Bariatric surgery provision in response to the COVID-19 pandemic: retrospective cohort study of a national registry.

BACKGROUND: When surgery resumed following the outbreak of the COVID-19 pandemic, guidelines recommended the prioritization of patients with greater obesity-related co-morbidities and/or higher body mass index. OBJECTIVE: The aim of this study was to record the effect of the pandemic on total number, patient demographics, and perioperative outcomes of elective bariatric surgery patients in the United Kingdom. SETTING AND METHODS: The United Kingdom National Bariatric Surgical Registry was used to identify patients who underwent elective bariatric surgery during the pandemic (1 yr from April 1, 2020). Characteristics of this group were compared with those of a pre-pandemic cohort. Primary outcomes were case volume, case mix, and providers. National Health Service cases were analyzed for baseline health status and perioperative outcomes. Fisher exact, χ2, and Student t tests were used as appropriate. RESULTS: The total number of cases decreased to one third of pre-pandemic volume (8615 to 2930). The decrease in operating volume varied, with 36 hospitals (45%) experiencing a 75%-100% reduction. Cases performed in the National Health Service fell from 74% to 53% (P < .0001). There was no change in baseline body mass index (45.2 ± 8.3 kg/m2 from 45.5 ± 8.3 kg/m2; P = .23) or prevalence of type 2 diabetes (26% from 26%; P = .99). Length of stay (median 2 d) and surgical complication rate (1.4% from 2.0%; relative risk = .71; 95% CI .45-1.12; P = .13) were unchanged. CONCLUSIONS: In the context of a dramatic reduction in elective bariatric surgery due to the COVID-19 pandemic, patients with more severe co-morbidities were not prioritized for surgery. These findings should inform preparation for future crises.

Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard of care for benign gallstone disease. There are no robust Indian data on the 30-day morbidity and mortality of this procedure. A prospective multicentre observational study was conducted by the Indian Association of Gastro-Intestinal Endo Surgeons (IAGES) to assess the 30-day morbidity and mortality of LC in India. MATERIALS AND METHODS: Participating surgeons were invited to submit data on all consecutive LCs for benign diseases performed between 09/12/2020 and 08/03/2021 in adults. Primary outcome measures were 30-day morbidity and mortality. Univariate and multivariate analyses were performed to identify variables significantly associated with primary outcomes. RESULTS: A total of 293 surgeons from 125 centres submitted data on 6666 patients. Of these, 71.7% (n = 4780) were elective. A total LC was carried out in 95% (n = 6331). Laparoscopic subtotal cholecystectomy was performed in 1.9% (n = 126) and the procedure were converted to open in 1.4% of patients. Bile duct injury was seen in 0.3% (n = 20). Overall, 30-day morbidity and mortality were 11.1% (n = 743) and 0.2% (n = 14), respectively. Nature of practice, ischemic heart disease, emergency surgery, postoperative intensive care, and postoperative hospital stay were independently associated with 30-day mortality. Age, weight, body mass index, duration of symptoms, nature of the practice, history of Coronavirus Disease-2019, previous major abdominal surgery, acute cholecystitis, use of electrosurgical or ultrasonic or bipolar energy for cystic artery control; use of polymer clips for cystic duct control; conversion to open surgery, subtotal cholecystectomy, simultaneous common bile duct exploration, mucocele, gangrenous gall bladder, dense adhesions, intraoperative cholangiogram, and use of drain were independently associated with 30-day morbidity. CONCLUSION: LC has 30-day morbidity of 11.1%, 30-day mortality of 0.2%, conversion to open rate of 1.4%, and bile duct injury rate of 0.3% in India.

