30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic:: a Multinational Cohort Study of 7704 Patients from 42 Countries

GENEVA collaborators

doi:10.1007/s11695-021-05493-9

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

GENEVA collaborators

Research output: Contribution to journal › Article › peer-review

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Abstract

BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Original language	English
Pages (from-to)	4272-4288
Number of pages	17
Journal	Obesity surgery
Volume	31
Issue number	10
Early online date	30 Jul 2021
DOIs	https://doi.org/10.1007/s11695-021-05493-9
Publication status	Published - Oct 2021

Bibliographical note

Funding Information:
GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting. GENEVA Collaborators, Micha? P?dziwiatr, Piotr Major, Piotr Zarzycki, Athanasios Pantelis, Dimitris P. Lapatsanis, Georgios Stravodimos, Chris Matthys. Marc Focquet, Wouter Vleeschouwers, Antonio G Spaventa, Carlos Zerrweck, Antonio Vitiello, Giovanna Berardi, Mario Musella, Alberto Sanchez-Meza, Felipe J Cantu Jr, Fernando Mora, Marco A Cantu, Abhishek Katakwar, D Nageshwar Reddy, Haitham Elmaleh, Mohammad Hassan, Abdelrahman Elghandour, Mohey Elbanna, Ahmed Osman, Athar Khan, Laurent layani, Nalini kiran, Andrey Velikorechin, Maria Solovyeva, Hamid Melali, Shahab Shahabi, Ashish Agrawal, Apoorv Shrivastava, Ankur Sharma, Bhavya Narwaria, Mahendra Narwaria, Asnat Raziel, Nasser Sakran, Sergio Susmallian, Levent Karag?z, Murat Akbaba, Salih Zeki Pi?kin, Ahmet Ziya Balta, Zafer Senol, Emilio Manno, Michele Giuseppe Iovino, Ahmed Osman, Mohamed Qassem, Sebasti?n Arana-Garza, Heitor P. Povoas, Marcos Le?o Vilas-Boas, David Naumann, Jonathan Super, Alan Li, Basil J Ammori, Hany Balamoun, Mohammed Salman, Amrit Manik Nasta, Ramen Goel, Hugo S?nchez-Aguilar, Miguel F Herrera, Adel Abou-Mrad, Lucie Cloix, Guilherme Silva Mazzini, Leonardo Kristem, Andre Lazaro, Jose Campos, Joaqu?n Bernardo, Jes?s Gonz?lez, Carlos Trindade, Oct?vio Viveiros, Rui Ribeiro, David Goitein, David Hazzan, Lior Segev, Tamar Beck, Hern?n Reyes, Jer?nimo Monterrubio, Paulina Garc?a, Marine Benois, Radwan Kassir, Alessandro Contine, Moustafa Elshafei, Sueleyman Aktas, Sylvia Weiner, Till Heidsieck, Luis Level, Silvia Pinango, Patricia Martinez Ortega, Rafael Moncada, Victor Valenti, Ivan Vlahovi?. Zdenko Boras, Arnaud Liagre, Francesco Martini, Gildas Juglard, Manish Motwani, Sukhvinder Singh Saggu, Hazem Al Momani, Luis Adolfo Aceves L?pez, Mar?a Angelina Contreras Cortez, Rodrigo Aceves Zavala, Christine D?Haese RN, Ivo Kempeneers, Jacques Himpens, Andrea Lazzati, Luca Paolino, Sarah Bathaei, Abdulkadir Bedirli, Ayd?n Yavuz, ?a?r? B?y?kkasap, Safa ?zayd?n, Andrzej Kwiatkowski, Katarzyna Bartosiak, Maciej Wal?dziak, Antonella Santonicola, Luigi Angrisani, Paola Iovino, Rossella Palma, Angelo Iossa, Cristian Eugeniu Boru, Francesco De Angelis, Gianfranco Silecchia, Abdulzahra Hussain, Srivinasan Balchandra, Izaskun Balciscueta Coltell, Javier Lorenzo P?rez, Ashok Bohra, Altaf K Awan, Brijesh Madhok, Paul C Leeder, Sherif Awad, Waleed Al-Khyatt, Ashraf Shoma, Hosam Elghadban, Sameh Ghareeb, Bryan Mathews, Marina Kurian, Andreas Larentzakis, Gavriella Zoi Vrakopoulou, Konstantinos Albanopoulos, Ahemt Bozdag, Azmi Lale, Cuneyt Kirkil, Mursid Dincer, Ahmad Bashir, Ashraf Haddad, Leen Abu Hijleh, Bruno Zilberstein, Danilo Dallago de Marchi, Willy Petrini Souza, Carl Magnus Brod?n, Hj?rtur Gislason, Kamran Shah, Antonio Ambrosi, Giovanna Pavone, Nicola Tartaglia, S Lakshmi Kumari Kona, Kalyan K, Cesar Ernesto Guevara Perez, Miguel Alberto Forero Botero, Adrian Covic, Daniel Timofte, Madalina Maxim, Dashti Faraj, Larissa Tseng, Ronald Liem, G?rdal ?ren, Evren Dilektasli, Ilker Yalcin, Hudhaifa AlMukhtar, Mohammed Al Hadad, Rasmi Mohan, Naresh Arora, Digvijaysingh Bedi, Claire Rives-Lange, Jean-Marc Chevallier, Tigran Poghosyan, Hugues Sebbag, Lamia Zina?, Saadi Khaldi, Charles Mauchien, Davide Mazza, Georgiana Dinescu, Bernardo Rea, Fernando P?rez-Galaz, Luis Zavala, Anais Besa, Anna Curell, Jose M Balibrea, Carlos Vaz, Luis Galindo, Nelson Silva, Jos? Luis Estrada Caballero, Sergio Ortiz Sebastian, Jo?o