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Bariatric surgery is an important treatment for obesity and most patients enjoy substantial improvements in coexisting type 2 diabetes (T2D). As a result of the historic failure to establish relevant long-term controlled trials, however, there is a need to separate evidence from unfounded belief. The short-term impact, operative morbidity and mortality rates, and potential long-term surgical and metabolic side effects of most (but not all) of the common forms of bariatric surgery are reasonably well described. In contrast, the longer-term evidence base for applying bariatric surgery as an approach to treating T2D is much weaker. While bariatric surgery may have a prolonged beneficial effect on hyperglycaemia, it also has risks, and its economics and sustainability are unproven. At the more fanciful end of opinion is a mismatch between expectation and reality, with the risk that patients' expectations may be unrealistically raised. Long-term relapse of weight and hyperglycaemia are well-recognised and patients who choose these treatments will never be free of medical supervision.The only way to guarantee that appropriate patients with T2D are safely selected for bariatric surgery, offered an appropriate choice of evidence-based procedures, and receive appropriate immediate and long-term postoperative medical care is for diabetologists to take on this mantle of responsibility. Copyright © 2011 John Wiley & Sons.