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Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients

      Abstract

      Background

      COVID-19 has transformed surgical care, yet little is known regarding implications for bariatric surgery.

      Objective

      We sought to characterize the effect of COVID-19 on bariatric surgery delivery and outcomes.

      Setting

      The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) collects data from 885 centers in North America.

      Methods

      The MBSAQIP database was evaluated with 2 cohorts described: the COVID-19 and the pre–COVID-19, with patients receiving surgery in 2020 and 2015–2019, respectively. Yearly operative trends were characterized, and bivariate analysis compared demographics and postoperative outcomes. Multivariable modeling evaluated 30-day readmission, reintervention, and reoperation rates and factors associated with undergoing Roux-en-Y gastric bypass.

      Results

      We evaluated 834,647 patients, with 155,830 undergoing bariatric surgery during the 2020 pandemic year. A 12.1% reduction in total cases (177,208 in 2019 versus 155,830 in 2020; P < .001) and 13.8% reduction in cases per center occurred (204.2 cases per center in 2019 versus 176.1 cases per center in 2020; P < .001). Patients receiving bariatric surgery during the pandemic were younger and had fewer co-morbidities. Use of sleeve gastrectomy increased (74.5% versus 72.5%; P < .001), and surgery during COVID-19 was associated with reduced Roux-en-Y gastric bypass procedure selection (odds ratio = .83; 95% CI: .82–.84; P < .001). Length of stay decreased significantly (1.4 ± 1.4 days versus 1.6 ± 1.4 days; P < .001), yet postoperative outcomes were similar. After adjusting for co-morbidities, patients during COVID-19 had decreased 30-day odds of readmission and reintervention and a small increase in odds of reoperation.

      Conclusion

      The COVID-19 pandemic dramatically changed bariatric surgery delivery. Further studies evaluating the long-term effects of these changes are warranted.

      Keywords

      The COVID-19 pandemic has drastically transformed delivery of surgical care worldwide [
      • Kibbe M.R.
      Surgery and COVID-19.
      ]. With concerns regarding hospital resources and COVID-19 perioperative morbidity and mortality, millions of surgical procedures were canceled in 2020 [
      • Kibbe M.R.
      Surgery and COVID-19.
      ,
      • Nepogodiev D.
      • Bhangu A.
      • Glasbey J.C.
      • et al.
      Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.
      ,
      COVIDSurg Collaborative
      Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans.
      ]. In response, patient selection, surgical techniques, and postoperative care have been affected, with substantial changes across every area of general surgery [
      • Kibbe M.R.
      Surgery and COVID-19.
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      • Wexner S.D.
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      COVID-19: impact on colorectal surgery.
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      COVID-19 and the global impact on colorectal practice and surgery.
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      • Wu X.-R.
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      Practice patterns of colorectal surgery during the COVID-19 pandemic.
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      COVIDSurg Collaborative
      Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study.
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      • Rocco N.
      • Montagna G.
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      The impact of the COVID-19 pandemic on surgical management of breast cancer: global trends and future perspectives.
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      Impact of the COVID-19 pandemic on acute general surgical admissions in a district general hospital in the United Kingdom: a retrospective cohort study.
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      • Beatty J.W.
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      • Sounderajah V.
      • et al.
      Impact of the COVID-19 pandemic on emergency adult surgical patients and surgical services: an international multi-center cohort study and department survey.
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      At a glance: the impact of COVID-19 on emergency general surgery.
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      Delivery of hepato-pancreato-biliary surgery during the COVID-19 pandemic: a European-African Hepato-Pancreato-Biliary Association (E-AHPBA) cross-sectional survey.
      ]. These changes are expected to have pervasive long-term health and care delivery effects [
      • Tran L.D.
      • Rose L.
      • Urech T.
      • et al.
      Short-term effects of canceled elective procedures due to COVID-19: evidence from the Veterans Affairs Healthcare System.
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      • Morris E.J.A.
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      • Spata E.
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      ,
      • Søreide K.
      • Hallet J.
      • Matthews J.B.
      • et al.
      Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services.
      ]. Despite substantial evidence across various surgical subspecialties, a multicenter international evaluation of the effect that COVID-19 has had on bariatric surgery has not been well characterized. This scarcity of evidence has occurred despite patients with obesity being disproportionately affected by COVID-19, alongside concerns that obesity treatments may be overlooked because of obesity stigma as we recover from the COVID-19 pandemic [
      • Singhal R.
      • Tahrani A.A.
      • Sakran N.
      • et al.
      Effect of COVID-19 pandemic on global bariatric surgery practices - the COBRAS study.
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      • Tahrani A.A.
      Obesity and COVID-19: a call for action from people living with obesity.
      ,
      • Singhal R.
      • Tahrani A.A.
      • Ludwig C.
      • et al.
      Global 30-day outcomes after bariatric surgery during the COVID-19 pandemic (GENEVA): an international cohort study.
      ,
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      • Cohen R.V.
      • Mingrone G.
      • et al.
      Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery.
      ].
      Early studies evaluating the effect of COVID-19 on bariatric surgery have reported a substantial reduction in procedures performed [
      • Singhal R.
      • Tahrani A.A.
      • Sakran N.
      • et al.
      Effect of COVID-19 pandemic on global bariatric surgery practices - the COBRAS study.
      ]. Unfortunately, delaying bariatric surgery because of COVID-19 has shown deleterious weight gain and psychological patient effects [
      • Ahmed B.
      • Altarawni M.
      • Ellison J.
      • Alkhaffaf B.H.
      Serious impacts of postponing bariatric surgery as a result of the COVID-19 pandemic: the patient perspective.
      ]. Other groups, including our own, have reported ongoing bariatric care delivery with careful patient selection to enable early patient discharge and limit the effect on hospital resources [
      • Abu-Omar N.
      • Marcil G.
      • Mocanu V.
      • et al.
      The effect of the COVID-19 pandemic on bariatric surgery delivery in Edmonton, Alberta: a single-centre experience.
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      • Ghanem A.
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      • Kerrigan D.
      • Ahmed A.R.
      Bariatric surgery during COVID-19 in the UK: a British Obesity and Metabolic Surgery Society (BOMSS) survey.
      ]. The largest study evaluating bariatric surgery patients during the COVID-19 pandemic has reported similar postoperative outcomes to historic studies but unfortunately did not characterize differences in delivery or patient selection [
      • Singhal R.
      • Tahrani A.A.
      • Ludwig C.
      • et al.
      Global 30-day outcomes after bariatric surgery during the COVID-19 pandemic (GENEVA): an international cohort study.
      ]. Better understanding of the consequences of COVID-19 on bariatric surgery is required to optimize future delivery during the ongoing COVID-19 waves and potentially after if COVID-19 cannot be limited or eradicated.
      Here, we report the largest multicenter international retrospective cohort study of prospectively collected data evaluating the effect of COVID-19 on the delivery of bariatric surgery care in North America. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was used to describe surgical volume, patient demographics, operative technique, and postoperative outcomes for patients undergoing bariatric surgery in accredited North American centers.

