Obesity Surgery (2020) 30:4623–4626

https://doi.org/10.1007/s11695-020-04741-8

LETTER TO THE EDITOR

Recommendations to Manage Patients for Bariatric Surgery

in the COVID-19 Pandemic: Experience from China
Zhiyong Dong 1 & Peng Zhang 2 & Jiangfan Zhu 3 & Jie Bai 4 & Chetan Parmar 5 & Wenhui Chen 1 & Ruixiang Hu 1 &
Jianxue Wang 1 & Tsz Hong Chong 1 & Shuwen Jiang 1 & Wah Yang 1 & Lilian Gao 1 & Xiaomei Chen 1 & Jingge Yang 1 &
Zefeng Xia 4 & Kaixiong Tao 4 & Cunchuan Wang 1,6

Received: 30 April 2020 / Revised: 22 May 2020 / Accepted: 28 May 2020 / Published online: 6 June 2020
# Springer Science+Business Media, LLC, part of Springer Nature 2020

To the Editor: In our bariatric surgery department, we stopped elective

The novel coronavirus that arose in Wuhan in December bariatric surgeries in January to prepare for a possible influx
2019 is a new strain of coronavirus [1]. Most coronaviruses of COVID-19 patients. Since our patients are obese and most
cause only mild respiratory illness such as the common cold, have significant health comorbidities, it is important that they
but the new virus, named SARS-CoV-2 by the WHO, can not be exposed to patients infected with SARS-CoV-2.
cause severe disease, pneumonia, severe acute respiratory syn- Bariatric patients also have relatively weak immunity [8, 9].
drome (ARDS), kidney failure, and death [2–5]. Since there is As the epidemic came under control, we reopened in March
no specific treatment, the goal now is to protect the susceptible and gradually started performing bariatric surgery again. Since
population [1–4]. After the first cases were reported in early bariatric surgery departments in other parts of the world will
December in Wuhan [6, 7], the epidemic spread rapidly, but face the same challenges, we would like to narrate our expe-
enforced lockdowns and other measures slowed the spread of riences and give the recommendations of Chinese Society for
the disease beyond Wuhan. By May, the number of new cases Metabolic and Bariatric Surgery (CSMBS) on how to scien-
were as few as 25 per week. Except for Wuhan, most cities in tifically and safely conduct bariatric programs under these
China returned to work gradually, but throughout the rest of epidemic conditions.
the world, the COVID-19 outbreak continued. Be aware that the initial inflow of patients for services once
you reopen can be enormous because of pent-up demand that
has grown in the interim. The demand will vary by region,
depending on to what extent facilities were closed during the
Zhiyong Dong, Peng Zhang and Jiangfan Zhu contributed equally to this
epidemic period. Our general rule for whether to open is based
work.
on the number of current confirmed cases at the time of the
* Cunchuan Wang
planned reopening. We only reopened in those provinces with
twcc@jnu.edu.cn less than < 100 confirmed cases and reopened cautiously in
regions with 100 to < 500 cases. Patients should join a bariat-
1
Department of Bariatric Surgery, The First Affiliated Hospital of ric surgery program nearest to home to avoid the risks of
Jinan University, Guangzhou 510632, China infection associated with travel. Surgery should not be per-
2
Department of General Surgery, Beijing Friendship Hospital, formed in a hospital that has treated COVID-19 patients
Beijing 100050, China until the hospital has been disinfected according to rec-
3
Department of Bariatric and Metabolic Surgery, Shanghai East ommendations [1].
Hospital, Tongji University, 1800 Yuntai Road, Shanghai 200124, For the prehospital evaluation, we recommend (1) that con-
China
sultation be conducted virtually by means of WeChat, email,
4
Department of Gastrointestinal Surgery, Union Hospital, Tongji or telephone, to investigate whether patients may have
Medical College, Huazhong University of Science and Technology,
Wuhan, China
COVID-19 by asking about symptoms or any history of recent
5
travel to epidemic areas. If the consultation suggests the pres-
Whittington Hospital, London, UK
ence of COVID-19 infection, the patient should be advised to
6
Department of Bariatric Surgery, The First Affiliated Hospital of report to a nearby COVID-19 test center. (2) If no concerns,
Jinan University, No. 613 Huangpu Avenue West,
Guangzhou 510630, China
then record demographics and clinical information and advise
4624 OBES SURG (2020) 30:4623–4626

the patient online about diet and physical exercise protocols. examination of cardiopulmonary function; use continuous
(3) If the BMI is more than 50 kg/m2, the patient should adopt positive airway pressure (CPAP) to improve lung ventilation
dietary adjustment and reasonable exercise to reduce 5% of and systemic hypoxia in cases of obesity hypoventilation syn-
the excess weight before admission [10, 11]. Make an appoint- drome (OHS); for cardiopulmonary insufficiency or severe
ment for CT scan, routine blood test, and nucleic acid test complications, there should be an online consultation of the
before admission. (4) After admission, the patient and medical departments of anesthesia, respiratory, cardiovascular, endo-
staff should take protective measures (use of personal protec- crine, and other relevant departments to plan the surgical
tive equipment [PPE]). The patient must test negative for timing and provide individualized diagnosis and treatment
COVID-19 by PCR. The admission flow chart should be [12]. The process for emergency patients should be followed
followed (Fig. 1). in those cases. If SARS-CoV-2 infection is confirmed or high-
For the preoperative evaluation, we recommend (1) re- ly suspected, preoperative preparation should be completed in
evaluation of epidemiological information to exclude an isolation ward (Fig. 2).
COVID-19-infected if necessary; (2) re-evaluate whether For operating room management, we recommend (1) main-
there is any history of fever or respiratory symptoms; confirm taining a high vigilance to prevent nosocomial infection until
the results of lung CT, nucleic acid test, routine blood exam- more is known about the disease. Be aware that some patients
inations, and other relevant tests. Repeat the PCR if necessary could be in a long incubation period following infection with
in case of a false positive; (3) complete a preoperative SARS-CoV-2 and have no clinical manifestations but could

