Evolution, breakthroughs, challenges, and the future of bariatric and metabolic surgery_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 WANG Cunchuan , JIANG Shuwen

Weight Loss Center, The First Affiliated Hospital of Jinan University, Guangzhou 510630, P. R. China;

Corresponding author：

WANG Cunchuan, Email: twcc@jnu.edu.cn

Keywords：

metabolic and bariatric surgery; robotic surgery; pharmacotherapy; endoscope

DOI：

10.7507/1007-9424.202508087

Video：

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Abstract Full text Figures/Tables Video References Cited by

This review systematically traces the two-decade evolution of bariatric and metabolic surgery. The high recidivism rate associated with conventional obesity treatments have driven rapid innovation in therapeutic strategies and simultaneously accelerated progress in the surgical management of metabolic diseases. The application of laparoscopic and robotic technologies has not only improved cosmetic outcomes through smaller incisions but also significantly enhanced operational precision, further promoting the adoption and dissemination of surgical interventions. Over time, sleeve gastrectomy and gastric bypass have become the mainstream procedures. Recent research has demonstrated that metabolic surgery mediates its benefits through reprogramming of the neuroendocrine axis, restructuring of the gut microbiota ecosystem, and activation of bile acid signaling pathways. Future efforts should focus on refining long-term complication management protocols and developing individualized prediction models. By utilizing precise phenotyping to optimize procedure selection and implement stratified technical approaches, the field aims to achieve sustained metabolic health.

