Clearly, humankind is experiencing one of its most uncertain times in modern history. Despite notable advances in scientific knowledge in general and viral epidemiology in particular, the planet was ill prepared to handle an event of this magnitude, even when several voices were raised in almost exact anticipation of what they deemed inevitable.19 Global dissemination of the coronavirus disease SARS-CoV-2 caught the most developed countries of the world off guard, rapidly exceeding their response capabilities and causing high death tolls amidst the impotence of well-trained physicians. The phenomenon began in the winter of the northern hemisphere, and moved slowly towards the southern hemisphere, possibly due to lower density of international flights and, to a lesser extent, to climatological reasons. Latin America had benefitted temporarily from receiving a vast amount of information regarding not only the disease itself, but the measures that could potentially mitigate the risk of contagion. In this sense, it is likely that Argentina is distinguished for being one particular nation that readily implemented severe restrictive measures, crushing the expected upward curve being replicated in all the countries massively affected. Other Latin American countries met the same fate, although not all. Limitations in health systems were quickly revealed in low-income countries, even if they showed few confirmed cases. Argentina has a healthcare system greatly impacted by the financial crisis derived from recessive and inflationary processes practically set ablaze in the past two years. This situation is exacerbated by the fact that 40% of the population does not reach the poverty threshold and largely depends on government financial aid. In this context, the forecasting efforts of the Executive Power to assess the pandemic impact quickly led to the implementation of measures that could potentially limit the spread of the disease, such as closing borders, isolating travelers from abroad, and establishing mandatory social distancing, with the subsequent economic paralysis.
The precocity of the government-issued provisions affected the operations throughout national territory, without distinguishing the epidemiological reality of each region. When the preventive and mandatory decree that introduced social distancing was issued, several provinces had not registered any confirmed cases. In light of the development of the pandemic, it is obvious that the measures had a positive effect, even if they also had undesirable economic outcomes and even affected the handling of chronic and acute pathologies, including obesity. Information stemming from the U.S. in mid-April uncovered that obesity8, on itself, was a factor associated with poor prognosis for the COVID-19 disease, increasing the risk of admission to the ICU and, ultimately, of death.
As the situation in Argentina stabilized, several proposals regarding the possibility of resuming elective bariatric surgeries emerged. To assess the conditions and expectations of the surgeons, the Latin American Chapter of IFSO (IFSOLAC) and SACO released the survey analyzed throughout this document. The perception of the surgeons surveyed in Argentina outlined the foregoing: the virtual paralysis of programmed healthcare even within institutions and the epidemiological context of low risk, judged objectively by the local infection and death rates. It is not within the scope of this study to determine whether the measures dictated were suitable or not, but rather to reexamine them in the context of a stable situation. It is comprehensible that other countries massively affected by the pandemic and surpassed by their response capacities, like the U.S. and some European countries, suspended all elective bariatric procedures. However, several of them, with epidemiological conditions far worse than the Argentinean, have begun to formulate terms and conditions to restart these activities. The proposal is fostered by the need of these patients to improve a chronic disease which exposes them to a greater risk of a fatal outcome caused by a viral infection, and the need to revitalize the national and individual economies.
In Argentina, the large proportion of bariatric surgeons that depend economically on their specific surgical activity is astounding. Most of these surgeons are pessimistic on their medium-term projections, without even knowing what is at the end of the road. As of the date of this analysis, the restrictive measures regarding movement of people and economic activities remain similar throughout most of the territory. Provincial autonomy, in accordance with the central government, allows for a reassessment of the situation in different regions of the country. In any event, areas with the largest concentrations of populations remain with the same constraints.
It is remarkable how most surgeons have implemented virtual communication mechanisms to ensure appropriate follow-up with their patients. These previously non-existent practices will probably not represent any financial gains for the surgeons, but quite the contrary.
The survey analysis revealed, to a large extent, the influence of foreign colleagues on general care and protective measures to be employed in case of performing a surgery. It is evident that many surgeons emulate the situation of other countries in their place of work, even when the contexts are rather different. It is comprehensible that in areas with a high viral load and, moreover, if there is no possibility of testing, levels of personal protection are maximized to avoid infection from a potential asymptomatic carrier. However, the validity of this situation in Argentina should be questioned, especially in certain regions of the country with practically no viral circulation. This level of equipment not only represents an inappropriate use of resources, but also exposes patients and medical personnel to increased complications because of the inconvenience and impaired vision it generates.
The dissemination of the concept of potential coronavirus aerosolization in laparoscopic surgeries has been remarkable, in terms of the high number of surgeons interested in using filters for pneumoperitoneum intake, smoke outflow and gases evacuated from the patient, as well as face masks with high filtration efficiency, even when treating patients without suspected COVID-19 infection.
One of the possible explanations is the lack of PCR testing in different regions. Even though kits have been made available in several provinces, their use is regulated by the highest sanitary authority, who establishes when to apply them - and it is usually upon the suspicion of infection. Probably, this is the reason why a large proportion of surgeons chooses a method of chest imaging as complementary screening. The shortage of this resource calls for a need to seek future alternatives to assess candidates for elective surgery.
Finally, although the expectations to resume elective surgeries are quite pessimistic, as previously described, most surgeons expressed they would make some strides in this direction if they had the backing of a more promising scenario. More than half of the respondents believe that an alignment of favorable epidemiological evolution, proper patient selection, and the endorsement of the scientific society on this matter is desirable. Obviously, though, these procedures would not take place without the consent of local and national sanitary agencies. While no surgeons considered that patient selection on its own is sufficient to perform elective surgery, 65% regards it as a requirement along with other conditions. On this subject, the main concern of surgeons is discarding possible asymptomatic infections, by rejecting patients with documented illnesses or in close contact with possible sources of transmission. There is also consensus in avoiding surgery in patients over 60 years, with chronic pulmonary disease, or immunocompromised. No agreement has been reached regarding specific characteristics of the most severe comorbidities of morbid obesity, like diabetes, hypertension, obstructive sleep apnea, and cardiopathy. There are two opposing conceptions: some surgeons propose conducting the least complex surgeries, like the sleeve gastrectomy, in less compromised patients, as suggested by Angrisani in informal presentations (webinar) at IFSO Virtual Academy last April 12th, while others like DSS group prioritize critical patients, with more severe or challenging comorbidities.20 There was no consensus amongst Argentinean surgeons in this respect, nor in the specific technique that would be preferable considering this epidemiological context. Most would not modify their study algorithms or the type of surgery performed, probably not linking these issues to an increased risk for the patient. Factors that encourage this practice are the short average length of stay in the referred cases and the low percentage that require ICU admission.
Results from this survey provide a clear picture of the current situation of bariatric surgery in Argentina. Hopefully, the opinions of these colleagues will help determine the recommendations for an eventual return of elective surgery activity.