GLP1s and Bariatric Surgery with Dr. Dan Azagury

With the advent of GLP1s like Ozempic, aren’t Bariatric Surgeons out of a job?

We take a deep dive into obesity treatments with Dr. Dan Azagury, an Associate Professor in the Division of General Surgery and Chief of Minimally Invasive and Bariatric Surgery at Stanford University's Department of Surgery. We discuss topics such as how GLP1s were discovered and the benefits and risks of GLP-1 agonists. We also touch on the importance of holistic treatment for obesity and how medication and surgery are just two of the mechanisms for weight loss in their arsenal.

To close out the show, Dr. Azagury shares his admiration for Dr. Claude LeCoultre, who was Head of the Department of Pediatric Surgery at the University of Geneva from 1991 to 2004, and—of course—the best advice he’s received in 10 words or less.

You can learn more about Stanford Medical Weight Loss program here.

Rachel Baker: [00:00:00] Welcome to Scrub Cast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Dan Azaguri. Welcome to the show. 

Dr. Dan Azagury: Thank you, Rachel. It's great to be here.

Rachel Baker: It's a pleasure having you here. Dr. Azaguri is an Associate Professor in the Division of General Surgery and Chief of Minimally Invasive and Bariatric Surgery.

I've always thought that was kind of an odd marriage. Why do MIS and bariatric surgery go together?

Dr. Dan Azagury: This is just historical. It started with MIS, with laparoscopy, and it was initially a technique that was used by a small group of people, and as it became mainstream, it sort of engulfed these different groups.

Surgeries or groups of surgeries that includes bariatric surgery, what we call foregut surgery. So gastric and esophageal surgeries [00:01:00] and what we call abdominal wall surgery. So there are these subgroups within MIS. It could be called just MIS, but bariatric has for a long time been a pretty large component in terms of surgical volume of an MIS section.

Rachel Baker: Okay. Well, do you prefer one or the other? 

Dr. Dan Azagury: A lot of my practice is bariatrics. So I am deeply passionate about it. And it's, that's really a lot of my day to day. So I will have, if I, I will have to say bariatrics is my, my preference, but I love foregut. I love MIS in general, obviously.

Rachel Baker: Well, so it's, it's good that you have something to fall back on because now that we have Ozempic, you're, you're basically out of a job, right?

Dr. Dan Azagury: I, I think it's the contrary. Uh, I think sort of middle, long term Ozempic is actually going to help patients get the help they need. I [00:02:00] think it's a doorway into finally getting obesity to be treated as a medical condition and patients coming to physicians to get it treated rather than trying to deal with it alone at home with advice and potentially Weight Watchers at best

Rachel Baker: for sure. So I do wanna know more about these medications that have become so popular over the last several months, uh, especially since my mom actually, who's a type two diabetic, was just prescribed it. And my incredibly scientific research into the search engine known as Google tells me that Ozempic is one of a group of drugs called glucagon, like peptide one agonist or GLP one.

Dr. Dan Azagury:  Yes. If you think about how you would design the human body, you would probably put somewhere in your gut, in your stomach, some sort of receptor that would tell your brain, that's [00:03:00] it, you know, I'm full. And that's what GLP 1 is, essentially. It's a, it's a gut based hormone that comes out of your gut when it detects that.

It has seen enough nutrients and has a series of actions. It stimulates your pancreas to say, Hey, we have work to do here. There's there's food around. Let's get going. And then it tells your brain, Hey, you can stop filling up the tank. You're no longer hungry. And the interesting part about that, that not a lot of people know is that.

These hormones were actually discovered because of bariatric surgery. The story behind that is, when we first started doing, uh, Roux en Y gastric bypass, which is one of the most common weight loss operations, what we noticed, and by we is the medical community, unfortunately not me, it was people a lot smarter than me who noticed that, people who were type 2 diabetics, Would stop being diabetic in a matter of days [00:04:00] after the surgery.

Crazy. That is crazy. And you obviously haven't had time to lose a very significant amount of weight in the Right, yeah. Those very smart people started looking into why that could be and that's that's how GLP 1 was actually discovered. And so the pharma industry obviously looked at that and said a diabetes drug.

