In the age of Ozempic, is there still a role for weight-loss surgery?

San Francisco Chronicle​

3 days ago

As weight-loss medications like Ozempic exploded across the U.S. over the past four years, bariatric surgeons faced a bit of an existential crisis: Were their jobs about to become obsolete?
For the first time, health care providers have a combination of highly effective therapies to offer patients with obesity, a condition that has long been one of the most difficult to treat. The outlook is especially exciting for patients who are severely overweight — including those who are considered too heavy for surgery.
Indeed, there may exist a future where drugs and other interventions prevent people from ever becoming obese and needing weight-loss surgery. But that future is far off, say surgeons and other weight-loss experts.
In fact, even as millions of Americans are now taking drugs that dramatically improve weight loss, surgeons say their tool may be more powerful than ever.
'A massive amount of people have tried these medications, so the question becomes: 'How well do they work and is there a role for bariatric surgery in the era of these drugs?'' said Dr. Jonathan Carter, a UCSF surgeon who specializes in minimally invasive procedures.
Bariatric surgery has for decades been the most effective and durable weight-loss tool available. The specific procedures vary, but the most common operation now is the gastric sleeve surgery, in which a large portion of the stomach is removed. Roughly a quarter of a million Americans undergo a bariatric procedure each year.
The surgeries are highly effective for weight loss — patients can lose about a third of their body weight within two years, and they generally keep off most of those pounds long-term. The side effects with the sleeve procedure are minimal and may include gas, bloating and nutritional deficiencies that can be alleviated with diet.
Meanwhile, more than 1 in 10 Americans have now taken the newest weight-loss medications. On these drugs, patients can lose about 15% of their weight, but they must remain on the drugs for life — those who stop gain all of the weight back. Side effects are similar to the surgery.
The drugs and the surgery work somewhat similarly by essentially quashing people's hunger and cravings. And though the surgery is more expensive at the outset — about $12,000 to $15,000 — it's cheaper in the long-term compared to drugs that cost about $1,000 a month. Both treatments are often, but not always, covered by insurance.
With the surgery, 'You take someone who is 100 pounds overweight and their knees hurt and they have sleep apnea,' said Carter, 'and you do a one-hour intervention and a year later they've lost 100 pounds and their knees don't hurt and the sleep apnea is gone. It's like a butterfly coming out of a cocoon.'
But bariatric surgery has never been a popular weight-loss option for those who need it most. Of all Americans who are eligible for surgery, only about 1% undergo the procedure. Surgeons and weight-loss experts say that's largely been due to misconceptions about the procedure and stigma around obesity.
'If you've been treating patients with obesity for decades, you always felt like, 'Yes, I have a great treatment, I can do these surgeries and do them safely, I believe in them whole-heartedly,'' said Dr. Dan Azagury, a Stanford University bariatric surgeon. 'But you were still limited in your capacity to treat patients.'
Azagury took over Stanford's Lifestyle and Weight Management Center in February 2020, about a year before Ozempic, the first blockbuster weight-loss drug, blew up. Over the next 18 months, the number of patients on weight-loss medications jumped from 50 to 2,000.
He said friends would often ask him if he would be out of a job soon. The drugs, though, have in some ways validated the surgical interventions, Azagury said.
Weight loss has notoriously been a fraught topic in doctors offices, with patients feeling judged and doctors feeling frustrated by their lack of treatment options. 'A lot of times doctors would just say that you should eat less,' Azagury said.
'And I think patients intrinsically didn't see obesity as a medical condition,' he said.
The success of recent weight-loss drugs, though, has made that conversation more palatable both to patients and providers, Azagury said. And he believes that is making some patients more amenable to a surgical option.
There are, broadly, now three buckets for treating weight loss: diet and exercise, medication and surgery. The first option is likely best for people who don't have a lot of weight to lose and who are not facing any immediate complications related to their weight. They can manage their own treatment, or get a referral to a community or private weight-loss program.
From there, patients with more serious obesity can decide if medication or surgery — or both — is the best option for them. Some people may be resistant to the idea of any surgical procedure and opt for medication. Others may decide that they would rather not deal with weekly injections for the rest of their life and prefer a one-time operation.
Many patients, though, will end up with multiple interventions over their lifetime. They may start with medication and eventually decide they want a more permanent solution. Or they may get bariatric surgery and a few years later decide to start a medication if their weight is creeping back up.
Mandy Hinz, 47, fought with her weight all her life, and it's only in the past two years that she finally felt like she had options. She had inquired about bariatric surgery about 20 years ago but was told she would need to lose 100 pounds before doctors would consider it safe. After that, she was up and down, peaking at about 415 pounds on her 5-foot, 3-inch frame.
She started Ozempic in early 2023, and though the drug made her feel 'super sick,' she stuck with it and lost about 30 pounds. Around that time, Hinz, a Sacramento resident, was referred to the bariatric program at UCSF, and in October 2023, she finally got a gastric sleeve. She got down to about 200 pounds from the surgery, then started a different weight-loss drug and lost another 20 pounds.
Though she's still obese for her height, Hinz said she's not interested in losing much more weight. 'I'm 180 and completely happy,' Hinz said. 'My journey has been absolutely amazing.'
She noted that even with all of the tools at her disposal, losing the weight was never easy. And she has friends for whom even the newest therapies aren't solving all of their weight issues. But for Hinz, the weight-loss drugs finally unlocked a path that had never felt accessible to her.
'Being big my whole life, I missed out on a lot of stuff,' she said. Walking up and down stairs had become difficult, or spending a day on her feet at an amusement park. 'Now I can run up and down the stairs, I can walk around the amusement park the whole day. I went on my first hike a year and a half ago. It's like, let's go, let's do this.'
Azagury said he's most thrilled for the patients — and their doctors — who have the most weight to lose, and especially those for whom a combination of medical and surgical therapies could be life-saving.
'The worst thing for a bariatric surgeon is when you get a patient in your clinic and it's too late — their condition is so bad that surgery is unsafe,' Azagury said. 'The conversation is, 'You have a condition I can treat, but I can't treat you.' It's the worst conversation. And I never have to have it anymore. Now I can tell them: 'I can't do surgery, but I have a good alternative for you.''