We spoke with Marc Bessler, MD, Chief of the Division of Minimal Access/Bariatric Surgery and Director of the Center for Metabolic and Weight Loss Surgery. Dr. Bessler gives his thoughts on how the field of weight loss surgery is evolving and improving in 2024, the shifting perspective on obesity as a disease, and how new medications like Ozempic and Wegovy are expanding treatment options for many in need.
New Medications | Pediatric Obesity | Procedure Developments | Patient Experience | In the News | What’s Next
New Medications for Weight Loss
What would you say is the most impactful development for weight loss in 2024?
Well, the elephant in the room is a group of medications: Glucagon-like peptide-1 (GLP-1) agonists. Ozempic, Wegovy, Mounjaro, Zepbound, etc. These medications are a sea change.
They are based on the research that was done—some of it here at Columbia—on the mechanisms of gastric bypass surgery that cause weight loss. It was originally thought it had to do with absorption and a small stomach. But it turns out that a big portion of the weight loss was from hormones.
We've known for years that hormones being released from the intestine cause satiety. So what's interesting about this is that the way you get those hormones released after, say, a gastric bypass, is that food goes into your intestine, where it stimulates the cells in the intestine to release the hormones.
By the time the food gets down to the intestine, the body releases hormones that tell you that you don't need to eat anymore. Normally, food is not in the intestine until much later in the process. So, getting food to your intestine sooner helps you terminate your meals more quickly.
The way these medications work is basically recreating this effect to be in your system all the time. You're getting constant stimulation from these GLP-1 medications. So instead of a signal for terminating your meals early, you're having all the effects of what GLP-1s do all the time, which means you feel more satiated more.
What we have found is that these medications help patients who have had surgery and are struggling to keep it off or are regaining weight. Some patients may need this effect around all the time to have success.
Do these medications have an impact outside of weight loss?
Yes, another interesting thing is that these medications have shown a reduction in other addictive behaviors. Not just eating behavior, but patients who have alcohol consumption or use disorders are finding that they drink less when they're on these medications.
Even gambling and other addictive behaviors are reduced. They may work in the brain's dopamine center to down-regulate the effects of those things in the brain.
People say when they're on these medications, the sort of "food chatter" that goes on in their brains is quieted down. So they're not always thinking about food–to the point that they sometimes even say they forget to eat.
Some of the more effective medications, like Zepbound and Mounjaro, work on another hormone called glucose-dependent insulinotropic polypeptide (GIP) that slows the emptying of the stomach even more than GLP-1 does. So, these medications are probably going to get better and better.
What are the downsides to the medications?
They can cause some side effects, like nausea. These side effects of the medications don't occur with a gastric bypass operation because the drugs are in the system all the time. We're still learning about the long, long-term effects. For example, the drugs slow the emptying of the stomach; I have a feeling that we're going to see side effects like gastroparesis turn into a chronic problem for some patients.
And the nausea, vomiting, and reflux that's going to come with that may become a bigger issue over time as we see these patients more and more. That's hard to know right now. And I think we're going to see patients that fail to keep the weight off. There may be a bunch of patients who gain their weight back despite taking the meds.
How are these medications impacting the demand for bariatric surgery?
As a result of their popularity, we're seeing a decrease in the number of patients who are seeking bariatric surgery. Nationally, there's a trend of about 10 to 20%, depending on the market decrease in volume in bariatric surgery.
That being said, I think that is happening more in the patients who have commercial insurance that covers these medications—because these medications are expensive. They're as much as $1,300 a month, and that can be a barrier. If you don't have access to insurance coverage for that, you are going to be more likely to ultimately seek surgery.
Is insurance coverage a roadblock for these medications?
Many companies have removed these medications from coverage because it has increased the cost of their coverage so much. Obesity is such a widespread disease, and these medications are a relatively expensive treatment.
About a third of our patients have taken and failed the medications or don't want to keep taking them because of their side effects and are coming to have surgery anyway.
It's funny. I've watched people say that obesity isn't something to be taken seriously as a disease, so why are you operating on that? And now, there's medication to treat it, so it must be a disease. I think a lot more patients are going to be treated for this disease, a portion of whom are going to come to surgery.
So I think we're going to see the treatments that are available expand, and the percentage of patients that get treatment will increase. But I don't see this as a replacement for surgery.
So, the popularity of the medications may wind up driving demand for surgery?
Exactly. I think this is a temporary lull. It's not entirely clear which way things are going, but in our experience, about a third of the patients we're seeing have tried these medications, and they're either having side effects or they're not effective enough. So, for whatever reason, they're still coming on to have surgery. So, I don't think weight loss surgery is going away anytime soon.
