Personal View

Bariatric and metabolic surgery during and after the

COVID-19 pandemic: DSS recommendations for
management of surgical candidates and postoperative
patients and prioritisation of access to surgery
Francesco Rubino, Ricardo V Cohen, Geltrude Mingrone, Carel W le Roux, Jeffrey I Mechanick, David E Arterburn, Josep Vidal, George Alberti,
Stephanie A Amiel, Rachel L Batterham, Stefan Bornstein, Ghassan Chamseddine, Stefano Del Prato, John B Dixon, Robert H Eckel, David Hopkins,
Barbara M McGowan, An Pan, Ameet Patel, François Pattou, Philip R Schauer, Paul Z Zimmet, David E Cummings

Lancet Diabetes Endocrinol The coronavirus disease 2019 pandemic is wreaking havoc on society, especially health-care systems, including
2020; 8: 640–48 disrupting bariatric and metabolic surgery. The current limitations on accessibility to non-urgent care undermine
Published Online postoperative monitoring of patients who have undergone such operations. Furthermore, like most elective surgery,
May 7, 2020
new bariatric and metabolic procedures are being postponed worldwide during the pandemic. When the outbreak
https://doi.org/10.1016/
S2213-8587(20)30157-1 abates, a backlog of people seeking these operations will exist. Hence, surgical candidates face prolonged delays of
Department of Diabetes, beneficial treatment. Because of the progressive nature of obesity and diabetes, delaying surgery increases risks for
School of Life Course Sciences, morbidity and mortality, thus requiring strategies to mitigate harm. The risk of harm, however, varies among patients,
King’s College London, London, depending on the type and severity of their comorbidities. A triaging strategy is therefore needed. The traditional
UK (Prof F Rubino MD,
weight-centric patient-selection criteria do not favour cases based on actual clinical needs. In this Personal View,
Prof G Mingrone MD,
Prof S A Amiel MD); Bariatric experts from the Diabetes Surgery Summit consensus conference series provide guidance for the management of
and Metabolic Surgery, King’s patients while surgery is delayed and for postoperative surveillance. We also offer a strategy to prioritise bariatric and
College Hospital, London, UK metabolic surgery candidates on the basis of the diseases that are most likely to be ameliorated postoperatively.
(Prof F Rubino,
Although our system will be particularly germane in the immediate future, it also provides a framework for long-term
G Chamseddine MD, A Patel MD);
Center for the treatment of clinically meaningful prioritisation.
Obesity and Diabetes, Oswaldo
Cruz German Hospital, Sao Introduction which are still commonly used today, do not reflect severity
Paulo, Brazil (R V Cohen MD);
Bariatric surgery has been used for decades to treat of disease,6 and they therefore cannot be used to prioritise
Fondazione Policlinico
Universitario Agostino Gemelli patients with severe obesity. In 2016, global guidelines treatment based on actual clinical needs. Furthermore,
IRCCS, Rome, Italy established through the Diabetes Surgery Summit (DSS), physical distancing policies and continued lockdowns
(Prof G Mingrone); Università an international consensus conference series, formally might limit adherence to lifestyle interventions, worsening
Cattolica del Sacro Cuore,
Rome, Italy (Prof G Mingrone);
recognised gastrointestinal surgery as a standard therapy metabolic deterioration among candidates for bariatric and
Diabetes Complications for type 2 diabetes; this practice is known as metabolic metabolic surgery. Additionally, reduced access to non-
Research Centre, Conway surgery.1 During the coronavirus disease 2019 (COVID-19) urgent care during the COVID-19 pandemic might impede
Institute, University College of outbreak, under unprecedented pressure to free up postoperative monitoring for potential surgical and
Dublin, Dublin, Ireland
(Prof C W le Roux MD);
inpatient capacity, and because of intraoperative risks for nutritional complications.
The Marie-Josee and viral contagion among patients and staff, hospitals A clear and urgent need therefore exists for strategies to
Henry R Kravis Center for worldwide have been obliged to postpone most elective mitigate harm to patients during and after the COVID-19
Clinical Cardiovascular Health operations, including bariatric and metabolic surgery. pandemic. These approaches should include non-surgical
at Mount Sinai Heart,
New York, NY, USA
Increased hazards of severe COVID-19 complications in interventions to optimise metabolic and weight control in
(Prof J I Mechanick MD); patients with obesity, type 2 diabetes, or both,2–5 further patients awaiting surgery, telemedicine protocols for
Divisions of Cardiology and support the rationale for a pause in elective surgery during postoperative surveillance, and use of appropriate criteria
Endocrinology, Diabetes, the peak of the pandemic. to triage surgical candidates during a foreseeable period of
and Bone Disease, Icahn School
of Medicine at Mount Sinai,
The return to normal services will be gradual, with reduced capacity for elective surgery. To address these
New York, NY, USA surgeons competing for reduced capacity to address a issues, the DSS1 organisers directed a group of
(Prof J I Mechanick); Kaiser backlog of elective procedures. Hence, access to bariatric international experts to assess the effect of the COVID-19
Permanente Washington and metabolic surgery will continue to be constrained. pandemic on candidates for surgical treatment of obesity
Health Research Institute,
Seattle, WA, USA
Given the uncertainty regarding the effects and duration of and type 2 diabetes. Our specific aim was to develop
(D E Arterburn MD); the COVID-19 outbreak, combined with the progressive criteria to help prioritise bariatric and metabolic surgery
Department of Medicine, nature of obesity, diabetes, and related conditions, delaying for when elective surgery is resumed and beyond.
Division of General Internal
bariatric and metabolic surgery could increase the risks for
Medicine, University of
Washington, Seattle, WA, USA morbidity and mortality in surgical candidates. The risk of Elective surgery: definitions and prioritisation
(D E Arterburn); Endocrinology harm, however, is variable among individuals, depending Surgery ameliorates a wide range of conditions and
and Nutrition Department, on the type and severity of disease and their indications for diseases, both acute and chronic. Emergency surgery is
Hospital Clinic Universitari,
bariatric and metabolic surgery. The traditional, weight- required when acute problems pose immediate threat to
Barcelona, Spain
(Prof J Vidal MD); Institut centric criteria for patient selection in bariatric surgery, life, organs, or limbs, and must be done without delay.

