This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.

There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness. To compare weight loss and safety among bariatric procedures. Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674) 41 health systems in the National Patient-Centered Clinical Research Network. 65 093 patients aged 20 to 79 years with body mass index (BMI) of 35 kg/m² or greater who had bariatric procedures. 32 208 Roux-en-Y gastric bypass (RYGB), 29 693 sleeve gastrectomy (SG), and 3192 adjustable gastric banding (AGB) procedures. Estimated percent total weight loss (TWL) at 1, 3, and 5 years; 30-day rates of major adverse events. Total numbers of eligible patients with weight measures at 1, 3, and 5 years were 44 978 (84%), 20 783 (68%), and 7159 (69%), respectively. Thirty-day rates of major adverse events were 5.0% for RYGB, 2.6% for SG, and 2.9% for AGB. One-year mean TWLs were 31.2% (95% CI, 31.1% to 31.3%) for RYGB, 25.2% (CI, 25.1% to 25.4%) for SG, and 13.7% (CI, 13.3% to 14.0%) for AGB. At 1 year, RYGB patients lost 5.9 (CI, 5.8 to 6.1) percentage points more weight than SG patients and 17.7 (CI, 17.3 to 18.1) percentage points more than AGB patients, and SG patients lost 12.0 (CI, 11.6 to 12.5) percentage points more than AGB patients. Five-year mean TWLs were 25.5% (CI, 25.1% to 25.9%) for RYGB, 18.8% (CI, 18.0% to 19.6%) for SG, and 11.7% (CI, 10.2% to 13.1%) for AGB. Patients with diabetes, those with BMI less than 50 kg/m², those aged 65 years or older, African American patients, and Hispanic patients lost less weight than patients without those characteristics. Potential unobserved confounding due to nonrandomized design; electronic health record databases had missing outcome data. Adults lost more weight with RYGB than with SG or AGB at 1, 3, and 5 years; however, RYGB had the highest 30-day rate of major adverse events. Small subgroup differences in weight loss outcomes were observed. Patient-Centered Outcomes Research Institute.

Macrovascular disease, including coronary artery disease and cerebrovascular disease, is one of the leading causes of morbidity and mortality for patients with type 2 diabetes. As a result, clinical guidelines for the management of type 2 diabetes emphasize lowering macrovascular disease risk factors by optimizing glycemic control, blood pressure, and serum lipid levels.^1,2 This multifactorial approach has been shown to substantially reduce the incidence of macrovascular complications.^2,3 However, most patients with type 2 diabetes do not achieve these recommended treatment goals,⁴ resulting in continued morbidity and costs.

Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions. However, little is known about how decision aids affect health care use when they are implemented outside of randomized controlled clinical trials. We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State. Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12–21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients’ and physicians’ preferences, may reduce rates of elective surgery and lower costs.

Bariatric surgery results in improved glycemic control in patients with type 2 diabetes mellitus and severe obesity, but whether it affects incidence of microvascular disease is uncertain. This lon... Background: Bariatric surgery improves glycemic control in patients with type 2 diabetes mellitus (T2DM), but less is known about microvascular outcomes. Objective: To investigate the relationship ...