Chapter 27 Bariatric Surgery

c h a p t e r
27
Bariatric Surgery
Su-Ann Ding, Travis McKenzie, Ashley H. Vernon, and Allison B. Goldfine
CHAPTER OUTLINE
OVERVIEW OF BARIATRIC PROCEDURES AND
ANTICIPATED WEIGHT LOSS, 480
WEIGHT LOSS MECHANISMS, 480
Gastrointestinal Hormonal Changes, 480
Central Nervous System Control, 483
Vagal Signaling, 483
Energy Expenditure, 483
EFFECTS OF BARIATRIC SURGERY ON
CARDIO-METABOLIC HEALTH AND MORTALITY, 483
DIABETES REMISSION FOLLOWING BARIATRIC
SURGERY,484
The Role of Insulin Sensitivity and Insulin Secretion
in Diabetes Remission after Gastric Bypass, 486
The Hindgut and the Foregut Hypotheses, 486
Incretin Effects in Diabetes Remission, 486
Branched-Chain Amino Acids and Aromatic
Amino Acids, 486
Bile Acids, 486
Gut Microbiota, 487
Changes in Glucose Production and Disposal
(Roux Limb), 487
IMPROVEMENTS OF OTHER OBESITY COMORBID

CONDITIONS,487
Fertility,487
Pulmonary Disease Including Obstructive Sleep
Apnea,487
COMPLICATIONS OF BARIATRIC SURGERY, 487
Weight Regain Following Bariatric Surgery, 488
Dumping Syndrome, 488
Long-Term Complications, 488
Hyperinsulinemic Hypoglycemia with
Neuroglycopenia,489
COMMONLY PERFORMED BARIATRIC SURGICAL
PROCEDURES,489
Roux-en-Y Gastric Bypass, 489
Sleeve Gastrectomy, 490
Adjustable Gastric Banding, 490
Biliopancreatic Diversion with or without Duodenal
Switch,490
KEY POINTS
B
ariatric surgery has been increasingly considered as a viable therapeutic option for
obesity and obesity related comorbidities, with emerging evidence supporting its
variable roles within the different types of surgical options available today.
Proposed mechanisms explaining the improvements in metabolic effects from bariatric
surgery are not completely understood and may not be fully explained by weight loss
alone.
This chapter highlights differences in the types of surgeries commonly performed
today and the evidence supporting the roles of these procedures in improving cardiometabolic and other health outcomes.
Diabetes remission has also been reported to occur at different rates following the
different types of surgical procedures, and there are multiple studies suggesting possible
mechanisms to explain this phenomenon.
There are potential short- and long-term complications that may occur with various
types of bariatric surgery.
Bariatric surgery should be considered in obese patients with comorbidities who are
surgically appropriate candidates, and the different types of surgical procedures should
be explored with each patient and tailored according to the individuals risks and
potential benefits from these procedures.
479
480
PART 4 OBESITY, ANOREXIA, AND NUTRITION
Diet, consisting of healthy food choices and portion

control, and exercise are important to treat and prevent obesity and related health disorders (see Chapter
26). Obesity-related comorbidities include metabolic
diseases, such as type 2 diabetes, hypertension, dyslipidemia, nonalcoholic steatohepatitis, and cardiovascular disease; structural complications such as sleep apnea
or degenerative diseases such as osteoarthritis; certain
neoplastic diseases of endometrial, breast, ovarian,
colorectal, and pancreatic origin; as well as psychological disorders, including depression. Eighteen percent of
all deaths in the United States are attributable to obesityrelated disease, making this a top public health priority. Even modest weight loss leads to health advantages,
but can be challenging to achieve and difficult to maintain.1,2 In contrast, weight loss following a variety of
bariatric surgical procedures is substantial and generally
sustained,2 but not without risks. While many consider
surgical approaches to obesity draconian,3 the obesity epidemic coupled with the development and widespread utilization of laparoscopic techniques has led to
a dramatic increase in the annual number of bariatric
procedures performed. The potential health benefits of
bariatric surgery extend beyond weight management
and may include improved survival, remission of type
2 diabetes, and reduced incident of diabetes, cardiovascular disease, and cancers in women. Some forms
of bariatric surgery represent metabolic surgery as they
primarily alter enteroendocrine hormones, neuronal signaling, beta cell function, and other processes thereby
contributing to health benefits, while other procedures
only have secondary changes from weight loss. From
studying bariatric procedures, there are many lessons to
be learned about physiology, and there is great potential
for discovery of novel therapeutic approaches for obesity and related disease management.
OVERVIEW OF BARIATRIC PROCEDURES AND

ANTICIPATED WEIGHT LOSS
Multiple types of bariatric procedures are performed
for weight management. More common procedures are
shown in Figure 27-1. Each procedure results in unique
anatomic and physiologic change, which influences their
outcomes as discussed later in this chapter. Benefits of the
laparoscopic compared to open approach for these procedures include fewer wound complications, less pain, and
earlier return to activities without compromise of efficacy,4,5 but it is not technically possible for all patients.
Excess weight loss (EWL), defined as the percent change
from excess to ideal body weight, can vary by procedural
approach. After biliopancreatic diversion with or without
duodenal switch, patients have the greatest excess weight
loss (70% to 80%), followed by Roux-en-Y gastric bypass
(RYGB) (60% to 70%), sleeve gastrectomy (50% to
60%), and adjustable gastric banding (45% to 50%).6-8
Weight loss for any individual patient is highly variable.
Procedures with the greatest weight loss also carry the
greatest surgical risk (Fig. 27-2). Recommendations for
a specific bariatric procedure should be individualized
to the patients particular needs, including presence and
severity of comorbid conditions rather than simply the

desire for weight loss, and include patient preferences as
risks, benefits, and long-term monitoring differ.
Bariatric procedures have classically been categorized
by the way in which they were previously considered
to promote weight loss. Restrictive procedures were
thought to cause weight loss solely by restricting food
(caloric) intake by creating a small stomach pouch or outlet. This category would include adjustable gastric banding or vertical banded gastroplasty, which is no longer
commonly performed but still seen among patients. The
procedures associated with the greatest weight loss, but
also the highest complication rates, are those associated
with malabsorption of calories. Malabsorptive procedures were previously considered to promote weight
loss primarily by intestinal rerouting leading to inadequate caloric and nutrient absorption despite normal
or excessive intake, such as the biliopancreatic diversion
or jejuno-ileal bypass, which is also no longer routinely
performed but still seen among patients. RYGB combines
both mechanisms. It has become increasingly apparent that restrictive and malabsorptive categories do not
encompass the myriad physiologic alterations that occur
following surgery, and there are multiple important metabolic components to all bariatric operations that influence overall success.
WEIGHT LOSS MECHANISMS