      Materials and Methods

      Data source

      The 2015–2020 MBSAQIP database was queried to collate data for this study. This data registry prospectively collects key preoperative, operative, and early postoperative information on patients undergoing bariatric surgery from 885 centers in the United States and Canada. Data within the registry are collected based on well-defined, standardized variables, and data integrity and collection practices are subject to frequent review [
      American College of Surgeons [homepage on the Internet]. Chicago: The College; c1996–2022 [cited January 3 2022]. MBSAQIP participant use data file (PUF); [about 2 screens].
      ]. This study was exempt from research ethics board review.

      Study design, patient population, and variable definitions

      This is a retrospective cohort study of prospectively collected MBSAQIP data. The study’s primary objective was to characterize bariatric surgery delivery, including case volume, during the COVID-19 pandemic compared with before the pandemic. Secondary outcomes involved ascertainment of trends in demographics, surgical technique, and postoperative outcomes for patients undergoing bariatric surgery in North America during the COVID-19 pandemic compared with those before COVID-19.
      Patients receiving bariatric surgery during the COVID-19 pandemic included any bariatric surgery occurring during the 2020 MBSAQIP year. Patients who underwent surgery before COVID-19 were categorized by bariatric surgery before 2020 and after 2015, when the MBSAQIP database began collecting data. Only patients receiving elective sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included because they represent the majority of bariatric procedures performed [
      • Kizy S.
      • Jahansouz C.
      • Downey M.C.
      • et al.
      National trends in bariatric surgery 2012-2015: demographics, procedure selection, readmissions, and cost.
      ]. Patients with a history of a previous bariatric surgery and those in whom the index procedure represented emergency surgery were excluded.
      Demographic data were obtained for all patients and included sex, race, and preoperative body mass index. The pulmonary co-morbidities evaluated were sleep apnea, active smoking, and chronic obstructive pulmonary disease. The cardiac co-morbidities evaluated were hypertension, hyperlipidemia, previous myocardial infarction (MI), previous cardiac surgery, and previous percutaneous coronary intervention. Other co-morbidities evaluated were history of venous thromboembolism, gastroesophageal reflux disease, diabetes, venous stasis, renal insufficiency, dialysis dependency, therapeutic anticoagulation, and chronic steroid use. Information regarding the surgical technique included the operative procedure (SG versus RYGB) and operative time.
      Postoperative outcomes evaluated length of inpatient hospital stay after bariatric surgery and 30-day readmissions to hospital, reoperations, and reinterventions based on MBSAQIP definitions [
      American College of Surgeons [homepage on the Internet]. Chicago: The College; c1996–2022 [cited January 3 2022]. MBSAQIP participant use data file (PUF); [about 2 screens].
      ]. Additionally, infectious complications such as the rate of urinary tract infection, deep and superficial surgical site infection, wound disruption, pneumonia, and sepsis are reported. Other postoperative complications evaluated include unplanned intubation, acute renal failure (described as any renal failure requiring dialysis), MI, cerebral vascular accidents, and mortality.