1.	GBD 2021 Adult BMI Collaborators. Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021. Lancet, 2025, 405(10481): 813-838.GBD 2021 Adult BMI Collaborators. Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021. Lancet, 2025, 405(10481): 813-838.
2.	NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3 663 population-representative studies with 222 million children, adolescents, and adults. Lancet, 2024, 403(10431): 1027-1050.
3.	Xu Y, Lu J, Li M, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health, 2024, 9(12): e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0.Xu Y, Lu J, Li M, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health, 2024, 9(12): e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0.
4.	Garrow JS. Morbid obesity: medical or surgical treatment? The case for medical treatment. Int J Obes, 1987, 11 Suppl 3: 1-4.
5.	Fisher BL, Schauer P. Medical and surgical options in the treatment of severe obesity. Am J Surg, 2002, 184(6B): 9S-16S. doi: 10.1016/s0002-9610(02)01173-x.
6.	Kissane NA, Pratt JS. Medical and surgical treatment of obesity. Best Pract Res Clin Anaesthesiol, 2011, 25(1): 11-25.
7.	Reid TJ, Korner J. Medical and surgical treatment of obesity. Med Clin North Am, 2022, 106(5): 837-852.
8.	Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA, 2004, 292(14): 1724-1737.
9.	Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med, 2017, 376(7): 641-651.
10.	Agirman G, Yu KB, Hsiao EY. Signaling inflammation across the gut-brain axis. Science, 2021, 374(6571): 1087-1092.
11.	Dos Santos A, Galiè S. The microbiota-gut-brain axis in metabolic syndrome and sleep disorders: a systematic review. Nutrients, 2024, 16(3): 390. doi: 10.3390/nu16030390.
12.	Verma A, Inslicht SS, Bhargava A. Gut-brain axis: role of microbiome, metabolomics, hormones, and stress in mental health disorders. Cells, 2024, 13(17): 1436. doi: 10.3390/cells13171436.
13.	Ryan KK, Tremaroli V, Clemmensen C, et al. FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature, 2014, 509(7499): 183-188.
14.	Panzitt K, Wagner M. FXR in liver physiology: multiple faces to regulate liver metabolism. Biochim Biophys Acta Mol Basis Dis, 2021, 1867(7): 166133. doi: 10.1016/j.bbadis.2021.166133.
15.	Adorini L, Trauner M. FXR agonists in NASH treatment. J Hepatol, 2023, 79(5): 1317-1331.
16.	Husted AS, Trauelsen M, Rudenko O, et al. GPCR-mediated signaling of metabolites. Cell Metab, 2017, 25(4): 777-796.
17.	Schoeler M, Caesar R. Dietary lipids, gut microbiota and lipid metabolism. Rev Endocr Metab Disord, 2019, 20(4): 461-472.
18.	Zimmermann M, Zimmermann-Kogadeeva M, Wegmann R, et al. Mapping human microbiome drug metabolism by gut bacteria and their genes. Nature, 2019, 570(7762): 462-467.
19.	Javdan B, Lopez JG, Chankhamjon P, et al. Personalized mapping of drug metabolism by the human gut microbiome. Cell, 2020, 181(7): 1661-1679.
20.	Takeuchi T, Kubota T, Nakanishi Y, et al. Gut microbial carbohydrate metabolism contributes to insulin resistance. Nature, 2023, 621(7978): 389-395.
21.	Su X, Gao Y, Yang R. Gut microbiota-derived tryptophan metabolites maintain gut and systemic homeostasis. Cells, 2022, 11(15): 2296. doi: 10.3390/cells11152296.
22.	王晓鹏, 王艳, 狐鸣, 等. 基于全球首例5G远程机器人辅助袖状胃切除术的可行性分析(附手术视频). 机器人外科学杂志(中英文), 2025, 6(1): 24-27.
23.	O’Neil PM, Birkenfeld AL, McGowan B, et al. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet, 2018, 392(10148): 637-649.
24.	El K, Douros JD, Willard FS, et al. The incretin co-agonist tirzepatide requires GIPR for hormone secretion from human islets. Nat Metab, 2023, 5(6): 945-954.
25.	Ji L, Jiang H, Bi Y, et al. Once-weekly mazdutide in Chinese adults with obesity or overweight. N Engl J Med, 2025, 392(22): 2215-2225.
26.	杨华, 陈缘, 王存川, 等. 中国肥胖代谢外科数据库: 2019年度报告. 中华肥胖与代谢病电子杂志, 2020, 6(3): 143-149.
27.	杨华, 陈缘, 董志勇, 等. 中国肥胖代谢外科数据库: 2020年度报告. 中华肥胖与代谢病电子杂志, 2021, 7(1): 1-7.
28.	Trujillo AB, Sagar D, Amaravadhi AR, et al. Incidence of post-operative gastro-esophageal reflux disorder in patients undergoing laparoscopic sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg, 2024, 34(5): 1874-1884.
29.	Carter J, Husain F, Papasavas P, et al. American Society for metabolic and bariatric surgery review of body composition. Surg Obes Relat Dis, 2025, 21(4): 354-361.
30.	Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the surgery of obesity and metabolic disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis, 2022, 18(12): 1345-1356.
31.	Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg, 2010, 20(12): 1720-1726.Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg, 2010, 20(12): 1720-1726.
32.	Storm AC, Abu Dayyeh BK. Endoscopic sleeve gastroplasty for obesity: defining the risk and reward after more than 1 600 procedures. Gastrointest Endosc, 2019, 89(6): 1139-1140.
33.	Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet, 2022, 400(10350): 441-451.
34.	Perdomo CM, Cohen RV, Sumithran P, et al. Contemporary medical, device, and surgical therapies for obesity in adults. Lancet, 2023, 401(10382): 1116-1130.
35.	Laferrère B, Heshka S, Wang K, et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care, 2007, 30(7): 1709-1716.
36.	郎敏, 郑克鸿, 曾松华 , 等. 肥胖2型糖尿病患者胃旁路术后肠道菌群的变化. 南方医科大学学报, 2017, 37(10): 1337-1344.
37.	Schneider KM, Candels LS, Hov JR, et al. Gut microbiota depletion exacerbates cholestatic liver injury via loss of FXR signalling. Nat Metab, 2021, 3(9): 1228-1241.
38.	Curry TB, Somaraju M, Hines CN, et al. Sympathetic support of energy expenditure and sympathetic nervous system activity after gastric bypass surgery. Obesity (Silver Spring), 2013, 21(3): 480-485.
39.	Ye Y, Abu El Haija M, Morgan DA, et al. Endocannabinoid receptor-1 and sympathetic nervous system mediate the beneficial metabolic effects of gastric bypass. Cell Rep, 2020, 33(4): 108270. doi: 10.1016/j.celrep.2020.108270.
40.	Ambrosi TH, Morales D, Chen K, et al. Basigin links altered skeletal stem cell lineage dynamics with glucocorticoid-induced bone loss and impaired angiogenesis. Nat Commun, 2025, 16(1): 7606. doi: 10.1038/s41467-025-62881-w.
41.	周于琳, 冯正平. 糖皮质激素诱导骨质疏松发病机制的研究进展. 中国骨质疏松杂志, 2023, 29(2): 288-291.
42.	Xiao F, Xia T, Lv Z, et al. Central prolactin receptors (PRLRs) regulate hepatic insulin sensitivity in mice via signal transducer and activator of transcription 5 (STAT5) and the vagus nerve. Diabetologia, 2014, 57(10): 2136-2144.
43.	Uno K, Katagiri H, Yamada T, et al. Neuronal pathway from the liver modulates energy expenditure and systemic insulin sensitivity. Science, 2006, 312(5780): 1656-1659.

