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Jenkins M, Kurian M. Comment on: "Bariatric surgery and COVID-19 outcomes: results from the PaTH to Health Diabetes Study. Surg Obes Relat Dis 2024:S1550-7289(24)00683-X. [PMID: 39117558 DOI: 10.1016/j.soard.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/07/2024] [Indexed: 08/10/2024]
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Soleymani T, Lehman EB, Kong L, Poger JM, Yeh HC, Kraschnewski JL. Bariatric surgery and COVID-19 outcomes: results from the PaTH to Health: Diabetes study. Surg Obes Relat Dis 2024:S1550-7289(24)00644-0. [PMID: 38991937 DOI: 10.1016/j.soard.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Obesity and type 2 diabetes mellitus (T2DM) are risk factors for severe COVID-19 infection. Bariatric surgery (BSG) is an effective treatment of obesity through weight loss and may reduce COVID-19 severity. OBJECTIVES We examined the effect of BSG on COVID-19 outcomes in patients with or at risk of T2DM. SETTING Electronic health record data from the PaTH Clinical Data Research Network, a partnership of 5 health systems reviewed from March 1, 2020, to December 31, 2020. METHODS Ambulatory and in-hospital patient encounters with COVID-19 diagnosis and obesity were identified. We constructed 2 patient groups: BSG and non-BSG (NBSG). The BSG group included patients with at least 1 encounter for the BSG procedure code and/or 1 BSG diagnosis code; the NBSG group included patients with no procedure or diagnosis code for BSG with body mass index (BMI) ≥40 or BMI ≥35 and at least 2 obesity-related co-morbidities. We matched 1 patient in the BSG group to 2 patients in the NBSG group based on age, gender (sex defined at birth), race and ethnicity, group (T2DM and at risk of T2DM), and site. The primary outcome was 30-day outcomes of COVID-19 severity. RESULTS After matching, we found that patients with BSG had lower odds of respiratory failure (41%) and ventilation/intensive care unit (ICU) admission/death (52%). Patients in the BSG group had lower odds of hospitalization, pneumonia, respiratory failure, and the most severe COVID-19 outcomes combined (ventilation/ICU admission/death). T2DM was identified as a risk factor for COVID-19 severity in the BSG group. CONCLUSIONS This retrospective, matched-cohort analysis found BSG to have a protective effect against severe COVID-19 outcomes.
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Affiliation(s)
- Taraneh Soleymani
- Division of General Internal Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Lan Kong
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennifer M Poger
- Division of General Internal Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania.
| | - Hsin-Chieh Yeh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jennifer L Kraschnewski
- Division of General Internal Medicine, Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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Rim DS, Kim BS, Sharma K, Shin JH, Kim DW. Prior bariatric surgery and risk of poor in-hospital outcomes in COVID-19: findings from a National Inpatient Sample. Surg Obes Relat Dis 2023; 19:1435-1443. [PMID: 37612187 DOI: 10.1016/j.soard.2023.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/19/2023] [Accepted: 07/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Obesity and obesity-related co-morbidities are risk factors for severe coronavirus disease 2019 (COVID-19). OBJECTIVES As bariatric surgery effectively addresses obesity-related conditions, we hypothesized that prior bariatric surgery may be associated with a reduced risk of severe COVID-19. Small-scale studies have suggested favorable outcomes; however, large-scale nationwide database studies are scarce. SETTING A retrospective analysis of the 2020 Healthcare Cost and Utilization Project National Inpatient Sample. METHODS All patients diagnosed with COVID-19 were examined and stratified by history of bariatric surgery. We performed 1:1 propensity score matching and compared patients with COVID-19 with and without prior bariatric surgery. The primary outcome was in-hospital mortality rate. Secondary outcomes included total hospital costs, length of hospital stay, and intensive treatment needs. Multivariate logistic regression analysis was performed to identify independent factors associated with in-hospital mortality. RESULTS In-hospital mortality rate was significantly lower in patients with prior bariatric surgery (6.2% versus 8.7%, P = .001). Furthermore, sepsis, acute kidney injury, and mechanical ventilation rates were significantly lower in patients with COVID-19 and prior bariatric surgery, resulting in a reduced need for intensive treatment (12.1% versus 14.9%, P = .005). The total hospitalization costs were lower, and the length of hospital stay was shorter in patients with prior bariatric surgery, demonstrating statistical significance. Old age, male sex, body mass index >50, and co-morbidities were significantly associated with in-hospital mortality in patients with COVID-19 and prior bariatric surgery. CONCLUSIONS Prior bariatric surgery was independently associated with decreased mortality and better in-hospital outcomes in patients hospitalized for COVID-19.