Recently, mechanisms other than restriction and malabsorption have been recognized to contribute to weight
loss and metabolic improvements following bariatric surgery. The entero-neuro-endocrine axis involves signaling
from multiple gut hormones and metabolites that influence appetite and satiety through circulation or neural
pathways, and altered gastrointestinal anatomy, secretion of these hormones, and neuronal signaling processes
are seen to a varying degree following different bariatric
procedures (Fig. 27-3).
Gastrointestinal Hormonal Changes

Ghrelin, a peptide hormone mainly produced by X/A cells
in the oxyntic glands of the fundus and body of the stomach, acts on the G-proteincoupled receptor known as
the growth hormone secretagogue receptor9 to stimulate
neuropeptide Yagouti-related protein (NPY-AgRP) neurons within the arcuate nucleus (ARC), thereby increasing food intake.10 Most studies show reduced circulating
ghrelin following RYGB11,12 and sleeve gastrectomy,13
but increased concentrations following adjustable gastric
banding14 and low-calorie diet.12
Glucagon-like peptide 1 (GLP-1), peptide YY (PYY),
and oxyntomodulin are anorexic hormones released from
L-cells of the distal bowel after meal ingestion. These
peptides act at the hypothalamic ARC and brainstem to
induce satiety and reduce food intake.15 Postprandial levels of these anorexic hormones increase after RYGB16-19
and sleeve gastrectomy20,21 but not with diet-induced
weight loss17,22 or adjustable gastric banding.23 Similarly, cholecystokinin (CCK), another anorexic peptide,
released from I-cells in the mucosal epithelium of the
Esophagus
Proximal pouch
of stomach
Short intestinal
Roux limb
Pylorus
Bypassed
portion of
stomach
Duodenum
Gastric
Sleeve
Pylorus
Excised
stomach
D
E
Figure 27-1 A, Adjustable gastric band (AGB). A silicone band is looped around the proximal stomach to create a 15- to 20-mL pouch with an
adjustable outlet. The stomach is wrapped around the band anteriorly to prevent the band from slipping out of position. The band consists of a rigid
outer ring and an inner inflatable balloon reservoir connected by tubing to a subcutaneous port that can be accessed through the skin to adjust the
tightness. B, Sleeve gastrectomy. A narrow gastric sleeve is created by stapling the stomach vertically. The fundus and greater curve of the stomach are
removed from the abdomen. C, Roux-en-Y gastric bypass (RYGB). A small gastric pouch (15 to 30 mL) is created by division of the upper stomach
connected to a 100- to 150-cm limb of jejunum called the roux limb. The small gastric pouch results in restriction of food intake. D, Biliopancreatic
diversion (BPD). Most of the small bowel is bypassed and only 50 to 100 cm of a common channel remains for absorption of calories and nutrients.
The upper pouch is larger than that of the RYGB to allow for ingestion of larger amounts of protein to prevent malnutrition. E. Biliopancreatic diversion with duodenal switch (BPD-DS). To avoid dumping syndrome and maintain the pylorus, the procedure was modified with the pouch based on
the lesser curve of the stomach and an anastomosis at the first portion of the duodenum.
482
n
tio
ca
pli
Adjustable
gastric band
m
co
ss
e
er
Le
w
Fe
ffe
cti
ve
Sleeve
gastrectomy
Mo
re
e
n
tio
ca
pli
ffe
cti
ve
m
co
re
Mo
Roux-en-Y
gastric bypass
Biliopancreatic diversion duodenal switch
Figure 27-2 Effectiveness
of bariatric surgery in
relation to the risk for developing complications
from surgery.
Vagus nerve
Food
Gastric
restriction
Partial
vagotomy
Exclusion
of the distal
stomach
Gall
bladder
Early delivery of
ingested nutrients
to the jejunum
Exclusion of
the proximal
intestine from
alimentary
flow
Delivery of partially
digested nutrients to
the distal intestine
Microbiome
changes
Segregation of
digestive secretions
from alimentary flow
small intestine and secreted in the duodenum in response

to food intake24 or in response to GLP-1 or duodenal
long-chain free fatty acids,25 also increases following
RYGB and sleeve gastrectomy.26,27
The adipokine adiponectin functions as an insulinsensitizing hormone regulating glucose and lipid metabolism28 with antiinflammatory properties and beneficial
effects on type 2 diabetes, atherosclerosis, obesity, and
Figure 27-3 Multiple mechanisms may contribute to weight
loss and metabolic improvements following

Roux-en-Y
gastric bypass. The relative importance of each mechanism
remains incompletely understood. Some of these mechanisms may occur with varying intensity following other
bariatric surgery procedures.
nonalcoholic fatty liver disease.29,30 Adiponectin levels increase following bypass and restrictive surgeries,
and the magnitude of increase may be larger following
RYGB than band surgery, or compared to weight loss by
caloric restriction.31 Leptin, also secreted by adipocytes,
acts primarily on the hypothalamus to increase energy
expenditure and reduce food intake.28 It remains unclear
to what extent changes in adiponectin, leptin, or other
27 BARIATRIC SURGERY
adipokine concentrations or activity contribute to weight

loss durability and metabolic improvements beyond that
seen with weight loss achieved through lifestyle modification alone.
Central Nervous System Control

