Patients’ views of long-term results of bariatric surgery for super-obesity: sustained effects,but continuing struggles

BackgroundBariatric surgery is a standard treatment for severe obesity, but little is known about patients’ perceptions about the long-term impact of such surgery.ObjectiveThe aim of this study was to explore patients’ experiences of living with a bariatric procedure for more than a decade.SettingUniversity hospital.MethodsAt the 10-year follow-up after undergoing Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS), 18 consecutive patients from a previous randomized controlled trial were assessed with a semi-structured interview. Data were analyzed using thematic analysis.ResultsWhen asked to reflect broadly on their experiences of living with bariatric surgery for over a decade, the participants rarely mentioned procedure-specific issues and complications. Instead, their accounts revealed 2 broad themes: sustained effects after surgery, incorporating subthemes of better health, brighter futures, and better eating and weight regulation, and continuing struggles, including difficulties with physical activity, finding support, helping their children with overweight, and self-criticism. Many positive changes were sustained, but continuing personal struggles were similar to those presurgery.ConclusionsParticipants expressed overall satisfaction with their bariatric surgery and related outcomes. Most participants acknowledged a continued effect on their appetite, which could be important information for patients who worry about a diminished effect after the first year postsurgery. Participants were prone to self-blame when things did not turn out the way they wanted. Therefore, healthcare providers must build a trustful relationship with their patients, so they will not hesitate to return when they face problems such as weight gain.     

Is age a real or perceived discriminator for bariatric surgery? A long-term analysis of bariatric surgery in the elderly

BackgroundBariatric surgery is the most effective treatment of obesity. There are few studies evaluating long-term outcomes in elderly patients.ObjectivesOur study was designed to evaluate the safety and long-term outcomes of bariatric surgery in the elderly compared with a contemporary medically managed cohort.SettingUniversity hospital.MethodsThree hundred thirty-seven patients age ≥60 who underwent a sleeve gastrectomy or Roux-en-Y gastric bypass between January 2007 and April 2017 were identified (ElderSurg) and compared with a matched cohort of medically managed elderly patients with obesity (ElderNonSurg).ResultsThirty-two patients underwent laparoscopic sleeve gastrectomy, 190 underwent laparoscopic Roux-en-Y gastric bypass, and 115 underwent open Roux-en-Y gastric bypass. The cohort was a mean of 64.4-years old, 75.4% female, mean preoperative body mass index was 46.9, and 62.6% had type 2 diabetes. During a median follow-up period of 56.2 months (confidence interval 49.5–62.9), mean percent excess weight loss (EWL) at nadir was 72.1 ± 24.7% and EWL at 36 months or beyond was 60.9 ± 27.6%. On regression analysis, diabetes, body mass index, and laparoscopic sleeve gastrectomy were negatively associated with EWL at all time periods (P < .05). Mean %EWL was greater for Roux-en-Y gastric bypass compared with laparoscopic sleeve gastrectomy (61.7 versus 41.2; P = .039). Diabetes remission rate was 45.8%. There was a statistically significant decrease in the risk of death in ElderSurg (hazard ratio .584, 95% confidence interval .362–.941) compared with ElderNonSurg.ConclusionsOur study supports that bariatric surgery is safe in elderly patients with effective long-term control of obesity, diabetes, and with improved overall survival.     

Patients’ preferences for sphincter preservation versus abdominoperineal resection for low rectal cancer

BackgroundSurgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients’ preferences for treatment for low rectal cancer.MethodsAmbulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection.ResultsA total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5?25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients.ConclusionAn important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients’ value functional outcomes with a low anastomosis.     

Patients’ experiences of laparoscopic fundoplication in day surgery

Previous research has concentrated mainly on surgical aspects and postoperative complication rates after day surgery laparoscopic fundoplications (LF), due to gastrooesophageal reflux (GERD) and less on patients'experiences and nursing care aspects. A qualitative study was conducted aimed at investigating patients’ experiences of day surgery LF. The very first patients who had day surgery LF (n=7) were interviewed. The findings demonstrate that patients with GERD experience limitations in their daily lives and feelings of social handicap. At discharge after day surgery, amnesia was experienced and the respondents did not recall important information about the operation given by the surgeon. Experience of postoperative pain varied greatly. All respondents experienced dysphagia, vomiting, distension and bloating. The need for additional pain medication, additional follow-ups by the Advanced Medical Home Care team and extended preoperative information was expressed. However, the great majority felt that returning home on the same day as the operation was positive.     