For a broader perspective, there's been an incremental growth in bariatric surgery. I just saw data that in '22 [the number of surgeries] was greater than in '21. But when the numbers come out, I think '23 is going to be a little bit less than '22.
Is the effectiveness of these medications a big surprise?
I started in practice doing bariatric surgery 28 years ago. And I've seen medications come and fail and come and fail and come and fail. But I think this stuff is revolutionary. And medication has its own appeal. It's much easier for most patients to wrap their heads around a medication that they inject once a week. And they can stop when they want a surgical change that could be more permanent. The bar to just get people to decide on surgery because of the fear and the recovery time is obviously a much bigger deal for them.
So it's offering treatment to a whole bunch of patients that would've never gotten any treatment. And I think that, eventually, the medications will get better and better. Surgery has gotten better and better a lot over the past 30 years. It is probably getting close to the maximum benefit we can provide.
However, we can explore ways to make surgery more affordable, like outpatient surgery for some patients. That is going to decrease the cost of surgery. If you can get surgery down to $25,000-$30,000, that's less than two years of medication. For an insurance company, that's an attractive option. We know it is effective for 70-80% of patients, and it's a much better value proposition.
I'd say to the insurance companies that, instead of requiring six months of medical management of obesity before they'll approve surgery, I'd like to see patients be required to have a surgery consult before they can get approved for medications. If you have to fail weight loss medication before you can have surgery, then you're committing yourself to a much more expensive lifetime of medications than a fix that might not involve medications anymore.
Or you might take patients with a BMI of 60 and above and put them on medications to reduce their weight to get them in better shape for surgery.
So, weight loss surgery and these new medications aren't at odds with each other?
I see it more like surgery and chemotherapy for cancer. They both have a place; sometimes they're additive, sometimes one's effective, and you don't need the other. They're all addressing the same mechanisms. But it's good to have multiple treatments. None of them are perfectly effective, so I think having more options for patients will lead to more treatment and better outcomes overall.
The weight loss drug world never really had anything that was nearly as effective or even in the same ballpark as surgery. And so they were never able to really show decreases in things like cardiovascular mortality. We know from sustained weight loss with surgery that this decreases in cardiovascular mortality, diabetes, and cancers.
These medications have created excitement in the medical world to see that sustained weight loss can actually do those things—Now they believe it. The medical world looks at surgery as a fringe thing despite those results. Medicine happens in larger numbers with more money behind it.
They're basically reshowing what we've shown. It's not the drugs that are doing this. It's the weight loss that's causing significant improvement. Obesity is a disease that causes all those things. Sustained weight loss, which we hadn't had available to us before outside of surgery, reverses that. So, it's really pretty remarkable.
Pediatric Obesity
How about in the pediatric space? Are these medications useful for adolescents struggling with their weight?
I don't know if it's approved for under 18 yet, but my guess is it would be fine. But you need to consider the impact and cost of taking an 18-year-old or younger and putting them on medication for the rest of their lives. It's a pretty big commitment. Would it make sense to take a teen who's 15 or 16 and help them lose a bunch of weight with either an endoscopic procedure or medication or both? Maybe.
Teenagers have a higher chance of not turning into obese adults than obese adults have of not being obese later on. So, it might make sense to reduce them and give them another chance because their physiology is changing, and they may have a better shot at keeping it off.
New Developments for Surgical Procedures
What are the current trends in surgical procedures?
One area that is gaining in popularity is what is called an anastomosis operation. For context, gastric sleeve surgery is still the most popular operation, but sometimes a sleeve isn't working, or there's a good reason to do something else. For example, a sleeve is a good weight loss operation but not a great diabetes operation. So, in a patient with severe diabetes, a sleeve isn't as good a choice.
Gastric bypass and duodenal switch are great weight loss operations and diabetes treatments. Both those operations are now being done in an updated version.
An anastomosis is a channel we surgically create between two structures. Traditionally, we used to divide the intestine and create two channels: one to carry the food and one to carry the enzymes. But we're seeing that a single anastomosis allows the bile and pancreatic enzymes to join with the food right away, which you would think wouldn't be as good for weight loss. However, in those operations, because more of the intestine is bypassed, the weight loss is still quite good.
It started with a duodenal switch—where we just attach the intestine as a loop to the duodenum underneath the sleeve. But it's become more common with gastric bypass to do one anastomosis, as well.
Are there any downsides?
