Bariatric surgery & endoscopic options

Sleeve gastrectomy (now the most common operation) removes ~75–80% of the stomach; Roux-en-Y gastric bypass reroutes the gut. Neither is merely ‘a smaller stomach’ — both drive large, favourable gut-hormone changes (including the body’s own GLP-1). Total weight loss is roughly 25–30% (sleeve) and 30–35% (bypass), durable to 12 years, with strong diabetes remission and a long-term reduction in mortality, heart attacks and strokes. Evidence ●●●●●

The adjustable band is largely abandoned (weak, high re-operation). Duodenal-switch variants give the most weight loss (~35–45%) and the best diabetes remission, but the greatest nutritional risk. Endoscopic, incision-free options — endoscopic sleeve gastroplasty (~15–20%) and the temporary intragastric balloon (~10–12%, usually regained after removal) — are less invasive and lower-magnitude.

The 2022 professional-society update lowered thresholds to BMI ≥35 regardless of other conditions, or ≥30 with metabolic disease (and lower still for Asian populations) — the biggest expansion in the field’s history, though insurance often lags behind it.

Modern bariatric surgery is remarkably safe (30-day mortality ~0.1–0.3%), but it demands lifelong vitamin and mineral supplementation and monitoring (B12, iron, calcium, vitamin D, protein), and carries risks of dumping syndrome, ulcers, gallstones, bone loss, and a raised rate of alcohol-use disorder after bypass. The tradeoff is durability: no drug yet matches surgery’s decade-plus staying power without continued treatment.