Faculty Bibliography

BACKGROUND:Semaglutide and tirzepatide have transformed obesity treatment, but recent changes to bariatric surgery utilization are not well understood. METHODS:Epic's nationwide Cosmos database was queried for patients who underwent primary sleeve gastrectomy or gastric bypass between 2018 and 2025. Patient characteristics including preoperative semaglutide or tirzepatide dispense history were compared using chi-squared and Wilcoxon rank sum tests. Modified Poisson regression was used to identify factors independently associated with pre-surgery GLP-1RA use. Multilevel models were used to examine hospital- and state-level variation in pre-surgery GLP-1RA use. RESULTS:Bariatric surgery utilization increased after Q3 2018, peaked in Q4 2022, and subsequently decreased 39% through Q4 2025. Between Q4 2018 and Q4 2025, the proportion of Hispanic bariatric surgery patients increased (8.1% vs. 16.8%, p < 0.001), and the proportion of patients who received pre-surgery GLP-1RA increased (0.2% vs. 35.3%, p < 0.001). Factors associated with receiving pre-surgery GLP-1RA were year, private insurance, White race, type 2 diabetes (RR 2.94 [2.88-3.00]), older age, sleep apnea, and metabolic dysfunction-associated steatotic liver disease. Factors associated with receiving surgery upfront were Hispanic ethnicity, Black race, and public or no insurance. After adjusting for patient characteristics and year, there was a 15-fold difference in pre-surgery GLP-1RA use between the highest and lowest hospitals (RR 0.19-2.88). CONCLUSIONS:In the Epic Cosmos database, bariatric surgery utilization decreased from 2022 to 2025, and those who underwent bariatric surgery increasingly received GLP-1RA before surgery. Patients who received pre-surgery GLP-1RA were older, White, privately insured, with diabetes and other weight-related comorbidities, while patients who received surgery upfront were Hispanic, Black, and publicly insured. Pre-surgery GLP-1RA use was also driven by center-specific non-clinical factors.

BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is increasingly utilized for treating obesity, but some patients may subsequently present for conversion to a surgical procedure. Foreign material or distorted anatomy may make conversion more challenging. The preoperative evaluation, intraoperative findings, and postoperative outcomes of converting ESG to bariatric surgery are not well described. METHODS:Bariatric surgery patients at a single center with history of ESG were identified by review of electronic medical records from 2016 to 2026. Background characteristics, preoperative imaging, endoscopic findings, intraoperative details, and outcomes were obtained by chart review. Intraoperative videos were obtained when possible. RESULTS:. Most patients (19/20, 95%) underwent preoperative esophagram, which showed a tubularized stomach in half of cases (10/19, 53%) but no radiopaque materials precluding conversion to surgery. Preoperative endoscopy (n = 5) and intraoperative endoscopy (n = 3), when performed, revealed no apparent gastroplasty. Intraoperative findings included mild adhesions around the stomach, with sutures sometimes visible, but an otherwise native stomach not requiring any changes to the staple line. Mean total weight loss was 29.1% at 1 year postoperatively. No stapler misfires occurred, and none of the postoperative complications were related to the gastric staple line. There were no gastric staple line leaks or bleeds. CONCLUSION/CONCLUSIONS:In our experience, sleeve gastrectomy and gastric bypass were both technically feasible and relatively straightforward to perform in patients with a history of ESG.

OBJECTIVE:Directly compare the real-world effectiveness of semaglutide and tirzepatide to bariatric operations: sleeve gastrectomy and gastric bypass. METHODS:This study included adults with BMI ≥ 35 who received injectable semaglutide or tirzepatide (GLP-1RAs) or sleeve gastrectomy or gastric bypass (bariatric surgery) at two urban health systems from 2018 to 2024. Total weight loss (TWL) was compared up to 3 years post treatment with inverse probability weighting and mixed linear models. Intention-to-treat (any GLP-1RA) and per-protocol (1 year of continuous GLP-1RA orders) analyses were performed. RESULTS:Of 44,025 patients studied, bariatric surgery was associated with greater weight loss at 1, 2, and 3 years post treatment: semaglutide (n = 25,804) TWL (95% CI): 5.4% (5.3%-5.6%), 6.5% (6.4%-6.7%), and 7.4% (7.3%-7.6%); tirzepatide (n = 7308): 9.1% (8.9%-9.4%) and 10.8% (10.2%-11.3%); sleeve gastrectomy (n = 8728): 24.4% (24.3%-24.6%), 22.4% (22.3%-22.5%), and 22.0% (21.8%-22.1%); gastric bypass (n = 2185): 29.8% (29.7%-29.9%), 28.1% (28.0%-28.2%), and 28.4% (28.3%-28.5%). With 1 year of continuous GLP-1RA, findings were: semaglutide TWL: 7.2% (7.0%-7.4%), 8.0% (7.8%-8.2%), and 8.8% (8.6%-9.0%); tirzepatide TWL: 11.7% (11.4%-11.9%) and 11.9% (11.5%-12.3%). CONCLUSIONS:In this retrospective two-center study, bariatric surgery was associated with greater weight loss than GLP-1RAs among patients eligible for both options.