Eating behaviors differ in patients who have had bariatric surgery compared to those on low- calorie diets. Dietinduced weight loss tends to decrease satiety, increase
hunger, and drive cravings for energy-dense foods.22,32
In contrast, patients describe early satiety and less hunger, and the compensatory consumption of energy-rich
foods is not observed following bariatric surgery.14,18,32,33
In part, these behavioral changes are related to adaptive learning to avoid adverse gastrointestinal symptoms
after surgery such as nausea, vomiting, diarrhea, reflux,
bloating, and dumping syndrome. The character of these
symptoms will vary due to differences in the surgical procedures and postsurgical adaptation.
Regulation of food intake can be influenced by the
central nervous system by affecting food-seeking behavior and satiety perception. The hypothalamus, frontal
cortex, and caudal brainstem regulate weight homeostasis by detecting internal and external signals to
stimulate appetite or satiety accordingly.34 The hypothalamus contains two groups of neurons within the
ARC with opposite effects; the pro-opiomelanicortin
(POMC)-derived peptides, which act via melanocortin
receptor 4 (MC4R) to reduce food intake and increase
energy expenditure, and the orexigenic peptides neuropeptide Y (NPY) and Agouti-related protein (AgRP),
which drive food intake.35 The expression of these peptides (POMC, NPY and AgRP) may change following
bariatric surgery as illustrated in studies of rats following vertical sleeve gastrectomy compared with pairfed rats undergoing sham surgery.36 AgRP levels were
unchanged in the vertical sleeve gastrectomy group
compared with pair-fed animals that had elevated
AgRP. These findings suggest calorically restricted rats
were hungry compared to those with vertical sleeve
gastrectomy.
Neural systems of reward, cognition, and emotion
may also contribute to regulation of eating behavior
postbariatric surgery, as shown in studies in humans
demonstrating altered effects of food visual cues on
brain activity in hedonistic centers assessed by functional
magnetic resonance imaging (fMRI).33,37 Post-RYGB
patients had lower activation of brain reward systems,
particularly to energy-rich foods, and chose healthier
food options compared to body mass indexmatched
controls or patients who had undergone adjustable gastric band.37 Likewise, patients reported less food motivation (decreased brain activity in response to being shown
food compared to nonfood pictures after a meal) and
increased cognitive restraint (the ability to intentionally
limit food intake in order to prevent weight gain) and
corresponding brain area activity by fMRI postadjustable
gastric banding, both fasting and fed, compared with
preoperative assessment. Similarly, patients reported less
hunger and increased cognitive restraint postoperatively
when assessed by standardized survey.33
483
Vagal Signaling
Vagal nerve afferent activity also contributes to food
intake.38 Stimulation of the vagal nerve by increased
intraluminal pressures may contribute to reduced food
intake and weight loss in patients who undergo adjustable gastric band. Patients with optimally filled bands are
less hungry compared with patients with suboptimally
filled or empty bands, as seen in a randomized masked
crossover study.14 However, vagal nerve preservation
does not influence clinical parameters (weight loss and
gastrointestinal symptoms) and satiety scores compared
with severing of the vagal nerve during RYGB procedures.39 Similarly in animal studies, no significant difference in body weight, body composition, meal patterns,
and energy expenditure are found comparing rats undergoing RYGB alone and RYGB with common hepatic
branch vagotomy.40 Thus further studies are required to
explore the role of the vagus nerve in weight loss induced
by bariatric surgical procedures.
Energy Expenditure
Exercise capacity can improve following bariatric surgery.2 Additionally, human and animal studies demonstrate increased resting energy expenditure (also see
Chapter 25) following RYGB compared to preoperative
values or nonsurgical controls41-43 in contrast to reductions in resting energy expenditure following diet-induced
weight loss. Mechanisms underlying this phenomenon
remain incompletely understood, but could include
increased fitness from increased physical activity after
weight loss, or mechanisms such as bile acid activation of
brown adipose tissue or skeletal muscle oxidation.44
EFFECTS OF BARIATRIC SURGERY ON

CARDIO-METABOLIC HEALTH AND MORTALITY
The hallmark prospective Swedish Obese Subjects (SOS)
study compared adjustable gastric banding, vertical
banded gastroplasty, and RYGB to medical management in well-matched but nonrandomized obese cohorts.
After bariatric procedures, the combined surgical cohort
lost an average of 16.1% of total body weight at 10
years compared to a slight weight gain in the nonsurgical management group.2 RYGB resulted in greater mean
weight loss (25%) than vertical banded gastroplasty
(-16.5%) and adjustable gastric banding (-13.2%) at
2 years and 10 years. Overall, the surgical group had
more favorable outcomes with both improved resolution and lower incidence rates of type 2 diabetes, and
reduced hypertriglyceridemia and hyperuricemia compared to medical management. Hypertension and dyslipidemia likewise improve,6,7 which together would be
anticipated to reduce major cardiovascular event rates
and improve survival. Indeed, both the SOS study and
a retrospective cohort study demonstrated improved
total mortality by 30% to 40% in surgically treated
groups.45,46 Neither study was randomized, thus referral biases could confound conclusions. Death attributed to cardiovascular disease was reduced by about
50%,45,47 and deaths from diabetes listed on the death
certificate were reduced by 90%.45 Incident diabetes
484
TABLE 27-1 Improvements in Obesity Comorbid

Conditions
Mortality
Nonrandomized studies suggest improved mortality.
Cardiometabolic
Major cardiovascular event rates (myocardial infarction,
stroke, and cardiovascular death)
Type 2 diabetes
Nephropathy related to diabetes
Type 2 diabetes prevention
Hypertension
Dyslipidemia
Hyperuricemia
Respiratory
Obstructive sleep apnea
Obesity hypoventilation
Gastrointestinal
Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis
Musculoskeletal
Degenerative joint disease (osteoarthritis of weight-bearing
joints)
General physical functioning and exercise capacity
Recovery and rehabilitation following joint surgery
Dermatological
Hirsutism
Intertrigo and candidiasis
Wound healing
Striae/stretch marks
Acanthosis nigricans
Reproductive System
Polycystic ovarian disease
Improved fertility (female and male)
Regulation of menstrual cycle
Libido
Oncology
Reduction in overall cancer risk and mortality
Psychosocial/Neurology
Quality-of-life health measures
Cognitive function (improvement in learning and memory)
Urology
Urinary incontinence
was reduced by approximately 80%.48 Indeed, multiple obesity-related comorbidities have been shown to
improve following bariatric surgery, including a reduction in cancers and an improvement in metabolic, cardiovascular, reproductive, musculoskeletal, respiratory,
and some psychiatric conditions6,46,49-52 (Table 27-1,
and Fig. 27-4).
In summary, substantial weight loss can occur and be sustained following bariatric surgery, with resultant improvement in obesity-related comorbidities. While intensive lifestyle
modification can be successful for weight loss, it is difficult to
achieve for many and weight regain is common.35,53 Newer
pharmacologic agents are available for weight management,
but information on long-term safety and efficacy are not

yet available. Thus, bariatric surgery represents an effective
therapeutic approach for the patient in whom surgical risk
is reasonable who is otherwise unable to achieve or sustain
weight goals. Bariatric surgical approaches are increasingly
considered for diabetes management at lower magnitudes of
excess weight.
DIABETES REMISSION FOLLOWING BARIATRIC

