Evaluation of Patients Undergoing Bariatric Surgery Who Required Hospitalization Due to Covid-19

doi:10.21203/rs.3.rs-4645461/v1

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Evaluation of Patients Undergoing Bariatric Surgery Who Required Hospitalization Due to Covid-19

https://doi.org/10.21203/rs.3.rs-4645461/v1

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Purpose

The aim of this study was to evaluate the demographic, anthropometric, and clinical profile of patients undergoing bariatric surgery who required hospitalization due to COVID-19.

Methods

We conducted a retrospective analysis from February 2021 to October 2022, involving individuals aged 20 to 59 years. These individuals were under the care of a bariatric surgery outpatient clinic, had previously undergone the surgical procedure, and tested positive for COVID-19. The study focused on those who had laboratory tests conducted six months before and after contracting the disease. The primary objective was to examine changes in laboratory test results six months before and after COVID-19 infection, considering hospitalization occurrences and symptoms manifested post-positive diagnosis. Additionally, secondary outcomes included exploring the correlation between laboratory test results and hospitalization for COVID-19, categorized by nutritional status.

Results

A total of 49 individuals actively participated in the study, with a notable predominance of females (87.8%). A significant majority, accounting for 73.5%, underwent sleeve gastrectomy. The study observed a prevalence of obese individuals who had recently undergone surgery. Common symptoms among hospitalized patients included fever, dry cough, tiredness, pain and discomfort, as well as difficulties in breathing, speaking, or moving. Individuals requiring hospitalization exhibited higher average levels of triglycerides (TG), low-density lipoprotein (LDL) and Gamma Glutamyl Transferase (Gamma GT) in the six months preceding the diagnosis of COVID-19 compared to those who did not require hospitalization. The timeframe between bariatric surgery and COVID-19 contamination was less than three years. Among those hospitalized for COVID-19, 27.3% had trouble breathing.

Conclusion

With a significance level set at 95%, it was observed that hospitalized patients exhibited elevated levels of triglycerides (TG), low-density lipoprotein (LDL), and Gamma Glutamyl Transferase (Gamma GT) compared to non-hospitalized patients in the six months leading up to the onset of the disease. Consequently, it can be deduced that heightened levels of TG, LDL, and Gamma GT are indicative factors that contribute to the likelihood of hospitalization.

Bariatric surgery

Pandemic

COVID-19

Sars-CoV-2

Heightened levels of TG, LDL, and Gamma GT are indicative factors that contribute to the likelihood of hospitalization due to COVID-19

COVID-19 primarily impacts the respiratory tract, causing complications that lead to extended ICU (Intensive Care Unit) stays and rank among the main causes of morbidity and mortality (MS, 2020). Critically ill individuals face additional risks, such as acquired weakness, malnutrition, loss of mass, and skeletal muscle function in the ICU (KLOK et al., 2020; MADU et al., 2022).

Obese individuals experience more severe COVID-19 outcomes, including heightened symptoms, increased hospitalization rates, and elevated mortality. Globally, obesity has become an epidemic, posing a significant public health challenge in the first two decades of the 21st century due to its escalating prevalence worldwide (MADU et al., 2022; BREDA et al., 2020; WHO, 2020).

Given the frequent failure of clinical, nutritional, and pharmacological treatments for obesity, bariatric surgery emerges as an option for treating and controlling this nutritional deviation (CUMMINGS; PRATT, 2015; PARROTT J. et al., 2017). In the last five years, 311,850 bariatric surgeries were performed in Brazil (SBCBM, 2018). However, during the initial period of the pandemic, there was a decline in surgeries due to cancellations of elective procedures, given the risks related to COVID-19 and the need for beds for severe cases (ROCCON, et al., 2022). Rodrigues, et al. (2023) assert that bariatric surgery is a powerful tool against COVID-19, addressing obesity and its comorbidities, significant risk factors for mortality from this viral infection.

