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Covid-19: Delaying bariatric and metabolic surgery puts patients at risk

An international team of experts has issued a guidance paper that identifies patients with the greatest need for bariatric and metabolic surgery, as experts warn delaying treatment could put them at a greater risk of complications from their disease, as well as from COVID-19.

The recommendations, ‘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’, published in The Lancet Diabetes & Endocrinology, from the multidisciplinary Diabetes Surgery Summit (DSS) and led by Professor Francesco Rubino from King’s College London, outline the surgical candidates at greatest risk of morbidity and mortality from type 2 diabetes or from severe obesity, for whom time-sensitive surgical therapy can be life-saving.

The Diabetes Surgery Summit (DSS) is an international consensus conference series. In 2015, clinical guidelines from the 2nd DSS (now endorsed by more than 55 scientific organizations and health insurers from around the world) formally recognised metabolic surgery as a standard therapy for type 2 diabetes.

Bariatric and metabolic surgery (BMS) has been suspended during the pandemic to free up inpatient capacity for COVID-19 and reduce the risks of infection among patients and staff. However, experts warn the backlog of operations could increase risks of morbidity and mortality for patients awaiting surgery.

“In times of limited resources, patients with greatest risk of harm from untreated disease should be identified and prioritized for timely-access to the treatment they need,” said Professor Rubino, chair of bariatric and metabolic surgery at King’s College London and a consultant surgeon at King’s College Hospital.

“The misconception that bariatric surgery is a ‘last resort’, widespread stigma of obesity and inadequate criteria for patients’ selection can penalize candidates for surgical treatment of obesity and diabetes.”

Social distancing policies and lockdown might limit adherence to lifestyle interventions such as healthy diet and physical exercise, which can worsen the health of affected patients. Compared to non-surgical treatments, bariatric and metabolic surgery leads to greater long-term weight loss, reduction of cardiovascular risk, remission of diabetes and can improve survival.

Severe obesity, diabetes, hypertensions can increase risk for severe Covid-19 complications and bariatric/metabolic surgery can dramatically and rapidly improve these conditions. Delaying surgery may therefore leave many people vulnerable to severe consequences of SARS-Cov-2 infection.

“These operations are called ‘elective’ because they can be scheduled in advance not because the treatment they provide is less necessary,” said Professor Paul Zimmet, from Monash University, Honorary President of the International Diabetes Federation and a co-author of the study. “Metabolic surgery is a potentially lifesaving treatment for selected obese persons with type 2 diabetes.”

Experts from the DSS recommend the following to have access to surgical treatment within 90 days:

  • Being at substantial risk of complications of diabetes such as cardiovascular disease or renal failure

  • Type 2 diabetes requiring insulin

  • Poor control of blood sugar levels despite taking multiple medications

  • Severe forms of obesity (BMI >60) or less severe obesity if there are at least three co-morbidities including liver, respiratory, renal or cardiac disease.

  • Need weight loss and/or metabolic improvement for other time sensitive treatments such as organ transplants.

  • Standard access to bariatric and metabolic surgery can be reserved for patients who are unlikely to deteriorate within six months, but these patients need to be optimised using intensive medical treatment to maintain optimal control.

The group also recommends mandatory COVID-19 screening pre-operatively for all patients considering metabolic surgery. Despite the theoretical higher risk of contagion for staff, the study found laparoscopic (keyhole) surgery remains the best approach, but appropriate personal protective equipment (PPE) should be used.

“Many candidates for bariatric and metabolic surgery are at high risk of morbidity and mortality from comorbid conditions. For these patients, access to surgical treatment should be prioritised on the basis of disease-focused clinical needs, rather than primarily on BMI, to mitigate harm from delaying surgery,” the authors concluded. “This approach is especially needed in periods in which access to surgery is reduced, as in the current COVID-19 pandemic. Societal crises often spur developments that provide benefits long after the storm passes. Disease-oriented, medically meaningful strategies to triage patients seeking metabolic surgery after the COVID-19 crisis should help prioritise patients in more urgent need, both now and long into the future.

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