SURGERY
Improvements are seen in glycemia, hypertension,
and dyslipidemia in patients with type 2 diabetes
following bariatric surgery. A meta-analysis by Buchwald and colleagues reported that 78% of patients
with type 2 diabetes undergoing bariatric surgery had
complete remission of type 2 diabetes, defined as normoglycemia without medication, and 86% had either
improvement or resolution of diabetes.54 Patients who
underwent biliopancreatic diversion had the highest
remission rate at 95%, followed by RYGB and gastroplasty at 80%, and adjustable gastric banding at 57%
(see Fig. 27-4). Surgical approaches may also reduce
the incidence of new diabetes.48 Interestingly, preoperative body mass index does not predict individuals most
likely to achieve diabetes remission or those most likely
to realize protection from incident disease. Thus, in the
future, criteria other than body mass index per se may
be used to identify patients most likely to attain metabolic benefits.
When considering patients with type 2 diabetes,
greater weight loss and better glycemic outcomes are
seen in the early years following bariatric surgery in
randomized studies that compare surgical to medical
diabetes and weight-management approaches.46,55-59
However, while randomized studies currently do not
extend beyond 2 years and longer-term follow up is
required to understand diabetes, cardiovascular, and
other obesity-related comorbidity outcomes in the
absence of selection bias, these observational studies are
informative.
While high numbers of patients may achieve diabetes remission following bariatric surgery, unsurprisingly, remission from diabetes may not be permanent.60
About 35% of patients who initially realize remission
may relapse within 5 years, with a median duration of
remission of approximately 8.3 years. Several factors predict lower remission and/or subsequent relapse, including poor preoperative glycemic control, longer duration
since diagnosis of diabetes, insulin use,60 and lower betacell glucose sensitivity,61 together suggesting adequate
residual beta cell function is important for initial remission, and progressive disease may contribute to relapse.
However, as many studies demonstrate important clinical
benefits from a period of glycemic control on subsequent
development of complications (metabolic memory),62
even moderate duration remission may be clinically
important.
Weight loss itself has substantial impact on improvement and remission of diabetes, but there is mounting evidence that additional mechanisms contribute
485
WEIGHT LOSS OUTCOMES FOR SURGICAL PROCEDURES

Gastric banding
Gastric bypass
BPD/DS
Sleeve gastrectomy*
Absolute mean change

in weight (kg)
10
20
30
40
50
60
% excess body weight loss
100
80
60
<2 years outcomes
2 years outcomes
% EXCESS BODY WEIGHT LOSS AND % DIABETES RESOLUTION

95.1
% diabetes resolution
80.3
56.7
40
20
0
Gastric banding
Gastric bypass
BPS/DS
OBESITY COMORBIDITIES OUTCOMES
Mean % of patients
improved
120
100
80
60
40
20
0
Hypertension
Hyperlipidemia
Gastric banding
Gastric bypass
Obstructive
sleep apnea
BPD/DS
Figure 27-4 A, Absolute mean change in weight (kg) at time points less than 2 years and more than or equal to 2 years for patients within the
surgical groups gastric banding, gastric bypass, and BPD/DS. B, Percent of excess body weight loss (EBWL) at time points less than 2 years and more
than or equal to 2 years in surgical groups. C, Mean percent of patients with improvement in obesity comorbidities outcomes including hypertension,
hyperlipidemia, and obstructive sleep apnea in surgical groups adapted from meta-analysis. (A, *Sleeve gastrectomy cohort depicts data adapted
from randomized controlled trial [Schauer PR, Kashyap SR, Wolski K, etal. Bariatric surgery versus intensive medical therapy in obese patients
with diabetes. N Engl J Med. 2012; 366:1567-1576] showing mean change in weight (kg) from baseline at 12 months following sleeve gastrectomy.
Adapted from meta-analysis by Buchwald H, Estok R, Fahrbach K, etal. Weight and type 2 diabetes after bariatric surgery: Systematic review and
meta-analysis. Am J Med. 2009; 122:248-256, e5. B, Adapted from meta-analysis by Buchwald etal [2009]. Line graph above the bar chart shows
the percent of diabetes resolution in each surgical group. C, Data from Buchwald H, Avidor Y, Braunwald E, etal. Bariatric surgery: A systematic
review and meta-analysis. JAMA. 2004; 292:1724-1737.)
to improvement in glucose homeostasis, although this

remains heavily debated. In particular, glycemic improvements occur within days following RYGB, before substantial weight loss occurs.63,64 This glycemic improvement is
not seen from perioperative reduced caloric intake with
other gastrointestinal surgery, such as cholecystectomy.
Weight loss achieved by surgery is associated with greater

improvement in glucose tolerance at similar weight lost
by diet and exercise or conventional medical therapy.57,65
Neither liposuction nor surgical resection of omental fat
corrects diabetes,66,67 such that fat loss alone is insufficient for metabolic improvement.
486
The Role of Insulin Sensitivity and Insulin Secretion

in Diabetes Remission after Gastric Bypass
Persons with type 2 diabetes are typically more insulin
resistant than persons without diabetes. There are parallel improvements in insulin sensitivity following RYGB in
persons with or without type 2 diabetes, although those
with diabetes continue to have lower insulin sensitivity at
any given body mass index.61 Improvements in glucose utilization are greater early after RYGB in persons with type
2 diabetes compared to those without diabetes, presumably due to elimination of glucotoxic effects. However, by
1 year glucose utilization is similarly improved for those
who did or did not have diabetes at the time of surgery.
Early postoperative improvements in glycemia are mediated in part by improved insulin suppression of endogenous glucose production, accompanied by decreased
oxidative glucose disposal and increased lipid oxidation.68
Effects of biliopancreatic diversion on insulin sensitivity
appear greater in proportion to weight lost69; whether
this is true for RYGB remains controversial. In contrast,
improvement in insulin sensitivity following adjustable
gastric banding appears proportionate to weight lost.16
There is a robust early increase in insulin secretion,
GLP-1, and beta-cell glucose sensitivity following a mixed
meal after RYGB but not adjustable gastric banding at
similar weight loss.70 The acute insulin response continues
to improve over the first year.68 Improvement in beta-cell
glucose sensitivity after RYGB may be disproportionally
greater than magnitude improvement in insulin sensitivity.71 Although improved from baseline, beta-cell glucose
sensitivity after RYGB remains lower in patients with
type 2 diabetes compared to those without.61
Whether RYGB leads to increased beta-cell replication or function remains controversial. RYGB increases
expression of pancreatic duodenal homeobox-1 (PDX1), a key transcription factor for beta-cell development, in the Goto Kakizaki (GK) rat.72 A small group
of patients have been described who develop hyperinsulinemic hypoglycemia following RYGB. Pancreatic
pathology shows diffuse increase in islet number of
varying size, both isolated and in clusters, and budding from ducts,73,74 with increased nuclear diameter,
although it remains unclear whether total beta-cell mass
is increased.75 While the time course at which hypoglycemia becomes manifest, on average 2 years after gastric
bypass when weight has stabilized, and the progressive
nature in some patients suggests increased beta-cell proliferation, this has not been established.
The Hindgut and the Foregut Hypotheses

