Bariatric and metabolic surgery during COVID-19 outbreak phase 2 in Italy: why, when and how to restart

The EPICOVID19-BS study: a web-based epidemiological survey in bariatric patients

PURPOSE

To assess the occurrence and severity of SARS-CoV-2 infection/COVID-19, frequency of symptoms, clinical manifestations and behaviours in a sample of patients undergoing bariatric surgery (BS).

METHODS

The EPICOVID19-BS is an observational cross-sectional study conducted in Italy during the second wave of the COVID-19 pandemic (September 2021-February 2022). Patients with severe/extreme obesity undergoing BS were asked to complete an online multiple-choice questionnaire and to provide additional clinical information and blood biochemistry. Positive COVID-19 cases were defined by the combination of positive nasopharyngeal swab test results and/or positive serological test results. Sociodemographic, clinical and behavioural characteristics were compared between positive and negative COVID-19 cases.

RESULTS

A total of 745 participants were enrolled (mean age 44.5 ± 10.5 years SD, 78% female). The proportion of positive COVID-19 cases was 20.4%. They were more likely to be health care workers, to have close contacts with confirmed cases, to use anti-inflammatory drugs, to have immune system disorders, to have previous CMV infection, to have lower cholesterol levels and to have less metabolic syndrome than negative cases. Infected participants significantly increased their use of national health resources for minor health problems. The majority of participants experienced flu-like symptoms and taste and smell disturbances. Only 9.6% were hospitalised and none required intubation.

CONCLUSIONS

Our results seem to support the evidence that patients undergoing BS have a low rate of severe SARS-CoV2. Further longitudinal studies in multiple obesity treatment centres are needed to more effectively monitor and control obesity in this specific population.

Bariatric Surgery Before and After the SARS-CoV-2 Pandemic: a Comparative Study of Cases Before the Onset of the Pandemic in a High-Volume Academic Center

INTRODUCTION

At the beginning of the pandemic, studies showed a higher risk of severe surgical complications and mortality among patients with perioperative SARS-CoV-2 infection, which led to the suspension of elective surgery. Confinement and lockdown measures were shown to be associated with weight gain and less access to medical and surgical care in patients with obesity, with negative health consequences. To evaluate the safety of bariatric surgery during the pandemic, we compared 30-day complications between patients who underwent bariatric surgery immediately before with those who underwent bariatric surgery during the opening phase of the pandemic.

METHODS

Observational analytical study of a non-concurrent cohort of patients who underwent bariatric surgery in 2 periods: pre-pandemic March 1 to December 31, 2019, and pandemic March 1 to December 31, 2020. Surgical complications were defined using the Clavien-Dindo classification.

RESULTS

Pre-pandemic and pandemic groups included 256 and 202 patients who underwent primary bariatric surgery, respectively. The mean age was 37.6 + 10.3 years. The overall complication rate during the first 30 days of discharge was 7.42%. No differences between groups were observed in severe complications (pre-pandemic 1.56% vs. pandemic 1.98%, p: 0.58). No mortality was reported. Overall 30-day readmission was 3.28% with no differences between groups.

CONCLUSION

The findings of this study did not find a difference in the rate of severe complications, nor also we report severe COVID-19 complications in this high-risk population. During the pandemic, with appropriately implemented protocol, the resumption of bariatric surgery is possible with no increased risk for patients.

Status of Body Contouring Following Metabolic Bariatric Surgery in a Tertiary Hospital of Greece-Still a Long Way to Go

Obesity is a disease rather than a state, and metabolic bariatric surgery (MBS) is its most effective treatment. Body contouring surgery (BCS) is an integral part of the continuum of care following MBS, provided that the body mass index (BMI) has stabilized for an adequate period. This study is an attempt to capture the current status of BCS following MBS in Greece, based on data from one of the country's highest-volume hospitals. We recruited patients from the Bariatric and Plastic-Reconstructive Surgery registries who had undergone both MBS and BCS and invited them to answer a structured questionnaire with components on demographics, safety and effectiveness of previous operations, quality of life (QoL), body image, social activity, sexual activity, and doctor-patient communication. Twenty-four patients participated in the survey (response rate 88.1%). The mean BMI pre-MBS was 43.8 kg/m² and that pre-BCS was 28.6 kg/m². Based on the Bariatric sub-cohort, only 2.5% of post-bariatric patients underwent BCS. The mean interval between MBS and BCS was 2.9 years. The distribution of patients by MBS was as follows: sleeve gastrectomy 8 (33.3%), gastric band 7 (29.2%), gastric bypass 5 (20.8%), and gastric plication 2 (8.3%). The distribution of patients by BCS was as follows: abdominoplasty 23 (94.7%), breast contouring 8 (33.3%), thigh contouring 3 (12.5%), and arm contouring 5 (20.8%). Most positive components (70.6%) regarding QoL were appraised by >80% of the participants, indicating overall satisfaction after BCS. Conversely, only 12.5% of negative components were endorsed by >20% of patients. In conclusion, BCS has a low prevalence after MBS, although it is related to an improved quality of life and body image.

