Association of Weight Loss Achieved Through Metabolic Surgery With Risk and Severity of COVID-19 Infection.

IMPORTANCE: Obesity is an established risk factor for severe COVID-19 infection. However, it is not known whether losing weight is associated with reduced adverse outcomes of COVID-19 infection. OBJECTIVE: To investigate the association between a successful weight loss intervention and improved risk and severity of COVID-19 infection in patients with obesity. DESIGN, SETTING, AND PARTICIPANTS: This cohort study involved adult patients with a body mass index of 35 or higher (calculated as weight in kilograms divided by height in meters squared) who underwent weight loss surgery between January 1, 2004, and December 31, 2017, at the Cleveland Clinic Health System (CCHS). Patients in the surgical group were matched 1:3 to patients who did not have surgical intervention for their obesity (control group). The source of data was the CCHS electronic health record. Follow-up was conducted through March 1, 2021. EXPOSURES: Weight loss surgery including Roux-en-Y gastric bypass and sleeve gastrectomy. MAIN OUTCOMES AND MEASURES: Distinct outcomes were examined before and after COVID-19 outbreak on March 1, 2020. Weight loss and all-cause mortality were assessed between the enrollment date and March 1, 2020. Four COVID-19-related outcomes were analyzed in patients with COVID-19 diagnosis between March 1, 2020, and March 1, 2021: positive SARS-CoV-2 test result, hospitalization, need for supplemental oxygen, and severe COVID-19 infection (a composite of intensive care unit admission, need for mechanical ventilation, or death). RESULTS: A total of 20 212 patients (median [IQR] age, 46 [35-57] years; 77.6% female individuals [15 690]) with a median (IQR) body mass index of 45 (41-51) were enrolled. The overall median (IQR) follow-up duration was 6.1 (3.8-9.0) years. Before the COVID-19 outbreak, patients in the surgical group compared with control patients lost more weight (mean difference at 10 years from baseline: 18.6 [95% CI, 18.4-18.7] percentage points; P < .001) and had a 53% lower 10-year cumulative incidence of all-cause non-COVID-19 mortality (4.7% [95% CI, 3.7%-5.7%] vs 9.4% [95% CI, 8.7%-10.1%]; P < .001). Of the 20 212 enrolled patients, 11 809 were available on March 1, 2020, for an assessment of COVID-19-related outcomes. The rates of positive SARS-CoV-2 test results were comparable in the surgical and control groups (9.1% [95% CI, 7.9%-10.3%] vs 8.7% [95% CI, 8.0%-9.3%]; P = .71). However, undergoing weight loss surgery was associated with a lower risk of hospitalization (adjusted hazard ratio [HR], 0.51; 95% CI, 0.35-0.76; P < .001), need for supplemental oxygen (adjusted HR, 0.37; 95% CI, 0.23-0.61; P < .001), and severe COVID-19 infection (adjusted HR, 0.40; 95% CI, 0.18-0.86; P = .02). CONCLUSIONS AND RELEVANCE: This cohort study found that, among patients with obesity, substantial weight loss achieved with surgery was associated with improved outcomes of COVID-19 infection. The findings suggest that obesity can be a modifiable risk factor for the severity of COVID-19 infection.

Bariatric Surgery is Safe for Patients After Recovery from COVID-19.

BACKGROUND: Studies of patients who have undergone surgery while infected with COVID-19 have shown increased risks for adverse outcomes in both pulmonary complications and mortality. It has become clear that the risk of complications from perioperative COVID-19 infection must be weighed against the risk from delayed surgical treatment. Studies have also shown that prior bariatric surgery conveys protection against mortality from COVID-19 and that obesity is the biggest risk factor for mortality from COVID-19 infection in adults under 45 years of age. Studies in patients who have fully recovered from COVID-19 and underwent elective surgery have not become widely available yet. OBJECTIVES: This multi-institutional case series is presented to highlight patients who developed COVID-19, fully recovered, and subsequently underwent elective bariatric surgery with 30-day outcomes available. SETTING: Nine bariatric surgery centers located across the United States. METHODS: This multicenter case series is a retrospective chart review of patients who developed COVID-19, recovered, and subsequently underwent bariatric surgery. Fifty-three patients are included, and 30-day morbidity and mortality were analyzed. RESULTS: Thirty-day complications included esophageal spasm, dehydration, and ileus. There were no cardiovascular, venous thromboembolism (VTE) or respiratory events reported. There were no 30- day mortalities. CONCLUSIONS: Bariatric surgery has been safely performed in patients who made a full recovery from COVID-19 without increased complications due to cardiovascular, pulmonary, venous thromboembolism, or increased mortality rates.

