Success (but Unfinished) Story of Metabolic Surgery
Ali Aminian, Steven E. Nissen
Abstract
In patients with type 2 diabetes (T2D), evidence has evolved rapidly in recent years demonstrating major benefits of metabolic surgery on control of blood glucose (1–3) and a wide range of cardiovascular (CV) and renal outcomes (4–6). Historically, the relative risks versus benefits of surgical treatment of obesity remained controversial for two principal reasons: the complicated nature of the surgery and the absence of compelling evidence for meaningful clinical benefits. Both of these concerns have now been substantially clarified, but there remains considerable scientific work to be done. Surgical treatment of obesity started more than half a century ago with complicated operations such as intestinal rerouting procedures (e.g., jejunoileal bypass). Severe adverse outcomes from these procedures, including malnutrition and liver failure, seemed to outweigh the benefits. Over the years, surgical innovations have resulted in the development of less complicated and less invasive, but metabolically effective, alternative procedures targeting the stomach (e.g., gastric bypass). In parallel, the growing epidemics of obesity and T2D and absence of effective and durable pharmacotherapy for severe obesity have resulted in increased demand for more effective treatments, which has fueled surgical innovations. The increased acceptance of metabolic surgery has been enhanced by many advancements in minimally invasive surgical techniques, formal training of bariatric surgeons, a rigorous accreditation process for recognition of bariatric surgeons and bariatric centers, and emergence of less invasive procedures (e.g., sleeve gastrectomy). Evidence generated through collaboration between the medical and surgical communities has strongly suggested that the metabolic and CV benefits of surgical procedures extend beyond the effects of weight loss alone (7,8). As …