Trends in risk factors for readmission after bariatric surgery 2015–2018

BackgroundReadmission after bariatric surgery is multifactorial. Understanding the trends in risk factors for readmission provides opportunity to optimize patients prior to surgery identify disparities in care, and improve outcomes.ObjectivesThis study compares trends in bariatric surgery as they relate to risk factors for all-cause readmission.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating facilities.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to analyze 760,076 bariatric cases from 854 centers. Demographics and 30-day unadjusted outcomes were compared between laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG), and Roux-en-Y gastric bypass (RYGB) performed between 2015 and 2018. A multiple logistic regression model determined predictors of readmission.ResultsA total of 574,453 bariatric cases met criteria, and all-cause readmission rates decreased from 4.2% in 2015 to 3.5% in 2018 (P < .0001). The percentage of non-Hispanic Black adults who underwent bariatric surgery increased from 16.7% of the total cohort in 2015 to 18.7% in 2018 (P < .0001). The percentage of Hispanic adults increased from 12.1% in 2015 to 13.8% in 2018 (P < .0001). The most common procedure performed was the LSG (71.5%), followed by RYGB (26.9%) and 1.6% LAGB (1.6%) (P < .0001). Men were protected from readmission compared with women (odds ratio [OR]: .87; 95% confidence interval [CI]: .84–.90). Non-Hispanic Black (OR: 1.52; 95% CI: 1.47–1.58)] and Hispanic adults (OR: 1.14; 95% CI: 1.09–1.19) were more likely to be readmitted compared with non-Hispanic White adults. LSG (OR: 1.27; 95% CI: 1.10–1.48) and RYGB (OR: 2.24; 95% CI: 1.93–2.60) were predictive of readmission compared with LAGB.ConclusionReadmission rates decreased over 4 years. Women, along with non-Hispanic Black and Hispanic adults, were more likely to be readmitted. Future research should focus on gender and racial disparities that impact readmission.     

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

Background

Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.

Is bariatric surgery safe in academic centers?

Contemporary outcomes of bariatric surgery are not well defined. Our aim was to document the outcomes of bariatric surgery on the basis of surgeon caseload and affiliation. We analyzed prospectively collected Florida-wide hospital discharge data. Forty-four surgeons undertook bariatric surgery in 933 patients during 1999. The ten surgeons who averaged more than two operations/month undertook 764 operations; 162 (17%) were done by academic surgeons. Complications [14% vs 7% (P = 0.008, chi-square)], length of stay (5 +/- 0.7 vs 4 +/- 0.1 days), and hospital charges (in thousands) ($31 +/- 4.0 vs $24 +/- 0.4) were greater in academic than in community-based centers (P < 0.05, Wilcoxon rank-sum). However, 36 per cent of patients operated upon by academic surgeons had a high Severity Index compared with only 16 per cent of patients operated upon by community-based surgeons (P < 0.001, chi-square). In high-risk patients complications (40% vs 46%), length of stay (7 +/- 1.0 vs 6 +/- 0.4 days), and hospital charges (in thousands) ($42 +/- 6 vs $35 +/- 2) were similar between academic and community-based surgeons. We conclude that outcomes of bariatric surgery in high-risk patients are similar among academic and community-based surgeons. Academic surgeons undertake bariatric surgery in high-risk patients more frequently than community-based surgeons, which underlies their increased complication rate. These prospectively collected data reflect surgical outcomes more accurately than clinical series and will impact our practice of bariatric surgery.     

Trends in utilization of bariatric surgery, 2009–2012

Background

Utilization of bariatric surgery has changed dramatically over the past two decades. The aim of this study was to update the trends in volume and procedural type of bariatric surgery in the USA. Data were derived from the National Inpatient Sample from 2009 through 2012.

Methods

We used ICD-9 diagnosis and procedural codes to identify all hospitalizations during which a bariatric procedure was performed for the treatment of severe obesity. The data were reviewed for patient demographics and characteristics, annual number of bariatric operations, and specific procedural types and proportion of laparoscopic cases. The US Census data were used to calculate the population-based annual rate of bariatric surgery per 100,000 adults.

Results

Between 2009 and 2012, the number of inpatient bariatric operations ranged between 81,005 and 114,780 cases annually. During this time period, the annual rate of bariatric procedures was highest for 2012 at 47.3 procedures per 100,000 adults. The bariatric surgery approach most commonly performed continues to be laparoscopic, ranging between 93.1 and 97.1 %. In 2012, there was a precipitous reduction in the number of gastric bypass and gastric banding operations and replaced by an increase in the number of sleeve gastrectomy operation. The in-hospital mortality rate remains low, ranging from 0.07 to 0.10 %.

