Send Orders for Reprints to reprints@benthamscience.

net
208 Current Diabetes Reviews, 2014, 10, 208-214
Bariatric Surgery - Effects on Obesity and Related co-Morbidities
Maria Saur Svane* and Sten Madsbad
Hvidovre Hospital, Dept. of Endocrinology, Kettegrd Alle 30, 2650 Hvidovre, Denmark
Abstract: Laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (RYGB) and laparo-
scopic sleeve gastrectomy (SG) are the three most commonly performed bariatric procedures. Obesity responds well to
bariatric surgery, with major long-lasting weight loss that is most pronounced after RYGB and SG, where the mean
weight loss is about 40 kg or 15 body mass index (BMI) units. Some of the benefits after RYGB and SG are independent
of weight loss, and the remission of type 2 diabetes is observed a few days after the operation; this depends on changes in
insulin sensitivity and gut hormone responses, especially a 10-fold increase in glucagon-like peptide-1 (GLP-1), which
improves insulin secretion. After gastric banding, the remission of diabetes depends more on weight loss. Bariatric sur-
gery reduces cardiovascular risk factors including hypertension, lipid disturbances, non-alcoholic fatty liver, muscu-
loskeletal pain and reduces mortality of diabetes, cardiovascular diseases and cancers. Bariatric surgery also improves
quality of life. The acute complications of surgery are infection, bleeding and anastomotic leak. Long-term complications
are nutritional deficiencies, including vitamins and minerals, and anemia. Some patients have dumping after meals, and a
few patients will develop postprandial hypoglycemia after RYGB. About 25% of patients require plastic surgery to pro-
vide relief from excessive skin tissue.
Keywords: Bariatric surgery, comorbidities, type 2 diabetes, metabolic syndrome, cancer, mortality.
INTRODUCTION
Obesity is a growing worldwide epidemic, which has
generated a secondary epidemic of metabolic syndrome,
characterized by abdominal obesity, dyslipidemia, hyperten-
sion and glucose intolerance associated with increased risk
of type 2 diabetes and cardiovascular disease [1,2]. Addi-
tional metabolic comorbidities include polycystic ovary syn-
drome (PCOS), non-alcoholic fatty liver disease (NAFLD),
obstructive sleep apnea (OSA) and several forms of cancers.
Lifestyle changes can lead to a weight reduction of 5-
10%, but most individuals start to regain weight after three
to six months, and about 90% return to or even exceed their
initial weight, indicating that obesity in most cases is refrac-
tory to lifestyle therapy [3]. The recent LOOK-ahead trial
[4], which randomized 5,145 overweight or obese patients
with type 2 diabetes to either intensive lifestyle intervention
or standard care, reported a 6% weight loss after 10 years in
the intervention group vs. 3.5% in the control group. How-
ever, the study failed to demonstrate an effect on cardiovas-
cular morbidity or mortality [4]. The use of anti-obesity
agents may result in a further weight loss of 2-8 kg; thus,
with the agents on the market or in development at present,
the mean weight loss does not exceed 10 kg in clinical trials
[5].
In contrast, in severely obese individuals, bariatric sur-
gery results in major weight loss of 20-30% that is sustained
for at least 15-20 years [6]. Some bariatric surgery proce-
dures are furthermore regarded as metabolic surgery, due


*Address correspondence to this author at the Hvidovre Hospital, Dept. of
Endocrinology, Kettegrd Alle 30, 2650 Hvidovre, Denmark;
Tel: +45 38626357/+45 27280918; E-mails: maria.saur.svane@regionh.dk
to their beneficial effects beyond weight loss on metabolic
syndrome and type 2 diabetes [7, 8]. The most commonly used
bariatric operation is laparoscopic Roux-en-Y gastric bypass
(RYGB), followed by laparoscopic sleeve gastrectomy (SG),
and laparoscopic adjustable gastric banding (LABG) [9].
The aim of this review is to provide an update on the ef-
fects of RYGB, SG and LAGB on obesity and related co-
morbidities.
EFFECT OF BARIATRIC SURGERY ON WEIGHT
The Swedish Obese Subjects study (SOS) [6] consisted
of a surgical group (n=2,010) and an obese control group
(n=2,037). The groups were matched at 18 clinical variables.
Patients in the surgical group underwent adjustable or non-
adjustable gastric banding (n=376), vertical-banded gastro-
plasty (n=1,369) or RYGB (n=265), while those in the con-
trol group received customary non-surgical obesity treatment
at their local health centers. In the control group, a maximal
weight loss of 1-2% of basal weight was seen, compared to
20%, 25% and 32% for adjustable gastric banding, vertical-
banded gastroplasty and RYGB, respectively. The maximal
weight loss was achieved 1-2 years after surgery. Hereafter,
some patients in all surgical subgroups showed a slight
weight gain, which leveled off after 8-10 years. At the 15
year follow-up, the weight loss was 13%, 18% and 27% in
the three surgical groups, respectively [10-12]. Another pro-
spective cohort study, LABS-2, reported a mean weight-loss
of 41 kg after 3 years in 1738 RYGB operated patients [13],
and several studies have shown that weight loss usually
peaks 1.5 to 2.0 years after surgery [6,14,15].
