Surgery – BMI of Texas: Recent Episodes
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It’s a very exciting time in obesity and bariatric science. Weight Loss Surgery vs. Weight Loss Drugs?
In addition to highly effective, safe, and accessible weight loss surgeries, powerful new medicines have entered the market in recent years that can trigger profound weight loss.
Semaglutide (sold as Wegovy and Ozempic) and liraglutide (sold as Saxenda and Victoza) make up a new generation of type 2 diabetes medications that are making waves for their powerful weight loss effects. Some studies on these drugs show an impressive 15% bodyweight loss over six months, while studies on a newer drug called irzepatide (sold as Mounjaro) show an astounding 22% weight loss over 6 months. Astonishingly, even more powerful medications are in development, and will likely become available in the next few years.
Those weight loss numbers are significant. For context, we know that losing just 5% bodyweight has a tremendous metabolic benefit for high BMI individuals. Achieving triple or quadruple those results via these new medications has profoundly positive implications for that person’s health.
How Do Weight Loss Drugs Work?What do these new drugs have in common? They all stimulate the production of Glucagon-like peptide-1, or GLP-1, a hormone made in the gut to help signal that you’re full, along with other weight loss benefits (fewer excess calories stored, slower movement of food through the GI tract).
We know from bariatric surgery that this hormone increases post-surgery. In effect, these new medicines are cloning the hormonal effects of bariatric surgery, allowing patients to absorb this hormone exogenously (via injections) for the first time.
Bariatric Surgery vs. GLP-1 DrugsDue to the effectiveness of these drugs, bariatric surgeons, weight loss experts, and prospect patients are asking the question: should I try weight loss medication instead of weight loss surgery?
It’s worth noting that at this time, bariatric procedures like gastric sleeve and gastric bypass are significantly more effective at triggering and maintaining weight loss. In part, this is because the surgical effect of increasing GLP-1 is logarithmically higher than it is with exogenous injections. Weight loss surgery is also a permanent solution — provided the patient sustains the necessary lifestyle changes — which is very different than needing weekly intravenous injections indefinitely.
But there is another, bigger downside to these medications: many of our patients report that they are only available at extremely high cost. In fact, these drugs can sometimes cost a patient over $1,000 per month — for many people in need of a weight loss intervention, this is simply unaffordable.
Because demand for these drugs vastly exceeds supply — even at their high price, Big Pharma can’t get them on shelves fast enough — it is unlikely that these drugs will come down in price any time soon.
Consider this: after ten months of exogenous treatment via these weight loss drugs, the patient or their insurance company has paid for the equivalent of a gastric sleeve procedure, with the results from the surgery being notably better and longer-lasting.
The Best Weight Loss Option: Combo TherapyAt BMI, we don’t view weight loss surgery and weight loss drugs as either-or options. Instead, we believe that whenever possible, the best therapy is combo therapy: weight loss surgery and GLP-1 drug treatment.
For instance, if a patient begins with weight loss surgery, and six months later, begins taking a GLP-1 drug, they might improve overall weight loss results by 20-30% — a significant advantage in the battle against obesity.
It’s worth noting that these new drugs were developed using research conducted on weight loss surgery patients. In other words, they are proven to work effectively together.
Every Effective Solution CountsGLP-1 drugs like Wegovy, Ozempic, Saxenda and Victoza represent an incredibly exciting breakthrough in bariatric science. With well over two thirds of the country suffering from over weight or obesity — not all of whom are eligible for bariatric surgery — it is unquestionably good to have more safe, effective weight loss solutions to combat obesity, no matter the financial cost.
That’s why we believe that choosing between weight loss surgery and GLP-1 medication is usually the wrong question: whenever possible, they should be combined together to maximize results.
Put another way: when suffering from obesity, nothing is more important than safeguarding your health by making changes now. The only wrong choice is sticking with the status quo: the lifestyle choices that have not been working for you in reaching your weight loss goals.
Do you know if you qualify for weight loss surgery? Take the Quiz
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It’s one of the most common questions our patients ask: if I’m going to have weight loss surgery, should I go with gastric bypass or gastric sleeve?
While both are highly effective weight loss interventions, these two popular surgeries differ in terms of their side effect profile, lifestyle management factors, medicinal effect, complexity, recovery time, and cost.
Before we weigh the pros and cons, it helps to have a basic understanding of each procedure.
Gastric Bypass vs. Gastric Sleeve: A Brief HistoryGastric bypass is the original weight loss surgery, whose history goes all the way to the 1950s. Although it has evolved over time, the basics remain the same: it’s a two-step procedure involving the creation of a small pouch out of the stomach. This pouch “detours” or “bypasses” around the larger portion of the stomach.
In contrast, gastric sleeve is a newer, simpler procedure. It’s a single-step surgery that involves removing a portion of the stomach, and sealing the remainder into a “sleeve”. Although its history goes back to the 1980s, it rose in popularity to become the number one weight loss surgery in the 2010s.
Both surgeries are performed laparoscopically (via highly targeted surgical incisions), involve unique but relatively mild side effects, are considered highly safe, and most importantly, trigger massive, potentially life-saving weight loss.
