Refining the Bariatric Journey: A Proposed Neoadjuvant and Adjuvant Framework for GLP-1 Receptor Agonists Inspired by Oncology.
This narrative review proposes a novel conceptual framework for integrating GLP-1 receptor agonists (GLP-1 RAs) into bariatric surgical care, drawing an analogy from oncology's neoadjuvant and adjuvant treatment models. The authors suggest that GLP-1 RAs used before surgery ("neoadjuvant") could reduce perioperative risk—particularly in super-obese patients—by promoting early weight loss and improving dyslipidemia. Used after surgery ("adjuvant"), GLP-1 RAs may address weight regain and sustain metabolic improvements in patients with suboptimal surgical outcomes. The review synthesizes findings from prospective trials, retrospective analyses, and meta-analyses, noting that preoperative GLP-1 RA use appears generally safe but requires monitoring for metabolic adaptation and a potential "ceiling effect" on postoperative results. The authors introduce a proposed "perioperative management ladder" as a structured decision-making tool. Importantly, the framework is described as primarily hypothesis-generating and intended to inform the design of future randomized controlled trials. Key limitations include the review's narrative (non-systematic) methodology, reliance on heterogeneous primary studies, and the absence of original data.
Why this grade: This is a narrative review synthesizing existing literature without original data collection or meta-analytic pooling, making it hypothesis-generating rather than confirmatory evidence for clinical claims.
Purpose of review Bariatric surgery is the most effective intervention for severe obesity, yet challenges such as perioperative risks in super-obesity and long-term weight regain persist. This narrative review proposes a novel multimodal framework for integrating GLP-1 receptor agonists (GLP-1 RAs) into surgical pathways. Drawing a conceptual analogy from oncologic "neoadjuvant" and "adjuvant" treatment models, we explore how pharmacotherapy can optimize surgical safety and reinforce long-term metabolic control. Recent findings Emerging clinical data from prospective trials demonstrate that a short-term "neoadjuvant" course of GLP-1 receptor agonists can significantly enhance early weight loss and dyslipidemia remission without compromising perioperative safety. Conversely, retrospective analyses suggest that while preoperative weight loss is achievable, it requires careful management to mitigate potential early metabolic adaptation and prevent the "ceiling effect" on postoperative outcomes. Regarding postoperative care, recent meta-analyses confirm that adjuvant pharmacotherapy effectively addresses weight regain and sustains metabolic improvements in suboptimal responders, supporting the implementation of a structured perioperative management ladder. Obesity management is shifting from a procedure-centric approach toward a chronic, multimodal disease model. The neoadjuvant/adjuvant paradigm encourages clinicians to leverage pharmacologic tools to enhance surgical efficacy ("downstaging" risk) and prevent disease recurrence. While primarily hypothesis-generating, this framework provides a structured foundation-including a proposed perioperative management ladder-for future randomized controlled trials to establish integrated, multidisciplinary clinical standards.
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