Bariatric Surgery- Current perspective and present challenges- A Narrative Review

Bariatric Surgery- Current perspective and present challenges- A Narrative Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bariatric Surgery- Current perspective and present challenges- A Narrative Review Maryam Amjad, Maanya Rajasree Katta, Nourhan Kanso, Muhammad Hamza Khan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4284797/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Diet, exercise, cognitive behavioral therapy and pharmacotherapy are the means to assist patients to lose weight, with bariatric surgery being the most effective. Over the last two decades, due to increased awareness of the systemic benefits of bariatric surgery, as well as the safety and the wider use of the laparoscopic approach, has made bariatric surgery flourish. Obesity-associated mortality and co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, renal dysfunction and depression improve significantly with bariatric surgery. The mechanisms of weight loss extend beyond restriction and malabsorption and include changes in hunger and satiety, food preferences, and possibly energy expenditure. Despite its safety and efficacy, bariatric surgery is under utilized as less than 1% of adults with obesity receive it. In view of the evolution of obesity into a global threat, access to bariatric surgery should be revised, whilst developing safer and less invasive weight loss treatments. In summary, this narrative review provides a valuable resource for the management of obesity with bariatric surgery. By providing a comprehensive analysis of the latest evidence and elucidating the underlying mechanisms, this review seeks to establish a foundation for the development of innovative strategies in the management of obesity. General Surgery Surgery bariatric surgery obesity complications treatment outcome Highlight The global obesity pandemic poses a grave danger to public well-being, as it is intimately connected to severe health issues such as diabetes and heart disease. While combating obesity is a multifaceted effort, weight loss surgery has been shown to be the most effective and long-lasting method of attaining significant weight loss when compared to more conventional approaches such as calorie restriction, exercise, and medication. Roux-en-Y gastric bypass (RYGB) is the second most popular bariatric treatment performed globally, with adjustable gastric banding (AGB) becoming less popular. Although less common treatments like duodenal switch (BPD/DS) and biliopancreatic diversion (BPD) have more potential for weight loss, they also come with more surgical risk and nutritional difficulties. Bariatric surgery results in weight loss that is not just attributable to dietary restriction and malabsorption of nutrients. Changes in gastrointestinal hormones, insulin sensitivity, food preferences, appetite, and possibly energy expenditure can also be brought on by these operations. The objective of future research studies is to enhance the results of bariatric surgery by expanding upon our knowledge of the variables that lead to weight gain, customizing post-operative care, promoting wholesome lifestyle adjustments, and creating treatments for obesity that are more individualized, approachable, and comprehensive. Introduction And Background Obesity represents a significant global public health issue associated with conditions such as diabetes and cardiovascular disease.( 1 ) 1.5 billion adults globally are reported to be obese, and this number is expected to increase dramatically to reach 3 billion by the year 2030. ( 2 ) Managing obesity is complex, with genetics and environment playing key roles. Classic methods such as diet and exercise exhibit restricted efficacy, whereas surgery is the most successful approach for achieving sustained weight loss. ( 1 ) Bariatric surgery targets multiple physiological processes involved in weight regulation. The failure of non-surgical and pharmacological methods is attributed to the intricate nature of body weight regulation.( 1 ) Roux-en-Y gastric bypass (RYGB) treatments are the second most frequent obesity surgery performed globally, accounting for around 40% of all bariatric surgeries performed. ( 3 ) The small intestine is joined in a Y-shape to the tiny stomach pouch that is created during this procedure.( 4 ) To lower the danger of problems like bleeding or intestinal leaks, the therapy consists of two anastomoses and a residual stomach. It can lead to a 50–60% decrease in excess weight.( 4 ) Conversely, Adjustable Gastric Banding (AGB), a method that is becoming less popular for managing obesity, is limited to 7% of bariatric procedures. ( 5 ) AGB involves placing a gadget on the upper stomach to restrict food consumption, however, it is less effective than other approaches.( 5 ) Although AGB is associated with fewer adverse events and is reversible, the weight reduction outcomes vary significantly, typically resulting in an average loss of approximately 20% of total body weight. As more advanced and effective options become available, AGB is decreasing, especially with the growing popularity of non-surgical treatments.( 6 ) Less frequently performed procedures for weight loss include Biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS), which involve rearranging the small intestines and removing part of the stomach. ( 7 ) These surgeries provide greater weight loss results compared to RYGB but come with increased risks during the operation and nutritional difficulties.( 7 ) Methodology A thorough search and screening strategy was followed using PUBMED, SCOPUS, EMBASE, Web of Science, Google Scholar. The following terms were used for database search – ‘Obesity’, ‘bariatric surgery’, ‘Treatment’, ‘Obese’, ‘postoperative complication’, ‘quality of life’, ‘cost effectiveness’. A database was created with the search results and duplicates were removed. Included criteria were- Systematic Reviews, Meta-analyses, Narrative reviews, Observational Studies, Case reports and Case series. Articles that are in English were included with no limit on the date till Match, 2024. Editorials, short communications, letters to the editor, articles not focusing on bariatric surgery were excluded. Articles where the study population was not human and full text unavailable were also excluded. Articles were evaluated thoroughly for high quality evidence by the 4 authors and 53 eligible articles were finally included. Data was extracted from each study and assessed by two independent investigators using predefined Google sheets forms. The findings of the included studies were integrated and presented in a cohesive and narrative manner. Bariatric treatment and procedure Bariatric surgery is a type of surgery performed to help people with obesity lose weight and improve health problems associated with obesity. ( 8 ) Bariatric surgery involves multiple procedures, which include reducing the size of the stomach and providing alternative routes for food to pass through the stomach. ( 2 ) It is a safe, minimal risk option for people struggling to lose weight improving health problems like diabetes and increases lifespan. The American Society of Metabolic and Bariatric Surgery (ASMBS) has established guidelines for the eligibility of metabolic and bariatric surgery. It is recommended for individuals with body mass index (BMI) > 35; or in patients with type 2 diabetes mellitus, BMI > 30. ( 8 ) Additionally, it is recommended for individuals with BMI 30-34.9 who fail to reduce weight or improve comorbidities using non-surgical methods.( 8 ) It can also be an option for obese children and teenagers in some cases. Compared to traditional weight management care, which includes diet and exercise, bariatric surgery has proven to be more effective. ( 9 ) In a study comparing the two, the surgery group lost significantly more weight than the traditional group after several years. The surgery group did not regain the lost weight over time while the traditional group did. ( 9 ) Patients in the surgery group also saw a bigger improvement in health problems such as diabetes and hypertension compared to the traditional group.