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

Behind The Knife: The Surgery Podcast

Education, Science, Health & Fitness, Medicine

4.8 • 1.4K Ratings

🗓️ 5 February 2026

⏱️ 32 minutes

🔗️ Recording | iTunes | RSS

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Summary

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 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.

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Transcript

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0:00.0	Behind the Knife, the Surgery Podcast, relevant We are officially looking for our next class of BTK fellows. We need creative residents heading into their researchers who are ready to build the next generation of surgical education content. You'll get mentorship,
0:38.5	access to great resources, and a global platform to display your work. Applications open in
0:44.6	early spring with more information to follow. Dominate the day. Hi everyone. Welcome back to the
0:50.5	bariatric surgery team on the Behind the Knife specialty series. We are welcome by the incredible panel of bariatric surgeons.
0:57.0	Hi, this is Matt Martin, bariatric surgeon at University of Southern California.
1:02.0	I'm Adrian D. Medical Director of the Bariatric Care Center and program director for the Advanced GIMIS Forgotten
1:09.0	Bariatric Surgery Fellowship at a place called
1:11.7	Summa Health, Northeast Ohio Medical University in Akron, Ohio.
1:15.9	And hey, I'm Crystal Johnson, man. I am a big surgeon at the University of Florida,
1:20.0	where I'm also our interim medical director for bariatric medical surgery.
1:24.4	And I am Katie Serenium, one of the general surgery residents at the University of Southern California.
1:29.6	In the last few years, it's felt like everything in obesity care has shifted.
1:33.9	GLP ones are everywhere. Primary care, endorphinology, social media, and increasingly they're showing up in bariatric
1:40.6	surgery clinics.
1:41.9	Exactly, Katie. We're now seeing patients who are on obesity
1:45.0	management medications before surgery, some after surgery, and sometimes both. And as surgeons,
1:51.1	we're being asked to help navigate how these therapies actually fit together with surgery.
1:56.3	Yeah, I'm actually waiting for, we're getting intraoperative admission of some of these medications.
2:01.8	But that's really what this episode is all about.
2:04.4	We're not going to be talking about surgery versus these medications strictly,
2:08.5	but surgery with these medications in combination, how we're using them pre-op,
2:13.3	pariop, and post-op, and also some of the challenges that come along.
	...

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