1. GBD 2021 Adult BMI Collaborators. Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021. Lancet, 2025, 405(10481): 813-838.GBD 2021 Adult BMI Collaborators. Global, regional, and national prevalence of adult overweight and obesity, 1990–2021, with forecasts to 2050: a forecasting study for the Global Burden of Disease Study 2021. Lancet, 2025, 405(10481): 813-838.
2. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3 663 population-representative studies with 222 million children, adolescents, and adults. Lancet, 2024, 403(10431): 1027-1050.
3. Xu Y, Lu J, Li M, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health, 2024, 9(12): e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0.Xu Y, Lu J, Li M, et al. Diabetes in China part 1: epidemiology and risk factors. Lancet Public Health, 2024, 9(12): e1089-e1097. doi: 10.1016/S2468-2667(24)00250-0.
4. Garrow JS. Morbid obesity: medical or surgical treatment? The case for medical treatment. Int J Obes, 1987, 11 Suppl 3: 1-4.
5. Fisher BL, Schauer P. Medical and surgical options in the treatment of severe obesity. Am J Surg, 2002, 184(6B): 9S-16S. doi: 10.1016/s0002-9610(02)01173-x.
6. Kissane NA, Pratt JS. Medical and surgical treatment of obesity. Best Pract Res Clin Anaesthesiol, 2011, 25(1): 11-25.
7. Reid TJ, Korner J. Medical and surgical treatment of obesity. Med Clin North Am, 2022, 106(5): 837-852.
8. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA, 2004, 292(14): 1724-1737.
9. Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus intensive medical therapy for diabetes—5-year outcomes. N Engl J Med, 2017, 376(7): 641-651.
10. Agirman G, Yu KB, Hsiao EY. Signaling inflammation across the gut-brain axis. Science, 2021, 374(6571): 1087-1092.
11. Dos Santos A, Galiè S. The microbiota-gut-brain axis in metabolic syndrome and sleep disorders: a systematic review. Nutrients, 2024, 16(3): 390. doi: 10.3390/nu16030390.
12. Verma A, Inslicht SS, Bhargava A. Gut-brain axis: role of microbiome, metabolomics, hormones, and stress in mental health disorders. Cells, 2024, 13(17): 1436. doi: 10.3390/cells13171436.
13. Ryan KK, Tremaroli V, Clemmensen C, et al. FXR is a molecular target for the effects of vertical sleeve gastrectomy. Nature, 2014, 509(7499): 183-188.
14. Panzitt K, Wagner M. FXR in liver physiology: multiple faces to regulate liver metabolism. Biochim Biophys Acta Mol Basis Dis, 2021, 1867(7): 166133. doi: 10.1016/j.bbadis.2021.166133.
15. Adorini L, Trauner M. FXR agonists in NASH treatment. J Hepatol, 2023, 79(5): 1317-1331.
16. Husted AS, Trauelsen M, Rudenko O, et al. GPCR-mediated signaling of metabolites. Cell Metab, 2017, 25(4): 777-796.
17. Schoeler M, Caesar R. Dietary lipids, gut microbiota and lipid metabolism. Rev Endocr Metab Disord, 2019, 20(4): 461-472.
18. Zimmermann M, Zimmermann-Kogadeeva M, Wegmann R, et al. Mapping human microbiome drug metabolism by gut bacteria and their genes. Nature, 2019, 570(7762): 462-467.
19. Javdan B, Lopez JG, Chankhamjon P, et al. Personalized mapping of drug metabolism by the human gut microbiome. Cell, 2020, 181(7): 1661-1679.
20. Takeuchi T, Kubota T, Nakanishi Y, et al. Gut microbial carbohydrate metabolism contributes to insulin resistance. Nature, 2023, 621(7978): 389-395.
21. Su X, Gao Y, Yang R. Gut microbiota-derived tryptophan metabolites maintain gut and systemic homeostasis. Cells, 2022, 11(15): 2296. doi: 10.3390/cells11152296.
22. 王晓鹏, 王艳, 狐鸣, 等. 基于全球首例5G远程机器人辅助袖状胃切除术的可行性分析(附手术视频). 机器人外科学杂志(中英文), 2025, 6(1): 24-27.
23. O’Neil PM, Birkenfeld AL, McGowan B, et al. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet, 2018, 392(10148): 637-649.
