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New recommendations for the management of metabolic and bariatric surgery candidates during and after the COVID-19 pandemic shift the focus from body mass index (BMI) alone to medical conditions most likely to be ameliorated by the procedures.
Meant as a guide for both surgeons and referring clinicians, the document was published online May 7 as a Personal View in Lancet Diabetes & Endocrinology.
“Millions of elective operations have been on hold because of COVID-19…in the next few months, we’re going to face a huge backlog of procedures of all types. Even when we resume doing surgery it’s not going to be business as usual for many months…Hospital clinicians and managers want to make decisions about who’s going to get those slots first,” lead author of the international 23-member writing panel, Francesco Rubino, MD, told Medscape Medical News.
Rubino is professor of metabolic and bariatric surgery at King’s College Hospital, London, UK.
The recommendations include a guide for prioritizing patients eligible for bariatric or metabolic surgery — the former referring to when it’s performed primarily for obesity and the latter for type 2 diabetes — once the pandemic restrictions on nonessential surgery are lifted.
Rather than prioritizing patients by BMI, the scheme focuses on medical comorbidities to place patients into “expedited” or “standard” access categories.
Historically, bariatric and metabolic surgery have had a low uptake due to factors such as lack of insurance coverage and stigma, with many physicians inappropriately viewing it as risky, ineffective, and/or as a “last resort” treatment, Rubino said.
“They don’t refer for surgery even though we have all the evidence that the benefits for patients are unquestionable,” he added.
Because of that background, “in the situation of limited capacity, patients with obesity and type 2 diabetes are likely to be penalized compared to any other conditions that need elective surgery,” Rubino stressed.
Asked to comment, Scott Kahan, MD, director of the National Center for Weight and Wellness in Washington, DC, called the document a “really valuable thought piece.”
Noting that only about 1% to 2% of people who are eligible for bariatric or metabolic surgery actually undergo the procedures, Kahan said, “because so few people get the surgery we’ve never really run into a situation of undersupply or over-demand.”
“But, as we’re moving forward, one would think that we will run into that scenario. So, better prioritizing and triaging patients likely will be more important down the line, given how effective surgery has been shown to be now, both short-term and long-term.”
Risks of Obesity, Shifting Away From BMI as the Main Metric
The new document extensively discusses the risks of obesity — including now as a major COVID-19 risk factor — and the benefits of the procedures and risks of delaying them.
It also addresses ongoing management of patients who had bariatric/metabolic surgery in the past and nonsurgical treatment to mitigate harm until patients can undergo the procedures.
Another important problem the document addresses, Rubino said, is the current BMI-focused bariatric/metabolic surgery criteria (≥ 40 kg/m2 or ≥ 35 kg/m2 with at least one obesity-related comorbidity).
“BMI is an epidemiological measure, not a measure of disease. But we select patients for bariatric surgery by saying who is eligible [without assessing] who has more or less severe disease, and who is at more or less risk for short-term complications from the disease compared to others,” he explained.
“We don’t have any mechanism, even in normal times, let alone during a pandemic, to differentiate between patients who need surgery sooner rather than later.”
Indeed, Kahan said, “Traditionally we tend to oversimplify risk stratification in terms of how heavy people are. While that is one factor of importance, it’s far from the only factor and may not be the most important factor.”
In “someone who is relatively lighter but sicker, it would be sensible, in my mind, to prioritize them for a potentially curative procedure compared with someone who is heavier — even much heavier — but is not as sick,” he added.
“Pandemic Forces Us to Do What Was Long Overdue”
The document confirms that bariatric/metabolic surgery should remain suspended during the most intense phase of the COVID-19 pandemic and only resume once overall restrictions on nonessential surgeries are lifted.
Exceptions are limited to emergency endoscopic interventions for complications of prior surgery, such as hemorrhage or leaks.
A section offers guidance for pharmacologic and other nonsurgical options to mitigate harm from delaying the procedures including use of drugs that promote weight loss, such as glucagon-like peptide-1 receptor agonists and/or sodium-glucose cotransporter 2 inhibitors.
Once less-urgent surgeries are allowed to resume, a prioritization scheme addresses which patients should receive “expedited access” (risk of harm if delayed beyond 90 days) versus “standard access” (unlikely to deteriorate within 6 months) within three indication categories: “diabetes (metabolic) surgery”, “obesity (bariatric) surgery”, or “adjuvant bariatric and metabolic surgery”.
Examples of patients who would qualify for “expedited” access in the “diabetes surgery” category include those with an A1c of 8% or greater despite use of two or more oral medications or insulin use, those with a history of cardiovascular disease, and/or those with stage 3-4 chronic kidney disease.
For the “obesity surgery” group, priority patients include those with a BMI of 60 kg/m2 or greater or with severe obesity hypoventilation syndrome or severe sleep apnea.
And for the adjuvant category, those requiring weight loss to allow for other treatments, such as organ transplants, would be expedited.
Individuals with less-severe obesity or chronic conditions could have their surgeries put off until a later date.
The panel also recommends that even though keyhole surgery involves aerosol-generating techniques that could increase the risk for coronavirus infection, laparoscopic approaches are still preferred over open procedures because they carry lower risks for complications and result in shorter hospital stays, thereby lowering infection risk.
Appropriate personal protective equipment is, of course, advised for use by clinicians.
Kahan said of the document: ”I think it’s a very sensible piece where they’re thinking through things that haven’t really needed to be thought through all that much. That’s partly with respect to COVID-19, but even beyond that I think this will be a valuable platform going forward.”
Indeed, Rubino said, “The pandemic forces us to do what was long overdue.”
Rubino has reported being on advisory boards for GI Dynamics, Keyron, and Novo Nordisk, has reported receiving consulting fees and research grants from Ethicon Endo-Surgery and Medtronic. Kahan has reported no relevant financial relationships.
Lancet Diabetes Endocrinol. Published online May 7, 2020. Full text