Bariatric and metabolic surgery during and after the COVID-19 pandemic

We read the article by Francesco Rubino and colleagues with interest.¹ It represents the recommendations of 23 authors on a diverse range of topics around bariatric and metabolic surgery during and after the COVID-19 pandemic, the collation of which is a difficult task. The methodology used to reach this consensus of opinion and recommendations needs to be detailed; we did not come across the use of any established instruments for this exercise, such as the Delphi or modified Delphi approach.²

The authors very correctly highlight that the remission rate of type 2 diabetes with surgery is higher for patients with shorter diabetes duration.¹ The overarching theme in these recommendations is about prioritising patients who are likely to benefit the most and where delays would be more likely put patients into a more disadvantageous category. We therefore find the authors’ recommendation to prioritise patients with diabetes of more than 5 years’ duration puzzling and is in direct contradiction to their priority statements.

We would also like to draw the readers’ attention to a recent publication by Luigi Angrisani and colleagues,³ which took a different view from Rubino and colleagues. This article was co-authored by the president of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), along with the president-elect and at least seven other current or past presidents of IFSO chapters. Angrisani and colleagues state that patients with higher BMI and multiple comorbidities (with uncontrolled type 2 diabetes being one of the main areas of concern) are at risk of life-threatening COVID-19-related complications in the perioperative setting, thus concluding that surgery should be offered to patients who are more likely to recover from a possible infection.³ The eligibility criteria for surgery proposed by Angrisani and colleagues included, among others, BMI below 50 kg/m² and no or controlled comorbidities.³

Considering that obesity is a major risk factor for severe COVID-19 and its related mortality, obesity treatment could offer an opportunity to reduce the burden of COVID-19. Bariatric surgery, which is the most effective treatment in producing sustained, long-term weight loss, came to a standstill globally with the COVID-19 pandemic. Hence, there is a lot of interest in restarting bariatric surgery safely. The two opposing views we highlight might only add to the confusion in the field. A wider consensus is needed to ensure this life-saving treatment is delivered to patients in a timely manner.