Podcasts · Behind The Knife: The Surgery Podcast

Clinical Challenges in Bariatric Surgery: Integration of Obesity Management Medications (OMMs)

· 32 min · Episode 98 · Bonus

Episode Clinical Challenges in Bariatric Surgery: Integration of Obesity Management Medications (OMMs)

0:00 32:17

What happens when the world of GLP-1s collides with the operating room? Today, we’re diving into the new era of obesity care.

Hosts · Matthew Martin, trauma and bariatric surgeon at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) @docmartin2 · Adrian Dan, bariatric and MIS surgeon, program director for the advanced MIS bariatric and foregut fellowship at Summa Health System (Akron, Ohio) @DrAdrianDan · Crystal Johnson Mann, bariatric and foregut surgeon at the University of Florida (Gainesville, Florida) @crys_noelle_ · Katherine Cironi, general surgery resident at the University of Southern California/Los Angeles General Medical Center (Los Angeles, California) @cironimacaroni

Learning objectives 1. Understand the evolving role of OMMs in bariatric surgical practice · Recognize how widespread GLP-1 and dual-incretin therapies have reshaped patient presentations, expectations, and referral patterns. · Appreciate current evidence comparing surgery to GLP-1 therapy, including the JAMA Surgery study out of Allegheny Health (2025), noting: o Superior weight loss with bariatric surgery (~28% TBWL vs ~10% with GLP-1s) o Higher health-care utilization and cost in GLP-1–treated patients. · Frame OMMs not as alternatives but as complementary tools within a chronic disease model when treating obesity. 2. Review pharmacologic classes and their expected efficacy · Surgeons should be able to articulate the mechanisms, efficacy, and limitations of: o GLP-1 receptor agonists – incretin-based satiety; 5–12% TBWL. o Dual GIP/GLP-1 agonists – most potent agents; 15–22% TBWL. o Sympathomimetics – norepinephrine-driven appetite suppression; 3–7% TBWL. o Combination agents (bupropion-naltrexone, phentermine-topiramate) – 5–12% TBWL depending on regimen. o Emerging therapies – retatrutide, maritide, oral GLP-1s, with promising TBWL in phase 2 trials 3. Apply OMMs strategically in the preoperative phase · Integrate OMMs without compromising surgical eligibility—OMM-related weight loss does not negate the indication for surgery. · Counsel patients that medication response does not equal disease resolution; surgery remains the most durable intervention. · Manage delayed gastric emptying and aspiration risk: o Pause weekly GLP-1 or dual agonists for ≥1 week pre-op (longer if symptomatic). o Collaborate closely with the anesthesia/OR teams · Screen for nutritional depletion before surgery, especially protein deficits exacerbated by appetite suppression. · Navigate insurance barriers that may paradoxically approve surgery but deny medication continuation. 4. Implement postoperative OMMs safely and effectively · Establish criteria for OMM introduction: o Typical initiation at 6–12 months, once the diet stabilizes and the physiologic curve flattens. o Earlier initiation (4–6 weeks) may be appropriate in pediatric or select high-risk populations. · Recognize altered pharmacokinetics after sleeve and bypass: o Injectables may be preferred due to altered absorption of oral agents. · Prevent postoperative nutritional compromise: o Monitor protein intake, hydration, and micronutrient status (including iron, B12, and fat-soluble vitamins). o Titrate doses slowly to minimize nausea/vomiting that can precipitate malnutrition. · Frame OMM use as a tool for disease persistence (plateau/regain), not as a marker of failure. 5. Identify systems-level barriers and the implementation of coordinated care · Understand insurance inconsistencies—coverage for surgery is often not paired with coverage for long-term medical therapy. · Clearly document disease persistence and medical necessity when appealing denials. · Avoid fragmented care: establish shared-care pathways between bariatric surgery, obesity medicine, and primary care. · Use patient-centered language emphasizing complementary therapy, not hierarchy or competition between surgery and medications. 6. Counsel patients ethically and accurately within a chronic…

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