( 9 ) Bariatric surgery helps lose weight effectively and while the exact mechanisms are difficult to understand. ( 10 ) In particular, RYGB surgery improves blood glucose control in patients with type 2 diabetes compared to reducing calories through diet. RYGB speeds up the movement of nutrients through the small intestine, which leads to a large rise in blood glucose followed by a rapid drop. ( 11 ) This rapid change in blood glucose triggers the release of guy hormones, especially GLP-1, which reduces appetite and stimulates the release of insulin. Traditionally, weight loss mediated by bariatric surgery was thought to occur due to malabsorption. ( 12 ) However, malabsorption plays only a minor role in weight loss. Moreover, bariatric surgery stimulates the release of hormones, leading to changes in appetite and food preferences. ( 12 ) This is thought to occur due to changes in taste and smell sensitivity, which modifies caloric intake of patients and leads to weight loss. Types of Bariatric surgery and WHO criteria for bariatric surgery Bariatric surgery affects weight loss through three basic mechanisms: malabsorption, restriction, and the neurohormonal response that regulates hunger and energy balance. Some procedures have both a restrictive and a malabsorptive component. (Table-1) Restrictive Procedures Vertical Banded Gastroplasty shrinks stomach size by using both staples and a band to create a small gastric pouch. Food can enter the pouch and the remainder of the stomach through a tiny opening in it.( 13 ) Globally, the most common bariatric surgery procedure is Laparoscopic adjustable gastric banding (LAGB). In LAGB, the stomach is physically reduced in size by placing an adjustable silicone band around it just below the gastroesophageal junction. This creates a pouch that has an initial volume of roughly 15ml. ( 13 ) Originally performed as the initial stage of the duodenal switch treatment, sleeve gastrectomy (SG) is now performed as a stand-lone procedure, frequently using a laparoscopic method. By resecting the stomach’s greater curvature, the operation produces a tubular stomach with dimensions similar to that of a banana.( 13 ) Malabsorptive Procedures The first surgical operation used to treat obesity was the jejuno-ileal bypass (JIB), which involves anastomosing the proximal jejunum to the terminal ileum. The jejuno-ileal bypass treatment has been discontinued due to its numerous severe side effects such as mineral, vitamin, and protein deficiencies, liver and renal failure, and even death. ( 14 ) Biliopancreatic diversion (BPD) procedure involves dividing the duodenum from the pylorus, removing the pylorus, and dividing the ileum. The distal ileum is then anastomosed to the stomach and the proximal ileum, with the output from the liver, pancreas, and duodenum (or biliopancreatic limb) anastomosed to the terminal ileum some 50 to 100 cm away from the ileocecal valve. ( 13 ) The biliopancreatic diversion with duodenal switch (BPD/DS) is a variant of the biliopancreatic diversion (BPD). The BPD with a DS procedure involves creating a sleeve gastrectomy with preservation of the pylorus and creation of a Roux limb with a short common channel. ( 15 ) Combination of restrictive and malabsorption RYGB is a common and most frequently performed bariatric procedure that involves creating a small gastric pouch and attaching it to a shortened small intestine. This restriction of food intake combined with nutrient absorption in the common channel helps with significant weight loss. ( 13 ) In 1992, the National Institutes of Health (NIH) established eligibility criteria for bariatric surgery; these are still the most commonly used criteria. The eligibility requirements state that a person must meet either a BMI threshold of 40 kg/m2 or, in case of high risk comorbidities like severe type 2 diabetes or cardiovascular risk factors, a BMI threshold of 35 to 40 kg/m2. Therefore, bariatric surgery is not an option for anyone with a BMI of 35 kg/m2 or less. ( 16 ) New NICE guidelines now recommend that these groups of people should be offered a comprehensive assessment for bariatric surgery without the requirement for all non-surgical interventions to have been tried first, or for patients to already be under the management of a tier 3 service. ( 17 ) Effects of bariatric surgery on : A. Health and postoperative complications Factors including current body-mass index (BMI), total weight loss, employment status, presence of comorbidities, age and time since surgery were associated with Health related quality of life postoperatively. ( 18 ) The most common long-term complications after gastric banding include band slippage and erosion.( 19 ) Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. ( 19 ) Hepatobiliary complications pose a particular challenge because of the altered anatomy. ( 19 ) Complications after laparoscopic adjustable gastric banding include stomal stenosis, malpositioned bands, pouch dilation, band slippage, perforation, gastric volvulus, intraluminal band erosion, and port- and band-related problems. ( 20 ) Revision surgery, high age, low BMI, large waist circumference, and dyspepsia or gastro-esophageal reflux disease were associated with an increased risk for severe postoperative complication. ( 21 ) B. Quality of life Bariatric surgery is a popular treatment option for obesity, enhancing the quality of life (QoL) of patients. Its significant physical health improvements include weight loss, improved mobility, reduced strain, and decreased obesity-related health issues. ( 22 ) This leads to improved social interactions, fostering a sense of belonging and satisfaction. Effective obesity management can lead to increased life expectancy, reducing health risks associated with obesity. ( 22 ) Preoperative screening and postoperative support protocols are crucial for addressing these challenges. A comprehensive review of 18 studies shows that bariatric treatment provides a persistent positive impact on QoL, especially in its physical component score. ( 23 ) Long-term QoL benefits persist over time, with patients experiencing improved QoL beyond five years post-surgery.( 24 ) More research is needed to fully understand the long-term impact on mental health aspects of QoL. Overall, bariatric surgery is a vital treatment option for obesity patients, enhancing their overall QoL ( 24 ) C. Psychological aspect Bariatric surgery has been found to have positive effects on the psychological well-being of patients with obesity, with a recent study showing improvements in depressive symptoms and overall quality of life following surgery. ( 25 ) However, another study also reported that pre-existing depressive symptoms do not significantly impact long-term weight loss outcomes. ( 26 ) The psychological aspects of bariatric surgery are profound and multifaceted. Many patients also reported improvements in mood, self-esteem, and overall mental health, as well as conditions like depression and anxiety. ( 25 ) Bariatric surgery can act as a catalyst for positive behavioral changes, such as increased physical activity and healthier eating habits. However, some patients may struggle with the significant lifestyle changes required after surgery and healthcare providers should offer psychological support to help them navigate these challenges. ( 25 , 26 ) D. Cost effectiveness Bariatric surgery has demonstrated remarkable effectiveness in addressing severe obesity, leading to substantial weight loss and improvement in comorbidities. ( 27 ) Despite the initial costs associated with surgical intervention, numerous studies have indicated significant long-term cost savings within healthcare systems. ( 28 ) These savings primarily stem from reduced healthcare utilization, including decreased hospitalizations and medication expenditures, as well as improved productivity and quality of life for patients. ( 29 ) Additionally, advancements in surgical techniques and perioperative care have contributed to enhanced outcomes and cost-effectiveness of bariatric procedures over time. ( 30 ) However, variations in healthcare delivery and patient populations necessitate ongoing research to optimize the economic value of bariatric surgery across different contexts. ( 31 ) E. Social factors Bariatric surgery has not only demonstrated significant physiological effects but has also been shown to profoundly impact various social factors in patients' lives. ( 32 ) Research indicates that post-surgery, individuals often experience improvements in