Current Atherosclerosis Reports

, Volume 14, Issue 6, pp 579–587 | Cite as

Gastrointestinal Surgery for Obesity and Diabetes: Weight Loss and Control of Hyperglycemia

Lipid and Metabolic Effects of Gastrointestinal Surgery (F Rubino, Section Editor)


Obesity is associated with a variety of weight-related metabolic comorbidities. Bariatric surgery (metabolic/gastrointestinal surgery) not only achieves significant and sustainable weight loss, but also induces extraordinary effects on nearly all obesity-related comorbidities, particularly remission of type 2 diabetes mellitus (T2DM). The mechanisms underlying such effects are slowly being elucidated, and it appears that the metabolic benefits of bariatric surgery are not only attributable to weight loss, but there are also weight independent mechanisms at play. This article outlines the metabolic effects of the most commonly performed bariatric procedures, with a particular emphasis on how they affect glucose metabolism and T2DM.


Obesity Diabetes mellitus Bariatric surgery Metabolic surgery Diabetes remission Weight loss 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med. 2006;355:763–78.PubMedCrossRefGoogle Scholar
  2. 2.
    Caterson ID, Finer N, Coutinho W, et al. Maintained intentional weight loss reduces cardiovascular outcomes: results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial. Diabetes Obes Metab. 2012;14:523–30.PubMedCrossRefGoogle Scholar
  3. 3.
    • Sjostrom L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56–65. This study has the longest follow-up of bariatric patients with regard to the effects of surgically induced weight loss on cardiovascular risk factors and mortality.PubMedCrossRefGoogle Scholar
  4. 4.
    Fisher BL, Schauer P. Medical and surgical options in the treatment of severe obesity. Am J Surg. 2002;184:9S–16S.PubMedCrossRefGoogle Scholar
  5. 5.
    Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303:235–41.PubMedCrossRefGoogle Scholar
  6. 6.
    Resnick HE, Foster GL, Bardsley J, Ratner RE. Achievement of American Diabetes Association clinical practice recommendations among U.S. adults with diabetes, 1999–2002: the National Health and Nutrition Examination Survey. Diabetes Care. 2006;29:531–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292:1724–37.PubMedCrossRefGoogle Scholar
  8. 8.
    •• Schauer PR, Rubino F. International Diabetes Federation position statement on bariatric surgery for type 2 diabetes: implications for patients, physicians, and surgeons. Surg Obes Relat Dis. 2011;7:448–51. This paper reports the recent recommendations of the IDF for weight loss surgery in the management of type 2 diabetes.PubMedCrossRefGoogle Scholar
  9. 9.
    Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.PubMedCrossRefGoogle Scholar
  10. 10.
    Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753–61.PubMedCrossRefGoogle Scholar
  11. 11.
    Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–29.PubMedCrossRefGoogle Scholar
  12. 12.
    Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351:2683–93.PubMedCrossRefGoogle Scholar
  13. 13.
    Agaba EA, Shamseddeen H, Gentles CV, Sasthakonar V, Gellman L, Gadaleta D. Laparoscopic vs open gastric bypass in the management of morbid obesity: a 7-year retrospective study of 1,364 patients from a single center. Obes Surg. 2008;18:1359–63.PubMedCrossRefGoogle Scholar
  14. 14.
    Sekhar N, Torquati A, Youssef Y, Wright JK, Richards WO. A comparison of 399 open and 568 laparoscopic gastric bypasses performed during a 4-year period. Surg Endosc. 2007;21:665–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. Trends in mortality in bariatric surgery: a systematic review and meta-analysis. Surgery. 2007;142:621–32. discussion 32–5.PubMedCrossRefGoogle Scholar
  16. 16.
    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.PubMedCrossRefGoogle Scholar
  17. 17.
    Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, Scopinaro N. Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry. Ann Surg. 2007;246:1002–7. discussion 7–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Poulose BK, Griffin MR, Zhu Y, et al. National analysis of adverse patient safety for events in bariatric surgery. Am Surg. 2005;71:406–13.PubMedGoogle Scholar
  19. 19.
    • Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469–75. This paper was the first systematic review of short-term to medium-term outcomes after sleeve gastrectomy.PubMedCrossRefGoogle Scholar
  20. 20.
    Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003;138:957–61.PubMedCrossRefGoogle Scholar
  21. 21.
    Tice JA, Karliner L, Walsh J, Petersen AJ, Feldman MD. Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008;121:885–93.PubMedCrossRefGoogle Scholar
  22. 22.
    Heneghan HM, Meron–Eldar S, Yenumula P, Rogula T, Brethauer SA, Schauer PR. Incidence and management of bleeding complications after gastric bypass surgery in the morbidly obese. Surg Obes Relat Dis. 2011.Google Scholar
  23. 23.
    Nguyen NT, Rivers R, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2003;13:62–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care. 2002;25:358–63.PubMedCrossRefGoogle Scholar
  25. 25.
    Pontiroli AE, Pizzocri P, Librenti MC, et al. Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications: a three-year study. J Clin Endocrinol Metab. 2002;87:3555–61.PubMedCrossRefGoogle Scholar
  26. 26.
    Ponce J, Haynes B, Paynter S, et al. Effect of Lap-Band-induced weight loss on type 2 diabetes mellitus and hypertension. Obes Surg. 2004;14:1335–42.PubMedCrossRefGoogle Scholar
  27. 27.
    Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–50. discussion 50–2.PubMedCrossRefGoogle Scholar
  28. 28.
    Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238:467–84. discussion 84–5.PubMedGoogle Scholar
  29. 29.
    Torquati A, Lutfi R, Abumrad N, Richards WO. Is Roux-en-Y gastric bypass surgery the most effective treatment for type 2 diabetes mellitus in morbidly obese patients? J Gastrointest Surg. 2005;9:1112–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Scopinaro N, Marinari GM, Camerini GB, Papadia FS, Adami GF. Specific effects of biliopancreatic diversion on the major components of metabolic syndrome: a long-term follow-up study. Diabetes Care. 2005;28:2406–11.PubMedCrossRefGoogle Scholar
  31. 31.
    Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7:477–84.PubMedGoogle Scholar
  32. 32.
    Dolan K, Bryant R, Fielding G. Treating diabetes in the morbidly obese by laparoscopic gastric banding. Obes Surg. 2003;13:439–43.PubMedCrossRefGoogle Scholar
  33. 33.
    Sugerman HJ, Sugerman EL, DeMaria EJ, et al. Bariatric surgery for severely obese adolescents. J Gastrointest Surg. 2003;7:102–7. discussion 7–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Wittgrove AC, Clark GW, Schubert KR. Laparoscopic Gastric Bypass, Roux-en-Y: Technique and Results in 75 Patients With 3–30 Months Follow-up. Obes Surg. 1996;6:500–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947–54.PubMedCrossRefGoogle Scholar
  36. 36.
    Scopinaro N, Gianetta E, Adami GF, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery. 1996;119:261–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3–60 month follow-up. Obes Surg. 2000;10:233–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Morinigo R, Lacy AM, Casamitjana R, Delgado S, Gomis R, Vidal J. GLP-1 and changes in glucose tolerance following gastric bypass surgery in morbidly obese subjects. Obes Surg. 2006;16:1594–601.PubMedCrossRefGoogle Scholar
  39. 39.
    Wickremesekera K, Miller G, Naotunne TD, Knowles G, Stubbs RS. Loss of insulin resistance after Roux-en-Y gastric bypass surgery: a time course study. Obes Surg. 2005;15:474–81.PubMedCrossRefGoogle Scholar
  40. 40.
    Pontiroli AE, Folli F, Paganelli M, et al. Laparoscopic gastric banding prevents type 2 diabetes and arterial hypertension and induces their remission in morbid obesity: a 4-year case-controlled study. Diabetes Care. 2005;28:2703–9.PubMedCrossRefGoogle Scholar
  41. 41.
    White S, Brooks E, Jurikova L, Stubbs RS. Long-term outcomes after gastric bypass. Obes Surg. 2005;15:155–63.PubMedCrossRefGoogle Scholar
  42. 42.
    Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care. 2009;32:2133–5.PubMedCrossRefGoogle Scholar
  43. 43.
    DiGiorgi M, Rosen DJ, Choi JJ, et al. Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up. Surg Obes Relat Dis. 2010;6:249–53.PubMedCrossRefGoogle Scholar
  44. 44.
    Chikunguwo SM, Wolfe LG, Dodson P, et al. Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2010;6:254–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299:316–23.PubMedCrossRefGoogle Scholar
  46. 46.
    •• 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. A randomized controlled trial comparing two bariatric procedures (gastric bypass and sleeve gastrectomy) with intensive medical therapy for the management of type 2 diabetes in obese patients.PubMedCrossRefGoogle Scholar
  47. 47.
