22).
It is recommended in the German clinical practice
guideline that self-injurious behavior should be
directly asked about if the patient has a relevant pre-
operative disturbance, and that the history of
self-injurious behavior should be appropriately docu-
mented (7). A meta-analysis of 29 studies revealed a
suicide rate of 2.7 per 1000 patients after obesity sur-
gery. The risk of suicide after obesity surgery was 1.9
times higher [1.23; 2.95] than in the same population
preoperatively, and 3.8 times higher than in matched
controls [2.91; 6.59] (e23). A comparison of the SOS
cohort with persons in two Swedish national registries
showed that the additional risk was much higher in
men than in women. Moreover, it was found that a his-
tory of psychological consultations, psychotropic drug
use, and sleep disturbances are risk factors for suicide
after obesity surgery (e24). A systematic review of 48
studies on depression, anxiety disorder, and binge eating
indicated that these disorders may improve 6–24 months
after obesity surgery; some of the included studies
showed, however, that these disorders may return to
baseline levels beyond 24 months after surgery (31). In
light of these findings a psycholocical follow up is
desirable, especially for patients at risk.
Data show that 4.6% of patients develop anasto-
motic ulcers after RYGB. Nonsteroidal anti-
inflammatory drugs (NSAID, OR 30.6 [6.4; 146])
and smoking (OR 11.5 [4.8; 28]) markedly increase
this risk (e25). Proton-pump inhibitors are protec-
tive and are thus recommended for ulcer prophy-
laxis for one to six months after gastric bypass (7).
Short-term NSAID use is, however, possible even
after RYGB (30). A meta-analysis of 10 031 pa-
tients revealed a 2% incidence of internal hernias
after RYGB, despite the initial closure of the mes-
enteric defects (e26). Because of the risk of incar-
ceration, such hernias should be treated surgically
(e27).
Follow-up
In Germany, approximately 20 000 surgical procedures for
obesity are performed per year. The rapidly rising numbers of
patients and operations will soon make it impossible for life-
long follow-up care to be provided in specialized centers
alone.
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Reflux
According to a meta-analysis of data from 460 984
patients, obesity (BMI ≥ 30 kg/m2) is associated with a
1.7-fold [1.46; 2.06] higher prevalence of
gastroesophageal reflux disease (GERD; absolute
prevalence, 22.1% versus 14.2%), (e28). For patients
with reflux who have an indication for obesity surgery,
gastric bypass is an optimal operative technique, as it
creates an anatomical barrier to reflux by bypassing a
large portion of the stomach. SG is a poorer choice for
this group of patients (7), as it is associated with de
novo reflux symptoms in 20% [14; 27], an overall
increase in reflux symptoms in 19% [15; 22], and a
28% rate of reflux esophagitis [–9; 66] in the first two
years after surgery (32). A meta-analysis of 680
patients who underwent SG accordingly showed an
11.5% [7.8; 16.7] prevalence of Barrett’s mucosa in
three years of follow-up (e29). Although no clear tem-
poral relationship was seen between surgery and the
onset of Barrett’s metaplasia, the prevalence of reflux
esophagitis was found to increase by 13% per year
after SG (e29). As there is no correlation between
endoscopic findings and reflux symptoms in more
than half of cases, the American Society for Meta-
bolic and Bariatric Surgery recommends endoscopic
follow-up of all patients three years after SG, and
potentially at five-year intervals thereafter, as long
as the findings remain unremarkable (e30). Reflux
after SG is often a consequence of scarring or func-
tional sleeve stenosis, both of which can relatively
impede gastric outflow. Furthermore, axial hiatal
hernias with intrathoracic migration of part of the
sleeve have been described, inevitably leading to
esophageal shortening and partial dysfunction of the
lower esophageal sphincter (e31, 33). As causes of
reflux after SG are prevalently anatomical in nature,
conservative treatment is often ineffective; the most
effective and most common treatment is conversion
of the sleeve to a RYGB. In a published series of 10
cases, this also led to the remission of Barrett’s
esophagus 80% of the time, after a median follow-up
of 33.4 months (e32). Other options include hiato-
plasty, possibly combined with augmentation using
the round ligament of the liver, or the implantation of
a magnetic ring (e33).
Patients who have undergone OAGB may develop
both acid and biliary reflux because of retrograde
flow of bile into the gastric pouch in the absence of a
Roux anastomosis (e34). The logical management of
clinically relevant biliary reflux would be the conver-
sion of the OAGB to a RYGB.
Reflux
According to a meta-analysis of data from 460 984 patients,
obesity (BMI ≥ 30 kg/m2) is associated with a 1.7-fold [1.46;
2.06] higher prevalence of gastroesophageal reflux disease.