Two general leading hypotheses have been proposed to
explain the effects of bariatric surgery on improved glycemia: the hindgut and the foregut hypothesis. The hindgut hypothesis proposes that glycemic improvement is
due to accelerated nutrient delivery to distal intestines,
which augments secretion of hormones that affect glucose
homeostasis, including GLP-1, PYY, oxynomodulin, and/
or CCK.27 The foregut hypothesis suggests that exclusion
of the proximal intestine from ingested food promotes
antidiabetic effects by inhibiting an unidentified signal
that promotes insulin resistance.76 There is compelling

data to support each hypothesis, and it is possible both
may contribute.
Incretin Effects in Diabetes Remission

Considerable interest has developed to determine the
role of incretin hormonesglucose-dependent insulinotropic polypeptide (GIP), which is secreted by duodenal K-cells, and glucagon-like peptide-1 (GLP-1),
which is secreted by L-cells in the distal intestinesin
the effects of bariatric surgery on diabetes remission. As
noted, postprandial GLP-1 concentrations are increased
following RYGB77,78 compared to patients with equivalent diet-induced weight loss,78 an effect not seen following adjustable gastric banding.70,79 Normalization of
the insulin response to incretins post-RYGB may be sustained up to 3 years,80 and endogenous GLP-1 accounts
for about 50% of incretin-stimulated insulin release following RYGB.81 Improved glucose tolerance is reversed
with administration of the GLP-1 receptor antagonist
exendin9-39 in the Goto-Kakizaki (GK) rat.82 GLP-1 is
also increased after jejuno ileal bypass, biliopancreatic
diversion, gastric bypass, and sleeve gastrectomy.13,83,84
Changes in GIP have been less consistent.
Branched-Chain Amino Acids and Aromatic

Amino Acids
Branched-chain amino acids (BCAAs) valine, leucine,
and isoleucine are among the nine essential amino acids
available to humans as dietary proteins. BCAAs and the
aromatic amino acids (AAs), especially phenylalanine and
tyrosine, are associated with obesity and insulin resistance,85-87 and BCAA concentrations decrease with weight
loss.85 Greater reductions in circulating BCAAs and AAs
are seen in type 2 diabetes following gastric bypass compared to patients with nonsurgical, matched weight loss.88
Reductions in BCAA correlate with improved insulin sensitivity estimated by homeostatic model assessment of
insulin resistance (HOMA-IR) or euglycemic clamp.87,89
However, other studies show BCAA decrease similarly
after RYGB compared to matched weight loss following
adjustable gastric banding in nondiabetic individuals,87
so further studies are required to determine the causal
significance of the relationship between amino acids
and modification of insulin sensitivity, and whether the
magnitude of effects differ following surgically-induced
weight loss.
Bile Acids
Bile acids (BA) are well recognized for their role in lipid
metabolism. Recently they have been found to have additional metabolic effects affecting gut peptide secretion,
energy expenditure, and glucose homeostasis.90 RYGB
leads to changes in the anatomy of bile acid and nutrient flow through the gut. Diverting bile from the common bile duct to drain into distal jejunum with a catheter
increases serum bile acids and postprandial GLP-1
response, and improves glucose tolerance and hepatic
steatosis compared to sham-operated rats.91 Bile acids
promote GLP-1 secretion through the G-proteincoupled
receptor TGR5.92 Intrarectal infusion of the bile salt
taurocholic acid (TCA) increases plasma GLP-1, PYY,

and insulin concentrations in obese men with type 2 diabetes,93 and oral tauroursodeoxycholic acid (TUDCA)
improves liver and muscle insulin sensitivity in obese
men.94 Circulating BA concentrations increase following
RYGB.95,96 Increased circulating bile acids are associated
with increased GLP-1 and improved glycemia,95,97 but
not to skeletal muscle insulin sensitivity, insulin response
to mixed meal, or resting energy expenditure.97 Changes
in circulating bile acids are less pronounced after adjustable gastric banding compared to RYGB.97 The relative
importance of altered bile acids in improved metabolism
also remains incompletely understood.
Gut Microbiota
The gut microbiota profile differs in obesity and metabolic syndrome compared to lean individuals. Recently,
gut microbiota are recognized to alter production or
bioavailability of small molecules, proteins, and nutrients, and contribute to inflammation in the host.98,99
Changes in the dynamic symbiotic relationship between
the microbiota and the host participate in the progression of obesity and diabetes. However, with a diversity
of microorganisms present and a variety of factors that
can affect the microbiome composition (such as dietary
macronutrient, anatomic variance, antibiotic usage,
pH, and bile flow), identifying the specific relationship
between various gut microbiota and obesity is a challenging new field of investigation. RYGB causes shifts in
the gut microbiome including the change in ratio of Firmicutes to Bacteroidetes phyla and increase in colonization of Proteobacteria.100 Transfer of gut bacteria from
mice that have undergone RYGB to unoperated germfree mice promotes weight loss and reduced fat mass in
recipient mice, suggesting changes in gut microbiota contributes to weight loss following RYGB.101 Changes in
gut microbiota may be relevant to humans. Intriguingly,
Vrieze and coworkers102 infused microbiota from lean
human donors into the duodenum of obese individuals
and showed improved insulin sensitivity independent of
weight change.
Changes in Glucose Production and Disposal

(Roux Limb)
A novel mechanism for glucose lowering proposed by
Saeidi and colleagues103 postulates morphologic changes
of the Roux limb following RYGB with increased cellular size and mass results in reprogramming of intestinal
glucose metabolism to improve the diabetic state, as demonstrated by positron emission tomographycomputed
tomography (PET-CT) scanning and biodistribution
analysis of isotopic labeled glucose. These adaptations
may be triggered by passage of undigested food from
the stomach pouch to the jejunum, requiring additional
energy expenditure that promotes reprogramming of glucose metabolism. GLUT-1mediated basolateral glucose
uptake and utilization is enhanced following RYGB due
to expanding gut tissue, which in turn reduces systemic
glucose concentrations and improves the diabetic state as
supported by metabolomic, proteomic, and gene expression approaches.
487
IMPROVEMENTS OF OTHER OBESITY COMORBID