Caetano Dallegrave Marchesini, Ricardo Arcanjo da Fonseca Pereira, Wagner Herbert Sobottka, Felipe Eduardo Fiolo, Matias Turchi, Antonio Claudio Jamel Coelho, Andre Luis Zacaron, Andr? Barbosa, Reynaldo Quinino, Gabriel Menaldi, Nicol?s Paleari, Pedro Martinez-Duartez, Gabriel Mart?nez de Aragon Ram?rez de Esparza, Valentin Sierra Esteban, Antonio Torres, Jose Luis Garcia-Galocha, Miguel Josa, Jose Manuel Pacheco-Garcia, Maria Angeles Mayo-Ossorio, Pradeep Chowbey, Vandana Soni, Hercio Azevedo de Vasconcelos Cunha, Michel Victor Castilho, Rafael Meneguzzi Alves Ferreira, Thiago Alvim Barreiro, Alexandros Charalabopoulos, Elias Sdralis, Spyridon Davakis, Benoit Bomans, Giovanni Dapri, Koenraad Van Belle, MazenTakieddine, Pol Vaneukem, Esma Seda Akal?n Karaca, Fatih Can Karaca, Aziz Sumer, Caghan Peksen, Osman Anil Savas, Elias Chousleb, Fahad Elmokayed, Islam fakhereldin, Hany Mohamed Aboshanab, Talal Swelium, Ahmad Gudal, Lamees Gamloo, Ayushka Ugale, Surendra Ugale, Clara Boeker, Christian Reetz, Ibrahim Ali Hakami, Julian Mall, Andreas Alexandrou, Efstratia Baili, Zsolt Bodnar, Almantas Maleckas, Rita Gudaityte, Cem Emir Guldogan, Emre Gundogdu, Mehmet Mahir Ozmen, Deepti Thakkar, Nandakishore Dukkipati, Poonam Shashank Shah, Shashank Subhashchandra Shah, Simran Shashank Shah, Md Tanveer Adil, Periyathambi Jambulingam, Ravikrishna Mamidanna, Douglas Whitelaw, Md Tanveer Adil, Vigyan Jain, Deepa Kizhakke Veetil, Randeep Wadhawan, Antonio Torres, Max Torres, Tabata Tinoco, Wouter Leclercq, Marleen Romeijn, Kelly van de Pas, Ali K. Alkhazraji, Safwan A. Taha, Murat Ustun, Taner Yigit, Aatif Inam, Muhammad Burhanulhaq, Abdolreza Pazouki, Foolad Eghbali, Mohammad Kermansaravi, Amir Hosein Davarpanah Jazi, Mohsen Mahmoudieh, Neda Mogharehabed, Gregory Tsiotos, Konstantinos Stamou, Francisco J. Barrera Rodriguez, Marco A. Rojas Navarro, Omar Mohamed Torres, Sergio Lopez Martinez, Elda Rocio Maltos Tamez, Gustavo A. Millan Cornejo, Jose Eduardo Garcia Flores, Diya Aldeen Mohammed, Mohamad Hayssam Elfawal, Asim Shabbir, Kim Guowei, Jimmy By So, Elif Tu??e Kaplan, Mehmet Kaplan, Tu?ba Kaplan, DangTuan Pham, Gurteshwar Rana, Mojdeh Kappus, Riddish Gadani, Manish Kahitan, Koshish Pokharel, Alan Osborne, Dimitri Pournaras, James Hewes, Errichetta Napolitano, Sonja Chiappetta, Vincenzo Bottino, Evelyn dorado, Axel Schoettler, Daniel Gaertner, Katharina Fedtke, Francisco Aguilar-Espinosa, Saul Aceves-Lozano, Alessandro Balani, Carlo Nagliati, Damiano Pennisi, Andrea Rizzi, Francesco Frattini, Diego Foschi, Laura Benuzzi, Chirag Parikh, Harshil Shah, Enrico Pinotti, Mauro Montuori, Vincenzo Borrelli, Jerome Dargent, Catalin A Copaescu, Ionut Hutopila, Bogdan Smeu, Bart Witteman, Eric Hazebroek, Laura Deden, Laura Heusschen, Sietske Okkema, Theo Aufenacker, Willem den Hengst, Wouter Vening, Yonta van der Burgh, Ahmad Ghazal, Hamza Ibrahim, Mourad Niazi, Bilal Alkhaffaf, Mohammad Altarawni, Giovanni Carlo Cesana, Marco Anselmino, Matteo Uccelli, Stefano Olmi, Christine Stier, Tahsin Akmanlar, Thomas Sonnenberg, Uwe Schieferbein, Alejandro Marcolini, Diego Awruch, Marco Vicentin, Eduardo Lemos de Souza Bastos, Samuel Azenha Gregorio, Anmol Ahuja, Tarun mittal, Roel Bolckmans, Tom Wiggins, Cl?ment Baratte, Judith Aron Wisnewsky, Laurent Genser, Lynn Chong, Lillian Taylor, Salena Ward, Lynn Chong, Lillian Taylor, Michael W Hi, Helen Heneghan, Naomi Fearon, Andreas Plamper, Karl Rheinwalt, Helen Heneghan, Justin Geoghegan, Kin Cheung Ng, Naomi Fearon, Krzysztof Kaseja, Maciej Kotowski, Tarig A Samarkandy, Adolfo Leyva-Alvizo, Lourdes Corzo-Culebro, Cunchuan Wang, Wah Yang, Zhiyong Dong, Manel Riera, Rajesh Jain, Hosam Hamed, Mohammed Said, Katia Zarzar, Manuel Garcia, Ahmet G?khan T?rk?apar, Ozan ?en, Edoardo Baldini, Luigi Conti, Cacio Wietzycoski, Eduardo Lopes, Tadeja Pintar, Jure Salobir, Cengiz Aydin, Semra Demirli Atici, An?l Ergin, Huseyin Ciyiltepe, Mehmet Abdussamet Bozkurt, Mehmet Celal Kizilkaya, Nezihe Berrin Dodur Onalan, Mariana Nabila Binti Ahmad Zuber, Wei Jin Wong, Amador Garcia, Laura Vidal, Marc Beisani, Jorge Pasquier, Ramon Vilallonga, Sharad Sharma, Chetan Parmar, Lyndcie Lee, Pratik Sufi, H?seyin Sinan, Mehmet Saydam

