This document summarizes options for bariatric surgery, trends in procedures over time, and latest innovations. It discusses various procedures like gastric bypass, sleeve gastrectomy, adjustable gastric banding, and duodenal switch. Key points covered include the mechanisms and outcomes of different procedures, controversies around aspects like limb length and hernia risk, and benefits of the laparoscopic approach like reduced pain and faster recovery. Bariatric surgery is shown to effectively induce significant and long-lasting weight loss as well as resolution of comorbidities like diabetes and hypertension. Procedures that involve both restriction and malabsorption like Roux-en-Y gastric bypass and biliopancreatic diversion achieve the highest levels of

1. 1

2. Bariatric surgery: options, trends,
and latest innovations
Fawzy El-Messallamy
A Prof. of Internal Medecine Diabetes & Endocrinology
Zagazig University
2

3. Metabolic Surgery
Alteration of the gastrointestinal tract that affects
cellular and molecular signaling leading to a
physiologic improvement in
Energy balance .
Nutrient utilization .
Metabolic disorders.
Kaplan LM, Seeley RJ, Harris JL. Bariatric Surgery and the Road Ahead, Bariatric Times, 9
(9): Supplement C, September 2012. http://bariatrictimes.epubxp.com/i/82655 4

4. What are parameters of obesity?
1) Body mass index
Normal BMI 20-25
Over weight 25-30
Obese >30
Class I 30-35
Class II 35-40
Class III > 40
BMI =
)(mHeight
kg/Weight
2

6. Waist circumference
 risk Substantial risk
Female  80 cm  88 cm
Male  94 cm  102 cm
Apple-shaped more risk than Pear-shaped

7.  Dramatic increase during
last 2 decades
 2/3 US individuals are
overweight
 50% of these are obese
 5% morbidly obese
 Rapid growth in BMI
subgroups ≥ 35 and ≥ 40
 Increase in comorbidities
 2.5 million deaths per
year worldwide from
comorbidities
1. National Center for Health Statistics NHANES IV Report
2. Flegal KM et al: Prevalence and trends in obesity among US adults 1999-2000. JAMA 2002; 288: 1723-1727

8. Derived from Center for Disease Control and Prevention website www.cdc.gov

9. Derived from Center for Disease Control and Prevention website www.cdc.gov

10.  BMI ≥ 35 kg/m²:
 Risk of death ≈ 2.5 times greater than if BMI of 20-25
kg/m²
 BMI ≥ 40 kg/m²:
 Risk of death 10 times greater
Obesity
2nd leading cause of preventable premature
death in US (smoking)

11. Stroke
Coronary
heart
disease
Cancer
(endometrial, breast,
colon)
Diabetes
THE PROBLEMS
20 Years Ago
210 Calories
2.4 ounces
Today
610 Calories
6.9 ounces
How to burn* 400
calories:
Walk 2 hr 20 MinutesLow HDL
Insulin
Resistance
CARDIOMETABOLIC
Syndrome
High LDL
Hypertension
Endothelial Dysfunction
Mortality

12. Obesity associated conditions
Diabetes
Hypertension
Sleep apnea
Congestive heart failure
Hyperlipidemia
Stroke
Coronary Artery Disease
Osteoarthritis
Gastroesophageal Reflux Disease
Non-alcoholic fatty liver
Psychological disturbances

13. 1. Calle et al. N Eng J Med, 1999; (15)341:1097-105.
2. Ali H, Mokdad AH, et al. JAMA 2004;291:1238-1245.

14.  Relatively ineffective:
 Diet with and without support organizations
 Pharmaceutical agents
 Only long-term options:
 Bariatric surgery
 Metabolic surgery
 1991 National Institute of Health Guidelines
 BMI ≥ 40 or ≥ 35 with significant comorbidities
1. North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. The Practical Guide: Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, Md: National Institutes of Health; 2000. NIH 00-4084.
2. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis.
JAMA 2004;292: 1724-37.
3. National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med. 1991; 115: 956-961

15.  First line of treatment
 Calorie restriction
 Exercise regimen
 Behavior modification
 Pharmacotherapy
 Average weight loss ≈ 5% to 10% initial body
weight at 3 to 6 months
 Regain weight after 1 to 2 years
1. Yanovski SZ, Yanovski JA. Obesity. N Engl J Med 2002;346: 591-602

16.  Consensus Guidelines 2003
 Surgical therapy should be considered for
individuals who:
 Have a BMI of greater than 40 kg/m²
OR
 Have a BMI greater than 35 kg/m² with significant
comorbidities
AND
 Can show that dietary attempts at weight control
have been ineffective
Derived from American Society of Bariatric Surgery website: www.asbs.org

17. Bariatric Surgery
Diet
Exercise
Behavior Modification
“Postoperative care, nutritional counseling, and surveillance should
continue for an indefinitely long period.”

