Abstract
In December 2019, the outbreak of SARS-CoV-2 started in mainland China, rapidly spreading across the globe. Currently, there is a global pandemic situation, and, with more or less success, countries such as Italy, Spain, France, and United States have initiated a first-level response. In this framework, the management of morbidly obese patients has been greatly affected. This article reviews the current hotspot issues and discusses different management strategies for patients with morbid obesity during the pandemic. The aim of this communication is to provide advice to bariatric/metabolic surgeons worldwide regarding the management and treatment of morbidly obese patients during this COVID-19 pandemic.
The current pandemic of COVID-19 is caused by the infection of a new coronavirus named SARS-CoV-2. Coronaviruses are a large family of viruses that are common in humans and many other animal species, including camels, cattle, cats, and bats. Animal coronaviruses have the potential to recombine with human strains, creating new viruses that can spread widely through naive populations. Although very rare, this has already happened earlier with MERS-CoV and SARS-CoV, and it seems that it is also the origin of the SARS-CoV-2.
In December 2019, an outbreak of a new coronavirus infection was noticed in Wuhan (Hubei Province, China). The Law of the People's Republic of China on the Prevention and Treatment of Infectious Diseases distinguishes three levels of risk, grading from A to C. There are only two diseases under Class A, the cholera and the bubonic plague. On January 20, 2020, the Chinese National Health Commission announced that the new coronavirus infection would be included as Class B, but should be treated similar to a Class A disease. 1 Nevertheless, it spread rapidly across China and has now reached the rest of the world. The outbreak has been declared a pandemic, 2 and countries such as Spain, France, and the United States have initiated, with more or less success, a first-level response.
Data are changing constantly, but to date there are more than 270,000 confirmed cases and more than 6500 deaths in the United States. Worldwide, the toll rises to more than 1.2 million infected and 66,000 deaths. Currently, age and obesity are known risk factors for mortality in patients with SARS-CoV-2 infection. However, according to a Chinese observational study based on 72,314 patients, other conditions such as a previous cardiovascular disease, diabetes, hypertension, chronic obstructive pulmonary disease, and cancer have also been associated with a higher COVID-19 mortality (10.5%, 7.3%, 6.3%, 6%, and 5.6%, respectively). 3 In this scenario, the management of morbidly obese patients has been greatly affected.
Characteristics of Morbid Obesity and Challenges in Diagnosis and Treatment During the Pandemic
Bariatric patients have a myriad of metabolic disorders, a deficient immune system, and a poor nutritional status, leading to a higher cardiovascular risk and a higher rate of premature death.4–6 Currently, overweight and obesity are the fifth leading cause of death risk worldwide, with more than 2.8 million adults dying annually. Moreover, they contribute to 44% of the health burden of diabetes and 23% of the health burden of ischemic heart disease. Even 7–41% of certain cancer loads are attributable to obesity.4,5 In this population, coronavirus can cause more severe symptoms and complications.
Nationwide surveillance data of COVID-19 patients show that the prevalence of severe obesity is ∼1.3%. Compared with nonobese patients, patients with morbid obesity have a higher risk of developing a severe form of the disease and of exhibiting a faster deterioration. 7 Therefore, specific management measures and reasonable response strategies are urgently needed to minimize the impact of this pandemic on morbidly obese patients.
Morbidly Obese Patient's Management in the Preoperative and Postoperative Periods
In a recent report from the Iranian experience, Aminian et al. described four patients who underwent elective abdominal surgery, of whom three developed postoperative complications. Out of these three cases, two died within the first postoperative month. Interestingly, the fourth patient was morbidly obese and due for bariatric surgery. He contracted COVID-19 and died the day before the scheduled procedure. 8
In order not to expose obese patients to unnecessary risks, many surgical associations, including the American College of Surgeons (ACS), have issued COVID-19 specific guidelines.9–11 In short, the general recommendation is that, for the moment, all nonemergency activity related to metabolic and bariatric surgery should be stopped.
Both standard bariatric procedures and revisional/corrective surgery should be delayed for the next few months, until conditions improve, and elective preoperative workout should be postponed. Besides, it is advisable to modify postoperative follow-up pathways. Bariatric patients could undergo only outpatient clinic consultations, avoiding direct physical contact with health professionals. Fortunately, apart from telephone calls, new technologies offer more attractive alternatives that range from direct videocalls to doctor–patient communication groups through social media. 12 Moreover, regular follow-up lab tests should be also postponed. In the absence of blood tests, nutritional supplements may be continued according to standard protocols.