OBJECTIVE:We compared health care spending and utilization associated with semaglutide relative to bariatric surgery in patients with obesity and type 2 diabetes (T2D). METHODS:Using MarketScan insurance claims of patients with BMI ≥ 35 and T2D from 2016 to 2021, we examined associations between choice of semaglutide, sleeve gastrectomy, or gastric bypass; 3-year health care spending (out-of-pocket [OOP] and total); and clinical outcomes (ED visits, hospital admissions, and major adverse cardiovascular events [MACE]). Analyses were adjusted using generalized linear models, inverse probability weighting, and instrumental variables. RESULTS:Among 6748 patients (2797 semaglutide, 2300 sleeve gastrectomy, 1651 gastric bypass), bariatric surgery patients had higher BMI and more comorbidities. In IPTW-adjusted analysis, semaglutide was associated with the highest 3-year OOP costs ($7752 vs. $5980 [sleeve gastrectomy] vs. $6591 [gastric bypass], p < 0.001), but total spending was not statistically different across the groups. Relative to semaglutide, the gastric bypass group showed higher observed ED visits (hazard ratio relative to semaglutide [95% CI]: 1.36 [1.28-1.45]) and inpatient admissions (1.25 [1.13-1.37]) and fewer MACE (0.71 [0.59-0.88]). Sleeve gastrectomy was associated with fewer long-term admissions (0.79 [0.72-0.86]) and MACE (0.79 [0.66-0.93]). CONCLUSIONS:For patients with T2D and obesity, compared with semaglutide, bariatric surgery is associated with lower OOP spending and similar total spending at 3 years, as well as lower long-term MACE rates.

BACKGROUND:Extended-course enoxaparin is increasingly used after bariatric surgery to prevent venous thromboembolism (VTE), the leading cause of death after bariatric surgery. Direct oral anticoagulants are widely used for extended thromboprophylaxis outside of bariatric surgery and offered to patients in our program who cannot tolerate or obtain enoxaparin. We evaluated the safety and efficacy of apixaban 2.5 mg twice daily relative to a weight-based dose of enoxaparin 40 mg or 60 mg twice daily for 30 days after discharge following sleeve gastrectomy. METHODS:Patients aged ≥18 years who underwent laparoscopic sleeve gastrectomy from 2019 to 2024 at a single high-volume urban academic center were included. Bleeding and thrombosis outcomes within 30 days were compared between patients receiving enoxaparin 40 mg twice daily or apixaban 2.5 mg twice daily. Weighted modified Poisson analyses were used to obtain covariate balance and assess differences in bleeding and thrombosis events. RESULTS:A total of 5921 patients were included for analysis (5274 enoxaparin 40 mg twice daily, 486 enoxaparin 60 mg twice daily, and 161 apixaban 2.5 mg twice daily). The 30-day thrombosis rate was significantly lower with enoxaparin versus apixaban (.1% versus 1.9%, P < .001). The composite outcome (VTE, portomesenteric venous thrombosis, and major/minor bleeding) was also significantly lower with enoxaparin versus apixaban (1.7% versus 5.6%, P < .01). In adjusted analyses, apixaban was associated with a relative risk of 12.09 for thrombosis (95% confidence interval [CI], 5.71-31.18), 1.93 for bleeding (95% CI, 1.27-3.00), and 2.59 (95% CI, 2.06-3.27) for any adverse outcome relative to enoxaparin. CONCLUSION/CONCLUSIONS:Enoxaparin is associated with both lower thrombosis and bleeding rates compared with apixaban for extended thromboprophylaxis after sleeve gastrectomy.

OBJECTIVE:Given frailty and comorbidities that occur with both aging and end-stage kidney disease (ESKD), it is unclear if older patients with ESKD derive the improved survival and kidney transplant (KT) access associated with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS:Using 2006-2021 USRDS data, we identified 876 patients with RYGB and 1508 patients with SG and compared 5-year mortality by age-group (18-29/30-39/40-49/50-59/60-69/≥ 70 years) to nonsurgical matched controls using 1:3 Mahalanobis distance matching, Kaplan-Meier, and Cox regression. We also compared age-stratified KT incidence between waitlisted patients and controls. RESULTS:) for patients with SG versus controls. CONCLUSIONS:RYGB in older patients with ESKD is associated with increased mortality and lower KT likelihood, whereas SG is associated with decreased mortality and higher KT likelihood compared to nonsurgical matched controls. Choice of bariatric surgery type may play a role in improving survival for older patients with ESKD.