Conclusions

In the USA, the annual volume of inpatient bariatric surgery continues to be stable. Utilization of the laparoscopic approach to bariatric surgery remains high, while the in-hospital mortality continues to be low at ≤0.10 % throughout the 4-year period.

     

Patients’ preferences regarding the delivery of health care in a hand surgical practice

Background

The Patient Protection and Affordable Care Act of 2010 includes patient satisfaction scores in the calculation of reimbursement for services provided. The Medicare and Medicaid Electronic Health Care Record Incentive Program mandate that physicians provide electronic communication with patients. Little data exists regarding patient preferences that might guide the physician adhering to these guidelines. We performed a survey study to examine patients’ attitudes regarding the delivery of their health care.

Methods

We provided an anonymous survey to all outpatient hand surgery patients within a 1-month period at our level I academic center. The survey was structured to ascertain patients’ attitudes toward outpatient wait times as well as delivery of patient-specific healthcare-related information. One-hundred and ninety-six surveys were available for review.

Results

Of the 196 patients surveyed, 106 (54 %) were between the ages of 45 and 64. Patients aged 25 to 44 were the least willing to wait for an initial outpatient appointment. The majority of patients in all age groups demonstrated unwillingness to wait more than 1 week for evaluation of a new problem. One hundred and forty patients (71 %) were willing to wait longer for an appointment with an upper extremity specialist rather than have an earlier appointment with a non-upper extremity specialist. Wait times of 30 min after arrival in the office were acceptable to 174 patients (89 %) while 40 patients (20 %) were willing to wait an hour or more. Patients preferred a typed handout detailing their specific problem as opposed to referral to a website or an e-mail containing information.

Conclusions

The results of our study indicate that patients prefer typed information as opposed to e-mail or websites regarding their health care. Our study also suggests that patients are willing to endure longer wait times if they can be given a sooner appointment, and most prefer a specialist for their problems. These results will provide some guidance to the physician regarding what patients find most appealing.     

Patients with clinically metabolically healthy obesity are not necessarily healthy subclinically: further support for bariatric surgery in patients without metabolic disease?

Background

Nonalcoholic fatty liver disease (NAFLD) increases the risk of liver cirrhosis and hepatocellular carcinoma and is also strongly correlated with extrahepatic diseases, including cardiovascular disease and type 2 diabetes. This risk of NAFLD among obese individuals who are otherwise metabolically healthy is not well characterized.

From bariatric to metabolic surgery: Looking for a “disease modifier” surgery for type 2 diabetes

In this review the recent evolution of the comprehension of clinical and metabolic consequences of bariatric surgery is depicted. At the beginning bariatric surgery aim was a significant and durable weight loss. Later on, it became evident that bariatric surgery was associated with metabolic changes, activated by unknown pathways, partially or totally independent of weight loss. Paradigm of this "metabolic" surgery is its effects on type 2 diabetes mellitus(T2DM). In morbid obese subjects it was observed a dramatic metabolic response leading to decrease blood glucose, till diabetes remission, before the achievement of clinically significant weight loss, opening the avenue to search for putative antidiabetic "intestinal" factors. Both proximal duodenal(still unknown) and distal(GLP1) signals have been suggested as hormonal effectors of surgery on blood glucose decrease. Despite these findings T2 DM remission was never considered a primary indication for bariatric surgery but only a secondary one. Recently T2 DM remission in obese subjects with body mass index(BMI) greater than 35 has become a primary aim for surgery. This change supports the idea that "metabolic surgery" definition could more appropriate than bariatric, allowing to explore the possibility that metabolic surgery could represent a "disease modifier" for T2 DM. Therefore, several patients have undergone surgery with a primary aim of a definitive cure of T2 DM and today this surgery can be proposed as an alternative therapy. How much surgery can be considered truly metabolic is still unknown. To be truly "metabolic" it should be demonstrated that surgery could cause T2 DM remission not only in subjects with BMI 35 but also with BMI 35 or even 30. Available evidence on this topic is discussed in this mini-review.     