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Affiliation(s)
- Daniel Sungku Rim
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Byung Sik Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Kavita Sharma
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Jeong-Hun Shin
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of Internal Medicine, Hanyang University College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea.
| | - Dong Wook Kim
- Department of Medicine, Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts.
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Cai Z, Zhong J, Jiang Y, Zhang J. Bariatric surgery and COVID-19 outcomes: a systematic review and meta-analysis. Surg Obes Relat Dis 2023; 19:1058-1066. [PMID: 37149418 PMCID: PMC10010835 DOI: 10.1016/j.soard.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/28/2023] [Accepted: 02/24/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Obesity and its associated complications have a negative impact on human health. Metabolic and bariatric surgery (MBS) ameliorates a series of clinical manifestations associated with obesity. However, the overall efficacy of MBS on COVID-19 outcomes remains unclear. OBJECTIVES The objective of this article is to analyze the relationship between MBS and COVID-19 outcomes. SETTING A meta-analysis. METHODS The PubMed, Embase, Web of Science, and Cochrane Library databases were searched to retrieve the related articles from inception to December 2022. All original articles reporting MBS-confirmed SARS-CoV-2 infection were included. Outcomes including hospital admission, mortality, intensive care unit (ICU) admission, mechanical ventilation utilization, hemodialysis during admission, and hospital stay were selected. Meta-analysis with fixed or random-effect models was used and reported in terms of odds ratios (ORs) or weighted mean differences (WMDs) along with their 95% confidence intervals (CIs). Heterogeneity was assessed with the I2 test. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS A total of 10 clinical trials involving the investigation of 150,848 patients undergoing MBS interventions were included. Patients who underwent MBS had a lower risk of hospital admission (OR: .47, 95% CI: .34-.66, I2 = 0%), mortality (OR: .43, 95% CI: .28-.65, I2 = 63.6%), ICU admission (OR: .41, 95% CI: .21-.77, I2 = 0%), and mechanical ventilation (OR: .51, 95% CI: .35-.75, I2 = 56.2%) than those who did not undergo surgery, but MBS did not affect hemodialysis risk or COVID-19 infection rate. In addition, the length of hospital stay for patients with COVID-19 after MBS was significantly reduced (WMD: -1.81, 95% CI: -3.11-.52, I2 = 82.7%). CONCLUSIONS Our findings indicate that MBS is shown to improve COVID-19 outcomes, including hospital admission, mortality, ICU admission, mechanical ventilation, and hospital stay. Patients with obesity who have undergone MBS infected with COVID-19 will have better clinical outcomes than those without MBS.
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Affiliation(s)
- Zixin Cai
- National Clinical Research Center for Metabolic Diseases, Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jiaxin Zhong
- National Clinical Research Center for Metabolic Diseases, Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yingling Jiang
- Department of Metabolism and Endocrinology, The Affiliated Zhuzhou Hospital Xiangya Medical College CSU, Zhuzhou, Hunan, China
| | - Jingjing Zhang
- National Clinical Research Center for Metabolic Diseases, Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.
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Wood GC, Benotti PN, Fano RM, Dove JT, Rolston DD, Petrick AT, Still CD. Prior metabolic surgery reduced COVID-19 severity: Systematic analysis from year one of the COVID-19 pandemic. Heliyon 2023; 9:e15824. [PMID: 37131447 PMCID: PMC10132834 DOI: 10.1016/j.heliyon.2023.e15824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/04/2023] Open
Abstract
Background Obesity is a risk factor for COVID-19 severity. Recent studies suggest that prior metabolic surgery (MS) modifies the risk of COVID-19 severity. Methods COVID-19 outcomes were compared between patients with MS (n = 287) and a matched cohort of unoperated patients (n = 861). Multiple logistic regression was used to identify predictors of hospitalization. A systematic literature review and pooled analysis was conducted to provide overall evidence of the influence of prior metabolic surgery on COVID-19 outcomes. Results COVID-19 patients with MS had less hospitalization (9.8% versus 14.3%, p = 0.049). Age 70+, higher BMI, and low weight regain after MS were associated with more hospitalization after COVID-19. A systematic review of 7 studies confirmed that MS reduced the risk of post-COVID-19 hospitalization (OR = 0.71, 95%CI = [0.61-0.83], p < 0.0001) and death (OR = 0.44, 95%CI = [0.30-0.65], p < 0.0001). Conclusion MS favorably modifies the risks of severe COVID-19 infection. Older age and higher BMI are major risk factors for severity of COVID-19 infection.
