Bridging strategy inspired by oncology: a novel pharmaco-surgical combination paradigm in obesity management_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

Mulusa Fumpa ^1,2 , HOU Dongsheng ^1,2 , SONG Xiaohai ^1,2 , DU Qiang ^1,2 , WAN Qianyi ^1,2 , ZHAO Rui ^1,2 , ZHANG Guixiang ¹ ,  CHEN Yi ^1,2

1. Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. West China School of Medicine, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

CHEN Yi, Email: toddy@scu.edu.cn

Keywords：

bariatric surgery; glucagon-like peptide-1; obesity; combination therapy

DOI：

10.7507/1007-9424.202506035

Video：

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Abstract Full text Figures/Tables Video References Cited by

Both bariatric surgery and pharmacotherapy, particularly glucagon-like peptide-1 receptor agonist (GLP-1RA), are effective interventions for obesity, yet each has its own advantages and limitations. Drawing on the “bridging” concept from cancer therapy, this commentary explores an innovative obesity management strategy that involves the combined application of GLP-1RA and bariatric surgery during the perioperative period, with the aim of optimizing treatment outcomes. The present analysis focuses specifically on the potential value of this approach: preoperatively, GLP-1RAs serve as a “bridging therapy” to promote weight loss and reduce surgical risks in severely obese patients; postoperatively, they might be used to manage weight rebound or insufficient weight loss. This multimodal integrated strategy is designed to overcome the inherent limitations of single therapies and offer patients more comprehensive treatment options. Emphasizing that future research must urgently focus on optimizing treatment parameters (e.g., timing, dosage), evaluating long-term safety and efficacy, and establishing patient selection criteria for combination therapy. Integrating surgical and pharmacological treatments, this comprehensive strategy based on the oncological “bridging” concept represents a highly promising paradigm shift in obesity management.