640 www.thelancet.com/diabetes-endocrinology Vol 8 July 2020

 Personal View

Elective surgery refers to operations that can be planned is associated with substantial benefits compared with d’Investigacions Biomèdiques
and scheduled in advance. These procedures, however, are traditional open surgery, especially in patients with August Pi Sunyer, Barcelona,
Spain (Prof J Vidal); Centro de
not optional, because they can have important, life- severe obesity. These benefits include lower rates of
Investigación Biomédica en
changing implications. When access to elective surgery is mortality and complications (including pulmonary and Red de Diabetes y
reduced, doctors should prioritise patients with the procedural), and shorter hospital stays.12,13 For these Enfermedades Metabólicas
greatest need or with a greater risk of harm from delayed reasons, laparoscopic access should remain the preferred Asociadas, Instituto de Salud
Carlos III, Madrid, Spain
treatment. In some health-care systems, elective surgery approach over open techniques when elective bariatric (Prof J Vidal); Department of
is categorised into urgent, semi-urgent, or non-urgent.7,8 and metabolic surgery resumes.  Appropriate personal Endocrinology and
Urgent elective surgery is required within 30 days for protective equipment should be used, however, given the Metabolism, Imperial College,
conditions that might deteriorate quickly. Semi-urgent increased risk of SARS-CoV-2 infection for staff. London, UK (Prof G Alberti MD);
Centre for Obesity Research,
conditions are those that, although not likely to deteriorate University College London,
quickly, could reasonably cause severe pain or dysfunction Risks of severe COVID-19 complications in obesity and London, UK
or further harm if delayed beyond 3 months. Non-urgent type 2 diabetes (Prof R L Batterham MD);
elective surgery is planned for conditions that are unlikely Obesity increases the risk of complications from viral University College London
Hospitals Bariatric Centre for
to cause substantial discomfort, dysfunction, or harm if respiratory infections. During the 2009 influenza H1N1 Weight Management and
treated within 1 year. pandemic in California, 91% of people who died had Metabolic Surgery, London, UK
Although some complications from bariatric and obesity, and higher BMI was associated with mortality.14 In (Prof R L Batterham); National
metabolic operations can require emergency surgical patients admitted to intensive care for SARS-CoV-2, Institute of Health Research
University College London
treatment (eg, haemorrhage, leak, or intestinal obstruc­ class 2–3 obesity (BMI >35 kg/m²) is an independent risk Hospitals Biomedical Research
tion), most bariatric and metabolic procedures represent factor for disease severity.5 Similarly, patients with diabetes Centre, London, UK
genuine elective surgery. To date, however, no consensus have augmented risk for severe COVID-19 and mortality.2–5 (Prof R L Batterham);
exists for criteria to identify urgent, semi-urgent, or non- Several mechanisms have been suggested to increase the Paul Langerhans Institute
Dresden, Helmholtz Center
urgent indications in bariatric and metabolic surgery on risk of complications from viral infections in obesity and Munich at the University
the basis of the type and severity of patients’ conditions. type 2 diabetes, including low-grade chronic inflammation Hospital Carl Gustav Carus and
with overproduction of proinflammatory cytokines, Faculty of Medicine, Technical
Delaying elective surgery during the peak of the reduced natural killer cell number and activity, and im­ University Dresden, Dresden,
Germany (Prof S Bornstein MD);
COVID-19 pandemic paired antigen-stimulation responses.15–17 Another factor Department of Clinical and
There are many reasons why most bariatric and metabolic that might have a role in the relationship between obesity, Experimental Medicine,
operations should be suspended during the most intense diabetes, and increased risk for complications is that Section of Metabolic Diseases
and Diabetes, University of
phase of the COVID-19 pandemic, including infection SARS-CoV-2 enters host cells by binding to the angiotensin-
Pisa, Pisa, Italy
risks among patients and staff, factors inherent to the converting-enzyme 2 (ACE2) receptor. ACE2 transforms (Prof S Del Prato MD); Iverson
operations, and increased hazards of severe COVID-19 angiotensin 2 to angiotensin,14–20 thereby reducing vaso­con­ Health Innovation Research
complications among patients with obesity or type 2 striction, sodium retention, inflammation, and metabolic Institute, Swinburne
University, Melbourne, VIC,
diabetes. degen­eration.21 Chronic hyperglycaemia down­ regulates
Australia (J B Dixon MD);
ACE2 expression,22 and further reduction of ACE2 during Division of Endocrinology,
Procedure-related risks COVID-19 infection could contribute to hyper­ inflam­ Metabolism and Diabetes and
Laparoscopic surgery involves aerosol-generating tech­ mation and respiratory failure in patients with type 2 Division of Cardiology,
University of Colorado
niques such as carbon dioxide, pneumoperitoneum, diabetes.23 People with obesity are also prone to hypo­
Anschutz Medical Campus,
electro­­cautery, and ultrasonic shearing. These techniques ventilation syndrome, cardiovascular disease,24 heart Aurora, CO, USA
could easily increase the risk of viral contagion for staff,9,10 failure,25 and other conditions that could increase the risk (Prof R H Eckel MD); King’s
including with severe acute respiratory syndrome of COVID-19 mortality. Health Partners’ Institute of
Diabetes, Endocrinology and
coronavirus 2 (SARS-CoV-2). Upper gastrointestinal endo­ When elective bariatric and metabolic surgery resumes, Obesity, London, UK
scopy (another aerosol-producing procedure) is also the pandemic will be contained, but SARS-CoV-2 will (D Hopkins MD); Institute of
commonly done before bariatric and metabolic surgery. probably still circulate in the population. Given the risks Diabetes, Endocrinology and
Patients undergoing major surgery are at risk of life- of severe complications from COVID-19 in patients with Obesity, Guy’s and St Thomas’
National Health Service
threatening inflammatory complications such as infection obesity and type 2 diabetes, we recommend that Foundation Trust, London, UK
(including from viruses), the systemic inflammatory COVID-19 screening should be mandatory preoperatively (B M McGowan MD);
response syndrome, and sepsis.11 for patients considering bariatric and metabolic surgery. Department of Epidemiology
Although there is no conclusive evidence that and Biostatistics, School of
Public Health, Tongji Medical
laparoscopy or upper endoscopy can promote COVID-19 Risk of disease progression from delayed College, Huazhong University
transmission, postponing elective metabolic and bariatric operations of Science and Technology,
interventions during the acute phase of the COVID-19 Class 2–3 obesity and type 2 diabetes, the most common Wuhan, China (Prof A Pan MD);
outbreak seems sensible, except for urgent revisional indications for bariatric and metabolic surgery, are European Genomic Institute
for Diabetes, Lille, France
surgery or emergency endoscopic interventions for comp­ associated with reduced quality of life and increased (Prof F Pattou MD);
lications (eg, haemorrhage, stoma stenosis, or leaks). morbidity and mortality. Their ability to cause life- Translational Research for
Despite the potential for a higher risk of contagion, the threatening complications, however, varies depending on Diabetes, University of Lille,
laparoscopic approach in bariatric and metabolic surgery the severity or stage of disease and the burden of Inserm, Centre Hospitalier