[Impact of the COVID pandemic on treatment of bariatric patients in Germany-An analysis of the national StuDoQ/MBE register]

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic the standard inpatient care of patients was restricted to increase overall and intensive care capacity reserves for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons.

OBJECTIVE

This article presents the impact of the COVID-19 pandemic on the surgical and postoperative care of bariatric patients in Germany.

MATERIAL AND METHODS

A statistical analysis of the national StuDoQ/MBE register data for the period from 1 May 2018 until 31 May 2022 was performed.

RESULTS

Throughout the entire study period there was a continuous increase in documented operations, which continued even during the COVID-19 pandemic. A significant intermittent decline in surgery performed was observed only during the imposition of first lockdown in the months of March to May 2020, with a minimum number of 194 cases performed monthly in April 2020. The pandemic had no measurable effect on the surgically treated patient population, the type of surgical procedure, the perioperative and postoperative outcomes and follow-up care.

CONCLUSION

Based on the results of the StuDoQ data and the current literature, it can be deduced that bariatric surgery can be carried out with no increased risk during the COVID-19 pandemic and the quality of postoperative care is not impaired.

Impact of COVID-19 on the Destiny of Bariatric Patients

Obese patients reported worse outcomes of COVID-19 related to prothrombotic and low-grade inflammation status. During the SARS-CoV-2 outbreak, all non-elective surgeries were postponed, including bariatric surgery (BS). This umbrella review wants to underline obesity as a condition provoking low-grade chronic inflammation, and increasing severe COVID-19 risk; to relaunch the prioritization of BS. The literature search was conducted in March 2022 via Pubmed (MEDLINE) and focused on reviews, systematic reviews, and meta-analyses published in peer-reviewed journals. Terms "bariatric surgery" OR "obesity surgery" OR "metabolic surgery" were analyzed with "COVID-19" OR "SARS-CoV-2" using the AND modifier. Only 13 studies of the 406 screened met the objective. The procrastination of BS over the past two years determined a delay in obesity treatment and severe consequences. The COVID-19 pandemic has had a huge impact on economic costs. Although BS has high costs, a lifetime cost advantage over conventional weight loss methods was demonstrated. As the pandemic continues, health policies must recognize obesity as a disease-predisposing factor for SARS-CoV-2 infection, considering COVID-19 as a new comorbidity mitigable by BS. Care pathways for obese patients in COVID/post-COVID era should be revitalized and the concept of elective surgery attributed to BS should be reformulated.

Bariatric surgery for metabolic unhealthy obesity (MUO) during the COVID era: short-term results of a high-volume center

PURPOSE

During the coronavirus disease 19 (COVID-19) outbreak, most public hospitals worldwide have been forced to postpone a major part of bariatric surgery (BS) operations with unfavorable consequences for weight and obesity complications. The aim of this study was to evaluate the effectiveness and safety of laparoscopic BS on subjects with metabolically unhealthy obesity (MUO) during COVID-19 pandemic in a high-volume Italian center.

METHODS

Between March 2020 and January 2021, all patients with MUO submitted to laparoscopic BS (sleeve gastrectomy [SG], one anastomosis gastric bypass [OAGB] and Roux-en-Y gastric bypass [RYGB]) were enrolled according to the ATP III Guidelines, with a minimum follow-up of 3 months.

RESULTS

In the study period, 210 patients with MUO underwent laparoscopic BS (77 RYGB, 85 SG and 48 OAGB) in our obesity referral center. Postoperative major complications occurred in 4 patients (1.9%) with zero mortality. At 9-month follow-up, a total weight loss (TWL) of 28.2 ± 18.4, 26.1 ± 23.1 and 24.5 ± 11.3% (p = 0.042) was observed in RYGB, OAGB and SG groups, respectively. The rate of comorbidity resolution was very similar for all type of surgeries (p = 0.871). Only two cases of postoperative SARS-CoV-2 infection were registered (0.9%) and both cases resolved with medical therapy and observation.

CONCLUSION

Among the patients studied, all surgical techniques were safe and effective for MUO during the COVID era. This group of patients is at high risk for general and SARS-CoV-2-related mortality and therefore should be prioritized for BS.