In a large meta-analysis by Buchwald et al. [8], weight
loss, expressed as per cent of excess weight (EBWL), in a
population of 34,000 patients, was 46% after gastric banding
1875-6417/14 $58.00+.00 2014 Bentham Science Publishers
Bariatric Surgery - Effects on Obesity and Related co-Morbidities Current Diabetes Reviews, 2014, Vol. 10, No. 3 209

and 60% after RYGB; a subgroup analysis (n= 14,000)
showed a slightly higher weight loss at 2 years postopera-
tively with EBWL of 49% after gastric banding and 63%
after RYGB.
In a recent small meta-analysis of randomized controlled
studies, the total weight loss was 26 kg after bariatric sur-
gery, but only 381 patients were included; the duration of the
follow-up period varied and the heterogeneity between stud-
ies was very high [16].
SG has been reported to result in similar [17] or slightly
lower weight loss than RYGB [18]. In a recent epidemiol-
ogical study of 2,949 patients, weight loss (EBWL) after
RYGB, SG and LAGB was 67%, 56% and 44%, respec-
tively, 3 years after surgery [18]. Lastly, in a randomized
controlled study (RCT) of SG (n=107) vs. RYGB (n=110),
an excessive BMI loss (EBMIL) of 72% vs. 77% was re-
ported at the 1 year follow-up [17].
The SOS-study, primarily using banding gastroplasty, re-
ported that 20-25% of the weight lost after surgery was re-
gained by the 10 year follow-up [10-12]. In the Utah-Obesity
study following 418 patients for 6 years after RYGB, the
weight loss at 2 years was higher than after 6 years, where a
regain of 7% of the initial 35% weight-loss was reported
[15].
EFFECTS OF BARIATRIC SURGERY ON CO-
MORBIDITIES
Effect on Blood Pressure
Bariatric surgery has been reported to ameliorate hyper-
tension, with normalization of blood pressure in 30-50% of
patients 1-2 years after RYGB surgery [13,15,19] and a re-
duced need antihypertensive treatment in a further 20-30%
of patients [19]. The remission of hypertension seems to be
associated with the degree of weight reduction [19], and pa-
tients seem to have a higher remission rate after RYGB than
after LAGB [13]. Remission of hypertension did not differ
between RYGB and SG in a randomized study [17], but only
a limited numbers of reports have included SG.
Interestingly, in the Utah- and SOS-studies, relapse of
hypertension was seen at the 6 to 10 year follow-up
[6,10,15].
The results from the epidemiological retrospective stud-
ies discussed here have not been confirmed in randomized
clinical trials including type 2 diabetic patients: Mingrone et
al. found no difference in systolic blood pressure between
patients undergoing intensive medical treatment and RYGB-
operated patients after 2 years [20], despite the antihyperten-
sive treatment being reduced or discontinued in 70% of the
medically treated group vs. 80% in the surgery group [20].
Ikramuddin et al. only found a modest effect on systolic
blood pressure of RYGB after 1 year, but with less medica-
tions for comorbidities; however, these were not completely
specified for hypertension [21].
Effect on Plasma Lipids
Weight loss is associated with an improved lipid profile
[22]. In the Utah-Obesity study, dyslipidemia, characterized
by high levels of low-density lipoprotein (LDL) and triglyc-
erides and low levels of high-density lipoprotein (HDL), was
resolved 6 years after RYGB in 57-69% of the patients [15],
and the remission-rate of dyslipidemia 3 years after RYGB
was 62% in the LABS-2 study [13]. The LABS-2 study also
reported a remission-rate of 17% after LAGB. Similar results
after LAGB have been described by Dixon et al., with favor-
able changes for fasting triglycerides and HDL-cholesterol
[22].
In a 24-month follow-up of diabetic patients randomized
to either intensive medical treatment, RYGB or SG, an in-
crease in HDL and decrease in triglyceride were seen [23],
and these results were sustained at 3 years [24]. The changes
were equal for SG compared to RYGB, while no decrease
was seen for LDL- or total cholesterol [23].
In the SOS-study, the triglycerides did not differ between
the surgical and control group at the two and ten year follow-
ups, but the reduction in triglycerides was greater in the sub-
group treated with RYGB [10]. Buchwald et al. also de-
scribed an overall improvement in dyslipidemia for all types
of bariatric surgery in approximately 70% of the patients, but
this improvement was not clearly defined [14]. In another
meta-analysis of randomized controlled trials (RCT) [16],
only triglyceride- and HDL-concentration changed benefi-
cially after surgery in comparison to controls.
Effect on Type 2 Diabetes
Bariatric surgery has a marked effect on type 2 diabetes
with rapidly normalized blood glucose concentrations in the
majority of patients. In the meta-analysis by Buchwald et al.
[8], including 4,973 patients with type 2 diabetes, remission
of diabetes was found to occur in 80% after RYGB and in
57% after LAGB. However, subsequent studies have demon-
strated that the remission rate of type 2 diabetes depends on
the definition of remission applied. This was exemplified by
Pournaras et al. in a recent study of 160 patients with type 2
diabetes, where diabetes remission was found to occur in
41% after RYGB [25] when applying the more strict criteria
for remission from a recent consensus [26]. Preoperative
treatment with insulin was associated with an even lower
remission rate [25]. Nevertheless, overall glycemic control
improved after RYGB, and glycosylated hemoglobin
(HbA1c) decreased from 8.0% to 6.2% [25].
