Metabolic Surgery: Paradigm Shift in Metabolic Syndrome/Diabetes Therapy.

Background: Obesity and metabolic disorders as type 2 diabetes (T2D), nonalcoholic fatty liver disease (NAFLD) or better called metabolic dysfunction fatty liver disease (MAFLD), arterial hypertension (AHT), and obstructive sleep apnea syndrome (OSAS) show a rising prevalence. The increased cardiovascular risk is one of the main causes for death of obese, metabolic ill patients. Sustainable and efficient therapeutic options are needed. Summary: Metabolic surgery not only permits a substantial and lasting weight loss but also ameliorates metabolic co-morbidities and reduces cardiovascular risk and mortality of obese patients. Most existing data focused on T2D, but evidence for other metabolic co-morbidities such as NAFLD, AHT, and OSAS increase constantly. After metabolic surgery, glycemic control of diabetic patients is superior compared to conservative treatment. Also, diabetes related micro- and macrovascular complications are reduced after surgery, and the median life expectancy is over 9 years longer. In patients with MAFLD, metabolic surgery leads to reduction of steatosis and fibrosis while the risk to develop a hepatocellular carcinoma is reduced significantly. Patients with OSAS have an improved lung function and continuous pressure airway treatment during the night is unnecessary in many patients. Patients with AHT need significantly less or even no antihypertensive medication after surgery and the hazard ratio of death is reduced by 49.2%. Therefore, the focus in treating obese and metabolic ill patients is no longer on pure weight loss but on improvement of co-morbidities and reduction of mortality. This is reflected by the updated S3-guidelines of 2018 that provide nationally established consistent guidelines with clear indications for metabolic surgery no longer focusing on body mass index (BMI) only. This article aims to give an overview over the existing literature concerning surgical treatment options for metabolic syndrome. Key Messages: Metabolic co-morbidities impact life-quality and life expectancy of obese patients. Metabolic surgery offers the chance to treat those metabolic co-morbidities independently of the preoperative BMI and should be considered early as a treatment option for obese patients.