18.  Obesity related to a metabolic or
endocrine disorder
 History of substance abuse or major
psychiatric problem
 Surgery contraindicated or high risk
 Women who want to become
pregnant within the next 18 months

19. Period or Decade Incidence of surgery Reason for change
Late 1970’s
Early 1980’s
25,000 procedures per
year
Innovative procedures
• gastroplasty
• loop GBP
• jejuno-ileal bypass
Late 1980’s
1990’s
5,000 procedures per
year
Multifactorial:
• High M&M
• Ineffective long-term
• Perceived failure
• Surgeon experience
2000’s
80,000 to 110,000
procedures per year
Multifactorial:
• Laparoscopy
• Long-term data
• Centers of Excellence
1. National Hospital Discharge Survey Public-use data file and documentation. Multi-year data CD-ROM. National Center for Health Statistics,
1979-1996.
2. Nguyen et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140: 1198-202.
3. Griffen et al. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet 1983; 157: 301-8.
4. Shirmer et al. Bariatric Surgery Training: Getting Your Ticket Punched. J Gastrointest Surg 2007;11: 807-12.

20. Study Type and size Effect on weight
Effect on
comorbidities
Buchwald et al.
Meta-analysis
n = 22,094 pts
Mean excess
weight loss: 61%
Resolution of:
•Diabetes: 70%
• HTN: 62%
• Sleep apnea: 86%
Swedish Obese
Subject trial
(SOS)
Prospective
matched cohort
n = 4,047 pts
At 10 years:
• Med: 1.6% gain
• Surg: 16% loss
Improved by surg:
• Diabetes
• Lipid profile
• HTN
• Hyperuricemia
1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and
meta-analysis. JAMA 2004;292: 1724-37.
2. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular
risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

21.  Jejuno-ileal bypass
 70% excess weight loss
 Reduced caloric intake
 Malabsorption
 Dehydration
 Acidosis
 Electrolyte abnormalities
 Liver failure
 Bacterial overgrowth
1. Griffen WO Jr, Bivins BA, Bell RM. The decline and fall of the jejunoileal bypass. Surg Gynecol Obstet
1983; 157: 301-8.

22.  Loop gastric bypass
 Reduced capacitance
 Aversive eating
 Dumping syndrome
 Alkaline reflux gastritis
 Esophagitis

23.  Horizontal gastroplasty
 “Gastric stapling”
 1970’s
 Regained weight
 Many pts left
 GERD
 Obesity
 May seek re-operation
for correction anatomy
1. Salmon PA. Salvage of failed horizontal gastroplasty by the addition of a distal gastric bypass. Obes
Surg 1993;3:45-51.

25.  “Gold Standard”
 80% of bariatric proc.
 Lap vs Open
 Restrictive and
Malabsorptive:
 Reduced calorie
intake
 Macronutrient
malabsorption

26. 27

27. 28

28. 29

29. 31

30. Controversy Study Type and size Results
Defunctionalized
jejunum limb lenght
Brolin et al.
Prospective (n = 45)
22 pts: 75 cm length
23 pts: 150 cm length
Mean f/u: 43 ± 17 m
Mean exc. wght loss:
• 50% for short limb
• 64% for long limb
• No difference in
complications
Internal hernia
• Lap vs Open
• Roux limb position
• Mesocolic closure
Higa et al.
Retrospective
(n = 2000)
Hernia site:
• mesocolic: 67%
• Jejunal: 21%
• Petersen: 7.5%
Leaks or bleeding:
• Drain placement
• UGI series
Dallal et al.
Prospective
(n = 352)
No drains or UGI
Small complication
rate recognized from
tachycardia
1. Brolin RE. Long limb Roux en Y gastric bypass revisited. Surg Clin North Am 2005;85:807-17, vii.
2. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: Incidence, treatment and prevention.
Obes Surg 2003;13(3):350–4.
3. Dallal RM, et al. Back to basics – clinical diagnosis in bariatric surgery. Routine drains and upper GI series are unnecessary. Surg
Endosc 2007;21:2268-71. Epub 2007 May 5.