Recently, three randomized controlled trials proved
RYGB superior to conventional pharmacological treatment
in achieving glycemic control within 1-2 years after surgery,
and demonstrated that lower HbA1c levels can be achieved
without or with less medication after RYGB [20,21,27]. In
one of the studies, a group of SG patients was included, and
the results were comparable to the RYGB operated patients
with respect to improvement in HbA1c and in percentage of
patients achieving the primary end-point of HbA1c 6.0%:
42% for RYGB and 37% for SG [24,27]. The same research-
ers report a slightly smaller remission rate at the 3 year fol-
low-up; 38% of patients after RYGB and 24% after SG, but
the glycemic control was still superior to intensive medical
therapy with only 5% of the patients achieving the HbA1c
target [24]. After 3 years HbA1c declined from 9.3%, 9.5%
and 9.0% at baseline to 6.7%, 7.0% and 8.4%; and the body
weight change from baseline was -26.2 kg, -21.3 kg and -4.3
kg for RYGB, SG and the medically treated group, respec-
210 Current Diabetes Reviews, 2014, Vol. 10, No. 3 Svane and Madsbad

tively. Furthermore the use of glucose-lowering medications
was lower in both surgical groups [24].
Also, LAGB has shown superiority in the treatment of
type 2 diabetes when compared to intensive pharmacological
and lifestyle intervention. In a randomized controlled study
with a 2 year follow-up period, the remission rates were 73%
for LAGB and 13% for the control group [28]. Diabetes re-
mission was related to weight loss and lower baseline
HbA1c levels [28]. Compared to RYGB, patients treated
with LAGB appeared to experience a lower rate of diabetes
remission.
The SOS-trial reported a higher remission rate of diabe-
tes after 2 (OR 8.4, CI 5.7-12.5) and 10 years (OR 3.5, CI
1.6-7.3) compared with the control group, but a 50% relapse
was observed at 10 years (remission rate 72% at 2 years and
36% at 10 years) [6]. In addition, bariatric surgery reduced
the incidence of type 2 diabetes (hazard ratio (HR) 0.22, CI
0.18-0.27) in the follow-up period of up to 15 years (mean
10 years) compared with the control group; this was most
efficient in patients at high risk due to impaired fasting glu-
cose (IFG) at baseline (number needed to treat (NNT) in
order to prevent one case of type 2 diabetes was 1.3 in pa-
tients with IFG and 7.0 in patients with normal fasting glu-
cose) [6,29].
The remission rates seem to be associated with the dura-
tion [24] and degree of glycemic control before the operation
[30]. Other predictors are C-peptide (beta-cell function),
preoperative glucose-lowering treatment (insulin vs. oral),
preoperative body mass index (BMI) and weight loss [31].
Relapse of diabetes is associated with failing beta-cell func-
tion. Recurrence rates of diabetes in recent epidemiological
studies with long-term follow-up (>5 years) were 13-35%
after RYGB [15,30,32], and were associated with weight
regain, longer duration of diabetes, poor preoperative glyce-
mic control and insulin treatment before surgery [30].
The effect on diabetes seems to include the improvement
or delayed progress of end-organ complications such as reti-
nopathy and nephropathy in addition to improved glycemic
control [33].
Effects on Metabolic Syndrome
Before surgery, most obese patients will display symp-
toms of metabolic syndrome, with components of high
triglycerides, low HDL, hypertension, high plasma glucose
and waist circumference. Batsis et al. found the prevalence
of metabolic syndrome to be decreased after 3.4 years of
follow-up from 87% to 29% in response to RYGB compared
to a decrease from 85% to 75% in the conventional lifestyle-
intervention control group [7]. The strongest predictor for
resolution was loss of body weight [7]. Furthermore, the
authors estimated that four deaths and 16 cardiovascular
events per 100 patients would be prevented by bariatric sur-
gery during a 10-year period.
Vidal et al. retrospectively compared diabetic patients af-
ter RYGB and SG and found comparable resolution rates of
both diabetes (85% in each group) and metabolic syndrome
(67% vs. 62%) [34].
In a recent study using the Bariatric Outcome Longitudi-
nal Database, 23,106 patients were identified to have meta-
bolic syndrome before surgery [35]. The 1 year resolution of
hypertension, diabetes and dyslipidemia after LAGB was
19%, 28% and 17%, respectively, compared to 45%, 62%
and 45%, respectively, after RYGB, and 35%, 52% and
34%, respectively, after SG [35].
Effect on Non-alcoholic Fatty Liver Disease
After bariatric surgery, a reduction in liver steatosis, in-
flammation and fibrosis was observed 15 months after
RYGB, SG or LAGB [36]. Thus, inflammation and fibrosis
were completely resolved in 37% and 20% of the patients,
respectively. In another study, NAFLD resolved in 89% of
RYGB-operated patients [37].
Effects on Cardiovascular Disease and Cardiovascular
Mortality
Bariatric surgery has beneficial effects on cardiovascular
risk factors such as left ventricular hypertrophy [38], carotis
intima thickness, and flow-mediated vessel dilatation [39].