The average time to reach the appropriate weight post-bariatric surgery is approximately 18 months. Weight loss is most pronounced in the first quarter after the procedure. Satisfactory outcomes include a 50% loss of excess weight in the first postoperative year (NICOLETTI et al., 2016; KARMALI et al., 2013). Weight loss maintenance typically occurs up to the third year after surgery, though it tends to stabilize between 12 to 24 months post-surgery, with potential regain after the second year. Individuals may regain weight and experience a recurrence of controlled comorbidities after surgical intervention (SBCBM, 2018; NICOLETTI et al., 2015).

Those who undergo bariatric surgery face limitations in food intake due to gastric capacity restriction and the exclusion of a significant portion of the small intestine, responsible for nutrient absorption, posing a risk of deficiencies in calcium, iron, folate, and vitamin B12. Therefore, long-term supplementation of vitamins and minerals is essential throughout life (PARROTT et al., 2016).

Nutrients play a crucial role in developing and maintaining the immune system, and any nutritional imbalance can compromise its competence and integrity. The human body constantly battles infections through the immune system, emphasizing the paramount importance of maintaining optimal functionality. Adequate nutrition is vital for strengthening immunity. The adverse impact of malnutrition on the immune system, including its inflammatory component, may contribute to the more severe outcomes of COVID-19 in at-risk groups (LÓPEZ PLAZA, 2017; GOMBART; PIERRE; MAGGINI, 2020; CALDER, 2021).

Considering that patients undergoing bariatric surgery may take time to achieve the appropriate weight, potentially placing them in the COVID-19 risk group and are prone to nutritional deficiencies that can be clinically significant if overlooked, directly impacting the immune system, it is crucial to conduct studies that characterize the demographic, anthropometric, and clinical profile of this group. Understanding factors associated with worse outcomes for COVID-19 is essential for planning actions to minimize complications.

Study design

Observational, longitudinal, and retrospective study was conducted between February 2021 and October 2022, focusing on individuals aged 20 to 59 years, under the care of a bariatric surgery outpatient clinic. The primary outcome involved analyzing laboratory tests in relation to hospitalization occurrences and symptoms post-positive COVID-19 diagnosis. Secondary outcomes included examining the correlation between laboratory tests and COVID-19 hospitalization, considering nutritional status. All procedures adhered to ethical standards outlined in the institutional research committee and the 1964 Helsinki Declaration with subsequent amendments. This research received approval from the Ethics Committee under the protocol CAAE 48206421.1.0000.8807.

Study population

The sampling method was non-probabilistic, selected through convenience. The study included patients of both genders aged between 20 and 59 years, who underwent Roux-en-Y gastric bypass or vertical gastrectomy as a treatment for severe obesity, between the years 2009 and 2020, who had positive PCR-RT test for COVID-19 and who had biochemical tests conducted up to six months before and six months after the infection. Patients under the age of 20 and who did not present a positive PCR-RT test were excluded from the final analysis.

Data collection

The study integrated into routine consultations queried patients about their COVID-19 status. Those with a positive RT-PCR result received detailed information about the research, including objectives, risks, and benefits, and signed the Informed Consent Form.

Initial data collection included age, gender, surgery type, and year. BMI, classified by WHO criteria, was calculated: overweight or pre-obese (BMI 25-29.9 kg/m2), obesity grade I (BMI 30-34.9 kg/m2), obesity grade II (BMI 30-39.9 kg/m2), and obesity grade III (BMI ≥ 40.0 kg/m2) (ABESO 2022; WHO 2017).

Participants completed a questionnaire addressing symptoms, onset time, hospitalization, duration, mechanical ventilation, sequelae, and pre-contamination illness frequency. Severe symptoms included difficulty breathing, speaking or moving, chest pain, and loss of speech or movement.