Deutsches Ärzteblatt International | Dtsch Arztebl Int 2022; 119: 70–80
MEDICINE
Dumping
The prevalence of dumping syndromes after RYGB is
20–40% (e35). There are two types of dumping syn-
drome. Type 1 dumping (early dumping, less than one
hour after food intake) is caused by rapid transport of
hyperosmolar chyme into the small intestine, leading
to an influx of interstitial fluid into the intestinal
lumen. The mechanism of type 2 dumping (late dump-
ing, one to three hours after food intake) is much less
well understood; it is probably due to excessive GLP-1
secretion in response to the rapid transport of glucose
into the small intestine (e36), which results in dispro-
portionate insulin secretion and ensuing hypoglyce-
mia. The main symptoms of both types of dumping are
dizziness, sweating, tachycardia, and hypotension.
They often occur in combination, as both are triggered
by the rapid passage of food into the small intestine.
Specific therapeutic measures are directed against this
rapid passage. The mainstay of treatment is nutritional
therapy, with the goal of getting the patient to ingest
multiple, small portions of food that are low in carbo-
hydrates, instead of a single large portion. Dumping
syndrome can be effectively treated endoscopically by
narrowing the gastroenterostomy (e37, e38); open sur-
gical reduction of the gastric pouch and implantation
of a silicone ring also markedly improves symptoms,
although only limited confirmatory data are available
to date (e39). The drugs used to treat dumping
syndrome slow glucose uptake (acarbose) and gas-
trointestinal motility (somatostatin analogues, GLP-1
agonists), or else inhibit insulin secretion (diazoxide,
somatostatin analogues) (e40). The treatment that
would theoretically seem most effective, i.e., reversal
of the gastric bypass, often fails to relieve the symp-
toms completely (e40).
Perspectives
As recommended in the German clinical practice
guideline, patients should be followed up 1, 3, 6, 12,
18, and 24 months after obesity surgery, and annually
thereafter (7). The appropriate follow-up is most
likely to be delivered under real-world conditions if
it is comprehensively reimbursed by health insurance
carriers. Yet, in Germany at present, full reimburse-
ment is only possible for standard care. The situation
is likely to improve markedly in the near future with
the adoption of a proposed law mandating the cre-
ation of a disease management program for obesity.
One result of this may be the reimbursement of phar-
macotherapy directed at weight loss, which is cur-
rently excluded under §34 of the German Social
Pharmacotherapy of dumping syndrome
The drugs used to treat dumping syndrome slow glucose
uptake (acarbose) and gastrointestinal motility (somatostatin
analogues, GLP-1 agonists), or else inhibit insulin secretion
(diazoxide, somatostatin analogues).
77
MEDICINE
Code, Book V. This would be of particular benefit to
patients with grade I obesity (BMI ≥ 30–35 kg/m2), a
group that suffers from increased mortality, yet often
cannot achieve sustained weight loss: these patients
generally are not candidates for bariatric surgery, and
conservative treatment often has no more than a
modest effect (34, e41). Moreover, the adjuvant use
of weight-reducing drugs after obesity surgery will
be increasingly important as better and more compre-
hensive data are acquired (e42, e43).
Conflict of interest statement
Prof. Fink has received lecture honoraria from KLS Martin GmbH + Co
KG and reimbursement of travel expenses from Bariatric Solutions
GmbH.
Prof. Marjanovic has received lecture honoraria from KLS Martin
GmbH + Co KG and reimbursement of travel expenses from Bariatric
Solutions GmbH.
PD Dr.Seifert has received lecture honoraria from KLS Martin GmbH +
Co KG and reimbursement of travel expenses from Bariatric Solutions
GmbH.
Prof. Blüher has received lecture honoraria from, and has served as a
paid advisor for, the following firms: Amgen, AstraZeneca, Bayer,
Böhringer Ingelheim, Daiichi-Sankyo, Lilly, MSD, Novartis, Novo
Nordisk, Pfizer, and Sanofi.
Prof. Fichtner-Feigl states that he has no conflict of interest.
Manuscript received on 27 March 2021, revised version accepted on
7 October 2021.
Translated from the original German by Ethan Taub, M.D.
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MEDICINE
Corresponding author
Prof. Dr. Jodok Fink
Klinik für Allgemein- und Viszeralchirurgie
Sektion für Adipositas und Metabolische Chirurgie
Universitätsklinikum Freiburg
Hugstetter Str. 55, D-79106 Freiburg, Germany
jodok.fink@uniklinik-freiburg.de
Cite this as:
Fink J, Seifert G, Blüher M, Fichtner-Feigl S, Marjanovic G:
Obesity surgery—weight loss, metabolic changes, oncological effects,
and follow-up. Dtsch Arztebl Int 2022; 119: 70–80.
DOI: 10.3238/arztebl.m2021.0359
►Supplementary material
eReferences:
www.aerzteblatt-international.de/m2021.0359
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79
MEDICINE