INTRODUCTION/BACKGROUND:Robotic sleeve gastrectomy (RSG) is increasingly used in bariatric surgery, but its safety compared to laparoscopic sleeve gastrectomy (LSG) remains debated. METHODS:We retrospectively reviewed electronic medical records of 927 (575 RSG, 352 LSG) patients at a single academic center from June 2021 to August 2023. The baseline and operative characteristics of the study groups were compared using two-sample t tests, Wilcoxon rank-sum tests, chi-square tests, and Fisher's exact tests. Thirty-day complication rates were compared using multiple logistic regression, adjusted for baseline factors, operative characteristics, ASA class, and staple-line reinforcement. Statistical analysis was conducted using SAS 9.4, and p-values < 0.05 were considered significant. Logistic regression was used to evaluate whether complication rates were different between RSG and LSG while adjusting for other factors. RESULTS:(RSG 43, LSG 43.12, p = 0.806), average age 39.8 (RSG 39.3, LSG 40.7, p = 0.084), and 74% were females (RSG 75%, LSG 69.8%, p = 0.032). Baseline characteristics were comparable between the two groups. Median operative time was 73 min for RSG vs 66 min for LSF (p = 0.0002). Thirty-day complication rates were 3.5% in both groups (adjusted OR = 1.00, 95% CI 0.43-2.35, p = 0.998). Quarterly analysis and CUSUM demonstrated no residual learning-curve effect on complications. Power analysis confirmed ≥ 80% power to detect a ≥ 5% absolute difference. Missing-data sensitivity analyses corroborated primary findings. CONCLUSIONS:RSG is as safe as LSG within 30 days, with a modest 7-min operative-time penalty that is unlikely to be clinically meaningful.

INTRODUCTION/BACKGROUND:GLP-1 receptor agonists (GLP1-RAs) are increasingly prescribed as an alternative to bariatric surgery for weight loss, and may pose as an alternative to conversion Roux-En-Y Gastric Bypass (cRYGB) in patients with insufficient weight loss or weight recurrence after sleeve gastrectomy [A C, N C, A I. Postoperative morbidity and weight loss after revisional bariatric surgery for primary failed restrictive procedure: a systematic review and network meta-analysis. International Journal of Surgery; 2022;Jensen et al. in Obes Surg 33:1017-1025, 2023; Jamal et al. in Obes Surg 34:1324-1332, 2024; Lautenbach A, Wernecke M, Stoll FD, Meyhöfer SM, Meyhöfer S, Aberel J. 1422-P: The potential of semaglutide once-weekly in patients without Type 2 Diabetes with weight regain or insufficient weight loss after bariatric surgery. Diabetes 2022; 71(Supplement_1);]. METHODS AND PROCEDURES/METHODS:Adult patients ≥ 18 years old, who previously underwent a sleeve gastrectomy and were subsequently treated with weekly injectable Semaglutide or Tirzepatide, or treated with conversion from sleeve gastrectomy were included for analysis. Patients converted for GERD, GLP1-RA use with BMI ≤ 35, or pre operative GLP1-RA use were excluded. Post operative weights and Hgb A1C were assessed from 3 months to 3 years post intervention (start of GLP1-RA or surgery). T-test, ANOVA, and chi-squared analysis were used to compare groups, while multivariable linear regression analysis was used to evaluate the effect of bariatric surgery on %TBWL at 3 years post intervention when adjusting for baseline characteristics. RESULTS:4901 patients were included for analysis (3004 cRYGB, 1897 GLP1-RA). There was no difference in pre-intervention weight (242.8 ± 44.4 GLP1-RA vs 242.3 ± 57.8 cRYGB, p = .993). cRYGB patients had a higher baseline Hgba1c (6.19 ± 1.4 vs 5.85 ± 1.2, p < 0.001). cRYGB was associated with significantly greater weight loss at all post operative time points up to 3 years post intervention, (26.1 vs 13.7%, p < 0.001). There was no significant difference in Hgba1c control between treatments at all post intervention time points (all p > 0.05). In the multivariate linear regression analysis, when adjusting for sex, baseline BMI, baseline age, and non-white race, cRYGB was associated with an 11% greater %TBWL compared to those who were treated with a GLP1-RA. CONCLUSIONS:For patients who have had insufficient weight loss or weight recurrence following sleeve gastrectomy, conversion to RYGB offers greater, long-term weight loss compared to GLP1-RAs.

OBJECTIVE:This study examined racial and ethnic differences in percent total weight loss (%TWL) and glycemic improvement following sleeve gastrectomy (SG) and explored the role of socioeconomic and psychosocial factors in postsurgical outcomes. METHODS:This longitudinal study included patients who underwent SG between 2017 and 2020, with follow-up visits over 24 months. RESULTS:Non-Hispanic Black (NHB) participants had lower %TWL at 3, 12, and 24 months compared with Hispanic (H) and non-Hispanic White (NHW) participants. Fat mass index was initially lower in NHB, with smaller reductions over time and significant group differences persisting at 24 months. NHB participants had higher baseline fat-free mass index values; by 24 months, fat-free mass index values were lower in H participants. Hemoglobin A1c decreased across all groups but remained consistently higher in NHB and H compared with NHW at 24 months. NHB participants reported higher perceived discrimination, sleep disturbance, and perceived stress than H and NHW participants at all time points. Employment status predicted %TWL at 12 months. There was a significant interaction between race and ethnicity and employment status observed at 12 and 24 months, suggesting that employment-related disparities could impact surgical outcomes. CONCLUSIONS:NHB participants experienced less favorable outcomes following SG, emphasizing the need for tailored interventions addressing socioeconomic and psychosocial disparities.