Behind The Knife: The Surgery Podcast

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 objectives1.          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 trials3.          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 disease model·       Set expectations: sustained success requires surgery + medication + behavioral change.·       Educate patients that postoperative OMM use does not imply surgical failure.·       Normalize long-term multimodal management of obesity, analogous to diabetes or hypertension models. *Sponsor Disclaimer: Visit goremedical.com/btkpod to learn more about GORE® SYNECOR Biomaterial, including supporting references and disclaimers for the presented content.  Refer to Instructions for Use at eifu.goremedical.com for a complete description of all applicable indications, warnings, precautions and contraindications for the markets where this product is available. 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