In the setting of morbid obesity, bariatric surgery is the best method of achieving and sustaining weight loss. However, in the setting of prevention and management of type 2 diabetes (T2DM), there are effective nonsurgical measures. The range and success of the diabetes prevention trials, including both lifestyle and drug therapy in high-risk patients, are impressive and sustained (1, 2). Similarly, although T2DM is a progressive disease, long-term glycemic control can be achieved and sustained with an important legacy effect associated with earlier intensive therapy (3, 4). Multifactorial interventions including multiple drug combinations and behavioral modification in high-risk patients with diabetes can reduce both morbidity and mortality (5). It is in this context of diabetes, that metabolic-diabetes surgery should be carefully assessed for its risks and benefits, and compared with current diabetes therapies or combined with current therapies. To date there have been few quality comparison studies (6?9), and priorities for clinical research will be largely driven by understanding the place that surgical procedures and devices have in a changing world of managing T2DM. Currently, very few patients are treated with gastrointestinal (GI) procedures, and the procedure rate has plateaued (10).