The evolving landscape of metabolic surgery: An evidence-based review

Obesity is increasingly recognised as a complex, adiposity-based chronic endocrine disease rather than a simple metric of excess weight. In India, the prevalence of the 'thin-fat' phenotype - characterised by high visceral adiposity and early-onset metabolic syndrome at lower body mass index thresholds - necessitates aggressive, regionally tailored interventions. While novel pharmacotherapies have expanded treatment options, metabolic and bariatric surgery (MBS) remains the most durable intervention for severe obesity.

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of PubMed, Scopus and Google Scholar (2000-2025) was conducted. We prioritised Level I and II evidence, including randomised controlled trials with ≥5 years of follow-up, meta-analyses and global registry reports. A total of 81 studies were included to critically evaluate comparative surgical effectiveness, metabolic outcomes and complication profiles.

Long-term data (e.g. SLEEVEPASS and STAMPEDE) confirm MBS achieves superior comorbidity remission compared to intensive medical therapy. Laparoscopic Roux-en-Y gastric bypass provides superior long-term remission of dyslipidaemia, hypertension and gastro-oesophageal reflux disease compared to laparoscopic sleeve gastrectomy (SG), though it carries higher mechanical and nutritional risks. To balance profound metabolic correction with the severe nutritional sequelae of classic malabsorptive procedures (biliopancreatic diversion with duodenal switch), emerging single-anastomosis variants (one-anastomosis gastric bypass and single anastomosis duodenal-ileal bypass with SG) demonstrate promising efficacy and improved gastrointestinal profiles.

The MBS landscape is undergoing a paradigm shift. Optimal obesity management is evolving beyond rigid anatomical algorithms towards precision medicine, driven by the synergistic integration of dual glucagon-like peptide-1/glucose-dependent insulinotropic polypeptide receptor agonists, procedure personalisation based on metabolic phenotyping and robust lifelong surveillance registries tailored to regional demographics.