Funding Information:
GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting.

Publisher Copyright:
© 2021, The Author(s).

Keywords

Bariatric Surgery
COVID-19
COVID-19 Testing
Cohort Studies
Diabetes Mellitus, Type 2
Humans
Incidence
Obesity, Morbid/surgery
Pandemics
Postoperative Complications/epidemiology
SARS-CoV-2

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

Access to Document

10.1007/s11695-021-05493-9Licence: Creative Commons: Attribution (CC BY)

Singhal2021_Article_30-DayMorbidityAndMortalityOfBFinal published version, 595 KBLicence: Creative Commons: Attribution (CC BY)

H2020_RIA_NANOCOMMONS_CO-ORDINATOR
Valsami-Jones, E., Lynch, I. & Gkoutos, G.
European Commission
1/01/18 → 30/06/22
Project: EU

Cite this

@article{88cbc98b2b3445298779d02861d20858,

title = "30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic:: a Multinational Cohort Study of 7704 Patients from 42 Countries",

abstract = "BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.",

keywords = "Bariatric Surgery, COVID-19, COVID-19 Testing, Cohort Studies, Diabetes Mellitus, Type 2, Humans, Incidence, Obesity, Morbid/surgery, Pandemics, Postoperative Complications/epidemiology, SARS-CoV-2",

author = "{GENEVA collaborators} and Rishi Singhal and Christian Ludwig and Gavin Rudge and Gkoutos, {Georgios V} and Abd Tahrani and Kamal Mahawar and Micha{\l} P{\c e}dziwiatr and Piotr Major and Piotr Zarzycki and Athanasios Pantelis and Lapatsanis, {Dimitris P} and Georgios Stravodimos and Chris Matthys and Marc Focquet and Wouter Vleeschouwers and Spaventa, {Antonio G} and Carlos Zerrweck and Antonio Vitiello and Giovanna Berardi and Mario Musella and Alberto Sanchez-Meza and Cantu, {Felipe J} and Fernando Mora and Cantu, {Marco A} and Abhishek Katakwar and Reddy, {D Nageshwar} and Haitham Elmaleh and Mohammad Hassan and Abdelrahman Elghandour and Mohey Elbanna and Ahmed Osman and Athar Khan and Laurent Layani and Nalini Kiran and Andrey Velikorechin and Maria Solovyeva and Hamid Melali and Shahab Shahabi and Ashish Agrawal and Apoorv Shrivastava and Ankur Sharma and Bhavya Narwaria and Mahendra Narwaria and Asnat Raziel and Nasser Sakran and Sergio Susmallian and Levent Karag{\"o}z and Murat Akbaba and David Naumann and Ashok Bohra",

