Severe obesity and its comorbidities, like hypertension, type 2 diabetes, dyslipidemia, and sleep apnea are widely prevalent. However, only a small proportion of patients with these conditions prefer to undergo bariatric surgery. Thus, there is a need for summarizing the expanding evidence on the benefits and risks of bariatric surgery to better guide shared decision-making conversations. Nearly 2,52,000 bariatric procedures (per 2018 numbers) are performed every year in the United States, of which approximately 15% are revisions. According to the 1991 National Institutes of Health guidelines, bariatric surgery should be considered in patients with a body mass index of 40 or 35 with serious obesity-related comorbidities. Moreover, mounting evidence indicates the need of bariatric procedures for patients with type 2 diabetes and a body mass index 30-35, if hyperglycemia is inadequately controlled despite optimal medical treatment.

A wealth of data indicates that surgery is associated with greater improvements in weight loss and type 2 diabetes outcomes, compared to non-surgical interventions, irrespective of the type of procedures used. The sleeve gastrectomy and gastric bypass are two most common procedures used currently. They have similar effects on weight loss and diabetes outcomes and similar safety through at least 5-year follow-up. However, the sleeve procedure is associated with fewer reoperations, and the bypass procedure may result in more durable weight loss and glycemic control. While safety is a concern, current data shows that the perioperative mortality rates vary from 0.03-0.2%, which has improved significantly since early 2000s. Thus, strong evidence supports the efficacy and safety of modern bariatric procedures. All patients with severe obesityand especially those with type 2 diabetesshould be engaged in a shared decision-making conversation about the risks and benefits of surgical interventionin comparison with continuing usual lifestyle and medical treatments. Lastly, the decision about surgery should be driven mainly by informed patient preferences.

Source: JAMA. 2020 Sep 1;324(9):879-887.