interpersonal relationships, including enhanced family dynamics and social support networks. ( 33 ) Furthermore, bariatric surgery has been associated with positive changes in psychosocial well-being, such as reduced depression and improved body image perception. ( 34 ) These improvements can lead to greater social integration and participation in activities previously avoided due to weight-related stigma. ( 35 ) However, it's crucial to acknowledge that social outcomes following bariatric surgery can vary widely among individuals, influenced by factors such as preoperative psychosocial functioning and postoperative adherence to behavioral recommendations. ( 36 ) Challenges in Bariatric Surgery Bariatric surgery has emerged as an effective treatment option in treating severe obesity, offering patients the chance to shed significant weight and keep it off long-term. It also has the potential to alleviate or even eliminate obesity-related health problems and reduce the risk of mortality. ( 37 ) However, the path to success after bariatric surgery is not always smooth, as patients may encounter various hurdles along the way, including physical, mental, and social challenges. A. Physical Challenges From a physical standpoint, patients must be prepared to commit to a lifetime of healthy habits, such as closely following a strict diet to prevent complications and ensure the surgery's effectiveness. ( 37 ) For some individuals, an unhealthy relationship with food may persist or even manifest after the surgery. Struggling with eating behaviors can lead to complications and jeopardize the long-term success of the procedure. Nutritional concerns are another critical aspect of post-bariatric surgery care. All types of bariatric procedures alter the structure and function of the digestive system to some extent, which can make patients more vulnerable to nutritional deficiencies such as anemia, osteoporosis, and protein malnutrition.( 38 ) It is essential to identify and address any pre-existing nutritional shortfalls, like vitamin D and iron deficiencies, before surgery.( 38 ) Even though patients often see impressive initial weight loss results, the risk of regaining weight is a real concern for many. ( 39 ) Weight regain following bariatric surgery is a complex problem, and researchers are still working to understand its prevalence, causes, and treatment options. ( 39 ) This can happen due to a combination of factors, such as behavioral, physiological, and metabolic changes. The inconsistencies in how weight regain is defined and reported in studies highlight the need for a more uniform approach to this issue. ( 40 ) Identifying factors that may predict weight regain, such as low blood sugar after surgery, is essential for creating personalized post-surgery care plans that minimize this risk. B. Psychological Challenges The mental and emotional aspects of bariatric surgery are also complex, with research emphasizing the need for thorough psychological evaluations before surgery and ongoing support to address any issues that may arise afterward. ( 41 ) Some patients may continue to struggle with unhealthy eating patterns or develop new ones, which can lead to complications and hinder long-term success. ( 32 ) Post operative depression is another serious concern after surgery, as the dramatic life changes and potential complications can contribute to its onset. For some individuals, the current postoperative care model may not be sufficient to prevent weight regain after bariatric surgery.( 42 ) These patients often perceive weight regain as a personal shortcoming, and the accompanying shame and self-blame can make them hesitant to reach out for professional help or social support. Consequently, it is crucial for healthcare professionals to adopt an empathetic and non-judgmental approach when working with these patients, creating a safe and supportive space that encourages them to seek the assistance they need to maintain their weight loss and overall health.( 42 ) Moreover, patients may have to contend with loose, excess skin after losing a substantial amount of weight, which can be uncomfortable and may require additional surgeries to remove. ( 38 ) Recent advancements have led to the development of scoring systems that can predict excess body weight loss and identify specific biomarkers associated with suboptimal weight loss following bariatric surgery.( 43 ) These tools provide valuable insights into a patient's potential for success and can help guide personalized treatment plans. In addition to these predictive measures, individualized counseling plays a crucial role in optimizing outcomes for bariatric surgery patients. ( 43 ) This tailored approach can assist in selecting the most appropriate surgical procedure, strengthening self-monitoring skills, enhancing motivation, and promoting mindful eating habits. By addressing these key factors, personalized counseling aims to reduce the risk of weight regain and ensure long-term success. ( 43 ) As the field of bariatric surgery continues to advance, more research is needed to develop better strategies for preventing weight regain and addressing the long-term effects of these procedures. C. Social Challenges Individuals who feel more supported by their social network tend to fare better after bariatric surgery, experiencing reduced symptoms of depression, fewer body image concerns, and more successful weight loss outcomes. ( 44 ) This crucial support can be derived from various sources, such as family members, friends, healthcare professionals, and support groups. Participating in support groups following bariatric surgery has been linked to greater weight loss success. ( 45 ) However, access to bariatric surgery can be hindered by a range of demographic factors, including insurance coverage, socioeconomic status, language barriers, ethnicity, and gender. ( 46 ) For example, some ethnic groups may face a lower likelihood of undergoing bariatric surgery due to financial limitations or the specific type of insurance they possess. Recognizing and tackling the social challenges associated with bariatric surgery is essential not only for optimizing individual outcomes but also for promoting fair and equitable access to this transformative procedure for all who could potentially benefit from it. By addressing these challenges, we can work towards ensuring that everyone who qualifies for and desires bariatric surgery has the opportunity to pursue this life-altering treatment, regardless of their background or circumstances. Conclusion and Future Perspectives The future of bariatric surgery is focused on improving outcomes and addressing the challenges associated with the procedure. There is a growing understanding of the factors that contribute to weight regain, including psychological, behavioral, hormonal, metabolic, anatomical, and genetic factors. ( 47 ) This knowledge can help in developing more effective strategies to prevent weight regain. Additionally, the role of body contouring is recognized as an important aspect of post-bariatric surgery care, helping patients achieve and maintain their desired body mass index (BMI) in a comprehensive and stable manner.( 48 ) Research is ongoing to identify predictors of weight regain, such as plasma cysteine levels, which are strongly connected with enlarged fat mass and the probability of developing obesity. ( 49 ) Understanding these predictors can help in tailoring postoperative care to minimize the risk of weight regain. Healthy dietary habits are acknowledged among weight loss maintainers and adverse eating behaviors, such as emotional binge eating, are identified as crucial factors in weight regain. ( 50 ) Physical inactivity, sleep deprivation, and excessive television watching are also associated with reduced sensitivity to internal satiety signals and can contribute to weight regain. ( 51 ) Recommendations from the American College of Sports Medicine suggest that performing 150 minutes per week of moderate or vigorous physical activity can help in weight loss and prevention of weight regain. ( 52 ) In conclusion, while bariatric surgery remains a powerful tool in the management of obesity, it is accompanied by a range of challenges that require careful consideration and management. Future perspectives suggest a move towards more personalized and multimodal approaches to obesity treatment, with an emphasis on improving access and long-term outcomes for patients. Declarations Funding Statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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The Association of Cysteine with Obesity, Inflammatory Cytokines and Insulin Resistance in Hispanic Children and Adolescents. PLOS ONE. 2012;7(9):e44166. Pinto-Bastos A, de Lourdes M, Brandão I, Machado PPP, Conceição EM. Weight loss trajectories and psychobehavioral predictors of outcome of primary and reoperative bariatric surgery: a 2-year longitudinal study. Surgery for Obesity and Related Diseases. 