Now that you have this basic understanding, lets explore which procedure might be best for you.
Determining Your PrioritiesIn helping patients choose the best procedure for them, we start with their priorities.
Are they trying to attain a specific weight goal? Are they pursuing a medical goal, like diabetes remission? Is it important for them to minimize downtime so they can get back to work? What kind of recovery are they prepared to commit to? What side effect profile sounds better?
Answers to these questions help us determine each patient’s unique circumstance, allowing us to point them in the right direction.
Choosing Your Side EffectsLet’s talk side effects.
Gastric sleeve can cause acid reflux in about 20-25% of patients. Sometimes that requires medicine, and less frequently, a surgical intervention (typically, a conversion into a gastric bypass).
By contrast, gastric bypass doesn’t pose a risk for acid reflux. However, it does pose a risk for dumping syndrome: when patients eat something on “the naughty list” — foods that are high in sugar and fat — they experience discomfort. Some people think that sounds terrible, while others want the motivation of “the stick” to stay on track with their weight loss goals. Bypass also carries a 4-7% chance of ulcer formation and a 4-6% chance of a bowel issue requiring surgery
The Role of Recovery TimeIn terms of downtime, gastric sleeve patients recover more quickly. In fact, sleeve patients can sometimes go home the same day as the procedure, and be back at work in a week. By contrast, gastric bypass entails 1-2 nights in the hospital and 2 weeks off work to recover.
For some patients, this is the most important factor; they need to get back to work as soon as possible. For others, a longer recovery time might be a non-issue.
Do You Need To Maximize Weight Loss?Moving down the road, gastric sleeve typically results in 60-65% of extra weight off, while bypass is 70-75% — an additional 10% in poundage. For someone with a fairly low BMI — for instance, 60 pounds of extra weight — that additional 10% (6 pounds) might not make a big difference. However, if you’re 250 pounds overweight, that additional 25 pounds is going to make a big difference.
What About Diabetes Remission?Some patients pursue bariatric surgery to accomplish a specific medical goal, like diabetes remission. Diabetes remission rates run about 60% with a gastric sleeve procedure, and 80% with a gastric bypass. If remission is your goal, that 20% bump probably makes it worth opting for gastric bypass, maximizing your chances of getting off insulin and diabetes medication.
Weighing the RisksLong-term side effects and other risks are an additional factor to consider.
For instance, gastric bypass surgery poses a 4-7% risk of developing an ulcer, whereas gastric sleeve patients don’t ulcer. Additionally, there is a 4-7% chance of a gastric bypass patient needing a follow-up laparoscopy — an additional surgery that removes obstructive scar tissue so that the procedure can remain effective. A follow-up laparoscopy is not a real risk factor with gastric sleeve surgery.
Although these are low percentages, adding them together means that gastric bypass poses a 14% greater chance of requiring additional surgery compared to gastric sleeve. For some patients, the benefits of the gastric bypass (additional weight loss, diabetes remission) make that increased risk worth it; for other patients, it’s better to not take the risk.
Zooming out and considering serious risks, we find that major complications from either procedure are rare. In our practice, major complications represent less than 1% of surgeries, with gastric bypass posing a slightly higher complication risk than gastric sleeve.
Considering the CostsHere’s the reality: for many patients, the single determinative factor in choosing a procedure will be cost. As of this writing, our self-pay patients can get a gastric sleeve procedure for as low as $9950. By contrast, a gastric bypass costs around $14,000 — a significant difference for most patients. These costs reflect the greater involvement of the surgery, and the additional hospital time.
Final ConsiderationsDepending on your circumstances, there are a handful of other considerations that might come into play in selecting your procedure.
If a patient has previously had abdominal surgery or history of previous bowel obstructions, we sometimes advise them to opt for the simpler gastric sleeve procedure. Likewise, if you have health issues that make anesthesia a concern, the shorter surgical time of a sleeve can make it a better option. Finally, if your circumstances make it important to minimize potential issues around medication absorption (for instance, if you take psychiatric medicine), we may also recommend gastric sleeve.
What Matters Most?This article has guided you through the main decision tree we use with patients who are considering their options. It starts with the big questions: why are they in our office? What do they really want to accomplish? What makes them tick?
If you’re considering one of these procedures, ask yourself: what’s most important to you? Are you trying to maximize weight loss at any cost? Minimize time off? Resolve an underlying medical problem like diabetes?
Armed with answers to these questions, we look at a patient’s medical profile. All other things being equal, we typically recommend a gastric sleeve if they don’t have diabetes, and a gastric bypass if they do.
There Is No Wrong ChoiceThe truth is, there is no “bad choice” when it comes to weight loss surgery. Both surgeries are overwhelmingly safe, and facilitate a massive amount of weight loss. Instead, you are choosing the other factors that matter most in your situation, from side effects to costs.
When battling obesity, the only wrong choice is no choice or status quo — the sooner you act, the sooner you commit to a potentially life-saving treatment to protect your health.
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