Bariatric Surgery for T2DM In light of this, bariatric surgery has recently emerged as one of the most effective means of providing durable, clinically-significant resolution of diabetes. The majority of subjects with T2DM who undergo these procedures have remission of this disorder. In a large bariatric surgery meta-analysis published in Journal of the American Medical Association in 2004, within studies reporting resolution of diabetes, 76.8% of subjects experienced complete resolution; within studies reporting both resolution and improvement or only improvement of diabetes, 85.4% of subjects experienced resolution or improvement of diabetes. All bariatric operations result in remarkable improvement in T2DM although with varying degrees of efficacy. Resolution of diabetes often occurs within days following bariatric surgery, even before marked weight loss is achieved. Resolution of diabetes is more prevalent following the more "malabsorptive" procedures (BPD or duodenal switch) and the mixed malabsorptive/restrictive Roux-en-y (RYGB) in contrast to the purely restrictive vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) procedures. In addition, there appears to be a gradation of diabetes resolution as a function of the operative procedure: 98.9% for BPD, 83.7% for RYGB, 71.6% for VBG, and 47.9% for LAGB. Subjects with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering subjects euglycemic. Recently, it has been published that subjects with long-standing uncontrolled diabetes and non-morbid obesity have a high remission rate (88%) of their diabetes following RYGB surgery. However, despite the considerable effectiveness shown by bariatric surgery in resolving diabetes, surgery has not yet become a standard of care for subjects who are obese with diabetes. In part because of an incomplete understanding of the mechanisms of action, this concept of gastrointestinal surgery as an endocrine modifier is not yet fully embraced by the clinical community and has yet to be incorporated into care strategies.12 But perhaps more importantly, some clinicians evoke the irreversibility of gastric bypass and the occasional reports of poor outcomes to label this approach "extreme" - to be reserved as a treatment of last resort.