Moreover, the resolution of diabetes, hypertension and
hyperlipidemia postoperatively results in an overall 10 year
reduction in the coronary heart disease Framingham risk
score from 6% to 3% [38], and other researchers have found
an even better improvement in the risk score [40], which was
most pronounced in men.
In the SOS-study, the number of cardiovascular events
was 234 in the control group vs. 199 in the surgery group
(HR 0.83, CI 0.69-1.00), and the number of cardiovascular
deaths was 49 vs. 28 (HR 0.56, CI 0.35-0.88), respectively
[12]. Surgery was also associated with a reduced number of
fatal myocardial infarctions [12]. Insulin resistance at base-
line rather than BMI predicted the beneficial effects of sur-
gery [12]. In type 2 diabetes patients, bariatric surgery also
reduced the incidence of cardiovascular events after a fol-
low-up period of 13 years (adjusted HR 0.56, CI 0.34-0.93)
[41] compared with the control group. NNT to prevent one
myocardial infarction in a 15 year period among the obese
diabetic population was 16 [41].
In the retrospective study by Christou and co-workers,
which compared 1035 patients after bariatric surgery (81%
RYGB, 19% vertical banded gastroplasty) with 5,746
matched control subjects during a five year follow-up, the
risk reduction in cardiovascular disorders was 82% in favor
of surgery [42]. Likewise, in the study by Adams et al.,
which compared 7,925 patients after RYGB with the same
number of matched controls, the reduction in mortality of
coronary artery disease was 56% [43].
Effect on Obstructive Sleep Apnea
A meta-analysis of 69 studies including 13,900 patients
indicated that bariatric surgery resolves or improves OSA in
more than 75% of patients with this condition, with the most
pronounced effect being reported after RYGB, followed by
SG and LAGB, probably reflecting the degree of weight loss
achieved by patients following these procedures [44]. Other
investigators have presented similar results [14,45,46]. Inter-
estingly, a randomized study of conventional weight loss
Bariatric Surgery - Effects on Obesity and Related co-Morbidities Current Diabetes Reviews, 2014, Vol. 10, No. 3 211

therapy vs. LAGB found no difference in OSA resolution
despite major differences in weight loss [47].
Effect on Musculoskeletal Pain
Obesity is associated with musculoskeletal pain [48]. Re-
sults from the SOS-study report an increased recovery as
well as a reduced incidence of work-restricting muscu-
loskeletal pain after bariatric surgery; furthermore, the re-
covery-rate was related to the degree of weight loss follow-
ing surgery [48].
Effects on Cancers
After a 10.9 year follow-up period in the SOS-study, the
number of first time cancers in the surgery group was re-
duced compared with the control group (HR 0.67, CI 0.53-
0.85; p=0.0009) [6]. In women, the number was 79 vs. 130
patients, respectively (HR 0.58, CI 0.44-0.77; p=0.0001),
whereas there was no effect of surgery reported in men.
Christou et al. reported 21 cancers in the surgery group
(n=1,035, 82% RYGB) compared with 487 cancers in the
control group (n=5,746), with a Relative Risk (RR) of 0.22
(CI 0.14-0.35 p=0.001) after a maximum follow-up of five
years [49]. Adams et al. found that the reduction in cancer-
caused mortality was 61% after a mean follow-up of 7.1
years [43]. In a later follow-up, after a mean of 12.5 years, a
24% reduction in cancers was found in the surgical group
compared with the control group, whereas the overall cancer
mortality was reduced by 46% [50]. In particular, the inci-
dence of uterine cancer was significantly lower among surgi-
cal patients.
The quality of the studies, except for the SOS-studies, is
poor and randomized controlled studies with long-term fol-
low-up are needed to obtain robust data on the effects of
bariatric surgery on the risk of developing cancer.
Effects on Mortality
In the SOS-study, after an average of 11 years follow-up,
the cumulative overall mortality was 129 subjects (6.3%) in
the control group compared with 101 (5.0%) in the surgery
group, indicating a relative risk reduction of 24% (HR 0.76,
p=0.04) [11]. The reduction in mortality was more pro-
nounced in subjects with a higher BMI, with a reduction in
the risk of death of about 30% in subjects with a BMI above
the median of 40.8 kg/m
2
and 20% in subjects below the
median [11].
Adams et al. retrospectively followed 7,925 people for
seven years and found a 40% reduction of total mortality in
the surgical group compared with a control group of subjects
matched for age, sex and BMI [43]. In a third study, the re-
duction in all-cause mortality was 89% in the surgical group
compared with a control group after at least five years of
follow-up [42]. A limitation of all three studies is that the
designs were not randomized and controlled and no informa-
tion on baseline morbidity was presented.
A meta-analysis from 2011 reported an overall reduction
in all-cause mortality of 45% (OR 0.55, CI 0.49-0.63), but
the included studies were not randomized and the heteroge-
neity of the studies was very high [51].
Effects on Quality-of-Life
The substantial and long-term weight loss following bari-
atric surgery has a beneficial effect on the quality-of-life in
most patients [52-54]. Furthermore, the degree of weight-
loss appears to affect the quality-of-life improvements [52-
54], and health-related quality-of-life over a 10 year period
followed phases of weight loss, weight gain and weight sta-
bility, and was related to the magnitude of weight loss and
weight regain in the SOS-study [53]. In contrast, Adams et
al. found no improvement in a mental component score after
bariatric surgery compared with two obese control groups
[15], and other authors have suggested an increased risk of
suicide after RYGB [43].
