Impact of COVID-19 pandemic on bariatric surgery in India: An obesity and metabolic surgery society of India survey of 1307 patients.

BACKGROUND: Although safe practice guidelines were issued by the Obesity and Metabolic Surgery Society of India (OSSI) in the end of May 2020, surgeons have been in a dilemma about risk of subjecting patients to hospitalisation and bariatric surgery. This survey was conducted with the objective to evaluate the risk of coronavirus disease-19 (COVID-19) infection in peri- and post-operative period after bariatric and metabolic surgery (BMS).
METHODS: A survey with OSSI members was conducted from 20 July 2020 to 31 August 2020 in accordance with EQUATOR guidelines. Google Form was circulated to all surgeon members through E-mail and WhatsAppTM. In the second phase, clinical details were captured from surgeons who reported positive cases.
RESULTS: One thousand three hundred and seven BMS were reported from 1 January 2020 to 15 July 2020. Seventy-eight per cent were performed prior to 31 March 2020 and 276 were performed after 1 April 2020. Of these, 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. All suffered from a mild disease and there was no mortality. Eighty-seven positive cases were reported from patients who underwent BMS prior to 31 December 2019. Of these, 82.7% of patients had mild disease, 13.7% of patients had moderate symptoms and four patients succumbed to COVID-19.
CONCLUSION: BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines.

INTRODUCTION

The “corona virus disease 19”- (COVID-19) was declared a pandemic by the World Health Organisation (WHO) on 11 March 2020. Surgical societies across the world responded by recommending to stop all elective surgeries. In April 2020, the International Federation for Surgery of Obesity and Metabolic Disorders (IFSO) recommended to postpone all elective surgical and endoscopic bariatric and metabolic procedures during the pandemic.[1] The rationale behind this was to minimise the risk to patients and healthcare teams and to reduce the use of limited resources.

First case with COVID-19 infection was reported in India on 30 January 2020. At the time of writing this paper, India has 10,323,965 COVID-19 cases and 149,435 deaths have been attributed to it.[2] World over, it has pushed the care of patients suffering from obesity to a backburner and these patients have found themselves at the bottom of every priority list. Lockdowns, stress and increasing uncertainty have made them more vulnerable to further weight gain and have led to worsening in the status of associated co-morbidities. To make matters worse, it is also known that the severity of COVID-19 infection is more in patients suffering from obesity.[34] Keeping this in mind, the Obesity and Metabolic Surgery Society of India (OSSI) came out with possible recommencement guidelines for bariatric and metabolic surgery (BMS) in India in May 2020.[5] However, surgeons across the world have been in a dilemma about subjecting patients to hospitalisation and surgery despite the benefits of ensuing weight loss. Paucity of data on safety of BMS during the pandemic is one of the reasons for this. The objective of this survey was to collate the data of patients who underwent BMS in India since the pandemic began this year. Our aim was to understand the impact of the ongoing pandemic on these operated patients in terms of post-operative susceptibility to infection with COVID-19 and whether there was any increase in morbidity or mortality. We also asked the respondents to report COVID-19-positive patients who underwent BMS before the pandemic (prior to 31 December 2019) to get a sense of their clinical profile.

METHODS

This survey was conducted as per the principles of good practice for conduct and reporting of survey research as recommended by the EQUATOR network guidelines.[6] It was conducted in two parts. The first part of the survey was conducted using an 11-point questionnaire with help of a Google Form (https://forms. gle/i9oWWuhr3ydVLjey8). This captured the data of patients who turned COVID-19 positive post-BMS (mainly for operations conducted after January 1 2020). In addition, we also captured data of post-operative patients who were operated prior to the pandemic (before 31 December 2019) and were reported positive for COVID-19.

The Google Form was circulated to all the surgeon members of OSSI through E-mail and WhatsApp™. Forty-five surgeons responded to the first part of the survey. In the second phase, an Excel spreadsheet intended to capture clinical details about the patients who turned COVID-19 positive was sent to the surgeons who reported positive cases. The survey was made live on 20 July 2020 and closed for analysis on 31 August 2020. Tables 1 and 2 enlist the details of the questions of the two parts of the survey. As this is a retrospective survey, for this type of study, formal consent is not required and hence informed consent does not apply.