      Statistical analysis

      All statistical analyses were completed using STATA 17 statistical software (StataCorp, College Station, TX, USA). Categorical data were expressed as absolute values with percentages, whereas continuous data were expressed as a weighted mean ± standard deviation. Between-group differences were evaluated using χ2 tests for categorical data and analysis of variance for continuous data. Trends were analyzed over time, with demographics and surgical technique reported for each year from 2015 to 2020. Given the MBSAQIP’s large data set, many statistically significant outcomes occurred; therefore, results presented here are those with substantial differences and clinical significance. Specific cases where statistical significance occurred without clinical significance are also highlighted.
      To determine independent predictors of postoperative complications, including 30-day readmissions, reinterventions, and reoperations, a nonparsimonious multivariable logistic regression model was developed using a hypothesis-driven purposeful selection methodology. Bivariate analysis of variables with a P value <.1 or from variables previously deemed clinically relevant to our primary outcome were used to generate a preliminary main effects model. Significant variables in the multivariable model were then identified (Wald test P < .05), and linear assumption of continuous variables and multicollinearity were checked using the variance inflation factors. Variables with variance inflation factors >10 were explored using collinearity diagnostic tests and excluded from the final model if they were collinear. The Brier score and the receiver operating characteristic curve were used to assess goodness of fit. This model included the pandemic as an independent variable to assess its effect on postoperative outcomes. A multivariable model also was developed in a similar fashion to evaluate factors independently associated with undergoing RYGB to assist with characterizing delivery of bariatric surgery during COVID-19.

      Results

      Patient demographics

      Patients undergoing elective bariatric surgery during the COVID-19 pandemic were marginally younger (44.0 ± 11.9 years COVID-19 versus 44.7 ± 12.0 years pre–COVID-19; P < .001) and were more likely to be female (81.6% COVID-19 versus 80.2% pre–COVID-19; P < .001) (Table 1). Notably, there was a large decrease in White patients receiving bariatric surgery during the COVID-19 pandemic (67.1% COVID-19 versus 71.7% pre–COVID-19; P < .001), with an ensuing increase in Black patients (19.7% COVID-19 versus 18.2% pre–COVID-19; P < .001) (Table 1).
      Table 1Patient characteristics comparing patients who received elective bariatric surgery during the COVID-19 pandemic with those who received elective bariatric surgery before the COVID-19 pandemic
      CharacteristicBariatric surgery before COVID-19 (n = 678,817), n (%)Bariatric surgery during COVID-19 (n = 155,830), n (%)P value
      Data on race combinations or other race were not captured in the Metabolic and Bariatric Accreditation and Quality Improvement Program database before 2020. P values were determined using χ2 analysis for categorical data and analysis of variance for continuous data.
      Age (y), mean ± SD44.7 ± 12.044.0 ± 11.9<.001
       <181246 (.2)214 (.1)<.001
       18–2977,324 (11.4)15,533 (10.0)
       30–39172,641 (25.4)37,297 (23.9)
       40–49198,416 (29.2)45,633 (29.3)
       50–59149,958 (22.1)36,779 (23.6)
       ≥6079,244 (11.7)20,394 (13.1)
      Sex<.001
       Female544,084 (80.2)127,095 (81.6)
       Male134,591 (19.8)28,691 (18.4)
       Nonbinary44 (.03)
      BMI (kg/m2), mean ± SD45.0 ± 7.844.8 ± 7.8<.001
       <3529,092 (4.3)11,592 (7.6)<.001
       35–39155,489 (23.1)34,471 (22.5)
       40–45342,772 (50.9)74,548 (48.5)
       45–50114,297 (17.0)25,442 (16.6)
       50–6025,575 (3.8)5754 (3.8)
       >606381 (1.0)1772 (1.2)
      Race
       White486,444 (71.7)104,570 (67.1)<.001
       American Indian or Alaska native2911 (.4)763 (.5)
       Asian3528 (.5)894 (.6)
       Black or African American123,326 (18.2)30,748 (19.7)
       Native Hawaiian or other Pacific Islander1885 (.3)415 (.3)
      Race combinations
      Data on race combinations or other race were not captured in the Metabolic and Bariatric Accreditation and Quality Improvement Program database before 2020. P values were determined using χ2 analysis for categorical data and analysis of variance for continuous data.
      83 (.1)
       Other698 (.5)
       Not reported60,723 (9.0)17,659 (11.3)
      Smoker55,356 (8.2)10,693 (6.9)<.001
      Diabetes
       No or diet controlled506,599 (74.6)120,266 (77.2)<.001
       Non–insulin dependent117,853 (17.4)25,484 (16.4)
       Insulin dependent54,365 (8.0)10,080 (6.5)
      Hypertension319,802 (47.1)69,229 (44.4)<.001
      GERD210,785 (31.1)49,719 (31.9)<.001
      COPD10,358 (1.5)1896 (1.2)<.001
      Hyperlipidemia157,651 (23.2)34,927 (22.4)<.001
      Chronic steroid use12,272 (1.8)3338 (2.1)<.001
      Renal insufficiency4195 (.6)900 (.6).064
      Dialysis dependent2116 (.3)496 (.3).647
      History of DVT11,345 (1.7)2755 (1.8).007
      History of PE8374 (1.2)2115 (1.4)<.001
      Venous stasis6200 (.9)1104 (.7)<.001
      Preoperative therapeutic anticoagulation19,581 (2.9)4514 (2.9).733
      Sleep apnea253,535 (37.4)57,557 (36.9).002
      History of MI8308 (1.2)1647 (1.1)<.001
      Previous major cardiac surgery7088 (1.0)1431 (.9)<.001
      Previous PCI12,601 (1.9)2332 (1.5)<.001
      SG492,070 (72.5)116,090 (74.5)<.001
      RYGB186,753 (27.5)39,753 (25.5)<.001
      Operative time (min), mean ± SD86.7 ± 49.889.9 ± 54.5<.001
      SD = standard deviation; BMI = body mass index; GERD = gastroesophageal reflux disease; COPD = chronic obstructive pulmonary disease; DVT = deep vein thrombosis; PE = pulmonary embolism; MI = myocardial infarction; PCI = percutaneous coronary intervention; SG = sleeve gastrectomy; RYGB = Roux-en-Y gastric bypass.
      Data on race combinations or other race were not captured in the Metabolic and Bariatric Accreditation and Quality Improvement Program database before 2020. P values were determined using χ2 analysis for categorical data and analysis of variance for continuous data.
      With regard to metabolic co-morbidities, patients during the COVID-19 pandemic were less likely to have hypertension (44.4% COVID-19 versus 47.1% pre–COVID-19; P < .001) or dyslipidemia (22.4% COVID-19 versus 23.2% pre–COVID-19; P < .001) and were more likely to not require medication for diabetes (77.2% COVID-19 versus 74.6% pre–COVID-19; P < .001). They also had fewer systemic co-morbidities, including less sleep apnea (36.9% COVID-19 versus 37.4% pre–COVID-19; P = .002), and fewer cardiac co-morbidities such as prior MI, prior cardiac surgery, or prior percutaneous coronary intervention (Table 1).
      In terms of operative technique, SG was performed in a higher proportion of patients during the COVID-19 pandemic (74.5% COVID-19 versus 72.5% pre–COVID-19; P < .001; Table 1). Despite this change, operative duration was shorter before the COVID-19 pandemic by 3.2 minutes (89.9 ± 54.5 minutes COVID-19 versus 86.7 ± 49.8 minutes pre–COVID-19; P < .001).