Let's do it. So you can't really do GLP 1 itself. You know, it would last a very short amount of time in your system. So they Created these receptor, I can, GLP 1 RAs is the name of these drugs. So they go to the receptor and they tell the receptor as if there were GLP 1 around and they stimulate the receptor and led to a successful diabetes, type 2 diabetes drug.

And then that's where the, it goes full circle. Then they realized, oh when we give the drug, [00:05:00] it actually leads to weight loss. Right. Which happens after the gastric bypass, obviously. Uh, now we can, you know, potentially use it as a weight loss drug.

Rachel Baker: Very cool. Let's say my New Year's resolution was to lose 20 pounds. Can I go on a GLP 1 for, you know, a few months and get back into my bikini bod?

Dr. Dan Azagury: You can. Now, you shouldn't, but you can. Okay. So, yes, if you want to lose 20 pounds and take the drug, it will work. Now, There are a series of reasons why you shouldn't. Okay. Number one is we have an agency called the FDA and their job is to decide when it's safe to use a drug.

And so to do that, they measure two things, the risks and the benefits. And so they established a, what's called an indication for use based on those risks and benefits, meaning that the goal is to have enough benefits to [00:06:00] outweigh the risks. So all drugs have risks, have side effects. If you're taking it for a lower benefit, it might not outweigh the risks anymore.

So if you're doing it to get into your bikini, the health benefit from that is Questionable at best. I'm sure there's some positive psychological outcomes, but unlikely to yield very significant health outcomes. You know, your, your blood pressure is probably not going to improve. Uh, your diabetes is probably not going to improve.

If you don't have them to, to start with. So that's the first reason. It's that it has been studied for a certain indication and that indication is patients who have a BMI that's greater than 30, which is the definition of having obesity, or a BMI greater than 27. And you have health conditions related to that.

For example, you have high blood pressure or diabetes [00:07:00] or hypercholesterolemia or one of these other medical conditions that is likely related to obesity and therefore is likely to improve when you treat obesity. The second reason is, at least at this point in time, if you start a GLP 1, you have to be okay with the idea of staying on it for the rest of your life.

Oh. Doesn't mean that everybody will, but majority of people who stop the drug regain weight. Got it. So, you have to be okay with the idea that if it works and you're doing great, you might need to stay on it forever to keep having those benefits. Again, it won't, it won't be the case for everybody, but if you plan to take it for You know, a couple of months and then stop it abruptly.

The chances of a weight rebound are really [00:08:00] significant. Uh, and you might even regain more weight than you've lost. So

Rachel Baker: I guess that brings us back to how you're still employed, right? You, if you're looking for a more permanent solution, then I guess, you know, jabbing yourself with the injection once a week.

Bariatric surgery is still a great option for these patients.

Dr. Dan Azagury: Yes. And so there are a couple of reasons why I think I'm going to stay employed for a while. One of the reasons I still have the job is I'm deeply convinced that our goal is really to treat obesity independently of the mechanisms that we use.

Um, and I, I heard a talk when I was a resident from a foregut surgeon who did anti reflux surgery for people with acid reflux and his entire sort of talk was about the fact that He was the perfect person [00:09:00] to treat the condition because he could use all of the techniques that were available for patients.

So one of the ways is a drug. It's omeprazole and that family of drugs that a lot of people use. And for some people, it works great. And then there's endoscopic therapies where you go through the mouth and do endoscopic. And then there are surgical treatments like in this infarct application where you wrap the stomach to create a valve.

And so he was explaining that, you know, if you go to your PCP or even a gastroenterologist, they don't offer the full gamut of treatments. But he can tailor the treatment to each patient based on history, their preference. And all those things. So I think it's the same for, for weight loss. And so when I started as, uh, Section Chief, one of the first people I hired, uh, after hiring a fantastic surgeon, Michaela Escobel, I hired, uh, Michelle Hauser.

Mm hmm. Yes. And [00:10:00] she is non surgeon. We hired her into a Department of Surgery to really sort of develop our medical weight loss program and we've been working to create a truly holistic clinic on on our weight management side so that when patients come in they come in Saying, I have this medical condition and I'm looking for treatment.