CONDITIONS
In addition to improvements in type 2 diabetes, hypertension, dyslipidemia, and cardiovascular health, bariatric
surgery may reduce major cardiovascular event rates, and
impact other obesity- related conditions (see Table 27-1).
There is specific interest in improvements in fertility and
obstructive pulmonary diseases.
Fertility
In the United States, women are approximately twice
as likely as men to be obese, yet within their reproductive years account for 83% of those undergoing bariatric
surgery.6,104 Systematic review of menstrual irregularities and pregnancy rates before and after surgery include
six studies.105 A retrospective study of RYGB found that
50% of women had menstrual irregularities preoperatively, while only 17.5% had persistent irregularities postoperatively.106 Menstrual cycles may normalize following
RYGB in women with polycystic ovarian syndrome.107
Obesity negatively impacts fertility in women.108,109 Most
evidence for improved fertility following bariatric surgery is retrospective and observational, as there are no
randomized data to support improved fertility following
bariatric surgery. A retrospective study examining 796
female patients after biliopancreatic diversion found that
47% of women previously unable to conceive preoperatively were successful postoperatively110; 82% of these
women had appropriate weight gain during pregnancy.
Miscarriage rates were not improved (26%).
The optimal timing for conception following bariatric
surgery remains uncertain, and evidence to guide recommendations is lacking. A small prospective cohort study
found approximately 50% of women had preterm delivery when pregnancy occurred within 1 year of bariatric
surgery, compared to 20% when conception was delayed
greater than 2 years.111 It is considered prudent to recommend delay of pregnancy for 12 to 24 months following bariatric surgery, as there is also a theoretical risk for
maternal and fetal malnutrition with adverse outcome
during the time of most active weight loss.
Pulmonary Disease Including Obstructive Sleep Apnea

Ten kilograms of weight loss leads to substantial improvement in obstructive sleep apnea (OSA) as measured by the
apnea-hypopnea index (AHI).112 As bariatric surgery has
been shown to be an effective method of sustained weight
loss, it is intuitive to think that bariatric surgery would result
in substantial amelioration or resolution of OSA. Indeed,
greater rates of resolution of OSA are seen following RYGB
(66%) than following lifestyle modification (40%), even
with the latter resulting in 8% total body weight loss.113,114
COMPLICATIONS OF BARIATRIC SURGERY

Bariatric surgery has proven to be both effective for
sustained weight loss and safe in the appropriate surgical candidate. However, as with any invasive surgical
procedure, there are inherent risks of which patients
should be educated. Obese patients are at higher risk for
488
perioperative complications, such as venous thromboembolism and pulmonary embolism, than the general population. Although rare, these can be lethal and represent a
leading cause of mortality in the perioperative period.115
The Longitudinal Assessment of Bariatric Surgery (LABS)
consortium observes the composite end point of death,
thrombotic event, reintervention, or prolonged hospital
stay (more than 30 days) occurred in 4.1% of surgical
patients.116 Complications generalizable to all surgical
procedures include those of bleeding, infection, injury to
other organs, complications of general anesthesia, and
death, which may occur in 0.1% to 0.5% of patients.
The most serious complication of bariatric surgery is
enteric leak, which occurs after RYGB with an incidence
between 0% and 5.6%.117 Gastrointestinal bleeding may
occur after any procedure in which the viscera are cut, such
as RYGB and biliopancreatic diversion, at any staple line or
anastomosis, with incidence ranging from 1.1% to 4%.118
Wound complications including infection and incisional
hernia have been dramatically reduced and rarely occur
with the advent and utilization of laparoscopic approaches.
The incidence of trocar site hernia is less than 1%.119 Procedure-specific complications are provided with a description of surgical procedures in the sections that follow.
from the intravascular to the enteric intraluminal space.

Patients have bloating, abdominal discomfort, diarrhea,
tachycardia, and lightheadedness. Late dumping symptoms are caused by exaggerated hyperinsulinism as a result
of hyperglycemia from absorption of the ingested glucose
load. Patients have dizziness, weakness, and diaphoresis
occurring approximately 2 to 3 hours after eating. Symptoms are usually responsive to dietary modification. Neuroglycopenia should not occur with dumping. Following
RYGB, a small percentage of patients may develop debilitating dumping symptoms that are unresponsive to dietary
modifications and may require somatostatin analogues for
therapy. The clinician should be careful to exclude endogenous hyperinsulinism resulting from nesideoblastosis in
the post-RYGB state, as therapy may differ.
Long-Term Complications
Surgical complications are provided in detail in Table 27-2.
Complications of interest to this audience are discussed in
greater detail in the section that follows.
TABLE 27-2 Potential Complications of Bariatric
Surgery
Weight Regain Following Bariatric Surgery
Early Complications (Within 30 Days of Surgery)
Each procedure has different kinetics of weight loss including the interval from surgery to nadir weight, as well as
the typical magnitude of weight regain from nadir. Sometimes the regained weight is considered as failed sustained
weight loss following bariatric surgery. The general definition of successful weight loss after bariatric surgery is
excess weight loss of 50% or more. The amount of excess
weight lost declines over time, for example after RYGB
66% excess weight loss is seen at 1 to 2 years, 60% at
5 years, and 50% at 10 years.120 Weight regain is also
seen in patients following sleeve gastrectomy and adjustable gastric banding, but less so following biliopancreatic diversion.2,121,122 Patients who are superobese, with
body mass index above 50 kg/m2, are at greater risk for
weight regain.121,123 Potential causes for weight regain
may be patient-related or surgery-related. Patient-related
etiologies may include poor dietary compliance, physical
inactivity, inadequate follow-up, and/or mental health
disorders.124-127 Surgery-related causes may include gastric pouch and sleeve dilatation or distension, and band
removal for gastric banding.128-131 Hormonal or metabolic
changes may be involved, such as higher ghrelin and/or
lower peptide YY in patients who experience weight regain
or fail to lose weight following bariatric surgery132,133
compared to those who achieve better weight outcomes,
but more studies are needed to elucidate these findings.
Hemorrhage
Infections
Anesthetic complications
Wound complications
Deep venous thromboembolism
Pulmonary embolism
Cardiorespiratory events
Technical failure
Anastomotic leaks (excludes adjustable gastric banding)
Perioperative mortality
Dumping Syndrome
Dumping syndrome may occur in over 70% of patients
after RYGB in response to a meal consisting of food with
a high glycemic index. This phenomenon is an expected
consequence of surgery and may lead to diminished intake
of concentrated sweets for symptom avoidance. Early
dumping is caused by the presence of hyperosmolar food
delivered to the small intestine, which causes a fluid shift
Late Complications
Gastric esophageal reflux
Anastomotic ulcers
Fistulas and strictures
Reoperation
Life-Threatening Complications
Internal hernia
Bowel obstruction
Intussusception
Long-Term Metabolic Complications
Malnutrition
RYGBIron, vitamin B12, calcium, vitamin D, secondary
hyperparathyroidism, folate
Biliopancreatic diversionProtein calorie malnutrition
and fat-soluble vitamin deficiency
Nausea and vomiting (may lead to thiamine deficiency)
Inadequate weight loss/weight regain
Dumping syndrome
Hypoglycemia
Hernia
Gallstones formation (secondary to rapid weight loss)
Bacterial overgrowth
Complications Specific to Gastric Band
Gastric outlet obstruction
Band slippage
Band erosion
Subcutaneous port complicationspain, leak
Hyperinsulinemic Hypoglycemia with Neuroglycopenia