      Trends in operative volume over time

      A total of 834,647 patients were evaluated, with 155,830 (18.7%) receiving bariatric surgery during the COVID-19 pandemic. Despite an increasing number of MBSAQIP-accredited centers in 2020 (n = 885 centers), the number of elective bariatric surgery cases completed during the COVID-19 pandemic decreased by 21,359 (12.1%) compared with 2019 (n = 868 centers; Fig. 1). The number of cases per MBSAQIP center showed a 13.8% decreased during the COVID-19 pandemic from 204.2 cases per center in 2019 to 176.1 cases per center in 2020 (P < .001).
      Figure thumbnail gr1
      Fig. 1Total number of elective bariatric surgeries, Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) reporting centers, and elective bariatric surgeries per center over time.

      Changes in patient selection and operative procedure over time

      Patient selection from 2015 to 2020 demonstrates a trend toward bariatric surgery for patients with diet-controlled or no diabetes from 74.0% in 2015 to 77.2% in 2020 (Table 2). Similarly, there has been a trend toward selecting fewer patients with hypertension (48.9% in 2015 versus 44.4% in 2020). For both diabetes and hypertension, patients receiving bariatric surgery during the COVID-19 pandemic (i.e., 2020) had the lowest rates since MBSAQIP began collecting data (Table 2). In terms of operative selection, there has been an increasing use of SG from 70.2% in 2015 to 74.5% in 2020, again with 2020 representing the greatest proportion of SGs ever reported in the MBSAQIP data.
      Table 2Five-year demographic and operative characteristics for patients who received elective bariatric surgery during the COVID-19 pandemic versus those who received elective bariatric surgery before the COVID-19 pandemic
      Characteristic201520162017201820192020
      SG47,176 (70.2)64,089 (72.9)125,515 (73.3)128,207 (73.1)127,077 (71.7)116,077 (74.5)
      RYGB20,029 (29.8)23,832 (27.1)45,649 (26.7)47,112 (26.9)50,131 (28.3)39,753 (25.5)
      Total elective bariatric surgeries67,20587,921171,164175,319177,208155,830
      Centers reporting MBSAQIP data742791832854868885
      Elective bariatric surgeries per MBSAQIP center90.6111.2205.7205.3204.2176.1
      BMI (kg/m2)
       <352793 (4.2)3592 (4.1)7209 (4.2)7444 (4.3)8054 (4.6)11,592 (7.6)
       35–3914,834 (22.3)19,863 (22.8)39,287 (23.1)40,943 (23.5)40,562 (23.1)34,471 (22.5)
       40–4533,221 (49.9)44,178 (50.8)86,978 (51.1)88,779 (50.9)89,616 (51.1)74,548 (48.5)
       45–5012,028 (18.1)15,027 (17.3)28,806 (16.9)29,213 (16.8)29,223 (16.7)25,442 (16.6)
       50–602690 (4.0)3524 (4.1)6378 (3.8)6574 (3.8)6436 (3.7)5754 (3.8)
       >601003 (1.5)778 (.9)1523 (.9)1487 (.9)1590 (.9)1772 (1.2)
      Diabetes
       No or diet controlled49,728 (74.0)65,438 (74.4)127,758 (74.6)130,893 (74.7)132,791 (74.9)120,280 (77.2)
       Non–insulin dependent11,602 (17.3)15,234 (17.3)29,665 (17.3)30,407 (17.3)30,947 (17.5)25,485 (16.4)
       Insulin dependent5878 (8.8)7249 (8.2)13,746 (8.0)14,022 (8.0)13,471 (7.6)10,085 (6.5)
      Hypertension32,888 (48.9)42,107 (47.9)80,922 (47.3)81,976 (46.8)81,914 (46.2)69,245 (44.4)
      GERD20,775 (30.9)27,654 (31.6)53,161 (31.1)53,694 (30.6)55,508 (31.3)49,727 (31.9)
      SG = sleeve gastrectomy; RYGB = Roux-en-Y gastric bypass; MBSAQIP = Metabolic and Bariatric Accreditation and Quality Improvement Program; BMI = body mass index; GERD = gastroesophageal reflux disease.
      Data are presented as n (%) or n.

