State of the Union: Weight Loss Surgery Today

An interview with Abraham Krikhely, MD, Chief of the Division of Minimally Invasive Surgery and Bariatric Surgery, with additional commentary from Francisco Guzman, MD, Bariatric Surgeon about the latest in weight loss surgery.

Read our previous conversation with Dr. Krikhely here: State of the Union: Weight Loss Surgery in 2025.

Medications and Surgery: Using Both Tools Thoughtfully

Last time we talked about how GLP-1 medications can help optimize patients before surgery and support those with weight regain after surgery. Have any new patterns developed?

Dr. Krikhely: They’ve been great tools to help people lose weight prior to surgery, especially when they start off at much higher weights. Even though with surgery most people are able to keep the weight off and do great, sometimes the weight comes back to a degree and we’ve been able to help them to achieve their goals with medications afterwards too.

The challenge has been and will be, at least in the near future, access. Availability and coverage remain a problem. And when you stop taking them, studies show the weight comes back. So you may help yourself in the short term, but what’s the long-term strategy? Staying on them forever is expensive. If you don’t, the weight can come back.

When Medications Make Sense, and When Surgery Does

Are there certain patient scenarios where you are more actively recommending medication vs. surgery, or a combined approach?

Dr. Krikhely: If somebody’s weight is very borderline and they have access to medications, one may consider using medications to get them down to where they need to be and see if they can stay there. But the question always is: what happens when you come off the medications?

If someone starts off at a much higher weight, medication is only going to take you so far. Statistically, what’s the point if it won’t get you to where you need to be? The magnitude of weight loss with medication isn’t what you get with surgery.

You also have to consider medical history. These medications can increase the risk for pancreatitis, reflux, and abdominal pain. If you’re already dealing with these issues, they may not be the right choice.

How is your team counseling patients on the limits of these medications?

Dr. Krikhely: It’s about setting expectations. You have to understand where you’re starting from and what kind of weight loss you can expect. You need weekly injections. You have to stay on these long-term. If you don’t want that, or can’t tolerate it, it’s less likely to work.

And none of these things—medications or surgery—replace the work of taking agency over your life. It’s about habits, environment, activity, and diet. It’s about using all the tools to set yourself up for success.

When you think about measuring successful outcomes, what matters most?

Dr. Krikhely: I would say health and happiness. That’s hard to put a number to. But long-term durability is key. I’ve referenced the Mayo Clinic study looking at gastric bypass 15 years out before. Patients were in the 20–25 percent total body weight loss range at 15 years. That’s meaningful.

So if surgery gives you that 15 years out, and medications give you less—plus 52 injections a year for 15 years—what does long-term really look like? That’s the comparison.

Revisions and Real-World Pathways Back to Surgery

You mentioned that more than a third of your cases are revisions [correcting bariatric surgeries previously performed elsewhere]. Have you seen shifts in why patients seek revisions?

Dr. Krikhely: At Columbia we see a lot of complexity. Many revisions are for reflux or hiatal hernias after previous surgery which is why we created a program to address them specifically. With weight regain, many patients have already tried medications. Either they didn’t tolerate them, didn’t have the result they wanted, or couldn’t continue them because of access. They realize that while medications were exciting initially, surgery ultimately fits their goals better.

How are you helping patients navigate weight stigma and emotional aspects of care?

Dr. Krikhely: Weight stigma is definitely a thing and it can be so damaging. It’s important to recognize that obesity is a disease and you’re not alone. We have a social worker and psychologist who meet with patients, and support groups where people talk about challenges together. That connection really matters.

Access and Insurance Realities

Are you seeing any changes in access to medications or surgery?

Dr. Krikhely: Some insurances are covering medications more now. And for surgery, many insurance carriers have reduced their requirements. The old requirement for four to six months of medical weight management didn’t actually change outcomes, it just prevented people from getting care. When barriers drop, outcomes improve. It’s simple, and extremely frustrating that we don’t yet have the access and coverage patients need.

Dr. Guzman: We updated the national guidelines two years ago to expand who is eligible for surgery, and most insurance companies ignore them. They don’t want to cover it, even though long-term it would reduce cost for everyone.

Dr. Krikhely: The crazy part is insurers only look at the next three years, because people change jobs and insurance. So they see short-term expense without long-term benefit. It’s economics—just very weird and very broken.

Looking Ahead

Have there been any technological advances in bariatric surgery since we last spoke?

Dr. Krikhely: Since last time, we got the newest-generation da Vinci system [for performing robotic surgery]. It’s faster and has 10,000 times the processing power. It has haptic feedback, so it can actually sense touch—you can feel how much force you’re applying to tissue. That’s new.

What I’m really excited about is what’s to come. That computing power means it’s set up to take advantage of AI technologies—software that can help guide safer surgery, provide insights during cases. Almost like having a little AI angel on your shoulder. That’s coming.

How do you see the future of weight loss care evolving over the next five to ten years?

Dr. Krikhely: Obesity is a chronic disease. It’s genetic, behavioral, cultural, environmental. It’s complex. Ideally we’d correct all of those, but that’s very difficult. So we keep expanding services and the way we collaborate with our patients and their goals.

With AI and devices that track habits and activity, perhaps people will have more agency over their health. And I don’t see it as medications vs. surgery. I think the best approach will likely be a combination of both. That gastric bypass long-term outcome was 25 percent weight loss. Maybe combined with medication, we could get to 30–35 percent. The good news is that tools are expanding, now access needs to follow.