Abstract
Bariatric patients are unique from other surgical patients due to their higher prevalence of hypertension, type 2 diabetes, cardiovascular disease, and respiratory illnesses. The outbreak of the Novel Coronavirus (COVID-19) has drastically changed the way bariatric surgeon's practice today. This review aims to access the best practices to treat our bariatric patient during the COVID-19 pandemic of 2019–2020. A practice overview of one academic and one community bariatric practice along with a literature search using the PubMed data source during the COVID-19 outbreak was conducted. Following the recommendation of the Centers for Medicare and Medicaid Service and American College of Surgeons “Guidance of Triage of Non-Emergent Surgical Procedures” released in March of 2020, it is recommended that elective cases be postponed. However, using robust telehealth modalities including video and phone call systems, practice patterns can be modified to mitigate interruptions in patient care.
Background
Bariatric patients are a unique surgical population owing to the higher prevalence of hypertension, type 2 diabetes, cardiovascular disease, and respiratory illnesses. 1 These obesity-related comorbidities render patients more vulnerable to complications postoperatively, and as such, standard of care presurgery practices include meticulous attention to managing these comorbidities. 2 Currently, the outbreak of the novel coronavirus disease-2019 (COVID-19) has drastically changed the way the health care system practices, supposing a defensive posture in an attempt to mitigate this global pandemic. COVID-19, caused by the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), is believed to spread mainly through large respiratory droplets, with clinical presentations ranging from a mild flu-like illness to pneumonia, respiratory failure, and death. 3 Currently, antivirals for treatment and vaccines for containment do not exist, with therapeutic strategies relying on supportive measures at best. As such is it incumbent on us as health care professionals to identify and protect the most vulnerable of our patients.
Studies examining the outbreak in Wuhan, China, demonstrated an association between known obesity-related comorbidities in symptomatic, hospitalized patients. Specifically, a systematic review and meta-analysis of 46,448 patients demonstrated hypertension, diabetes, cardiovascular and respiratory system disease was the most prevalent comorbidities in COVID-19–positive hospitalized patients. 4 Albeit COVID-19 disease severity was not specifically defined in this study, stratifying by severity demonstrated the presence of hypertension (odds ratio [OR] 2.36; 95% confidence interval [CI] 1.46–3.83), respiratory system disease (OR 2.46; 95% CI 1.76–3.44), and cardiovascular (OR 3.42; 95% CI 1.88–6.22) independently predicted more severe COVID-19 disease. 4 More recent evidence examining susceptibility to severe disease outside Wuhan suggested that characteristics of the most severe cases included older age, male gender, and the presence of hypertension (HTN), diabetes (DM2), cardiovascular disease (CVD), and/or malignancy, HTN, DM2, and CVD independently predicting severe disease in this study. 5 Finally, the Centers for Disease Control additionally lists living in a nursing home or long-term care facility, chronic lung disease or moderate to severe asthma, those who are immunocompromised including patients undergoing cancer treatment, and a person of any age with severe obesity (body mass index [BMI] >40) as being risk factors for severe illness. 5
Given that patients with obesity often check several of the preceding boxes, on a background of inadequate testing and lack of effective treatments, those of us who electively treat these patients for weight loss must make it our mission to protect them by keeping them healthy and motivated during this critical time. As such, with limited resources, including personal protective equipment and ventilation support, limiting patient exposure to the health care system and healthcare workers are the sine qua non in achieving this goal. As of March 25, 2020, there were over 436,159 confirmed cases and over 19,648 deaths worldwide, 6 with Italy accounting for 16% of cases but 35% of the deaths. In the United States, which leads the world in bariatric surgical case volume, 7 there were over 55,238 cases of COVID-19 with over 709 deaths. Assuming a lag time of about 2–4 weeks with respect to testing and health system preparedness, preventable hospital admissions will increase, resulting in more pressure on the healthcare system that has no release valve. If we are not proactive, we too may have to make difficult decisions on resource allocation based on the probability of survival. 5 Therefore the following information reflects an amalgamation of society recommendations and best practices.