      Bivariate analysis of postoperative outcomes comparing pandemic and nonpandemic cohorts

      During the COVID-19 pandemic, length of inpatient hospital stay was significantly reduced compared with previously (1.4 ± 1.4 days COVID-19 versus 1.6 ± 1.4 days pre–COVID-19; P < .001). Patients undergoing bariatric surgery during the COVID-19 pandemic experienced similar postoperative outcomes to those having surgery before the pandemic. Reoperation rates within 30 days were statistically similar (1.3% COVID-19 versus 1.3% pre–COVID-19; P = .142), and both reinterventions (1.0% COVID-19 versus 1.2% pre–COVID-19; P < .001) and readmissions (3.5% COVID-19 versus 3.8% pre–COVID-19; P < .001) were clinically similar despite statistical difference. Overall, none of the postoperative complications had a difference >.4% and are unlikely to be clinically significant when comparing those undergoing bariatric surgery during COVID-19 with prior patients (Table 3).
      Table 3Thirty-day postoperative outcomes for patients who received elective bariatric surgery during the COVID-19 pandemic versus those who received surgery before the COVID-19 pandemic
      OutcomeBariatric surgery before COVID-19 (n = 678,817), n (%)Bariatric surgery during COVID-19 (n = 155,830), n (%)P value
      Length of stay (d)1.6 ± 1.41.4 ± 1.4<.001
      Reoperation8791 (1.3)2081 (1.3).205
      Reintervention8236 (1.2)1587 (1.0)<.001
      Readmission25,600 (3.8)5449 (3.5)<.001
      UTI2291 (.3)523 (.3).908
      Superficial SSI2838 (.4)569 (.4).022
      Deep SSI435 (.06)118 (.08).381
      Wound disruption391 (.06)87 (.06).001
      Pneumonia1401 (.2)357 (.2).134
      Sepsis770 (.1)226 (.2).001
      Unplanned intubation870 (.1)250 (.2).002
      Acute renal failure453 (.07)147 (.1)<.001
      MI168 (.02)47 (.03).181
      Cerebral vascular accidents92 (.01)27 (.02).261
      Mortality595 (.09)196 (.13)<.001
      UTI = urinary tract infection; SSI = surgical site infection; MI = myocardial infarction.

      Multivariable logistic regression of factors associated with postoperative complications

      Undergoing bariatric surgery during the COVID-19 pandemic was associated with a minor decrease in 30-day readmissions (odds ratio [OR] = .93; 95% CI: .91–.96; P < .001) and reinterventions (OR = .86; 95% CI: .82–.91; P < .001) and a small increase in odds of 30-day reoperation (OR = 1.07; 95% CI: 1.02–1.13; P = .001) (Table 4). These differences, while statistically significant, are unlikely to represent clinically significant changes over time. The most significant independent factors associated with increased odds of 30-day readmission, reoperation, and reintervention were undergoing RYGB as opposed to SG, gastroesophageal reflux disease, chronic obstructive pulmonary disease, prior MI, prior deep vein thrombosis, and preoperative anticoagulation (Table 4). The models for readmission, reintervention, and reoperation had receiver operating characteristic curve areas of .64, .67, and .68, and Brier scores of .036, .012, and .017, respectively.
      Table 4Multivariable logistic regression for 30-day postoperative readmission, reoperation, reintervention, and death after elective bariatric surgery
      Risk factor30-day readmission30-day reoperation30-day reintervention
      Odds ratio95% CIP valueOdds ratio95% CIP valueOdds ratio95% CIP value
      COVID-19 pandemic.93.91–.96<.0011.071.02–1.13.004.86.82–.91<.001
      Age.96.95–.97<.0011.081.06–1.10<.001.96.94–.98<.001
      RYGB1.531.49–1.57<.0011.851.77–1.92<.0012.051.96–2.14<.001
      GERD1.351.32–1.39<.0011.301.25–1.35<.0011.361.30–1.42<.001
      Male sex.84.82–.87<.0011.03.98–1.09.98.86.81–.90<.001
      BMI1.011.00–1.02.046.96.95–.98<.001.99.98–1.01.227
      Hypertension1.091.06–1.12<.0011.061.01–1.10.0151.091.04–1.14<.001
      Hyperlipidemia1.081.05–1.11<.001.98.93–1.03.4341.00.95–1.05.961
      Diabetes
       Non–insulin dependent.94.91–.97<.001.92.87–.97.001.93.88–.98.011
       Insulin dependent1.301.25–1.36<.001.94.87–1.00.0681.081.00–1.56.038
      Previous DVT1.481.38–1.59<.0011.411.25–1.59<.0011.241.10–1.41
      Preoperative therapeutic anticoagulation1.621.53–1.71<.0011.311.19–1.45<.0011.741.58–1.92<.001
      Operative duration1.001.00–1.00<.0011.001.00–1.01<.0011.001.00–1.00<.001
      History of MI1.321.21–1.43<.0011.241.08–1.43.0021.641.44–1.88<.001
      Renal insufficiency1.531.37–1.71<.0011.481.23–1.78<.0011.21.99–1.49.067
      Dialysis1.751.52–2.02<.0012.161.71–2.73<.0011.981.53–2.54<.001
      Smoker1.141.09–1.18<.0011.231.55–1.32<.0011.181.10–1.27<.001
      COPD1.411.31–1.51<.0011.401.24–1.58<.0011.251.09–1.42<.001
      Sleep apnea1.01.99–1.04.285.98.94–1.02.2381.02.98–1.07.395
      CI = confidence interval; RYGB = Roux-en-Y gastric bypass; GERD = gastroesophageal reflux disease; BMI = body mass index; DVT = deep vein thrombosis; MI = myocardial infarction; COPD = chronic obstructive pulmonary disease.