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 Personal View

Regional Universitaire, Lille, comorbidities. The degree of harm from delaying of obesity hypoventilation syndrome is highest among
France (Prof F Pattou); metabolic and bariatric surgery depends on each patient’s patients with a BMI of more than 50 kg/m².34  Mortality
Pennington Biomedical
condition, the surgical efficacy at different stages of from untreated obesity hypoventilation syndrome can be as
Research Center, Louisiana
State University, Baton Rouge, disease, and the availability and effectiveness of non- high as 24% at 1·5–2 years after diagnosis.35 Obesity heart
LA, USA (Prof P R Schauer MD); surgical therapies to control disease progression while failure is associated with increased mortality, and for each
Department of Diabetes, awaiting surgery. Understanding the prognostic factors 5-unit increase in BMI, heart failure-related mortality
Central Clinical School, Monash
University, Melbourne, VIC,
of morbidity and mortality in obesity and type 2 diabetes increases by 1·4 times.36
Australia (Prof P Z Zimmet MD); can help to define criteria for surgical prioritisation. Since BMI alone does not reflect obesity-related
University of Washington mortality and morbidity, staging systems such as the
Medicine Diabetes Institute, Prognosis and prognostic factors of type 2 diabetes King’s Obesity Criteria37 and Edmonton Obesity Staging
University of Washington,
Seattle, WA, USA
Diabetes is a major cause of morbidity and death, System (EOSS)38 have been developed to assess individual
(Prof D E Cummings MD); and including from cardiovascular, renal, neurological, and patients’ risk on the basis of evidence of subclinical,
Weight Management Program, retinal complications. Approximately two-thirds of people established, or end-stage comorbidities.39 Retrospective
Veterans Affairs Puget Sound with diabetes die of cardiovascular disease, with a relative application of EOSS to data from the National Health and
Health Care System, University
of Washington, Seattle, WA,
risk 1·8–2·6 times greater than in people without Nutrition Examination Survey showed that patients in
USA (Prof D E Cummings) diabetes.26 The biological progression of type 2 diabetes, stages 2–4 of EOSS have increased all-cause mortality
Correspondence to: characterised by declining β-cell function and continuing compared with stages 0 or 1. This finding supports the
Prof Francesco Rubino, Metabolic insulin resistance, is manifested clinically by deteriorations idea that the presence, type, and severity of obesity-related
and Bariatric Surgery, King’s in multiple parameters, including HbA1c, fasting, and complications, in addition to BMI,39 should inform
College Hospital,
London SE5 9NU, UK
postprandial glucose levels. The UK prospective diabetes decision making about the prioritisation of treatment,
francesco.rubino@kcl.ac.uk study27 reported significant associations between hyper­ especially surgery.
glycaemia and development of diabetes complications or
death, and a 21% risk reduction for any diabetes-related Non-alcoholic fatty liver disease
endpoint with each 1% absolute HbA1c reduction. Non-alcoholic fatty liver disease is characterised by
Factors beyond hyperglycaemia can also influence type 2 excess hepatic fat. Its more aggressive form, non-
diabetes prognosis. In the TRIAD study,28,29 predictors of alcoholic steatohepatitis, includes hepatocyte injury,
all-cause mortality at 4 years and 8 years of study follow-up inflammation, and fibrosis.40–42 These two conditions
included older age, male sex, non-Hispanic white race, affect 20–25% of the western population, with rates
lower education and income, longer duration of diabetes, rising worldwide.40,43 66% of patients with obesity and
lower BMI, hypertension, macrovascular disease, retino­ diabetes have non-alcoholic fatty liver disease or non-
pathy, nephropathy, and neuropathy. Among the specific alcoholic steatohepatitis.44,45
predictors of cardiovascular mortality were also treatment Non-alcoholic steatohepatitis can lead to cirrhosis (in
with insulin (with or without oral medication), higher 15–20% of cases), liver failure, or hepatocellular
LDL cholesterol, history of nephropathy, transient carcinoma.46 Beyond liver-related mortality, non-alcoholic
ischaemic attack, stroke, angina, myocardial infarction, steatohepatitis can substantially increase microvascular
coronary artery and peripheral vascular disease, and use of and macrovascular complications, and cardiovascular
antihypertensive or cholesterol-lowering medications. mortality in patients with obesity and type 2 diabetes.40–43,47,48
Non-randomised trials suggest that Roux-en-Y gastric
Factors predicting obesity-related morbidity and bypass resolves the histological features of non-alcoholic
mortality steatohepatitis in up to 80% of patients.49,50
Obesity increases the risks of many other illnesses,
including diabetes, hypertension, dyslipidaemia, liver Effects of bariatric and metabolic surgery
disease, coronary artery and cerebrovascular disease, Randomised clinical trials and observational studies show
many cancers, cholelithiasis, infertility, psychosocial that in patients with all classes of obesity, bariatric and
dys­function, osteoarthritis, chronic kidney disease, and metabolic surgery promotes greater long-term weight
now also COVID-19. Together, these complications loss than the best available non-surgical interventions,
power­fully reduce quality of life and exacerbate obesity- regardless of the operation chosen.47,51–53 Multiple obser­
associated mortality. Even before COVID-19, obesity vational studies also indicate that bariatric and metabolic
reduced life expectancy by 5–20 years.30 Notably, higher surgery lowers long-term risk of all-cause mortality
all-cause mortality is associated with obesity class 2 compared with matched non-surgical patients.54–59 Data
(BMI 35–39·9 kg/m²) and 3 (BMI ≥40 kg/m²), corres­ from eight observational studies involving a total of
ponding to candidates for bariatric surgery, but not with 635 642 patients suggest that bariatric and metabolic
class 1 obesity (BMI 30–34·9 kg/m²).31 surgery is associated with a reduced risk of all types of
Obesity hypoventilation syndrome and obesity-associated cancer (odds ratio [OR]=0·72; 95% CI 0·59–0·87) and
heart failure substantially increase mortality. Obesity obesity-associated cancer (OR=0·55; 95% CI
hypoventilation syndrome represents the combination of 0·31–0·96).60–62 Without exception, each of the 29 all-cause
obesity and chronic daytime hypercapnia.32,33 The prevalence mortality studies published to date shows that patients

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who have bariatric and metabolic surgery live longer than operations, including hysterectomy, chole­cystectomy, and
matched non-surgical controls.54–59,63,64 knee replacement. Surgical treatments for diabetes are
Concerning type 2 diabetes, at least 12 randomised highly cost-effective, with the cost per quality-adjusted life-
controlled trials comparing bariatric and metabolic surgery year ranging between US$3200 and $13 000.1,65,67
with conventional diabetes therapies (ie, lifestyle plus Based on this evidence, DSS guidelines, which have
medication) in patients with type 2 diabetes show that been formally endorsed by 56 worldwide medical or
surgery is superior for control of hyperglycaemia, reduction scientific organisations and recognised by payers world­
of cardiovascular and overall mortality risk, improvement wide, recommend the consideration of bariatric and
in quality of life, and reduction in risk of renal metabolic surgery for appropriate candidates (including
complications.1,65,66 The safety of bariatric and metabolic those with only class 1 obesity), who do not achieve
surgery compares favourably with that of most elective adequate glycaemic control with medical therapy.1

