key: cord-0936531-so6c5nkc
authors: Santos, Melissa; Mackey, Eleanor; Gaffka, Bethany; Ward, Wendy; Burton, E Thomaseo
title: Bariatric and metabolic surgery during and after the COVID-19 pandemic
date: 2020-08-18
journal: Lancet Diabetes Endocrinol
DOI: 10.1016/s2213-8587(20)30278-3
sha: 941d4ed1625902be3c2538db122119ea648dc036
doc_id: 936531
cord_uid: so6c5nkc

nan

We read the article by Francesco Rubino and colleagues with interest. 1 It represents the recommendations of 23 authors on a diverse range of topics around bariatric and metabolic surgery during and after the COVID-19 pandemic, the collation of which is a difficult task. The methodology used to reach this consensus of opinion and recommendations needs to be detailed; we did not come across the use of any established instruments for this exercise, such as the Delphi or modified Delphi approach. 2 The authors very correctly highlight that the remission rate of type 2 diabetes with surgery is higher for patients with shorter diabetes duration. 1 The overarching theme in these recommendations is about prioritising patients who are likely to benefit the most and where delays would be more likely put patients into a more disadvantageous category. We therefore find the authors' recommendation to prioritise patients with diabetes of more than 5 years' duration puzzling and is in direct contradiction to their priority statements.

We would also like to draw the readers' attention to a recent publication by Luigi Angrisani and colleagues, 3 which took a different view from Rubino and colleagues. This article was co-authored by the president of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), along with the president-elect and at least seven other current or past presidents of IFSO chapters. Angrisani and colleagues state that patients with higher BMI and multiple comorbidities (with uncontrolled type 2 diabetes being one of the main areas of concern) are at risk of life-threatening COVID-19-related complications in the perioperative setting, thus concluding that surgery should be offered to patients who are more likely to recover from a possible infection. 3 The eligibility criteria for surgery proposed by Angrisani and colleagues included, among others, BMI below 50 kg/m² and no or controlled comorbidities. 3 Considering that obesity is a major risk factor for severe COVID-19 and its related mortality, obesity treatment could offer an opportunity to reduce the burden of COVID-19. Bariatric surgery, which is the most effective treatment in producing sustained, long-term weight loss, came to a standstill globally with the COVID-19 pandemic. Hence, there is a lot of interest in restarting bariatric surgery safely. The two opposing views we highlight might only add to the confusion in the field. A wider consensus is needed to ensure this life-saving treatment is delivered to patients in a timely manner.

We declare no competing interests. The COVID-19 pandemic has caused serious disruptions to the health-care system and has revealed substantial racial, ethnic, socioeconomic, and other health-care disparities. The role of obesity has also been highlighted, as obesity severity appears to be related to higher rates of hospitalisation and poorer clinical outcomes of COVID-19. 1 Obesity treatment has been hugely affected by the pandemic, leaving millions of children, adolescents, and adults at high risk for worsening comorbidities, with less access to treatment and increased risk for poor outcomes from COVID-19. We applaud Francesco Rubino and colleagues' recommendations for bariatric and metabolic surgery during and after the COVID-19 pandemic, published in The Lancet Diabetes & Endocrinology. 2 The attention to detail of resumption of services for individuals with obesity and diabetes are comprehensive and serve as a call to action for this important patient population. However, we were disappointed at the omission of psychosocial factors in their framework, which research suggests impact assessment and decision making for bariatric and metabolic surgery. Surgery teams are interdisciplinary, requiring the expertise of multiple providers, and the necessary role of a mental health provider on a surgical team is well documented. 3 Notably, clinics and insurance companies require extensive preoperative investment by patients to have access to surgery. The individuals who are now experiencing delays in their care have probably been eagerly anticipating needed treatment for their illness for many months. Even under normal circumstances, research indicates that waiting for surgery is anxiety provoking for individuals. 4 Now there is the additional stress of potential concerns about disruption to insurance coverage because of job loss, worries about risk of exposure to COVID-19, isolation, and lack of social support. Moreover, COVID-19 increases risk for compromised mental health overall, 5 resulting in another disproportionate burden on those with severe obesity who might already have high rates of psychological concerns. Obesity increases risk for poor physical and mental health outcomes related to COVID-19, and delaying surgery will exacerbate both of these risks, necessitating monitoring by and involvement of both medical and mental health providers.

To complement the proposed framework, we urge that mental health concerns be assessed for those at risk for surgery delays and that such assessments be included in determining who is prioritised as urgent for surgery. Mental health providers play an important role on surgery teams in assessment, support for psychological concerns, promotion of healthful behaviour change, and adherence to treatment and behaviour change.

We declare no competing interests.

Division of Psychology, Children's National Hospital

High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) requiring invasive mechanical ventilation

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

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

Health status, quality of life, and satisfaction of patients awaiting multidisciplinary bariatric care

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

We sincerely appreciate the comments by Bruno Halpern and Marcio Mancini about our Personal View on bariatric and metabolic surgery during and after the COVID-19 pandemic. 1 We take this opportunity to clarify the objectives of the Diabetes Surgery Summit (DSS) recommendations regarding the prioritisation of patients who are already candidates for bariatric or metabolic surgery. The authors assert that individuals with diabetes and established cardiovascular disease should be treated with SGLT2 inhibitors or glucagon-like peptide-1 receptor agonists instead of bariatric or metabolic surgery, because the former have been shown in randomised controlled trials to reduce cardiovascular disease, whereas there is less evidence for that with bariatric and metabolic surgery in this population. However, our current treatment algorithm is not designed to help to decide between surgical and pharmaceutical diabetes therapies. Rather, it prioritises the timing of operations among patients who are eligible for surgery and have already decided to undergo it, presumably because medical or lifestyle interventions have proven insufficient.We heartily agree that a secondary prevention cardiovascular outcomes randomised controlled trial on surgical versus medical treatments for obesity and diabetes is needed, and we are attempting to actualise this. Nevertheless, it is clear that tight glycaemic control reduces diabetes microvascular complications and, in the long term, macrovascular events, 2 as well as that bariatric and metabolic surgery almost universally improves hyperglycaemia, causing diabetes remission in most cases. 3 Thus, it seems highly likely that such operations reduce cardiovascular disease. Numerous excellent observational studies have reported this, and 29 independent investigations have universally found bariatric and metabolic surgery to be associated with reduced mortality among patients with and without established cardiovascular disease. 4 We are aware of evidence currently under review showing impressive reductions in major adverse cardiovascular events after bariatric and metabolic surgery, specifically among patients with preexisting cardiovascular disease. In a study presented in 2018, bariatric and metabolic surgery has proven to confer significant protective effects on patients who, after surgery, end