2019;15(7):1104-12. Chaput J-P, Klingenberg L, Astrup A, Sjödin AM. Modern sedentary activities promote overconsumption of food in our current obesogenic environment. 2011;12(5):e12-e20. DONNELLY JE, BLAIR SN, JAKICIC JM, MANORE MM, RANKIN JW, SMITH BK. Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. 2009;41(2):459-71. Table Table 1 is available in the Supplementary Files section Additional Declarations The authors declare no competing interests. Supplementary Files Table1.jpg Table 1: Types of bariatric surgery mechanism Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4284797","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":292573130,"identity":"36135ab7-a688-45be-b99b-93911015692e","order_by":0,"name":"Maryam Amjad","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Amjad","suffix":""},{"id":292573131,"identity":"7c17d9e7-c139-46e3-bedd-6cd069c2773b","order_by":1,"name":"Maanya Rajasree Katta","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Maanya","middleName":"Rajasree","lastName":"Katta","suffix":""},{"id":292573132,"identity":"edd59c2a-ec6a-4886-b46a-ad20429c6bfe","order_by":2,"name":"Nourhan Kanso","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Nourhan","middleName":"","lastName":"Kanso","suffix":""},{"id":292573133,"identity":"f5cd97f4-f35f-4c13-a93f-d1aaa0e17273","order_by":3,"name":"Muhammad Hamza Khan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Hamza","lastName":"Khan","suffix":""},{"id":292573134,"identity":"93f2ced1-f2f7-41f8-8faa-d886c70e6dd4","order_by":4,"name":"Fatima Khurshid","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Fatima","middleName":"","lastName":"Khurshid","suffix":""},{"id":292573135,"identity":"7570a798-651a-4825-aed2-0f1f489a77c2","order_by":5,"name":"Mariam Anwar","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Mariam","middleName":"","lastName":"Anwar","suffix":""},{"id":292573136,"identity":"da647331-2fe1-4c71-bbe3-0b2e70d4328d","order_by":6,"name":"Sehar Fatima","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Sehar","middleName":"","lastName":"Fatima","suffix":""},{"id":292573137,"identity":"2a211248-702e-4b66-8ed5-4604e5c70a8d","order_by":7,"name":"Bikona Ghosh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACA2Y2MJ3AwMADJA1sgGzGxgPEa/lQkAbS0oBfCwOSFsYZHw6DeXi1mLOzJT4uqKnN4+c/e4CZx+C83dr2w0BbamyicWmxbGY7bDzj2PFiyRl5CUAtt5O3nUkEajmWltuAy2GH2dukediOJW64wWMA1mJ2AKiFseEwAS3/gFrOnwFpOZdsdv4hIS1sx6R522oSNxzIMWCcYXDAzuwGAVuAfkk25u07kDhzRo7BgQ8GyQlmN4C2JODxizn/McPHPN/qEvv5zxg+SPhjZ292Pv3hgw81Nji1QAEiOhLBKhPwKweBOjjLnrDiUTAKRsEoGGkAAOzDY+LEMqYAAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Bikona","middleName":"","lastName":"Ghosh","suffix":""}],"badges":[],"createdAt":"2024-04-18 03:28:16","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-4284797/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4284797/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54946642,"identity":"20bc6075-4ec6-41b2-b7af-04bbb05a7622","added_by":"auto","created_at":"2024-04-19 03:31:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":320274,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4284797/v1/4b7a5975-49bf-411b-9a7a-fa9086afaa3d.pdf"},{"id":54945983,"identity":"94d40ab3-b65f-4d69-9b6e-d4fadeb2584d","added_by":"auto","created_at":"2024-04-19 03:23:38","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":44430,"visible":true,"origin":"","legend":"\u003cp\u003eTable 1: Types of bariatric surgery mechanism\u003c/p\u003e","description":"","filename":"Table1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4284797/v1/d4029cdc4d06cb00c9e322d4.jpg"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eBariatric Surgery- Current perspective and present challenges- A Narrative Review\u003c/p\u003e","fulltext":[{"header":"Highlight","content":"\u003col\u003e\n \u003cli\u003eThe global obesity pandemic poses a grave danger to public well-being, as it is intimately connected to severe health issues such as diabetes and heart disease.\u003c/li\u003e\n \u003cli\u003eWhile combating obesity is a multifaceted effort, weight loss surgery has been shown to be the most effective and long-lasting method of attaining significant weight loss when compared to more conventional approaches such as calorie restriction, exercise, and medication.\u003c/li\u003e\n \u003cli\u003eRoux-en-Y gastric bypass (RYGB) is the second most popular bariatric treatment performed globally, with adjustable gastric banding (AGB) becoming less popular. Although less common treatments like duodenal switch (BPD/DS) and biliopancreatic diversion (BPD) have more potential for weight loss, they also come with more surgical risk and nutritional difficulties.\u003c/li\u003e\n \u003cli\u003eBariatric surgery results in weight loss that is not just attributable to dietary restriction and malabsorption of nutrients. Changes in gastrointestinal hormones, insulin sensitivity, food preferences, appetite, and possibly energy expenditure can also be brought on by these operations.\u003c/li\u003e\n \u003cli\u003eThe objective of future research studies is to enhance the results of bariatric surgery by expanding upon our knowledge of the variables that lead to weight gain, customizing post-operative care, promoting wholesome lifestyle adjustments, and creating treatments for obesity that are more individualized, approachable, and comprehensive.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction And Background","content":"\u003cp\u003eObesity represents a significant global public health issue associated with conditions such as diabetes and cardiovascular disease.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) 1.5\u0026nbsp;billion adults globally are reported to be obese, and this number is expected to increase dramatically to reach 3\u0026nbsp;billion by the year 2030. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Managing obesity is complex, with genetics and environment playing key roles. Classic methods such as diet and exercise exhibit restricted efficacy, whereas surgery is the most successful approach for achieving sustained weight loss. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Bariatric surgery targets multiple physiological processes involved in weight regulation. The failure of non-surgical and pharmacological methods is attributed to the intricate nature of body weight regulation.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRoux-en-Y gastric bypass (RYGB) treatments are the second most frequent obesity surgery performed globally, accounting for around 40% of all bariatric surgeries performed. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The small intestine is joined in a Y-shape to the tiny stomach pouch that is created during this procedure.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) To lower the danger of problems like bleeding or intestinal leaks, the therapy consists of two anastomoses and a residual stomach. It can lead to a 50\u0026ndash;60% decrease in excess weight.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eConversely, Adjustable Gastric Banding (AGB), a method that is becoming less popular for managing obesity, is limited to 7% of bariatric procedures. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) AGB involves placing a gadget on the upper stomach to restrict food consumption, however, it is less effective than other approaches.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Although AGB is associated with fewer adverse events and is reversible, the weight reduction outcomes vary significantly, typically resulting in an average loss of approximately 20% of total body weight. As more advanced and effective options become available, AGB is decreasing, especially with the growing popularity of non-surgical treatments.