Re-opening Weight Loss Surgery

COVID-19

It has been a miserable season worrying about COVID19, but hospitals have started elective operations. This is the letter from my partner, Dr. Helmuth Billy, to other hospitals in the Southern California area. Of note- weight loss surgery is the single best thing a person can do who is morbidly obese – and in the era of COVID19 it turns out that obesity is one of the major risk factors for people who get on the vent. So, if you are considering weight loss surgery, but worried about coming to the doctor’s office or hospital, please know that hospitals are the safest place you can go. Hospital staff (like myself) are screened daily, as is every person who enters the hospital. Weight loss surgery is the best thing you can do for your health. – Terry

\"ASMBSPersons with obesity around the world are already at high risk for severe complications of COVID-19, by virtue of the increased risk of the chronic diseases that obesity drives. On April 22, 2020 Governor Gavin Newsom stated that hospitals could begin rescheduling postponed and delayed operations that are “foundational to people’s health including tumor removals, heart valve replacements, colonoscopies and operations to treat chronic diseases like diabetes”1. Proceeding with metabolic and bariatric operations during this time of reopening operating rooms to elective operations meets the Governor’s definition of operations that are “foundational to people’s health” and should not be further delayed. To define bariatric surgery as purely elective and to delay patients who have already been postponed is not medically justified and is not supported by the medical literature.

The United States faces a high prevalence of obesity at 42.4% in 2017-2018. In addition, Americans have a high burden of class III obesity, with 9.2% of the population with BMI > 40 kg/m2. This has serious implications for our health care system during the Covid-19 pandemic. Metabolic operations gastric bypass, sleeve gastrectomy produce more than just a return to normal glucose levels, they reduce the mortality from all other causes and comorbid conditions (from 4.5 percent to 1 percent per year), reduce cardiovascular events such as strokes and heart attacks, reduce cancer mortality and improve or resolve hypertension, hyper-cholesterolemia, gastroesophageal reflux disease and obstructive sleep apnea. No other operative therapies have achieved such results. 2,3,4

As we move into the phase of reopening hospitals for elective operations there are significant benefits to patients and our healthcare system by proceeding with previously postponed bariatric operation. Bariatric surgery is the only operation that plays a direct role in the treatment and cure of diabetes. The most recent publications demonstrate that the morbidly obese patients are utilizing a disproportionate number of hospital beds, intensive care unit beds and ventilators among those hospitalized with Covid-19. We will no doubt experience a collision of the two public health epidemics in the US with obesity and COVID- 19 interacting to strain our health system to its 3,4

The article Obesity and its Implications for COVID-19 Mortality was recently accepted for publication in the journal “Obesity”. The authors review the devastating statistics with respect to untreated obesity and Covid-19 infections. During the Covid-19 pandemic obesity has become one of the pre-existing diseases associated with increased death. This should come as no surprise given the well documented impact of obesity on mortality during the previous H1N1 Influenza. The expected duration of current Covid-19 pandemic is unknown but is expected to extend into the fall 2020 and winter 2021. The prevalence of obesity in the US continues to be increasing. The impact of Obesity and mortality from COVID-19 should increase the sensitivity of clinicians as to the need for aggressive treatment of such patients.5

Over the past five weeks the combined efforts of social distancing, the shutting down of nonessential businesses and the focused effort of all Californians towards minimizing the potential spread of COVID-19 has resulted in a successful decrease in the numbers of coronavirus patients being admitted to California hospitals. In an effort to conserve personal protective equipment (PPE), maintain available hospital beds and maximize resources vital to the pandemic response, elective surgeries were temporarily suspended and thousands of operations were necessarily postponed and delayed. The healthcare systems of California have not experienced the expected overwhelming surge of COVID-19 patients. As a result, the process of reopening hospital operating rooms has begun and many hospitals throughout California will begin to move forward with elective surgery for patients whose operations were previously postponed.

As mentioned previously, on Tuesday April 22, Governor Newsom stated that hospitals could begin rescheduling postponed and delayed operations that are “foundational to people’s health including tumor removals, heart valve replacements, colonoscopies and operations to treat chronic diseases like diabetes”.

There is a clear distinction between purely elective operations such as common cosmetic procedures and operations to treat chronic disease. As hospitals develop protocols to allow the re-opening of operating rooms to elective surgery, it has become apparent that some facilities have unfortunately described bariatric operations used for the treatment of morbid obesity, diabetes, severe obstructive sleep apnea and hypertension as purely elective. In some cases, hospitals are still delaying the access to bariatric surgery and the operative care for morbidly obese individuals for reasons that are not justified.

