Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Bariatric surgery for obesity and metabolic disorders: state of the art

Key Points

  • Obesity continues to be a major public health problem worldwide

  • Bariatric surgery is an effective treatment for severe obesity that results in the improvement or remission of many obesity-related comorbid conditions, as well as sustained weight loss and improvement in quality of life

  • The four most common bariatric operations performed worldwide are laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding and duodenal switch

  • Bariatric surgery is now safe, with mortality comparable to common elective general surgical operations

  • Level 1 evidence show that bariatric surgery provides superior short-term and long-term weight loss and improvement of type 2 diabetes mellitus compared with conventional medical therapy

  • Newly approved laparoscopic and endoscopic devices are now available for management of patients with obesity; however, the long-term efficacy of these devices is unknown

Abstract

Obesity is one of the most important public health conditions worldwide. Bariatric surgery for severe obesity is an effective treatment that results in the improvement and remission of many obesity-related comorbidities, as well as providing sustained weight loss and improvement in quality of life. Contemporary bariatric operations include Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric band and the duodenal switch. The vast majority of these procedures are now performed using laparoscopic technique, the main advantages of which include rapid recovery, the reduction of postoperative pain and the reduction of wound-related complications, compared with open surgery. Contemporary bariatric surgery is now safe, with a mortality of three in 1,000 patients; however, all bariatric operations are associated with their own unique short-term and long-term nutritional and procedural-related complications. Type 2 diabetes mellitus (T2DM) is the most studied metabolic disorder associated with obesity, with data demonstrating that improvement and remission of T2DM in patients with obesity is superior after bariatric surgery compared with conventional medical therapy. Bariatric surgery is now a part of some treatment algorithms for the medical management of patients with T2DM and severe obesity. New, minimally invasive and endoscopic devices for the treatment of obesity have now been approved in the USA, which will expand the treatment options for individuals with obesity.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.

$32.00

All prices are NET prices.

Figure 1: Common bariatric surgical procedures.
Figure 2: New bariatric procedures.

References

  1. World Health Organization. Obesity and overweight fact sheet. WHO http://www.who.int/mediacentre/factsheets/fs311/en/ (accessed 28 December 2015).

  2. Mingrone, G. et al. Bariatric–metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet 386, 964–973 (2015).

    Article  PubMed  Google Scholar 

  3. Adams, T. D. et al. Long-term mortality after gastric bypass surgery. N. Engl. J. Med. 357, 753–761 (2007).

    CAS  Article  PubMed  Google Scholar 

  4. Esteban Varela, J. & Nguyen, N. T. Laparoscopic sleeve gastrectomy leads the U. S. utilization of bariatric surgery at academic medical centers. Surg. Obes. Relat. Dis. 11, 987–990 (2015).

    Article  PubMed  Google Scholar 

  5. Nguyen, N. T. et al. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann. Surg. 234, 279–289 (2001).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. Blondet, J. J., Morton, J. M. & Nguyen, N. T. Hospital accreditation and bariatric surgery: is it important? Adv. Surg. 49, 123–129 (2015).

    Article  PubMed  Google Scholar 

  7. Chousleb, E., Rodriguez, J. A. & O'Leary, J. P. in The ASMBS Textbook of Bariatric Surgery (eds Nguyen, N. T., Blackstone, R. P., Morton, J. M., Ponce, J. & Rosenthal, R. J.) 37–46 (Springer, 2015).

    Google Scholar 

  8. Ponce, J., Nguyen, N. T., Hutter, M., Sudan, R. & Morton, J. M. American Society for Metabolic and Bariatric Surgery estimation of bariatric surgery procedures in the United States, 2011–2014. Surg. Obes. Relat. Dis. 11, 1199–2000 (2015).

    Article  PubMed  Google Scholar 

  9. Puzziferri, N., Austrheim-Smith, I. T., Wolfe, B. M., Wilson, S. E. & Nguyen, N. T. Three-year follow-up of a prospective randomized trial comparing laparoscopic versus open gastric bypass. Ann. Surg. 243, 181–188 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  10. Dixon, J. B., Zimmet, P., Alberti, K. G., Rubino, F & International Diabetes Federation Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese type 2 diabetes. Arq. Bras. Endocrinol. Metabol. 55, 367–382 (2011).

    CAS  Article  PubMed  Google Scholar 

  11. Jensen, M. D. et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Circulation 129 (Suppl. 2), S102–S138 (2014).

    Article  PubMed  Google Scholar 

  12. Handelsman, Y. et al. American Association of Clinical Endocrinologists and American College of Endocrinology — clinical practice guidelines for developing a diabetes mellitus comprehensive care plan — 2015. Endocr. Pract. 21 (Suppl. 1), 1–87 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  13. American Diabetes Association. Standards of medical care in diabetes — 2015: summary of revisions. Diabetes Care 38 (Suppl. 1), S4 (2015).

  14. Ogden, C. L., Carroll, M. D., Kit, B. K. & Flegal, K. M. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA 311, 806–814 (2014).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. Finklestein, E. A., Trogdon, J. G., Cohen, J. W. & Dietz, W. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Aff. (Millwood) 28, w822–w831 (2009).