    •• 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. A randomized controlled trial comparing two bariatric procedures (gastric bypass and BPD) with conventional medical therapy for the management of type 2 diabetes in severely obese patients.PubMedCrossRefGoogle Scholar
  48. 48.
    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.PubMedCrossRefGoogle Scholar
  49. 49.
    Cummings DE, Overduin J, Shannon MH. Foster–Schubert KE. Hormonal mechanisms of weight loss and diabetes resolution after bariatric surgery. Surg Obes Relat Dis. 2005;1:358–68.PubMedCrossRefGoogle Scholar
  50. 50.
    Rubino F, Forgione A, Cummings DE, 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. 2006;244:741–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol. 2011;108:1499–507.PubMedCrossRefGoogle Scholar
  52. 52.
    Livingston EH, Arterburn D, Schifftner TL, Henderson WG, DePalma RG. National Surgical Quality Improvement Program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg. 2006;203:625–33.PubMedCrossRefGoogle Scholar
  53. 53.
    Torquati A, Wright K, Melvin W, Richards W. Effect of gastric bypass operation on Framingham and actual risk of cardiovascular events in class II to III obesity. J Am Coll Surg. 2007;204:776–82. discussion 82–3.PubMedCrossRefGoogle Scholar
  54. 54.
    MacDonald Jr KG, Long SD, Swanson MS, et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg. 1997;1:213–20. discussion 20.PubMedCrossRefGoogle Scholar
  55. 55.
    Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg. 2004;240:416–23. discussion 23–4.PubMedCrossRefGoogle Scholar
  56. 56.
    Sampalis JS, Sampalis F, Christou N. Impact of bariatric surgery on cardiovascular and musculoskeletal morbidity. Surg Obes Relat Dis. 2006;2:587–91.PubMedCrossRefGoogle Scholar
  57. 57.
    Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543–51.PubMedCrossRefGoogle Scholar
  58. 58.
    Maciejewski ML, Livingston EH, Smith VA, et al. Survival among high-risk patients after bariatric surgery. JAMA. 2011;305:2419–26.PubMedCrossRefGoogle Scholar
  59. 59.
    Abel ED, Litwin SE, Sweeney G. Cardiac remodeling in obesity. Physiol Rev. 2008;88:389–419.PubMedCrossRefGoogle Scholar
  60. 60.
    Pontiroli AE, Laneri M, Veronelli A, et al. Biliary pancreatic diversion and laparoscopic adjustable gastric banding in morbid obesity: their long-term effects on metabolic syndrome and on cardiovascular parameters. Cardiovasc Diabetol. 2009;8:37.PubMedCrossRefGoogle Scholar
  61. 61.
    Garza CA, Pellikka PA, Somers VK, et al. Structural and functional changes in left and right ventricles after major weight loss following bariatric surgery for morbid obesity. Am J Cardiol. 2010;105:550–6.PubMedCrossRefGoogle Scholar
  62. 62.
    Ikonomidis I, Mazarakis A, Papadopoulos C, et al. Weight loss after bariatric surgery improves aortic elastic properties and left ventricular function in individuals with morbid obesity: a 3-year follow-up study. J Hypertens. 2007;25:439–47.PubMedCrossRefGoogle Scholar
  63. 63.
    Leichman JG, Aguilar D, King TM, et al. Improvements in systemic metabolism, anthropometrics, and left ventricular geometry 3 months after bariatric surgery. Surg Obes Relat Dis. 2006;2:592–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Rider OJ, Francis JM, Ali MK, et al. Beneficial cardiovascular effects of bariatric surgical and dietary weight loss in obesity. J Am Coll Cardiol. 2009;54:718–26.PubMedCrossRefGoogle Scholar
  65. 65.
    Russo V, Ammendola E, De Crescenzo I, et al. Effect of weight loss following bariatric surgery on myocardial dispersion of repolarization in morbidly obese patients. Obes Surg. 2007;17:857–65.PubMedCrossRefGoogle Scholar
  66. 66.
    Bezante GP, Scopinaro A, Papadia F, et al. Biliopancreatic diversion reduces QT interval and dispersion in severely obese patients. Obesity (Silver Spring). 2007;15:1448–54.CrossRefGoogle Scholar
  67. 67.
    Russo V, Ammendola E, De Crescenzo I, Docimo L, Santangelo L, Calabro R. Severe obesity and P-wave dispersion: the effect of surgically induced weight loss. Obes Surg. 2008;18:90–6.PubMedCrossRefGoogle Scholar
  68. 68.
    Brethauer SA, Chand B, Schauer PR, et al. Risks and Benefits of Bariatric Surgery: Current Evidence. Cleve Clin J Med. 2006;73:993–1007.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Bariatric and Metabolic Institute, M61Cleveland ClinicClevelandUSA
  2. 2.Heart & Vascular InstituteCleveland ClinicClevelandUSA

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