Panel 1: Diabetes Surgery Summit recommendations for managing bariatric and metabolic surgical candidates and
postoperative patients during the coronavirus disease 2019 pandemic
Non-surgical options to mitigate harm from delaying surgery • There is insufficient evidence to justify deviations from
• Glycaemic control should be optimised in patients awaiting current evidence-based recommendations for postoperative
metabolic surgery for type 2 diabetes, especially for those with nutritional care in patients who have had bariatric and
advanced microvascular or macrovascular complications; this metabolic surgery
is desirable to prepare for surgery and also in case of severe • To minimise risk of nutrition-related complications,
acute respiratory syndrome coronavirus 2 infection providers should engage with patients at the same intervals
• In patients who do not achieve glycaemic targets with lifestyle as in current guidelines
modifications and metformin, the addition of a glucagon-like • Clinical signs (eg, weight, visual changes, rash, weakness,
peptide-1 receptor agonist (GLP-1RA) or sodium/glucose oedema or anasarca, and neuropsychiatric signs),
cotransporter 2 (SGLT-2) inhibitor, or both, can advance the and symptoms (eg, nausea, tingling, bowel-habit changes,
combined goals of improving metabolic control and causing and fatigue) of nutritional deficiency must be assessed
weight loss or limiting weight gain; use of SGLT-2 inhibitors, during virtual clinic sessions
however, is not recommended in the case of acute • Routine laboratory tests (eg, albumin, thiamine, B12,
coronavirus disease 2019 (COVID-19) infection because of vitamin A, vitamin D, iron, and calcium) should not be
concerns about potential subclinical vascular congestion and deferred but obtained at standard intervals, particularly for
risk of acute metabolic decompensation associated with these patients who had operations with greater risk of nutrient
drugs malabsorption, such as long-limb diversionary procedures
• For patients with multiple weight-responsive comorbidities • Urgent face-to-face meetings and laboratory tests are
who face prolonged waiting times for surgery, dietary or mandated when symptoms suggest severe biochemical
pharmacological interventions for weight control might deficiencies or surgical complications (eg, intestinal
become necessary obstruction or acute cholecystitis)
• Diets with higher protein content and lower glycaemic
Preparation for surgery and surgical technique
index can be effective and should be considered
• Misconceptions and stigma about obesity and bariatric and
• Among patients already taking weight-loss medications,
metabolic surgery might further penalise candidates for
efforts should be made to continue the drug(s) until surgery
surgical treatment of obesity and diabetes in times of
is scheduled, since rapid weight regain is predictable when
limited resources; clinicians, policy makers, and hospital
they are discontinued
managers should recognise the seriousness of the diseases
• In countries where weight-loss medications (eg, phentermine,
that require metabolic and bariatric surgery and ensure that
orlistat, GLP-1RAs, naltrexone–bupropion, and phentermine–
these operations are not further delayed
topiramate) are accessible, clinicians could consider their use
• Given the risks of severe complications from COVID-19 in
when weight loss or weight maintenance is important, such
patients with obesity and type 2 diabetes, COVID-19
as for patients with multiple weight-responsive comorbidities
screening should be mandatory preoperatively for patients
Management of patients who have had surgery considering bariatric and metabolic surgery
• Telemedicine strategies that are supervised by specialist • Despite the potential higher risk of contagion for staff,
bariatric and metabolic surgery providers should be used the risk and benefit of a laparoscopic approach remain
• In people with persistent or recurrent type 2 diabetes after favourable for patients and should be preferred over the use
surgery, weight-reducing diabetes medications of open techniques
(eg, GLP-1RAs) should be considered; weight maintenance • Appropriate personal protective equipment should be used
should also be encouraged in patients with type 2 diabetes as recommended by professional bodies and public health
remission to mitigate risk of disease recurrence agencies to minimise risk for staff and operators

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Health and economic costs of delaying bariatric and risks of harm from delaying bariatric and metabolic
metabolic surgery surgery.
The delay of bariatric and metabolic surgery that is Patients with surgically remediable metabolic diseases,
occurring due to COVID-19 will augment the burden of especially diabetes, incur more health-care costs per day
disease among surgical candidates. This increase will than do those without these conditions. All studies that
particularly affect patients with type 2 diabetes, given compared costs for 1–5 years between surgical and
that metabolic surgery causes remission of hyper­ non-surgical patients found that pharmacy expenses
glycaemia in most cases.65 The likelihood of decrease substantially after bariatric and metabolic surgery
hyperglycaemia remission, however, depends upon how compared with matched non-surgical patients,74–77,78
soon an operation is done during the natural history of primarily due to lower diabetes medication costs.69 Hence,
diabetes. Algorithms designed to predict surgical metabolic surgery decreases daily health-care costs,
remission (eg, DiaRem-2, AD-DiaRem, DiaBetter, and especially for patients requiring multidrug therapy. The
ABCD)68–71 consistently show that longs­tanding disease longer surgery is delayed for these patients, the less cost-
is one of the most powerful indicators of failure to saving it becomes.
achieve this benefit.72 Remission rates drop off notably
after 10 years of diabetes. Moreover, the SOS study73 Management of surgical candidates and
reported substantially lower type 2 diabetes remission postoperative follow-up in times of COVID-19
among patients with only 4 years of known disease than Various non-surgical options can be used to mitigate the
in those with 2 years of known disease. Thus, delaying harm from delaying bariatric and metabolic surgery and
metabolic surgery reduces the chances of diabetes to manage patients who have had surgery (panel 1).
remission. Regarding the need to optimise glycaemic control in
Delayed metabolic surgery might cause even greater patients with type 2 diabetes, especially those with
harm to patients with type 2 diabetes who are at higher risk advanced microvascular or macrovascular complications,79
of microvascular and macrovascular complications and we considered available evidence of pharmacological
mortality, especially when medications and lifestyle inter­ strategies that promote weight loss, such as glucagon-like
ventions are not achieving adequate metabolic control. peptide-1 receptor agonists (GLP-1RA) or sodium/glucose
Patients without diabetes but with severe respiratory cotransporter 2 (SGLT-2) inhibitors, or both.80 GLP-1RAs
(obesity hypoventilation syndrome), cardiac, or renal reduce HbA1c by about 1%81 while promoting clinically
complications of obesity, and individuals for whom weight relevant weight loss.82 SGLT-2 inhibitors, however, might
reduction is crucial to advancing time-sensitive and life- be contraindicated with COVID-19, because of concerns
saving treatments (eg, organ transplants) also have greater about potential subclinical vascular congestion and risk of
acute metabolic decompensation associated with these
drugs.83
Panel 2: Categories of access to bariatric and metabolic surgery We also considered available data regarding the efficacy
Urgent access: surgery within 30 days of dietary or pharmacological interventions for weight
Patient’s condition is associated with one of the following: loss,84,85–88 or both, as a strategy to achieve weight loss or
• Conditions with potential to deteriorate quickly weight maintenance in patients with multiple weight-
• Severe symptoms or dysfunction responsive comorbidities who face prolonged waiting
• Examples include severe dysphagia or vomiting from anastomotic stenosis, times for bariatric and metabolic surgery. Regarding
symptomatic internal hernia, severe nutritional deficiencies, or acute band-related strategies to maximise surgical outcomes in patients who
complications have already had surgery, our recommendations are
based on results from studies investigating the efficacy of
Expedited access: surgery within 90 days pharmacological approaches in people with persistent or
Patient’s conditions are not likely to deteriorate quickly but are associated with one of the recurrent type 2 diabetes after surgery. Among these
following: individuals, a recent study89 showed that the GLP-1RA
• Substantial risk of morbidity or mortality liraglutide can reduce HbA1c by 1·2%, with up to 5%
• Reasonable risk of harm or reduced efficacy of treatment if surgery is delayed beyond additional weight loss. We reviewed existing evidence-
90 days based recommendations for postoperative nutritional
• Complex medical regimens or insulin requirement care79 to define safe and pragmatic methods of virtual
• Weight loss, metabolic improvement, or both, are required to allow other consultation by telemedicine (panel 1).
time-sensitive treatments (eg, organ transplants or orthopaedic surgery)
Standard access: surgery after 90 days Priorities in resuming elective bariatric and
• Patient’s conditions are unlikely to deteriorate within 6 months metabolic procedures
• Only mild dysfunction or symptoms Even before the COVID-19 pandemic, metabolic and
• Delaying surgical treatment beyond 90 days is unlikely to significantly reduce bariatric surgery was underused for many reasons,
effectiveness of surgery including misconceptions and stigma about obesity and
bariatric surgery.90 Such barriers might further penalise

