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Recommendations for restarting elective bariatric and metabolic surgery

Tue, 06/30/2020 - 13:42
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An international team of bariatric and metabolic surgery (B&M) experts has published a series of protocols designed to assist B&M surgeons and Allied Healthcare Professionals when restarting elective B&M surgery following the outbreak of COVID-19, based on experts’ opinions, reviews of small series and publications from previous different viral epidemic outbreaks. The paper, ‘How are We Going to Restart Elective Bariatric and Metabolic Surgery after the Peak of Covid-19 Pandemic?’ was published in Research Open (Sur Res Rep, Volume 3(1): 1–5, 2020).

As the COVID-19 pandemic swept the world, elective surgery was effectively cancelled as healthcare systems re-allocated resources to deal with the disease. Although European and American guidelines, as well as IFSO recommendations, have been published, as the pandemic begins to subside in some regions and countries, the authors stated that there are no clear guidelines or a strategy to restart B&M surgery.

They caution that any resumption of elective B&M surgery should only be begun once the COVID-19 outbreak is clearly on the decline and when it is deemed safe to do so (eg. few newly diagnosed cases and the hospitals do not receive a surge of COVID-19 patients) and with an awareness of the regional health care status and Intensive Care Unit (ICU) bed capacity.

Specifically, the protocols in the paper refer to hospitals under the non COVID-19 category therefore, there should be a preference on specialised B&M surgery centres and surgical practise should be gradually restarted with only 1-2 cases per day. The authors also noted that there should be a priority to identify patients who will benefit most from B&M surgery, while keeping the risks as low as possible, and surgeons should rely on their clinical sense, realise their surgical capabilities and consider the available facilities.

In summary, the paper makes the following recommendations (please click on the link at the end of the article to access the full and complete recommendations):

Pre-surgery

  • Hospital admission on the same day of surgery minimises the hospital stay.
  • As many pre-operative medical consultations should be via telemedicine and video phone calls as possible
  • The surgical consent should explain that the patients are at an increased risk of acquiring a COVID-19 infection during their hospital course.

Screening

  • Patients being considered for elective B&M surgery must be screened for COVID-19, 24 hours before the admission and only patients with negative results will have surgery
  • Both the RT-PCR and the antibodies serology tests are recommended for more accurate results, in case only one test is feasible, the RT-PCR is mandatory

Surgery

  • Negative pressure systems decrease the risk of infection and operating in a negative pressure OR should be done, when available
  • Non-essential staff should leave the OR during surgery and not return until 20 minutes after an Aerosol Generating Procedure (AGP) is completed. In addition, no trainees or observers should be allowed in the OR.
  • The authors recommend using frequency/electrothermal bipolar devices and not ultrasonic coagulating devices, due to possible risk of infection from smoke plume
  • If an electrothermal device is used, a smoke evacuator machine must be used or connect the insufflation system to a filter, as this minimises the possible risk of infection through aerosolisation
  • The smoke evacuation systems in a closed-circuit are highly recommended in case of specimen removal and during Co2 extraction at the end of the procedure.
  • Only experienced surgeons should be operating as the more skilful and experienced the surgeon is, the faster the procedure is performed, leading to a shorter operative time and less exposure to the aerosol

Personal protective equipment (PPE)

  • All patients must be treated as if they are suspected to be COVID-19 positive and proper PPE should be applied
  • Staff must follow all hand hygiene instructions at all times and follow the contact, airborne and droplet precautions
  • All OR personnel should always wear gloves

Post-surgery

  • Patients must agree on self-quarantine post-operatively for a minimum of 14 days however, they advise a period of up to one month
  • The patient should be discharged as soon as possible, and the authors recommend 36-48 hours (or less) of hospital stay.
  • The RT-PCR screening test should be repeated to make sure that the patient is COVID-19 free when he/she leaves the hospital.
  • All post-operative follow-up consultations should be via telemedicine and video phone calls.

“The resumption of elective B&M surgeries during the deceleration stage of COVID-19 is a delicate process, that must be gradual and prudent. There should be a priority for patients who would benefit most from a B&M procedure. The use of smoke evacuation machines is essential,” the authors concluded. “The preference of using radiofrequency energy device versus ultrasonic remains controversial. This scholarly protocol can be adjusted according to the regulations established by the local health departments and available facilities. This paper is intended only as a recommendation to professionals and can in no way be used as an argument for possible legal claims.”

To access this paper and the recommendation in full, please click here