1.	NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3 663 population-representative studies with 222 million children, adolescents, and adults. Lancet, 2024, 403(10431): 1027-1050.
2.	Tsai AG, Remmert JE, Butryn ML, et al. Treatment of obesity in primary care. Med Clin North Am, 2018, 102(1): 35-47.
3.	Vitiello A, Angrisani L, Santonicola A, et al. Bariatric surgery versus lifestyle intervention in class Ⅰobesity: 7-10-year results of a retrospective study. World J Surg, 2019, 43(3): 758-762.
4.	O’Brien PE, Hindle A, Brennan L, et al. Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year outcomes after adjustable gastric banding. Obes Surg, 2019, 29(1): 3-14.
5.	Schulman AR, Thompson CC. Complications of bariatric surgery: what you can expect to see in your GI practice. Am J Gastroenterol, 2017, 112(11): 1640-1655.
6.	Athanasiadis DI, Martin A, Kapsampelis P, et al. Factors associated with weight regain post-bariatric surgery: a systematic review. Surg Endosc, 2021, 35(8): 4069-4084.
7.	Popoviciu MS, Păduraru L, Yahya G, et al. Emerging role of GLP-1 agonists in obesity: a comprehensive review of randomised controlled trials. Int J Mol Sci, 2023, 24(13): 10449. doi: 10.3390/ijms241310449.
8.	Ilanga M, Heard JC, McClintic J, et al. Use of GLP-1 agonists in high risk patients prior to bariatric surgery: a cohort study. Surg Endosc, 2023, 37(12): 9509-9513.
9.	Iglesias P, Civantos S, Vega B, et al. Clinical effectiveness of exenatide in diabetic patients waiting for bariatric surgery. Obes Surg, 2015, 25(3): 575-578.
10.	Docimo S, Shah J, Warren G, et al. A cost comparison of GLP-1 receptor agonists and bariatric surgery: what is the break even point?. Surg Endosc, 2024, 38(11): 6560-6565.
11.	Shetty R, Basheer FT, Poojari PG, et al. Adverse drug reactions of GLP-1 agonists: a systematic review of case reports. Diabetes Metab Syndr, 2022, 16(3): 102427. doi: 10.1016/j.dsx.2022.102427.
12.	Bezin J, Gouverneur A, Pénichon M, et al. GLP-1 receptor agonists and the risk of thyroid cancer. Diabetes Care, 2023, 46(2): 384-390.
13.	Drucker DJ. Efficacy and safety of GLP-1 medicines for type 2 diabetes and obesity. Diabetes Care, 2024, 47(11): 1873-1888.
14.	Klair N, Patel U, Saxena A, et al. What is best for weight loss? A comparative review of the safety and efficacy of bariatric surgery versus glucagon-like peptide-1 analogue. Cureus, 2023, 15(9): e46197. doi: 10.7759/cureus.46197.
15.	Wolff Sagy Y, Lavie G, Ramot N, et al. Effectiveness of bariatric metabolic surgery versus glucagon-like peptide-1 receptor agonists for prevention of congestive heart failure. Nat Med, 2024, 30(8): 2337-2342.
16.	Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism, 2018, 79: 97-107.
17.	De Luca M, Shikora S, Eisenberg D, et al. Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS). Obes Surg, 2024, 34(11): 3963-4096.
18.	Widjaja J, Chu Y, Yang J, et al. Can we abandon foregut exclusion for an ideal and safe metabolic surgery?. Front Endocrinol (Lausanne), 2022, 13: 1014901. doi: 10.3389/fendo.2022.1014901.
19.	Fouse T, Brethauer S. Resolution of comorbidities and impact on longevity following bariatric and metabolic surgery. Surg Clin North Am, 2016, 96(4): 717-732.
20.	Schwartz ML, Drew RL, Chazin-Caldie M. Laparoscopic Roux-en-Y gastric bypass: preoperative determinants of prolonged operative times, conversion to open gastric bypasses, and postoperative complications. Obes Surg, 2003, 13(5): 734-738.
21.	Iannelli A, Treacy P, Sebastianelli L, et al. Perioperative complications of sleeve gastrectomy: review of the literature. J Minim Access Surg, 2019, 15(1): 1-7.
