Latest / Behind The Knife: The Surgery Podcast / Clinical Challenges in Bariatric Surgery: Integration of Obesity Management Medications (OMMs)
Transcript
- OMM Audio === [00:00:00] Hi everyone. Welcome back to the Bariatric Surgery Team on the Behind the Knife Specialty series. We are welcomed by the incredible panel of bariatric surgeons. Hi, this is Matt Martin, bariatric surgeon at University of Southern California. I'm Adrian D, medical Director of the Bariatric Care Center and Program Director for the advanced G-I-M-I-S Forgotten Bariatric Surgery Fellowship at a place called Summa Health. Northeast Ohio Medical University in Akron, Ohio. And hey, I am Crystal Johnson Mann. I am a big surgeon at the University of Florida, where I'm also our interim medical director for bariatric metabolic surgery. And I am Katie Serone. I'm one of the general surgery residents at the University of Southern California. In the last few years, it's felt like everything and obesity care has shifted. GLP ones are everywhere. Primary care, endocrinology, social media. Increasingly they're showing up in bariatric surgery clinics. Exactly. Katie, we're now seeing patients who are on obesity management medications before surgery, some after surgery, and [00:01:00] sometimes both. And as surgeons, we're being asked to help navigate how these therapies actually fit together with surgery. Yeah. I'm actually waiting for, we're getting intraoperative administration of, of some of these medications, but that's really what this episode is all about. We're not gonna be talking about surgery versus these medications strictly, but surgery, with these medications in combination, how we're using them, pre-op, periop and post-op and also some of the challenges that come along. You know, there was a study that came out earlier this year that really caught my eye, and honestly it surprised me a little bit. It was published in JAMA Surgery and it came outta Allegheny Health. And in this study, this team compared bariatric surgery and GLP one therapy. They did a large retrospective review of over 30,000 patients. About 14,000 underwent metabolic bariatric surgery sleeve, or gastric bypass, and roughly 16,000 were treated with GLP one receptor agonists. The team looked at outcomes and cost [00:02:00] over the course of two years, and it's the cost piece that really stood out. So over two years, the total cost of care was significantly higher in the GLP one group compared to the surgical group. This was mostly driven by increasing emergency room visits and hospitalizations. The weight loss wasn't even close. The surgery group had an average total body weight loss of about 28% compared to roughly 10% in the GLP one group. Yeah, and I think that this really challenges some of the narrative we're hearing right now. That these medications are the cheaper and easier long-term solution. And I think clearly they're not the cheaper solution. And I think this just reinforces bariatric surgery is still the most durable treatment we have right now. While also raising some important questions about how these medications can be used with surgery rather than instead of it, yeah, I think surgery still reigns supreme as the best, most effective durable therapy. And I think it's important to point out that within a clinical trial. You're gonna have different results than you are in the real world. And I think [00:03:00] that's where our good friend George Eid, a bariatric surgeon from Allegheny, showed in this excellent, excellent paper, him and his research team. But before we dive into the pre-op, the periop, the post-op challenges that go along with these medications, I think it's helpful to level, set, and quickly review the main categories of obesity management medications. That we're talking about. Katie, can you walk us through some of these medications? I'll start with the most familiar group, GLP one receptor agonists like semaglutide or liraglutide. These are the ozempic or wegovy. We all know far too well. These work through in incretin mediated appetite suppression and delayed gastric M empty their injectable, have strong data behind them and typically result in about five to 12% total body weight loss. They're especially attractive because of their favorable effects on glycemic control and cardiometabolic risk. And then on the other side, we have the newer dual GIP GLP one [00:04:00] agonist tirzepatide. So these combine two reine pathways, the most effective medications that we have on the market weight loss in the 15 to 22% range. In trials, they also come a weekly injectables, but from an efficacy standpoint, they really change the expectations for weight loss that patients experience. And I think it's important though to remember that these are not the only agents out there. We still have the older agents that are still in use. Sym patho mimetics are one classification, and this is typically phentermine. These work through hypothalamic norepinephrine release to suppress appetite, but weight loss is significantly more modest compared to the GLP ones, usually around three to 7%. And these are FDA approved only for short-term use. But they are oral. They are inexpensive. There are some cardiovascular and neuropsychiatric side effects, though that limit their use. And finally, the combination agents. These target multiple central pathways, bupropion and Naltrexone [00:05:00] tend to work best for reward based or emotional eating with average weight loss at around five to 9%. Ermine and Topiramate combine appetite suppression with enhanced satiety. These tend to be the most effective oral option with weight loss closer to eight to 12%, but at the cost of more neurologic or cognitive side effects. We've recently seen in the last couple of days that even semaglutide will now be available orally. It's FDA approved as of early 2026. These medications clearly work and they're gonna get