Participants provided biochemical test results pre-infection and post-infection for comparison: Leukocytes, Lymphocytes, Platelets, Platelet/Lymphocyte Ratio, Fasting Blood Glucose, C-peptide, Insulin, HbA1c, Total Cholesterol, LDL-Cholesterol, HDL-Cholesterol, Triglycerides, AST, ALT, Gamma GT, Ferritin, Iron, Zinc, Magnesium, Vitamin B12, and Vitamin D.

Statistical analysis

The data were tabulated in Excel® and analyzed using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA). Proportions were calculated, and Pearson's Chi-square test and Fisher's Exact test were employed to assess associations. Continuous variables underwent normality testing using the Kolmogorov-Smirnov test. Those with symmetric distribution were expressed as mean and standard deviation, compared using the Student's t-test. Variables with asymmetric distribution were described using median and interquartile range (25–75% IQ), and comparisons were made using the Mann-Whitney test. A significance level of 5.0% was applied in the decision-making process for the statistical tests.

A study of 49 individuals revealed that the majority (87.8%) were females who had undergone sleeve gastrectomy (73.5%). The age ranged from 23 to 79 years, with a median of 39 (IQ25-75%, 34–45). Over half had undergone bariatric surgery less than 3 years before being diagnosed with COVID-19. Hospitalization due to COVID-19 occurred in 22.4%, with 72.7% of those admitted reporting difficulty breathing, as detailed in Table 1.

Table 1

Demographic, anthropometric, and clinical characteristics of individuals who underwent bariatric surgery and were diagnosed with COVID-19
Variables	n	%
Sex
Famele	43	87,8
Man	6	12,2
Age
Less than 45	37	75,5
45 or more	12	24,5
Nutritional status *
Eutrophy	14	28,6
Overweight	19	38,7
Obesity	16	32,7
Type of surgery
Vertical gastrectomy	36	73,5
Roux-en-Y gastric bypass	13	26,5
Time after surgery and occurrence of COVID-19 infection
Less than 3 years	29	59,2
3 years or more	20	40,8
The use of multivitamins
Yes	48	98,0
No	1	2,0
Hospitalization for COVID-19
Yes	11	22,4
No	38	77,6
Hospitalization for breathing difficulties due to COVID-19
Yes	8	72,7
No	3	27,3
*According to the classification of body mass index by WHO

Among the hospitalized individuals (n = 11), only 1 (9.1%) was male. There was a prevalence of individuals with obesity (45.5%) who had recently undergone surgery (Table 2).

Table 2

Demographic, anthropometric, and clinical characteristics of individuals who underwent bariatric surgery and required hospitalization for COVID-19

Variables

Sex

Female

90,9

Male

9,1

Age (years)

Less than 45

54,5

Less than 45

45,5

Nutritional status*

Eutrophy

18,2

Overweight

36,4

Obesity

45,5

Type of surgery

Vertical gastrectomy

81,8

Roux-en-Y gastric bypass

18,2

Time after surgery and occurrence of COVID-19 infection

Less than 3 years

90,9

3 years or more

9,1

Use of multivitamins

Yes

90,9

9,1

*According to the classification of body mass index by WHO

When comparing COVID-19 symptoms between hospitalized (n = 11) and non-hospitalized individuals (n = 38), it was observed that fever, dry cough, fatigue, pain and discomfort, and difficulty breathing, speaking, or moving were more frequent among the hospitalized (Table 3).

