We spoke with Abraham Krikhely, MD, Chief of the Division of Minimally Invasive Surgery and Bariatric Surgery, to discuss the current state of weight loss surgery. Dr. Krikhely shares insights on the role of new medications, evolving surgical techniques, and the importance of prevention and multidisciplinary care in treating obesity.
New Medications for Weight Loss
What do you see as the most impactful development in weight loss treatment today?
We are very excited about the emergence of more effective weight loss medications (the GLP1 category of medications) in our battle against obesity and to be able to offer these medications to help our patients. These medications seem to have better outcomes than prior weight loss medications. We can use these medications to better optimize our patients for surgery. We can also use these medications for patients who have already had surgery but need additional weight loss or for those who have regained weight.
Obesity and weight-related medical problems carry a very significant burden throughout the world. About 40 percent of people in the United States suffer from obesity, and another 30 percent are considered overweight. Obesity is also associated with many medical problems, such as hypertension, diabetes, high cholesterol, fatty liver disease, heart disease, sleep apnea, and different types of cancers, just to name a few.
While these medications are a great tool, they are not a long-term solution. A big challenge is that they don’t always work, and once you stop taking them, the weight comes right back. Also, the long-term outcomes and effects of these medications are unknown. Bariatric surgical options, on the other hand, have been proven to be safe and effective long term with improvement or resolution in numerous medical problems, including diabetes, hypertension, heart disease, sleep apnea, and joint pain. Bariatric surgery has been shown to have a decrease in the incidence of multiple different types of cancers compared to patients who had obesity and didn’t have surgery. A recent study from the Mayo Clinic also showed that gastric bypass had sustained weight loss results 15 years out from surgery! Ultimately, with bariatric surgery, we aim to add years to patients’ lives and quality of life to those years.
Are there barriers to using these medications?
There are multiple barriers to these medications. Availability and cost are big issues. I recently participated as a discussant at ASMBS, where Dr. Morton ( past president of ASMBS and a leading surgeon at Yale) presented his work comparing the effectiveness and cost of a long term strategy of surgery vs semaglutide. Long term, surgery was noted to be much more effective and lower cost – it wasn’t close!
Then there’s adherence—nobody likes to take medicine. People forget, run out, or can’t afford it. On top of that, these medications have side effects, and not everyone can tolerate them. If any of these issues interrupt the ability to continue taking the medication, the weight is likely to come back. We currently see many patients who are coming for bariatric surgery who had previously tried these medications but couldn’t sustain the success.
Do you see these medications reducing the need for bariatric surgery?
Ultimately, neither medications nor surgery will replace the roles of proper lifestyle, nutrition, and exercise. Medications will be effective for some people. However, there are many for whom these medications will not prove to be a great long-term solution.
Today, people want to try the pill or the injection first. But once they realize it doesn’t work or they can’t tolerate it, they’re still coming back for surgery. I think these medications might actually drive more awareness about treatment options, which could lead more people to consider surgery as a long-term solution.
Surgical Trends and Techniques
How has bariatric surgery evolved in recent years?
Surgery is the most effective treatment option we have for achieving sustained weight loss and helping address the many medical problems that are associated with obesity. Through many technological advancements, better training, and better science in the understanding of taking care of patients suffering from obesity, surgery has become very safe. In another study published this year out of the Mayo Clinic, bariatric surgery was shown to be very safe – as safe as other common surgeries such as gallbladder, hernia, or appendix surgeries.
Bariatric surgery works It works by addressing weight loss through multiple mechanisms, including restriction, hormonal changes, and, in some cases, reduced absorption.
The most common surgery is sleeve gastrectomy. It’s the most common in my practice, in the country, and in the world because it’s very effective and simpler than other options. With a sleeve, the stomach is smaller, so you have restriction. But it also decreases ghrelin, which is thought to be one of the hormones that make us hungry. Many sleeve patients are less hungry afterward.
When is gastric bypass the procedure you recommend to patients? Are there particular conditions?