31. 33

32.  Popular in 80’s and 90’s
 Less common than RYGB
 Purely restrictive
 Rapid sense of satiety
 Reduced calorie intake
 Pouch creation
 Hole through anterior and posterior wall
 Staple line to angle of His
 Nondistensible band around distal neo-pouch

33.  Randomized trials:
 VBG vs RYGB
 Better weight loss w/ RYGB
 Similar operative risks
 Replaced by Adjustable gastric band
 Similar outcomes
 Technically easier
1. Hall JC, Watts JM, O’Brien PE, Dunstan RE, Walsh JF, Slavotinek AH, et al. Gastric surgery for morbid obesity. The Adelaide Study. Ann
Surg 1990;211:419-27.
2. Howard L, Malone M, Michalek A, Carter J, Alger S, Van Woert J. Gastric bypass and vertical banded gastroplasty – a prospective
randomized comparison and 5 – year follow-up. Obes Surg 1996;5:55-60.

34.  Dr. Cadiere 1992
 Technically simple
 Purely restrictive
 Decrease hunger
 Early satiety
 Food aversion
 Adjustment to stoma
diameter

35.  Scopinaro (Italy)
 Significant weight loss
 75% excess weight loss
 Maintained > 20 yrs
 Super-morbid obesity
 BMI ≥ 60 kg/m²
 Restrictive
 Malabsorptive
 Decreased hunger
 Hormonal changes: distal delivery of nutrients
1. Marinary GM, Murelli F, Camerini G, Papadia F, Carlini F, Stabilini C, et al. A 15 year evaluation of biliopancreatic diversion
according to the Bariatric Analysis Reporting Outcome (BAROS). Obes Surg 2004;14:325-8.
2. Scopinaro N, Gianetta E, Adami GF, Friedman D, Traverso E, Marinari GM, et al. Biliopancreatic diversion for obesity at eighteen
years. Surgery 1996;119:261-8.

36.  Partial gastrectomy
 200 – 500 ml gastric pouch
 Ileal transection
 250 cm above ileocecal valve
 Gastro-ileal anastomosis
 End-to-side ileoileostomy
 50 cm proximal to ICV
 Alimentary channel = 200 cm
 Common channel = 50 cm

37.  Induced weight loss:
 Improves comorbidities before 2nd operation
 Silechia et al:
 41 superobese pts
 2nd stage operation
 60% resolved comorbidities
 24% resoved prior to 2nd procedure
 Avoids complications:
 Anastomotic leak
 Stricture
 Internal hernia
1. Silechia G, et al. Effectiveness of laparoscopic sleeve gatrectomy (first stage of biliopancreatic diversion with duodenal switch) on
comorbidities in super obese high-risk patients. Obes Surg 2006;16:1138-44.
2. Frezza EE, et al. Laparoscopic vertical sleeve gastrectomy for morbid obestiy. The future procedure of choice? Surg Today 2007;37:275-81.

38. 41

39. OPEN
 ↑ post op pain
 Longer
hospitalizations
 ↑ wound
complications
 Infection
 Hernias
 Seromas
 Return to work in 4-8
weeks
LAPAROSCOPIC
 ↓ post op pain
 Early mobility
 ↓ Wound
complications
 2-3 day hospital stay
 Return to work in 1-3
weeks
1. Nguyen NT, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch
Surg 2005;140:1198-202.

40. 43

41.  VBG vs LAGB
 Similar % excess weight loss:
 38% at 12 months
 45% at 24 months
 54% at 36 months
 European trials: LAGB up to 70%
1. Ren CJ, Horgan S, Ponce J. US experience with the LAP-BAND system. Am J Surg 2002;184(6B):46S-50S.
2. Belachew M, Belva PH, Desaive C. Long term results of laparoscopic adjustable gastric banding for the treatment of morbid
obesity. Obes Surg 2002;12:564-8.
Laparoscopic Adjustable Gastric Banding LAGB Vertical Banded Gastroplasty VBG