Hypoglycemia is increasingly recognized as a potentially
rare devastating complication of gastric bypass surgery.
Hypoglycemia typically occurs 2 to 3 hours after meals,
with inappropriately high insulin and C-peptide concentrations, and can be managed in most patients with dietary
modification emphasizing controlled portions of low glycemic index carbohydrates, and attention to correcting macroand micronutrient deficiencies. Treatment may also include
alpha-glucosidase inhibition (i.e., acarbose) to slow carbohydrate absorption and minimize postprandial glycemia and
thus reduce the stimulus for insulin secretion. However, rare
patients develop severe hypoglycemia with neuroglycopenia,
manifest by confusion, loss of consciousness, seizures, and/
or motor vehicle accidents.73,74 The frequency is estimated
at 0.2% of bypass patients.134 Additional interventions may
include use of somatostatin analogues or diazoxide to suppress insulin secretion.135 Partial pancreatectomy may lead
to improvement, but recurrence of hyerinsulinemic hypoglycemia may occur. Altering the route of nutrient delivery,
fundoplication and deconstruction of RYGB have been
tried with varying short-term success.
Nutrient Deficiencies
Malnutrition may occur after any bariatric procedure.
However, the risk is highest with malabsorptive procedures secondary to bypass of a large portion of the absorptive capacity of the intestine. Malabsorption may lead
to diarrhea, dehydration, and macro- and micronutrient
deficiency. Deficiencies of fat-soluble nutrients or those
absorbed in the bypassed portion of the gut are most common and include vitamins B1 and B12, vitamin A, vitamin
D, folate, iron, and calcium. General or specific nutrient
deficiencies can lead to anemias, alopecia, polyneuropathies, Wernickes encephalopathy, or other deficiencies. It
is recommended that all patients use a daily multivitamin to
lower risk. Replacement may be difficult, and higher doses
or methods other than oral replacement may be required.
Metabolic Bone Disease
Most studies examining the effects of bariatric surgery on
bone health have focused on patients after RYGB, with
sparse literature regarding changes in bone mineral density after other procedures. Early catabolic bone remodeling, evidenced by increased circulating levels of markers
of bone turnover, have been found that persist, and subsequent decrease in bone mineral density can occur.136-139
Mechanisms are likely multifactorial. Some bone remodeling after bariatric surgery may represent physiologic
changes in skeletal structure in response to unloading from
rapid weight loss. Pathologic mechanisms leading to bone
catabolism include calcium and vitamin D deficiency with
or without secondary hyperparathyroidism.140 All patients
should receive calcium citrate and vitamin D supplements
to prevent secondary hyperparathyroidism and subsequent
bone loss following RYGB or biliopancreatic diversion.
Addictive Behavior
Obesity has been associated with maladaptive eating
habits including binge eating, which may be a form of
addictive personality and is found to be associated with
489
other addictive behaviors (such as substance or alcohol

dependence or overconsumption).141 Anecdotal reports
suggest that addictive behavior including alcoholism,
gambling, compulsive shopping, and sex addiction could
be potentially concerning for patients postbariatric
surgery.142 Most research on addictive behavior in this
cohort of patients is centered on alcohol use. Malabsorptive procedures such as RYGB and the significant weight
loss after surgery alter the pharmacokinetics of alcohol.
Patients report experiencing alcohol effects earlier, with
less concentration of alcohol consumed, and take longer to recover from these effects following surgery.143
Additionally, rapid emptying of alcohol from the gastric
pouch results in a greater peak of alcohol concentration
in a shorter time interval,144 and a smaller gastric pouch
results in reduced alcohol dehydrogenase and prolonged
alcohol clearance in surgical patients145 when compared
to nonsurgical controls. Assessment of prevalence of
alcohol use disorders (AUD) within the Longitudinal
Assessment of Bariatric Surgery-2 (LABS-2) cohort of surgical patients pre- and postoperatively reports a greater
prevalence of AUD in the second postoperative year.146
It remains unclear whether the increase in prevalence of
AUD postbariatric surgery is due to a preoperative history of AUD and a subsequent relapse or the development
of new incidence of AUD in the surgical cohort. Longterm outcomes studies show that alcohol abuse or dependence is increased or unchanged following surgery when
compared to prevalence preoperatively.147,148 Additionally, another study reports 2% to 6% of patients treated
at a substance abuse treatment center having previous
bariatric surgery, and these patients reported more alcohol withdrawal and consumed more drinks daily when
compared to nonbariatric patients, but both groups had
equal likelihood of being diagnosed with alcohol dependence.149 Currently, results are inconclusive to determine
if bariatric surgery increases incidence of AUD, and additional research is required to fully understand this outcome risk.
COMMONLY PERFORMED BARIATRIC SURGICAL