Gastric bypass is more effective for GERD (acid reflux or heartburn) and diabetes. It involves making your stomach smaller and bypassing a small portion of your small intestines. It impacts multiple hormones, including GLP1 and PYY.
Duodenal switch is the most effective option for diabetes and has the best weight loss. This involves combining a sleeve gastrectomy with bypassing about 2/3 of your small intestine. I remember this one patient who was suffering from complications of diabetes. He had a stent in his heart, was losing his kidneys, was losing his eyesight, and was on numerous diabetes medications. We did the duodenal switch – one year later, his eyes and kidneys were better, he had lost weight, and he was off most of his diabetes medications. Cases like this inspire me to keep going!
We use the patient’s preferences and individual medical profiles to guide them towards the right option.
Are there new trends or innovations in surgical procedures?
Surgery is increasingly being done minimally invasively with robotic approaches. At Columbia, we were among the earliest to lead the way with application of robotics to weight loss surgery. We’re seeing growth in single anastomosis procedures, like SADI or loop gastric bypass. This is a simplified versions of traditional surgery, with good weight loss outcomes but potentially safer.
We are excited to now offer LINX as a treatment for patients suffering from persistent reflux. We’re also seeing more non-surgical options like endoscopic gastroplasty, which involves folding the stomach to reduce its capacity. While it’s less effective than surgery, it’s a promising option for patients who don’t qualify for or don’t want surgery.
Multidisciplinary Care and Patient Experience
How important is a multidisciplinary approach in treating obesity?
It’s critical to recognize that treating obesity is a team effort. It takes a village. We’ve come a long way since the origins of bariatric surgery in the 1960s. The tools we use are better, and our understanding of the disease is better.
Our program includes surgeons, social workers, nutritionists, and nurse practitioners, all working together to provide comprehensive care. We collaborate with a team of specialists and your medical doctors. We also offer support groups led by our team, which can be incredibly valuable for patients as they navigate their weight loss journey.
What does the onboarding process look like for patients considering surgery?
Patients meet one-on-one with a provider—either a surgeon or nurse practitioner—to discuss all their options, including non-surgical ones. If they decide to proceed with surgery, our coordinators guide them through the process, including the workup required by their insurance.
Every patient also has a psychosocial evaluation as part of the process, and our social worker helps identify any emotional or mental health needs. We try to make it as seamless as possible for patients.
Revisions and Long-Term Outcomes
How often do you see patients for revision surgeries?
At Columbia, we’re a referral center for complex cases, so we take care of many patients seeking revisional surgery and perform a large volume of these surgeries. so we see a lot of revisions—more than a third of our procedures. Sometimes, a revision is sought due to weight regain, and at other times, it’s for issues like reflux after a sleeve. These cases are rather complex and require a high level of expertise.
When it comes to weight regain, the most common reason is that life happens. I recently spoke to a young woman who came to me for a revision after having three or four pregnancies back-to-back. For others, it’s a matter of not making the necessary lifestyle changes. Surgery is a tool, but it’s not a replacement for proper nutrition, exercise, and long-term commitment.
What’s Next for Weight Loss Surgery?
What are your goals for the future of the practice?
We take great joy in helping our patients achieve their weight loss goals, get healthier, and live longer and happier lives! We have seen the amazing impact that bariatric surgery has had on our patients and believe that it will be a great option to help change your life for years to come. We plan to continue our commitment to individualized care, great clinical outcomes, and minimally invasive and robotic approaches. We routinely treat the simplest and the most complex of cases.
We also collaborate with our excellent team of colleagues, which allows us to offer bariatric surgeries to patients who are being optimized for kidney transplants.
What do you see as the biggest challenge in treating obesity?
The biggest challenge is access—both to medications and to surgery. There’s also a lot of bias against bariatric surgery, even though the data is clear: it adds years to people’s lives, improves quality of life, and reverses many medical conditions.
Ultimately, obesity is a complex disease, and there’s no one-size-fits-all solution. Having multiple tools in our toolbox—whether it’s medications, surgery, or other procedures—gives us the best chance of helping patients achieve lasting success.