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Affiliation(s)
| | | | - Rodrigo M Fano
- Geisinger Commonwealth School of Medicine, Geisinger, Scranton, PA, USA
| | | | | | | | - Christopher D Still
- Obesity Institute, Geisinger, Danville, PA, USA
- Department of Medicine, Geisinger, Danville, PA, USA
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Gao X, Li P, Dai S, Wang G, Li W, Song Z, Zhu L, Zhu S. Is prior bariatric surgery associated with poor COVID-19 outcomes? A systematic review and meta-analysis of case-control studies. J Glob Health 2023; 13:06012. [PMID: 37058575 PMCID: PMC10104427 DOI: 10.7189/jogh.13.06012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023] Open
Abstract
Background Obesity is an independent risk factor for severe coronavirus disease 2019 (COVID-19), but there is little evidence on whether prior bariatric surgery benefits the outcomes of patients with COVID-19. We aimed to summarize this relationship by conducting a systematic review and meta-analysis of current case-control studies. Methods We searched several electronic databases for case-control studies conducted between January 2020 and March 2022. We compared the rates of mortality, mechanical ventilation, intensive care unit (ICU) admission, dialysis, hospitalization, and length of hospital stay between COVID-19 patients with and without a history of bariatric surgery. Results We included six studies with 137 903 patients; 5270 (3.8%) had prior bariatric surgery, while 132 633 (96.2%) did not. COVID-19 patients with a history of bariatric surgery had significantly lower mortality (odds ratio (OR) = 0.42; 95% confidence interval (CI) = 0.23-0.74), ICU admission (OR = 0.48; 95% CI = 0.36-0.65), and mechanical ventilation rates than those with a history of non-bariatric surgery (OR = 0.51; 95% CI = 0.35-0.75). Conclusions Prior bariatric surgery was associated with a reduced risk of mortality and reduced severity of COVID-19 in patients with obesity compared to those with no prior bariatric surgery. Further large-sample prospective studies are needed to support these results. Registration CRD42022323745.
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Affiliation(s)
| | | | - Song Dai
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Guohui Wang
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Weizheng Li
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhi Song
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, China
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Efficacy of Bariatric Surgery in COVID-19 Patients: An Updated Systematic Review and Meta-Analysis. SURGERY IN PRACTICE AND SCIENCE 2022; 11:100140. [PMID: 36337713 PMCID: PMC9616481 DOI: 10.1016/j.sipas.2022.100140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Obesity is linked with poor prognostic outcomes in patients with SARS-CoV-2 infection. In patients with BMI>35 kg/m2, increased rates of hospital and subsequently ICU admissions have been noted. Bariatric surgery resulting in sustained weight loss is hypothesized to decrease the morbid outcomes associated with COVID. In this review, we planned to update the evidence on the topic presented by Aminian et al. Methods An extensive literature search was conducted of the electronic databases. Screening of the articles based on the eligibility criteria was followed by relevant data extraction. Other than the articles used in the previous meta-analysis, relevant databases were searched to filter for any new articles. Initially, two independent reviewers screened Pubmed and Cochrane database followed by a thorough search of additional databases such as Google scholar and Medrxiv. The articles were first screened using title and abstract, followed by a full text read. Duplicates, meta-analysis, letter to the editors, and commentaries were excluded. No language restrictions were placed. Results A total of nine articles with a population of 1,130,341 were entered into the RevMan. Patients with bariatric surgery were significantly associated with decreased hospitalizations (OR: 0.52, 95% CI [0.45, 0.61]), less likely to be admitted to the ICU (OR: 0.44, 95% CI [0.29,0.67]), and reported reduced overall mortality (OR: 0.42, 95% CI [0.25, 0.70]). Conclusion Surgically induced weight loss is more beneficial in reducing the morbidity and mortality burden of COVID-19. More studies are needed to stratify the effect of demographics and metabolic profiles on disease progression.
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Chen G, Mainous A, Ayzengart A, Hong YR. Association Between Bariatric Surgery and Severe COVID-19 Outcomes in Florida. Obes Surg 2022; 32:3807-3810. [PMID: 36166178 PMCID: PMC9514198 DOI: 10.1007/s11695-022-06281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/30/2022]
Abstract
Less is known whether bariatric surgery (BS) is associated with improved outcomes of COVID-19 complications among patients with class III obesity. Using data from the Florida’s state inpatient database (SID) in 2020, we performed multivariable logistic regressions to investigate the impact of prior BS on three separate events, including admission due to COVID-19 among patients eligible for BS (non-BS) and those with prior BS, ventilator usage, and all-cause mortality among those admitted due to COVID-19. Of 409,665 patients included in this study, 25,116 (6.1%) had a history of BS. Results from adjusted logistic regression showed that prior BS was associated with decreased risk of admission due to COVID-19 than that in non-BS group. The risk reduction was smaller among those with class III obesity (adjusted odds ratio [aOR]: 0.58; 95% CI: 0.51–0.66; p < 0.001) than those without (aOR: 0.32; 95% CI: 0.28–0.38; p < 0.001). Compared with the non-BS group, aOR of ventilator use and all-cause mortality for patients without class III obesity decreased by 58% and 78% (p < 0.05), respectively. However, these significances disappeared among patients with continued class III obesity after BS. Our findings suggest that patients with continued class III obesity after BS were still at higher risk of severe COVID-19 outcomes than those without.