RISKS OF BARIATRIC SURGERY
In the best centers, the 30 day mortality is about 0.2-0.4%
after laparoscopic RYGB [55,56] and below 0.1% after gas-
tric banding [14,56]. The acute complications are bleeding,
infections, anastomotic leak, arrhythmias and venous embo-
lism. The risk of serious complications is reported to be
4.8% for laparoscopic RYGB and 1.0% for LAGB [55], and
the total complication rate is about 17% [56]. Long-term
complications after RYGB include internal hernias and anas-
tomotic stenosis with vomiting, stoma ulceration erosions
and nutritional deficiencies [57] and the patients need to be
supplementedwith vitamins and minerals. Some of the long-
term risks are not seen after SG; instead, there is a longer
stable-line of the stomach with associated risk of leakage.
SG in general seems to cause fewer minor complications
than RYGB [58] but the published data include only a small
number of patients and further studies are needed.
Some patients will develop dumping, with symptoms
such as abdominal pain and cramping, sweating, dizziness,
nausea, tachycardia and diarrhea. Dumping symptoms be-
come less prominent over time [57]. Few patients will de-
velop postprandial symptomatic hypoglycemia, presumably
because of an imbalance of excessive insulin secretion due to
an exaggerated GLP-1 response and improved insulin sensi-
tivity [59].
In summary, RYGB seem to have the highest rates of
complication, followed by SG and LAGB, but the overall
mortality is low.
DISCUSSION
Obesity is accompanied by comorbidities, making obe-
sity a major threat to health. Treating obesity has been
proven to be difficult and ineffective, and it is often consid-
ered to be a self-induced behavioral problem of the patients
themselves instead of a physiological dysregulation. Many
people often overestimate the benefits of lifestyle and phar-
macological interventions, but unfortunately, lifestyle and
pharmacological treatments rarely result in sustained weight
loss, and many physicians consider obesity an intractable
disease.
The only effective treatment for obesity is bariatric sur-
gery, providing substantial long-term weight loss, which is
most pronounced following RYGB and SG. The weight loss
after LAGB is slower and less pronounced.
212 Current Diabetes Reviews, 2014, Vol. 10, No. 3 Svane and Madsbad

Obesity is associated with accelerated atherosclerosis and
improvements in the CVD risk factor profile, including
metabolic syndrome; a lower risk of ischemic heart disease
and mortality has been demonstrated after bariatric surgery.
Thus, improvements in hypertension and especially the lipid
profile associated with metabolic syndrome, which is charac-
terized by high triglycerides and low HDL cholesterol, have
been reported. The effect on LDL cholesterol seems to be
minimal. The weight loss after bariatric surgery also improves
NAFLD, OSA, musculoskeletal pains and quality-of-life.
Increased body adiposity is an established risk factor for
the development of cancer. Although the studies may be
criticized, several have provided evidence that weight reduc-
tion in obese individuals is associated with a subsequent re-
duction in cancer incidence. The effect seems limited to
women, and the reductions are most robust for breast cancer
and endometrial cancers, which are both hormone-sensitive.
It is unknown whether different bariatric procedures may
have different effects on the incidence of cancer.
Bariatric surgery also prevents new cases of diabetes
compared with lifestyle treatment. A robust finding in many
studies, independent of bariatric procedure, has been im-
provements or remission of type 2 diabetes already a few
days after surgery, before any significant weight loss. This
observation has introduced the term metabolic surgery,
because of the marked modification of type 2 diabetes
pathophysiology for the better without any weight loss. Ran-
domized studies have shown the superiority of bariatric sur-
gery compared to an intensive lifestyle and medical man-
agement in relation to both weight loss and remission of dia-
betes, but all of the studies have been of short duration and
have included only few patients. Larger and longer trials are
needed to estimate the benefit of bariatric surgery compared
with the conventional treatment of type 2 diabetes. The re-
mission rate of diabetes is higher and faster after RYGB and
SG than after LAGB, but for all procedures, diabetes remis-
sion trended downwards over time.
The effects of all three procedures on glucose metabo-
lism are explained by an increase in hepatic insulin sensitiv-
ity, which is induced at least in part by calorie restriction,
and can be observed only a few days after surgery [60,61].
No hormonal changes explain the weight loss and remission
of type 2 diabetes after LAGB. After RYGB and SG, an im-
proved postprandial insulin secretion, associated with an
exaggerated postprandial glucagon-like peptide-1 (GLP-1)
secretion due to altered transit time of nutrients to the termi-
nal ilium, is seen [60]. Thus, the physiological explanation of
the remission of type 2 diabetes relies on GLP-1 and im-
proved beta-cell function after RYGB and SG, which can
also explain the lower diabetes remission rate in patients
with advanced disease and longer duration and thus failing
beta-cell function. Later, a weight loss-induced improvement
in peripheral skeletal muscle insulin sensitivity is the final
determinator of glucose tolerance after all three procedures
[61].