note = "Funding Information: GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting. GENEVA Collaborators, Micha? P?dziwiatr, Piotr Major, Piotr Zarzycki, Athanasios Pantelis, Dimitris P. Lapatsanis, Georgios Stravodimos, Chris Matthys. Marc Focquet, Wouter Vleeschouwers, Antonio G Spaventa, Carlos Zerrweck, Antonio Vitiello, Giovanna Berardi, Mario Musella, Alberto Sanchez-Meza, Felipe J Cantu Jr, Fernando Mora, Marco A Cantu, Abhishek Katakwar, D Nageshwar Reddy, Haitham Elmaleh, Mohammad Hassan, Abdelrahman Elghandour, Mohey Elbanna, Ahmed Osman, Athar Khan, Laurent layani, Nalini kiran, Andrey Velikorechin, Maria Solovyeva, Hamid Melali, Shahab Shahabi, Ashish Agrawal, Apoorv Shrivastava, Ankur Sharma, Bhavya Narwaria, Mahendra Narwaria, Asnat Raziel, Nasser Sakran, Sergio Susmallian, Levent Karag?z, Murat Akbaba, Salih Zeki Pi?kin, Ahmet Ziya Balta, Zafer Senol, Emilio Manno, Michele Giuseppe Iovino, Ahmed Osman, Mohamed Qassem, Sebasti?n Arana-Garza, Heitor P. Povoas, Marcos Le?o Vilas-Boas, David Naumann, Jonathan Super, Alan Li, Basil J Ammori, Hany Balamoun, Mohammed Salman, Amrit Manik Nasta, Ramen Goel, Hugo S?nchez-Aguilar, Miguel F Herrera, Adel Abou-Mrad, Lucie Cloix, Guilherme Silva Mazzini, Leonardo Kristem, Andre Lazaro, Jose Campos, Joaqu?n Bernardo, Jes?s Gonz?lez, Carlos Trindade, Oct?vio Viveiros, Rui Ribeiro, David Goitein, David Hazzan, Lior Segev, Tamar Beck, Hern?n Reyes, Jer?nimo Monterrubio, Paulina Garc?a, Marine Benois, Radwan Kassir, Alessandro Contine, Moustafa Elshafei, Sueleyman Aktas, Sylvia Weiner, Till Heidsieck, Luis Level, Silvia Pinango, Patricia Martinez Ortega, Rafael Moncada, Victor Valenti, Ivan Vlahovi?. Zdenko Boras, Arnaud Liagre, Francesco Martini, Gildas Juglard, Manish Motwani, Sukhvinder Singh Saggu, Hazem Al Momani, Luis Adolfo Aceves L?pez, Mar?a Angelina Contreras Cortez, Rodrigo Aceves Zavala, Christine D?Haese RN, Ivo Kempeneers, Jacques Himpens, Andrea Lazzati, Luca Paolino, Sarah Bathaei, Abdulkadir Bedirli, Ayd?n Yavuz, ?a?r? B?y?kkasap, Safa ?zayd?n, Andrzej Kwiatkowski, Katarzyna Bartosiak, Maciej Wal?dziak, Antonella Santonicola, Luigi Angrisani, Paola Iovino, Rossella Palma, Angelo Iossa, Cristian Eugeniu Boru, Francesco De Angelis, Gianfranco Silecchia, Abdulzahra Hussain, Srivinasan Balchandra, Izaskun Balciscueta Coltell, Javier Lorenzo P?rez, Ashok Bohra, Altaf K Awan, Brijesh Madhok, Paul C Leeder, Sherif Awad, Waleed Al-Khyatt, Ashraf Shoma, Hosam Elghadban, Sameh Ghareeb, Bryan Mathews, Marina Kurian, Andreas Larentzakis, Gavriella Zoi Vrakopoulou, Konstantinos Albanopoulos, Ahemt Bozdag, Azmi Lale, Cuneyt Kirkil, Mursid Dincer, Ahmad Bashir, Ashraf Haddad, Leen Abu Hijleh, Bruno Zilberstein, Danilo Dallago de Marchi, Willy Petrini Souza, Carl Magnus Brod?n, Hj?rtur Gislason, Kamran Shah, Antonio Ambrosi, Giovanna Pavone, Nicola Tartaglia, S Lakshmi Kumari Kona, Kalyan K, Cesar Ernesto Guevara Perez, Miguel Alberto Forero Botero, Adrian Covic, Daniel Timofte, Madalina Maxim, Dashti Faraj, Larissa Tseng, Ronald Liem, G?rdal ?ren, Evren Dilektasli, Ilker Yalcin, Hudhaifa AlMukhtar, Mohammed Al Hadad, Rasmi Mohan, Naresh Arora, Digvijaysingh Bedi, Claire Rives-Lange, Jean-Marc Chevallier, Tigran Poghosyan, Hugues Sebbag, Lamia Zina?, Saadi Khaldi, Charles Mauchien, Davide Mazza, Georgiana Dinescu, Bernardo Rea, Fernando P?rez-Galaz, Luis Zavala, Anais Besa, Anna Curell, Jose M Balibrea, Carlos Vaz, Luis Galindo, Nelson Silva, Jos? Luis Estrada Caballero, Sergio Ortiz Sebastian, Jo?o Caetano Dallegrave Marchesini, Ricardo Arcanjo da Fonseca Pereira, Wagner Herbert Sobottka, Felipe Eduardo Fiolo, Matias Turchi, Antonio Claudio Jamel Coelho, Andre Luis Zacaron, Andr? Barbosa, Reynaldo Quinino, Gabriel Menaldi, Nicol?s Paleari, Pedro Martinez-Duartez, Gabriel Mart?nez de Aragon Ram?rez de Esparza, Valentin Sierra Esteban, Antonio Torres, Jose Luis Garcia-Galocha, Miguel Josa, Jose Manuel