Anesthesiologists’ preferences for preoperative cardiac evaluation before vascular surgery: results of a mail survey

Study ObjectiveTo investigate whether anesthesiologists’ decisions to request preoperative cardiac evaluation (cardiologist consultation, echocardiography, and cardiac stress testing) before vascular surgery were influenced by patient comorbidity and magnitude of surgery; and to explore whether factors unrelated to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines influence these decisions.DesignSurvey instrument.SettingUniversity medical center.Subjects2,000 U.S. anesthesiologists who were mailed a survey.MeasurementsSix factors in a hypothetical patient presenting for vascular surgery [gender, race (white vs. black), age (65 yrs vs. 85 yrs), comorbidities (sick vs. healthy), functional status, and magnitude of surgical stress] were evaluated. Respondents were asked about their demographics, practice patterns, and how they would manage the hypothetical patient.Main ResultsOf 2,000 mailed surveys, 439 U.S. anesthesiologists responded (22%). Multivariate ordinal logistic regression analysis showed that anesthesiologists were more likely to recommend preoperative cardiology consultation for patients with more comorbidities [odds ratio = 5.53; 95% confidence interval (CI) = 3.76, 8.15], for those with poorer functional status (odds ratio = 1.45; 95% CI = 1.02, 2.07), for those undergoing a more significant surgery (odds ratio = 1.61; 95% CI = 1.13, 2.30), as the clinicians’ estimated risk of perioperative myocardial infarction increased (P < 0.001), or if they only infrequently anesthetized patients such as the one described in the scenario (P = 0.05). They also would request a preoperative echocardiogram for patients with more comorbidities (odds ratio = 2.58; 95% CI = 1.80, 3.68) and for those undergoing a more significant surgery (odds ratio = 1.59; 95% CI = 1.12, 2.25). A preoperative stress test was recommended for patients with more comorbidities (odds ratio = 3.01; 95% CI = 2.06, 4.38) and for those with a more significant surgery (odds ratio = 1.74; 95% CI = 1.15, 2.63). Other factors associated with request for a preoperative stress test were female gender of the anesthesiologist (odds ratio = 1.79; 95% CI = 1.11, 2.87), those with less experience with such patients (P = 0.05), and those from New England (odds ratio = 2.16; 95% CI = 1.01, 4.62).ConclusionsAnesthesiologists’ preferences for preoperative cardiac evaluation are generally consistent with evidence-based and expert-based AHA/ACC guidelines. However, other physician factors (ie, gender, years in practice, and familiarity with the surgical procedure) also influenced these decisions.     

Patients’ preferences for delaying metastatic castration-resistant prostate cancer: Combining health state and treatment valuation

PurposeMen with castration-resistant prostate cancer (CRPC) experience disease progression at different rates. The purpose of this study was to quantify the strength of patient preferences for delaying prostate cancer progression utilizing a discrete choice experiment (DCE) and valuing 3 health states in the continuum of CRPC.Patients and MethodsMen with CRPC, recruited from US patient panels, completed a cross-sectional web-based survey. The survey consisted of vignette-based time trade-off and a DCE designed to quantify patients’ willingness to pay to delay metastatic CRPC. Three health states were presented: (1) living with non-metastatic castration-resistant prostate cancer (nmCRPC) (2) living with metastatic CRPC (mCRPC) before chemotherapy, and (3) living with mCRPC either on or after chemotherapy. The DCE consisted of 15 hypothetical choices with attributes characterizing CRPC (pain, fatigue, out of pocket cost, dosing, and time until cancer metastasizes). Patients’ willingness to pay for changes in each attribute were derived.ResultsA total of 176 patients with CRPC were surveyed (mean age: 64.2 years; 74% nmCRPC). Patients valued the nmCRPC health state (0.865) significantly higher than mCRPC before chemotherapy (0.743) or mCRPC on or after chemotherapy (0.476), both P < 0.001. In the DCE, patient treatment valuation was most affected by increasing the number of months until cancer metastasized; patients were willing to pay an additional $682 per month to delay time to metastases from 6 to 24 months (95% Confidence Interval: $387–$977) and additional $1,041 per month to delay time to metastasis to 48 months (95% Confidence Interval: $591–$1,490).ConclusionsThe results of this study demonstrated men with CRPC place significant value on delaying metastases. This study represents the first time 2 stated preference methods, time trade-off and DCE, were used together to understand patients’ preferences and valuation of health states in CRPC.     

Is bariatric surgery safe in patients who refuse blood transfusion?

BackgroundA small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States.MethodsA retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications.ResultsThirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred.ConclusionBariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group.     

