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The experience of Israeli bariatric surgeons during COVID

Tue, 11/17/2020 - 15:52
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In the public sector, 85% surgeons reported that bariatric surgeries were stopped compared to 61% in the private sector

Bariatric surgeons in Israel have reported experiencing a variance in their reactions during the COVID-19 pandemic, according to the results from an anonymous web-based questionnaire sent to all active bariatric surgeons (n=63) in Israel that sought to portray the practices and attitudes of Israeli bariatric surgeons in the first phase of the pandemic. The study, ‘Practices and attitudes of bariatric surgeons in Israel during the first phase of the COVID-19 pandemic’, published in the Israel Journal of Health Policy Research, found substantial differences between the private and the public sectors and noted that a lack of compliance of the guidelines must be considered by regulators, administrators and surgeons when planning to re-establish elective bariatric surgery or in case a second wave.

In 2019, approximately 7,500 bariatric procedures were performed in Israel during 2019 and according to the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) registry, Israel’s rate of bariatric surgeries is high and was 835 per million in 2018 and 824 per million in 2019. On March 22nd, the Israeli the Ministry of Health (MOH) decreed that all elective surgery was banned in all public hospitals, the ban was lifted on April 26th.

The survey examined the practices and attitudes of bariatric surgeons in the public and the private sectors during the first phase of the pandemic in light of conflicting guidelines. In total, 53 bariatric surgeons completed an online questionnaire anonymously, which asked questions about bariatric surgery practice by sector (public, private), as well as contra-indications for bariatric procedures and use of protective equipment.

Most responders (46, 87%) were male and most were aged between 45-60y (37, 70%). Over 53% had professional experience of more than 15 years, and over 43% reported that they perform 200 or more procedures annually. Nine (17%) and six (11%) responders, respectively, reported working in the only in the public or the private sector with the vast majority (n=38, 72%) working in both sectors. No correlation was found between age and annual number of BS procedures, and the correlation between experience years and annual number of BS procedures was low (p= 0.03).

In the public sector, 85% surgeons reported that bariatric surgeries were stopped compared to 61% in the private sector (p=0.006). Interestingly, hospital administrations specifically issued instructions to stop bariatric surgery in 72% of the public bariatric departments, but only in 7% of those in the private sector (p < 0.0001).

Unsurprisingly, both sectors reported a decline in the number of bariatric procedures performed during the pandemic (98% in the public sector; 86% in the private sector, p=0.0391). A decline of 60% and over was more common in the public (85%) compared to the private (43%) sector (p<0.0001). Between 22nd March and 1st May 423 bariatric procedures were performed in Israel: 330 (78%) in private hospitals and 93 (22%) in public centres, compared with 856 bariatric surgeries (497 (58%) in a private hospitals and 359 (42%) in public hospitals), over the same period in 2019. This was a total reduction of 49%, 32% in the private and 73% in the public sector. According to the survey almost 100% of the surgeons in the public sector encountered a tremendous decline in surgical activity, 63% of them witnessed a more than 70% decline.

Most surgeons (77%) reported no specific contra-indications with respect to bariatric surgery performance, the 23% of surgeons who implemented ‘new’ COVID-19 related contra-indications noted age (over 60y or over 70y) and background morbidity (diabetes, hypertension, ischemic heart disease, chronic lung disease). Most surgeons (57%) informed their patients regarding a potentially increased risk of bariatric surgery performance during the pandemic, although 31% did not think that the risk is increased and 12% perceived the increase in risk as minimal and did not inform their patients about it.

Concerning the operating room, 24 surgeons (33%) replied that no special measures were taken, although 18 surgeons (25%) indicated a special laparoscopic Insufflated gas evacuation system and enhanced personal protective equipment (n=16, 22%) were utilised. A mere 14 (28%) surgeons reported applying changes to the post-operative supervision of patients during the pandemic.

When asked under which conditions regular activity should be resumed (multiple replies were allowed, 66 were received in total):

  • The most frequent answer was (n=26, 39%%) that no special conditions were needed
  • Operations should only be carried out on patients that are PCR-negative (n=18, 27%)
  • Operating only on patients that are IgG-positive to COVID-19 (n=10. 15%)
  • Resuming elective surgery only upon the end of the pandemic (n=6, 9%) or having only IgG positive OR staff operate (n=6, 9%).
  • Two surgeons reported on two patients that were diagnosed with COVID-19 following surgery

“We call for a more coherent and transparent decision-making process by all parties in the future,” the paper’s authors concluded. “With respect to practical recommendations concerning bariatric surgery in times of COVID-19 pandemic, since obesity is considered a risk factor for infection, especially with severe clinical course, and since it is clear by now that the COVID-19 pandemic will accompany us for a while, considering that vaccinations are known to be less effective in obese patients, our recommendation is to continue to perform bariatric surgeries only to PCR negative patients and to place patients postoperatively in quarantine for two weeks (the period with the highest risk of postoperative complications).”

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