Recommendations and Best Practices
Postpone all elective bariatric surgeries and procedures
As outlined above, medical conditions associated with COVID-19 disease severity are the same as the top-ranked comorbidities associated with obesity. Given the elective nature of bariatric surgery, and the fact that surgery itself is a stress on the body, to perform elective bariatric surgery at this time could do more harm than good for both the patient and the system, regardless of the degree of presurgery optimization. Indeed, the “Guidance for Triage of Non-Emergent Surgical Procedures,” released in March, 2020, by the Centers for Medicare and Medicaid Service (CMS) and the American College of Surgeons (ACS) recommended that elective cases be postponed. 8
In keeping with this, postponing elective bariatric procedures would help the health care system in three ways. First, postponing surgery would obviate patients from recovering in an environment with a higher prevalence of COVID-19 disease from either hospitalized COVID-19-positive patients and/or asymptomatic COVID-19-positive healthcare personnel, who have likely not been tested. Second, keeping patients out of the hospital and at home is a key strategy to flatten the pandemic curve. Finally, given the lag in response to this crisis, the need for ventilators will outpace supply if it has not already. Patients with obesity undergoing elective bariatric surgery have a much higher rate of reintubation compared to the nonobese general surgery population. 9 In a study by Biouw and colleagues, the rates of respiratory failure and total postoperative complications were 8% in the group with a BMI <43 kg/m2 and 14% in the group with a BMI >43 kg/m2. 8 Given that conservation of ventilators will be a key component to manage the impending COVID-19 surge, superimposing elective surgery on a patient population that is more likely to need ventilators would only add pressure onto a system that is ready to burst.
Therefore, in conjunction with recommendations from both the CMS/ACS and local state departments of health, bariatric programs housed in both academic and provate practice settings have followed these recommendations.
Continue to communicate with your patients
Maintaining a line of communication with bariatric patients during this period of uncertainty is essential for continuity of care. However, communication must be balanced with minimizing harm, and as such, utilizing telehealth technology is one way to follow patients postoperatively and also keep those whose surgeries were postponed engaged in their health. Certainly, the use of telehealth is not new, with evidence suggesting a positive impact on both patient satisfaction 10 and management of chronic conditions such as diabetes. 11 Therefore, practice standards should not change, although patients should be triaged such that only immediate postoperative patients and those experiencing complications related to surgery (e.g., dysphagia, poor oral intake, epigastric pain), should be scheduled for a face-to-face visit. For other patients, programs can establish a telehealth system through which patients can be called by their physician/advanced practitioner, nurse, dietician, exercise physiologist, psychologist, or any other health professional involved in their care, to ensure they remain on course both pre- and postoperatively. Ultimately, the use of telehealth, either through video or phone calls, will maintain a line of communication while minimizing exposure for both your patient and healthcare workers.
Protect your clinic staff
The key to restarting after the COVID-19 pandemic is over is to have your staff fully functional and healthy. If there is exposure to any of your office staff without the proper personal protection equipment, this may mandate a 14-day self-quarantine period for that staff member and most likely, the entire bariatric office and clinic staff. If possible, a work from home/stay at home environment could be implemented. Another option is to reduce your staff to a minimal number to reduce exposure risk. Key considerations should be whether you are an office-based or hospital-based facility.
Emergent and semi-emergent bariatric procedures
If the situation arises that a bariatric patient needs to be taken for an emergent surgical or endoscopic procedure, and the patient has tested positive or is being ruled out for COVID-19 disease, certain additional precautions should be implemented:9,10,11,13
All members in the OR should wear N-95 masks.
During laparoscopic cases or cases when CO2 insufflation is utilized, an ultrafiltration (smoke evacuation system) should be used. 14
During desufflation, all escaping CO2 gas should be captured with the ultra-filtration system or if available, desufflation mode should be used.
Specimen removal, if needed should be done after all CO2 gas is filtered out of the abdomen.
The surgical procedure or endoscopy should be done in a properly ventilated room. Intubation and extubation should be carried out in a negative pressure room. 15
Conclusion
Elective bariatric surgery should be postponed until the COVID-19 pandemic is over. Close follow-up of postoperative patients can be done via telemedicine if available. Patients in the pipeline for surgery should also be followed closely, but remotely, to ensure continued weight loss or weight maintenance. If emergent surgical or endoscopic intervention is needed, follow best practice guidelines.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.