42.  RYGB vs LAGB
 Recent Italian randomized study
 5 year follow-up
 RYGB: significantly lower weight and BMI
 BPD or Duodenal switch
 Greater weight loss in super-obese
 70% excess weight loss up to 25 yrs post op
 Minimal rebound at 10 yrs post op
Laparoscopic Adjustable Gastric Banding LAGB Vertical Banded Gastroplasty VBG
Biliopancreatic Diversion BPD
1. Angrisani L, et al. Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5 year results of prospective randomized trial Surg Obes Relat Dis 2007;3:127-32, discussion 132-2.
2. Prachand VN, et al. Duodenal switch provides superior weight loss in the super-obese (BMI > 50) compared with gastric bypass. Ann Surg 2006;244:611-19.
3. De Maria EJ, Schauer P, Patterson E, Nguyen NT, Jacob BP, Inabnet WB, et al. The optimal surgical management of the super-obese patient: the debate. Presented at the annual meeting of the Society of
American Gastroenterology and Endoscopic Surgeons, Hollywood, Florida, USA, April 13-16, 2005. Surg Innov 2005;12:107-21.

43.  Surgical patients vs Control subjects
 Recent studies:
 Mortality decreased by 40% in surgical group
 Long-term death lower in surgical group
 Multiple studies:
 Weight loss and improved comorbidities
30% to 85% Reduced Mortality
compared to nonsurgical care

44. N=104
1 year post op
Number
Pre-op % Worse
% No
change
%
Improved
%
Resolved
Osteoarthritis 64 2 10 47 41
Hypercholesterolemia 62 0 4 33 63
GERD 58 0 4 24 72
Hypertension 57 0 12 18 70
Sleep Apnea 44 2 5 19 74
Hypertriglyceridemia 43 0 14 29 57
Peripheral Edema 31 0 4 55 41
Stress Incontinence 18 6 11 39 44
Asthma 18 6 12 69 13
Diabetes 18 0 0 18 82
Average 1.6% 7.8% 35.1% 55.7%
90.8%
Improved or ResolvedSchauer, et al. Ann Surg 2000 Oct;232(4):515-29

45. 48

46.  Rapid decrease in serum blood sugar
 Decrease in medication requirements
 66% to 75% complete resolution
 Increased insulin sensitivity
 Inhibits progression of disease
 Swedish Obese Subject Trial:
 Reduced relative risk by factor of 30 compared to
medically treated population
1. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-
analysis. JAMA 2004;292: 1724-37.
2. Pories WJ, Swanson MS, MacDonald KG, Long SB, Morris PG, Brown BM, et al. Who would have thought it ? An operation
proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;22:339-50, discussion 350-2.
3. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk
factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

47.  50% complete resolution
 25% reduced medications
 Swedish Obese Subject Trial: 2 years post
op
 Decreased relative risk of new onset
HTN = 10
 Time interval for resolution not cleared
1. SjostromL, Lindros AK, Peltonem M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular
risk factors 10 years after bariatric surgery. N Engl J Med 2004;351: 2683-93.

48.  70% prevalence in gastric bypass pts
 80% improvement
 No more CPAP
 Decreased pCO2
 Increased pO2
1. Dixon JB, et al. Predicting sleep apnea and excessive day sleepiness in the severity obese: indicators for
polysomnography. Chest 2003;123:1134-41.
2. Sugerman HJ, et al. Gastric surgery for respiratory insufficiency of obestiy. Chest 1986;90:81-6.

49.  Non-alcoholic fatty liver:
 Resolution of steatosis
 Improved liver contour
 Osteoarthritis:
 50% reduced medication intake
 Decreased joint stress from weight loss
 Delayed operative joint intervention
 Depression:
 High prevalence in obese
 Decreased medication use
1. Clark JM, et al. Roux-en-Y gastric bypass improves liver histology in patients with non-alcoholic fatty liver disease. Obes Res
2005;13:1180-6
2. Abu-Abeid S, et al. The influence of sugically-induced weight loss on the knee joint. Obes Surg 2005;15:1437-42.
3. Sarwer DB, et al. Psychiatric diagnoses and psychiatric treatment among bariatric surgery candidates. Obes Surg 2004;14:1148-56.