      Multivariable logistic regression evaluating predictors of procedural selection

      When evaluating predictors of undergoing RYGB as opposed to SG, we see few independent predictors (Table 5). However, undergoing bariatric surgery during the COVID-19 pandemic was independently associated with a reduced likelihood of receiving RYGB (OR = .83; 95% CI: .82–.84; P < .001). The only patients with a greater reduction in RYGB likelihood were those with renal insufficiency and those who were dependent on dialysis (Table 5). The model was accurate with a receiver operating characteristic curve area of .76 and a Brier score of .16.
      Table 5Multivariable logistic regression evaluating predictors of procedural selection (RYGB versus SG)
      Risk factorOdds ratio95% CIP value
      COVID-19 pandemic.83.82–.84<.001
      Age.94.94–.95<.001
      Male sex.77.76–.78<.001
      GERD1.361.34–1.37<.001
      BMI1.031.03–1.04<.001
      Hypertension1.01.98–1.02.108
      Hyperlipidemia1.061.04–1.07<.001
      Diabetes: non–insulin dependent; insulin dependent.98; 1.27.80–1.20; 1.02–1.58.869; .032
      Previous DVT1.03.98–1.07.269
      Preoperative therapeutic anticoagulation.86.83–.89<.001
      History of MI1.03.98–1.08.189
      Renal insufficiency.82.76–.88<.001
      Dialysis.45.40–.50<.001
      COPD.91.87–.95<.001
      Sleep apnea1.071.05–1.08<.001
      CI = confidence interval; GERD = gastroesophageal reflux disease; BMI = body mass index; DVT = deep vein thrombosis; MI = myocardial infarction; COPD = chronic obstructive pulmonary disease.