PROCEDURES
Roux-en-Y Gastric Bypass
In the United States, the Roux-en-Y gastric bypass (RYGB)
is currently considered the gold standard by which other
bariatric procedures are compared. This procedure, most
commonly performed laparoscopically, entails division of
the upper stomach to create a small gastric pouch (15
to 30 mL) connected to a 100- to 150-cm limb of jejunum called the Roux limb. Ingested food bypasses the
majority of the stomach, the duodenum, and the proximal jejunum and then enters a long common intestinal
channel where mixing of food with digestive enzymes
occurs. The mechanism of action leading to weight loss
and comorbidity amelioration is multifactorial (see Fig.
27-1). The very small gastric pouch results in restriction
of food intake, and the patient can therefore only tolerate
very small amounts of food at any given time. Bypass of
the remnant stomach, duodenum, and proximal jejunum
leads to malabsorption of micro- and macronutrients
490
(such as vitamins D and B12, iron, and calcium). However, given the long common enteric channel, malabsorption of calories plays little to no role. Enteroendocrine
hormonal changes following RYGB are discussed earlier
in the chapter.
Perioperative mortality after RYGB estimated from
a large prospective randomized trial was 0.7%150 and,
as previously mentioned, are related to enteric leak and
complications from deep venous thrombosis and anesthesia. The most serious long-term complications of RYGB
include marginal ulceration and internal hernia. Marginal
ulceration of the unprotected jejunal mucosa at the gastrojejunostomy occurs in 1% to 16% of patients151 and
may be due to presence of acid secretion from the parietal
cells in the pouch or when a gastro-gastric fistula is present.
Nonsteroidal anti-inflammatory drug (NSAID) use and
smoking contribute to risk for ulcers, and all patients are
advised to avoid both. There is a lifetime risk for developing intestinal obstruction, which may be caused by internal
herniation through one of the three possible defects created with gastric bypass anatomy (two when an antecolic
approach is used). The incidence is less than 2%.152
Sleeve Gastrectomy
The sleeve gastrectomy has gained popularity among bariatric surgeons and patients for its excellent short-term
results as well as its comparative ease to other surgical
procedures. Sleeve gastrectomy, also performed laparoscopically, involves creating a narrow gastric sleeve by
stapling the stomach vertically. The fundus and greater
curve of the stomach are removed from the abdomen (see
Fig. 27-1). The mechanism of action of the sleeve gastrectomy involves a component of restriction from creation of
a narrow gastric lumen and lack of receptive relaxation,
as well as hormonal changes that are currently being
investigated. Durability of weight loss and other health
changes are less well understood with this procedure.
The perioperative mortality of sleeve gastrectomy is
estimated to be 0.19%.153 Sleeve gastrectomy entails the
longest staple line of any bariatric procedure, which can
result in two problems: leakage or gastric lumenal narrowing secondary to stenosis or twisting of the sleeve.
The incidence of leak is less than 2%.154,155
Adjustable Gastric Banding

Placement of an adjustable gastric band was first used
in the mid-1980s abroad and was approved by the FDA
in 2001 for use in the United States. The procedure
involves looping a silicone band around the proximal
stomach, which functionally creates a 15- to 20-cc pouch
with an adjustable outlet (see Fig. 27-1). The stomach is
wrapped around the band anteriorly to prevent the band
from slipping out of position. The band consists of a

rigid outer ring and an inner inflatable balloon reservoir,
which is connected by tubing to a subcutaneous port that
can be accessed through the skin to adjust the tightness.
After band placement, patients need frequent clinic visits
and possible band adjustments, approximately every 4
to 6 weeks over the first year, and less frequently beyond
this timeframe, but continued adjustments can be made
as needed.
Adjustable gastric banding is prone to unique complications due to introduction of a foreign body. These
complications include band slippage or erosion (0% to
5.5%),156 gastric prolapse, and port complications, such
as leakage or infection, which may require revision surgery, band removal, or conversion to another surgical
weight-loss procedure. The perioperative mortality rate
is 0.03%, which is the lowest of the various bariatric
procedures.157
Biliopancreatic Diversion with or without Duodenal

Switch
Biliopancreatic diversion involves intestinal rerouting in
which most of the small bowel is bypassed and only 50
to 100 cm of a common channel remains for absorption.
The upper pouch is larger than that of the RYGB (approximately 150 to 250 cc) so that patients can eat adequate
amounts of protein to prevent protein calorie malnutrition. There is little malabsorption of carbohydrates, and
patients are advised to restrict their intake after surgery.
To avoid dumping syndrome (discussed earlier in the
chapter), the procedure was modified to maintain the
pylorus of the stomach, which can slow emptying of
ingested food into the small intestine. The upper 150- to
250-cc pouch is instead based on the lesser curve of the
stomach. Because of an anastomosis at the first portion of
the duodenum, the biliopancreatic diversion with duodenal switch carries the highest perioperative risk.
Complications of biliopancreatic diversion include
those previously described for RYGB including venous
thromboembolism, intestinal leak, and internal hernia.
The perioperative mortality is 2.5% and may be higher
for the superobese.158 Of the procedures discussed, biliopancreatic diversion has the greatest weight loss, but
also the greatest morbidity and mortality, malabsorption,
macro- and micronutrient deficiency, and diarrhea.

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524.

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IMPROVEMENTS OF OTHER OBESITY COMORBID

PART 4 OBESITY, ANOREXIA, AND NUTRITION

Diet, consisting of healthy food choices and portion

OVERVIEW OF BARIATRIC PROCEDURES AND

severity of comorbid conditions rather than simply the

WEIGHT LOSS MECHANISMS

Gastrointestinal Hormonal Changes

PART 4 OBESITY, ANOREXIA, AND NUTRITION

Biliopancreatic diversion duodenal switch

Figure 27-2 Effectiveness

small intestine and secreted in the duodenum in response

Figure 27-3 Multiple mechanisms may contribute to weight

loss and metabolic improvements following

adipokine concentrations or activity contribute to weight

Central Nervous System Control

EFFECTS OF BARIATRIC SURGERY ON

PART 4 OBESITY, ANOREXIA, AND NUTRITION

TABLE 27-1 Improvements in Obesity Comorbid

but information on long-term safety and efficacy are not

DIABETES REMISSION FOLLOWING BARIATRIC

WEIGHT LOSS OUTCOMES FOR SURGICAL PROCEDURES

Absolute mean change

% excess body weight loss

<2 years outcomes

% EXCESS BODY WEIGHT LOSS AND % DIABETES RESOLUTION

OBESITY COMORBIDITIES OUTCOMES

to improvement in glucose homeostasis, although this

Weight loss achieved by surgery is associated with greater

PART 4 OBESITY, ANOREXIA, AND NUTRITION

The Role of Insulin Sensitivity and Insulin Secretion

The Hindgut and the Foregut Hypotheses

that promotes insulin resistance.76 There is compelling

Incretin Effects in Diabetes Remission

Branched-Chain Amino Acids and Aromatic

taurocholic acid (TCA) increases plasma GLP-1, PYY,

Changes in Glucose Production and Disposal

IMPROVEMENTS OF OTHER OBESITY COMORBID

Pulmonary Disease Including Obstructive Sleep Apnea

COMPLICATIONS OF BARIATRIC SURGERY

PART 4 OBESITY, ANOREXIA, AND NUTRITION

from the intravascular to the enteric intraluminal space.

Weight Regain Following Bariatric Surgery

Early Complications (Within 30 Days of Surgery)

Hyperinsulinemic Hypoglycemia with Neuroglycopenia

other addictive behaviors (such as substance or alcohol

COMMONLY PERFORMED BARIATRIC SURGICAL

PART 4 OBESITY, ANOREXIA, AND NUTRITION

Adjustable Gastric Banding

from slipping out of position. The band consists of a

Biliopancreatic Diversion with or without Duodenal

1. Knowler WC, Barrett-Connor E, Fowler SE, etal. Reduction in

149. Saules KK, Wiedemann A, Ivezaj V, etal. Bariatric surgery history

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