better, there'll be more access to them, or the routes will be more palatable to the patients, but they work differently. They raise new questions when layered with bariatric surgery. Also, remember, bariatric surgery in and of itself increases your GLP ones. We were GLP one before it was called to be GLP one receptor agonists. So the real conversation begins on how do we integrate them into the practice of metabolic and bariatric surgery. I'll say one thing, those who know me, I actually in 2024, went back [00:06:00] and got my A BOM Obesity Medicine Board certification, and currently I prescribe medications along. With bariatric surgery patients who aren't candidates or patients who have had bariatric surgery, and use these medications to augment what we can offer through surgical therapies. So let's shift into the pre-op phase and talk about how some of these medications intersect with surgical decision making. And I think this is where many of us are encountering some real world challenges, clinical, logistical, and financial. So to start this discussion, let's start with a case. So for this scenario, we have a 42-year-old woman with A BMI of 46 type two diabetes on metformin and basal insulin hypertension and obstructive sleep apnea, who presents for bariatric surgery evaluation. She's motivated, has completed her nutritional and psychological assessments and qualifies for surgery while waiting for insurance authorization. Her PCP starts her on semaglutide over six months, she [00:07:00] loses about 14% of her total body weight. Her BMI drops to 39, insulin is discontinued and her A1C improves to 6.4. So, and this is not an uncommon presentation. And now the question really becomes, this patient is benefiting from the medication. It has had a significant effect, but does that change her candidacy for surgery or our recommendation to proceed with surgery? And this is a scenario we're certainly all seeing more in our clinics. So from a surgical standpoint, how would you frame expectations when meaningful preoperative weight loss occurs with medication, Adrian? Well, it depends in my opinion, on the patient's BMI and the severity of the metabolic dysfunction. You know, I'm very explicit with patients that pharmacotherapy induced weight loss does not replace the long-term durability of metabolic surgery or the effectiveness outside of a clinical trial in the real world that's never been shown. Even when patients lose 10 to 15% of the total body weight, preoperatively surgery still offers [00:08:00] superior and sustained weight reduction. Being able to keep that weight off long term, metabolic disease, remission, diabetes, remission, and even superior survival benefit, particularly in those patients that have obesity and type two diabetes. No, Adrian I, I absolutely agree. I think that for our patient population, preoperative weight loss can be extremely beneficial from a technical standpoint with reduced liver volumes and improved visualization, potentially shorter operative times. But I do feel very strongly that this should not be become a moving target for surgical eligibility. And I think we need to be clear that response to these medications doesn't mean that obesity has resolved or won't recur if the medications are stopped, and it nor does it negate the indication for surgery. In fact, the A-S-M-B-S guidance supports surgery based on disease severity and risk, not on short-term response to therapy. So the question shouldn't be, should she still get surgery, but rather how do we [00:09:00] integrate these therapies to optimize our outcomes? Let's talk about operative planning, particularly with GLP one based therapies. What concerns are you all navigating Adrian and Crystal? The most immediate issue is delayed gastric ketan. We see that when we do endoscopies. We see that with our anesthesia colleagues for general endotracheal anesthesia. We now recognize that GLP one receptor agonists, especially higher doses or dual and incretin agents, can significantly slow gastro ketin. Even in patients who do not have symptoms, but we'll see patients who complain about increased gerd and to some degree, I just don't feel that it's fair for us to point that out as a weakness because that's to some degree how they work, but as a side effect and it's important to keep that in mind. Right. As you mentioned, Adrian, there are some anesthesia concerns here when you're talking about putting people under general. There's increasing awareness of the aspiration risk that goes along with these medications, especially in patients who appear NPO compliant, but [00:10:00] may still have some residual gastric contents. In our practice at our institution, we closely coordinate with anesthesia. For those who are on weekly GLP one or dual agonists, we typically hold the medication for at least one week preoperatively patients that have a lot of symptoms such as nausea, vomiting, or known gastroparesis. Yeah, and we're pretty similar here. But also I think if a patient is reporting a lot of early satiety, bloating, or nausea, that's very close to the operation. Sometimes we might even consider delaying surgery, but obviously that's a highly individualized decision. 