How should one balance the potential risks of surgery?

Hi doctor,

I am seeking advice regarding metabolic surgery after a decade-long struggle with severe metabolic complications. My health is deteriorating rapidly. I was diagnosed with type 2 diabetes seven years ago and currently require seventy-five units of insulin daily, in addition to oral medications. Despite this, my glycated hemoglobin (A1C) remains elevated at 9.8 percent.

My blood pressure consistently remains above 170/100 mm of Hg, even while taking the maximum tolerated doses of three antihypertensive medications. I currently weigh 378 pounds, and my height is 5 feet 8 inches. I have made multiple unsuccessful attempts at achieving and maintaining weight loss.

I have recently been diagnosed with non-alcoholic steatohepatitis, with early cirrhotic changes detected on a FibroScan, which showed a score of 12.6 kilopascals. I also suffer from obstructive sleep apnea, which requires bilevel positive airway pressure (BiPAP) therapy at high settings, along with supplemental home oxygen during the night due to persistent oxygen desaturations.

A recent echocardiogram revealed that I have an enlarged heart with an ejection fraction of 42 percent. My cardiologist has expressed concern about the early development of heart failure. What concerns me the most at present is the progressive decline in my kidney function. My estimated glomerular filtration rate (GFR) is now 48 milliliters per minute per 1.73 square meters, and I have persistent proteinuria.

My family history is significant for early cardiac death, and I am deeply afraid that I may not live long enough to see my children grow up.

At the metabolic surgery center, I was presented with several procedural options. However, I am confused about the differences between the procedures. The surgical team referred to "metabolic benefits" beyond weight loss but did not clearly explain what that would mean in the context of my specific medical conditions.

I would be grateful for clarification on the following questions:

1. Is metabolic surgery capable of reversing my diabetes and liver disease, or is it more likely to result in temporary improvement only?

2. Which specific surgical procedure is associated with the best outcomes for a patient with my combination of metabolic complications?

3. How should I balance the potential risks of surgery against the near certainty of continued health decline if no intervention is undertaken?

I would greatly appreciate a comprehensive explanation to assist me in making an informed decision regarding my treatment options.

Please help me.

Thanks.