ASMBS Statement on Resumption of Surgery Released

[Alex Brecher 10,502]

American Society for Metabolic and Bariatric Surgery (ASMBS) calls for safe resumption of bariatric and metabolic surgery before COVID-19 pandemic is declared over

Newberry, Fla. — Jun. 23, 2020 — The American Society for Metabolic and Bariatric Surgery (ASMBS), the leading organization of bariatric surgeons and integrated health professionals in the nation, declared metabolic and bariatric surgery "medically necessary and the best treatment for those with the life-threatening and life-limiting disease of severe obesity" and called for the safe and rapid resumption of procedures, which have been largely postponed along with other surgeries deemed elective amid the COVID-19 pandemic.

In a new position statement entitled, "Safer Through Surgery," published online in the journal SOARD, the ASMBS strongly rejects classifying metabolic and bariatric surgery as "elective" and prefers the use of the term "Medically Necessary Time-Sensitive Surgery" or "Medically Necessary Non-Emergent Surgery" to better characterize the effectiveness of the intervention and the progressive nature of the many diseases it treats including obesity, type 2 diabetes, hypertension and heart disease.

"COVID-19 may be a factor for quite some time and the longer the treatment of obesity, type 2 diabetes and other related diseases are postponed, the greater the chance they will become worse," said Matthew M. Hutter, MD, MPH, president of the ASMBS and professor of surgery at Harvard Medical School. "Each state, doctor and patient must make a decision as to when conditions for metabolic and bariatric surgery are right, but the sooner it can be safely performed, the more quickly obesity, type 2 diabetes and other diseases can be reduced or resolved."

The ASMBS recommends that the precise timing for surgery be carefully considered based on factors including an individual patient’s health status, local prevalence of COVID-19 and the availability of resources including hospital beds, ventilators and personal protective equipment (PPE).

The ASMBS statement concludes, "Before COVID-19 began, it was clear that patients with obesity were ‘safer through surgery’. In the era of COVID-19, ‘safer through surgery’ for patients with obesity may prove to be even more important than before." Obesity has been identified as an independent risk factor for adverse outcomes including death among COVID-19 patients.

Metabolic/bariatric surgery has been shown to be the most effective and long-lasting treatment for severe obesity. ¹ Its safety profile is comparable to some of the safest and most commonly performed surgeries in the U.S. including gallbladder surgery, appendectomy and knee replacement. ²

An estimated 252,000 bariatric surgeries were performed in the United States in 2018, which is approximately less than 1 percent of the population eligible for surgery based on BMI. ³ The U.S. Centers for Disease Control and Prevention (CDC) reports 42.4 percent of Americans had obesity in 2017-2018. ⁴ Obesity has been linked to more than 40 diseases including type 2 diabetes, hypertension, heart disease, stroke, sleep apnea, osteoarthritis and at least 13 different types of cancer. ^5,6,7

About the ASMBS

The ASMBS is the largest organization for bariatric surgeons in the nation. It is a non-profit organization that works to advance the art and science of bariatric surgery and is committed to educating medical professionals and the lay public about bariatric surgery as an option for the treatment of severe obesity, as well as the associated risks and benefits. It encourages its members to investigate and discover new advances in bariatric surgery, while maintaining a steady exchange of experiences and ideas that may lead to improved surgical outcomes for patients with severe obesity. For more information, visit www.asmbs.org.

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1 Weiner, R. A., et al. (2010). Indications and principles of metabolic surgery. U.S. National Library of Medicine. 81(4) pp.379-394. https://www.ncbi.nlm.nih.gov/pubmed/20361370

2 Gastric Bypass is as Safe as Commonly Performed Surgeries. Health Essentials. Cleveland Clinic. Nov. 6, 2014. Accessed October 2017 https://health.clevelandclinic.org/2014/11/gastric-bypass-is-as-safe-as-commonly-performed-surgeries/

3 https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers

4 https://www.cdc.gov/obesity/data/adult.html

5 The Effectiveness and Risks of Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2003-2012. Accessed from: https://jamanetwork.com/journals/jamasurgery/fullarticle/1790378

