Bariatric surgery volumes fell 39%

Bariatric surgery volumes in the United States peaked in the fourth quarter of 2022 and have since fallen by 39%, according to a study published in Surgical Endoscopy on 17 July 2026^[1]. The authors, led by Akio Kozato at NYU Langone Health, used Epic's nationwide Cosmos database to track every primary sleeve gastrectomy or gastric bypass performed between 2018 and 2025. Their data capture a before-and-after picture that corresponds closely with the commercial launch of semaglutide for obesity in 2021 and tirzepatide in 2022.

The decline matters for three reasons: it is large, it is accompanied by a measurable change in who receives surgery, and it has exposed a striking gap in which patients can access the new medicines before choosing the operating table.

The volume picture

Bariatric surgery utilization grew steadily from 2018 onward, briefly dipped during the COVID-19 disruption, and then climbed to a peak in Q4 2022^[1]. That peak coincides with the months just before tirzepatide (Mounjaro) received FDA approval for type 2 diabetes and before Eli Lilly began aggressive sampling to bariatric programs. From Q4 2022 through Q4 2025, the Cosmos dataset shows a 39% fall in surgical volume across the facilities in the network.

The study does not show that GLP-1 receptor agonists caused the decline in the same way that a randomized trial would. What it shows is coincidence in timing and a mechanistic plausibility: surgeons and their patients now have an alternative that did not exist at scale before 2021. The literature reports weight loss of roughly 14.9% at 68 weeks on semaglutide 2.4 mg in the STEP 1 trial^[4] and 20.9% at 72 weeks on tirzepatide 15 mg in SURMOUNT-1^[3], figures that overlap with outcomes achievable through sleeve gastrectomy for many patients.

Who is still going to surgery

The demographic composition of the surgical population shifted alongside the volume decline^[1]. Hispanic patients represented 8.1% of the bariatric surgery cohort in Q4 2018 and 16.8% by Q4 2025. That near-doubling suggests Hispanic patients are continuing to choose, or arriving at, surgery at rates that are not declining at the same pace as the overall trend.

Meanwhile, patients receiving GLP-1 receptor agonist therapy before surgery looked different: they were older, more likely to be White, more likely to carry private insurance, and more likely to have type 2 diabetes (relative risk 2.94, 95% confidence interval 2.88 to 3.00)^[1]. Sleep apnea and liver disease also associated with pre-surgical GLP-1RA use. In other words, the patients who are now taking semaglutide or tirzepatide before a surgical procedure are a specific subset: privately insured, with metabolic comorbidities, and receiving care at centers that have adopted the drugs early.

Patients who went straight to surgery without a prior GLP-1 receptor agonist were more likely to be Hispanic, Black, and publicly insured^[1]. That pattern maps onto the access barriers that have already been documented for the new obesity medicines: list prices for Wegovy and Zepbound remain above USD 1,000 per month before rebates, and Medicaid coverage of the obesity indication is inconsistent across states.

The 15-fold hospital gap

After adjusting for patient characteristics, the study found a 15-fold difference in pre-surgery GLP-1RA use between the highest- and lowest-adopting hospitals in the Cosmos network^[1]. That spread cannot be explained by case mix alone: it points to center-level practice variation, which in turn reflects differing institutional protocols, payer relationships, and formulary access. Two patients with similar clinical profiles presenting at different hospitals can have very different chances of receiving a GLP-1 receptor agonist before their surgical decision.

This variation has clinical implications beyond the immediate treatment choice. Pre-surgical GLP-1RA use can reduce liver volume and visceral fat, potentially making the technical aspects of a laparoscopic procedure safer. Whether the drug is used as a bridge to surgery, as a trial of medical therapy, or as a long-term alternative that defers or replaces surgery is a conversation that is currently being shaped more by hospital policy and insurance access than by consistent clinical guidelines.

What the data does not settle

The Kozato et al. analysis is observational and covers a specific network of facilities that use Epic's Cosmos database^[1]. It cannot show causation, and the Epic network, while large, is not a nationally representative sample. Surgery volumes at facilities outside that network may have followed different trends.

The study also does not track outcomes for the patients who declined surgery in favor of GLP-1 receptor agonist therapy. Whether those patients achieve durable weight loss, whether they eventually return for surgery, and whether long-term health outcomes differ between the groups are questions that the Cosmos data cannot answer at this point.

The American Society for Metabolic and Bariatric Surgery reported 270,089 total bariatric procedures for 2023, the most recent full-year figure in their estimate series^[2]. The Kozato figures suggest that by 2025, the surgical volume within Epic-network facilities had declined substantially from its 2022 peak. How that translates into a revised national estimate will depend on data from facilities not captured in Cosmos.

What this means for patients weighing their options

Bariatric surgery remains an evidence-backed intervention for severe obesity. The literature reports greater percentage weight loss with sleeve gastrectomy and gastric bypass than with any currently approved medical therapy, along with remission of type 2 diabetes in a substantial proportion of patients. The decision between surgery and pharmacotherapy is not resolved by a 39% volume decline; it is a clinical conversation that should account for individual anatomy, comorbidities, adherence history, and access to follow-up care.

The emerging picture is that semaglutide and tirzepatide have meaningfully expanded the range of options available to people with obesity, and that range is not being distributed equally. Privately insured patients at high-adopting hospitals are the ones accessing GLP-1 receptor agonists as part of their care pathway. Publicly insured patients, and those at lower-adopting hospitals, are more often proceeding directly to surgery or not receiving any formal obesity treatment at all.

This is not a medical advice article. Any decision about obesity treatment, whether pharmacologic or surgical, belongs with a clinician who knows your individual history. For background on the pharmacology of the relevant drugs, see the semaglutide and tirzepatide pages on this site.