Pacheco-Garcia, Maria Angeles Mayo-Ossorio, Pradeep Chowbey, Vandana Soni, Hercio Azevedo de Vasconcelos Cunha, Michel Victor Castilho, Rafael Meneguzzi Alves Ferreira, Thiago Alvim Barreiro, Alexandros Charalabopoulos, Elias Sdralis, Spyridon Davakis, Benoit Bomans, Giovanni Dapri, Koenraad Van Belle, MazenTakieddine, Pol Vaneukem, Esma Seda Akal?n Karaca, Fatih Can Karaca, Aziz Sumer, Caghan Peksen, Osman Anil Savas, Elias Chousleb, Fahad Elmokayed, Islam fakhereldin, Hany Mohamed Aboshanab, Talal Swelium, Ahmad Gudal, Lamees Gamloo, Ayushka Ugale, Surendra Ugale, Clara Boeker, Christian Reetz, Ibrahim Ali Hakami, Julian Mall, Andreas Alexandrou, Efstratia Baili, Zsolt Bodnar, Almantas Maleckas, Rita Gudaityte, Cem Emir Guldogan, Emre Gundogdu, Mehmet Mahir Ozmen, Deepti Thakkar, Nandakishore Dukkipati, Poonam Shashank Shah, Shashank Subhashchandra Shah, Simran Shashank Shah, Md Tanveer Adil, Periyathambi Jambulingam, Ravikrishna Mamidanna, Douglas Whitelaw, Md Tanveer Adil, Vigyan Jain, Deepa Kizhakke Veetil, Randeep Wadhawan, Antonio Torres, Max Torres, Tabata Tinoco, Wouter Leclercq, Marleen Romeijn, Kelly van de Pas, Ali K. Alkhazraji, Safwan A. Taha, Murat Ustun, Taner Yigit, Aatif Inam, Muhammad Burhanulhaq, Abdolreza Pazouki, Foolad Eghbali, Mohammad Kermansaravi, Amir Hosein Davarpanah Jazi, Mohsen Mahmoudieh, Neda Mogharehabed, Gregory Tsiotos, Konstantinos Stamou, Francisco J. Barrera Rodriguez, Marco A. Rojas Navarro, Omar Mohamed Torres, Sergio Lopez Martinez, Elda Rocio Maltos Tamez, Gustavo A. Millan Cornejo, Jose Eduardo Garcia Flores, Diya Aldeen Mohammed, Mohamad Hayssam Elfawal, Asim Shabbir, Kim Guowei, Jimmy By So, Elif Tu??e Kaplan, Mehmet Kaplan, Tu?ba Kaplan, DangTuan Pham, Gurteshwar Rana, Mojdeh Kappus, Riddish Gadani, Manish Kahitan, Koshish Pokharel, Alan Osborne, Dimitri Pournaras, James Hewes, Errichetta Napolitano, Sonja Chiappetta, Vincenzo Bottino, Evelyn dorado, Axel Schoettler, Daniel Gaertner, Katharina Fedtke, Francisco Aguilar-Espinosa, Saul Aceves-Lozano, Alessandro Balani, Carlo Nagliati, Damiano Pennisi, Andrea Rizzi, Francesco Frattini, Diego Foschi, Laura Benuzzi, Chirag Parikh, Harshil Shah, Enrico Pinotti, Mauro Montuori, Vincenzo Borrelli, Jerome Dargent, Catalin A Copaescu, Ionut Hutopila, Bogdan Smeu, Bart Witteman, Eric Hazebroek, Laura Deden, Laura Heusschen, Sietske Okkema, Theo Aufenacker, Willem den Hengst, Wouter Vening, Yonta van der Burgh, Ahmad Ghazal, Hamza Ibrahim, Mourad Niazi, Bilal Alkhaffaf, Mohammad Altarawni, Giovanni Carlo Cesana, Marco Anselmino, Matteo Uccelli, Stefano Olmi, Christine Stier, Tahsin Akmanlar, Thomas Sonnenberg, Uwe Schieferbein, Alejandro Marcolini, Diego Awruch, Marco Vicentin, Eduardo Lemos de Souza Bastos, Samuel Azenha Gregorio, Anmol Ahuja, Tarun mittal, Roel Bolckmans, Tom Wiggins, Cl?ment Baratte, Judith Aron Wisnewsky, Laurent Genser, Lynn Chong, Lillian Taylor, Salena Ward, Lynn Chong, Lillian Taylor, Michael W Hi, Helen Heneghan, Naomi Fearon, Andreas Plamper, Karl Rheinwalt, Helen Heneghan, Justin Geoghegan, Kin Cheung Ng, Naomi Fearon, Krzysztof Kaseja, Maciej Kotowski, Tarig A Samarkandy, Adolfo Leyva-Alvizo, Lourdes Corzo-Culebro, Cunchuan Wang, Wah Yang, Zhiyong Dong, Manel Riera, Rajesh Jain, Hosam Hamed, Mohammed Said, Katia Zarzar, Manuel Garcia, Ahmet G?khan T?rk?apar, Ozan ?en, Edoardo Baldini, Luigi Conti, Cacio Wietzycoski, Eduardo Lopes, Tadeja Pintar, Jure Salobir, Cengiz Aydin, Semra Demirli Atici, An?l Ergin, Huseyin Ciyiltepe, Mehmet Abdussamet Bozkurt, Mehmet Celal Kizilkaya, Nezihe Berrin Dodur Onalan, Mariana Nabila Binti Ahmad Zuber, Wei Jin Wong, Amador Garcia, Laura Vidal, Marc Beisani, Jorge Pasquier, Ramon Vilallonga, Sharad Sharma, Chetan Parmar, Lyndcie Lee, Pratik Sufi, H?seyin Sinan, Mehmet Saydam Funding Information: GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting. Publisher Copyright: {\textcopyright} 2021, The Author(s).",