Table 3

Symptoms of COVID-19 reported by individuals who underwent bariatric surgery according to the occurrence of hospitalization
Variables	Hospitalized		Not Hospitalized
Variables	N	%	n	%
Fever
Yes	9	81,8	15	39,4	0,01
No	2	18,2	23	60,6
Dry cough
Yes	9	81,8	16	42,1	0,02
No	2	18,2	22	57,9
Fatigue ^#
Yes	10	100,0	17	44,7	< 0,01**
No	0	0,0	21	55,3
Loss of taster or smell
Yes	7	63,6	28	73,7	0,71**
No	4	36,4	10	26,3
Sore throat
Yes	7	63,6	13	34,2	0,10**
No	4	36,4	25	65,8
Headache ^#
Yes	6	54,5	22	59,6	1,00**
No	5	45,5	15	40,4
Pain and discomfort
Yes	8	80,0	16	42,1	0,03
No	2	20,0	22	57,9
Diarrhea
Yes	3	30,0	8	21,1	0,67
No	7	70,0	30	78,9
Skin rashes or discoloration of fingers or toes
Yes	2	18,2	2	5,3	0,21
No	9	81,8	36	94,7
Conjunctivitis
Yes	2	18,2	2	5,3	0,21
No	9	81,8	36	94,7
Difficulty breathing, speaking or moving
Yes	8	72,7	6	15,8	0,001
No	3	27,3	32	84,2
Chest pain or pressure, loss of speech or movement
Yes	2	18,2	6	15,8	1,00
No	9	81,8	32	84,2

#Total n is different according to the number of respondents. *Pearson Chi-square test. **Fisher's exact test

Comparing laboratory tests of individuals before and after COVID-19 diagnosis, based on hospitalization occurrence, revealed that those hospitalized had higher averages of LDL, triglycerides, and GAMA GT before the COVID-19 diagnosis. After the diagnosis, lower levels of HDL were observed among the hospitalized (Table 4).

Table 4

Laboratory tests of individuals who underwent bariatric surgery six months before and six months after the diagnosis of COVID-19 according to the occurrence of hospitalization
Variables	6 months before		p*	6 months after		p*
	Hospitalized (n = 11)	Not Hospitalized (n = 38)		Hospitalized (n = 11)	Not Hospitalized (n = 38)
Leukocytes (cells/mm³)	5680,0 (4900,0-7287,5)	5900,0 (4600,0-7495,0)	0,98	5150,0 (4100,0-9630,0)	5545,0 (4637,5-6300,0)	0,73
Lymphocytes (cells/mm³)	2009,0 (1582,0-2877,0)	1991,5 (1685,5-2515,7)	0,80	2019,0 (1555,0-2419,0)	1910,0 (1611,7-2407,5)	0,89
Platelets (cells/mm³)	277000,0 (221000,0-317000,0)	271000,0 (232000,0-307250,0)	0,94	247000,0 (215000,0-281000,0)	258000,0 (229500,0-316000,0)	0,45
Platelet/lymphocyte ratio	135,2 (101,7-153,8)	138,1 (113,4-179,3)	0,63	117,1 (106,5-166,8)	131,1 (109,6-168,8)	0,57
Fasting glucose (mg/dL)	91,0 (83,0–97,0)	85,0 (81,0–94,5)	0,40	83,0 (77,0–92,0)	84,5 (81,0–90,0)	0,59
C-peptide (ng/mL)	2,0 (1,5 − 2,5)	2,0 (1,7 − 3,1)	0,13	2,0 (1,5 − 2,5)	1,7 (1,3 − 2,3)	0,25
Insulin	9,0 (8,0–9,0)	7,0 (5,0–13,0)	0,26	9,0 (8,0–9,0)	6,0 (5,0–8,5)	0,14
glycated hemoglobina (%)	5,5 ± 0,5	5,3 ± 0,8	0,38_**	5,3 ± 0,6	5,1 ± 0,4	0,10**
Total cholesterol (mg/dL)	202,2 ± 37,9	185,4 ± 30,3	0,13_**	182,5 ± 22,2	179,9 ± 34,7	0,82**
LDL cholesterol (mg/dL)	129,9 ± 36,2	107,9 ± 28,9	0,04_**	113,8 ± 25,6	107,2 ± 32,1	0,53**
HDL cholesterol (mg/dL)	42,9 (38,0–53,0)	53,0 (40,0–69,0)	0,29	42,9 (38,0–53,0)	55,5 (41,7–67,0)	0,05
Triglycerides (mg/dL)	88,5 (62,5-115,7)	80,5 (55,5-111,2)	0,03	88,5 (62,5-115,7)	70,0 (55,0-110,0)	0,32
AST (U/L)	20,0 (14,0–23,0)	20,0 (17,0–25,5)	0,90	20,0 (14,0–23,0)	20,0 (16,3–25,5)	0,44
ALT (U/L)	17,0 (14,0–26,0)	22,0 (15,0–28,5)	0,60	17,0 (14,0–26,0)	20,5 (15,7–24,7)	0,41
GGT (U/L)	37,0 (20,5–42,5)	20,0 (14,0–30,5)	0,04	20,1 (15,5–48,5)	14,0 (13,0–25,7)	0,23
Ferritin (ng/mL)	187,0 (64,0-462,0)	89,5 (50,7-171,0)	0,19	100,0 (25,2-233,0)	73,0 (49,6-170,0)	0,76
Iron (µg/dL)	69,0 ± 32,1	84,3 ± 29,4	0,14_**	71,2 ± 25,1	85,2 ± 25,6	0,12_**
Zinc (µg/dL)	71,0 (71,0–71,0)	68,0 (59,0–79,5)	0,86	59,5 (51,0–59,5)	80,0 (69,5–88,5)	0,11
Magnesium (mg/dL)	2,0 (2,0–2,0)	2,0 (2,0–2,0)	1,00	2,0 (1,8 − 2,1)	1,9 (1,8 − 2,0)	0,13
Vitamin B12 (pg/mL)	495,0 (398,0-891,0)	446,0 (326,0-591,0)	0,36	392,0 (319,5-700,0)	465,0 (345,0-563,0)	0,80
Vitamin D (ng/mL)	21,0 ± 5,7	28,2 ± 10,6	0,37**	29,2 ± 7,9	28,7 ± 7,9	0,85**