And I think that's the segue to why I'm still employed is there are a number of reasons why one treatment might not be ideal or sufficient. So I can give you many examples but let's start with patients with a higher BMI. So a higher weight to start with. All of these therapies have inherently what we call a plateau.

We're designed as a species what's going to kill us is Starvation, as a species. We're not designed to fight over eating, or over abundance. We're designed to fight starvation [00:11:00] and lack

Rachel Baker: of food. Fighting centuries of evolution

Dr. Dan Azagury: here. That is not going to go away in a few decades or a century. So what our body is going to do is it's going to fight the weight loss and at some point the body is going to win and the weight loss is going to stop.

And if you start at a weight that is high enough that weight loss will be great, you'll start feeling better, you'll have Improvements in your blood pressure, your, your other medical conditions pretty quickly. You start to see improvements after you lose about 5 percent of your weight. So you don't need to lose a whole lot of weight to start to see health improvements.

But at some point, you will get to a plateau. And there are different ways to break the plateau. We can add drugs, we can do different things. An option is to then go to surgery. And that will lead to much more significant weight loss. In a sort of a second step to get you where you want to go in terms of weight loss.

So that's [00:12:00] one option. The other option is not everybody tolerates the drugs. Um, there's some side effects. There's a significant cost to them. And, um, we're actually working on a paper to compare the cost of weight loss surgery versus Drugs, and it's pretty clear that after a non very long amount of time, weight loss surgery is actually more cost effective as a treatment.

Makes sense. And for a patient, the out of pocket costs, even if it's covered by their insurance, the out of pocket costs are correct. Um, and just like we've seen, for example, for Um, Epizole patients say, well, yes, it's working, but I don't want to stay on a medication forever. Right? And I want to get off the medication.

And so weight loss surgery is a great tool to be able to solidify the, the weight loss and get off the drugs.

Rachel Baker: So let's talk about some of those side effects and risks, because my mom was reading me the back of this, [00:13:00] uh, the box and she's like, Um, there's a lot of stuff on here like nausea and vomiting, and I'm like, it sounds like they're giving you gastroparesis here.

Like, is that? Yes. Doesn't seem like a good idea, but I mean, so this is what we're talking about, the health risk versus benefit.

Dr. Dan Azagury: Correct. There are some side effects, uh, and yes, it's a gut hormone. So it's going to kind of wreak a little bit of havoc in your gut and the way that your gut reacts is by, uh, pushing things out one way or another.

So it's nausea, vomiting. Diarrhea, potentially constipation, uh, so it can be one or the other, and those are pretty frequent. Now, most of the time, these side effects tend to be temporary, and so there's a certain way that these drugs are prescribed. Like most drugs, you'll, you know, for blood pressure, here's a 10 milligram dose, and you start at 10 milligrams, and that should be it.

Here, you start at a low dose, and [00:14:00] you stay on that dose for a month, and then You have sort of an escalation dose.

Rachel Baker: So it's like the opposite of a steroid taper? 

Dr. Dan Azagury: Exactly. It's the exact opposite. It's a, it's a reverse taper, uh, over, uh, and you do it a month at a time to be able to go through sort of those side effects in a way that's not too bothersome.

And so your body sort of gets used to it, and so the side effects tend to go away. And that's a great segue back to the prior question. Some people will never tolerate the side effects and get off the drugs because it just doesn't, it's too Just not for you. Too much. That's another reason to consider surgery, but most patients I will say have these side effects Or a period of time and then it gets better and some of them obviously don't have any side effects I'm like we're minimal and very short lived.

Rachel Baker: Got it. All right. Well, so I want to move on to some other topics But there was one other thing about GLP ones that came across my desk in the past few months And that was this new protocol for [00:15:00] performing surgery on patients who are taking one of these medications Yes, what was that all

Dr. Dan Azagury: about? So that's the gastroparesis so because it does essentially have that effect of Slowing down your gastric emptying.