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLess frequently performed procedures for weight loss include Biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS), which involve rearranging the small intestines and removing part of the stomach. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) These surgeries provide greater weight loss results compared to RYGB but come with increased risks during the operation and nutritional difficulties.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eA thorough search and screening strategy was followed using PUBMED, SCOPUS, EMBASE, Web of Science, Google Scholar. The following terms were used for database search \u0026ndash; \u0026lsquo;Obesity\u0026rsquo;, \u0026lsquo;bariatric surgery\u0026rsquo;, \u0026lsquo;Treatment\u0026rsquo;, \u0026lsquo;Obese\u0026rsquo;, \u0026lsquo;postoperative complication\u0026rsquo;, \u0026lsquo;quality of life\u0026rsquo;, \u0026lsquo;cost effectiveness\u0026rsquo;. A database was created with the search results and duplicates were removed. Included criteria were- Systematic Reviews, Meta-analyses, Narrative reviews, Observational Studies, Case reports and Case series. Articles that are in English were included with no limit on the date till Match, 2024. Editorials, short communications, letters to the editor, articles not focusing on bariatric surgery were excluded. Articles where the study population was not human and full text unavailable were also excluded. Articles were evaluated thoroughly for high quality evidence by the 4 authors and 53 eligible articles were finally included. Data was extracted from each study and assessed by two independent investigators using predefined Google sheets forms. The findings of the included studies were integrated and presented in a cohesive and narrative manner.\u003c/p\u003e\n\u003ch3\u003eBariatric treatment and procedure\u003c/h3\u003e\n\u003cp\u003eBariatric surgery is a type of surgery performed to help people with obesity lose weight and improve health problems associated with obesity. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Bariatric surgery involves multiple procedures, which include reducing the size of the stomach and providing alternative routes for food to pass through the stomach. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) It is a safe, minimal risk option for people struggling to lose weight improving health problems like diabetes and increases lifespan.\u003c/p\u003e \u003cp\u003eThe American Society of Metabolic and Bariatric Surgery (ASMBS) has established guidelines for the eligibility of metabolic and bariatric surgery. It is recommended for individuals with body mass index (BMI)\u0026thinsp;\u0026gt;\u0026thinsp;35; or in patients with type 2 diabetes mellitus, BMI\u0026thinsp;\u0026gt;\u0026thinsp;30. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Additionally, it is recommended for individuals with BMI 30-34.9 who fail to reduce weight or improve comorbidities using non-surgical methods.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) It can also be an option for obese children and teenagers in some cases. Compared to traditional weight management care, which includes diet and exercise, bariatric surgery has proven to be more effective. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) In a study comparing the two, the surgery group lost significantly more weight than the traditional group after several years. The surgery group did not regain the lost weight over time while the traditional group did. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Patients in the surgery group also saw a bigger improvement in health problems such as diabetes and hypertension compared to the traditional group.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBariatric surgery helps lose weight effectively and while the exact mechanisms are difficult to understand. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) In particular, RYGB surgery improves blood glucose control in patients with type 2 diabetes compared to reducing calories through diet. RYGB speeds up the movement of nutrients through the small intestine, which leads to a large rise in blood glucose followed by a rapid drop. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) This rapid change in blood glucose triggers the release of guy hormones, especially GLP-1, which reduces appetite and stimulates the release of insulin. Traditionally, weight loss mediated by bariatric surgery was thought to occur due to malabsorption. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) However, malabsorption plays only a minor role in weight loss. Moreover, bariatric surgery stimulates the release of hormones, leading to changes in appetite and food preferences. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) This is thought to occur due to changes in taste and smell sensitivity, which modifies caloric intake of patients and leads to weight loss.\u003c/p\u003e\n\u003ch3\u003eTypes of Bariatric surgery and WHO criteria for bariatric surgery\u003c/h3\u003e\n\u003cp\u003eBariatric surgery affects weight loss through three basic mechanisms: malabsorption, restriction, and the neurohormonal response that regulates hunger and energy balance. Some procedures have both a restrictive and a malabsorptive component. (Table-1)\u003c/p\u003e \u003cp\u003e \u003cb\u003eRestrictive Procedures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eVertical Banded Gastroplasty shrinks stomach size by using both staples and a band to create a small gastric pouch. Food can enter the pouch and the\u003c/p\u003e \u003cp\u003eremainder of the stomach through a tiny opening in it.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eGlobally, the most common bariatric surgery procedure is Laparoscopic adjustable gastric banding (LAGB). In LAGB, the stomach is physically reduced in size by placing an adjustable silicone band around it just below the gastroesophageal junction. This creates a pouch that has an initial volume of roughly 15ml. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOriginally performed as the initial stage of the duodenal switch treatment, sleeve gastrectomy (SG) is now performed as a stand-lone procedure, frequently using a laparoscopic method. By resecting the stomach\u0026rsquo;s greater curvature, the operation produces a tubular stomach with dimensions similar to that of a banana.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eMalabsorptive Procedures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe first surgical operation used to treat obesity was the jejuno-ileal bypass (JIB), which involves anastomosing the proximal jejunum to the terminal ileum. The jejuno-ileal bypass treatment has been discontinued due to its numerous severe side effects such as mineral, vitamin, and protein deficiencies, liver and renal failure, and even death. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBiliopancreatic diversion (BPD) procedure involves dividing the duodenum from the pylorus, removing the pylorus, and dividing the ileum. The distal ileum is then anastomosed to the stomach and the proximal ileum, with the output from the liver, pancreas, and duodenum (or biliopancreatic limb) anastomosed to the terminal ileum some 50 to 100 cm away from the ileocecal valve. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe biliopancreatic diversion with duodenal switch (BPD/DS) is a variant of the biliopancreatic diversion (BPD). The BPD with a DS procedure involves creating a sleeve gastrectomy with preservation of the pylorus and creation of a Roux limb with a short common channel. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eCombination of restrictive and malabsorption\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRYGB is a common and most frequently performed bariatric procedure that involves creating a small gastric pouch and attaching it to a shortened small intestine. This restriction of food intake combined with nutrient absorption in the common channel helps with significant weight loss. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn 1992, the National Institutes of Health (NIH) established eligibility criteria for bariatric surgery; these are still the most commonly used criteria. The eligibility requirements state that a person must meet either a BMI threshold of 40 kg/m2 or, in case of high risk comorbidities like severe type 2 diabetes or cardiovascular risk factors, a BMI threshold of 35 to 40 kg/m2. Therefore, bariatric surgery is not an option for anyone with a BMI of 35 kg/m2 or less. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNew NICE guidelines now recommend that these groups of people should be offered a comprehensive assessment for bariatric surgery without the requirement for all non-surgical interventions to have been tried first, or for patients to already be under the management of a tier 3 service. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eEffects of bariatric surgery on\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cb\u003eA. Health and postoperative complications\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFactors including current body-mass index (BMI), total weight loss, employment status, presence of comorbidities, age and time since surgery were associated with Health related quality of life postoperatively. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe most common long-term complications after gastric banding include band slippage and erosion.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Deflation or removal of the band is often required. Internal hernia, adhesions and anastomotic stenosis are common causes of intestinal obstruction after gastric bypass surgery. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Hepatobiliary complications pose a particular challenge because of the altered anatomy. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Complications after laparoscopic adjustable gastric banding include stomal stenosis, malpositioned bands, pouch dilation, band slippage, perforation, gastric volvulus, intraluminal band erosion, and port- and band-related problems. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Revision surgery, high age, low BMI, large waist circumference, and dyspepsia or gastro-esophageal reflux disease were associated with an increased risk for severe postoperative complication. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eB. Quality of life\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBariatric surgery is a popular treatment option for obesity, enhancing the quality of life (QoL) of patients. Its significant physical health improvements include weight loss, improved mobility, reduced strain, and decreased obesity-related health issues. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) This leads to improved social interactions, fostering a sense of belonging and satisfaction. Effective obesity management can lead to increased life expectancy, reducing health risks associated with obesity. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) Preoperative screening and postoperative support protocols are crucial for addressing these challenges. A comprehensive review of 18 studies shows that bariatric treatment provides a persistent positive impact on QoL, especially in its physical component score. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Long-term QoL benefits persist over time, with patients experiencing improved QoL beyond five years post-surgery.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) More research is needed to fully understand the long-term impact on mental health aspects of QoL. Overall, bariatric surgery is a vital treatment option for obesity patients, enhancing their overall QoL (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eC. Psychological aspect\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBariatric surgery has been found to have positive effects on the psychological well-being of patients with obesity, with a recent study showing improvements in depressive symptoms and overall quality of life following surgery. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) However, another study also reported that pre-existing depressive symptoms do not significantly impact long-term weight loss outcomes. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) The psychological aspects of bariatric surgery are profound and multifaceted. Many patients also reported improvements in mood, self-esteem, and overall mental health, as well as conditions like depression and anxiety. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Bariatric surgery can act as a catalyst for positive behavioral changes, such as increased physical activity and healthier eating habits. However, some patients may struggle with the significant lifestyle changes required after surgery and healthcare providers should offer psychological support to help them navigate these challenges. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eD. Cost effectiveness\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBariatric surgery has demonstrated remarkable effectiveness in addressing severe obesity, leading to substantial weight loss and improvement in comorbidities. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) Despite the initial costs associated with surgical intervention, numerous studies have indicated significant long-term cost savings within healthcare systems. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) These savings primarily stem from reduced healthcare utilization, including decreased hospitalizations and medication expenditures, as well as improved productivity and quality of life for patients. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Additionally, advancements in surgical techniques and perioperative care have contributed to enhanced outcomes and cost-effectiveness of bariatric procedures over time. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) However, variations in healthcare delivery and patient populations necessitate ongoing research to optimize the economic value of bariatric surgery across different contexts. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eE. Social factors\u003c/b\u003e \u003c/p\u003e \u003cp\u003eBariatric surgery has not only demonstrated significant physiological effects but has also been shown to profoundly impact various social factors in patients' lives. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Research indicates that post-surgery, individuals often experience improvements in interpersonal relationships, including enhanced family dynamics and social support networks. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) Furthermore, bariatric surgery has been associated with positive changes in psychosocial well-being, such as reduced depression and improved body image perception. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) These improvements can lead to greater social integration and participation in activities previously avoided due to weight-related stigma. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) However, it's crucial to acknowledge that social outcomes following bariatric surgery can vary widely among individuals, influenced by factors such as preoperative psychosocial functioning and postoperative adherence to behavioral recommendations. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eChallenges in Bariatric Surgery\u003c/h3\u003e\n\u003cp\u003eBariatric surgery has emerged as an effective treatment option in treating severe obesity, offering patients the chance to shed significant weight and keep it off long-term. It also has the potential to alleviate or even eliminate obesity-related health problems and reduce the risk of mortality. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) However, the path to success after bariatric surgery is not always smooth, as patients may encounter various hurdles along the way, including physical, mental, and social challenges.\u003c/p\u003e \u003cp\u003e \u003cb\u003eA. Physical Challenges\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFrom a physical standpoint, patients must be prepared to commit to a lifetime of healthy habits, such as closely following a strict diet to prevent complications and ensure the surgery's effectiveness. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) For some individuals, an unhealthy relationship with food may persist or even manifest after the surgery. Struggling with eating behaviors can lead to complications and jeopardize the long-term success of the procedure. Nutritional concerns are another critical aspect of post-bariatric surgery care. All types of bariatric procedures alter the structure and function of the digestive system to some extent, which can make patients more vulnerable to nutritional deficiencies such as anemia, osteoporosis, and protein malnutrition.