Page 30 - World Journal of Laparoscopic Surgery

Bariatric Surgery during the COVID-19 Pandemic
Table 2: Outcomes (Clavien-Dindo classification—CD) malattie metaboliche (SICOB) have recommended the cessation of
Overall morbidity 3 bariatric surgery. 2,18,19 However, The American Society of Bariatric
Postoperative intractable nausea and vomiting (PONV) 1 (CD i) and Metabolic Surgery have categorically stated that metabolic
Postoperative bleed 1 (CD iiib) surgery is not elective and disagrees with the concept that bariatric
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surgery should be postponed until the pandemic is declared over.
Anastomotic/staple line leak 1 (CD iiib) Studies confirm a survival benefit with metabolic surgery and its
Wound infection 1 ability to significantly improve life-threatening obesity-related
Pneumonia 1 (CD ii) conditions. 21,22 Moreover, Prachand et al. have labeled this as
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Acute kidney injury 1 (CD iva) “medically necessary time-sensitive surgery.” Delays for months
In-hospital mortality 0 and potentially years, given the huge backlog, will unquestionably
Median length of hospital stay, days 1 (1–44) lead to the detriment of these patients and result in an increased
30-day readmission rate 1 burden on the healthcare system.
As the COVID-19 infection and mortality rates in Devon had
been relatively low, urgent elective and cancer surgery continued
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dependency unit (HDU) for 3 days and she was discharged on throughout the pandemic with good outcomes. Along with a
the 7th postoperative day. One patient underwent preplanned thorough risk assessment and support from hospital management,
monitoring in HDU due to preexisting dialysis-dependent chronic bariatric surgery was restarted as the rate of infection decreased
kidney disease. He was transferred to the surgical ward on and lockdown restrictions eased from June 2020 onward. The
day 1 and discharged on the following day. One patient with principle finding of this study is that bariatric surgery can be
RYGB presented to emergency department with complaints of safely performed with the necessary precautions in an area with
severe nausea and vomiting 10 days following surgery. A barium a relatively low infection rate. We have steadily continued with
swallow did not reveal any mechanical obstruction. Her symptoms bariatric procedures even through the second UK lockdown (from
settled with antiemetics and she was discharged home the next November 5 to December 3, 2020). As far as we are aware, there
day. One patient who underwent RYGB developed hemodynamic have been no reports on outcomes after bariatric surgery during
instability on the second postoperative day. A relook laparoscopy the COVID-19 pandemic. Our cohort of patients had a median age of
was converted to a laparotomy, washout, and drain placement for 51 years and a median BMI of 42.9 with over 75% of patients classed
a leak at the gastrojejunal anastomosis. He suffered acute kidney as “severely obese.” Over two-thirds of them had more than one
injury and required intensive therapy unit (ITU) support for 10 days. obesity-related comorbidity. In addition, training occurred in almost
He was discharged after 44 days, eating and drinking when a barium half the cases. Despite this, complication rates compare favorably
swallow confirmed resolution of leak. with international standards. 25–27
All patients were followed up at 6 weeks. The median (range) This study has potential limitations. Observational studies
excess weight loss (%EWL) was 24.4% (−0.9–53.6), taking a BMI are understandably prone to selection bias. However, this was
2
of 25 kg/m as target. The median difference in BMI was 4.2 minimized as we reported a consecutive series of patients
(−0.4–9.6). The median loss of weight in kilograms was 12.8 prospectively and we followed our usual practice of operating on
(−1.2–25.4) which translated to a median 9.52% (−0.5–21.1) loss patients according to their place on our urgent waiting list. There
of total body weight. No patients developed any respiratory was no additional screening of patients to gauge their suitability
symptoms suggestive of COVID-19 even during the “second for bariatric surgery, outside of the usual tier-3 weight management
wave” of the pandemic in the United Kingdom (UK). There were program. This is a 6-month cohort with adequate follow-up and
no patients lost to follow-up. we felt it was important to report our encouraging outcomes to
provide evidence for the resumption of elective bariatric surgery
dIscussIon during this phase of the pandemic, with COVID cases continuing to
The COVID-19 pandemic has highlighted the significance of the be reported in the community amid ongoing vaccination programs.
obesity crisis as it is an independent risk factor for severe illness and There are numerous factors that allowed us to recommence
death from COVID-19. 11,12 Even prior to the COVID-19 outbreak, the this service safely. Firstly, patients were subjected to early and
stigma surrounding obesity has been known to lead to delays and rapid testing. The relatively low rate of COVID-19 infection in our
underutilization of bariatric surgery. 13 population meant that our hospital was not overwhelmed with
The pandemic will result in further delays because of limited infected cases, thus reducing the risk of in-hospital transmission.
resources and the misconception that such surgery should be the last There are various ways of measuring the rate of infection and
14
resort. A lack of understanding about the complex nature of obesity risk of transmission in a population. The reproduction number or
has led to the suggestion that these patients can simply be put on a R number is the average number of secondary infections produced
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diet until the pandemic is over. The increased morbidity and mortality by one infected person. Although this has limitations in areas with
in obese patients with COVID-19 have understandably resulted in a small number of cases and geographies smaller than at regional
a cautious approach toward the resumption of elective bariatric level, it can be a guide to aid decision-making for restarting
procedures in the current climate. However, our patient population bariatric services. Interestingly nationally reported R numbers
are reporting increased levels of anxiety over the media coverage for the southwest were consistently less than one during the
regarding the link between obesity and adverse outcomes with time period under review. As widespread and increasingly more
COVID-19. Patients are anxious to undergo their bariatric surgery convenient methods of antibody testing are being implemented,
to reduce these risks that have been documented in the published this may prove to be another tool for decision-making in the near
literature. 15–17 future. 29,30
Numerous societies including the IFSO, Diabetes Surgery The definite diagnosis of COVID-19 is based on virus isolation
Summit (DSS), and Società Italiana di Chirurgia dell’Obesità e or a positive result of polymerase chain reaction (PCR) test from

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