22.	Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures—2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity Society, American Society for metabolic & bariatric surgery, obesity medicine association, and American Society of Anesthesiologists—executive summary. Endocr Pract, 2019, 25(12): 1346-1359.
23.	Jumbe S, Hamlet C, Meyrick J. Psychological aspects of bariatric surgery as a treatment for obesity. Curr Obes Rep, 2017, 6(1): 71-78.
24.	Drucker DJ. GLP-1 physiology informs the pharmacotherapy of obesity. Mol Metab, 2022, 57: 101351. doi: 10.1016/j.molmet.2021.101351.
25.	Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med, 2022, 387(3): 205-216.
26.	Frías JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes. N Engl J Med, 2021, 385(6): 503-515.
27.	Emanuel EJ, Dellgren JL, McCoy MS, et al. Fair allocation of GLP-1 and dual GLP-1-GIP receptor agonists. N Engl J Med, 2024, 390(20): 1839-1842.
28.	Aronne LJ, Sattar N, Horn DB, et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 randomized clinical trial. JAMA, 2024, 331(1): 38-48.
29.	Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab, 2022, 24(8): 1553-1564.
30.	Santo MA, Riccioppo D, Pajecki D, et al. Preoperative weight loss in super-obese patients: study of the rate of weight loss and its effects on surgical morbidity. Clinics (Sao Paulo), 2014, 69(12): 828-834.
31.	van Wissen J, Bakker N, Doodeman HJ, et al. Preoperative methods to reduce liver volume in bariatric surgery: a systematic review. Obes Surg, 2016, 26(2): 251-256.
32.	36 Salman MA, Qassem MG, Aboul-Enein MS, et al. Effect of preoperative diet regimen on liver size before laparoscopic sleeve gastrectomy in morbidly obese patients. Surg Endosc, 2022, 36(5): 2981-2986.
33.	37 Spurzem GJ, Broderick RC, Ruiz-Cota P, et al. GLP-1 receptor agonists are a transformative prehabilitation tool for weight loss in obese patients undergoing elective hernia repair. Surg Endosc, 2025, 39(1): 440-447.
34.	38 Martines G, Giove C, Carlucci B, et al. Effect of preoperative liraglutide 3. 0 mg on incidence of intraoperative adhesions in laparoscopic sleeve gastrectomy. Surg Endosc, 2024, 38(12): 7152-7157.
35.	El Ansari W, Elhag W. Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps—a scoping review. Obes Surg, 2021, 31(4): 1755-1766.
36.	Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the longitudinal assessment of bariatric surgery (LABS) study. JAMA Surg, 2018, 153(5): 427-434.
37.	Franken RJ, Sluiter NR, Franken J, et al. Treatment options for weight regain or insufficient weight loss after sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg, 2022, 32(6): 2035-2046.
38.	Esparham A, Mehri A, Dalili A, et al. Safety and efficacy of glucagon-like peptide-1 (GLP-1) receptor agonists in patients with weight regain or insufficient weight loss after metabolic bariatric surgery: a systematic review and meta-analysis. Obes Rev, 2024, 25(11): e13811. doi: 10.1111/obr.13811.
39.	Aronne LJ, Horn DB, le Roux CW, et al. Tirzepatide as compared with semaglutide for the treatment of obesity. N Engl J Med, 2025, 393(1): 26-36.
40.	Jastreboff AM, Kaplan LM, Frías JP, et al. Triple-hormone-receptor agonist retatrutide for obesity—a phase 2 trial. N Engl J Med, 2023, 389(6): 514-526.
41.	Ji L, Jiang H, Bi Y, et al. Once-weekly mazdutide in Chinese adults with obesity or overweight. N Engl J Med, 2025, 392(22): 2215-2225.
42.	Garvey WT, Blüher M, Osorto Contreras CK, et al. Coadministered cagrilintide and semaglutide in adults with overweight or obesity. N Engl J Med, 2025, 393(7): 635-647.
43.	Mounjaro® (tirzepatide) pricing/list-price information (manufacturer pricing page). Eli Lilly and Company. [online pricing info]. Accessed 2025.
44.	Sánchez-Pernaute A, Rubio MÁ, Conde M, et al. Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy. Surg Obes Relat Dis, 2015, 11(2): 351-355.

