How High a Priority Is Bariatric Surgery During COVID-19?

Miriam E. Tucker

July 20, 2020

The American Society for Metabolic & Bariatric Surgery (ASMBS) has issued a statement declaring that obesity surgery is not "elective" and should be resumed as soon as it's safe to do so during the COVID-19 pandemic.  

The ASMBS statement, "Safer Through Surgery," was published online in Surgery for Obesity and Related Diseases by the ASMBS executive committee.

It is a reaction to the fact that some US states have placed metabolic and bariatric surgery in the same low-priority category as cosmetic surgery as examples of "elective" procedures that should be among the last to be restarted when pandemic restrictions are eased.

Rather, ASMBS argues, although obesity surgery must be postponed along with other non-emergency procedures when surges in the novel coronavirus make them unsafe, such operations should be resumed as soon as possible along with other medically necessary procedures.

"Metabolic and bariatric surgery is NOT elective. Metabolic and bariatric surgery is medically necessary and the best treatment for those with the life-threatening and life-limiting disease of severe obesity," the statement says.

And obesity itself is a major risk factor for worse COVID-19 outcomes, ASMBS President Matt Hutter, MD, told Medscape Medical News, noting that individuals with obesity are "more likely to be in [intensive care units]."

"Mortality rates are higher, even in young patients. And [obesity] associated with other comorbidities including diabetes and heart disease...We know the clock is ticking for some folks. For those with early diabetes, the sooner the [bariatric] surgery the more likely it is [for diabetes] to go into remission."

Because the pandemic may be around for a while, "If we can make people [with obesity] safer...because they've had surgery...they may be better off," should they get COVID-19 later, he pointed out.

Hutter noted that the ASMBS recorded a series of webinars, archived on the society's website, with panels discussing in-depth issues to consider in prioritizing patients when re-starting metabolic and bariatric surgery.

There are some differences of opinion, such as whether the sickest patients should be the first to have the surgeries upon re-opening, or whether those individuals might be worse off if they contract COVID-19 in the perioperative setting.

"I don't think there's a right or wrong answer, but I think we have to figure out what's right for the individual patient, considering their specific risks of having versus not having surgery, of waiting 1 month, 2 months, or 6 months. One thing we do know is that obesity is a significant disease."

"Before, During, and After COVID, Obesity Itself Remains an Epidemic"

Asked to comment on the ASMBS stance, Obesity Society president Lee M. Kaplan, MD, PhD, sent Medscape Medical News a statement.

"We do not fully understand which aspects of obesity pathophysiology...are most responsible for the adverse COVID-19 outcomes, nor do we know the degree to which reduced access to care, social isolation, and other social and environmental determinants of health disproportionately affect COVID-19 patients with obesity," he noted.

"At this early stage, we have not yet determined the impact of weight loss and various types of anti-obesity therapies on these risks."

Nonetheless, Kaplan said, "the extended COVID-19 pandemic underscores the importance of increasing, not diminishing, our commitment to understanding and treating obesity, using all available, evidence-based therapies, including lifestyle modification, anti-obesity medications, bariatric surgery, and combinations thereof."

As all health care delivery is being re-organized around the pandemic, Kaplan added, "Rethinking and changing our approach to obesity needs to be a central feature of this process."

"Before, during, and after COVID, obesity itself remains an epidemic. Its high global prevalence, increasing severity, and profound impact on all aspects of health and disease require that it be addressed more universally within the health care system, with the same commitment afforded to other chronic diseases."

Obesity treatment isn't generally considered an emergency, he noted, "because obesity is a chronic disease, whose adverse health effects often accumulate slowly and insidiously. Its generally slow progression allows for careful and coordinated care planning, and advanced scheduling of therapeutic interventions, including surgery. These characteristics, however, should not lead us to infer that treating obesity itself is optional."

Hutter has reported receiving honoraria from Ethicon and Medtronic, and is a consultant for Vicarious Surgical and Sigilon Therapeutics. Kaplan has reported consulting for Boehringer Ingelheim, Fractyl, Gelesis, GI Dynamics, Johnson & Johnson, Novo Nordisk, Pfizer, Rhythm Pharmaceuticals, the US National Institutes of Health, and the US Department of State.

Surg Obes Relat Dis. Published online June 5, 2020. Full text

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