The explanation of weight loss also differs between the
three procedures. After LAGB distension, stimuli from the
small pouch above the band may be transmitted via afferent
vagal nerves to areas of the central nervous system that are
implicated in satiety and reducing food intake [62]. The
changes in food texture and eating small volumes to preserve
digestive comfort may also explain modified eating behav-
iors and thereby part of the weight loss. Following RYGB
and SG, increased postprandial responses of GLP-1, peptide
YY (PYY) and oxyntomodulin seem to stimulate anorectic
pathways in the hypothalamus and brain stem, leading to
reduced appetite and food intake.
In a position statement from 2011, the International Dia-
betes Federation (IDF) recognized bariatric surgery as an appro-
priate treatment for type 2 diabetes if recommended glyce-
mic targets are not reached with the available medical thera-
pies, especially if hypertension and dyslipidemia also exist.
CONCLUSION
Thus, bariatric surgery results in substantial weight loss
with excellent beneficial effects on comorbidities to obesity,
but with the cost of surgical and medical complications, i.e.
from micronutrient deficiencies, which require life-long
monitoring. Many patients will also need to undergo plastic
surgery to provide relief from excessive skin tissue, and this
is expensive and may induce new complications.
This review has also revealed the shortcomings of many
studies. Studies with long-term follow-up periods are limited
and often report poor retention of participants. Another main
limitation in many studies is their lack of randomization; the
quality of studies varied from very few randomized studies
to retrospective cohort studies without a control group. Stan-
dardized definitions for the resolution of co-morbidities are
also needed for comparisons of the results of future studies.
Longer and larger clinical trials comparing lifestyle and
pharmacological treatments with bariatric surgery are an
unmet need. Although RYGB and SG are more effective
than LAGB for the reversal of obesity and diabetes, they also
confer greater surgical risks; therefore, long-term studies
comparing the different procedures are warranted.
The effects of bariatric surgery are intriguing and have
created a new understanding of the pathogenesis of obesity
and type 2 diabetes; however, it is impractical to perform
surgery in all obese people. A goal must be to develop less-
invasive methods, and ultimately, understand the effects of
bariatric surgery on metabolism beyond that expected of
weight loss, which may enable the development of new ef-
fective therapeutic strategies for weight loss and the treat-
ment of diabetes.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
Declared none.
REFERENCES
[1] Desprs J , Lemieux I. Abdominal obesity and metabolic syndrome.
Nature 2006; 444: 881-7.
[2] Must A, Spadano J , Coakley EH, Field AE, Colditz G, Dietz WH.
The disease burden associated with overweight and obesity. J AMA
1999; 282: 1523-9.
[3] Franz MJ , VanWormer J J , Crain AL, et al. Weight-loss outcomes:
a systematic review and meta-analysis of weight-loss clinical trials
Bariatric Surgery - Effects on Obesity and Related co-Morbidities Current Diabetes Reviews, 2014, Vol. 10, No. 3 213

with a minimum 1-year follow-up. J Am Diet Assoc 2007; 107:
1755-67.
[4] Wing RR, Bolin P, Brancati FL, et al. Cardiovascular effects of
intensive lifestyle intervention in type 2 diabetes. N Engl J Med
2013; 369: 145-54.
[5] Derosa G, Maffioli P. Anti-obesity drugs: a review about their
effects and their safety. Expert Opin Drug Saf 2012; 11: 459-71.
[6] Sjstrm L. Review of the key results from the Swedish Obese
Subjects (SOS) trial - a prospective controlled intervention study of
bariatric surgery. J Intern Med 2013; 273: 219-34.
[7] Batsis J A, Romero-Corral A, Collazo-Clavell ML, Sarr MG,
Somers VK, Lopez-J imenez F. Effect of bariatric surgery on the
metabolic syndrome: a population-based, long-term controlled
study. Mayo Clin Proc 2008; 83: 897-907.
[8] Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2
diabetes after bariatric surgery: systematic review and meta-
analysis. Am J Med 2009; 122: 248-256.e5.
[9] Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide
2011. Obes Surg 2013; 23: 427-36.
[10] Sjstrm L, Lindroos A-K, Peltonen M, et al. Lifestyle, diabetes,
and cardiovascular risk factors 10 years after bariatric surgery. N
Engl J Med 2004; 351: 2683-93.
[11] Sjstrm L, Narbro K, Sjstrm CD, et al. Effects of bariatric
surgery on mortality in Swedish obese subjects. N Engl J Med
2007; 357: 741-52.
[12] Sjstrm L, Peltonen M, J acobson P, et al. Bariatric surgery and
long-term cardiovascular events. J AMA 2012; 307: 56-65.
[13] Courcoulas AP, Christian NJ , Belle SH, et al. Weight change and
health outcomes at 3 years after bariatric surgery among
individuals with severe obesity. J AMA 2013; 310: 2416-25.
[14] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a
systematic review and meta-analysis. J AMA 2004; 292: 1724-37.
[15] Adams TD, Davidson LE, Litwin SE, et al. Health benefits of
gastric bypass surgery after 6 years. J AMA 2012; 308: 1122-31.
[16] Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-
surgical treatment for obesity: a systematic review and meta-
analysis of randomised controlled trials. BMJ 2013; 347: f5934.
