The Heresy of Hypoabsorptive Bariatric Surgery: A Critical Reappraisal of Long-Term Outcomes and Clinical Trade-Offs

: Hypoabsorptive bariatric procedures remain underutilized despite offering superior durable weight loss and metabolic comorbidity resolution. This review examines evidence from registry analyses, comparative studies, and long-term cohorts with follow-up extending to 30 years. When adjusted for baseline characteristics, hypoabsorptive procedures do not incur higher 30-day morbidity than RYGB. Five-year data confirm superiority in total weight loss (40.6% versus 33.8% for RYGB) and diabetes remission (92.8%). However, long-term follow-up reveals substantial nutritional costs affecting > 80% of patients in cohorts that often include patients treated with historical techniques, with cumulative reoperation rates reaching 37% at 10 years. Complication timing correlates with patient frailty-older age, lower BMI, and greater comorbidity burden predict earlier decompensation. Hypoabsorptive surgery offers unmatched efficacy at substantial long-term cost that manifests earlier in vulnerable populations, demanding rigorous patient selection and honest acknowledgment of trade-offs.