Median (IQ25-75%) or mean ± standard deviation. *Mann Whitney test. **Student's t-test for independent samples

Analyzing laboratory differences among individuals hospitalized for COVID-19, based on the occurrence of obesity, it was found that there was no significant difference. Among individuals hospitalized for COVID-19 (n = 11), when analyzing laboratory differences based on the occurrence of obesity, there was no statistically significant difference between the laboratory tests of obese and non-obese hospitalized individuals (Table 5).

Table 5

Laboratory tests of individuals who underwent bariatric surgery hospitalized for COVID-19 according to nutritional status
Variables	Hospitalized for COVID-19		p*
Variables	With obesity (n = 5)	Without obesity (n = 6)	p*
Leukocytes (cells/mm³)	5900,0 (3640,0-9560,0)	5085,0 (4667,5-5125,0)	0,71
Lymphocytes (cells/mm³)	2391,0 (945,0-2629,5)	1909,5 (1595,5-2481,5)	1,00
Platelets (cells/mm³)	247000,0 (202000,0-300500,0)	243000,0 (207000,0-291000,0)	0,93
Platelet/lymphocyte ratio	132,7 (102,0-218,8)	115,4 (104,4-149,7)	0,54
Fasting glucose (mg/dL)	84,0 (76,0-115,5)	82,3 (74,2–87,7)	0,43
C-peptide (ng/mL)	2,2 (1,9 − 2,9)	1,7 (1,4 − 2,4)	0,26
Insulin	9,0 (9,0–9,0)	8,0 (8,0–8,0)	0,67
glycated hemoglobina (%)	5,5 ± 0,8	5,2 ± 0,3	0,44
Total cholesterol (mg/dL)	180,3 ± 24,2	184,3 ± 22,7	0,78
LDL cholesterol (mg/dL)	108,6 ± 23,5	118,2 ± 28,7	0,57
HDL cholesterol (mg/dL)	51,0 (36,5–56,0)	42,5 (36,7–57,5)	0,93
Triglycerides (mg/dL)	70,0 (56,0-103,0)	108,0 (74,0-152,0)	0,22
AST (U/L)	15,0 (13,7–52,5)	20,5 (15,8–23,7)	0,79
ALT (U/L)	20,0 (12,5-115,0)	16,6 (13,0–25,0)	0,54
GGT (U/L)	18,0 (12,5–33,2)	22,6 (15,5–95,0)	0,48
Ferritin (ng/mL)	100,0 (19,1-263,8)	150,8 (36,8-273,0)	0,66
Iron (µg/dL)	55,8 ± 28,3	84,0 ± 13,4	0,09
Zinc (µg/dL)	51,0 (51,0–51,0)	68,0 (68,0–68,0)	1,00
Magnesium (mg/dL)	2,0 (1,9 − 2,1)	2,0 (1,7 − 2,4)	0,93
Vitamin B12 (pg/mL)	700,0 (358,5-914,7)	360,0 (319,5-396,0)	0,29
Vitamin D (ng/mL)	26,2 ± 6,1	31,8 ± 8,7	0,26