LEVEL OF EVIDENCE

Level III, single-center retrospective cohort study.

Laparoscopic bariatric surgery is safe during phase 2-3 of COVID-19 pandemic in Italy: A multicenter, prospective, observational study

BACKGROUND

Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS' resumption. A new, more severe COVID-19 surge, the "second wave", started on October 2020 (phase 3).

AIM

The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2-3; secondary end points were readmission and reoperation rates.

METHODS

Study design prospective, multicenter, observational.

SETTING

Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group.

RESULTS

1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality.

CONCLUSIONS

Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

Telematics pre-operative psychological and nutritional assessment in candidates for bariatric surgery during COVID-19 phase 2: a pilot prospective observational study

BACKGROUND

Obesity represents a risk factor for COVID-19 infection. Therefore, in order to reduce COVID-19 related comorbidities in obese population a continuation of obesity treatment is needed. However, bariatric procedures were postponed because of COVID-19 restrictions, delaying treatment for obese patients seeking for surgery. This study aimed to test the feasibility of a telematics pre-operative psychological and nutritional assessment as an alternative tool during COVID-19 outbreak.

METHODS

Twenty-six patients were contacted. The pre-operative assessment consisted in 3-weekly one-to-one online sessions and a final in-person multidisciplinary session. The protocol feasibility has been evaluated on the following outcome: rejection rate (%), dropout rate (%), compliance and satisfaction's degree.

RESULTS

Eighteen participants completed the whole protocol and 10% dropped-out. Seventy-two percent of participants obtained an excess weight loss ≥5%. All participants were satisfied of the telematics assessment.

CONCLUSIONS

COVID-19 emergency has changed standard hospital procedures and this study could represent a landmark for an online pre-operative assessment method to adopt in case of new restrictions.

Eighty-Seven Consecutive Sleeve Gastrectomies Between the Two Peaks of the Covid-19 Pandemic. An Opening-Phase Experience

Purpose

During the Covid-19 pandemic, the outcome of symptomatic Covid-19 infection occurring early after elective operations is reportedly associated with fatalities. Incidence is unknown and data on bariatric practice is scarce. Covid-19 exposure status and outcomes of sleeve gastrectomy (SG) between the first two peaks of the pandemic are prospectively evaluated.

Material and Methods

During our “opening-phase,” candidates for SG were enrolled after written informed consent was obtained which specifically emphasized the additional risks of the Covid-19. Viral exposure history and swab/RNA testing were obtained from all. Preoperative antibody testing was also performed, once became available. Preoperative workout, definitions, and surgical technique were standard. Patients were followed up with video-calls. All perioperative data is prospectively recorded.

Results

Between June 23 and November 20, 87 consecutive SGs were performed without mortality and conversion with a 1.2% major early complication rate. Single complication was due to Covid-19, acutely becoming symptomatic one day following the SG. During the first year of the pandemic, a minimum of 13.8% of the patients had encountered the virus and the rate of developing postoperative symptomatic Covid-19 was 6.3% including a patient with full-blown Covid-19 pneumonia 1 day after SG. Results on weight loss matched expectations.

Conclusion

Currently, differing from the first peak of pandemic, vaccines are underway although a more serious surge continues. Given the high rate of morbidity and mortality of Covid-19 infection early after elective operations, caution is warranted when balancing the expected benefit from an elective procedure against the risk of acquiring perioperative Covid-19 infection.

Global pandemics interconnected - obesity, impaired metabolic health and COVID-19

Obesity and impaired metabolic health are established risk factors for the non-communicable diseases (NCDs) type 2 diabetes mellitus, cardiovascular disease, neurodegenerative diseases, cancer and nonalcoholic fatty liver disease, otherwise known as metabolic associated fatty liver disease (MAFLD). With the worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), obesity and impaired metabolic health also emerged as important determinants of severe coronavirus disease 2019 (COVID-19). Furthermore, novel findings indicate that specifically visceral obesity and characteristics of impaired metabolic health such as hyperglycaemia, hypertension and subclinical inflammation are associated with a high risk of severe COVID-19. In this Review, we highlight how obesity and impaired metabolic health increase complications and mortality in COVID-19. We also summarize the consequences of SARS-CoV-2 infection for organ function and risk of NCDs. In addition, we discuss data indicating that the COVID-19 pandemic could have serious consequences for the obesity epidemic. As obesity and impaired metabolic health are both accelerators and consequences of severe COVID-19, and might adversely influence the efficacy of COVID-19 vaccines, we propose strategies for the prevention and treatment of obesity and impaired metabolic health on a clinical and population level, particularly while the COVID-19 pandemic is present.