[17] Peterli R, Borbly Y, Kern B, et al. Early Results of the Swiss
Multicentre Bypass or Sleeve Study (SM-BOSS): A prospective
randomized trial comparing laparoscopic sleeve gastrectomy and
Roux-en-Y gastric bypass. Ann Surg 2013; 258: 690-5.
[18] Carlin AM, Zeni TM, English WJ , et al. The comparative
effectiveness of sleeve gastrectomy, gastric bypass, and adjustable
gastric banding procedures for the treatment of morbid obesity.
Ann Surg 2013; 257: 791-7.
[19] Hinojosa MW, Varela J E, Smith BR, Che F, Nguyen NT.
Resolution of systemic hypertension after laparoscopic gastric
bypass. J Gastrointest Surg 2009; 13: 793-7.
[20] Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery
versus conventional medical therapy for type 2 diabetes. N Engl J
Med 2012; 366: 1577-85.
[21] Ikramuddin S, Korner J , Lee W-J , et al. Roux-en-Y gastric bypass
vs intensive medical management for the control of type 2 diabetes,
hypertension, and hyperlipidemia: the Diabetes Surgery Study
randomized clinical trial. J AMA 2013; 309: 2240-9.
[22] Dixon J B, OBrien PE. Lipid profile in the severely obese: changes
with weight loss after lap-band surgery. Obes Res 2002; 10: 903-
10.
[23] Kashyap SR, Bhatt DL, Wolski K, et al. Metabolic effects of
bariatric surgery in patients with moderate obesity and type 2
diabetes: analysis of a randomized control trial comparing surgery
with intensive medical treatment. Diabetes Care 2013; 36: 2175-82.
[24] Schauer PR, Bhatt DL, Kirwan J P, et al. Bariatric surgery versus
intensive medical therapy for diabetes - 3-year outcomes. NEJ M
2014; doi: 10.1056/NEJ Moa1401329 [Epub ahead of print]
[25] Pournaras DJ , Aasheim ET, Svik TT, et al. Effect of the definition
of type II diabetes remission in the evaluation of bariatric surgery
for metabolic disorders. Br J Surg 2012; 99: 100-3.
[26] Buse J B, Caprio S, Cefalu WT, et al. How do we define cure of
diabetes? Diabetes Care 2009; 32: 2133-5.
[27] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus
intensive medical therapy in obese patients with diabetes. N Engl J
Med 2012; 366: 1567-76.
[28] Dixon J B, OBrien PE, Playfair J , et al. Adjustable gastric banding
and conventional therapy for type 2 diabetes: a randomized
controlled trial. J AMA 2008; 299: 316-23.
[29] Carlsson LMS, Peltonen M, Ahlin S, et al. Bariatric surgery and
prevention of type 2 diabetes in Swedish obese subjects. N Engl J
Med 2012; 367: 695-704.
[30] Arterburn DE, Bogart A, Sherwood NE, et al. A multisite study of
long-term remission and relapse of type 2 diabetes mellitus
following gastric bypass. Obes Surg 2013; 23: 93-102.
[31] Dixon J B, Chuang L-M, Chong K, et al. Predicting the glycemic
response to gastric bypass surgery in patients with type 2 diabetes.
Diabetes Care 2013; 36: 20-6.
[32] Brethauer SA, Aminian A, Romero-Talams H, et al. Can diabetes
be surgically cured? Long-term metabolic effects of bariatric
surgery in obese patients with type 2 diabetes mellitus. Ann Surg
2013; 258: 628-36.
[33] Heneghan HM, Cetin D, Navaneethan SD, Orzech N, Brethauer
SA, Schauer PR. Effects of bariatric surgery on diabetic
nephropathy after 5 years of follow-up. Surg Obes Relat Dis 2013;
9: 7-14.
[34] Vidal J , Ibarzabal A, Romero F, et al. Type 2 diabetes mellitus and
the metabolic syndrome following sleeve gastrectomy in severely
obese subjects. Obes Surg 2008; 18: 1077-82.
[35] Inabnet WB, Winegar DA, Sherif B, Sarr MG. Early outcomes of
bariatric surgery in patients with metabolic syndrome: an analysis
of the bariatric outcomes longitudinal database. J Am Coll Surg
2012; 214: 550-6.
[36] Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced
weight loss significantly improves nonalcoholic fatty liver disease
and the metabolic syndrome. Ann Surg 2005; 242: 610-7.
[37] Barker KB, Palekar NA, Bowers SP, Goldberg J E, Pulcini J P,
Harrison SA. Non-alcoholic steatohepatitis: effect of Roux-en-Y
gastric bypass surgery. Am J Gastroenterol 2006; 101: 368-73.
[38] Vest AR, Heneghan HM, Agarwal S, Schauer PR, Young J B.
Bariatric surgery and cardiovascular outcomes: a systematic
review. Heart 2012; 98: 1763-77.
[39] Habib P, Scrocco J D, Terek M, Vanek V, Mikolich J R. Effects of
bariatric surgery on inflammatory, functional and structural
markers of coronary atherosclerosis. Am J Cardiol 2009; 104:
1251-5.
[40] Batsis J A, Romero-Corral A, Collazo-Clavell ML, et al. Effect of
weight loss on predicted cardiovascular risk: change in cardiac risk
after bariatric surgery. Obesity 2007; 15: 772-84.