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candidates for this surgery in times of limited resources. largely on a first-come first-served basis, rather than on
Given the seriousness of the diseases that require clinical need. This approach is comparable to putting all
metabolic and bariatric surgery, clinicians, hospital colorectal surgery candidates on the same waiting list with
managers, and policy makers should ensure that these similar priority, regardless of whether their diagnosis is
operations are not further delayed because of the cancer or benign neoplasia. A strong need therefore exists
widespread misconception that they are a last resort.90 for clinically sound criteria to help prioritise access to
Eventually, the COVID-19 crisis will abate, and elective surgery in times of pandemics with limited resources.
operations will resume, leaving an enormous backlog of These criteria can also inform future waiting list
patients who would benefit from bariatric and metabolic management and decision making about the structure of
surgery. How should we prioritise whom to serve first with surgical services.
limited resources? At a broad level, the answer is simple. If
patients are well enough to be safe surgical candidates, Principles of prioritisation for bariatric and metabolic
preference should be afforded to those with the greatest surgery
risk of morbidity and mortality from their disease, if it is The prioritisation of any elective operation should seek to
probable that this risk can be reduced by surgery. This facilitate access according to clinical need, maximise equity
logic would apply, for instance, to many surgical candidates of access, and minimise the harm from delayed access. We
with poorly controlled type 2 diabetes or substantial have adapted previous categorisations of elective surgery7
metabolic, respiratory, or cardiovascular disease. to define an objective prioritisation system reflecting these
Traditional BMI-centric criteria for patient selection, principles for bariatric and meta­bolic operations (panel 2;
however, tend to skew access to bariatric and metabolic figure).
surgery in the opposite direction. Despite strong evidence Given the factors contributing to morbidity and mortality
that surgery achieves its greatest health benefits among in obesity and type 2 diabetes, surgical prioritisation
patients with type 2 diabetes, a minority of those who have should be based on disease-specific consider­ations. For
such operations have preoperative type 2 diabetes or patients with type 2 diabetes, we suggest that surgery be
cardiometabolic disease.91 Furthermore, in many publicly prioritised for patients at increased risk of morbidity and
funded health-care systems (eg, UK National Health mortality. This risk would be indicated by poor glycaemic
Service), candidates for bariatric and metabolic surgery control despite maximal medical therapy, use of insulin,
are currently placed on a single elective surgery waiting previous cardiovascular disease, albuminuria and chronic
list, regardless of their indication. Priority is established kidney disease, non-alcoholic steatohepatitis, or multiple

Bariatric and metabolic surgery

Indications Diabetes surgery Adjuvant bariatric and Obesity surgery

for surgery metabolic surgery

• HbA1c ≥8% on two or • HbA1c <8% on oral • Organ transplant • BMI <60 kg/m2 • BMI ≥60 kg/m2
more oral medications medications • Need to enable time- • At most two • More than two other
• Insulin use • No history of cardio- sensitive treatment metabolic diseases metabolic conditions
• History of cardio- vascular disease for other conditions • Mild or moderate (other than type 2
vascular disease • At most one other (eg, coronary artery obstructive sleep diabetes) increasing
• Non-alcoholic metabolic condition bypass graft, knee or apnoea or obesity cardiovascular risk
steatohepatitis or two increasing cardio- hip replacement, back hypoventilation (ie, non-alcoholic
or more other vascular risk surgery, or infertility) syndrome steatohepatitis or
Patients’
metabolic conditions • Normoalbuminuria • Mild or moderate hypertension)
conditions
increasing • No evidence of osteoarthritis • Severe obesity hypo-
cardiovascular risk significant micro- ventilation syndrome
• Albuminuria or chronic vascular disease • Severe obstructive
kidney disease sleep apnoea
(stage 3 or 4) • Heart failure (AHA
• >5 years of diabetes stage C)
history • Chronic kidney
(stage 3 or 4)

Priority of
Expedited access Standard access Expedited access Standard access Expedited access
access

Figure: Examples of conditions that warrant expedited access to bariatric and metabolic surgery
AHA=American Heart Association.

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 Personal View

cardio­metabolic comorbidities.28 Insulin use is a mean­ for prior­itisation. Expedited access to surgery should also
ingful prioritisation criterion because it correlates with be considered when bariatric and metabolic operations are
increased cardiovascular mortality28 and reduced quality of used as adjuvant therapy to enable other time-sensitive
life.92 Moreover, metabolic surgery reduces or abolishes the treatments that are made unfeasible or unsafe by excess
need for insulin in most patients.1,47,52 To mitigate the risk weight, poor metabolic control, or both (figure).
of substantially reducing treatment efficacy, we suggest Many candidates for bariatric and metabolic surgery are
prioritising surgery in patients with more than 5 years of at high risk of morbidity and mortality from comorbid
diabetes. This suggestion is based on evidence that conditions. For these patients, access to surgical treatment
individuals with shorter diabetes duration have greater should be prioritised on the basis of disease-focused
chances of achieving disease remission,92 whereas type 2 clinical needs, rather than primarily on BMI, to mitigate