year = "2021",

month = oct,

doi = "10.1007/s11695-021-05493-9",

language = "English",

volume = "31",

pages = "4272--4288",

journal = "Obesity surgery",

issn = "0960-8923",

publisher = "Springer",

number = "10",

}

TY - JOUR

T1 - 30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic:

T2 - a Multinational Cohort Study of 7704 Patients from 42 Countries

AU - GENEVA collaborators

AU - Singhal, Rishi

AU - Ludwig, Christian

AU - Rudge, Gavin

AU - Gkoutos, Georgios V

AU - Tahrani, Abd

AU - Mahawar, Kamal

AU - Pędziwiatr, Michał

AU - Major, Piotr

AU - Zarzycki, Piotr

AU - Pantelis, Athanasios

AU - Lapatsanis, Dimitris P

AU - Stravodimos, Georgios

AU - Matthys, Chris

AU - Focquet, Marc

AU - Vleeschouwers, Wouter

AU - Spaventa, Antonio G

AU - Zerrweck, Carlos

AU - Vitiello, Antonio

AU - Berardi, Giovanna

AU - Musella, Mario

AU - Sanchez-Meza, Alberto

AU - Cantu, Felipe J

AU - Mora, Fernando

AU - Cantu, Marco A

AU - Katakwar, Abhishek

AU - Reddy, D Nageshwar

AU - Elmaleh, Haitham

AU - Hassan, Mohammad

AU - Elghandour, Abdelrahman

AU - Elbanna, Mohey

AU - Osman, Ahmed

AU - Khan, Athar

AU - Layani, Laurent

AU - Kiran, Nalini

AU - Velikorechin, Andrey

AU - Solovyeva, Maria

AU - Melali, Hamid

AU - Shahabi, Shahab

AU - Agrawal, Ashish

AU - Shrivastava, Apoorv

AU - Sharma, Ankur

AU - Narwaria, Bhavya

AU - Narwaria, Mahendra

AU - Raziel, Asnat

AU - Sakran, Nasser

AU - Susmallian, Sergio

AU - Karagöz, Levent

AU - Akbaba, Murat

AU - Naumann, David

AU - Bohra, Ashok

N1 - Funding Information: GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting. GENEVA Collaborators, Micha? P?dziwiatr, Piotr Major, Piotr Zarzycki, Athanasios Pantelis, Dimitris P. Lapatsanis, Georgios Stravodimos, Chris Matthys. Marc Focquet, Wouter Vleeschouwers, Antonio G Spaventa, Carlos Zerrweck, Antonio Vitiello, Giovanna Berardi, Mario Musella, Alberto Sanchez-Meza, Felipe J Cantu Jr, Fernando Mora, Marco A Cantu, Abhishek Katakwar, D Nageshwar Reddy, Haitham Elmaleh, Mohammad Hassan, Abdelrahman Elghandour, Mohey Elbanna, Ahmed Osman, Athar Khan, Laurent layani, Nalini kiran, Andrey Velikorechin, Maria Solovyeva, Hamid Melali, Shahab Shahabi, Ashish Agrawal, Apoorv Shrivastava, Ankur Sharma, Bhavya Narwaria, Mahendra Narwaria, Asnat Raziel, Nasser Sakran, Sergio Susmallian, Levent Karag?z, Murat Akbaba, Salih Zeki Pi?kin, Ahmet Ziya Balta, Zafer Senol, Emilio Manno, Michele Giuseppe Iovino, Ahmed Osman, Mohamed Qassem, Sebasti?n Arana-Garza, Heitor P. Povoas, Marcos Le?o Vilas-Boas, David Naumann, Jonathan Super, Alan Li, Basil J Ammori, Hany Balamoun, Mohammed Salman, Amrit Manik Nasta, Ramen Goel, Hugo S?nchez-Aguilar, Miguel F Herrera, Adel Abou-Mrad, Lucie Cloix, Guilherme Silva Mazzini, Leonardo Kristem, Andre Lazaro, Jose Campos, Joaqu?n Bernardo, Jes?s Gonz?lez, Carlos Trindade, Oct?vio Viveiros, Rui Ribeiro, David Goitein, David Hazzan, Lior Segev, Tamar Beck, Hern?n Reyes, Jer?nimo Monterrubio, Paulina Garc?a, Marine Benois, Radwan Kassir, Alessandro Contine, Moustafa Elshafei, Sueleyman Aktas, Sylvia Weiner, Till Heidsieck, Luis Level, Silvia Pinango, Patricia Martinez Ortega, Rafael Moncada, Victor Valenti, Ivan Vlahovi?. Zdenko Boras, Arnaud Liagre, Francesco Martini, Gildas Juglard, Manish Motwani, Sukhvinder Singh Saggu, Hazem Al Momani, Luis Adolfo Aceves L?pez, Mar?a Angelina Contreras Cortez, Rodrigo Aceves Zavala, Christine D?Haese RN, Ivo