Practice patterns regarding post-discharge chemoprophylaxis for venous thromboembolism following bariatric surgery in the United States

BackgroundThere is no consensus regarding the optimal venous thromboembolism (VTE) prevention strategy following bariatric surgery. Post-discharge chemoprophylaxis is frequently recommended for high-risk patients with little supporting data.ObjectivesTo define practices related to post-discharge chemoprophylaxis in the United States.SettingUnited States.MethodsFrom the Truven Health MarketScan Research database we identified patients age 18 to 64 years undergoing laparoscopic sleeve gastrectomy and gastric bypass (2009–2015). Use of post-discharge low-molecular-weight or unfractionated heparin, vitamin K antagonists, Factor Xa inhibitors, or direct thrombin inhibitors was determined, as was the occurrence of VTE events from discharge to 90 days. Patients with VTE during the index admission were excluded to focus on chemoprophylaxis after discharge (versus treatment). Multivariate logistic regression was used to evaluate the association between VTE and anticoagulant usage.ResultsOf 105,246 patients, .8% with VTE prior to discharge were excluded. The study cohort was 78.1% female, with a median age of 44 years. Hypercoagulable disorder was present in .9%. Post-discharge chemoprophylaxis rates were 11.3% and varied from state to state (.5%–37.4%). VTE rates varied from state to state (.4%–2.6%). VTE after discharge occurred in 1.3%. On multivariate analysis, hypercoagulable disorder (odds ratio [OR] 14.0; 95% confidence interval [CI] 11.6–16.9, P < .001), age ≥60 years (OR 2.3; 95% CI 1.0-5.3; P = .047), and male sex (female OR .8; 95% CI .7–.9, P < .001) increased the risk for VTE. Post-discharge chemoprophylaxis was associated with increased VTE risk (OR 2.1; 95% CI 1.8–2.4; P < .001).ConclusionsPost-discharge chemoprophylaxis following laparoscopic bariatric surgery is employed in 11.3% of patients. Variation in VTE rates and prophylaxis strategies exist nationally.     

Prior bariatric surgery in COVID-19–positive patients may be protective

BackgroundPatients infected with novel COVID-19 virus have a spectrum of illnesses ranging from asymptomatic to death. Data have shown that age, sex, and obesity are strongly correlated with poor outcomes in COVID-19–positive patients. Bariatric surgery is the only treatment that provides significant, sustained weight loss in the severely obese.ObjectivesExamine if prior bariatric surgery correlates with increased risk of hospitalization and outcome severity after COVID-19 infection.SettingUniversity hospitalMethodsA cross-sectional retrospective analysis of a COVID-19 database from a single, New York City–based, academic institution was conducted. A cohort of COVID-19–positive patients with a history of bariatric surgery (n = 124) were matched in a 1:4 ratio to a control cohort of COVID-19–positive patients who were eligible for bariatric surgery (BMI ≥40 kg/m² or BMI >35 kg/m² with a co-morbidity at the time of COVID-19 diagnosis) (n = 496). A comparison of outcomes, including mechanical ventilation requirements and deceased at discharge, was done between cohorts using χ² test or Fisher’s exact test. Additionally, overall length of stay and duration of time in intensive care unit (ICU) were compared using Wilcoxon rank sum test. Conditional logistic regression analyses were done to determine both unadjusted (UOR) and adjusted odds ratios (AOR).ResultsA total of 620 COVID-19–positive patients were included in this analysis. The categorization of bariatric surgeries included 36% Roux-en-Y gastric bypass (RYGB, n = 45), 36% laparoscopic adjustable gastric banding (LAGB, n = 44), and 28% laparoscopic sleeve gastrectomy (LSG, n = 35). The body mass index (BMI) for the bariatric group was 36.1 kg/m² (SD = 8.3), which was significantly lower than the control group, 41.4 kg/m² (SD = 6.5, P < .0001). There was also less burden of diabetes in the bariatric group (32%) compared with the control group (48%) (P = .0019). Patients with a history of bariatric surgery were less likely to be admitted through the emergency room (UOR = .39, P = .0001), less likely to require a ventilator during the admission (UOR=.42, P = .028), had a shorter length of stay in both the ICU (P = .033) and overall (UOR = .44, P = .0002), and were less likely to be deceased at discharge compared with the control group (OR = .42, P = .028).ConclusionA history of bariatric surgery significantly decreases the risk of emergency room admission, mechanical ventilation, prolonged ICU stay, and death in patients with COVID-19. Even when adjusted for BMI and the co-morbidities associated with obesity, patients with a history of bariatric surgery still have a significant decrease in the risk of emergency room admission.