Handling of the Covid-19 Pandemic and Its Effects on Bariatric Surgical Practice: Analysis of GENEVA Study Database.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic led to a worldwide suspension of bariatric and metabolic surgery (BMS) services. The current study analyses data on patterns of service delivery, recovery of practices, and protective measures taken during the COVID-19 pandemic by bariatric teams. MATERIALS AND METHODS: The current study is a subset analysis of the GENEVA study which was an international cohort study between 01/05/2020 and 31/10/2020. Data were specifically analysed regarding the timing of BMS suspension, patterns of service recovery, and precautionary measures deployed. RESULTS: A total of 527 surgeons from 439 hospitals in 64 countries submitted data regarding their practices and handling of the pandemic. Smaller hospitals (with less than 200 beds) were able to restart BMS programmes more rapidly (time to BMS restart 60.8 ± 38.9 days) than larger institutions (over 2000 beds) (81.3 ± 30.5 days) (p = 0.032). There was a significant difference in the time interval between cessation/reduction and restart of bariatric services between government-funded practices (97.1 ± 76.2 days), combination practices (84.4 ± 47.9 days), and private practices (58.5 ± 38.3 days) (p < 0.001). Precautionary measures adopted included patient segregation, utilisation of personal protective equipment, and preoperative testing. Following service recovery, 40% of the surgeons operated with a reduced capacity. Twenty-two percent gave priority to long waiters, 15.4% gave priority to uncontrolled diabetics, and 7.6% prioritised patients requiring organ transplantation. CONCLUSION: This study provides global, real-world data regarding the recovery of BMS services following the COVID-19 pandemic.

Effect of BMI on Safety of Bariatric Surgery during the COVID-19 pandemic, Procedure Choice, and Safety Protocols – an analysis from the GENEVA Study

Background It has been suggested that patients with a Body Mass Index (BMI) of >60 kg/m2 should be offered expedited Bariatric Surgery (BS) during the Coronavirus Disease-2019 (COVID-19) pandemic. The main objective of this study was to assess the safety of this approach. Methods We conducted a global study of patients who underwent BS between 1/05/2020 and 31/10/2020. Patients were divided into three groups according to their preoperative BMI - Group I (BMI<50 kg/m2), Group II (BMI 50–60 kg/m2), and Group III (BMI>60 kg/m2). The effect of preoperative BMI on 30-day morbidity and mortality, procedure choice, COVID-19 specific safety protocols, and comorbidities was assessed. Results This study included 7084 patients (5197;73.4% females). The mean preoperative weight and BMI were 119.49±24.4 Kgs and 43.03±6.9 Kg/m2, respectively. Group I included 6024 (85%) patients, whereas Groups II and III included 905 (13%) and 155 (2%) patients, respectively. The 30-day mortality rate was higher in Group III (p=0.001). The complication rate and COVID-19 infection were not different. Comorbidities were significantly more likely in Group III (p=<0.001). A significantly higher proportion of patients in group III received Sleeve Gastrectomy or One Anastomosis Gastric Bypass compared to other groups. Patients with a BMI of >70 kg/m2 had a 30-day mortality of 7.7% (2/26). None of these patients underwent a Roux-en-Y Gastric Bypass. Conclusion The 30-day mortality rate was significantly higher in patients with BMI >60 kg/m2. There was, however, no significant difference in complications rates in different BMI groups, probably due to differences in procedure selection.

Laparoscopic subtotal cholecystectomy for difficult gallbladders: A lifesaving bailout or an incomplete operation? A systematic review

Background Cholecystectomy is one of the commonest abdominal operations performed worldwide. Sometimes, the operation can be technically difficult due to dense adhesions in Calot’s triangle. Conversion to open surgery or subtotal cholecystectomy have been described to deal with these situations. A recent systematic review and meta-analysis on STC suggested high perioperative morbidity associated with STC. These findings are at odds with a previous systematic review and meta-analysis on the topic which concluded that morbidity rates for STC were comparable to those reported for total cholecystectomy. However, both these reviews included patients undergoing Open Subtotal Cholecystectomy (OSTC). This makes it difficult for us to understand the outcomes of LSTC as surgeons are not faced with the choice of converting to open surgery to perform a subtotal cholecystectomy. The choice they face is whether they should perform a LSTC or convert to open surgery to perform a total cholecystectomy. It is, therefore, important to establish the outcomes of LSTC alone (without including patients who underwent OSTC). This is all the more important during COVID-19 pandemic when the complexity of gall stone disease appears to have worsened. There is thus an enhanced need to understand technical nuances and outcomes of LSTC alone. Methods Search strategy: We searched PUBMED (Medline), Google Scholar, and Embase for all relevant English language articles describing experience with LSTC in adult human population (≥18 years) anywhere in the world using key-words like “subtotal cholecystectomy”, “gallbladder resection”, “gallbladder excision”, “gallbladder removal”, “partial”, “incomplete”, “insufficient”, “deroofing”, and “near-total”. Case reports, articles only published as conference s, case series with <5 cases, and reviews were excluded. Only English-language studies were included. Participants: All studies with 5 or more cases, describing any experience with an adult cohort (≥18 years) of patients undergoing STC while attempting a Laparoscopic Cholecystectomy were included. Studies on patients who underwent preoperative cholecystostomy were excluded. Studies that had LSTC as part of another surgery were also excluded as we wanted to understand the morbidity and mortality of LSTC alone. Studies on patients who underwent OSTC (Open from start) were excluded as were those where the LSTC cohort was merged with the OSTC cohort and outcomes of LSTC were not separately reported. Study outcome: Primary outcome measure was early (≤30 days) morbidity and mortality. Secondary outcome measures were bile duct injury, bile leak rates, conversion to open surgery rates, duration of hospital stay, and late (>30 days) morbidity. Results 45 studies were identified, with a total of 2166 patients. Mean age was 55 +/- 15 years with 51% females;53% (n = 390) were elective procedures. The conversion rate was 6.2% (n = 135). Most common indication was acute cholecystitis (n = 763). Different techniques were used with the majority having a closed cystic duct/gallbladder stump (n = 1188, 71%). The most common closure technique was intracorporeal suturing (53%) followed by endoloop closure. There were a total of four, 30-day mortality [1] in this review. Early morbidity (≤30 days) included bile duct injury (0.23%), bile leak rates (18%), intra-abdominal collection (4%). Reoperation was reported in 23 patients (1%), most commonly for unresolving intra-abdominal collections and failed ERCP to control bile leak. Long term follow-up was reported in 30 studies with a median follow up period of 22 months. Late morbidity included incisional hernias (6%), CBD stones (2%), and symptomatic gallstones in 4% (n = 41) with 2% (n = 22) requiring completion of cholecystectomy. Conclusions Laparoscopic subtotal cholecystectomy is an acceptable alternative in patients with a “difficult” Calot’s triangle. However, this has to be taken seriously s it is associated with a high early and late morbidity and mortality.

30-day morbidity and mortality of sleeve gastrectomy, Roux-en-Y gastric bypass and one anastomosis gastric bypass: a propensity score-matched analysis of the GENEVA data.

BACKGROUND: There is a paucity of data comparing 30-day morbidity and mortality of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB). This study aimed to compare the 30-day safety of SG, RYGB, and OAGB in propensity score-matched cohorts. MATERIALS AND METHODS: This analysis utilised data collected from the GENEVA study which was a multicentre observational cohort study of bariatric and metabolic surgery (BMS) in 185 centres across 42 countries between 01/05/2022 and 31/10/2020 during the Coronavirus Disease-2019 (COVID-19) pandemic. 30-day complications were categorised according to the Clavien-Dindo classification. Patients receiving SG, RYGB, or OAGB were propensity-matched according to baseline characteristics and 30-day complications were compared between groups. RESULTS: In total, 6770 patients (SG 3983; OAGB 702; RYGB 2085) were included in this analysis. Prior to matching, RYGB was associated with highest 30-day complication rate (SG 5.8%; OAGB 7.5%; RYGB 8.0% (p = 0.006)). On multivariate regression modelling, Insulin-dependent type 2 diabetes mellitus and hypercholesterolaemia were associated with increased 30-day complications. Being a non-smoker was associated with reduced complication rates. When compared to SG as a reference category, RYGB, but not OAGB, was associated with an increased rate of 30-day complications. A total of 702 pairs of SG and OAGB were propensity score-matched. The complication rate in the SG group was 7.3% (n = 51) as compared to 7.5% (n = 53) in the OAGB group (p = 0.68). Similarly, 2085 pairs of SG and RYGB were propensity score-matched. The complication rate in the SG group was 6.1% (n = 127) as compared to 7.9% (n = 166) in the RYGB group (p = 0.09). And, 702 pairs of OAGB and RYGB were matched. The complication rate in both groups was the same at 7.5 % (n = 53; p = 0.07). CONCLUSIONS: This global study found no significant difference in the 30-day morbidity and mortality of SG, RYGB, and OAGB in propensity score-matched cohorts.

Safe Surgery During the COVID-19 Pandemic.

PURPOSE OF REVIEW: Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future. RECENT FINDINGS: Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates. METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020. RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country. CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic - The GENEVA study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. OBJECTIVES: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. RESULTS: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2 , respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. CONCLUSIONS: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients.

Effect of COVID-19 pandemic on global Bariatric surgery PRActiceS - The COBRAS study.

INTRODUCTION: There is a paucity of data in scientific literature on the impact of Coronavirus Disease 2019 (COVID-19) pandemic on bariatric surgery. The aim of this study was to evaluate the impact of COVID-19 pandemic on Bariatric Surgery globally. METHODS: We conducted a global online survey of bariatric surgeons between 16/04/20 - 15/05/20. The survey was endorsed by five national bariatric surgery societies and circulated amongst their memberships. Authors also shared the link through their personal networks, email groups, and social media. RESULTS: 703 respondents from 77 countries completed the survey. Respondents reported a drop in elective bariatric activity from a median (IQR) of 130 (60-250) procedures in 2019 to a median of 0 (0-2) between16/03/2020 and 15/04/2020 during the pandemic. The corresponding figures for emergency activity were 5 (2-10) and 0 (0-1) respectively. 441 (63%) respondents did not perform any bariatric procedures during this time period. Surgeons reported outcomes of 61 elective bariatric surgical procedures during the pandemic with 13 (21%) needing ventilation and 2 (3.3%) deaths. Of the 13 emergency bariatric procedures reported, 5 (38%) needed ventilation and 4 (31%) died. 90 (13%) surgeons reported having had to perform a bariatric surgical or endoscopic procedure without adequate Personal Protective Equipment. CONCLUSIONS: COVID-19 pandemic led to a remarkable decline in global elective and emergency bariatric surgery activity at its beginning. Both elective and emergency procedures performed at this stage of the pandemic had considerable morbidity and mortality.

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.

SARS-CoV-2 and Obesity: "CoVesity"-a Pandemic Within a Pandemic.

Individuals who are overweight or suffering from obesity are in a chronic state of low-grade inflammation, making them particularly susceptible to developing severe forms of respiratory failure. Studies conducted in past pandemics link obesity with worse health outcomes. This population is thus of particular concern within the context of the COVID-19 pandemic, considering the cessation of obesity management services. This systematic review highlights [1] the reciprocal link between the obesity and COVID-19 pandemics, [2] obesity as a risk factor for more severe disease in past pandemics, [3] potential mechanisms that make individual's suffering from obesity more susceptible to severe disease and higher viral load, and [4] the need to safely resume bariatric services as recommended by expert guidelines, in order to mitigate the health outcomes of an already vulnerable population.

Emotional Resilience and Bariatric Surgical Teams: a Priority in the Pandemic.

The infection control measures implemented as a result of COVID-19 led to a postponement of bariatric surgical procedures across many countries worldwide. Many bariatric surgical teams were in essence left without a profession, with many redeployed to other areas of clinical care and were not able to provide the levels of patient support given before COVID-19. As the pandemic continues, some restrictions have been lifted, with staff adjusting to new ways of working, incorporating challenging working conditions and dealing with continuing levels of stress. This article explores the concept of emotional labour, defined as 'inducing or suppressing feelings in order to perform one's work', and its application to multidisciplinary teams working within bariatric surgery, to offer insight into the mental health issues that may be affecting healthcare professionals working in this discipline.

Impact of COVID-19 on Obesity Management Services in the United Kingdom (The COMS-UK study).

Coronavirus Disease-2019 (COVID-19) has had a severe impact on all aspects of global healthcare delivery. This study aimed to investigate the nationwide impact of the pandemic on obesity management services in the UK in a questionnaire-based survey conducted of professionals involved in the delivery. A total of 168 clinicians took the survey; the majority of which maintained their usual clinical roles and were not redeployed except physicians and nurse specialists. Nearly all (97.8%) elective bariatric surgery was cancelled, 67.3% of units cancelled all multidisciplinary meeting activity, and the majority reduced clinics (69.6%). Most respondents anticipated that the services would recommence within 1-3 months. This study found that the COVID-19 pandemic has had a severe impact on the services involved in the management of patients suffering from severe, complex obesity in the UK.