As bariatric and metabolic surgery restarts across the world, Bariatric News spoke to Ricardo Cohen about how the bariatric community can safely resume surgery...
1. Our survey showed that the vast majority of bariatric specialists do not support prioritising surgery for low-BMI groups and non-diabetic patients. Do you believe there any group of patients who should be prioritised?
Very recently, the Diabetes Surgery Summit (DSS) faculty, which I’m part of it, published in Lancet Diabetes & Endocrinology, recommendations for management of surgical candidates and prioritization of access to surgery (Rubino F, Cohen RV, Mingrone G, et al. 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. Lancet Diabetes Endocrinol. 2020;8(7):640-648. doi:10.1016/S2213-8587(20)30157-1).
If patients are well enough to be safe surgical candidates, preference should be afforded to those with the greatest risk of morbidity and mortality from their disease, if it is probable that this risk can be reduced by surgery. This logic would apply, for instance, to many surgical candidates with poorly controlled type 2 diabetes or substantial metabolic, respiratory, or cardiovascular disease.
Traditional BMI-centric criteria for patient selection, however, tend to distort access to bariatric and metabolic surgery in the opposite direction. Given the factors contributing to morbidity and mortality in obesity and type 2 diabetes, surgical prioritization should be based on disease-specific considerations, regardless of BMI. For patients with type 2 diabetes, it is suggested that surgery be prioritized for patients at increased risk of morbidity and mortality. This risk would be indicated by poor glycemic mic control despite maximal medical therapy, use of insulin, previous cardiovascular disease, albuminuria and chronic kidney disease, non-alcoholic steatohepatitis, or multiple cardiometabolic comorbidities
Regarding prioritization for bariatric surgery, the severity of obesity-associated symptoms (i.e. mobility issues or joint pain as consequence of extremely high BMI, regardless of comorbidities) must also be considered when establishing priorities. Equally important is the effect of obesity-related conditions that increase morbidity and mortality (obesity hypoventilation syndrome, chronic kidney disease, or severe obstructive sleep apnoea). Many candidates for bariatric and metabolic surgery are at high risk of morbidity and mortality from comorbid conditions. Therefore, prioritization is mandatory to mitigate harm from delaying surgery.
2. Our survey showed that 66% of bariatric specialists believe all healthcare staff should be regularly tested for COVID-19. Do you agree and what do you believe should be ‘regularly’ (weekly, b-weekly, monthly etc)?
Testing of healthcare staff depends on local epidemiological conditions. Testing for asymptomatic people remains controversial. The Diamond Princess cruise ship study, published at the NEJM (Sakurai A, Sasaki T, Kato S, et al. Natural History of Asymptomatic SARS-CoV-2 Infection [published online ahead of print, 2020 Jun 12]. N Engl J Med. 2020;NEJMc2013020. doi:10.1056/NEJMc2013020), reported that around 50% of asymptomatic patients tested positive (RT-PCR), while the other half could spread the disease, however tested negative. A negative test is not a guarantee of being "COVID-19 free”. In high-risk contamination areas, healthcare workers may be tested weekly, but the limitations of tests should be taken into account.
3. In your opinion, do you think the current restrictions and protections in place will remain until the pandemic is over or do you think some will remain in place (such as testing, full PPE) over a much longer period?
Historically, no pandemic remained forever. The 1918 influenza pandemic infected 500 million people – about a third of the world's population at the time – in four successive waves. The death toll may have been anything from 17 million to 50 million, and possibly as high as 100 million. Regarding COVID-19, herd immunity and vaccines will come. It may reappear seasonally - more in the winter, spring and autumn and less in the early summer, as other respiratory viruses. I don’t believe that testing will remain. Therefore, healthcare staff have learned how to improve protective measures against all viruses, as Sars-Cov2, influenza, hepatitis and etc. The proper use of PPEs (not full Ebola-style protection) will prevail. Life will go on.