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Revista argentina de cirugía

versión impresa ISSN 2250-639Xversión On-line ISSN 2250-639X

Rev. argent. cir. vol.112 no.3 Cap. Fed. jun. 2020 


Recomendations for elective bariatric surgery during the COVID-19 pandemic

Comisión de Cirugía Bariátrica y Metabólica

In the current setting, the Board of Directors defined that the recommendations and guidelines generated by Asociación Argentina de Cirugía during the COVID-19 pandemic should be implemented according to the following issues:

The surgeon is responsible for the decision‐making process about the surgery, based on the regulations issued by the Crisis Committee according to the phase of the pandemic (described by the Spanish Association of Surgery) in which the health institution is located and to the viral replication in the corresponding geographical area, ad-referendum to the recommendations of the National and Regional Health Authorities.

July 2020

Joint document prepared by the Committee on Bariatric and Metabolic Surgery of Asociación Argentina de Cirugía

This document updates and replaces the recommendations made in May 2020. These recommendations may be rapidly modified, so they should be continually checked for possible updates.

They constitute a guideline but are not intended to replace medical judgment in any way.

These recommendations have been made based on the current knowledge of the COVID-19 pandemic, supported by expert recommendations and society consensus1-27and in accordance with the local situation, where the performance of the health institutions that have adapted to the infection has already been assessed.

The surgical treatment of severe obesity and its comorbidities (type 2 diabetes mellitus, cardiovascular diseases, respiratory diseases, liver involvement, disabling osteoarthritis, etc.) is an ELECTIVE PROCEDURE THAT CANNOT BE POSTPONED, is medically necessary and is the best treatment for these conditions. Deferring this surgery produces overall impairment in the patient, progression of obesity and life-threatening comorbidities, and increases costs of direct and indirect medical care 28-53.

The health measures adopted to prevent massive infections and the restrictions imposed by executive decrees in relation to the COVID-19 pandemic resulted in unwanted disruption of programmed medical care in general. A survey conducted by the SACO reported a reduction of more than 90% of bariatric surgeries and 75% of consultations before and after bariatric surgery, leaving many morbid obese patients exposed to serious consequences of an eventual SARS-CoV-2 infection.

Since the beginning of the pandemic, there is clear evidence that obesity predisposes to a greater number of SERIOUS CASES OF COVID-19 IN YOUNG PEOPLE, increasing THE RISK OF COMPLICATIONS by 3.4 times and the MORTALITY RATE1-12. According to Boletín integrado de vigilancia en Argentina N502 SE26 released on July 13,202054, these data identified in other countries are reproduced in Argentina, where diabetes and obesity are the main risk factors associated with COVID-19 mortality in patients < 60 years. In addition, a recent report revealed that obese patients have HIGHER RISK OF SARS-CoV-2 INFECTION and prolonged viral shedding, suggesting that quarantine in obese subjects should be longer than in normal weight individuals12.

The following information has been collected by the SACO and the AAC among their members, emphasizing the appropriate criteria for restarting elective bariatric surgery:

▪▪Mean age of patients in the waiting list ranged from 30 to 50 years.

▪▪Most procedures have short duration and are performed following a protocol55.

▪▪Mean hospital length of stay is short (1.6 days)55.

▪▪ICU requirement is rare, < 1%55.

▪▪89.3% of the institutions performing bariatric surgery have been adapted to treat COVID-19 negative and positive patients.

▪▪There were no cases of SARS-CoV-2 infection after bariatric surgery during the pandemic, like other countries24.

▪▪The rate of complications does not seem to be affected by the pandemic56.

▪▪Surgery prevents the progression of a chronic disease as obesity and its comorbidities (diabetes, hypertension, OSAS), thus reducing the risk of unfavorable outcome in case of infection with SARS-CoV-239-53.

▪▪The impaired immune system in morbidly obese patients is reversed with bariatric surgery57-58.

▪▪Many patients preparing for surgery who had their intervention postponed have already accumulated a significant delay (which can exceed one year). AND A LARGE NUMBER of severely obese patients have given up starting or continuing the necessary process to solve their problem, which will necessarily lead to a prolonged delay.

▪▪Many patients require bariatric surgery to access to other types of treatments, which are also delayed if bariatric surgery is postponed.

From a public health- and patient-centered point of view, it is essential to resume bariatric and metabolic surgery in all the patients with an indication. These surgeries should be performed when the patient is in clinical condition to undergo the procedure according to the criteria of the treating team, without arbitrary delays imposed by their medical coverage, since there is scientific evidence that preoperative waiting does not reduce complications or improve results in terms of weight loss or resolution of comorbidities59-60. Furthermore, there are no medical or legal reasons to let a sick patient persist with his/her illness for a prolonged period to obtain the indicated treatment.

The global nature of the disease, the possibility of a second wave or persistent infection in some regions around the world, together with the more traditional risks such as annual influenza outbreaks, could lead to a potentially indefinite postponement. For this reason, the guidelines should define the conditions for safe bariatric surgery.

The following recommendations are made in view of the high risk of viral transmission, the difficulty in detecting its presence in 100% of the carriers, even those who are asymptomatic, its incubation period and persistence in humans, the particular exposure of health care workers to the virus, the increased risk of serious complications in obese patients are the and the diversity of the epidemiological situation in the country.