'cause you have to balance the risk of proceeding with the risk of delaying surgery. And this is where our protocols, I think, are still evolving until we have more data. This should be an individualized risk assessment and communication with anesthesia. It's definitely essential and also important to consider the pre-op optimization of nutrition. Some of these medications can compromise that With the use of obesity management medications, we must ensure that our patients are maintaining nutritional [00:11:00] adequacy while also losing weight. As you well know, patient centering surgery in the catabolic or protein deficient state may have impaired tissue quality, reduced physiologic reserve, and potentially a greater. Vulnerability to stress responses during surgery. Yeah, and in addition, if they begin the initial post-op phase already, protein depleted, they're certainly at higher risk for sarcopenia, poor wound healing, delayed recovery, or obviously I think all of us would be concerned about it at anastomotic or staple line leak. In these cases, what looks like early post-op PO intolerance might actually be an exacerbation. Either preexisting nutritional compromise or just continued GLP one medication effect. Absolutely, and this is why the adequacy of nutrition has to be protected so that surgery doesn't tip the patient over into overt malnutrition. But let's pivot to what may be the most frustrating part of this scenario. Insurance. [00:12:00] I don't know how insurance is where you all are, but where we are in Florida can be a challenge. Insurance is where the system can become quite irrational. Many payers will approve bariatric surgery for this patient, but then deny coverage for obesity management medications even when those medications are clearly improving the health of the patient. Preoperatively crystal insurance is synonymous with frustration, and it's not just access to care, but also utilization when patients have access to care. So. In many cases when the patient assumes the financial risk of the medication, they're okay with that. But when they have to pay for it, they're not, and they're not okay with surgery if they have to pay for that also. And in some cases, paradoxically, we see an opposite concern where payers are questioning surgical necessity because the patient is actually doing well on medication. And as we mentioned earlier, that is not a reason to delay something that can add durability. [00:13:00] To the weight loss. Despite meeting the criteria of having a chronic relapsing disease, these patients are excluded from having those benefits. That creates a perverse incentive. Surgery is covered as a one-time intervention, but the medical therapy that could optimize patients before and after surgery is often excluded. It's very difficult to make sense out of all that, despite. The fact that we have so much evidence-based reasons to provide these therapies for our patients. Yeah. And we're seeing this play out in California, you know, as of January 1st, they are highly restricting the GLP one access for our Medi-Cal patients, which is our version of Medicaid. So that's gonna be a real issue in the state. Uh, and this fragmentation really undermines a chronic disease model of obesity care. So now we're being forced to choose between therapies that should be complimentary and, and oftentimes might be more effective in [00:14:00] combination. I think the main takeaway from this case is that the integration of omms should start preoperatively with very clear expectations, very clear and coordinated perioperative planning, and continue advocacy for our patients from the payers. Now let's discuss how medication is being integrated after bariatric surgery. I'll start with a case. A 19-year-old woman with severe obesity and insulin resistance undergoes a sleeve gastrectomy. She initially loses 22% of her total body weight over the first year, but then plateaus at 18 months remaining at A BMI of 36. She's adherent to follow up, denies maladaptive eating behaviors, and her sleeve anatomy looks intact on imaging. Given her age and long disease horizon, the team considers adding pharmacotherapy. And this also mirrors what we're doing routinely in our pediatric bariatric program, where these obesity management medications are often considered part of the long-term treatment plan [00:15:00] rather than a rescue therapy. Yeah. We need to normalize the idea that bariatric surgery is not a standalone cure, so to say, that idea of multimodal therapy, that includes surgery, medicine, and behavioral health therapy. Obesity is a chronic, progressive relapsing disease. I'd always love to say that. And obesity management medications are a legitimate adjunct in its treatment, particularly in cases of inadequate weight loss, early plateau and weight regain. And it's important for bariatric surgeons to understand the definitions of inadequate weight loss and weight regain. And there's some great studies out there showing the efficacy of these medications in patients who have had weight regain. In those situations, you could actually lose about two thirds of the weight, again, using obesity management medications. In some cases, patients lost even more than they had lost at their lowest with bariatric surgery. So their legitimacy as an adjunct [00:16:00] is tremendous. Exactly. And we've accepted this model in pediatrics for a long time, and I think the adult practices are starting to come around similarly. Pharmacotherapy is often initiated early after surgery to maximize durability, not just as a rescue therapy in in adults. We typically tended to wait until weight loss stops or until regain occurs, and at this point it just might be too late for a rescue therapy. Practice. The indication is, is not failure rather, but just persistence of disease. So if the patient is plateauing above a healthy weight, medications can help reengage weight loss physiology. But you know, timing can be a challenge. So, you know, mad and Adrian, when do you guys consider starting medications? Postoperatively and my practice, I generally avoid initiating OMS in the immediate postoperative period. Very early on, there's weight loss that is driven by surgical restriction and hormonal changes that occur with [00:17:00] surgery and adding medication too soon. Risks and tolerance and nutritional compromise, it's very important early on to ensure that the patient has plenty of nutritional intake to maintain vitamin levels, et cetera. But once you get to the three month point and you can see that the patient is possibly not doing as well. The weight loss may be inadequate. That's time to pull the trigger to augment potential capabilities of surgery, Matt? Yeah, and I think our, our traditional model had been to delay it, wait until the patient's clearly on a regular diet, they're having adequate nutritional intake, and then their weight loss curve starts to flatten typically around the six to 12 month post-op period. And then consider starting, uh, that being said in select high risk patients. We might initiate these earlier. And certainly in our pediatric practice, we are being very aggressive at initiating these as early as the four to six week postoperative visit. And we do [00:18:00] have some prelim data that we're actually gonna be presenting at A-A-S-M-B-S showing better weight loss and no increase in complications. 