Table 1

Survey part 1 - Questionnaire circulated on Google Forms

Question	Response
Name of the surgeon
Mobile number
City of practice
Email address
OSSI membership	Yes
Total number of bariatric/metabolic operations performed from 1 January 2020 to 31 March 2020	1031
Total number of bariatric/metabolic operations performed from 1 April 2020 to 15 July 2020	276
Did any of your patients who underwent bariatric/metabolic surgery from 1 January 2020 to 15 July 2020 test positive for COVID-19?	4 surgeons responded in the affirmative
If yes, how many patients operated between 1 January 2020 and 15 July 2020 test positive for COVID-19	13 patients
Did any of your patients who underwent bariatric/metabolic surgery before 31 December 2019 test positive for COVID-19?	16 surgeons responded in the affirmative
If yes how many patients operated before 31 December 2019 tested positive for COVID-19?	87 patients

OSSI: Obesity and Metabolic Surgery Society of India, COVID-19: Coronavirus disease-19

Table 2

Survey part 2 - Questionnaire circulated to surgeons who reported coronavirus disease-19-positive cases

Question
Age of the patient
Gender
Pre-operative weight in kilogram
Height in centimeter
Pre-operative BMI
Associated co-morbidity - T2DM
Associated co-morbidity - hypertension
Associated co-morbidity - heart disease
Associated co-morbidity - OSA
Associated co-morbidity - others
City of residence of the patient
City in which surgery was conducted
Date of surgery
Type of surgery
Date of COVID-19 detection
Weight at the time of COVID-19 infection
BMI at the time of COVID-19 infection
Severity of COVID-19 infection - mild
Severity of COVID-19 infection - moderate
Severity of COVID-19 infection - severe
Recovered
Mortality

BMI: Body mass index, T2DM: Type 2 diabetes mellitus, OSA: Obstructive sleep apnoea, COVID-19: Coronavirus disease-19

Analysis was done using descriptive statistics and using graphs wherever applicable.

RESULTS

Forty-five surgeons responded to the survey. A total of 1307 bariatric operations were reported from 1 January 2020 to 15 July 2020. Out of these, 78% of the operations were performed prior to 31 March 2020. Two hundred and seventy-six bariatric operations were reportedly performed by this group between 1 April 2020 and 15 July 2020.

Patients who underwent bariatric surgery after 1 January 2020 and were reported to be COVID-19 positive

Of 1307 patients who underwent bariatric surgery since 1 January 2020, a total of 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. Table 3 depicts the clinical characteristics of these 13 patients. Of these 13 patients, four patients underwent laparoscopic sleeve gastrectomy (LSG), four underwent laparoscopic one anastomosis gastric bypass (OAGB) and five underwent laparoscopic Roux-en y gastric bypass (RYGB). The average number of days taken to contract COVID-19 infection after bariatric surgery in these 13 patients was 82.5 ± 58.25 days. Out of 13 patients, three patients became COVID-19 positive within 30 days of having BMS. All patients had a mild course of the illness and none of them required hospitalisation. There was no mortality.

Table 3

Clinical characteristics of patients who underwent bariatric surgery after 1 January 2020 and turned coronavirus disease-19 positive

Parameter	Result
N	13
Mean age (years)	39±10.96
Mean pre-operative weight (kg)	119.84±16.21
Mean post-operative weight (kg)	97.64±15.50
Mean pre-operative BMI (kg/m2)	43.7±6.84
Mean post-operative BMI (kg/m2)	35.69±6.53
Time taken to turn COVID-19 positive after bariatric surgery (days)	82.5±58.25
Number of patients with T2DM	2
Number of patients with hypertension	4
Number of patients with OSA	5

T2DM: Type 2 diabetes mellitus, OSA: Obstructive sleep apnoea, BMI: Body mass index, COVID-19: Coronavirus disease-19

Patients who underwent bariatric surgery before 31 December 2019 and were reported to be COVID-19 positive

The survey also captured data of COVID-19-positive patients who underwent bariatric surgery before 31 December 2019. In this group, 87 COVID-19-positive patients were reported. Of these, 34 patients (39%) underwent LSG, 16 patients (18.3%) underwent OAGB and 38 patients (43%) underwent RYGB. In this group, we could not capture the total number of operated patients, and hence, the denominator is not known. However, data pertaining to weight, BMI, age, key co-morbidities and severity of illness were captured for these patients. Table 4 depicts the clinical characteristics of these 87 patients. Almost 82.7% of patients had a mild course of the disease and did not need hospitalisation. About 13.7% of patients experienced moderate symptoms and required hospitalisation. Nearly 4.5% had severe illness and four patients succumbed to COVID-19 infection. The clinical details of these four patients are listed in Table 5.

