Original article
History, recent status and future of bariatric surgery in Slovakia

Introduction
Obesity is often called the epidemic of the third millennium. The growing incidence from year to year makes this problem more serious. It is alarming that the numbers of obese people are growing in both developed and developing countries. It is due to an inactive way of life, use of modern technologies and high calorie food. The prevention of this “globesity” seems to be impossible. Its treatment should be complex. In the end stage of the disease only surgical treatment is the right option [1].
History
The history of surgical treatment of obesity started in the 1970s. At that time the group around Dr. Jaroslav Rozhold performed jejuno-ileal bypasses. Their results were published in Slovak medical literature [2, 3]. The first procedures were performed in 1972. In spite of very good weight loss, poor quality of life and serious metabolic adverse effects caused this method to be abandoned, not only in Slovakia but throughout the world as well [4]. Other, less invasive methods became popular. In fact, two methods became the favourites: gastric banding and gastric bypass. In both great technical and surgical development could be observed [5]. It is a pity that in Slovakia bariatric surgery disappeared. In former Czechoslovakia these operations were limited to two centres: Praha, and Hradec Králové. For Slovak patients it was enough. After the split of Czechoslovakia in 1993, mostly due to antagonism between prime ministers Klaus and Mečiar, treatment in the Czech Republic for Slovak patients became impossible. It was abroad and Slovak health insurance companies were not willing to cover the expenses. It was a signal for us to start with bariatric surgery. After initial experience with laparoscopic surgery we started in December 1997, after two years of preparation, with laparoscopic adjustable gastric banding. It was in the Surgical Department of the Railway Hospital in Bratislava. We persuaded the General Health Insurance Company to cover the expenses of this procedure for the first 39 operations. They were performed in 18 months. Afterwards the Insurance Company quit the coverage. Due to the financial situation of Slovak patients only a few patients could be operated in the following year. No-one was willing to pay for bariatric surgery. After a promising start further development has been very slow. We have to say, at this place, that at the beginning there were rather frequent complications. Now we can consider these complications as the learning curve. At that time we were forced to defend our image. A lot of criticism was made, but no-one looked abroad at what the situation looked like there. In bariatric surgery 100 operations count as the learning curve. We presented our results in Obesity Surgery [6] and no one penalized us. It was a source of information for us and for others too. A great handicap for us was that we had not had any experience with open bariatric surgery before; it is one of the guidelines of IFSO [7]. We came through complications with ports (infection, migration), and performed some reoperations for slippage, pouch dilatation and for band erosion as well. Another reoperation was needed for connection tube rupture. Once we had to remove the band for patient noncompliance. The complications were observed mostly in the first part of our group (39 patients). These were operated on in the first 18 months. In the second part of the group the complication rate went down to a minimum. At this place it is necessary to thank Prof. MUDr. Martin Fried, CSc. for his kind support of the Slovak bariatric community. Martin Fried, as the only one among Czech and Slovak surgeons, was President of the international association IFSO – International Federation for Surgery of Obesity. He was the one who helped us to come to Europe. He helped us with much good advice and personal support. Recently he has published a very good book about bariatric surgery, based on his long experience [8]. There is a lot of useful information for all who are active in the field of bariatric surgery in our countries.
Recent status
After starting bariatric surgery in 1997 we continued in the programme of surgical treatment of obesity. We were not able to create a really functioning interdisciplinary team. This is at world standard. The activities also in postoperative follow-up were mostly on the arms of surgeons. This is not the optimal situation. But it is not only our problem. In spite of problems and troubles in 2000 colleagues in Košice started with bariatric surgery. We performed the first two procedures together. In 2002 a program of obesity surgery was started in Banska Bystrica. Up till the end of 2004 there were in Bratislava 81 operations, in Banska Bystrica 48 and in Košice 31 performed. In Banská Bystrica there were 24 nonadjustable and 24 adjustable gastric bandings used. In Bratislava and Košice there were only adjustable bands implanted. At this place we do not want to evaluate pros and cons of different band types. The number of procedures is not large. Compared with data from the Czech Republic our group of patients is really very small. We have mentioned the reasons above. But we can also say that we have learned from the problems we were facing at the beginning. At present the complication rate for Slovakia is acceptable.
Future
We do not want to be visionaries, but we shall try to explain our vision of bariatric surgery in Slovakia. We see as an optimistic event the creation of the Obesitology section in 2002 as a part of Slovak diabetologic society. From that time the section has organised once a year an excellent symposium called Obesitologic days, a meeting devoted to interdisciplinary communication. The problems in our country can be discussed there – and sometimes solved as well. It is a place for exchange of experience. We can inform each other about possibilities of our disciplines in our countries, because this Symposium has become international. Czech colleagues are regular participants at this event. We also appreciate the activities of Johnson and Johnson on the Slovak and Czech market. These have had a positive influence on the situation in bariatric surgery. The influence on the health insurance companies could be seen, too. We expect some positive influence on Slovak obesitology from cooperation with international organisations. Among these we can count the SCOPE project. Perhaps closer cooperation with Polish surgeons in the field of bariatric surgery will be possible and useful for both. According to procedure types we suppose that mostly gastric banding will be done. They are less demanding than gastric bypasses. Also they are fully reversible, which is not the case for bypasses. In spite of better weight loss, we do not expect a higher frequency of bypasses in Slovakia. What kind of gastric banding will be the most used depends on activities of band selling companies. Some advantages of one band are described by Fried in his book [8]. The band is called the high volume low pressure band. We believe that three centres for Slovakia are enough. It is very important to perform minimally 20 procedures in a year. It is clear that only by a higher operation count can better results be achieved and the complication rate be depressed. Maybe a certain regulatory role can be played by health care insurance companies. Surely there is a need for close cooperation among the centres. Close cooperation in interdisciplinary teams is needed as well, not only in the preoperative phase but also in the follow-up. It is evident that in the centres where cooperation works the results are better. In 2005 in Slovakia another three departments started with bariatric surgery, but their results gave us no proof that it should be the proper way to the future. To have five or six “centres” with five or six operations in a year is not the best solution to the problem of bariatric surgery in Slovakia.
Conclusion
To conclude, we can say that we have an optimistic view of the future of Slovak bariatric surgery. The reason for it lies also in the kind support of the Czech bariatric community. This community has much more experience and is better organised. We hope that closer cooperation with the Polish bariatric society can be useful for both. We believe that some controversies among politicians in Europe will not have a bad influence on surgery and on bariatric surgery too. We believe that also in Slovakia we will be able to fulfil the international guidelines serving our obese patients.
References
1. Deitel M. Bariatric surgery is a cost-saving for the healthcare system. Obes Surg 2005; 15: 301-303. 2. Rozhold J. Intestinal bypass in the treatment of obesity. Bratisl Lek Listy 1975; 63: 459-465. 3. Rozhold J, Beòo I, Siman J i wsp. Jejunoileal bypass I. Common remarks. Bratisl Lek Listy 1979; 71: 129-138. 4. Hell E, Miller K. Morbide Adipositas – Klinik und chirurgische Therapie. Ecomed Verlag 2000; 10. 5. Weiner R. Neue chancen bei Adispositas. TRIAS Verlag 2002; 160 p 6. Holéczy P, Novák P, Králová A. Complications in the first year of laparoscopic gastric bandig: is it acceptable? Obes Surg 1999; 9: 453-455. 7. The Cancun IFSO statment on bariatric surgeon qualifications. www.obesity-online.com 8. Fried M. Moderní chirurgické metody léèby obezity. Grada publishing a.s. 2005.