There is still the potential for bile refluxing up into the stomach. Whereas with Roux-en-Y gastric bypass (RYGB), you don't have that. So, if a patient has significant reflux, we would still do a RYGB. But for a patient without reflux, we do a single anastomosis gastric bypass, or loop gastric bypass, instead of a root gastric bypass.
So, those surgeries have become more popular than they previously were. What some people call a SADI, or single anastomosis duodenal ileostomy, or loop duodenal switch, was already gaining popularity some years back, so we've been doing those for a while. The one anastomosis gastric bypass is newer.
What about endoscopic procedures? Are they gaining in popularity?
I don't think they're necessarily growing in popularity as a whole, mainly because I think these medications deliver as good, if not better,weight loss as you might with, say, a gastric balloon. And while a minimally invasive, reversible option is great, the medications are even easier. So I don't think that's gaining in popularity.
Endoscopic gastroplasty—which some people confusingly call an endoscopic sleeve gastroplasty—is an enfolding of the stomach to create a shape that reduces spaces for food in the stomach. That procedure is gaining a bit in popularity; there's new data showing that it's probably close to as effective as these medications are, but it lasts as long as three years. So, from a perspective of cost, it may even cost less than three years' worth of medication.
So it has a few elements that are appealing?
Indeed. It's a procedure, it's renewable, and it's reversible in that it reverses itself over time (although they continue to work on ways to make it last longer and be more durable). Overall, the weight loss is probably a little less than the actual surgery, like a sleeve, so it's somewhere in between medications and a true sleeve.
But most insurances aren't covering it yet. The company that makes the device was just bought out by a very large company with a significant endoscopic portfolio. So there's a push to get physicians to try and get coverage to move the insurance companies towards coverage. And the new data that's out has led to FDA approval for the device to be used. So, rather than just having a device that was approved to be used for sewing in the GI tract, endoscopic gastroplasty is an approved indication for the device.
How would you identify a candidate for the endoscopic procedures?
They got $10,000 burning a hole in their pocket? <laughs> The lack of insurance coverage is a big issue. Endoscopic gastroplasty is approved for a body mass index (BMI) of 30 to 50 by multiple relevant societies, like the GI Society, the American Society for Metabolic and Bariatric Surgery, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), etc. All these societies came out with a statement saying that surgery should be offered to patients with a BMI of 35 without medical problems. And also for certain patients, especially those with severe diabetes in the BMI 30 to 35 category, and certainly BMI 40 and above. But most insurances aren't there yet.
However, as compared to medication, which costs $15,000 a year, a surgery that costs $30,000 as a one-time cost might be quite attractive. It lasts much, much longer than those medications. And we don't even know the long-term effects and costs of medications.
What portion of the procedures you perform would you say are revisions from previous surgeries?
For our group, it's more than a third. You can get the surgery at almost any hospital. We're left with the more difficult ones that a lot of people don't won't perform since we're known for doing more complex and revisional surgery. The revision surgery can be the result of a poorly performed surgery initially, or the doctors didn't make the right surgery choice, or weight regain, or reflux after a sleeve surgery. It runs the gamut.
Primary surgeries have become really good and can be done at a lot of places. It's when you're having problems, the complications, when surgery doesn't go well, that's when it's important to work with a group like ours.
I think the fact that we've put all these things together in one place—medical management, endoscopic treatments, surgery, and a team that is working together all within one group—I would say that's really important. We've gotten so good at the surgeries that we can focus on ways to reduce the rare problems.
What are some of those rare problems?
Well, the single most common cause of death after these operations is blood clots like pulmonary emboli that cause damage. In our group, we've pioneered extended prophylaxis with low-dose blood thinners after surgery for a month. We're about to publish our findings that show that it dramatically decreases the presence of those complications. So we've gotten things down to one in a thousand now.
When it used to be near one and a half percent, that's a dramatic change in how we're managing patients after surgery. They have less pain, use less narcotics, and we see fewer complications and fewer deaths from surgery.
Again, these operations are so good now; they're probably safer than just having your gallbladder out. And we're comparing that to a life of medications. So I think we've made a lot of progress in that regard.
The Patient Experience
What would you say is the biggest fear or concern that people have when they come for a surgical consult?
I think patients are worried about a lot of different things. Some people are just scared to death of having surgery; they're worried about not waking up from anesthesia. Some people are scared that they're going to gain weight back. They've gained it back so many times after so many attempts, they almost don't believe that they can lose it and keep it off. And a percentage of patients who have operations do gain weight back, so it's not an unrealistic fear.
I tell patients that there are three things they need to do after a weight loss operation: stay away from carbs as much as possible, eat small portion sizes, and do regular exercise.
