Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery.

Francesco Rubino, Ricardo V Cohen, Geltrude Mingrone, Carel W le Roux, Jeffrey I Mechanick, David E Arterburn, Josep Vidal, George Alberti, Stephanie A Amiel, Rachel L Batterham, Stefan Bornstein, Ghassan Chamseddine, Stefano Del Prato, John B Dixon, Robert H Eckel, David Hopkins, Barbara M McGowan, An Pan, Ameet Patel, François Pattou, Philip R Schauer, Paul Z Zimmet, David E Cummings

Journal: The lancet. Diabetes & endocrinology 2020;8(7):640-648

PMID: 32386567

Free Full Text on PubMed Central View on PubMed

Plain Language Summary

Bariatric surgery has been proven for weight loss in people with severe obesity. However, during the covid-19 pandemic, surgery has been postponed for many individuals. Under normal conditions, patients who are awaiting bariatric surgery are prioritised based on weight, however this does not necessarily reflect severity of their condition. This review paper aimed to develop new criteria in order to help prioritise individuals who are awaiting bariatric surgery. The authors began by reviewing the reasons for delaying bariatric surgery and the need for beds, the risks of covid-19 transmission during the procedure and the severe covid-19 complications that individuals with obesity can experience were discussed. A recommendation was made that all patients having bariatric surgery be tested for Covid-19. Solutions were proposed for those awaiting surgery such as diets, exercise, optimal blood sugar control and the potential use of weight loss medications. Prioritisation of surgery should focus on clinical need; it should be accessible and minimise harm from delays. Individuals with obesity and type 2 diabetes should be prioritised based on those who have an increased risk of death, determined by whether the individual; has poor blood sugar control despite maximal use of medications to control it, uses insulin, has previous heart disease, has liver disease or if they have other risk factors. It was concluded that weight alone is inadequate to prioritise candidates for bariatric surgery. Disease severity should be at the centre of decisions, especially when access to surgery is reduced, as is during the Covid -19 pandemic. This paper could be used by healthcare professionals to understand how to prioritise their obese and type 2 diabetic patients who are awaiting bariatric surgery.

Abstract

The coronavirus disease 2019 pandemic is wreaking havoc on society, especially health-care systems, including disrupting bariatric and metabolic surgery. The current limitations on accessibility to non-urgent care undermine postoperative monitoring of patients who have undergone such operations. Furthermore, like most elective surgery, new bariatric and metabolic procedures are being postponed worldwide during the pandemic. When the outbreak abates, a backlog of people seeking these operations will exist. Hence, surgical candidates face prolonged delays of beneficial treatment. Because of the progressive nature of obesity and diabetes, delaying surgery increases risks for morbidity and mortality, thus requiring strategies to mitigate harm. The risk of harm, however, varies among patients, depending on the type and severity of their comorbidities. A triaging strategy is therefore needed. The traditional weight-centric patient-selection criteria do not favour cases based on actual clinical needs. In this Personal View, experts from the Diabetes Surgery Summit consensus conference series provide guidance for the management of patients while surgery is delayed and for postoperative surveillance. We also offer a strategy to prioritise bariatric and metabolic surgery candidates on the basis of the diseases that are most likely to be ameliorated postoperatively. Although our system will be particularly germane in the immediate future, it also provides a framework for long-term clinically meaningful prioritisation.

Address: Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Bariatric and Metabolic Surgery, King's College Hospital, London, UK. Electronic address: [email protected].; Center for the treatment of Obesity and Diabetes, Oswaldo Cruz German Hospital, Sao Paulo, Brazil.; Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.; Diabetes Complications Research Centre, Conway Institute, University College of Dublin, Dublin, Ireland.; The Marie-Josee and Henry R Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, NY, USA; Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA.; Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA.; Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain.; Department of Endocrinology and Metabolism, Imperial College, London, UK.; Department of Diabetes, School of Life Course Sciences, King's College London, London, UK.; Centre for Obesity Research, University College London, London, UK; University College London Hospitals Bariatric Centre for Weight Management and Metabolic Surgery, London, UK; National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.; Paul Langerhans Institute Dresden, Helmholtz Center Munich at the University Hospital Carl Gustav Carus and Faculty of Medicine, Technical University Dresden, Dresden, Germany.; Bariatric and Metabolic Surgery, King's College Hospital, London, UK.; Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, Italy.; Iverson Health Innovation Research Institute, Swinburne University, Melbourne, VIC, Australia.; Division of Endocrinology, Metabolism and Diabetes and Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.; King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK.; Institute of Diabetes, Endocrinology and Obesity, Guy's and St Thomas' National Health Service Foundation Trust, London, UK.; Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.; European Genomic Institute for Diabetes, Lille, France; Translational Research for Diabetes, University of Lille, Inserm, Centre Hospitalier Regional Universitaire, Lille, France.; Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA.; Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia.; University of Washington Medicine Diabetes Institute, University of Washington, Seattle, WA, USA; Weight Management Program, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA.

DOI: 10.1016/S2213-8587(20)30157-1

Patient Centred Factor

Mediators: Obesity

Clinical Imbalances

Immune and inflammation

Nutrition Evidence Keywords

Obesity Type 2 diabetes Weight loss COVID-19 Bariatric surgery Clinical need

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MeSH Terms: Bariatric Surgery, Betacoronavirus, COVID-19, Coronavirus Infections, Disease Management, Humans, Obesity, Pandemics, Pneumonia, Viral, Postoperative Care, Postoperative Complications, SARS-CoV-2