      Discussion

      During the COVID-19 pandemic, there was a 12.1% decrease in total elective bariatric surgery cases and a 13.8% decrease in cases per MBSAQIP-accredited center. Less metabolically co-morbid patients were selected for elective surgery, and there was a greater shift toward SG selection at the expense of RYGB delivery. While unadjusted outcomes were similar between cohorts, multivariable analysis revealed small differences in 30-day readmission, reintervention, and reoperation.
      Beyond the overall reduction in operative volume, patient selection and operative techniques were the most drastic changes during the COVID-19 pandemic. These outcomes partly contradict the recommendations initially proposed by Rubino et al. [
      • Rubino F.
      • Cohen R.V.
      • Mingrone G.
      • et al.
      Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery.
      ], who suggested that patients with severe obesity, substantial co-morbidities, and risk of deterioration from obesity-related complications should be prioritized for bariatric surgery. Regardless, both the trend toward SG and less co-morbid patient selection appears to have begun before the COVID-19 pandemic but was emphasized during the pandemic. It is likely that recent data showing favorable outcomes and long-term benefits in patients with obesity but without co-morbidities led to selection of these patients during the pandemic, considering the limited operative time, hospital occupancy, and postoperative follow-up [
      • Singhal R.
      • Tahrani A.A.
      • Sakran N.
      • et al.
      Effect of COVID-19 pandemic on global bariatric surgery practices - the COBRAS study.
      ,
      • Abu-Omar N.
      • Marcil G.
      • Mocanu V.
      • et al.
      The effect of the COVID-19 pandemic on bariatric surgery delivery in Edmonton, Alberta: a single-centre experience.
      ]. Similarly, favorable outcomes, shorter hospital stays, and reduced postoperative complications with SG in the recently published The Swiss Multicenter Bypass or Sleeve Study and Sleeve vs Bypass trials likely explain its increased use during the COVID-19 pandemic [
      • Peterli R.
      • Wölnerhanssen B.K.
      • Peters T.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y Gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.
      ,
      • Dang J.T.
      • Shelton J.
      • Mocanu V.
      • et al.
      Trends and outcomes of laparoscopic sleeve gastrectomy between 2015 and 2018 in the USA and Canada.
      ,
      • Salminen P.
      • Helmiö M.
      • Ovaska J.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity: the SLEEVEPASS randomized clinical trial.
      ]. The advent and success of bariatric day surgery, again before the COVID-19 pandemic, have also likely contributed to these findings [
      • Rebibo L.
      • Dhahri A.
      • Badaoui R.
      • Dupont H.
      • Regimbeau J.M.
      Laparoscopic sleeve gastrectomy as day-case surgery (without overnight hospitalization).
      ,
      • Rebibo L.
      • Dhahri A.
      • Badaoui R.
      • et al.
      Laparoscopic sleeve gastrectomy as day-case surgery: a case-matched study.
      ]. In contrast, the reason for the increased proportion of surgeries being performed on Black patients during the COVID-19 pandemic is unclear. This may represent a change over time with increased recognition of bariatric surgery benefits for Black individuals or another factor not measured within this study. Future studies evaluating the effect of COVID-19 on bariatric surgery access related to ethnicity may be of interest. Overall, limited acute care resources during the COVID-19 pandemic likely contributed to surgeons and centers directing delivery toward patients more likely to be fit for day or short-stay surgery.
      Fortunately, despite changes in delivery, bariatric surgery procedures during the COVID-19 pandemic did not appear to have substantially worse outcomes. However, when adjusting for co-morbidities, COVID-19 was associated with decreased odds of readmission and reintervention and a small increase in the odds of reoperation. While our study design does not allow us to evaluate reasons for these findings, a potential reason could be earlier discharge during COVID-19 and increased postoperative management of non–life-threatening complications via telehealth solutions [
      • Brown A.M.
      • Ardila-Gatas J.
      • Yuan V.
      • et al.
      The impact of telemedicine adoption on a multidisciplinary bariatric surgery practice during the COVID-19 pandemic.
      ,
      • Chao G.F.
      • Li K.Y.
      • Zhu Z.
      • et al.
      Use of telehealth by surgical specialties during the COVID-19 pandemic.
      ]. Overall, outcomes during the COVID-19 pandemic were similar to those before the pandemic, which is in keeping with the largest international retrospective study by Singhal et al. [
      • Singhal R.
      • Tahrani A.A.
      • Ludwig C.
      • et al.
      Global 30-day outcomes after bariatric surgery during the COVID-19 pandemic (GENEVA): an international cohort study.
      ]. This study and ours support continuation of bariatric surgery during the COVID-19 pandemic with careful patient selection in order to provide care for patients with obesity who also happen to be at substantial risk of morbidity and mortality from COVID-19 [
      • Le Brocq S.
      • Clare K.
      • Bryant M.
      • Roberts K.
      • Tahrani A.A.
      Obesity and COVID-19: a call for action from people living with obesity.
      ,
      • Gao M.
      • Piernas C.
      • Astbury N.M.
      • et al.
      Associations between body mass index and COVID-19 severity in 6.9 million people in England: a prospective, community-based, cohort study.
      ]. Long-term outcomes are warranted, and careful scrutiny of these practices is encouraged, especially considering the ongoing trend toward use of SG despite novel studies suggesting that RYGB outperforms SG in terms of long-term weight loss and co-morbidity resolution, particularly in patients with super obesity [
      • Peterli R.
      • Wölnerhanssen B.K.
      • Peters T.
      • et al.
      Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y Gastric bypass on weight loss in patients with morbid obesity: the SM-BOSS randomized clinical trial.
      ,
      • Sharples A.J.
      • Mahawar K.
      Systematic review and meta-analysis of randomised controlled trials comparing long-term outcomes of Roux-en-Y gastric bypass and sleeve gastrectomy.
      ,
      • Shoar S.
      • Saber A.A.
      Long-term and midterm outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass: a systematic review and meta-analysis of comparative studies.
      ,
      • Roslin M.
      • Tugertimur B.
      • Zarabi S.
      • Cottam D.
      Is there a better design for a bariatric procedure? The case for a single anastomosis duodenal switch.
      ,
      • Gonzalez-Heredia R.
      • Sanchez-Johnsen L.
      • Valbuena V.S.
      • et al.
      Surgical management of super-super obese patients: Roux-en-Y gastric bypass versus sleeve gastrectomy.
      ,
      • Verhoeff K.
      • Mocanu V.
      • Dang J.
      • et al.
      Five years of MBSAQIP data: characteristics, outcomes, and trends for patients with super-obesity.
      ].
      Considering the decrease in bariatric surgeries performed, the COVID-19 pandemic has created a substantial deficit in care for thousands of patients with obesity. Further, considering the shift toward selecting less co-morbid patients who can successfully be managed with SG, patients with super obesity or substantial co-morbidities are likely at a further deficit. Unfortunately, it is these patients who also stand to benefit most from bariatric intervention [
      • Verhoeff K.
      • Mocanu V.
      • Dang J.
      • et al.
      Five years of MBSAQIP data: characteristics, outcomes, and trends for patients with super-obesity.
      ,
      • Sugerman H.J.
      • Wolfe L.G.
      • Sica D.A.
      • Clore J.N.
      Diabetes and hypertension in severe obesity and effects of gastric bypass-induced weight loss.
      ,
      • Bloomston M.
      • Zervos E.E.
      • Camps M.A.
      • Goode S.E.
      • Rosemurgy A.S.
      Outcome following bariatric surgery in super versus morbidly obese patients: does weight matter?.
      ]. We hypothesize that as COVID-19 is eliminated or becomes endemic, a transition back to operating on patients with increased co-morbidities may occur. Studies evaluating delivery of bariatric surgery care in the next year will be critical to further evaluate the long-term effect of COVID-19. This would further characterize trends that are specific to COVID-19 and others that have occurred secondary to bariatric surgery optimization over time. Regardless, while surgical delays and deficits are often discussed in the oncologic setting, a similar call to action to prioritize surgical care of patients with obesity is needed considering the social, financial, and functional benefits offered with these interventions [
      • Boyers D.
      • Retat L.
      • Jacobsen E.
      • et al.
      Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model.
      ,
      • Lester E.L.W.
      • Padwal R.S.
      • Birch D.W.
      • et al.
      The real-world cost-effectiveness of bariatric surgery for the treatment of severe obesity: a cost-utility analysis.
      ,
      • Miranda W.R.
      • Batsis J.A.
      • Sarr M.G.
      • et al.
      Impact of bariatric surgery on quality of life, functional capacity, and symptoms in patients with heart failure.
      ,
      • Gokce N.
      • Karki S.
      • Dobyns A.
      • et al.
      Association of bariatric surgery with vascular outcomes.
      ].
      Limitations of this study are primarily related to its retrospective nature and data limitations from MBSAQIP. In this study, the COVID-19 pandemic cohort was defined by any surgery occurring during the 2020 MBSAQIP data collection year. However, as we have all experienced, waves of the pandemic have differed drastically, and the effect on bariatric surgery delivery likely also varied during that time. Similarly, the COVID-19 pandemic has had variable effects on different countries, regions, and municipalities; because center-specific data are not collected, the variability of those effects could not be evaluated. Additionally, because the COVID-19 pandemic began in 2019, some of the reported patients from 2019 may also have received bariatric surgery during the pandemic. In contrast, the beginning of 2020 had fewer cases, restrictions, and healthcare effects than other periods of the year, and this temporal variability is summarized as an average throughout the year in this study. Comparing patients receiving bariatric surgery during COVID-19 with all patients from 2015 to 2019 also presents substantial limitations considering changes that occurred over time; to limit this effect we presented all operative trends by year in order to put differences in context. Finally, as detailed earlier, the MBSAQIP database does not characterize outpatient management or other changes that likely occurred during the COVID-19 pandemic, which may represent substantial confounders in this study. Data from this study are also limited to 30 days after operation. Studies evaluating the effect of COVID-19 on outpatient management of bariatric surgery patients and long-term outcomes after bariatric surgery during the COVID-19 pandemic are warranted. Despite these limitations, this study characterizes important trends and effects on bariatric surgery in North America secondary to the COVID-19 pandemic that will prove useful in evaluation of next steps as we continue to improve surgical care in the setting of healthcare resource limitations.
      Understanding the effect that COVID-19 has elicited on bariatric surgery delivery in North America is crucial to evaluating future patient and technique selection. This is especially true as subsequent waves of the COVID-19 pandemic occur. During the COVID-19 pandemic, patients undergoing bariatric surgery have had fewer metabolic co-morbidities and received SG at an unprecedented rate. It remains uncertain whether these changes will continue in the future and how these changes will affect future bariatric surgery care. Regardless of COVID-19’s trajectory, a growing trend toward SG has been hastened by the COVID-19 pandemic, and ongoing evaluations of long-term outcomes as well as the socioeconomic consequences of this affected delivery are warranted.