And for each one of those things that they don't do, they can expect to gain back about a third of the weight they lost. For some patients, it's just not true; they don't do any of it, and they keep the weight off.
And some people swear that they're doing those things, and the weight comes back anyway. I have to admit, I have a hard time believing that, but occasionally, we do see that. Everyone's metabolism is a little different, but for the most part, you need to do the work after these operations to make the changes people are after. Having the right support for those changes is an important part of it.
A lot of people have adjustment concerns. "What am I going to do when I can't eat? You've taken away my joy, my emotional management." I think a lot of people use food as a way of managing emotions. I send a lot of patients to Overeaters Anonymous, which is a food addiction program based on Alcoholics Anonymous. They aim to help people learn other ways of managing stress without food as their coping mechanism.
Is mental health adjustment a common issue?
Interestingly, one thing we know about gastric bypass and mental health is that it's one area where mental health is not necessarily improved. We know that in some patients, there's an increased rate of suicide or accidental death after gastric bypass in particular. It may be that if you take away their coping mechanism and don't help them replace it with something else, they're not going to do as well just in life afterwards.
Some patients don't need that level of support; they're just great with the change. However, patients who are using eating for emotional management might need that additional support.
If someone comes to you and they're not a candidate for surgery, do you have general advice that you would offer them for maintaining or pursuing weight loss?
Yes, medication is the new answer to that question, for the most part. These medications are so much more effective than they used to be. If someone has a BMI of 30 and is not happy about their weight, has tried to lose weight in the past, telling them to go home and diet and exercise and work with a nutritionist? We just know it doesn't work that well.
These medications change the equation a lot. I hate to use this expression, but it's almost like surgery in a syringe. Not exactly, but they're approaching the equivalent of surgery in a syringe. It's not quite as good for as many patients, but for some patients, these medications have as good an effect as some other patients might have with surgery.
How important is pre and post-care for patients to be successful in keeping the weight off?
Pre-care can reduce risk to the patient and make surgery happen safer and easier. Post-care has a lot to do with how the patients do as far as long-term weight loss.
I think that everybody says these operations are a tool to help patients lose weight. They have to eat properly, and that means good decision-making. So they have to be educated about that. Even with the surgery, change doesn't come easily.
Patients want to please their provider, their doctor, and their surgeon especially. So, those relationships might actually help patients stick to it.
Weight Loss Surgery in the News
There have been some stories in the news about high-volume programs possibly performing questionable surgeries. What's the best way to make sure that patients are getting the right care?
I think it's having a surgeon help make that decision. In some programs, an NP or a PA makes that decision, and then the surgeon just carries that out. That is certainly not our model at Columbia. That being said, 70% of people get the gastric sleeve. So, if you're picking a sleeve, you're going to be right 70% of the time.
But for bad reflux or diabetes, a bypass can be a better choice. We pride ourselves on being a bit more careful and thoughtful. I don't do seven surgeries a day; I'll do nine a week. I don't think that my patient is best served by me rushing through operations to get it done as fast as I can. especially because we focus on the more complex stuff.
I'd be shocked if, a week after surgery, my patient didn't know that I was their surgeon because they'd seen me before the surgery and they'd seen me in the hospital. They've met with me. I've developed a relationship with them.
What's Next for Treating Obesity
Any exciting innovations on the horizon?
There are a few exciting areas. One is endoscopic treatment specifically for diabetes. A company called Fractal has an endoscopic radiofrequency ablation for treatment of the duodenal mucosa, specifically for diabetes. They raised over a hundred million dollars with their initial public offering to hopefully bring that to market.
Medication will get better, endoscopy will get better. All these things are important because they make more options available. 90-plus percent of patients still aren't getting treatment for their obesity.
I think the next wave of research will see if these medications can predict the outcome of surgery. If you don't do well with the medication, are you going to be less likely to do well with surgery? How are they additive? Could you take a sleeve and add a GLP-1 agonist to it and get significantly better results in both weight loss and diabetes?
The model for medication is changing, too. Eli Lilly is selling their drug directly to patients. They've got their own telehealth system set up where patients can call in, be screened, and be prescribed medication. And shipping it directly to them will make it cost less. And as it costs less, it'll make it more attractive to patients... and maybe insurers.
I'd like to see wider coverage for it because getting patients into treatment for obesity is really important. You know, if 2% of patients are having surgery, now we have treatment for the other 98%. I think that's all a good thing. This is a complex disease, and there's no one treatment that's going to be a perfect fit for everybody.