diabetes duration of 8–10 years remits far less often harm from delaying surgery. This approach is especially
postoperatively.1,65,93 needed in periods in which access to surgery is reduced,
The severity of obesity-associated symptoms (eg, mobility as in the current COVID-19 pandemic. Societal crises
issues or joint pain as a consequence of extremely high often spur developments that provide benefits long after
BMI, regardless of comorbidities) must also be considered the storm passes. Disease-oriented, medically meaningful
when establishing priorities. Equally important is the strategies to triage patients seeking metabolic surgery
effect of obesity-related conditions that increase morbidity after the COVID-19 crisis should help prioritise patients
and mortality (eg, obesity hypo­ ventilation syndrome, in more urgent need, both now and long into the future.
chronic kidney disease, or severe obstructive sleep Contributors
apnoea).38 The availability of non-surgical options that slow FR conceived the idea for this initiative. FR, RVC, GM, CWR, JIM, DEA,
disease progression (ie, pharmacological diabetes treat­ JV, and DEC reviewed relevant medical literature and prepared the first
draft of this report. GA, SAA, RLB, SB, GC, SDP, JBD, RHE, DH, BMM,
ments achieving adequate glycaemic control) reduces need APan, APat, FP, PRS, and PZZ provided additional input in the
appraisal of evidence and in manuscript preparation. All co-authors
Search strategy and selection criteria participated in the development of the recommendations and reviewed
and approved this report.
We did a rapid narrative literature review for this Personal Declaration of interests
View. For references about the effect of viral infections FR is on advisory boards for GI Dynamics, Keyron, and Novo Nordisk, has
including coronavirus disease 2019 (COVID-19) on diabetes, received consulting fees from Ethicon Endosurgery and Medtronic, and
has received research grants from Ethicon Endosurgery and Medtronic.
obesity, and laparoscopic surgery, we searched PubMed for
CWR reports receiving research grants from Science Foundation of
articles in English published between Jan 1, 2002, and Ireland, Health Research Board, and Irish Research Council, personal
April 10, 2020. We used combinations of terms such as advisory board fees from Novo Nordisk and GI Dynamics, honoraria for
“SARS”, “H1N1”, “coronavirus”, “COVID-19”, “SARS-CoV-2”, lectures and advisory work for Eli Lilly, Johnson and Johnson, Sanofi
Aventis, AstraZeneca, Janssen, Bristol-Myers Squibb, Boehringer-
“diabetes”, “obesity”, “BMI” “laparoscopy”, “endoscopy”,
Ingelheim, AnaBio, and Keyron. JIM has received honoraria for lectures
“severe acute respiratory syndrome”, “acute respiratory and programme development from Abbott Nutrition. DEA reports
distress syndrome”, and “co-morbidities”. receiving grants from the US National Institutes of Health and Patient-
Centered Outcomes Research Institute, and travel expenses from World
We also reviewed recent guidelines from professional Congress for Interventional Therapy for Diabetes and from International
organisations and public health agencies about elective Federation of Surgery for Obesity Latin American Chapter. SAA reports
surgery and the COVID-19 pandemic. For evidence about the receiving advisory member fees from Medtronic, Novo Nordisk, Abbott,
benefits of bariatric and metabolic surgery, the predicting and Roche via her employer, King’s College London. RLB is a principal
investigator for clinical trials funded by Novo Nordisk and Fractyl (all
factors of morbidity and mortality from type 2 diabetes, funds go directly to her institution, University College London), and has
obesity, non-alcoholic fatty liver disease, and non-alcoholic consultancy agreements with Novo Nordisk, Pfizer, ViiV, and
steatohepatitis, and the classification of elective surgery, International Medical Press. JBD reports consultancy with Bariatric
Advantage, iNova, and Reshape, is on advisory boards for Novo Nordisk
we reviewed recently published systematic reviews and
and Nestlé Health Science, and receives research support from Australia’s
consensus statements by major scientific societies and National Health and Medical Research Council. PRS is a board member
relevant individual articles cited in these documents. and advisory panel member for GI Dynamics, has consulted for Ethicon,
Medtronic, WL Gore, Global Academy for Medical Education, and BD
Members of the expert panel were selected on the basis of Surgical, and has received research support from Ethicon, the US
their previous participation in the Diabetes Surgery Summit National Institutes of Health, Medtronic, and Pacira. All other authors
series and their relevant expertise. Additional experts were declare no competing interests.
also invited to join the group and provide complementary References
expertise or ensure global representation, or both. A subgroup 1 Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the
treatment algorithm for type 2 diabetes: a joint statement by
of the expert panel did a first appraisal of the evidence and international diabetes organizations. Diabetes Care 2016; 39: 861–77.
draft recommendations, and they generated the first draft of 2 Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme
the report, synthetising the literature review in response to inhibitors and angiotensin receptor blockers: what is the evidence?
JAMA 2020; published online March 24. DOI:10.1001/jama.2020.4812.
each specific query. The entire expert group then engaged in
3 Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics
online discussion to further appraise the evidence and refine of patients dying in relation to COVID-19 in Italy. JAMA 2020;
the final consensus recommendations. published online March 23. DOI:10.1001/jama.2020.4683.