Fig. 1 Clinic process of morbid obesity patients

OBES SURG (2020) 30:4623–4626 4625

Fig. 2 Admission process of emergency patients

be infective. (2) Routine blood exam, PCR, CT, and epidemi- in a negative pressure/infection room for surgery, and the
ological screening should be redone when the patient is about number of theater team members should be minimized.
to enter the operating room. (3) Proper donning and doffing of After the operation, the operation room should be thoroughly
full PPE is necessary; patients should wear a surgical mask. disinfected [1, 2].
Since endotracheal tube insertion is an aerosol generating pro- For prevention of nosocomial infection, we recommend
cedure (AGP), the anesthesiologist should wear appropriate that (1) unnecessary visitors not be allowed in the hospital.
PPE and use a disposable breathing tube. (4) Rapid recovery (2) Medical staff should practice secondary protection during
anesthesia should be used for a quick and enhanced recovery. routine diagnosis and treatment and during AGP procedures.
(5) If the patient needs to be admitted to ICU/HDU postoper- (3) A preoperative health handbook should be provided, and
atively, they should be in a designated non-COVID-19 area to personnel instructed to wear masks, perform hand hygiene,
prevent cross-infection. (6) When patients return to the ward and reduce unnecessary close contact. (4) Patients with any
after surgery, use a single room to avoid potential cross- sign of fever and cough during hospitalization should undergo
infection and limit the number of visitors. (7) Patient mobility a COVID-19 test. (5) Testing before discharge is unnecessary
should be restricted within the patient’s room or in an area for all patients. We advise limited social activities after dis-
with good air circulation, and the patient be required to wear charge [14].
a mask throughout the hospital [13]. If SARS-CoV-2 infection For follow-up after discharge, we recommend follow up by
is confirmed or highly suspected, the patient should be placed telephone, WeChat, email, QQ, Facebook, or online medical
4626 OBES SURG (2020) 30:4623–4626

platform. (1) Immunocompromised or patients with weak im- 2. World Health Organization. Clinical management of severe acute
respiratory infection when novel coronavirus (nCoV) infection is
munity after surgery need to be isolated and rest at home after
suspected: interim guidance, 25 January 2020. World Health
discharge to avoid infection. (2) If patients encounter compli- Organization, 2020.
cations, treatment at a local hospital is recommended. 3. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospi-
For nutritional support, we recommend that inpatients re- talized patients with 2019 novel coronavirus–infected pneumonia
ceive a nutritional risk evaluation from a dietician so that they in Wuhan, China. JAMA. 2020;323(11):1061–9.
4. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an
have a high-protein diet with carbohydrates and vitamins ap- unfolding crisis. Br J Surg. 2020;10
propriate to the blood profile of the patient [13]. The diet 5. Lai CC, Shih TP, Ko WC, et al. Severe acute respiratory syndrome
should be based on the type of surgical procedure. Patients coronavirus 2 (SARS-CoV-2) and corona virus disease-2019
should exercise and perform strength training [14]. (COVID-19): the epidemic and the challenges. Int J Antimicrob
Agents. 2020;105924
For mental health problems, we recommend that (1) pa-
6. COVID-19 situation in China. http://www.nhc.gov.cn/.
tients be aware of and avoid rumors and fake news. (2) 7. World Health Organization. Novel coronavirus (COVID-19) situa-
Reduce somatization symptoms and improve the immune re- tion dashboard. 2020.
sponse by mental self-regulation. Good mental health can be 8. Francisco V, Pino J, Campos-Cabaleiro V, et al. Obesity, fat mass
maintained by (3) a healthy diet, regular exercise, and ade- and immune system: role for leptin. Front Physiol. 2018;9:640.
quate sleep and (4) keeping in contact with relatives, friends, 9. Honce RR, Schultz-Cherry S. Impact of obesity on influenza A
virus pathogenesis, immune response, and evolution. Front
or colleagues by online means to control emotions, express Immunol. 2019;10:1071.
feelings, and (5) maintain communication with society. (6) 10. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and
Take the crisis as an opportunity for growth. (7) If symptoms the novel coronavirus outbreak: lessons learned in China and Italy.
cannot be alleviated, ask for help from the surgeon and pro- Ann Surg. 2020; Publish Ahead of Print
fessional bariatric surgery team [15]. 11. Busetto L, Dicker D, Azran C, et al. Practical recommendations of
the obesity management task force of the European Association for
the Study of obesity for the post-bariatric surgery medical manage-
Compliance with Ethical Standards ment. Obes Facts. 2017;10(6):597–632.
12. Pratt JSA, Browne A, Browne NT, et al. ASMBS pediatric meta-
Conflict of Interest The authors declare that they have no conflict of bolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis.
interest. 2018;14(7):882–901.
13. Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional rec-
Ethical Approval Statement This article does not contain any studies ommendations for adult bariatric surgery patients: clinical practice.
with human participants or animals performed by any of the authors. Adv Nutr. 2017;8(2):382–94.
14. Jin YH, Cai L, Cheng ZS, et al. A rapid advice guideline for the
diagnosis and treatment of 2019 novel coronavirus (2019-nCoV)
Informed Consent Statement Informed consent does not apply.
infected pneumonia (standard version). Mil Med Res. 2020;7(1):4.
15. Lai J, Ma S, Wang Y, et al. Factors associated with mental
health outcomes among health care workers exposed to co-
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Compiled According to Clinical Experience, 2020. tional claims in published maps and institutional affiliations.