24. El K, Douros JD, Willard FS, et al. The incretin co-agonist tirzepatide requires GIPR for hormone secretion from human islets. Nat Metab, 2023, 5(6): 945-954.
25. Ji L, Jiang H, Bi Y, et al. Once-weekly mazdutide in Chinese adults with obesity or overweight. N Engl J Med, 2025, 392(22): 2215-2225.
26. 杨华, 陈缘, 王存川, 等. 中国肥胖代谢外科数据库: 2019年度报告. 中华肥胖与代谢病电子杂志, 2020, 6(3): 143-149.
27. 杨华, 陈缘, 董志勇, 等. 中国肥胖代谢外科数据库: 2020年度报告. 中华肥胖与代谢病电子杂志, 2021, 7(1): 1-7.
28. Trujillo AB, Sagar D, Amaravadhi AR, et al. Incidence of post-operative gastro-esophageal reflux disorder in patients undergoing laparoscopic sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg, 2024, 34(5): 1874-1884.
29. Carter J, Husain F, Papasavas P, et al. American Society for metabolic and bariatric surgery review of body composition. Surg Obes Relat Dis, 2025, 21(4): 354-361.
30. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the surgery of obesity and metabolic disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis, 2022, 18(12): 1345-1356.
31. Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg, 2010, 20(12): 1720-1726.Sánchez-Pernaute A, Herrera MA, Pérez-Aguirre ME, et al. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). One to three-year follow-up. Obes Surg, 2010, 20(12): 1720-1726.
32. Storm AC, Abu Dayyeh BK. Endoscopic sleeve gastroplasty for obesity: defining the risk and reward after more than 1 600 procedures. Gastrointest Endosc, 2019, 89(6): 1139-1140.
33. Abu Dayyeh BK, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial. Lancet, 2022, 400(10350): 441-451.
34. Perdomo CM, Cohen RV, Sumithran P, et al. Contemporary medical, device, and surgical therapies for obesity in adults. Lancet, 2023, 401(10382): 1116-1130.
35. Laferrère B, Heshka S, Wang K, et al. Incretin levels and effect are markedly enhanced 1 month after Roux-en-Y gastric bypass surgery in obese patients with type 2 diabetes. Diabetes Care, 2007, 30(7): 1709-1716.
36. 郎敏, 郑克鸿, 曾松华 , 等. 肥胖2型糖尿病患者胃旁路术后肠道菌群的变化. 南方医科大学学报, 2017, 37(10): 1337-1344.
37. Schneider KM, Candels LS, Hov JR, et al. Gut microbiota depletion exacerbates cholestatic liver injury via loss of FXR signalling. Nat Metab, 2021, 3(9): 1228-1241.
38. Curry TB, Somaraju M, Hines CN, et al. Sympathetic support of energy expenditure and sympathetic nervous system activity after gastric bypass surgery. Obesity (Silver Spring), 2013, 21(3): 480-485.
39. Ye Y, Abu El Haija M, Morgan DA, et al. Endocannabinoid receptor-1 and sympathetic nervous system mediate the beneficial metabolic effects of gastric bypass. Cell Rep, 2020, 33(4): 108270. doi: 10.1016/j.celrep.2020.108270.
40. Ambrosi TH, Morales D, Chen K, et al. Basigin links altered skeletal stem cell lineage dynamics with glucocorticoid-induced bone loss and impaired angiogenesis. Nat Commun, 2025, 16(1): 7606. doi: 10.1038/s41467-025-62881-w.
41. 周于琳, 冯正平. 糖皮质激素诱导骨质疏松发病机制的研究进展. 中国骨质疏松杂志, 2023, 29(2): 288-291.
42. Xiao F, Xia T, Lv Z, et al. Central prolactin receptors (PRLRs) regulate hepatic insulin sensitivity in mice via signal transducer and activator of transcription 5 (STAT5) and the vagus nerve. Diabetologia, 2014, 57(10): 2136-2144.
43. Uno K, Katagiri H, Yamada T, et al. Neuronal pathway from the liver modulates energy expenditure and systemic insulin sensitivity. Science, 2006, 312(5780): 1656-1659.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Latest ArticlesEvolution, breakthroughs, challenges, and the future of bariatric and metabolic surgery

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