Guidance for bariatric surgery during, beyond COVID-19
Bariatric surgery may play a role in reducing the risk for severe COVID-19 disease course among adults with obesity; however, guidance is needed regarding best candidates and which procedures might be safely delayed, according to a speaker.
“Individuals hospitalized for COVID-19 infection have the same prevalence of obesity compared with the general population, and obesity comorbidities are the cause of the severity of COVID-19,” Geltrude Mingrone, MD, professor of diabetes and nutrition at King’s College London, United Kingdom, told Healio. “Moreover, bariatric surgery should be performed for individuals with severe obesity and relevant associated diseases to improve their health and COVID-19 outcome.”
Mingrone said it is important to understand what data suggest regarding obesity status and association with COVID-19 disease course, as well as who should be prioritized for elective surgery during a pandemic to help minimize their risk for COVID-19 mortality.
Conflicting obesity data
Study data suggest that obesity alone may not be associated with COVID-19 outcomes and mortality, Mingrone said during an online presentation at the virtual World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. She cited a prospective study published in The Lancet assessing epidemiology, clinical course and outcomes of 257 critically ill adults with COVID-19 in New York City, of whom 119 (46%) had obesity, defined as a BMI of at least 30 kg/m². In the analysis of risk factors for in-hospital COVID-19 mortality, a BMI of at least 40 kg/m² was not associated with COVID-19 death; however, hypertension, chronic obstructive pulmonary disease and diabetes were, she said.
Similarly, in an analysis of more than 10,000 Veterans Affairs patients published in JAMA Network Open, the only weight-related significant predictor of COVID-19 mortality was a BMI of less than 18 kg/m², indicating malnutrition and underweight, Mingrone said.
“Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity,” she said.
There are discordant opinions regarding obesity and COVID-19 risk, particularly with smaller studies, Mingrone said. Race and socioeconomic disparities also play a role in risk for worse COVID-19 disease course, she said.
Bariatric surgery, COVID-19 risk
Clinicians and surgeons must balance the risk for severe COVID-19 complications in obesity with comorbidities such as type 2 diabetes vs. risk of progression of COVID-19 when bariatric surgery is delayed, Mingrone said. Compared with medical management, bariatric surgery is shown to reduce risk for all-cause mortality and is associated with a reduction in vascular complications, in particular microvascular complications, among adults with obesity and type 2 diabetes. She noted that the association is attenuated among those with a diabetes duration of at least 4 years.
In cases when bariatric surgery is urgently needed, “the patients usually need to stay in intensive care for several days,” Mingrone said. “Since we are struggling with resources during the COVID-19 outbreak and we need the beds, this is a problem.”
Expert consensus suggests patients be stratified to three categories of access to bariatric surgery. “Urgent access,” or surgery within 30 days, is recommended for adults with obesity and unstable clinical conditions with the potential to deteriorate quickly. Examples include severe dysphagia or vomiting from anastomotic stenosis, symptomatic internal hernia, severe nutritional deficiencies or acute, gastric band-related complications.
Expedited access, or surgery within 90 days, is recommended for adults with obesity and complex medical regimens or insulin requirements, substantial risk for morbidity or mortality and conditions in which weight loss, metabolic improvement or both are required to allow for other time-sensitive treatments.
Standard access, or surgery after 90 days, is recommended when a patient’s conditions are unlikely to deteriorate within 6 months, when there is only mild dysfunction or symptoms, and when delaying surgery beyond 90 days is unlikely to reduce the effectiveness of surgery, Mingrone said.
For nonsurgical options, “we can prescribe drugs which reduce body weight, like GLP-1 receptor agonists and SGLT2 inhibitors,” Mingrone said. “For those patients with obesity and without diabetes, we should use anti-obesity medications and, when necessary, a very low-calorie diet or liquid meal replacement programs.”
For patients who already underwent surgery, utilize telemedicine as much as possible, and consider weight-reducing diabetes medications for those with persistent or recurrent type 2 diabetes after surgery, she said.
Access to pharmacotherapy, vaccines
In a Q&A session after the presentation, Mingrone noted that health systems should advocate for greater access to obesity medications for those with excess weight, particularly during COVID-19-related lockdown periods, when physical activity may be limited.
“These drugs are costly and often paid for out of a patient’s own pocket,” Mingrone said. “During this time, government should try to help people access these medications to lose body weight during this lockdown period.”
Asked about priority access in the U.K. for a COVID-19 vaccine for those with a BMI of at least 40 kg/m², Mingrone said there is currently not enough evidence to prioritize some categories of obesity over others.
“Rather than prioritize people with a BMI higher than 40 kg/m²— severe obesity — we should try to prioritize people with obesity and complications, like diabetes or respiratory conditions,” Mingrone said. “There are people with severe obesity who may not have complications. Those people could wait longer for a vaccine vs. those at higher risk.”
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Mingrone G. Obesity and metabolic surgery during and beyond COVID-19. Presented at: World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease; Dec. 3-6, 2020 (virtual meeting).
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