CME credit for this unit can be obtained via cme.aerzteblatt.de until 3 February 2023.
Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1 Question 6
How high is the reported risk of developing colorectal cancer In a relevant observational study, to what extent was the incidence of
after obesity surgery, in comparison to the corresponding risk in obesity-related types of cancer lowered after obesity surgery?
the general population? a) by approximately 70% at 7 years
a) Twice as high b) by approximately 30% at 5.5 years
b) Three times as high
c) by approximately 70% at 3 years
c) 34% higher
d) by approximately 30% at 3.5 years
d) Only half as high
e) The same e) by approximately 50% at 5 years

Question 2 Question 7
What is the most likely mechanism of the long-term weight- What is the most commonly performed surgical procedure for obe-
reducing effect of gastric bypass and sleeve gastrectomy? sity in Germany?
a) Severe protein malabsorption a) Gastric banding
b) Altered intestinal hormone stimulation and secretion b) Roux-en-Y gastric bypass
c) Increased epinephrine secretion c) Duodenal switch
d) Primarily mechanical restriction
d) One-anastomosis gastric bypass
e) Shortened colon transit time
e) Sleeve gastrectomy

Question 3
In general, in what situation is a surgical procedure indicated on
the basis of metabolic parameters?
a) Only when conservative treatment has been found to be insufficient
b) If the patient has arterial hypertension and BMI ≥ 40 kg/m2
c) If the patient has lymphedema and BMI ≥ 40 kg/m2
d) If the patient has type 2 diabetes and BMI ≥ 40 kg/m2
e) If the patient has pulmonary arterial hypertension and BMI ≥ 35
kg/m2
Question 8
What factors elevate the risk of an anastomotic ulcer
after Roux-en-Y gastric bypass surgery?
a) A diet rich in bran combined with laxative use
b) Moderate consumption of alcohol and red meat
c) Regular use of nonsteroidal anti-inflammatory drugs and smoking
d) Aerobic training and regular use of proton pump inhibitors
e) A low-carbohydrate diet and intermittent fasting

Question 4
What surgical technique should be chosen for patients who Question 9
suffer from gastroesophageal reflux and, at the same time, are What vitamin or trace element deficiency most commonly arises after
concerned about the possibility of bilious reflux? a sleeve gastrectomy?
a) Roux-en-Y gastric bypass a) Vitamin C deficiency
b) Gastric banding b) Vitamin K deficiency
c) Duodenal switch c) Vitamin E deficiency
d) Sleeve gastrectomy d) Copper deficiency
e) One-anastomosis gastric bypass
e) Vitamin D deficiency

Question 5
In a relevant randomized and controlled trial with 10 years of Question 10
clinical follow-up, what was the remission rate of type 2 diabetes Which of the following would be appropriate management of a
after obesity surgery? patient with severe dumping symptoms after Roux-en-Y gastric
a) 17.5% bypass who has already obtained no relief from nutritional therapy or
b) 22.5% from acarbose?
c) 27.5% a) Wait and observe further.
d) 32.5% b) Treat postprandial tachycardia with a β-blocker.
e) 37.5% c) Perform surgical distalization of the intestinal loops.
d) Perform surgical reduction of the gastric pouch, combined with silicon
implantation.
►Participation is possible only via the Internet: cme.aerzteblatt.de e) Prescribe antacids to be taken with meals.

80 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2022; 119: 70–80


Supplementary material to:
Obesity Surgery
Weight Loss, Metabolic Changes, Oncological Effects, and Follow-Up
by Jodok Fink, Gabriel Seifert, Matthias Blüher, Stefan Fichtner-Feigl, and Goran Marjanovic
Dtsch Arztebl Int 2022; 119: 70–80. DOI: 10.3238/arztebl.m2021.0359
eReferences
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der Bevölkerung 2017. Statistisches Bundesamt 2018; 11. www.
destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Gesund
heitszustand-Relevantes-Verhalten/Publikationen/Downloads-Ge-
sundheitszustand/koerpermasse-5239003179004.pdf?__blob=pub-
licationFile (last accessed on 17 January 2022).
e2. Mokdad AH, Ford ES, Bowman BA, et al.: Prevalence of obesity,
diabetes, and obesity-related health risk factors, 2001. JAMA 2003;
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