A multidisciplinary team, including nurses, surgeons, and endocrinologist, should be aware of the specific needs of these patients undergoing a preoperative study or postoperative follow-up. Clinical departments and expert teams could open online consultation platforms to allow patients to get suitable guidance and emotional counseling. A maximal use of telemedicine should be used at this time to minimize morbidly obese patients' risk to get infected by SARS-CoV-2.
Emergency Response and Management of Morbidly Obese Patients During the Pandemic
In case of perforated marginal ulcer, bleeding, anastomotic or staple-line leaks, small bowel obstruction, or gastric band complications, however, the required surgical procedures may not be delayed. However, the intraoperative and postoperative safety for both patient and surgeon should be guaranteed. 11 Bariatric surgeons will need to follow the available security protocols from their own institutions should an emergency surgery be performed during the COVID-19 pandemic. 10
Laparoscopic surgery could have certain advantages compared with laparotomy because of two important aspects: less contact between the surgeon and the patient and a faster postoperative recovery. As opening the stomach or small bowel can expose intestinal contents and liberate aerosols, the relatively closed operative field of laparoscopic surgery could reduce the exposure and virtually eliminate the environmental aerosols generated by electrical equipment and dispersion. 13 Thus, it would seem reasonable to favor fully laparoscopic procedures and, especially, intracorporeal anastomosis. Obviously, there is no scientific evidence to support that statement for SARS-CoV-2 infection, but it has been proven in other related viral diseases. 14 On the other hand, the procedures should be as limited as possible. Besides, an operation room with negative pressure is mandatory and trocar removal would need to be done carefully, to avoid a high-pressure efflux of contaminated air.
Moreover, current research has shown that SARS-CoV-2 can be transmitted through direct contact and also through microdroplets, even by asymptomatic carriers. In addition, the virus has been isolated in the feces and blood of patients, so fecal
It must be emphasized that, before any emergency treatment, all patients would need to be rigorously screened to exclude an active or inactive COVID-19 infection. 11 If the diagnosis of SARS-CoV-2 infection is confirmed, the patient would need to be quarantined immediately. An expert consultation would be warranted, and an individualized treatment plan should be designed according to the risks and situation of the patient. Some critical conditions, such as a life-threatening gastrointestinal bleeding or an acute intestinal obstruction, may need to be transferred to the designated hospital for isolation and emergency surgery. A notification to the infectious diseases control authorities within the institution should also be issued as soon as possible.
General recommendations for morbidly obese patients, with or without a previous bariatric procedure
According to the previously exposed data, and given the ongoing pandemic situation, we strongly recommend our colleagues to consider the following bullet points about the best practice in the management of morbidly obese patients:
Any elective bariatric surgery, including revisional procedures, should be postponed until a safe perioperative management can be guaranteed. All nonemergency bariatric procedures should be postponed. Preoperative workout should be cancelled and postoperative follow-up severely minimized. Telemedicine strategies should be prioritized. Bariatric patients without symptoms and without a history of epidemiological contact should be strongly advised to wear masks and other personal protective equipment, as well as to respect social distancing. Bariatric patients with a suspected SARS-Cov-2 infection should be observed and treated in isolation. In the emergency room, the principles of management for these patients are the same as for any other patient. The treatment of any respiratory, neurological, or digestive symptoms must be prioritized in patients with positive SARS-CoV-2 test. Only in life-threatening situations, a major surgery should be considered. The risk of delay to the individual patient should be balanced against the availability of resources for patients with COVID-19. According to the criteria established by the WHO, it is advisable to screen for a SARS-CoV-2 infection in patients who undergo an emergency surgery. No strong recommendations can be made about the selection of a laparoscopic or an open approach. The one that minimizes surgical time and maximizes safety for both patients and health care staff should be preferred. After an emergency surgery, SARS-CoV-2 infection should be included in the differential diagnosis of immediate, early, and late postoperative fever, with or without respiratory symptoms.
Limitations of this work
There is a paucity of high-evidence published data about the specific management of bariatric patients. This text is based on the latest literature, produced mainly in China, following the pandemic of SARS-Cov-2. It is a dynamic document that will need to be updated, as more evidence is made available.
Summary and prospects
At present, the COVID-19 pandemic is still severe in many countries and morbidly obese patients are especially at risk. This situation requires us to adjust the treatment strategies to avoid unnecessary exposures for both patients and health professionals. Only life-threatening emergency operations should be performed, and any required outpatient consultation should try to take advantage of new technological platforms. Through the joint effort of all society statements, a common victory over the pandemic will be achieved soon and treatment of obese patients restored to normality.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.