      Conclusion

      The COVID-19 pandemic has dramatically changed the landscape of bariatric surgery delivery in North America. During the COVID-19 pandemic, there was a 13.8% decrease in elective bariatric surgery cases despite the increased number of reporting centers. Patients receiving surgery were less co-morbid and more likely to receive SG, whereas outcomes were similar to before the pandemic. Future studies evaluating persistent changes that occur after the COVID-19 pandemic and further work characterizing the long-term effect of the COVID-19 pandemic on outcomes and the socioeconomic consequences of this affected delivery are warranted.

      Disclosures

      The authors have no commercial associations that might be a conflict of interest in relation to this article.

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      Linked Article

      • Comment on: Effect of the COVID-19 pandemic on bariatric surgery in North America: a retrospective analysis of 834,647 patients
        Surgery for Obesity and Related DiseasesVol. 18Issue 7
        • Preview
          This is the first large study [1] reporting on the effect of the COVID-19 pandemic on bariatric and metabolic surgery (BMS) in North America, making it highly interesting. Significant morbidity and mortality with perioperative COVID-19 [2], higher mortality with COVID-19 in those with obesity, diversion of health care resources to dealing with the pandemic, and guidelines from the International Federation for the Surgery of Obesity and Metabolic Disorders at the beginning of the pandemic to cease all elective BMS severely affected the provision of BMS worldwide.
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