Bariatric Surgeons Consider Sustainability of Bariatric Surgery in GLP-1 Era

The rise of anti-obesity medications (AOMs) has created a sea change in obesity treatment.

Surgeons considered the many questions raised by AOMs in a Sunday Panel Session (PS125) moderated by Yewande Alimi, MD, MHS, FACS, a bariatric surgeon at MedStar Georgetown University Hospital in Washington, DC, and Maria Altieri, MD, MS, FACS, section chief of GI surgery at the University of Pennsylvania in Philadelphia.

The session included two presentations on the biological and pharmacological evidence underpinning AOMs.

First, David Harris, MD, FACS, a bariatric surgeon and biological researcher at the University of Wisconsin-Madison, offered a brief overview of incretins—hormones the intestine releases after a meal to stimulate insulin secretion and regulate blood sugar. The most notable incretin is glucagon-like peptide-1 receptor agonist (GLP-1), the target of semaglutide (Ozempic/Wegovy). The blockbuster AOM tirzepatide (Mounjaro) is a dual agonist of GLP-1 and another incretin, glucose-dependent insulinotropic polypeptide (GIP).

Additionally, Dr. Harris described amylin, a hormone the pancreas secretes with insulin. This is the target of amylcretin, an anorexigenic agent currently under study.

Monique Hassan, MD, MBA, FACS, a bariatric surgeon at Baylor Scott & White in Temple, Texas, later offered insights into pharmaceutical drugs in development. “I’m really excited to talk to you about the future of GLP-1s,” she began.

The evidence is indeed exciting. Recent trials of cagrilintide, an amylin analog drug tested individually and in combination with semaglutide, have found it boosts weight loss beyond what semaglutide alone can achieve. An August 2025 New England Journal of Medicine study showed both drugs led to 20.4% body weight reduction over 68 weeks, versus 14% with cagrilintide alone and 11% with just semaglutide.

Another randomized clinical trial on nondiabetic adults in China tested mazdutide, a dual GLP-1 and glucagon agonist. It found nearly half of participants lost at least 15% of body weight in 32 weeks. 

Trials of orforglipron, an oral GLP-1 agonist in a once-daily dose, and MET-097i, a GLP-1 agonist formulated for monthly injection, have shown competitive tolerability and weight loss. Summarizing, Dr. Hassan predicted multiple GLP-1 oral formulations would be available starting in 2027 and ultralong-acting injectables by 2030.

“To manage our patients, we have to get comfortable with these medications,” she said. 

Other speakers emphasized the complexities AOMs have introduced into surgical practice. 

Tammy Lyn Kindel, MD, PhD, FACS, medical director of the Bariatric Surgery Program at Froedtert Hospital and the Medical College of Wisconsin in Milwaukee, presented on perioperative considerations for patients taking AOMs.

Because GLP-1 drugs slow gastric emptying, they heighten concerns about aspiration during surgery, even in patients who fast. The American Society of Anesthesiologists offered guidance in 2023 that GLP-1 drugs should be stopped before surgery for a day in patients taking daily doses, or a week, if taken weekly.

This has led to surgeries canceled, as well as concerns about care for diabetic patients and others for whom stopping AOMs presents additional healthcare needs. In 2024, the American Gastroenterological Association advised proceeding with surgery in patients without digestive symptoms and to otherwise use ultrasonography, rapid sequence intubation, and/or a 24-hour liquid diet before surgery to reduce risk.

Dr. Kindel shared evidence that residual gastric contents (RGC) are 16.5 times more likely in patients with both semaglutide use and digestive symptoms, versus patients with neither condition. However, she noted, those with digestive symptoms alone have 4.65 times the likelihood of RGC—and they undergo surgery without specific precautions. She also presented multiple studies that confirmed RGC issues but could not determine a time range to hold AOMs until surgery was safe.

Ultimately, Dr. Kindel said, multisociety consensus guidance has specified that “cancelation is the very last consideration if there is high risk.”

She concluded with pharmacokinetic data suggesting that 1-day or 1-week holds are not sufficient to alter drug concentration in the body. “If you’re going to do the society guidance, you might as well just give them, because we’re not getting the drugs out of the system anyway,” she said.

In his presentation, Shanu Kothari, MD, FACS, FASMBS, the Jean & H. Harlan Stone Chair of Surgery at Prisma Health in Greenville, South Carolina, addressed an issue on many bariatric surgeons’ minds: the purported reduction in bariatric procedures with the rise of AOMs.

He noted that the Bariatric Surgery Department at Norman Regional Hospital in Oklahoma, shut down in summer 2024, citing declining profitability after AOM introduction. He further suggested the reduced need for many non-bariatric surgeries may also affect hospital revenue.

However, he shared multiple studies that have found that surgical treatment is superior to AOM-only care in weight loss, long-term mortality, cost, and other outcomes. 

“We need to embrace this cancer model,” he said, meaning an approach based on multimodal care involving surgery preceded and/or followed by medication. “We know it’s a chronic disease, and we need to treat it as such.”

In closing, Dr. Kothari predicted that, as the cost of widespread AOM use proved prohibitive, “the scales will rebalance” toward surgery.

Concurring, Dr. Harris referred to his research work and added, “From someone whose side gig is trying to put us all out of business in bariatric surgery—we’re nowhere close.”