The outcomes of an online survey conducted by Bariatric News has revealed that there is little consensus among bariatric and metabolic specialists around prioritising specific groups (non-diabetics, BMI, age) when bariatric surgery is resumed during the current COVID-19 pandemic. However, there was a high degree of consensus concerning testing, personnel protective equipment, who should perform surgery and utilising post-operative tele-conferencing.
The aim of the anonymous survey was to collect and report the opinions of bariatric and metabolic specialists on safely returning to bariatric surgery post COVID-19. The survey was carried out between 6-22 June 2020 and subscribers to www.bariatricnews.net/survey were asked via email and social media (Twitter and Facebook), to complete a short survey. The survey consisted of 13 questions, the first two questions asked their profession and the region where they practise. For the remaining questions, readers were asked to rate statements using the Likert scale (‘Strongly agree’ to ‘Strongly disagree’).
In total, 146 specialists completed the survey, the vast majority were surgeons (84%, n=123) followed by Allied Healthcare Professionals (AHPs) (7%), nurses (5%) and dieticians/nutritionist (4%), Unfortunately, no anaesthetists took part in the survey (Figure 1).
Regarding geographic region, most responders were from Europe (41%, n=60), then Central and South America (25%), Africa and the Middle East (15%), North America (12%), Australasia (4%) and Asia (3%) (Figure 2).
PPE and testing
There was an overwhelming consensus that ‘all staff must have adequate PPE and PPE training before returning to surgery’ with 132 (90%) responders who strongly agreed or agreed with the statement. However, there was less agreement when asked ‘all staff must be regularly tested for covid-19’, with 68% strongly agreeing or agreeing and 20% disagreeing or strongly disagreeing (Figure 3).
When ask about patients testing (‘all patients must be tested and test negative for covid-19 pre-operatively’), there was again overwhelming agreement with 85% either strongly agreeing or agreeing with the statement.
In the next section, the survey posed a serious of statements about whether certain patients should be prioritised for bariatric surgery over others. When asked to rate the statement, ‘priority for surgery must be given to non-diabetic patients’, 50% said they strongly disagreed or disagreed, 27% neither agreed nor disagreed with the remaining 23% strongly agreed or agreed that priority should be given to non-diabetic patients (Figure 4).
When asked to rate the statement, ‘priority for surgery must be given to patients in the lower BMI groups’, very similar rates to non-diabetic statement were given with 54% saying they strongly disagreed or disagreed, 24% neither agreed nor disagreed with the remaining 22% strongly agreeing or agreeing that priority should be given to lower BMI groups (Figure 5).
However, there was little consensus when asked about age groups (‘priority for surgery must be given to patients in the lower age groups’), 40% said they strongly agreed or agreed, 32% neither agreed nor disagreed with the remaining 28% strongly disagreeing or disagreeing that priority should be given to lower age groups (Figure 6).
There was significant consensus when asked, ‘there is no evidence to suggest an increased risk of laparoscopy compared to open surgery in the elective setting’, with 73% strongly agreeing or agreeing with the statement. Again, there was significant consensus when asked about operator experience, ‘laparoscopic procedures should be carried out by senior, trained laparoscopic surgeons, in order to minimise operating time and potential of aerosolisation’, with 81% strongly agreeing or agreeing (Figure 7).
Unsurprisingly, there was also considerable consensus concerning filtration systems in the operating room (‘ultra-filtration (smoke evacuation system or filtration) should be used, if available’), with 82% strongly agreeing or agreeing.
Regarding patient follow-up, 90% strongly agreed or agreed that ‘some patient follow-up should be done remotely via tele-conferencing’, however, only 70% strongly agreed or agreed ‘there is adequate infrastructure in place for some patient follow-up to be done remotely via tele-conferencing in my hospital’. (Figure 8).
Although this was a small sample survey, the outcomes do provide some interesting insights and concerns about returning to bariatric surgery in a post-COVID-19 environment. Overall, a general consensus was seen for most of the statements however, the statements on patient demographics and surgical priorities clearly show some disagreement.
Some 90% of responders said that ‘all staff must have adequate PPE and PPE training before returning to surgery’, it would be interesting to further investigate what type of training and if they have received any training. A large majority also believed in ‘regularly’ testing all staff for COVID-19 however, exactly how regularly (daily, weekly etc) staff should be tested and which test they should have does vary between hospitals.
It is clear there was little consensus on surgical prioritisation and there maybe several reasons for this, some believing that some groups of patients (non-diabetic, lower BMI, lower age) should be given priority as they are low risk, whilst others believe that prioritising patients was unnecessary. Conversely, it could be argued that delaying surgery for higher risk groups (diabetic, higher BMI, older age) would be detrimental to their long-term health and these patients should be prioritised. It would be interesting to further investigate if any specific patient demographics (eg. duration of diabetes, significant comorbidities etc) can be identified that would lead towards a consensus.
Finally, although there was clearly a consensus on follow-up and tele-conferencing exactly how this can be achieved clearly warrants further discussion. For example, what type of follow-up can be done via tele-conferencing, what IT systems are required (for patients and staff) and how do centres that have inadequate infrastructures (18% of responders) address these issues?
Bariatric News would like to thank all those who completed the survey, we are grateful for your time and cooperation.