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‘Returning to surgery’ – the views of bariatric and metabolic experts

Wed, 08/05/2020 - 10:53
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As bariatric and metabolic surgery restarts across the world, Bariatric News spoke to Michel Gagner about how the bariatric community can safely resume surgery... 

1. There has been much debate surrounding the use of radiofrequency energy/ electrothermal bipolar devices versus ultrasonic coagulating devices, with regards to the possible risk of infection through aerosolization. What are your thoughts on device use and aerosolization?

Michel Gagner
Michel Gagner

Indeed, I have refrained from using instruments that promote aerosolization, but bipolar devices also create fumes, so the risk exists with both, the important part is to have an exsufflation strategy, with a filter that collects particles below 0.1 microns, and aspirates to the outside of the operating room. I have basically embraced the SAGES recommendations regarding this, but await clinical studies on virus particles found in those filters. It is my understanding that the viruses are rarely in the peritoneal cavity (Langenbecks Arch Surg. 2020 May;405(3):353-355.doi: 10.1007/s00423-020-01891-2. Epub 2020 May 9.), and we do not operate on positive patients (as everybody gets tested prior to bariatric/metabolic surgery), so the risk is extremely low. I think endotracheal intubation carries a higher risk and is probably the moment of the operation where the risk of contamination/infection for the personnel to be at the highest.

There is also concern with the plumes from the trocar opening in and out or during specimen extraction, as demonstrated by a nice video from Khan, Dalli and Cahil from Dublin Ireland (Colorectal Dis. 2020 Jun 24. doi: 10.1111/codi.15215. Online ahead of print.), hence the surgical team should wear an N95 mask until the incidence of cases is very low in the general population. However, recent data of air samples around Covid-19 isolated patients have been found to be negative (Infect Control Hosp Epidemiol. 2020 Jun 8;1-8. doi: 10.1017/ice.2020.282. Online ahead of print.) Having gone through a period where the AIDS virus was prevalent without treatment, Hepatitis B and C without treatment and vaccines, I think Covid-19 is pretty low risk compared to what surgeons got exposed in the '80s and '90s.

2. In our survey, over 80% of responders agreed or strongly agreed that laparoscopic procedures should be carried out by senior, trained laparoscopic surgeons, in order to minimise operating time and potential of aerosolization. Do you agree with this view and how to do less experienced laparoscopic surgeons gain much-needed experience in such circumstances?

There is no data to back this up, and you may find some senior surgeons that are slower than trainees.

3. As you learn more about the COVID virus, has this in any way changed your choice or the technique of your procedure/s?

As an owner of an ambulatory surgical centre, I have a different perspective than most practising surgeons who have everything organised for their practice by a large administrative structure, governmental or otherwise. We have taken the decision to test all patients ahead of surgery, and test all personnel every week, with an RT-PCR nasopharyngeal test. Further, we use maximum protection in the OR for the anaesthesiology team and scrubbed surgical team, as well as circulating. And after seven weeks of full surgeries, and hundreds of tests, we have seen only one false positive in an anaesthesiologist, who subsequently 2 days later had 2 negative RT-PCR tests and confirmation of negative IgG and IgM antibodies. We have had no personnel or patients getting infected and our low morbidity has not changed. It is more costly to operate with these conditions, but probably cost-effective by eliminating the probability of pulmonary complications from Covid-19 postoperatively.

We have started to do only sleeve gastrectomies without pulmonary problems and without super obesity, but after seven weeks, we are operating all cases without restrictions. We have found that Ambulatory Surgical centres have become even more popular than large hospitals in North America, due to the absence of Covid-19 patients in their structures (lesser risk of cross contaminations), and the short stay required. Patients and medical/surgical personnel seem less afraid of contracting Covid-19 in these circumstances.

The 'Return to work' survey and interviews with bariatric and metabolic specialists were carried out in partnership with Medtronic Inc.