Table 4

Clinical characteristics of patients who underwent bariatric surgery before 31 December 2019 and turned coronavirus disease-19 positive

Parameter	Result
N	87
Mean age (years)	45.64±10.64
Mean pre-operative weight (kg)	116.77±20.75
Mean weight at the time of detection with COVID-19 (kg)	82.67±17.32
Mean pre-operative BMI (kg/m2)	44.17±6.41
Mean BMI at the time of detection with COVID-19 (kg/m2)	31.18±8.16
Number of patients with T2DM	38 (43%)
Number of patients with hypertension	49 (56%)
Number of patients with OSA	33 (37%)

T2DM: Type 2 diabetes mellitus, OSA: Obstructive sleep apnoea, BMI: Body mass index, COVID-19: Coronavirus disease-19

Table 5

Clinical details of patients who suffered a mortality due to coronavirus disease-19 infection post-bariatric surgery

Parameter	Patient 1	Patient 2	Patient 3	Patient 4
Age in years	66	74	50	35
Gender	Male	Male	Male	Female
Pre-operative weight (kg)	136	90	126	111
Pre-operative BMI (kg/m2)	40	36.5	50	46
T2DM	No	Yes	No	Yes
Hypertension	Yes	Yes	Yes	Yes
OSA	Yes	No	No	Yes
Chronic renal failure	Yes	No	No	Yes
Date of surgery	February 2013	January 2012	August 2013	February 2019
Date of COVID-19 detection	10 August 2020	19 June 2020	9 May 2020	29 May 2020
Weight at the time of COVID-19 detection (kg)	115	60	95	85
BMI at the time of COVID-19 detection (kg/m2)	35	24.3	37.6	35

T2DM: Type 2 diabetes mellitus, OSA: Obstructive sleep apnoea, BMI: Body mass index, COVID-19: Coronavirus disease-19

DISCUSSION

With a population of almost 1.4 billion people, today, India has the third largest number of people in the world who suffer from obesity.[7] Exponential economic growth coupled with genetic predisposition and changing environmental factors has led to a burgeoning obesity epidemic. BMS was started in India in the late nineties and currently, India is the largest hub for BMS in the Asian continent and the numbers of BMS procedures have shown a steady increase over the last five years.[8]

During the COVID-19 pandemic, India also observed one of the strictest lockdowns in the world. Sudden and prolonged prohibition on movement led to stoppage of all avenues for physical activity such as parks and gyms. Patients suffering from obesity were particularly affected. Lockdowns made them more vulnerable to overeating and a sedentary lifestyle. Added to this were increased stress and sleep disorders which predisposed them to further weight gain and worsening of co-morbidities.

Obesity has emerged as an adverse prognostic factor for COVID-19 infection. Patients suffering from obesity have a greater rate of hospitalisation and also tend to develop a more severe illness and related mortality.[34910] It has also been seen that obesity increased the odds of being admitted to the intensive care unit by 74%.[11] Obesity is associated with multiple co-morbidities such as type 2 diabetes, hypertension and dyslipidaemia and has a detrimental effect on overall lung function. Malnutrition is one of the factors that may possibly lead to an impaired immune response in these patients.[12] The increase in risk is also attributed to the chronic low-grade inflammation associated with obesity which can lead to metabolic and immune derangement. In addition, increased production of cytokines like tumour necrosis factor α, interleukin-1 (IL-1), IL-6 and monocyte chemoattractant protein 1 causes oxidative stress and leads to defective immunity. Finally, endothelial dysfunction, alteration in cardiac structure and a prothrombotic state associated with obesity may be a link to increased cardiovascular morbidity in patients suffering from obesity.[13]

While we need to focus on prevention of obesity and management of patients who are overweight, those who suffer from severe or morbid obesity need maximum attention. Patients suffering from severe obesity are the most vulnerable to severe sickness and mortality. At present, BMS is the only effective option to treat patients suffering from clinically severe obesity and it also leads to rapid improvement in obesity-associated co-morbidities.[14] It is also reasonable to presume that BMS is one option to help decrease the risk and severity of COVID-19 infection in this group of patients. However, as the pandemic raged on month after month, the number of BMS operations started decreasing. After the IFSO guidelines pertaining to elective surgery were issued in April 2020, most surgeons refrained from performing surgery.[1] The reasons behind this were twofold. First, at that time, we were not sure about what we were dealing with and what would be the magnitude of the disease. Hence, it was important to save the precious resources. Second, we did not want to needlessly subject our patients to be exposed to a risk of contracting COVID-19 infection during their hospital stay. It has been almost a year that COVID-19 pandemic has been raging on and there is no end in sight. Even though at this moment we are at the threshold of a vaccine, it will be a long time before we can achieve a reasonable herd immunity. Hence, it is crucial that BMS services must not be delayed any further and must be restarted.