Kempeneers, Jacques Himpens, Andrea Lazzati, Luca Paolino, Sarah Bathaei, Abdulkadir Bedirli, Ayd?n Yavuz, ?a?r? B?y?kkasap, Safa ?zayd?n, Andrzej Kwiatkowski, Katarzyna Bartosiak, Maciej Wal?dziak, Antonella Santonicola, Luigi Angrisani, Paola Iovino, Rossella Palma, Angelo Iossa, Cristian Eugeniu Boru, Francesco De Angelis, Gianfranco Silecchia, Abdulzahra Hussain, Srivinasan Balchandra, Izaskun Balciscueta Coltell, Javier Lorenzo P?rez, Ashok Bohra, Altaf K Awan, Brijesh Madhok, Paul C Leeder, Sherif Awad, Waleed Al-Khyatt, Ashraf Shoma, Hosam Elghadban, Sameh Ghareeb, Bryan Mathews, Marina Kurian, Andreas Larentzakis, Gavriella Zoi Vrakopoulou, Konstantinos Albanopoulos, Ahemt Bozdag, Azmi Lale, Cuneyt Kirkil, Mursid Dincer, Ahmad Bashir, Ashraf Haddad, Leen Abu Hijleh, Bruno Zilberstein, Danilo Dallago de Marchi, Willy Petrini Souza, Carl Magnus Brod?n, Hj?rtur Gislason, Kamran Shah, Antonio Ambrosi, Giovanna Pavone, Nicola Tartaglia, S Lakshmi Kumari Kona, Kalyan K, Cesar Ernesto Guevara Perez, Miguel Alberto Forero Botero, Adrian Covic, Daniel Timofte, Madalina Maxim, Dashti Faraj, Larissa Tseng, Ronald Liem, G?rdal ?ren, Evren Dilektasli, Ilker Yalcin, Hudhaifa AlMukhtar, Mohammed Al Hadad, Rasmi Mohan, Naresh Arora, Digvijaysingh Bedi, Claire Rives-Lange, Jean-Marc Chevallier, Tigran Poghosyan, Hugues Sebbag, Lamia Zina?, Saadi Khaldi, Charles Mauchien, Davide Mazza, Georgiana Dinescu, Bernardo Rea, Fernando P?rez-Galaz, Luis Zavala, Anais Besa, Anna Curell, Jose M Balibrea, Carlos Vaz, Luis Galindo, Nelson Silva, Jos? Luis Estrada Caballero, Sergio Ortiz Sebastian, Jo?o Caetano Dallegrave Marchesini, Ricardo Arcanjo da Fonseca Pereira, Wagner Herbert Sobottka, Felipe Eduardo Fiolo, Matias Turchi, Antonio Claudio Jamel Coelho, Andre Luis Zacaron, Andr? Barbosa, Reynaldo Quinino, Gabriel Menaldi, Nicol?s Paleari, Pedro Martinez-Duartez, Gabriel Mart?nez de Aragon Ram?rez de Esparza, Valentin Sierra Esteban, Antonio Torres, Jose Luis Garcia-Galocha, Miguel Josa, Jose Manuel Pacheco-Garcia, Maria Angeles Mayo-Ossorio, Pradeep Chowbey, Vandana Soni, Hercio Azevedo de Vasconcelos Cunha, Michel Victor Castilho, Rafael Meneguzzi Alves Ferreira, Thiago Alvim Barreiro, Alexandros Charalabopoulos, Elias Sdralis, Spyridon Davakis, Benoit Bomans, Giovanni Dapri, Koenraad Van Belle, MazenTakieddine, Pol Vaneukem, Esma Seda Akal?n Karaca, Fatih Can Karaca, Aziz Sumer, Caghan Peksen, Osman Anil Savas, Elias Chousleb, Fahad Elmokayed, Islam fakhereldin, Hany Mohamed Aboshanab, Talal Swelium, Ahmad Gudal, Lamees Gamloo, Ayushka Ugale, Surendra Ugale, Clara Boeker, Christian Reetz, Ibrahim Ali Hakami, Julian Mall, Andreas Alexandrou, Efstratia Baili, Zsolt Bodnar, Almantas Maleckas, Rita Gudaityte, Cem Emir Guldogan, Emre Gundogdu, Mehmet Mahir Ozmen, Deepti Thakkar, Nandakishore Dukkipati, Poonam Shashank Shah, Shashank Subhashchandra Shah, Simran Shashank Shah, Md Tanveer Adil, Periyathambi Jambulingam, Ravikrishna Mamidanna, Douglas Whitelaw, Md Tanveer Adil, Vigyan Jain, Deepa Kizhakke Veetil, Randeep Wadhawan, Antonio Torres, Max Torres, Tabata Tinoco, Wouter Leclercq, Marleen Romeijn, Kelly van de Pas, Ali K. Alkhazraji, Safwan A. Taha, Murat Ustun, Taner Yigit, Aatif Inam, Muhammad Burhanulhaq, Abdolreza Pazouki, Foolad Eghbali, Mohammad Kermansaravi, Amir Hosein Davarpanah Jazi, Mohsen Mahmoudieh, Neda Mogharehabed, Gregory Tsiotos, Konstantinos Stamou, Francisco J. Barrera Rodriguez, Marco A. Rojas