Association of obesity with postacute sequelae of COVID-19.

Obesity is a major risk factor for the development of severe coronavirus disease 2019 (COVID-19) infection and mortality. However, it is not known whether patients with obesity are at a greater risk of developing postacute sequelae of COVID-19 (PASC). In a median follow-up time of 8 months and counting from 30 days following a positive viral test of 2839 patients who did not require intensive care unit admission and survived the acute phase of COVID-19, 1230 (43%) patients required medical diagnostic tests, 1255 (44%) patients underwent hospital admission, and 29 (1%) patients died. Compared with patients with a normal body mass index (BMI), the risk of hospital admission was 28% and 30% higher in patients with moderate and severe obesity, respectively. The need for diagnostic tests to assess different medical problems, compared with patients with normal BMI, was 25% and 39% higher in patients with moderate and severe obesity, respectively. The findings of this study suggest that moderate and severe obesity (BMI ≥ 35 kg/m2 ) are associated with a greater risk of PASC.

Abdominal Surgery in Patients With COVID-19: Detection of SARS-CoV-2 in Abdominal and Adipose Tissues.

Multiple tissue samples were obtained during emergent abdominal surgery in 4 patients with coronavirus disease 2019 (COVID-19) to examine for tissue involvement by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first patient underwent a laparoscopic cholecystectomy for gallbladder empyema and died from severe respiratory failure. The second patient with Crohn disease underwent emergent laparotomy for a perforation in the terminal ileum and recovered. The third patient underwent an open appendectomy and recovered. The fourth patient underwent emergent laparotomy for a perforated peptic ulcer and died from sepsis. Although the SARS-CoV-2 RNA was found in the feces of 3 patients and in the duodenal wall of the patient with perforated peptic ulcer, real time reverse transcriptase polymerase chain reaction (RT-PCR) examination of abdominal fluid was negative for the virus. The RT-PCR did not detect viral RNA in the wall of small intestine, appendix, gallbladder, bile, liver, and urine. Visceral fat (omentum) and abdominal subcutaneous fat of 4 patients were also not infected with the SARS-CoV-2. Although this limited experience did not show direct involvement of abdominal fluid and omentum, assessment in large series is suggested to provide answers about the safety of abdominal surgery in patients with COVID-19.

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.

Association of Bariatric Surgery with Clinical Outcomes of SARS-CoV-2 Infection: a Systematic Review and Meta-analysis in the Initial Phase of COVID-19 Pandemic.

INTRODUCTION: Obesity worsens clinical outcomes of coronavirus disease 2019 (COVID-19). The aim of this study was to measure the association between history of bariatric surgery and the severity of COVID-19. METHODS: Data source included PubMed/MEDLINE, Scopus, Google Scholar, and pre-print servers between January and November 1, 2020. Literature was screened and selected to extract the relevant data. The two outcomes of this meta-analysis were the difference in mortality and hospitalization rates in patients with SARS-CoV-2 infection with and without history of bariatric surgery. Random-effect models were used to estimate the pooled effects. RESULTS: The systematic review yielded 3 retrospective studies on 9022 patients. The risk of mortality without previous bariatric surgery was 133 per 1000 cases and its risk with previous bariatric surgery was 33 per 1000 (summary OR 0.22, 95% CI 0.19-0.26). No heterogeneity was observed between the included studies (I2 = 0%, P = 0.98 for heterogeneity). In the pooled analysis, the hospitalization rate in patients without previous bariatric surgery was 412 per 1000 cases and its rate in patients with previous bariatric surgery was 164 per 1000 (summary OR 0.28, 95% CI 0.12-0.65). No heterogeneity was observed between the included studies (I2 = 0%, P = 0.71 for heterogeneity). There was a substantial risk of bias across the studies for confounding and selection bias. CONCLUSION: Findings of this meta-analysis of observational studies suggest that prior bariatric surgery is associated with a lower rate of mortality and hospital admission in patients with obesity who become infected with SARS-CoV-2. Confirmation of these findings will require larger studies with better quality data.

Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity.

BACKGROUND: Obesity is a risk factor for poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19). OBJECTIVES: To investigate the relationship between prior metabolic surgery and the severity of COVID-19 in patients with severe obesity. SETTING: Cleveland Clinic Health System in the United States. METHODS: Among 4365 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 8, 2020 and July 22, 2020 in the Cleveland Clinic Health System, 33 patients were identified who had a prior history of metabolic surgery. The surgical patients were propensity matched 1:10 to nonsurgical patients to assemble a cohort of control patients (n = 330) with a body mass index (BMI) ≥ 40 kg/m2 at the time of SARS-CoV-2 testing. The primary endpoint was the rate of hospital admission. The exploratory endpoints included admission to the intensive care unit (ICU), need for mechanical ventilation and dialysis during index hospitalization, and mortality. After propensity score matching, outcomes were compared in univariate and multivariate regression models. RESULTS: The average BMI of the surgical group was 49.1 ± 8.8 kg/m2 before metabolic surgery and was down to 37.2 ± 7.1 at the time of SARS-CoV-2 testing, compared with the control group's BMI of 46.7 ± 6.4 kg/m2. In the univariate analysis, 6 (18.2%) patients in the metabolic surgery group and 139 (42.1%) patients in the control group were admitted to the hospital (P = .013). In the multivariate analysis, a prior history of metabolic surgery was associated with a lower hospital admission rate compared with control patients with obesity (odds ratio, 0.31; 95% confidence interval, 0.11-0.88; P = .028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P = .021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died. CONCLUSION: Prior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities was associated with lower rates of hospital and ICU admission in patients with obesity who became infected with SARS-CoV-2. Confirmation of these findings will require larger studies.

A Structured Approach for Safely Reintroducing Bariatric Surgery in a COVID-19 Environment.

Due to the profound effect of novel coronavirus disease 2019 (COVID-19) on healthcare systems, surgical programs across the country have paused surgical operations and have been utilizing virtual visits to help maintain public safety. For those who treat obesity, the importance of bariatric surgery has never been more clear. Emerging studies continue to identify obesity and several other obesity-related comorbid conditions as major risk factors for a more severe COVID-19 disease course. However, this also suggests that patients seeking bariatric surgery are inherently at risk of suffering severe complications if they were to contract COVID-19 in the perioperative period. The aim of this protocol is to utilize careful analysis of existing risk stratification for bariatric patients, novel COVID-19-related data, and consensus opinion from multiple academic bariatric centers within our organization to help guide the reanimation of our programs when appropriate and to use this template to prospectively study this risk-stratified population in real time. The core principles of this protocol can be applied to any surgical specialty.

Bariatric Surgical Practice During the Initial Phase of COVID-19 Outbreak.

There is no data on patients with severe obesity who developed coronavirus disease 2019 (COVID-19) after bariatric surgery. Four gastric bypass operations, performed in a 2-week period between Feb 24 and March 4, 2020, in Tehran, Iran, were complicated with COVID-19. The mean age and body mass index were 46 ± 12 years and 49 ± 3 kg/m2. Patients developed their symptoms (fever, cough, dyspnea, and fatigue) 1, 2, 4, and 14 days after surgery. One patient had unnoticed anosmia 2 days before surgery. Three patients were readmitted in hospital. All 4 patients were treated with hydroxychloroquine. In two patients who required admission in intensive care unit, other off-label therapies including antiretroviral and immunosuppressive agents were also administered. All patients survived. In conclusion, COVID-19 can complicate the postoperative course of patients after bariatric surgery. Correct diagnosis and management in the postoperative setting would be challenging. Timing of infection after surgery in our series would raise the possibility of hospital transmission of COVID-19: from asymptomatic patients at the time of bariatric surgery to the healthcare workers versus acquiring the COVID-19 infection by non-infected patients in the perioperative period.

COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period.

: Little is known about surgical practice in the initial phase of coronavirus disease 2019 (COVID-19) global crisis. This is a retrospective case series of 4 surgical patients (cholecystectomy, hernia repair, gastric bypass, and hysterectomy) who developed perioperative complications in the first few weeks of COVID-19 outbreak in Tehran, Iran in the month of February 2020. COVID-19 can complicate the perioperative course with diagnostic challenge and a high potential fatality rate. In locations with widespread infections and limited resources, the risk of elective surgical procedures for index patient and community may outweigh the benefit.