[41] Romeo S, Maglio C, Burza MA, et al. Cardiovascular events after
bariatric surgery in obese subjects with type 2 diabetes. Diabetes
Care 2012; 35: 2613-7.
[42] Christou NV, Sampalis J S, Liberman M, et al. Surgery decreases
long-term mortality, morbidity, and health care use in morbidly
obese patients. Ann Surg 2004; 240: 416-24.
[43] Adams TD, Gress RE, Smith SC, et al. Long-term mortality after
gastric bypass surgery. N Engl J Med 2007; 357: 753-61.
[44] Sarkhosh K, Switzer NJ , El-Hadi M, Birch DW, Shi X, Karmali S.
The impact of bariatric surgery on obstructive sleep apnea: a
systematic review. Obes Surg 2013; 23: 414-23.
[45] Ashrafian H, le Roux CW, Rowland SP, et al. Metabolic surgery
and obstructive sleep apnoea: the protective effects of bariatric
procedures. Thorax 2012; 67: 442-9.
[46] Fritscher LG, Canani S, Mottin CC, et al. Bariatric surgery in the
treatment of obstructive sleep apnea in morbidly obese patients.
Respiration 2007; 74: 647-52.
[47] Dixon J B, Schachter LM, OBrien PE, et al. Surgical vs
conventional therapy for weight loss treatment of obstructive sleep
apnea: a randomized controlled trial. J AMA 2012; 308: 1142-9.
[48] Peltonen M, Lindroos AK, Torgerson J S. Musculoskeletal pain in
the obese: a comparison with a general population and long-term
changes after conventional and surgical obesity treatment. Pain
2003; 104: 549-57.
[49] Christou NV, Lieberman M, Sampalis F, Sampalis J S. Bariatric
surgery reduces cancer risk in morbidly obese patients. Surg Obes
Relat Dis 2008; 4: 691-5.
[50] Adams TD, Stroup AM, Gress RE, et al. Cancer incidence and
mortality after gastric bypass surgery. Obesity 2009; 17: 796-802.
[51] Pontiroli AE, Morabito A. Long-term prevention of mortality in
morbid obesity through bariatric surgery. a systematic review and
meta-analysis of trials performed with gastric banding and gastric
bypass. Ann Surg 2011; 253: 484-7.
[52] Batsis J A, Lopez-J imenez F, Collazo-Clavell ML, Clark MM,
Somers VK, Sarr MG. Quality of life after bariatric surgery: a
214 Current Diabetes Reviews, 2014, Vol. 10, No. 3 Svane and Madsbad

population-based cohort study. Am J Med 2009; 122: 1055.e1-
1055.e10.
[53] Karlsson J , Taft C, Rydn A, Sjstrm L, Sullivan M. Ten-year
trends in health-related quality of life after surgical and
conventional treatment for severe obesity: the SOS intervention
study. Int J Obes 2007; 31: 1248-61.
[54] Kolotkin RL, Davidson LE, Crosby RD, Hunt SC, Adams TD. Six-
year changes in health-related quality of life in gastric bypass
patients versus obese comparison groups. Surg Obes Relat Dis
2012; 8: 625-33.
[55] Flum DR, Belle SH, King WC, et al. Perioperative safety in the
longitudinal assessment of bariatric surgery. N Engl J Med 2009;
361: 445-54.
[56] Chang SH, Stoll CR, Song J , Varela J E, Eagon CJ , Colditz GA.
The effectiveness and risks of bariatric surgery: An updated
systematic review and meta-analysis, 2003-2012. J AMA Surg
2014; 149: 275-87.
[57] Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J , Still
C. Endocrine and nutritional management of the post-bariatric
surgery patient: an Endocrine Society Clinical Practice Guideline. J
Clin Endocrinol Metab 2010; 95: 4823-43.
[58] Helmi M, Victorzon M, Ovaska J , et al. SLEEVEPASS: a
randomized prospective multicenter study comparing laparoscopic
sleeve gastrectomy and gastric bypass in the treatment of morbid
obesity: preliminary results. Surg Endosc 2012; 26: 2521-6.
[59] Salehi M, Gastaldelli A, DAlessio DA. Blockade of glucagon-like
peptide 1 receptor corrects post-prandial hypoglycemia after gastric
bypass. Gastroenterology 2014; 146: 669-680.
[60] Dirksen C, J rgensen NB, Bojsen-Mller KN, et al. Mechanisms of
improved glycaemic control after Roux-en-Y gastric bypass.
Diabetologia 2012; 55: 1890-901.
[61] Bojsen-Mller KN, Dirksen C, J rgensen NB, et al. Early
enhancements of hepatic and later of peripheral insulin sensitivity
combined with increased postprandial insulin secretion contribute
to improved glycemic control after Roux-en-Y gastric bypass.
Diabetes 2014; 63: 1725-37.
[62] Kampe J , Stefanidis A, Lockie SH, et al. Neural and humoral
changes associated with the adjustable gastric band: insights from
a rodent model. Int J Obes 2012; 36: 1403-11.

Received: March 25, 2014 Revised: May 17, 2014 Accepted: J une 13, 2014