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COVID-19 GUIDELINES

COVID-19 Guidelines for Metabolic and Bariatric Surgery Patients 27 March 2020

Introduction:

Coronavirus (COVID-19) pandemic continues to challenge the entire world. Expert predict the worst is yet to come in spite of the social distancing and hygiene measures being practised. We as surgeons should help prepare the nation for the potential increase in COVID-19 patients.

COVID-19 rates are expected to peak in late April/May given lessons learned from the last two months. There will be variability in rates, peaks, and timing, As we cannot accurately predict many aspects, we recommend that surgeons curtail the performance of “elective” surgical procedures.

Triage:

Emergency

(Needs immediate action; life threatening or permanent organ damage)

  • Patients in hemorrhagic shock
  • Patients in septic shock
  • Necrotizing soft tissue infections
  • Perforated viscus
  • Airway emergencies
  • Risk of Ischemic bowel
  • Specific Bariatric: Perforated marginal ulcer, bleeding, anastomatic or staple-line leak, obstruction particularly internal hernia, gastric band perforation or prolapse

Urgent

(Needs surgery; may be delayed by a few days/weeks)

  • Bariatric: revisions for dysphagia, severe gerd, pain, dehydration/ malnutrition, slipped band, anastomotic strictures at risk for aspiration
  • Primary cases for patients pending surgery requiring preop weight loss ie transplant, etc.

Elective

(May be delayed for months without threat to life or organ damage)

  • Bariatric: primary restrictive, malabsorptive and combine procedures
  • Revisions for weight gain / inadequate weight loss

Outpatients

(Needs to be reschedule after the 14 day exclusion )

  • Consider alternate methods of conducting the appointment if appropriate (e.g. telephone or tele-medicine)
  • If it is not possible, reschedule their appointment after the lockdown unless it is medically necessary
  • During outpatient attendance, ask the patient to wear a surgical mask

Recommended principles for metabolic & bariatric surgeries:

  1. Most of the triage guidelines are “Level 1” recommendations, and the rates of COVID-19 cases are predicted to multiply in the following weeks.
  2. Surgical care should be recommended in appropriate and timely manner including preoperative preparation, operative management based on sound surgical judgement and availability of resources.
  3. Non-operative management should be considered wherever appropriate for the patient
  4. COVID-19 testing is recommended in patients who are suspected of infection or in benefit of doubt
  5. Aerosol generating procedures (AGPs) may be avoided unless mandatory as it increases the risk to the health care worker. AGPs should only be performed by wearing full PPE including an N95 mask, and air-purifying respirator (PAPR). Examples of known and possible AGPs include:
    • Intubation, extubation, bag masks, bronchoscopy, chest tubes
    • Electrocautery of blood, gastrointestinal tissue, body fluids
    • Laparoscopy/endoscopy
  6. There is insufficient data available to recommend for/against an open versus laparoscopy approach; however, the surgical team should choose an approach that minimizes OR time and maximizes safety for both patients and healthcare staff.

References:

  1. ASMBS, COVID-19 guidelines for Triage of Metabolic and Bariatric Surgery, American College of Surgeons (v3.23.20); 24 March 2020
  2. RCS, Updated Intercollegiate General Surgery Guidance on COVID-19, Association of Surgeons of Great Britan, 26 March 2020
  3. David Kerrigan, Covid-19: A message from BOMSS President, Bariatric News, 24 March 2020
  4. Ali Aminian, MD, et al, COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period, Annals of Surgery (accepted for publication)