'cause that was always our fear. If we start 'em early, we might cause vomiting and anastomotic leak or staple line blowout. And I think the data now says that's probably not a valid concern. Now let's talk pharmacokinetics intolerance. As we know, after sleeve gastrectomy and especially bru wide gastric bypass, drug absorption can be altered, particularly for oral agents. Thus injectable GLP ones can be favorable. However, patient tolerance can be the limiting factor. Yes, absolutely. So nausea and vomiting, of course, are major concerns, especially in patients that have small sleeves or tight pouches. What might be considered a very tolerable dose for them. Preoperatively can be very problematic postoperatively with this change in their anatomy, and so I think this is where lowering the starting doses, slower titration of doses and symptom driven escalation are [00:19:00] essential. If patients can't maintain their hydration or their protein intake, then the medication absolutely needs to be paused. And nutritionally, what should we be watching out for? GLP one receptor agonist specifically, and those similar therapies further suppress appetite in patients who already have a restricted nutritional intake postoperatively. This increases the risk of micronutrient deficiencies, sarcopenia and loss of lean body mass in order particularly vigilant about protein intake Iron B12. Fat soluble vitamins, especially after hypo absorptive procedures. And in patients who have additional problems with postoperative nausea and vomiting, you've gotta be aware of the potential for a vitamin B one thymine deficiency. It's a key nutritional deficiency to keep an eye on. So adding GLP ones to someone who's already having a decreased intake from surgery is something you gotta be very [00:20:00] cautious about. The key is that medication should never compromise nutritional adequacy in any way. If weight loss is accelerated at the expense of protein intake or with a loss of lean body mass, that's really not a success. That's not the way that we want to achieve weight loss. Very good point. And there's also concern that medications may overshadow the critical postoperative period of habit formation. Patients still need to learn portion control, mindful eating. Physical activity. How do you all frame medication integration for your patients? Yeah, you know, so when I talk to people just before surgery in general, I frame it all like that and it's no different when you're having this conversation about medications because it's a support, it's not a substitution. So surgery and medications change, physiology, behavioral change, and what sustains these changes? And so if we use Omms without reinforcing the lifestyle adaptation that is required, we risk [00:21:00] recreating the same sort of dependency cycle that leads to relapse when the therapy is withdrawn. Yeah, so I think the postoperative message is clear. These medications are powerful adjuncts when used appropriately after bariatric surgery, but you have to be very careful using intentional timing, paying careful attention to their nutrition and intake. And continue emphasis on behavioral adaptation. But when integrated thoughtfully, these medications can certainly extend the durability of surgery and the overall health benefit to the patient rather than compete with it. Now we've learned about preoperative and postoperative integration of obesity management medications with bariatric surgery. To close the episode, let's zoom out and discuss the systems, levels, challenges surgeons face. 'cause even when the clinical rationale is clear, implementation is often not. Let's start with insurance, which is often the biggest obstacle. One of the most frustrating inconsistencies is variable coverage for obesity management [00:22:00] medications after surgery. Many payers will cover bariatric surgery as a one-time intervention, but explicitly exclude medication cotherapy once surgery has occurred, and that creates a major problem when we're treating obesity as a chronic progressive disease. We're then expected to manage long-term outcomes, but the tools needed to do that and the best available tools are not consistently accessible to us. This is like a really sore slot for me. I feel like, and this resonates in my soul so much from an advocacy standpoint. Documentation is critical, framing weight loss, or rather weight regain or insufficient weight loss, as did be's. Persistence, not a failure of the surgery is essential. When appealing these denials in the appeals, like our bigger group with our metabolic center sort of esque practice with our obesity medicine colleagues, it's been really helpful to clearly document the indication, plateau or [00:23:00] regain, along with their prior response to surgery, adherence to follow up, and the medical necessity that is consistent with chronic disease management. Insurance aside, integration requires coordination. How is this playing out in practice? But so now there can be a disconnect between bariatric surgery programs and obesity medicine specialists, but as you just heard from Adrian, many bariatric surgeons are getting their