The resumption of elective bariatric and metabolic surgery is crucial and must be a priority similar to oncological surgery because it is not only a weight loss operation but also resolves or improves comorbidities and appears to be an immune restorative procedure of obese patients in the medium term, according to recommendations from IFSO’s Latin America Chapter. The paper, ‘COVID-19: IFSO LAC Recommendations for the Resumption of Elective Bariatric Surgery’, was published in Obesity Surgery.
The recommendations stats that bariatric and metabolic surgery should be resumed once hospitals reach phase I or II (as described in the Spanish Association of Surgeons classification) with less than 15% of its hospitalised patients derived from COVID-19. Such surgery should be performed in medical facilities with the necessary infrastructure to treat obesity patients in a non-COVID area. Therefore, hospitals must separate into three areas: non-COVID, COVID-positive and an area for patients under investigation.
The recommendations endorse the ‘Closing the back door’ recommendations from the Society of American Gastrointestinal and EndoscopicSurgeons (SAGES), the European Association for EndoscopicSurgery (EAES) and the Spanish Association of Surgery, which include:
- Limit the number of medical visits and, when possible, conduct remote visits by video conference instead
- Use surgical masks during patient care
- Assign and divide surgical equipment teams, avoiding contact amongst them during shift changes
- Observe social distancing in common areas, especially in the cafeterias
- Limit to one companion per patient physically present in the same room, without symptoms and with no history of having been in close contact with a person at risk at least 14 days before the intervention
- Use face masks in public spaces and within the hospital environment permanently
- Orientation webinars and online briefings, remote visits by video conference, and virtual groups should be implemented for pre- and postoperative consults during the therapeutic process.
- Pre- and postoperative isolation: observe self-isolation and social distancing measures from the date of the preoperative clinical/anaesthesia consultation (at least 72 hours previous to surgery and 14 days after).
The paper states that certain patients should be excluded from surgery if they meet the following criteria: patient decompensation of associated conditions, high-risk patients over the age of 60, those who need immunosuppressant drugs or suffer chronic lung diseases and bariatric revisional surgery for insufficient weight loss.
- The port incisions for laparoscopy must be as small as possible and allow stability but prevent leaks.
- Where the insufflation port has to be relocated, it should be closed before removing the tube and the new port should not be opened until the insufflator tube is connected.
- The insufflator should be turned on before the new port valve is opened to prevent gas and smoke from back-flowing into the insufflator.
- A filter should be used for safe gas insufflation and intra-abdominal pressure must remain low (10–15mmHg)
- An ultrafiltration system or water trap should be used for gas evacuation and, if the insufflator has a smoke evacuation option, it should be used
- Complete evacuation of the pneumoperitoneum must be performed prior to removal of surgical specimens or completing fascial closures.
In addition, they recommend that postoperative hospital stays should be kept to a minimum and the use of postoperative accelerated recovery protocols.
“It might be possible that timely resumption of elective surgery for the treatment of obesity could enhance the immune systems of these patients in the medium term, offering them the same probability of contracting the disease as the regular population,” the paper concludes. “In view of the constant changes in the scientific evidence generated by this disease, these recommendations constitute a suggestion and by no means should replace the medical criteria of the attending physician. Moreover, they are susceptible to revisions at any given time and vary according to the realities of each region.”
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