Surgical dilemmas: Should bariatric surgery for people with diabetes be delayed during the COVID-19 pandemic?
As hospital beds fill with COVID-19 patients, elective surgery is being delayed for millions of people across the world and doctors in every area of medicine are having to make tough decisions about who gets treatment and who must wait. Even once the pandemic begins to recede, waiting times will continue to lengthen as pent-up demand for surgery is worked through.
Presenting at the 18th World Congress on Insulin Resistance, Diabetes and Cardiovascular Disease (WCIRDC) in December, Professor Geltrude Mingrone, Associate Professor of Internal Medicine at the Catholic University of Rome and Professor of Diabetes and Nutrition King’s College London gave an interesting summary of how this dilemma is unfolding in metabolic and bariatric surgery.
Professor Mingrone first questioned whether it’s obesity per se or its comorbidities that increase risk of COVID-19 infection. Our understanding of the links between obesity and COVID-19, the influence of comorbidities and who is at higher risk of severe infection is evolving. And with so many papers being published, there are bound to be discordant opinions when data clashes.
The benefits of metabolic and bariatric surgery, such as reduction in all-cause mortality, are well demonstrated outside of the pandemic, but an important question during the pandemic is whether surgery might reduce susceptibility to SARS-CoV-2 infection. Here, Professor Mingrone highlighted a French survey which showed that patients who had been operated on a year before lockdown and those still on a waiting list had similar rates of infection (although a bias was that cases were identified as likely or unlikely based on self-reporting symptoms, not tests). More work is needed to get a definitive answer to that question.
She cited a Personal View from the Diabetes Surgery Summit in The Lancet Diabetes & Endocrinology, which discussed why most elective surgery should be delayed during the pandemic because the risk of infection is there not only for the patient but also for medical staff – laparoscopy used in metabolic and bariatric surgery generates aerosols. In addition, there are the inherent risks of surgery and increased hazards of severe COVID-19 complications among patients with obesity and type 2 diabetes. All of this needs to be balanced with the risk of disease progression from the delayed operation.
So what can we do to mitigate harm when surgery is delayed and access to post-operative care is restricted? Those with obesity and diabetes should be encouraged to optimise glycaemic control by intensifying lifestyle changes, although Professor Mingrone acknowledged that this is difficult in a group with generally poor compliance. Another tool is prescription of medications that reduce bodyweight, such as SGLT-2 inhibitors and GLP-1 receptor agonists. Dietary interventions may be needed for those with obesity.
Post-operatively, telemedicine should be used to manage patients, monitoring for nutritional deficiency along with the prescribing of weight-reducing diabetes medications in people with persistent or recurrent type 2 diabetes.
In preparation for surgery resuming, stigmas surrounding metabolic/bariatric procedures should be broken down by healthcare professionals to ensure operations are not further delayed, and pre-operative screening for COVID-19 should be mandatory for people with obesity and diabetes due to their much-increased risk of complications from the disease.
New EASD e-Learning courses on recent literature around diabetes and COVID-19 as well as on diabetes and metabolic surgery are currently in development and will be launching in 2021.
The opinions expressed in this blog are those of the author, Dr Eleanor D Kennedy.
Sessions at the 18th World Congress on Insulin Resistance, Diabetes and Cardiovascular Disease (WCIRDCD) are now available online at https://www.wcir.org/virtualmeeting