The first response was collected on 30th October 2016, the last on the 21st of August 2017. On average, respondents spent 34 min on the questionnaire, which was twice as long compared to the validation outcomes (15 min). Of the 51 European countries, three did not perform any metabolic surgery in 2015 (Liechtenstein, Montenegro, Vatican City). Although many efforts were made, there were no responses and thus missing data from seven countries (Bulgaria, Cyprus, Kosovo, Monaco, San Marino, Slovakia and the Czech Republic). One country (Czech Republic) provided an incomplete response and was, therefore, discarded from the final analysis. In total, 45 complete responses were collected with four double responses. This resulted in data based on responses from 41 countries (Fig. 1). A summary table of our data is given in Table 1.
The first topic of the questionnaire considered nationally used guidelines (Table 1). Twenty-eight countries (68%) had guidelines on eligibility criteria for metabolic surgery, whilst 46% had reimbursement criteria (51% did not, 3% unknown). In the countries that had national guidelines on inclusion criteria for metabolic surgery, 59% adhered to these, 20% did not and frequently there was a large variation between clinics (21%). IFSO guidelines were defined (15). Sixty-eight percent of responding countries complied with IFSO guidelines, 17% did not comply and in 15% there was variation between clinics within the country.
For plastic surgery, 41% had eligibility criteria and 31% reimbursement criteria. Considering plastic surgery, many remarked that national guidelines were vague, and often individually set or set per clinic. Sometimes surgeons charged full process costs without reimbursement.
Patient Pathways and Timelines
Concerning the patient pathway, referral practices differed; in most countries, patients could self-refer themselves (81%), be referred by their general practitioner (61%) or be referred by other specialists (endocrinology, gastroenterology, etc.) (66%). Multidisciplinary team (MDT) meetings were mandatory in 78% of the countries. Twelve percent of countries did not mandate MDTs and 12% had variable practice across the country. Frequently, multidisciplinary meetings were not performed in private clinics for metabolic surgery. In the preoperative period, medical or conservative management was started by 61% of the respondents and this period generally varied from 1 to 12 months with an exception of several years in Serbia. It was mandatory for patients preoperatively (as part of the MDT) to consult various specialists as demonstrated in Fig. 2.
Criteria for referral for plastic surgery were present in 51% of countries. These were, however, very diverse (BMI < 30 after metabolic surgery, stable weight for between 6 and 24 months depending on the country, skin problems and patient’s decision).
In 45% (18/40) of European countries, pure metabolic surgeons existed to perform metabolic surgery. However, metabolic surgery was often also performed by general surgeons (24/40, 60%), with or without varying differentiations: upper GI (17/40, 43%), GI (13/40, 13%), colorectal (2/40, 5%), endocrine (4/40, 10%), HPB (2/40, 5%), trauma (1/40, 2.5%) and plastic (2/40, 5%) surgeons. A specialised metabolic training programme was available for surgeons in 23% of countries.
In the case of bariatric complications requiring emergency surgery, 70% of countries reported that a general GI surgeon would take the patient back to theatre, whilst 28% reported that a bariatric surgeon would re-operate. One free-text response stated: ‘anyone with a knife in the hand.’
Waiting times (Table 1) from the moment of referral to the decision to perform metabolic surgery was overall less than 6 months (70%), less than 1 year in 10% of and over 1 year in the remainder. From this decision, the physical surgery itself took less than 6 months in most countries (81%) (Fig. 3). There were official patient organisations in 39% of the countries (Table 1).
The mean tariff for Roux-en-Y gastric bypass (RYGB) was € 6559 ± 4039 (range € 800–18,000), for gastric sleeve (GS) € 6280 ± 3754 (range € 800–16,000), adjustable gastric band (AGB) € 4622 ± 2945 (range € 800–12,000), one anastomosis gastric bypass (OAGB) € 7080 ± 4507 (range € 800–18,000), redo surgery € 7486 ± 5666 (range € 800–20,158) and for abdominal plastic surgery € 4227 ± 3146 (range € 400–10,000) (Table 1). The conversion of local currency into euros is based on currency exchange on October 6, 2017. The average tariffs for a metabolic procedure were the lowest in Lithuania (mean € 800) and highest in Italy (mean € 16,000) (Fig. 4).