In view of this, in May 2020, OSSI constituted a committee of experienced surgeons who formulated the recommendations for resumption of BMS services with an emphasis on safe delivery and high-quality care.[5] Around the same time, DSS guidelines published in May 2020 recommended to prioritise those with greatest risk of morbidity and mortality from their disease. This includes patients with uncontrolled type 2 diabetes mellitus or substantial metabolic, respiratory or cardiovascular illness.[15]

Although these guidelines have been in place for the last 3 months, surgeons have been hesitant to conduct surgeries in the current scenario. One of the major concerns has been the paucity of data regarding COVID-19 infection in the peri- and post-operative period. Hence, this survey was undertaken to collate the data of patients who underwent BMS since January 2020 as the first positive case with COVID-19 infection in India was detected in January 2020. Forty-five surgeons responded to this survey. A total of 1307 BMS procedures were reported from 1 January 2020 to 15 July 2020 in this survey. Seventy-eight per cent of these operations were performed before 31 March. The mean BMI at the time of surgery was 43.7 ± 6.84 Kg/m2. About 0.99% (13) of these patients tested positive for COVID-19 infection in the post-operative period at various stages. Mean BMI at the time of detection of COVID-19 infection was 35.69 ± 6.53 Kg/m2. All patients were reported to have a mild disease and none of them needed hospitalisation. The key point here is that 276 of the reported patients underwent surgery after the countrywide lockdown was implemented and yet it did not increase the positivity rate in the peri- and post-operative period. None of these positive cases appeared to be hospital-acquired infections, thus indicating that BMS performed with due care during pandemic times was also safe. In a retrospective review of 218 patients who underwent bariatric surgery during the COVID-19 pandemic in Italy, three (1.5%) patients were reportedly detected positive. All three patients required hospitalisation, but there was no mortality.[16] In April 2020, four cases were reported from Iran which were complicated with COVID-19 within 14 days of BMS. Three of these patients were readmitted and two required intensive medical care. This was in early days of the pandemic and the timing of infection may raise the possibility of hospital-acquired infection in these cases.[17] In our series, none of the patients turned positive for COVID-19 so early in the post-operative period. Minimum time period was 24 days, hence ruling out the possibility of hospital-acquired infection in these cases.

In addition to the data of operations performed during the pandemic, we also attempted to collate the data of COVID-19-positive patients who had undergone BMS prior to 31 December 2019. The objective was to evaluate the clinical characteristics of these patients and get a bird’s eye view of COVID-19 infection in post-bariatric surgery patients. Forty-five surgeons reported 87 patients positive for COVID-19 who were operated prior to 31 December 2020. Of these, 82.7% of patients were reported to have a mild course of the disease, 13.7% of patients experienced moderate symptoms and required hospitalisation and four mortalities were reported. Table 4 enlists the clinical characteristics of these patients. Table 5 depicts the characteristics of patients who succumbed to COVID-19 infection. These clinical characteristics corroborate that a high number of these patients had associated co-morbidities.

One of the limitations of this study is that only 45 surgeons responded to this survey out of about 350 members of OSSI. However, over 1300 BMS procedures were reported which is a good sample size to reflect on and serves the aim of this survey which was to get a snapshot of patients who were operated during the pandemic to assess the safety from COVID-19 perspective. The other limitation was the lack of denominator in the second subset of post-BMS patients who underwent surgery prior to 31 December 2019. Some of the limitations of survey design per se include a very general nature of questions. Hence, survey results may not be as valid as results obtained using other methods of data collection and may lack depth. Online surveys may also have lower participation and lower respondent availability.

This survey is our first attempt to capture the data pertaining to COVID-19 infection in the peri- and post-operative period. As reported in this survey, the outcomes are favourable and patients undergoing BMS during the pandemic appear to have a <1% risk of contracting COVID-19 infection in the post-operative period. Even this 1% may or may not be attributed specifically to the process of surgery and hospitalisation as the average time taken to turn positive after BMS was 82.5 ± 58.25 days. Of note in particular is that none of the positive patients required hospitalisation and suffered only from a mild course of the disease.

In conclusion, BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines recommended by the association. In the future, we shall continue to collate pertinent data from our members. COVID-19 pandemic has presented the bariatric surgical community with unique challenges. This is our first step on the road to help our patients and we need to continue our efforts to get them the treatment that they deserve in a safe manner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.