For the Region

Rationale: The degree of viral circulation in the community is critical to assess the risk of asymptomatic infection and to manage the diagnostic resources and personal protective equipment for the health care team.

The rate of new infections within the past 15 days does not constitute a contraindication for surgery. Based on the epidemiological context, the treating team should consider the feasibility of scheduled surgery and define the necessary safety measures.

Scheduled medical practice and elective surgeries should not be banned by the competent health authority.

For the Institution

Rationale: SARS-CoV-2 is transmitted by contact with secretions of patients or by droplets expelled by the carriers. For this reason, the institution where elective surgery is to be performed must strictly follow protocols for the isolation, hygiene and monitoring of workers.

To perform elective surgery, the institution must meet certain requirements:

There must be separate areas for COVID-19 positive and negative patients, including ICU and operating room.

The institution should provide the health care workers with information and protective measures and monitor them to prevent infection among staff members and patients.

Cleaning protocols for the different areas of the institution should be improved to minimize the presence of contaminating particles on contact surfaces.

Personal protective equipment should be provided to all the professionals according to the case.

For the attending team

Rationale: The health care workers are probably the main vectors of viral transmission and are at high risk of infection when treating patients who are virus carriers but have not been detected.

Therefore: Every member of the team should receive basic information about the COVID-19 pandemic, personal hygiene and protection measures for each type of contact with colleagues and patients and should know the institutional protocols in case of confirmed or suspected COVID-19 patients.

It is highly recommended that the members of each team develop their activity in a single institution. Otherwise, they should work in the same epidemiological area, avoiding traveling to and from regions or provinces with different health situations.

The team should offer electronic consultation services for preoperative assessments and postoperative follow-up, ensuring fluent communication with the patient. The medical coverage systems should ensure this service to their members.

Equipment available

Rationale: To reduce the possibility of infection of any member of the team, the necessary equipment for personal and operating room protection must be available for each situation of exposure.

The institution must provide the personal protective equipment required for each level of protection.

The usual protection used in any surgery is recommended in COVID-19 negative patients and with low risk criteria for SARS-CoV-2 infection (except in case of institutional regulations).

If SARS-CoV-2 infection is not suspected in a patient and there is no possibility of testing, the level of protection will be determined by the institutional protocols and in line with the decision of the attending physician.

Protection level 3 should be used in cases of positive or suspected patients requiring emergency surgery: disposable clothing, fluid resistant gown, hermetic goggles, N95 respirator and face shield.

For the patient

Rationale: Determining the priorities for elective surgery is a matter of debate. Certain positions recommend the selection of younger patients with few comorbidities and more favorable conditions, while other recommendations give priority to seriously ill patients with a higher probability of complications or progression of their comorbidities61. This decision will be at the discretion of the treating team, based on their experience and ability to manage more complex patients, following the guidelines of the Consenso Intersocietario de Cirugia Bariátrica y Metabólica 201940.

For every patient who is a candidate for elective surgery, the treating team should evaluate the risk of performing the procedure, considering the impact of the pandemic on their institution, in terms of safe separate paths and availability of resources, as opposed to the risk of postponing the surgery in light of the patient’s clinical situation.

The following recommendations are established for all elective surgeries in the context of the pandemic and should be maximized in areas with the highest community circulation of the virus.

Patients must have completed strict isolation during the previous 14 days, without developing activities that exposed them to contact with other people and keeping social distancing at home from other members of the family with greater social exposure.

Surgical masks should be used during visits to the health center.

Absence of symptoms of SARS-CoV-2 infection within the previous 30 days before the intervention.

They must not have had contact with a COVID-19 positive patient within 30 days before surgery.

Patients with previous SARS-Cov2 infection should not present functional consequences and should have a recent test to rule out the presence of virus. If the patient has been asymptomatic, the recommendation is to wait 21 day and perform new PCR test before surgery. It is recommended not to delay surgery for more than 2 months since recent studies have reported that antibodies decreased to undetectable levels in 40% of asymptomatic and 13% of symptomatic individuals 8 weeks after recovery from COVID-1962,63.

Patients must be tested for SARS-CoV-2 within 72 hours before surgery according to the regulations and the own resources of each institution. If the patient has fulfilled the medical indications and has tested negative, the surgical plan will continue. In case the regional health authorities do not authorize the test, the attending team will determine whether clinical screening and a chest x-ray are sufficient. If the test is positive, the procedure should be deferred until the infectologist at the institution considers it safe for the patient and the health staff.

Patients must be informed of the ways of transmission of SARS-CoV-2, the necessary hygiene measures to protect their health and the risks of undergoing an elective surgery in this context, assuming this risk by signing the informed consent form. We suggest adding the COVID-19 Contingency Appendix proposed by Asociación Argentina de Cirugía (April/2020) to the informed consent form.

During hospitalization, limit to one visitor per patient in the room or do not permit visitors according to the institutional policy. If one visitor is permitted per patient in the room, he/she should not have typical symptoms, should have been in strict isolation for 14 days before surgery and should wear a mask during the visit.

The hospital length of stay will be reduced to the maximum extent possible.

Patients must undergo strict social isolation, similar to the one of the preoperative period, for 15 days after surgery, and will wear surgical masks at all times.

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