    Article  Google Scholar 

  16. Hammond, R. A. & Levine, R. The economic impact of obesity in the United States. Diabetes Metab. Syndr. Obes. 3, 285–295 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Angrisani, L. et al. Bariatric surgery worldwide 2013. Obes. Surg. 25, 1822–1832 (2015).

    CAS  Article  PubMed  Google Scholar 

  18. Mason, E. E. & Ito, C. Gastric bypass in obesity. Surg. Clin. North Am. 47, 1345–1351 (1967).

    CAS  Article  PubMed  Google Scholar 

  19. Hocking, M. P., Duerson, M. C., O'Leary, J. P. & Woodward, E. R. Jejunoileal bypass for morbid obesity — late follow-up in 100 cases. N. Engl. J. Med. 308, 995–999 (1983).

    CAS  Article  PubMed  Google Scholar 

  20. Maclean, L. D., Rhode, B. M. & Forse, R. A. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 107, 20–27 (1990).

    CAS  PubMed  Google Scholar 

  21. Scopinaro, N. et al. Surgical revision of biliopancreatic diversion. Gastroenterol. Clin. North Am. 16, 529–531 (1987).

    CAS  PubMed  Google Scholar 

  22. Hess, D. S. & Hess, D. W. Biliopancreatic diversion with a duodenal switch. Obes. Surg. 8, 267–282 (1998).

    CAS  Article  PubMed  Google Scholar 

  23. Marceau, P. et al. Biliopancreatic diversion with duodenal switch. World J. Surg. 22, 947–954 (1998).

    CAS  Article  PubMed  Google Scholar 

  24. Regan, J. P., Inabnet, W. B., Gagner, M. & Pomp, A. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes. Surg. 13, 861–864 (2003).

    CAS  Article  PubMed  Google Scholar 

  25. ASMBS Clinical Issues Committee. Updated position statement on sleeve gastrectomy as a bariatric procedure. Surg. Obes. Relat. Dis. 8, e21–e26 (2012).

  26. Wittgrove, A. C., Clark, G. W. & Tremblay, L. G. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes. Surg. 4, 353–357 (1994).

    CAS  Article  PubMed  Google Scholar 

  27. Nguyen, N. T., Ho, H. S., Palmer, L. S. & Wolfe, B. M. A comparison study of laparoscopic versus open gastric bypass for morbid obesity. J. Am. Coll. Surg. 191, 149–155 (2000).

    CAS  Article  PubMed  Google Scholar 

  28. Nguyen, N. T., Hinojosa, M., Fayad, C., Varela, E. & Wilson, S. E. Use and outcomes of laparoscopic versus open gastric bypass at academic medical centers. J. Am. Coll. Surg. 205, 248–255 (2007).

    Article  PubMed  Google Scholar 

  29. Nguyen, N. T., Vu, S., Kim, E., Bodunova, N. & Phelan, M. J. Trends in utilization of bariatric surgery, 2009–2012. Surg. Endosc. 30, 2723–2727 (2016).

    Article  PubMed  Google Scholar 

  30. NIH Conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann. Intern. Med. 115, 956–961 (1991).

  31. Rubino, F. et al. The mechanism of diabetes control after gastrointestinal bypass surgery reveals a role of the proximal small intestine in the pathophysiology of type 2 diabetes. Ann. Surg. 244, 741–749 (2006).

    Article  PubMed  PubMed Central  Google Scholar 

  32. Kashyap, S. R., Bhatt, D. L., Schauer, P. R. & STAMPEDE Investigators. Bariatric surgery versus advanced practice medical management in the treatment of type 2 diabetes mellitus: rationale and design of the Surgical Therapy And Medications Potentially Eradicate Diabetes Efficiently trial (STAMPEDE). Diabetes Obes. Metab. 12, 452–454 (2010).

    Article  PubMed  Google Scholar 

  33. Dixon, J. B. et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 299, 316–323 (2008).

    CAS  PubMed  Google Scholar 

  34. ASMBS Clinical Issues Committee. Bariatric surgery in class I obesity (body mass index 30–35 kg/m2). Surg. Obes. Relat. Dis. 9, e1–e10 (2013).

  35. O'Brien, P. E. et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program: a randomized trial. Ann. Intern. Med. 144, 625–633 (2006).

    Article  PubMed  Google Scholar 

  36. Kumar, R. et al. Fat malabsorption and increased intestinal oxalate absorption are common after Roux-en-Y gastric bypass surgery. Surgery 149, 654–661 (2011).

    Article  PubMed  Google Scholar 

  37. Cohen, R. V., Rubino, F., Schiavon, C. & Cummings, D. E. Diabetes remission without weight loss after duodenal bypass surgery. Surg. Obes. Relat. Dis. 8, e66–e68 (2012).

    Article  PubMed  Google Scholar 

  38. Buchwald, H. et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 292, 1724–1737 (2004).

    CAS  Article  PubMed  Google Scholar 

  39. Wang, Y. & Liu, J. Plasma ghrelin modulation in gastric band operation and sleeve gastrectomy. Obes. Surg. 19, 357–362 (2009).