6 Steele CB, Thomas CC, Henley SJ, et al. Vital Signs: Trends in Incidence of Cancers Associated with Overweight and Obesity — United States, 2005-2014. MMWR Morb Mortal Wkly Rep2017;66:1052-1058. DOI: http://dx.doi.org/10.15585/mmwr.mm6639e1

7 Centers for Disease Control and Prevention. (2015) The Health Effects of Overweight and Obesity. Accessed from: https://www.cdc.gov/healthyweight/effects/index.html

[Alex Brecher 10,502]

ASMBS Guidelines/Statements

Safer through surgery: American Society for Metabolic and Bariatric Surgery statement regarding metabolic and bariatric surgery during the COVID-19 pandemic

Executive Council of ASMBS Published: June 05, 2020

DOI: https://doi.org/10.1016/j.soard.2020.06.003

The surgical treatment of obesity and its complications has been postponed in many parts of the world during the COVID-19 pandemic, similar to the postponements for nonurgent surgical treatment of many other human conditions and disease processes. Many have characterized bariatric and metabolic surgery along with cosmetic plastic surgery as clear-cut examples of elective procedures that must be postponed during COVID-19. Some U.S. states have included these types of procedures in their state-wide order as examples of “elective” surgical procedures that should be the last to be restarted.

For those who define “elective” surgery as not necessary or optional, the American Society for Metabolic and Bariatric Surgery (ASMBS) asserts that 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 definition of elective in the Merriam-Webster dictionary is “relating to, being, or involving a non-emergency medical procedure and especially surgery that is planned in advance and is not essential to the survival of the patient.” Metabolic and bariatric surgery is life-saving surgery, with multiple studies confirming the survival benefit for patients treated by surgery over those treated without surgery [1]. Metabolic and bariatric surgery creates long-term changes in metabolism and reduces or eliminates multiple serious obesity-related diseases improving long-term health and quality of life as well as survival. The ASMBS supports the use of the term “medically necessary time-sensitive surgery,” as proposed by Prachand et al. [2], or “medically necessary nonemergent surgery,” as far superior to the term “elective” surgery and what it connotes.

Metabolic and bariatric surgery should be restarted when it is safe to do so. The ASMBS disagrees with the concept that bariatric surgery should be postponed until the pandemic is declared over.

The global nature of the pandemic, the potential for a second wave or persistent ongoing infection in some parts of the world, along with more traditional risks, such as annual influenza outbreaks, make postponement potentially indefinite. There is clear evidence bariatric surgery improves survival [1] and significantly improves the disease of obesity and several critical obesity-related conditions (including diabetes, hypertension, and cardiovascular events). Obesity and obesity-related diseases have been identified as independent risk factors for adverse outcomes in COVID-19 infection [3], including need for intubation, ventilatory support, intensive care unit care, and mortality. From a patient-centered and public health standpoint, it is critical to resume metabolic and bariatric surgery.

We also understand that obesity and related diseases are the same risk factors that must be taken into consideration for temporarily postponing bariatric surgery in certain higher-risk subsets of patients. The risks and benefits at that particular time for that specific patient need to be carefully considered. Factors to consider in making that decision also include the local prevalence of COVID-19, the availability of testing, the available resources, including hospital beds, ventilators, and personal protection equipment, as well as strategies to protect healthcare workers and patients. However, delay in the life-saving surgical treatment of obesity and its complications for many months or years is not in the best interest of our patients.

The ASMBS has advocated for many years that patients suffering from the disease of obesity and its many serious associated diseases should strongly consider metabolic and bariatric surgery as a life-changing intervention that improves health, quality of life, and long-term survival. COVID-19 is the most recent of many diseases in which underlying obesity worsens the prognosis.

Before COVID-19 began, it was clear that patients with obesity were “safer through surgery.” In the era of COVID-19, “safer through surgery” for patients with obesity may prove to be even more important than before.

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