646 www.thelancet.com/diabetes-endocrinology Vol 8 July 2020

 Personal View

4 Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus 28 McEwen LN, Karter AJ, Waitzfelder BE, et al. Predictors of
disease 2019 in China. N Engl J Med 2020; published online Feb 28. mortality over 8 years in type 2 diabetic patients: Translating
DOI:10.1056/NEJMoa2002032. Research Into Action for Diabetes (TRIAD). Diabetes Care 2012;
5 Simonnet A, Chetboun M, Poissy J, et al. High prevalence of obesity 35: 1301–09.
in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) 29 McEwen LN, Kim C, Karter AJ, et al. Risk factors for mortality
requiring invasive mechanical ventilation. Obesity (Silver Spring) among patients with diabetes: the Translating Research Into Action
2020; published online April 9. DOI:10.1002/oby.22831. for Diabetes (TRIAD) Study. Diabetes Care 2007; 30: 1736–41.
6 Livingston EH. Inadequacy of BMI as an indicator for bariatric 30 Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB.
surgery. JAMA 2012; 307: 88–89. Years of life lost due to obesity. JAMA 2003; 289: 187–93.
7 Bureau of Health Information. Elective surgery hospital quarterly: 31 Abdelaal M, le Roux CW, Docherty NG. Morbidity and mortality
performance of NSW public hospitals April to June 2013. 2013. associated with obesity. Ann Transl Med 2017; 5: 161.
http://www.bhi.nsw.gov.au/__data/assets/pdf_file/0003/196446/ 32 Rudnick EF, Walsh JS, Hampton MC, Mitchell RB. Prevalence and
HQ13_ES_Apr-Jun2013.pdf (accessed April 10, 2020). ethnicity of sleep-disordered breathing and obesity in children.
8 Government of Western Australia Department of Health. Elective Otolaryngol Head Neck Surg 2007; 137: 878–82.
Surgery Patient Information. August, 2014. http://www.health.wa. 33 Kaditis AG, Alexopoulos EI, Hatzi F, et al. Adiposity in relation to
gov.au/electivesurgery/docs/Elective_Surgery_Patient_ age as predictor of severity of sleep apnea in children with snoring.
Information_ENGLISH.pdf (accessed April 10, 2020). Sleep Breath 2008; 12: 25–31.
9 Kwak HD, Kim S-H, Seo YS, Song K-J. Detecting hepatitis B virus 34 Nowbar S, Burkart KM, Gonzales R, et al. Obesity-associated
in surgical smoke emitted during laparoscopic surgery. hypoventilation in hospitalized patients: prevalence, effects, and
Occup Environ Med 2016; 73: 857–63. outcome. Am J Med 2004; 116: 1–7.
10 Wisniewski PM, Warhol MJ, Rando RF, Sedlacek TV, Kemp JE, 35 Hartemink N, Boshuizen HC, Nagelkerke NJ, Jacobs MA,
Fisher JC. Studies on the transmission of viral disease via the CO2 van Houwelingen HC. Combining risk estimates from
laser plume and ejecta. J Reprod Med 1990; 35: 1117–23. observational studies with different exposure cutpoints:
11 Alazawi W, Pirmadjid N, Lahiri R, Bhattacharya S. Inflammatory a meta-analysis on body mass index and diabetes type 2.
and immune responses to surgery and their clinical impact. Am J Epidemiol 2006; 163: 1042–52.
Ann Surg 2016; 264: 73–80. 36 Aune D, Sen A, Norat T, et al. Body mass index, abdominal fatness,
12 Nguyen NT, Hinojosa M, Fayad C, Varela E, Wilson SE. Use and and heart failure incidence and mortality: a systematic review and
outcomes of laparoscopic versus open gastric bypass at academic dose-response meta-analysos of prospective studies. Circulation
medical centers. J Am Coll Surg 2007; 205: 248–55. 2016; 133: 639–49.
13 Weller WE, Rosati C. Comparing outcomes of laparoscopic versus 37 Aylwin S, Al-Zaman Y. Emerging concepts in the medical and
open bariatric surgery. Ann Surg 2008; 248: 10–15. surgical treatment of obesity. Front Horm Res 2008; 36: 229–59.
14 Louie JK, Acosta M, Samuel MC, et al. A novel risk factor for 38 Padwal RS, Pajewski NM, Allison DB, Sharma AM. Using the
a novel virus: obesity and 2009 pandemic influenza A (H1N1). Edmonton Obesity Staging System to predict mortality in a
Clin Infect Dis 2011; 52: 301–12. population-representative cohort of people with overweight and
15 Shapouri-Moghaddam A, Mohammadian S, Vazini H, et al. obesity. CMAJ 2011; 183: e1059–66.
Macrophage plasticity, polarization, and function in health and 39 Kuk JL, Ardern CI, Church TS, et al. Edmonton Obesity Staging
disease. J Cell Physiol 2018; 233: 6425–40. System: association with weight history and mortality risk.
16 Torres-Castro I, Arroyo-Camarena ÚD, Martínez-Reyes CP, et al. Appl Physiol Nutr Metab 2011; 36: 570–76.
Human monocytes and macrophages undergo M1-type inflammatory 40 Sattar N, Forrest E, Preiss D. Non-alcoholic fatty liver disease. BMJ
polarization in response to high levels of glucose. Immunol Lett 2016; 2014; 349: g4596.
176: 81–89. 41 Tai FW, Syn WK, Alazawi W. Practical approach to non-alcoholic fatty
17 Cheng C-I, Chen P-H, Lin Y-C, Kao Y-H. High glucose activates liver disease in patients with diabetes. Diabet Med 2015; 32: 1121–33.
Raw264.7 macrophages through RhoA kinase-mediated signaling 42 Mantovani A, Byrne CD, Bonora E, Targher G. Nonalcoholic fatty
pathway. Cell Signal 2015; 27: 283–92. liver disease and risk of incident type 2 diabetes: a meta-analysis.
18 Cerwenka A, Lanier LL. Natural killer cell memory in infection, Diabetes Care 2018; 41: 372–82.
inflammation and cancer. Nat Rev Immunol 2016; 16: 112–23. 43 Mantovani A, Zaza G, Byrne CD, et al. Nonalcoholic fatty liver
19 O’Brien KL, Finlay DK. Immunometabolism and natural killer cell disease increases risk of incident chronic kidney disease:
responses. Nat Rev Immunol 2019; 19: 282–90. a systematic review and meta-analysis. Metabolism 2018; 79: 64–76.
20 Sun JC, Beilke JN, Lanier LL. Adaptive immune features of natural 44 Tilg H, Moschen AR, Roden M. NAFLD and diabetes mellitus.
killer cells. Nature 2009; 457: 557–61. Nat Rev Gastroenterol Hepatol 2017; 14: 32–42.
21 Walls AC, Park Y-J, Tortorici MA, Wall A, McGuire AT, Veesler D. 45 Rinella ME. Nonalcoholic fatty liver disease: a systematic review.
Structure, function, and antigenicity of the SARS-CoV-2 spike JAMA 2015; 313: 2263–73.
glycoprotein. Cell 2020; 181: 281–292. 46 Younossi ZM, Blissett D, Blissett R, et al. The economic and clinical
22 Bindom SM, Lazartigues E. The sweeter side of ACE2: physiological burden of nonalcoholic fatty liver disease in the United States and
evidence for a role in diabetes. Mol Cell Endocrinol 2009; 302: 193–202. Europe. Hepatology 2016; 64: 1577–86.
23 Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 cell 47 Schauer PR, Bhatt DL, Kirwan JP, et al. Bariatric surgery versus
entry depends on ACE2 and TMPRSS2 and is blocked by a clinically intensive medical therapy for diabetes—5-year outcomes.
proven protease inhibitor. Cell 2020; 181: 271–280. N Engl J Med 2017; 376: 641–51.
24 Masa JF, Pépin J-L, Borel J-C, Mokhlesi B, Murphy PB, 48 O’Brien R, Johnson E, Haneuse S, et al. Microvascular outcomes
Sánchez-Quiroga MÁ. Obesity hypoventilation syndrome. in patients with diabetes after bariatric surgery versus usual care:
Eur Respir Rev 2019; 28: 180097. a matched cohort study. Ann Intern Med 2018; 169: 300–10.
25 Aune D, Sen A, Norat T, et al. Body mass index, abdominal fatness, 49 Chavez-Tapia NC, Tellez-Avila FI, Barrientos-Gutierrez T,
and heart failure incidence and mortality: a systematic review and Mendez-Sanchez N, Lizardi-Cervera J, Uribe M. Bariatric surgery
dose–response meta-analysis of prospective studies. Circulation for non-alcoholic steatohepatitis in obese patients.
2016; 133: 639–49. Cochrane Database Syst Rev 2010; 1: CD007340.
26 Centres for Disease Control and Prevention. National diabetes 50 Lassailly G, Caiazzo R, Buob D, et al. Bariatric surgery reduces
statistics report 2020: estimates of diabetes and its burden in the features of nonalcoholic steatohepatitis in morbidly obese patients.
United States. https://www.cdc.gov/diabetes/pdfs/data/statistics/ Gastroenterology 2015; 149: 379–88.
national-diabetes-statistics-report.pdf (accessed April 29, 2020). 51 Ikramuddin S, Korner J, Lee WJ, et al. Lifestyle intervention and
27 Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia medical management with vs without Roux-en-Y gastric bypass and
with macrovascular and microvascular complications of type 2 control of hemoglobin A1c, LDL cholesterol, and systolic blood
diabetes (UKPDS 35): prospective observational study. BMJ 2000; pressure at 5 years in the Diabetes Surgery Study. JAMA 2018;
321: 405–12. 319: 266–78.