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Affiliation(s)
- Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, USA.
| | - Arch Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA.,Department of Community Health and Family Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
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Grosser R, Romero-Velez G, Pereira X, Moran-Atkin E, Choi J, Camacho DR. Postoperative pneumonia after bariatric surgery during the COVID-19 pandemic: A NSQIP study. Surg Obes Relat Dis 2022; 18:1239-1245. [PMID: 35843783 PMCID: PMC9212841 DOI: 10.1016/j.soard.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/07/2022] [Accepted: 06/11/2022] [Indexed: 11/13/2022]
Abstract
Background During the COVID-19 pandemic, surgical centers had to weigh the benefits and risks of conducting bariatric surgery. Obesity increases the risk of developing severe COVID-19 infections, and therefore, bariatric surgery is beneficial. In contrast, surgical patients who test positive for COVID-19 have higher mortality rates. Objective This study investigates the national prevalence of postoperative pneumonia during the COVID-19 pandemic in the bariatric surgery population. Setting The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Methods This is a cross-sectional study using the ACS-NSQIP database. The population of concern included patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Information was extracted on rate of postoperative pneumonia and other 30-day complications between 2018 and 2020. Results All baseline characteristics were similar among patients who underwent bariatric surgery between 2018 and 2020. However, there was a 156% increase in postoperative pneumonia in 2020 compared with the previous year. Furthermore, despite the similar postoperative complication rates across the years, there was a statistically significant increase in all-cause mortality in 2020. The multivariate analysis showed that having surgery in 2020 was a statistically significant risk factor for pneumonia development postoperatively. Conclusions This study showed a statistically significant increase in the prevalence of postoperative pneumonia during the COVID-19 pandemic among bariatric surgery patients. Surgical centers must continuously evaluate the risks associated with healthcare-associated exposure to COVID-19 and weigh the benefits of bariatric surgery.
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Impact of prior bariatric surgery on risk and severity of COVID-19 infection: A meta-analysis of observational studies. Obes Res Clin Pract 2022; 16:439-446. [PMID: 36471505 PMCID: PMC9574468 DOI: 10.1016/j.orcp.2022.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/25/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The association of prior bariatric surgery (BS) with infection rate and prognosis of coronavirus disease 2019 (COVID-19) remains unclear. We conducted a meta-analysis of observational studies to address this issue. METHODS We searched databases including MEDLINE, Embase, and CENTRAL from inception to May, 2022. The primary outcome was risk of mortality, while secondary outcomes included risk of hospital/intensive care unit (ICU) admission, mechanical ventilation, acute kidney injury (AKI), and infection rate. RESULTS Eleven studies involving 151,475 patients were analyzed. Meta-analysis showed lower risks of mortality [odd ratio (OR)= 0.42, 95% CI: 0.27-0.65, p < 0.001, I2 = 67%; nine studies; 151,113 patients, certainty of evidence (COE):moderate], hospital admission (OR=0.56, 95% CI: 0.36-0.85, p = 0.007, I2 =74.6%; seven studies; 17,810 patients; COE:low), ICU admission (OR=0.5, 95% CI: 0.37-0.67, p < 0.001, I2 =0%; six studies; 17,496 patients, COE:moderate), mechanical ventilation (OR=0.52, 95% CI: 0.37-0.72, p < 0.001, I2 =57.1%; seven studies; 137,992 patients, COE:moderate) in patients with prior BS (BS group) than those with obesity without surgical treatment (non-BS group). There was no difference in risk of AKI (OR=0.74, 95% CI: 0.41-1.32, p = 0.304, I2 =83.6%; four studies; 129,562 patients, COE: very low) and infection rate (OR=1.05, 95% CI: 0.89-1.22, p = 0.572, I2 =0%; four studies; 12,633 patients, COE:low) between the two groups. Subgroup analysis from matched cohort studies demonstrated associations of prior BS with lower risks of mortality, ICU admission, mechanical ventilation, and AKI. CONCLUSION Our results showed a correlation between prior BS and less severe COVID-19, which warrants further investigations to verify.
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Altieri MS. Comment on: Prior bariatric surgery in COVID-19 positive patients may be protective. Surg Obes Relat Dis 2021; 17:e55-e56. [PMID: 34583892 PMCID: PMC8416295 DOI: 10.1016/j.soard.2021.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 08/28/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Maria S Altieri
- Division of General and Bariatric Surgery, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina
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