1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3 663 population-representative studies with 222 million children, adolescents, and adults. Lancet, 2024, 403(10431): 1027-1050.
2. Tsai AG, Remmert JE, Butryn ML, et al. Treatment of obesity in primary care. Med Clin North Am, 2018, 102(1): 35-47.
3. Vitiello A, Angrisani L, Santonicola A, et al. Bariatric surgery versus lifestyle intervention in class Ⅰobesity: 7-10-year results of a retrospective study. World J Surg, 2019, 43(3): 758-762.
4. O’Brien PE, Hindle A, Brennan L, et al. Long-term outcomes after bariatric surgery: a systematic review and meta-analysis of weight loss at 10 or more years for all bariatric procedures and a single-centre review of 20-year outcomes after adjustable gastric banding. Obes Surg, 2019, 29(1): 3-14.
5. Schulman AR, Thompson CC. Complications of bariatric surgery: what you can expect to see in your GI practice. Am J Gastroenterol, 2017, 112(11): 1640-1655.
6. Athanasiadis DI, Martin A, Kapsampelis P, et al. Factors associated with weight regain post-bariatric surgery: a systematic review. Surg Endosc, 2021, 35(8): 4069-4084.
7. Popoviciu MS, Păduraru L, Yahya G, et al. Emerging role of GLP-1 agonists in obesity: a comprehensive review of randomised controlled trials. Int J Mol Sci, 2023, 24(13): 10449. doi: 10.3390/ijms241310449.
8. Ilanga M, Heard JC, McClintic J, et al. Use of GLP-1 agonists in high risk patients prior to bariatric surgery: a cohort study. Surg Endosc, 2023, 37(12): 9509-9513.
9. Iglesias P, Civantos S, Vega B, et al. Clinical effectiveness of exenatide in diabetic patients waiting for bariatric surgery. Obes Surg, 2015, 25(3): 575-578.
10. Docimo S, Shah J, Warren G, et al. A cost comparison of GLP-1 receptor agonists and bariatric surgery: what is the break even point?. Surg Endosc, 2024, 38(11): 6560-6565.
11. Shetty R, Basheer FT, Poojari PG, et al. Adverse drug reactions of GLP-1 agonists: a systematic review of case reports. Diabetes Metab Syndr, 2022, 16(3): 102427. doi: 10.1016/j.dsx.2022.102427.
12. Bezin J, Gouverneur A, Pénichon M, et al. GLP-1 receptor agonists and the risk of thyroid cancer. Diabetes Care, 2023, 46(2): 384-390.
13. Drucker DJ. Efficacy and safety of GLP-1 medicines for type 2 diabetes and obesity. Diabetes Care, 2024, 47(11): 1873-1888.
14. Klair N, Patel U, Saxena A, et al. What is best for weight loss? A comparative review of the safety and efficacy of bariatric surgery versus glucagon-like peptide-1 analogue. Cureus, 2023, 15(9): e46197. doi: 10.7759/cureus.46197.
15. Wolff Sagy Y, Lavie G, Ramot N, et al. Effectiveness of bariatric metabolic surgery versus glucagon-like peptide-1 receptor agonists for prevention of congestive heart failure. Nat Med, 2024, 30(8): 2337-2342.
16. Phillips BT, Shikora SA. The history of metabolic and bariatric surgery: development of standards for patient safety and efficacy. Metabolism, 2018, 79: 97-107.
17. De Luca M, Shikora S, Eisenberg D, et al. Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS). Obes Surg, 2024, 34(11): 3963-4096.
18. Widjaja J, Chu Y, Yang J, et al. Can we abandon foregut exclusion for an ideal and safe metabolic surgery?. Front Endocrinol (Lausanne), 2022, 13: 1014901. doi: 10.3389/fendo.2022.1014901.
19. Fouse T, Brethauer S. Resolution of comorbidities and impact on longevity following bariatric and metabolic surgery. Surg Clin North Am, 2016, 96(4): 717-732.
20. Schwartz ML, Drew RL, Chazin-Caldie M. Laparoscopic Roux-en-Y gastric bypass: preoperative determinants of prolonged operative times, conversion to open gastric bypasses, and postoperative complications. Obes Surg, 2003, 13(5): 734-738.
21. Iannelli A, Treacy P, Sebastianelli L, et al. Perioperative complications of sleeve gastrectomy: review of the literature. J Minim Access Surg, 2019, 15(1): 1-7.
22. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures—2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, the Obesity Society, American Society for metabolic & bariatric surgery, obesity medicine association, and American Society of Anesthesiologists—executive summary. Endocr Pract, 2019, 25(12): 1346-1359.