boards and becoming obesity medicine specialists, which I think is the ideal. So patients might be prescribed these medications outside of your surgical practice, and sometimes without a good awareness of the altered anatomy or nutritional risk. Uh, and obviously this lack of communication can lead to problems with dosing. Poor tolerance or nutritional compromise. So we really need clear handoffs and shared care models when these are being done by different providers. Exactly. Matt, in our center, we're working on standardized protocols when to refer, when to initiate omms, and [00:24:00] how to monitor patients postoperatively. But adoption is variable across the various institutions and practices. Without standardization, patients receive mixed messages and that undermines trust and the continuity of care. And you know, it's really important to maintain that trust so that we can continue continuity of care from the patient perspective. Patients, sometimes these surgery is an option only if medications fail or conversely they see surgery as a failure if medications are needed postoperatively. That's why language matters. We need to clearly frame Omms as complimentary and not competitive to surgery. I tell patients that surgery can change anatomy and physiology, medications and surgery can modify neurohormonal signaling and behavioral therapy changes in sustains both. There's no single modality that treats obesity in isolation, and that's why I think the idea of [00:25:00] metabolic centers and multimodal therapy. Have to be promoted. Yeah. And, and this is particularly important in the current environment where these medications have hit the popular media. You know, you can't surf the internet now without being assaulted with multiple advertisements to get your easy GOP one access. There's certainly less discussion about integrating these medications with surgery, so patients might not even be aware of that option. Ultimately, we need evidence-based frameworks from standardized trials to guide patient care and help create informed individualized options. Okay, so what do you guys think are some newer medications coming down the pipeline? Well, obviously these are highly effective medications and there's a lot of interest in developing new and better versions. At least as of May, there were over 40 new GLP ones in development. There are several oral GLP ones, one now, which is FDA approved and several others coming on the market. [00:26:00] There's another medication that's a triple agonist for GIP GLP one and Glucagon, and shows about 24% total weight loss in phase two trials, so pretty impressive results. There's also a monoclonal antibody to GLP one and GIP called meritide. This is a once a month injection, so you know, even more convenient versus the weekly or daily injections and they've shown 20% total weight loss in phase two. So a, a lot of medications in the pipeline and that we will be coming on board and I think we can just expect better and better efficacy with these medications. I think, you know, as these sort of medications continue to be developed and come out of the pipeline, I, I think cost. Will be a major discussion with these as well, because there's pockets of the population that can have access to these. So, and then there's pockets that cannot just from sheer lack of affordability. Yeah, and I think it shifts the surgery discussion too, of now surgery is looking like a much, much more cost [00:27:00] effective option if you're just purely looking at cost compared to lifelong therapy with some of these expensive medications. I think it's also important to put in context that these are clinical trials that do not necessarily reproduce the findings and the results that we're gonna see in the real world, but it will also increase the number of people who will look for treatment of their obesity, and with a larger number of people seeking that treatment, there will be a larger number of people who will opt for a permanent, durable, and effective therapy, such as. A bariatric procedure. Now, to wrap things up, what's clear from this conversation? Is it obesity, management medication and bariatric surgery, or not competing therapies? They're complimentary tools in the treatment of a chronic relapsing disease. Yes, KD surgery remains the most effective, the most durable intervention. It continues to reign supreme. And [00:28:00] in terms of the ability to bring obesity and metabolic dysfunction and conditions into remission, there's really nothing that has been shown to be as effective. But we have medications that can play an important role before and after surgery, and that remains a very important point, and they have to be used intentionally and with attention to nutrition and tolerance and the long-term changes in physiology and neurohormonal response. They have to be used together with everything we have in our armamentarium to combat this difficult tore disease. You know, and as surgeons, we're now being asked to think beyond the operation itself. With coordinating care across disciplines, navigating insurance barriers and helping patients understand that needing medication after surgery does not represent failure. Again, this is sort of where the language is important. And I think that's the challenge moving forward in aligning our systems, our messaging, and [00:29:00] our published evidence. So patients are enforced into either or decision scenarios, but instead are offered integrated individualized treatment pathways. And ultimately that's the goal, right? Durable weight loss, most importantly improve metabolic health and care that reflects the complexity of obesity as a chronic disease. So with that, we'll wrap it up. I wanna thank everyone for joining us. I wanna thank my co-moderator, Katie, Adrian, and Crystal, and we'll say it all together and as always, make the day, dominate the day. Make the day. We're the worst.