50.  Surgical
 Technical errors
 Errors in
judgment
 Type of
procedure
1. Mason EE, et al. Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction.
Obes Surg 2005;71:9-14.
 Metabolical
 Malabsorption
 Nutrients
 Vitamins

51. Carbohydrate
Lipid
Proteins
Ca²+
Fe ²+
B 12
A, D, E, K

52. 56

53. A growing consensus favors bariatric surgery
page 57
“Bariatric surgery should be considered for adults with BMI ≥
35 kg/m2 and type 2 diabetes, especially if the diabetes is
difficult to control with lifestyle and pharmacologic therapy.”
– American Diabetes Association (2009)
“When indicated, surgical intervention leads to significant
improvements in decreasing excess weight and co-
morbidities that can be maintained over time.”
– American Heart Association (2011)
“Bariatric surgery is an appropriate treatment for people with
type 2 diabetes and obesity not achieving recommended
treatment targets with medical therapies”
– International Diabetes Federation (2011)
“The beneficial effect of surgery on reversal of existing DM
and prevention of its development has been confirmed in a
number of studies”
– American Association of Clinical Endocrinologists (2011)
Sources: American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care 2009; 32(S1):S13-S61,
Poirier P, Cornier M-A, Mazzone T et al. Bariatric surgery and cardiovascular risk factors: A scientific statement from the American Heart Association. Circulation 2011; 123:00-00.
International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. 2011.
Handelsman Y, Mechanick JI, Blone L et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive plan. Endocr Prac 2011; 17(Suppl 2).

54. A growing consensus favors bariatric surgery
“The Endocrine Society recommends that practitioners
consider several factors in recommending surgery for
their obese patients with type 2 diabetes, including
patient’s BMI and age, the number of years of diabetes and
the assessment of the (patient’s) ability to comply with the
long-term lifestyle changes that are required to maximize
success of surgery and minimize complications.”
“… remission of diabetes, even if temporary, will still
lead to a reduction in the progression to secondary
complications of diabetes (such as retinopathy,
neuropathy and nephropathy), which would be an important
outcome of … surgery.”
– The Endocrine Society (March 2012)
page 58
Source: The Endocrine Society, Evaluating the Benefits of Treating Type 2 Diabetes with Bariatric Surgery, March 30, 2012.

55. 59

56. 60This article was published on March 31, 2014, at NEJM.org.

57.  In short-term randomized trials (duration, 1 to
2 years), bariatric surgery has been associated
with improvement in type 2 diabetes mellitus.
 Assessed outcomes 3 years after the
randomization of 150 obese patients with
uncontrolled type 2 diabetes :
1. Intensive medical therapy alone.
2. Intensive medical therapy plus
Roux-en-Y gastric bypass.
3. Intensive medical therapy plus
sleeve gastrectomy.
The primary end point was a glycated hemoglobin
level of 6.0% or less.

58.  At 3 years, the criterion for the primary
end point was met by:
1. 5% of the patients in the medical-therapy
group.
2. 38% of those in the gastric-bypass group
(P<0.001)
3. 24% of those in the sleeve-gastrectomy
group (P = 0.01).
The use of glucose-lowering medications,
including insulin, was lower in the surgical
groups than in the medical-therapy group

59.  Reductions in weight from baseline, with
reductions of
1. 24.5±9.1% in the gastric-bypass group.
2. 21.1±8.9% in the sleeve-gastrectomy group.
3. 4.2±8.3% in the medical-therapy group (P<0.001
for both comparisons).
 Quality-of-life measures were significantly better
in the two surgical groups than in the medical-
therapy group.
 There were no major late surgical complications.

65.  Among obese patients with uncontrolled type 2
diabetes, 3 years of intensive medical therapy
plus bariatric surgery resulted in glycemic
control in significantly more patients than did
medical therapy alone.
 Secondary end points, including body weight,
use of glucose-lowering medications, and
quality of life, also showed favorable results at
3 years in the surgical groups, as compared
with the group receiving medical therapy
alone.
 (Funded by Ethicon and others; STAMPEDE ClinicalTrials.gov number, NCT00432809.)

66. 70

68.  Significant improvement in the albumin-to-
creatinine ratio with surgery as compared with
medical therapy.
 The incidence of Nephropathy (defined as a
doubling of the serum creatinine level, >20%
reduction in the estimated glomerular filtration
rate, new macro- albuminuria, or the need for
renal-replacement therapy) was increased in
the surgical groups, particularly in the gastric-
bypass group.