23. Jumbe S, Hamlet C, Meyrick J. Psychological aspects of bariatric surgery as a treatment for obesity. Curr Obes Rep, 2017, 6(1): 71-78.
24. Drucker DJ. GLP-1 physiology informs the pharmacotherapy of obesity. Mol Metab, 2022, 57: 101351. doi: 10.1016/j.molmet.2021.101351.
25. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med, 2022, 387(3): 205-216.
26. Frías JP, Davies MJ, Rosenstock J, et al. Tirzepatide versus semaglutide once weekly in patients with type 2 diabetes. N Engl J Med, 2021, 385(6): 503-515.
27. Emanuel EJ, Dellgren JL, McCoy MS, et al. Fair allocation of GLP-1 and dual GLP-1-GIP receptor agonists. N Engl J Med, 2024, 390(20): 1839-1842.
28. Aronne LJ, Sattar N, Horn DB, et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: the SURMOUNT-4 randomized clinical trial. JAMA, 2024, 331(1): 38-48.
29. Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab, 2022, 24(8): 1553-1564.
30. Santo MA, Riccioppo D, Pajecki D, et al. Preoperative weight loss in super-obese patients: study of the rate of weight loss and its effects on surgical morbidity. Clinics (Sao Paulo), 2014, 69(12): 828-834.
31. van Wissen J, Bakker N, Doodeman HJ, et al. Preoperative methods to reduce liver volume in bariatric surgery: a systematic review. Obes Surg, 2016, 26(2): 251-256.
32. 36 Salman MA, Qassem MG, Aboul-Enein MS, et al. Effect of preoperative diet regimen on liver size before laparoscopic sleeve gastrectomy in morbidly obese patients. Surg Endosc, 2022, 36(5): 2981-2986.
33. 37 Spurzem GJ, Broderick RC, Ruiz-Cota P, et al. GLP-1 receptor agonists are a transformative prehabilitation tool for weight loss in obese patients undergoing elective hernia repair. Surg Endosc, 2025, 39(1): 440-447.
34. 38 Martines G, Giove C, Carlucci B, et al. Effect of preoperative liraglutide 3. 0 mg on incidence of intraoperative adhesions in laparoscopic sleeve gastrectomy. Surg Endosc, 2024, 38(12): 7152-7157.
35. El Ansari W, Elhag W. Weight regain and insufficient weight loss after bariatric surgery: definitions, prevalence, mechanisms, predictors, prevention and management strategies, and knowledge gaps—a scoping review. Obes Surg, 2021, 31(4): 1755-1766.
36. Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the longitudinal assessment of bariatric surgery (LABS) study. JAMA Surg, 2018, 153(5): 427-434.
37. Franken RJ, Sluiter NR, Franken J, et al. Treatment options for weight regain or insufficient weight loss after sleeve gastrectomy: a systematic review and meta-analysis. Obes Surg, 2022, 32(6): 2035-2046.
38. Esparham A, Mehri A, Dalili A, et al. Safety and efficacy of glucagon-like peptide-1 (GLP-1) receptor agonists in patients with weight regain or insufficient weight loss after metabolic bariatric surgery: a systematic review and meta-analysis. Obes Rev, 2024, 25(11): e13811. doi: 10.1111/obr.13811.
39. Aronne LJ, Horn DB, le Roux CW, et al. Tirzepatide as compared with semaglutide for the treatment of obesity. N Engl J Med, 2025, 393(1): 26-36.
40. Jastreboff AM, Kaplan LM, Frías JP, et al. Triple-hormone-receptor agonist retatrutide for obesity—a phase 2 trial. N Engl J Med, 2023, 389(6): 514-526.
41. Ji L, Jiang H, Bi Y, et al. Once-weekly mazdutide in Chinese adults with obesity or overweight. N Engl J Med, 2025, 392(22): 2215-2225.
42. Garvey WT, Blüher M, Osorto Contreras CK, et al. Coadministered cagrilintide and semaglutide in adults with overweight or obesity. N Engl J Med, 2025, 393(7): 635-647.
43. Mounjaro® (tirzepatide) pricing/list-price information (manufacturer pricing page). Eli Lilly and Company. [online pricing info]. Accessed 2025.
44. Sánchez-Pernaute A, Rubio MÁ, Conde M, et al. Single-anastomosis duodenoileal bypass as a second step after sleeve gastrectomy. Surg Obes Relat Dis, 2015, 11(2): 351-355.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

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