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) It is essential to identify and address any pre-existing nutritional shortfalls, like vitamin D and iron deficiencies, before surgery.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEven though patients often see impressive initial weight loss results, the risk of regaining weight is a real concern for many. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) Weight regain following bariatric surgery is a complex problem, and researchers are still working to understand its prevalence, causes, and treatment options. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) This can happen due to a combination of factors, such as behavioral, physiological, and metabolic changes. The inconsistencies in how weight regain is defined and reported in studies highlight the need for a more uniform approach to this issue. (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) Identifying factors that may predict weight regain, such as low blood sugar after surgery, is essential for creating personalized post-surgery care plans that minimize this risk.\u003c/p\u003e \u003cp\u003e \u003cb\u003eB. Psychological Challenges\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe mental and emotional aspects of bariatric surgery are also complex, with research emphasizing the need for thorough psychological evaluations before surgery and ongoing support to address any issues that may arise afterward. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) Some patients may continue to struggle with unhealthy eating patterns or develop new ones, which can lead to complications and hinder long-term success. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Post operative depression is another serious concern after surgery, as the dramatic life changes and potential complications can contribute to its onset.\u003c/p\u003e \u003cp\u003eFor some individuals, the current postoperative care model may not be sufficient to prevent weight regain after bariatric surgery.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) These patients often perceive weight regain as a personal shortcoming, and the accompanying shame and self-blame can make them hesitant to reach out for professional help or social support. Consequently, it is crucial for healthcare professionals to adopt an empathetic and non-judgmental approach when working with these patients, creating a safe and supportive space that encourages them to seek the assistance they need to maintain their weight loss and overall health.(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMoreover, patients may have to contend with loose, excess skin after losing a substantial amount of weight, which can be uncomfortable and may require additional surgeries to remove. (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) Recent advancements have led to the development of scoring systems that can predict excess body weight loss and identify specific biomarkers associated with suboptimal weight loss following bariatric surgery.(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) These tools provide valuable insights into a patient's potential for success and can help guide personalized treatment plans.\u003c/p\u003e \u003cp\u003eIn addition to these predictive measures, individualized counseling plays a crucial role in optimizing outcomes for bariatric surgery patients. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) This tailored approach can assist in selecting the most appropriate surgical procedure, strengthening self-monitoring skills, enhancing motivation, and promoting mindful eating habits. By addressing these key factors, personalized counseling aims to reduce the risk of weight regain and ensure long-term success. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) As the field of bariatric surgery continues to advance, more research is needed to develop better strategies for preventing weight regain and addressing the long-term effects of these procedures.\u003c/p\u003e \u003cp\u003e \u003cb\u003eC. Social Challenges\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIndividuals who feel more supported by their social network tend to fare better after bariatric surgery, experiencing reduced symptoms of depression, fewer body image concerns, and more successful weight loss outcomes. (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) This crucial support can be derived from various sources, such as family members, friends, healthcare professionals, and support groups. Participating in support groups following bariatric surgery has been linked to greater weight loss success. (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHowever, access to bariatric surgery can be hindered by a range of demographic factors, including insurance coverage, socioeconomic status, language barriers, ethnicity, and gender. (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) For example, some ethnic groups may face a lower likelihood of undergoing bariatric surgery due to financial limitations or the specific type of insurance they possess.\u003c/p\u003e \u003cp\u003eRecognizing and tackling the social challenges associated with bariatric surgery is essential not only for optimizing individual outcomes but also for promoting fair and equitable access to this transformative procedure for all who could potentially benefit from it. By addressing these challenges, we can work towards ensuring that everyone who qualifies for and desires bariatric surgery has the opportunity to pursue this life-altering treatment, regardless of their background or circumstances.\u003c/p\u003e"},{"header":"Conclusion and Future Perspectives","content":"\u003cp\u003eThe future of bariatric surgery is focused on improving outcomes and addressing the challenges associated with the procedure. There is a growing understanding of the factors that contribute to weight regain, including psychological, behavioral, hormonal, metabolic, anatomical, and genetic factors. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) This knowledge can help in developing more effective strategies to prevent weight regain. Additionally, the role of body contouring is recognized as an important aspect of post-bariatric surgery care, helping patients achieve and maintain their desired body mass index (BMI) in a comprehensive and stable manner.(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eResearch is ongoing to identify predictors of weight regain, such as plasma cysteine levels, which are strongly connected with enlarged fat mass and the probability of developing obesity. (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) Understanding these predictors can help in tailoring postoperative care to minimize the risk of weight regain. Healthy dietary habits are acknowledged among weight loss maintainers and adverse eating behaviors, such as emotional binge eating, are identified as crucial factors in weight regain. (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) Physical inactivity, sleep deprivation, and excessive television watching are also associated with reduced sensitivity to internal satiety signals and can contribute to weight regain. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) Recommendations from the American College of Sports Medicine suggest that performing 150 minutes per week of moderate or vigorous physical activity can help in weight loss and prevention of weight regain. (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn conclusion, while bariatric surgery remains a powerful tool in the management of obesity, it is accompanied by a range of challenges that require careful consideration and management. Future perspectives suggest a move towards more personalized and multimodal approaches to obesity treatment, with an emphasis on improving access and long-term outcomes for patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor this type of study formal consent is not required\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeclarations of interest: none\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlbaugh VL, Abumrad NN. Surgical treatment of obesity. F1000Res. 2018;7.