69.  Gastric bypass surgery is associated with :
 Long -term increase in urinary oxalate excreation .
 Risk of urolithiasis.
 Increased oxalate absorption, probably due to fat malab-
sorption and subsequent reductions in the intra- luminal free
calcium concentration,may provide one mechanism for renal
injury after gastric bypass surgery.
 The devastating consequences of oxalate
nephropathy after bypass surgery in a case
series of 11 patients.
 Although bariatric surgery represents a
valuable treatment to combat the epidemic of
obesity and its complications, unintended
consequences of this gross distortion of gut
physiology should not be overlooked

70.  We have some concerns about the conduct and interpretation of
this study
 First: Medical- therapy group did receive intensive glucose-
lowering therapy. After 3 years, the mean (±SD) glycated
hemoglobin level was 8.4±2.2%, the number of glucose-lowering
drugs was 2.6±1.1, and only 55% of patients used insulin. Hence,
although not reaching protocol targets, medical therapy was not
intensified according to published guide- lines. Nearly half the
patients did not use insulin despite ample evidence that it can
improve glycemic control.
 Second : levels of low-density lipoprotein cholesterol and blood
pressure were not significantly reduced in the surgical groups,
findings that are at variance with those in previous reports from
us and others

71.  Despite convincing data, the question remains whether surgery
can provide the solution to the obesity epidemic.
 In the past 20 years, rates of severe obesity tripled in the United
States.
 According to current projections, 50% of the adult population will
be obese by 2030. Thus, do we need more bariatric surgery?
 At an estimated cost of about $25,000 per surgery,operating on
only severely obese persons would consume 15 to 20% of annual
health care expenditures.
 Expenditures do not stop with the surgical procedure, as prior
studies have shown persistently high health care utilization and
costs for at least 6 years after surgery.
 Truly overcoming this epidemic will require different strategies
that have proved affordable and effective in dealing with the
devastating effects of unhealthy food

72. 76

73. Bariatric surgery is an effective treatment for diabetes
and impaired glucose tolerance in patients with a body
mass index of at least 35 but less than 40 kg/m2 who are
followed up to 2 years.
Weight-loss and glucose-control outcomes achieve
greater improvement than typically seen with behavioral
interventions (e.g., diet, exercise).
Head-to-head comparisons are needed to determine
comparative effectiveness among surgical interventions.
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.
Available at www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

74. The rates of short-term adverse effects (cardiovascular,
respiratory, gastrointestinal, and metabolic) were low.
Reported complications of laparoscopic adjustable gastric
banding include band slippage, leakage, and pouch
dilation, and those reported for Roux-en-Y gastric bypass
include stricture, ulcers, and rarely hemorrhage.
While not discussed in the review, it has been suggested
that weight regain and recurrence of diabetes might be
observed after bariatric surgery.
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.
Available at www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

75. Despite promising short-term outcomes, very few studies
of this target population have follow up durations greater
than 2 years.
The long-term effects of bariatric surgical procedures on
major clinical endpoints in this patient population with a
lower body mass index are not known.
Studies comparing surgical intervention to comprehensive
care and behavioral interventions to each other are also
needed to determine the relative effectiveness of these
strategies in the long term.
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.
Available at www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

76.  There is a scarcity of high-quality studies for patients with a body
mass index of 30.0 to 34.9 kg/m2 and metabolic comorbidities.
 Very few studies had long-term follow up (more than 2 years).
 The effectiveness of bariatric surgery in preventing the clinical
consequences of diabetes and its impact on major clinical endpoints
such as cardiovascular mortality or morbidity have not been studied.
 Of the 54 studies included in the comparative effectiveness review, a
very limited number were conducted in the United States, making
applicability of findings from studies conducted outside the United
States to American patients unclear.
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82. Available
www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

77. Quality-of-life and psychological outcomes after surgery
were rarely reported.
Most studies were not designed to assess adverse events
and reflected events reported by the surgeon or the
surgical team. The rates of adverse events in these studies
may, therefore, be lower than rates experienced in the
wider community.
For all surgical procedures, there is concern that published
studies usually come from academic medical centers.
Outcomes for patients in these studies may not reflect the
outcomes achieved in the wider community.
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.
Available at www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

78.  The possible benefits of bariatric surgery for patients with a body mass index
between 30.0 and 34.9 kg/m2 and with diabetes or IGT
 The possibility that the patient could be referred to a surgeon who would
discuss the different types of bariatric surgery recommended for the patient
 The possible adverse effects of bariatric surgery
 Whether or not the specific bariatric surgery recommended for the patient
would be covered by the patient's insurance and how that would impact the
patient's decision making
 Lifestyle changes that are necessary to fully benefit from bariatric surgery
 Nonsurgical treatment options for diabetes and other metabolic conditions
 The expected course of the patient's diabetes with continued nonsurgical
therapy
Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.
Available at www.effectivehealthcare.ahrq.gov/weight-loss-surgery.cfm.

81. 85