Tariffs were different for state and private sectors in 86% and similar in only 14%. There was a national standard tariff in 38%, no standard in 55% and it was unknown in 8% of the countries. To be able to get funding, the patient (or the hospital) were required to apply to their insurance company or the government and were subsequently fully reimbursed in 24% of countries (15/41). Patients were required to pay partially for their surgery in 27% (11/41), varying from 10 to 30% of the total cost, to the cost of the used instruments alone. In some countries, both full reimbursement at state hospitals and no funding at private clinics existed (7%; 3/41). In the remainder, the funding process was unknown or differed greatly between hospitals (17%; 7/41).
The access to metabolic surgery was rated fair to excellent in 68% and poor to very poor in 33% of the countries by their representatives (Fig. 5). The overall care for obese patients was rated high (fair to excellent in 81%) in most countries (Fig. 6). However, 53% of the responders shared the opinion that although the care was good, fundamental changes needed to be made (Fig. 7). Using thematic analysis, the biggest problems within the metabolic access and care system were identified as being funding/reimbursement, lack of national training programme and the differences in care for public and private hospitals.
Thirty-five percent (n = 14) of countries had a bariatric register and 63% (n = 26) of countries reported estimates or registry data of annual numbers of operations. Countries that stated that they had a national bariatric register included Austria, Belgium, Italy, Denmark, France, Germany, Netherlands, Norway, Russia, Slovenia, Sweden, Switzerland, Turkey and UK. In countries with a bariatric registry, there was no significant difference (p > 0.05) in the number of countries with or without guidelines on eligibility criteria for metabolic surgery or body contouring surgery; reimbursement criteria for metabolic or body contouring surgery; adherence to these guidelines or compliance with IFSO guidelines. Looking at countries with and without a bariatric registry, there was also no significant difference in the number of countries that mandated MDT meetings or in the waiting times from referral to decision to operate for both metabolic and plastic surgery, nor from the decision to operate the actual operation. There was also no significant difference in whether tariffs were standardised or patients were asked to contribute towards surgery, nor in whether countries had a metabolic surgery training programme, or the surgeon’s rating of access or overall care. Countries with a bariatric register were significantly more likely to have a patient organisation (p = 0.006), significantly more likely to have minimum case number criteria for bariatric centres (p = 0.005) and surgeons were more likely to operate in a bariatric centre (p = 0.043).
In total, an estimated 80,355 procedures were performed in the 26 responding countries per year, with the GS being the most performed procedure. This is concordant with previously published data . All reporting countries performed GS procedures, with a total of 40,981 (mean 1639, range 1 (Kazakhstan)–30,000 (France)). RYGB surgery was performed in 25/41 countries, with a total of 30,873 procedures (mean 1286, range 1 (Serbia)–12,000 (France)). AGB was still performed in 18/41 countries (total 5889, mean 294, range 1 (Croatia)–5000 (France)). Thirteen countries performed OAGB surgery (total 1339, mean 84, range 1 (Estonia)–585 (Austria)). The number of redo procedures was 817. Despite requesting data for the year 2015, international respondents gave operative numbers for varying years from 2003 to 2016.
In Europe, there are an estimated 810 hospitals that offer metabolic surgery, with the highest density in France (150) and lowest in Malta (1). In 10 out of 41 of the countries, there are a minimum number of procedures required to be a legitimate metabolic centre, varying from 25 procedures in Switzerland to a minimum of 200 in the Netherlands. According to the data from this questionnaire, a total of 1786 surgeons were performing the procedures reported on, varying from 1 per country in Andorra to 300 in Germany. Almost all reported not doing metabolic surgery in specialist unit except from Denmark, the Netherlands, Romania and Slovenia.