Navarro, Omar Mohamed Torres, Sergio Lopez Martinez, Elda Rocio Maltos Tamez, Gustavo A. Millan Cornejo, Jose Eduardo Garcia Flores, Diya Aldeen Mohammed, Mohamad Hayssam Elfawal, Asim Shabbir, Kim Guowei, Jimmy By So, Elif Tu??e Kaplan, Mehmet Kaplan, Tu?ba Kaplan, DangTuan Pham, Gurteshwar Rana, Mojdeh Kappus, Riddish Gadani, Manish Kahitan, Koshish Pokharel, Alan Osborne, Dimitri Pournaras, James Hewes, Errichetta Napolitano, Sonja Chiappetta, Vincenzo Bottino, Evelyn dorado, Axel Schoettler, Daniel Gaertner, Katharina Fedtke, Francisco Aguilar-Espinosa, Saul Aceves-Lozano, Alessandro Balani, Carlo Nagliati, Damiano Pennisi, Andrea Rizzi, Francesco Frattini, Diego Foschi, Laura Benuzzi, Chirag Parikh, Harshil Shah, Enrico Pinotti, Mauro Montuori, Vincenzo Borrelli, Jerome Dargent, Catalin A Copaescu, Ionut Hutopila, Bogdan Smeu, Bart Witteman, Eric Hazebroek, Laura Deden, Laura Heusschen, Sietske Okkema, Theo Aufenacker, Willem den Hengst, Wouter Vening, Yonta van der Burgh, Ahmad Ghazal, Hamza Ibrahim, Mourad Niazi, Bilal Alkhaffaf, Mohammad Altarawni, Giovanni Carlo Cesana, Marco Anselmino, Matteo Uccelli, Stefano Olmi, Christine Stier, Tahsin Akmanlar, Thomas Sonnenberg, Uwe Schieferbein, Alejandro Marcolini, Diego Awruch, Marco Vicentin, Eduardo Lemos de Souza Bastos, Samuel Azenha Gregorio, Anmol Ahuja, Tarun mittal, Roel Bolckmans, Tom Wiggins, Cl?ment Baratte, Judith Aron Wisnewsky, Laurent Genser, Lynn Chong, Lillian Taylor, Salena Ward, Lynn Chong, Lillian Taylor, Michael W Hi, Helen Heneghan, Naomi Fearon, Andreas Plamper, Karl Rheinwalt, Helen Heneghan, Justin Geoghegan, Kin Cheung Ng, Naomi Fearon, Krzysztof Kaseja, Maciej Kotowski, Tarig A Samarkandy, Adolfo Leyva-Alvizo, Lourdes Corzo-Culebro, Cunchuan Wang, Wah Yang, Zhiyong Dong, Manel Riera, Rajesh Jain, Hosam Hamed, Mohammed Said, Katia Zarzar, Manuel Garcia, Ahmet G?khan T?rk?apar, Ozan ?en, Edoardo Baldini, Luigi Conti, Cacio Wietzycoski, Eduardo Lopes, Tadeja Pintar, Jure Salobir, Cengiz Aydin, Semra Demirli Atici, An?l Ergin, Huseyin Ciyiltepe, Mehmet Abdussamet Bozkurt, Mehmet Celal Kizilkaya, Nezihe Berrin Dodur Onalan, Mariana Nabila Binti Ahmad Zuber, Wei Jin Wong, Amador Garcia, Laura Vidal, Marc Beisani, Jorge Pasquier, Ramon Vilallonga, Sharad Sharma, Chetan Parmar, Lyndcie Lee, Pratik Sufi, H?seyin Sinan, Mehmet Saydam Funding Information: GVG acknowledges from support the NIHR Birmingham ECMC, NIHR Birmingham SRMRC, Nanocommons H2020-EU (731032), and the NIHR Birmingham Biomedical Research Centre and the MRC Health Data Research UK (HDRUK/CFC/01), an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities.We thank Naomi Campton (Translational Research and DatabaseManager at University of Birmingham) for providing the support withdatabase maintenance and troubleshooting. Publisher Copyright: © 2021, The Author(s).

PY - 2021/10

Y1 - 2021/10

N2 - BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

AB - BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

KW - Bariatric Surgery

KW - COVID-19

KW - COVID-19 Testing

KW - Cohort Studies

KW - Diabetes Mellitus, Type 2

KW - Humans

KW - Incidence

KW - Obesity, Morbid/surgery

KW - Pandemics

KW - Postoperative Complications/epidemiology

KW - SARS-CoV-2

U2 - 10.1007/s11695-021-05493-9

DO - 10.1007/s11695-021-05493-9

M3 - Article

C2 - 34328624

SN - 0960-8923

VL - 31

SP - 4272

EP - 4288

JO - Obesity surgery

JF - Obesity surgery

IS - 10

ER -