www.thelancet.com/diabetes-endocrinology Vol 8 July 2020 647

 Personal View

52 Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric-metabolic 76 Finkelstein EA, Allaire BT, Globe D, Dixon JB. The business case
surgery versus conventional medical treatment in obese patients for bariatric surgery revisited: a non-randomized case-control study.
with type 2 diabetes: 5 year follow-up of an open-label, single-centre, PLoS One 2013; 8: e75498.
randomised controlled trial. Lancet 2015; 386: 964–73. 77 Smith VA, Olsen MK, Arterburn DE, et al. Long-term expenditures
53 Simonson DC, Halperin F, Foster K, Vernon A, associated with bariatric surgery in VA. JAMA Surg (in press).
Goldfine AB. Clinical and patient-centered outcomes in obese 78 Smith VA, Arterburn DE, Berkowitz TSZ, et al. Association
patients with type 2 diabetes 3 years after randomization to Roux- between bariatric surgery and long-term health care expenditures
en-Y gastric bypass surgery versus intensive lifestyle management: among veterans with severe obesity. JAMA Surg 2019; published
the SLIMM-T2D study. Diabetes Care 2018; 41: 670–79. online Oct 30. DOI:10.1001/jamasurg.2019.3732.
54 Maciejewski ML, Livingston EH, Smith VA, et al. Survival among 79 Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice
high-risk patients after bariatric surgery. JAMA 2011; guidelines for the perioperative nutrition, metabolic,
305: 2419–26. and nonsurgical support of patients undergoing bariatric
55 Padwal RS, Klarenbach SW, Wang X, et al. A simple prediction rule procedures, 2019 update: cosponsored by American Association of
for all-cause mortality in a cohort eligible for bariatric surgery. Clinical Endocrinologists/American College of Endocrinology,
JAMA Surg 2013; 148: 1109–15. The Obesity Society, American Society for Metabolic and Bariatric
56 Adams TD, Gress RE, Smith SC, et al. Long-term mortality after Surgery, Obesity Medicine Association, and American Society of
gastric bypass surgery. N Engl J Med 2007; 357: 753–61. Anesthesiologists. Obesity (Silver Spring) 2020; 28: O1–58.
57 Telem DA, Talamini M, Shroyer AL, et al. Long-term mortality rates 80 American Diabetes Association. 9. Pharmacologic approaches to
(>8-year) improve as compared to the general and obese population glycemic treatment: standards of medical care in diabetes—2020.
following bariatric surgery. Surg Endosc 2015; 29: 529–36. Diabetes Care 2020; 43 (suppl 1): S98–110.
58 Perry CD, Hutter MM, Smith DB, Newhouse JP, McNeil BJ. Survival 81 Hussein H, Zaccardi F, Dhalwani NN, Davies MJ, Khunti K,
and changes in comorbidities after bariatric surgery. Ann Surg 2008; Gray LJ. Efficacy and safety of sodium-glucose cotransporter 2
247: 21–27. inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists
59 Arterburn D, Livingston EH, Schifftner T, Kahwati LC, (GLP-1RAs) in patients with type 2 diabetes: a systematic review and
Henderson WG, Maciejewski ML. Predictors of long-term mortality network meta-analysis study protocol. BMJ Open 2018; 8: e023206.
after bariatric surgery performed in Veterans Affairs medical 82 Ahrén B, Atkin SL, Charpentier G, et al. Semaglutide induces
centers. Arch Surg 2009; 144: 914–20. weight loss in subjects with type 2 diabetes regardless of baseline
60 Wiggins T, Antonowicz SS, Markar SR. Cancer risk following BMI or gastrointestinal adverse events in the SUSTAIN 1 to 5 trials.
bariatric surgery-systematic review and meta-analysis of national Diabetes Obes Metab 2018; 20: 2210–19.
population-based cohort studies. Obes Surg 2019; 29: 1031–39. 83 Bornstein SR, Rubino F, Khunti K, et al. Consensus
61 Schauer DP, Feigelson HS, Koebnick C, et al. Bariatric surgery and the recommendations for the management of diabetes in patients with
risk of cancer in a large multisite cohort. Ann Surg 2019; 269: 95–101. COVID-19. Lancet Diabetes Endocrinol 2020; published online
April 23. https://doi.org/10.1016/S2213-8587(20)30152-2.
62 Feigelson HS, Caan B, Weinmann S, et al. Bariatric surgery is
associated with reduced risk of breast cancer in both 84 Larsen TM, Dalskov SM, van Baak M, et al. Diets with high or low
premenopausal and postmenopausal women. Ann Surg 2019; protein content and glycemic index for weight-loss maintenance.
published online April 13. DOI:10.1097/SLA.0000000000003331. N Engl J Med 2010; 363: 2102–13.
63 Aminian A, Aleassa EM, Bhatt DL, et al. Bariatric surgery is 85 Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss
associated with a lower rate of death after myocardial infarction and and metabolic benefits with controlled-release phentermine/
stroke: a nationwide study. Diabetes Obes Metab 2019; 21: 2058–67. topiramate in obese and overweight adults (SEQUEL): a randomized,
placebo-controlled, phase 3 extension study. Am J Clin Nutr 2012;
64 Aminian ANS. Success (but unfinished) story of metabolic surgery.
95: 297–308.
Diabetes Care (in press).
86 Wadden TA, Foreyt JP, Foster GD, et al. Weight loss with naltrexone
65 Cummings DE, Rubino F. Metabolic surgery for the treatment of
SR/bupropion SR combination therapy as an adjunct to behavior
type 2 diabetes in obese individuals. Diabetologia 2018; 61: 257–64.
modification: the COR-BMOD trial. Obesity (Silver Spring) 2011;
66 Schauer PR, Mingrone G, Ikramuddin S, Wolfe B. Clinical 19: 110–20.
outcomes of metabolic surgery: efficacy of glycemic control, weight
87 Torgerson JS, Hauptman J, Boldrin MN, Sjöström L. XENical in the
loss, and remission of diabetes. Diabetes Care 2016; 39: 902–11.
prevention of diabetes in obese subjects (XENDOS) study:
67 Hoerger TJ, Zhang P, Segel JE, Kahn HS, Barker LE, Couper S. a randomized study of orlistat as an adjunct to lifestyle changes for
Cost-effectiveness of bariatric surgery for severely obese adults with the prevention of type 2 diabetes in obese patients. Diabetes Care
diabetes. Diabetes Care 2010; 33: 1933–39. 2004; 27: 155–61.
68 Lee WJ, Chong K, Chen SC, et al. Preoperative Prediction of type 2 88 le Roux CW, Astrup A, Fujioka K, et al. 3 years of liraglutide versus
diabetes remission after gastric bypass surgery: a comparison of placebo for type 2 diabetes risk reduction and weight management
DiaRem scores and ABCD scores. Obes Surg 2016; 26: 2418–24. in individuals with prediabetes: a randomised, double-blind trial.
69 Pucci A, Tymoszuk U, Cheung WH, et al. Type 2 diabetes remission Lancet 2017; 389: 1399–409.
2 years post Roux-en-Y gastric bypass and sleeve gastrectomy: the 89 Miras AD, Pérez-Pevida B, Aldhwayan M, et al. Adjunctive liraglutide
role of the weight loss and comparison of DiaRem and DiaBetter treatment in patients with persistent or recurrent type 2 diabetes
scores. Diabet Med 2018; 35: 360–67. after metabolic surgery (GRAVITAS): a randomised, double-blind,
70 Aron-Wisnewsky J, Sokolovska N, Liu Y, et al. The advanced- placebo-controlled trial. Lancet Diabetes Endocrinol 2019; 7: 549–59.
DiaRem score improves prediction of diabetes remission 1 year 90 Rubino F, Puhl RM, Cummings DE, et al. Joint international
post-Roux-en-Y gastric bypass. Diabetologia 2017; 60: 1892–902. consensus statement for ending stigma of obesity. Nat Med 2020;
71 Still CD, Wood GC, Benotti P, et al. Preoperative prediction of type 2 26: 485–97.
diabetes remission after Roux-en-Y gastric bypass surgery: 91 Rubino F, Shukla A, Pomp A, Moreira M, Ahn SM, Dakin G.
a retrospective cohort study. Lancet Diabetes Endocrinol 2014; 2: 38–45. Bariatric, metabolic, and diabetes surgery: what’s in a name?
72 Shen SC, Wang W, Tam KW, et al. Validating risk prediction models Ann Surg 2014; 259: 117–22.
of diabetes remission after sleeve gastrectomy. Obes Surg 2019; 92 Jing X, Chen J, Dong Y, et al. Related factors of quality of life of
29: 221–29. type 2 diabetes patients: a systematic review and meta-analysis.
73 Sjöholm K, Pajunen P, Jacobson P, et al. Incidence and remission Health Qual Life Outcomes 2018; 16: 189.
of type 2 diabetes in relation to degree of obesity at baseline and 93 Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic
2 year weight change: the Swedish Obese Subjects (SOS) study. Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg
Diabetologia 2015; 58: 1448–53. 2003; 238: 467–84.
74 Neovius M, Narbro K, Keating C, et al. Health care use during
20 years following bariatric surgery. JAMA 2012; 308: 1132–41. © 2020 Elsevier Ltd. All rights reserved
75 Weiner JP, Goodwin SM, Chang HY, et al. Impact of bariatric
surgery on health care costs of obese persons: a 6-year follow-up of
surgical and comparison cohorts using health plan data. JAMA Surg
2013; 148: 555–62.

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