One of the things that anesthesiologists are worried about is when they intubate you. So when they put a breathing tube. There is, during that period of time, those few seconds where you're completely relaxed, that your muscles and your airway is no longer able to protect. If something were to come back up from your stomach, it might go into your lungs.

And so, if your stomach is Not emptying quickly, and they tell you, well, don't eat or drink anything for 12 hours, but your stomach takes 24 hours to clear things, your stomach might still be full of food, and it might lead to having things go into your lungs, which is obviously a big issue if you're undergoing surgery.

So that is why they, these new protocols are in saying, if you are on the GLP 1 and you're going to [00:16:00] have surgery, stop your GLP 1 agonist a week before the surgery. And so, um, that's what we do, and it's, uh, relatively straightforward. We tell our patients to not do the injection that we require.

Rachel Baker: So on the show, we ask each of our guests the same two questions. The first one is, who is a surgeon you admire and why? 

Dr. Dan Azagury: So I think, you know, many of us tend to have these, you know, be influenced by the early encounters in our, in our career. So I think I'm not very different in that. One of the surgeons I truly admire is one of the first surgeons I worked with. As a medical student, I started doing these summer jobs and I worked in the I was cleaning the floor in the, uh, in the OR and the, on the pediatric, uh, surgery side.

And that sort of, I, my passion [00:17:00] for surgery and, uh, decided to become a pediatric surgeon. And, uh, so one of the surgeons I admire is the chief of pediatric surgery. And she was just this incredibly dedicated, one of the most technically skilled surgeons I've ever met. Just fully dedicated to her craft to the kids and was also extremely humble.

All of her achievements were just, it was just, she would just do things and she achieved all these things and she never had to show or brag about anything because she would just, the actions was just speak for themselves. And, you know, she became a doc in the 60s, a surgeon in the 70s. A pediatric surgeon at the time where, you know, I don't know how many female pediatric surgeons there were in the world at that time.

She started pediatric transplant in, in Geneva. Uh, so just [00:18:00] an incredible, incredible surgeon who also did a lot of set up all this program to bring in kids from lower income countries to have more significant surgeries. So just a, somebody who was. Essentially a visionary, but without sort of the all the PR that goes around it.

So yeah Professor Claude Lecoultre is her name

Rachel Baker: Okay, I'm gonna have to get the spelling for for the description

Dr. Dan Azagury: That's a big imprint on me

Rachel Baker: Fantastic. Well, our second question is what is the best advice you have received in 10 words or less?

Dr. Dan Azagury: easy: Your kids will never read your CV

Rachel Baker: Okay, I believe that. It's probably a fascinating read.

Dr. Dan Azagury: So, especially, you know, the Stanford formatted CV that is, you know, [00:19:00] 220 pages long. Many of us in this field focus a lot on on our work and our job and our patients and spend a lot of time here. But it's a good reminder to have, you know, what are the things that will truly have an impact on on your life and who you have an impact on.

And being there for. One of your kids events, be it what it may be, they will remember that a lot more than, you know, this extra thing that you did at work, uh, that day, so.

Rachel Baker: It's good to keep perspective. Well, it has been such a pleasure chatting with you. Uh, before I go, um, I want to ask one last question, and that is, what is next for Dr. Dan Azagury?

Dr. Dan Azagury: What is next? So, what is next? Uh, I think there's some exciting prospects, hopefully, to, uh, recruit some people into our section. And really Hiring's always fun. Yes. Our fellowship [00:20:00] is doing really well. We've expanded the fellowship, and I think we're providing fellows a fantastic experience.

And so, the next focus is really to try to put a bigger emphasis on our section's research. And our ability to have a bigger impact in the field and recruit, hopefully, some folks to do that within the section. 

Rachel Baker: Thank you so much for coming on the show. It was really great talking to you today.

Dr. Dan Azagury: It was great to be here, Rachel. Thank you so much for having me. It was really a pleasure talking to you. 

Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts. Scrubcast is a production of Stanford University's Department of Surgery.

Today's episode was produced by Rachel Baker. The music is by Midnight Rounds. And our chair is Dr. Mary Hawn.[00:21:00]