Median (IQ25-75%) or mean ± standard deviation. *Mann Whitney test for independent samples

The study's findings suggest that most patients are females who underwent bariatric surgery in the last three years. According to SBCBM (2018), despite obesity affecting both genders similarly, about 76% of bariatric surgery patients are women, often driven by concerns about aesthetics and quality of life related to weight gain. Hospitalized bariatric surgery patients with COVID-19 tend to be younger women with excess weight who had surgery within the last three years.

The recent surgery timeframe may not have allowed sufficient weight loss for individuals to move out of the overweight and obesity categories, indicating a higher risk for COVID-19 complications. Several studies have found that overweight and obesity are risk factors for severe COVID-19 outcomes. A retrospective cohort study in France with 124 patients revealed that the prevalence of obesity among ICU-admitted patients was 47.6% (SIMONNET et al., 2020).

A prospective cohort study in England involving 387,109 individuals revealed a correlation between severe COVID-19 infection and risk factors such as overweight and obesity. These conditions may be associated with several mechanisms, including hyperimmune reactivity, impaired metabolic responses, and adverse effects of obesity on lung function, leading to a reduction in forced expiratory volume and forced vital capacity (SIMONNET et al., 2020). It is important to note that individuals with excess weight or obesity often experience heightened inflammatory responses due to the secretion of inflammatory cytokines by excess adipose tissue. Furthermore, the accumulation of adiposity in the chest area restricts diaphragmatic mobility and chest movement, resulting in pulmonary imbalance (JORDÃO et al., 2019).

Bariatric surgery is an effective treatment for obesity, but challenges exist in reaching and maintaining appropriate weight. Factors include selecting the right surgical technique and adopting a suitable lifestyle post-procedure (ZEVE; NOVAIS; JÚNIOR, 2012). Regarding surgical techniques, Vertical Gastrectomy (VG) was the most common (73.5%), contrasting with trends in Brazil where Roux-en-Y Gastric Bypass (RYGB) was more prevalent (SBCBM, 2018).

Vertical Gastrectomy (VG) offers the advantage of lower incidence of nutrient absorption-related changes such as iron, calcium, and vitamin B12. Despite not being disabsorptive, VG yields outcomes comparable to RYGB in terms of mortality, weight loss, and comorbidity resolution, making it an excellent approach with effective indications and susceptibility (CHUNG AY, et al., 2018; PETERLI R, et al., 2017; SBCBM, 2019).

The most frequent COVID-19 symptoms included fever, dry cough, fatigue, pain and discomfort, and difficulty breathing, speaking, or moving. According to MS (2021), mild signs of the disease include cough, sore throat, or runny nose, possibly accompanied by anosmia, ageusia, diarrhea, abdominal pain, fever, chills, myalgia, fatigue, and/or headache. In a study conducted in Wuhan at the onset of the pandemic, with 1099 COVID-19 hospitalized patients, 81.8% reported fever and cough (GUAN et al., 2020). In our study, the most prevalent symptoms among hospitalized individuals for COVID-19 were difficulty breathing or moving and pain and discomfort. Hospitalization due to difficulty breathing, speaking, or moving was identified as a severe symptom in the study.