\u003c/li\u003e\n\u003cli\u003eRogers AM. 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Journal of clinical medicine. 2023;12(13).\u003c/li\u003e\n\u003cli\u003eJumbe S, Hamlet C, Meyrick J. Psychological Aspects of Bariatric Surgery as a Treatment for Obesity. Current obesity reports. 2017;6(1):71-8.\u003c/li\u003e\n\u003cli\u003eMurton LM, Plank LD, Cutfield R, Kim D, Booth MWC, Murphy R, et al. Bariatric Surgery and Psychological Health: A Randomised Clinical Trial in Patients with Obesity and Type 2 Diabetes. Obes Surg. 2023;33(5):1536-44.\u003c/li\u003e\n\u003cli\u003eAdams TD, Davidson LE, Litwin SE, Kolotkin RL, LaMonte MJ, Pendleton RC, et al. Health benefits of gastric bypass surgery after 6 years. J Am Med Assoc. 2012;308(11):1122-31.\u003c/li\u003e\n\u003cli\u003eCourcoulas AP, Yanovski SZ, Bonds D, Eggerman TL, Horlick M, Staten MA, et al. Long-term outcomes of bariatric surgery: a National Institutes of Health symposium. JAMA surgery. 2014;149(12):1323-9.\u003c/li\u003e\n\u003cli\u003eKarim MA, Clifton E, Ahmed J, Mackay GW, Ali A. Economic evaluation of bariatric surgery to combat morbid obesity: a study from the West of Scotland. Asian journal of endoscopic surgery. 2013;6(3):197-202.\u003c/li\u003e\n\u003cli\u003eGloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ (Clinical research ed). 2013;347:f5934.\u003c/li\u003e\n\u003cli\u003ePuzziferri N, Roshek TB, 3rd, Mayo HG, Gallagher R, Belle SH, Livingston EH. Long-term follow-up after bariatric surgery: a systematic review. J Am Med Assoc. 2014;312(9):934-42.\u003c/li\u003e\n\u003cli\u003eSarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obesity research. 2005;13(4):639-48.\u003c/li\u003e\n\u003cli\u003eBond DS, Phelan S, Wolfe LG, Evans RK, Meador JG, Kellum JM, et al. Becoming physically active after bariatric surgery is associated with improved weight loss and health-related quality of life. Obesity (Silver Spring, Md). 2009;17(1):78-83.\u003c/li\u003e\n\u003cli\u003eEngel SG, Crosby RD, Kolotkin RL, Hartley GG, Williams GR, Wonderlich SA, et al. Impact of weight loss and regain on quality of life: mirror image or differential effect? Obesity research. 2003;11(10):1207-13.\u003c/li\u003e\n\u003cli\u003eWhite MA, Kalarchian MA, Levine MD, Masheb RM, Marcus MD, Grilo CM. Prognostic Significance of Depressive Symptoms on Weight Loss and Psychosocial Outcomes Following Gastric Bypass Surgery: A Prospective 24-Month Follow-Up Study. Obes Surg. 2015;25(10):1909-16.\u003c/li\u003e\n\u003cli\u003eBurgmer R, Grigutsch K, Zipfel S, Wolf AM, de Zwaan M, Husemann B, et al. The influence of eating behavior and eating pathology on weight loss after gastric restriction operations. Obes Surg. 2005;15(5):684-91.\u003c/li\u003e\n\u003cli\u003eKissler HJ, Settmacher U. Bariatric Surgery to Treat Obesity. Seminars in Nephrology. 2013;33(1):75-89.\u003c/li\u003e\n\u003cli\u003eLupoli R, Lembo E, Saldalamacchia G, Avola CK, Angrisani L, Capaldo B. Bariatric surgery and long-term nutritional issues. World journal of diabetes. 2017;8(11):464-74.\u003c/li\u003e\n\u003cli\u003eRibeiro-Parenti L, Baratte C, Poghosyan T. Weight Regain after Bariatric Surgery. 2023;12(9):3265.\u003c/li\u003e\n\u003cli\u003eNedelcu M, Khwaja HA, Rogula TG. Weight regain after bariatric surgery\u0026amp;#x2014;how should it be defined? Surgery for Obesity and Related Diseases. 2016;12(5):1129-30.\u003c/li\u003e\n\u003cli\u003eGreenberg I. Psychological Aspects of Bariatric Surgery. 2003;18(2):124-30.\u003c/li\u003e\n\u003cli\u003eTolvanen L, Svensson \u0026Aring;, Hemmingsson E, Christenson A, Lagerros YT. Perceived and Preferred Social Support in Patients Experiencing Weight Regain After Bariatric Surgery\u0026mdash;a Qualitative Study. Obes Surg. 2021;31(3):1256-64.\u003c/li\u003e\n\u003cli\u003eDemerdash HMJWJoM-A. Weight regain after bariatric surgery: Promoters and potential predictors. 2021;9(5):438-54.\u003c/li\u003e\n\u003cli\u003eConcei\u0026ccedil;\u0026atilde;o EM, Fernandes M, de Lourdes M, Pinto-Bastos A, Vaz AR, Ramalho S. Perceived social support before and after bariatric surgery: association with depression, problematic eating behaviors, and weight outcomes. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2020;25(3):679-92.\u003c/li\u003e\n\u003cli\u003eLivhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, et al. Is social support associated with greater weight loss after bariatric surgery?: a systematic review. 2011;12(2):142-8.\u003c/li\u003e\n\u003cli\u003eIuzzolino E, Kim Y. Barriers impacting an individuals decision to undergo bariatric surgery: A systematic review. Obesity Research \u0026amp; Clinical Practice. 2020;14(4):310-20.\u003c/li\u003e\n\u003cli\u003eKarmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight Recidivism Post-Bariatric Surgery: A Systematic Review. Obes Surg. 2013;23(11):1922-33.\u003c/li\u003e\n\u003cli\u003eBalagu\u0026eacute; N, Combescure C, Huber O, Pittet-Cu\u0026eacute;nod B, Modarressi A. Plastic Surgery Improves Long-Term Weight Control after Bariatric Surgery. 2013;132(4):826-33.\u003c/li\u003e\n\u003cli\u003eElshorbagy AK, Valdivia-Garcia M, Refsum H, Butte N. The Association of Cysteine with Obesity, Inflammatory Cytokines and Insulin Resistance in Hispanic Children and Adolescents. PLOS ONE. 2012;7(9):e44166.\u003c/li\u003e\n\u003cli\u003ePinto-Bastos A, de Lourdes M, Brand\u0026atilde;o I, Machado PPP, Concei\u0026ccedil;\u0026atilde;o EM. Weight loss trajectories and psychobehavioral predictors of outcome of primary and reoperative bariatric surgery: a 2-year longitudinal study. Surgery for Obesity and Related Diseases. 2019;15(7):1104-12.\u003c/li\u003e\n\u003cli\u003eChaput J-P, Klingenberg L, Astrup A, Sj\u0026ouml;din AM. Modern sedentary activities promote overconsumption of food in our current obesogenic environment. 2011;12(5):e12-e20.\u003c/li\u003e\n\u003cli\u003eDONNELLY JE, BLAIR SN, JAKICIC JM, MANORE MM, RANKIN JW, SMITH BK. Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. 2009;41(2):459-71.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"bariatric surgery, obesity, complications, treatment, outcome","lastPublishedDoi":"10.21203/rs.3.rs-4284797/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4284797/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDiet, exercise, cognitive behavioral therapy and pharmacotherapy are the means to assist patients to lose weight, with bariatric surgery being the most effective. Over the last two decades, due to increased awareness of the systemic benefits of bariatric surgery, as well as the safety and the wider use of the laparoscopic approach, has made bariatric surgery flourish.\u003c/p\u003e\n\u003cp\u003eObesity-associated mortality and co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, renal dysfunction and depression improve significantly with bariatric surgery. The mechanisms of weight loss extend beyond restriction and malabsorption and include changes in hunger and satiety, food preferences, and possibly energy expenditure. Despite its safety and efficacy, bariatric surgery is under utilized as less than 1% of adults with obesity receive it. In view of the evolution of obesity into a global threat, access to bariatric surgery should be revised, whilst developing safer and less invasive weight loss treatments. In summary, this narrative review provides a valuable resource for the management of obesity with bariatric surgery. By providing a comprehensive analysis of the latest evidence and elucidating the underlying mechanisms, this review seeks to establish a foundation for the development of innovative strategies in the management of obesity.\u003c/p\u003e","manuscriptTitle":"Bariatric Surgery- Current perspective and present challenges- A Narrative Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 03:23:34","doi":"10.21203/rs.3.rs-4284797/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0cb6abf7-c296-4651-9342-b2d5a0c28b67","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":30824558,"name":"General Surgery"},{"id":30824559,"name":"Surgery"}],"tags":[],"updatedAt":"2024-04-19T03:23:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 03:23:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4284797","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4284797","identity":"rs-4284797","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}