Surgery for the treatment of morbid obesity and the common associated comorbid conditions of diabetes, hypertension, obstructive sleep apnea and other disease is not and cannot be considered a purely elective operation with the consequence of delaying these procedures indefinitely. The following statement was published by the American College of Surgeons on March 17, 2020.6

“It is not possible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. While some cases can be postponed indefinitely, the vast majority of the cases performed are associated with progressive disease that will continue to progress at variable, disease-specific rates.” – ACS communication 3/17/2020

At the early stages of the COVID-19 pandemic the American College of Surgeons published guidelines designed to conserve resources, manage beds, intensive care unit and ventilator census as well as preserving valuable personal protective equipment for front line providers and hospital personnel. Although these guidelines included postponement of elective operations, the risk of potential detrimental health care effects as a result of postponing elective surgery was encouraged to be monitored. The additional risks patients and the healthcare system would endure due to progression of chronic and untreated diseases is not known although it has become clear that some medical conditions, most notably morbid obesity, have contributed to poor patient outcomes should they become infected with COVID-19.

“Indeed, given the uncertainty regarding the impact of COVID-19 over the next many months, delaying some cases risks having them reappear as more severe emergencies at a time when they will be less easily handled.”

The American College of Surgeons has considered how hospital administrations, surgery departments and medical staff leadership should approach the issue of medical risk and further delay of elective operations.

“The medical need for a given procedure should be established by a surgeon with direct expertise in the relevant surgical specialty to determine what medical risks will be incurred by case delay.” 6

California’s experience during the H1N1 pandemic of April 2009 to January 2010 is directly relevant to the severity of the experience we can expect with COVID-19. In California between April and August 2009, 1088 patients with H1N1 Influenza were either hospitalized or died.7 Of 268 patients >20 years old in whom BMI was calculated, 58% had obesity (BMI >30) and 67% of those had severe obesity (BMI > 40). Sixty-six percent of those with obesity also had underlying diseases, such as chronic lung disease, including asthma, cardiac problems, or diabetes. 8

The H1N1 Influenza experience should serve as a reminder as to the need for the care of patients with obesity, and particularly patients with severe obesity. The growing body of evidence with respect to COVID-19 and obesity show that obesity plays a major role in COVID-19 mortality. We can furthermore expect that the proportion of patients with obesity, severe obesity, and COVID-19 infections will increase compared to the H1N1 experience. Resolution of diabetes and decreasing BMI occurs rapidly following bariatric surgery. For those patients that remain morbidly obese during this pandemic and subsequently test positive for COVID-19, the disease will likely have a more severe course in such patients. These observations also emphasize the need for increased vigilance and aggressive therapy for patients with obesity during the COVID-19 pandemic. There are no justifiable reasons based on the body of literature previously and recently published to exclude patients seeking bariatric surgery from the list of approved procedures being performed at hospitals and surgery centers as we progress to reopening of our operating room abilities at California Hospitals.

— Helmuth T. Billy, MD
President, Southern California Chapter ASMBS
May 4, 2020

  1. https://www.sfchronicle.com/politics/article/Gov-Newsom-says-California-hospitals-can-begin-15218992.php
  2. Kothari SN1, Nguyen NT, Who Would Have Thought It? Surgery Is a Treatment for Diabetes Ann Surg. 2015 Mar;261(3):43
  3. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222:339–350.
  4. Schauer PR1, Burguera B, Ikramuddin S, Cottam D, et al Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus Ann Surg. 2003 Oct; 238(4): 467–485
  5. Dietz, W, Redstone M., Santos-Burgoa, C., Obesity and its Implications for Covid-19 Mortality, Obesity (Silver Spring). 2020 Apr 1
  6. American College of Surgeons, COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures, March 17, 2020
  7. Louie JK, Acosta M, Winter K, et al. Factors associated with death or hospitalization due to pandemic 2009 influenza A(H1N1) infection in California. JAMA. 2009;302(17):1896–1902. doi:10.1001/jama.2009.1583
  8. Ryan D. H., Ravussin E., Heymsfield S., COVID 19 and the Patient with Obesity – The Editors Speak Out. Obesity (Silver Spring). 2020 May;28(5):847. Epub 2020 Apr 1
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