Episode Details

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 persiste