    Article  PubMed  Google Scholar 

  40. Bradley, D. et al. Matched weight loss induced by sleeve gastrectomy or gastric bypass similarly improves metabolic function in obese subjects. Obesity (Silver Spring) 22, 2026–2031 (2014).

    CAS  Article  Google Scholar 

  41. Chang, S. H. et al. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 149, 275–287 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  42. Hutter, M. M. et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass. Ann. Surg. 254, 410–420 (2011).

    Article  PubMed  Google Scholar 

  43. Himpens, J. et al. Long-term outcomes of laparoscopic adjustable gastric banding. Arch. Surg. 146, 802–807 (2011).

    Article  PubMed  Google Scholar 

  44. Kindel, T., Martin, E., Hungness, E. & Nagle, A. High failure rate of the laparoscopic-adjustable gastric band as a primary bariatric procedure. Surg. Obes. Relat. Dis. 10, 1070–1075 (2014).

    Article  PubMed  Google Scholar 

  45. Altieri, M. S. et al. Lap band outcomes from 19,221 patients across centers and over a decade within the state of New York. Surg. Endosc. 30, 1725–1732 (2016).

    Article  PubMed  Google Scholar 

  46. Mingrone, G. et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N. Engl. J. Med. 366, 1577–1585 (2012).

    CAS  Article  PubMed  Google Scholar 

  47. Morton, J. M., Garg, T. & Nguyen, N. Does hospital accreditation impact bariatric surgery safety? Ann. Surg. 260, 504–508 (2014).

    Article  PubMed  Google Scholar 

  48. Villamere, J., Gebhart, A., Vu, S. & Nguyen, N. T. Utilization and outcome of laparoscopic versus robotic general and bariatric surgical procedures at Academic Medical Centers. Surg. Endosc. 29, 1729–1736 (2015).

    Article  PubMed  Google Scholar 

  49. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N. Engl. J. Med. 361, 445–454 (2009).

  50. Buchwald, H., Estok, R., Fahrbach, K., Banel, D. & Sledge, I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery 142, 621–632 (2007).

    Article  PubMed  Google Scholar 

  51. Inge, T. H. et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N. Engl. J. Med. 374, 113–123 (2016).

    CAS  Article  PubMed  Google Scholar 

  52. Inge, T. H. et al. Perioperative outcomes of adolescents undergoing bariatric surgery: the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study. JAMA Pediatr. 168, 47–53 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  53. Gebhart, A., Young, M. T. & Nguyen, N. T. Bariatric surgery in the elderly: 2009–2013. Surg. Obes. Relat. Dis. 11, 393–398 (2015).

    Article  PubMed  Google Scholar 

  54. Ikramuddin, S. et al. Roux-en-Y gastric bypass versus intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial. JAMA 309, 2240–2249 (2013).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  55. Courcoulas, A. P. et al. Three-year outcomes of bariatric surgery versus lifestyle intervention for type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA Surg. 150, 931–940 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  56. Schauer, P. R. et al. Bariatric surgery versus intensive medical therapy for diabetes — 3 year outcomes. N. Engl. J. Med. 370, 2002–2013 (2014).

    PubMed  PubMed Central  Google Scholar 

  57. Cummings, D. E. et al. Gastric bypass surgery versus intentive lifestyle and medical intervention for type 2 diabetes: the CROSSROADS randomised controlled trial. Diabetologia 59, 945–953 (2016).

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  58. Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: the look AHEAD study. Obesity (Silver Spring) 22, 5–13 (2014).

  59. Buchwald, H. et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am. J. Med. 122, 248–256. e5 (2009).

    Article  PubMed  Google Scholar 

  60. Grundy, S. M. et al. Definition of metabolic syndrome: report of the National Heart, Lung, and Blood Institue/American Heaty Association conference on scientific issues related to definition. Circulation 109, 433–438 (2004).

    Article  PubMed  Google Scholar 

  61. Batsis, J. A. et al. Effect of bariatric surgery on the metabolic syndrome: a population-based, long-term controlled study. Mayo Clin. Proc. 83, 897–907 (2008).

    Article  PubMed  Google Scholar 

  62. Sjostrom, L. et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N. Engl. J. Med. 357, 741–752 (2007).

    Article  PubMed  Google Scholar 

  63. Sarr, M. G. et al. The EMPOWER study: randomized, prospective, double-blind, ulticentre trial of vagal blockade to induce weight loss in morbid obesity. Obes. Surg. 22, 1771–1782 (2012).

    Article  PubMed  Google Scholar 

  64. Ponce, J. et al. The REDUCE pivotal trial: a prospective, randomized controlled pivotal trial of a dual intragastric balloon for the treatment of obesity. Surg. Obes. Relat. Dis. 11, 874–878 (2015).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

The authors contributed equally to this Review.

Corresponding author

Correspondence to Ninh T. Nguyen.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

PowerPoint slides

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nguyen, N., Varela, J. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol 14, 160–169 (2017). https://doi.org/10.1038/nrgastro.2016.170

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrgastro.2016.170

Further reading

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing