Page 29 - World Journal of Laparoscopic Surgery

Bariatric Surgery during the COVID-19 Pandemic
The primary outcome measure was COVID-19-related mortality COVID-19 swab tests were performed between 24 and 48 hours
and morbidity at a 6-week follow-up. The secondary outcome prior to surgery. Results were available within 24 hours. Computed
measures were non-COVID-19-related morbidity as defined by the tomography (CT) of the thorax was not routinely performed
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Clavien-Dindo classification, in-hospital mortality, and length of preoperatively. Patients were informed that there was a slightly
hospital stay. increased risk of developing COVID-19-related morbidity as part
of the consent process but no detailed figures on risk were given.
Standard of Care
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Patients with body mass indices (BMI) greater than 40 kg/m or Intraoperative
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35–39.9 kg/m , with at least one obesity-related comorbidity, were Based on evolving national and local guidelines, anesthesia and
offered bariatric surgery following successful completion of a surgery were performed in amber personal protective equipment
supervised tier-3 weight management program. A multidisciplinary (PPE) (visor/goggles, standard surgical masks). A closed filtration
team that includes a bariatric medical specialist, specialist bariatric system was used to safely evacuate pneumoperitoneum before
nurse, dietitian, and surgeon is involved in a comprehensive trocar removal and closure. 10
assessment of the patient. Formal psychological assessment is
undertaken following a routine screening questionnaire. In general, Postoperative
patients are given a choice between Roux-en-Y gastric bypass (RYGB) Patients were nursed in a COVID-19 light ward. Asymptomatic
and sleeve gastrectomy (SG). RYGB is preferred if patients suffer from elective patients with a negative COVID-19 swab test who had been
gastroesophageal reflux disease. SG is usually offered to patients isolating for 14 days were admitted there. Emergency patients were
2
with a BMI greater than 60 kg/m . Patients undergo a supervised only admitted there after 24 hours, in our Surgical Admissions Unit
low-calorie liver-reducing diet for 3 weeks prior to surgery. (SAU) in addition to ensuring that they were asymptomatic from
Our technique of RYGB involves the creation of an approximately COVID-19 point of view with negative swab tests. COVID-19 swab
30-mL gastric pouch. The small bowel is divided 50 cm from the tests were performed if patients developed a temperature.
ligament of Treitz creating the proximal biliopancreatic limb,
which is then anastomosed to a 100-cm-long alimentary limb. results
The alimentary limb is then advanced to the gastric pouch for an Demographic and treatment details are listed in Table 1. All patients
antecolic antegastric end-to-side gastrojejunostomy, which is then underwent preoperative COVID-19 swab tests. No patients were
closed with a double-layered 3/0 STRATAFIX™ (Johnson & Johnson). diagnosed with COVID-19 in the preoperative screening process.
The SG involves an initial 60-mm green stapler (Powered ECHELON All patients who were offered surgery agreed to undergo the
FLEX™ GST System, Johnson & Johnson) with reducing staple height procedure. Two patients required postoperative COVID-19 swab
according to tissue thickness over a 34-French orogastric bougie, test according to hospital testing protocol and had negative results.
starting at least 3 cm from the pylorus and ending at 2 cm from All procedures were completed laparoscopically. One patient who
the gastroesophageal junction. After the gastric mobilization is developed an anastomotic leak had a re-look laparotomy, lavage,
completed, 20 mg of hyoscine butylbromide is given intravenously. and drain placement.
The systolic blood pressure is reduced to approximately 100 mm Hg Outcomes are detailed in Table 2. One patient, who underwent
prior to stapling and then increased to 140 mm Hg after stapling is a SG re-laparoscopy on day 1 for a staple line bleed, had no active
completed, to reveal any staple line bleeding. Active bleeding points bleeding point but a hematoma around the staple line was
R
are then either clipped or sutured with 2/0 PDS II (polydiaxonone, evacuated. This was managed by lavage and partial oversewing
Johnson & Johnson). All patients receive 1 g of tranexamic acid of the staple line. The patient was monitored on the high
routinely at the beginning of the procedure. A leak test is performed
routinely on all patients. Dual consultant operating occurred only Table 1: Demographic and treatment details
for mentoring purposes and in selected patients. Total number 38
Ward-based care is provided for all patients unless preoperative
anesthetic assessment recommends a higher level of care. Patients Male: female 14 : 24
are allowed to drink free fluids postoperatively. Patients are Median age (range) years 51 (24–63)
discharged on the first postoperative day if well, on a liquid diet Median BMI at surgery, kg/m 2 42.9 (32.4–62.5)
for 2 weeks. This is increased to a pureed diet for further 2 weeks. Ethnicities 37 White British;
Patients are reviewed initially after 1 week by phone followed by a 1 Black British/Caribbean
clinical review in 6 weeks, 3 months, and 6 months. Excess weight Comorbidities
2
loss (%EWL) is calculated with a target BMI of 25 kg/m . Patients are Diabetes 21
then reviewed at 1 and 2 years prior to being discharged to their Hypertension 13
general practitioner if there are no ongoing concerns. Nutritional
supplements and blood tests are in line with British Obesity & Osteoarthritis 19
Metabolic Surgery Society (BOMSS) recommendations. 9 Respiratory disease 9
Chronic kidney disease 4
COVID-19 Precautions and Deviations from Standard Nonalcoholic fatty liver disease (NAFLD) 7
of Care Polycystic ovarian disease 2
Preoperative Obstructive sleep apnea 11
We resumed bariatric surgery with patients who had been Surgical approach
categorized as urgent from our waiting list. All patients were Laparoscopic 38
requested to self-isolate for 14 days prior to surgery. Preoperative Open 0

World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022) 27