A multicenter international cross-sectional study assessed COVID-19 clinical outcomes before and after bariatric surgery. Authors observed more frequent hospitalization in individuals who did not undergo bariatric surgery and operated patients showed a lower incidence of most COVID-19-related symptoms, such as anosmia, ageusia/disgeusia, sudden fever, asthenia, and notably, cough and productive cough (MARCHESI, et al., 2021).

A study conducted by Santa Cruz et al. (2022) retrospectively analyzed two patient groups: those with COVID-19 before bariatric surgery and those within 3 months post-operation. Patients with COVID-19 both before and after vertical gastrectomy showed no statistically significant differences in symptoms, hospitalization, ICU (Intensive Care Unit) admission, or invasive ventilation. In our study, 22.4% required hospitalization, primarily due to difficulty breathing, with none requiring mechanical ventilation.

In relation to laboratory tests, Yanling et al. (2020) correlated iron levels with COVID-19 severity, revealing persistent iron homeostasis alterations in 38% of severe/critical patients. However, Habibi et al. (2021) indicated not only iron excess but also compensatory hyperferritinemia, acting as a predictor for COVID-19 severity. In a Wuhan study with 158 COVID-19 hospitalized individuals, 38% of severe/critical patients had persistent iron homeostasis alterations, correlating with inflammatory anemia and lung pathologies. Contrary to this, our study found normal serum iron levels. In the case series documented by Santa Cruz et al. (2022), with 17 patients undergoing bariatric surgery who tested positive for Sars-CoV-2 by RT-PCR in the preoperative period serum iron levels were within the normal range, corroborating with our research.

Obese individuals exhibited higher platelet and leukocyte counts, commonly seen in infections. Our study revealed no statistically significant differences in leukocyte and lymphocyte counts based on symptom severity. Hematological complications emphasized the importance of assessing leukocytes, neutrophils, and platelets in COVID-19 patients. The study also noted a zinc deficiency in hospitalized patients six months after diagnosis. Strengthening the immune system is crucial for COVID-19 patients, particularly in bariatric surgery individuals susceptible to immune changes.

The HbA1c values, reflecting blood glucose levels over the last approximately 120 days, were found within the normal range and did not statistically differ between hospitalized and non-hospitalized individuals. HbA1c serves as a crucial marker for assessing diabetes control and predicting future complications. According to the American Diabetes Association (ADA) 2018, HbA1c values ≥ 6.5% are diagnostic for diabetes mellitus (DM) if altered on two occasions or associated with other abnormal tests like fasting glucose or oral glucose tolerance test. A study in New York with COVID-19-positive diabetic patients admitted to hospitals observed no significant difference in mortality based on HbA1c levels, but admission glucose levels correlated with higher mortality. Another study indicated that HbA1c levels below 7% at admission were associated with better outcomes compared to levels of 9% or higher. In our study, individuals with obesity had higher HbA1c levels, though within the normal range, and experienced no severe COVID-19 complications.

The relationship between triglycerides (TG), low-density lipoprotein (LDL), and gamma-glutamyl transferase (Gamma GT) in obesity is complex and multifactorial.

Elevated levels of LDL can be observed in conditions of obesity due to alterations in lipid metabolism. High levels of Gamma GT may indicate liver dysfunction, and obesity is related to the development of non-alcoholic fatty liver disease, which can contribute to increases in Gamma GT. Obesity is also linked to insulin resistance, which can negatively affect lipid metabolism, contributing to elevations in TG and LDL.

A study conducted during the COVID-19 pandemic indicated that HDL may be associated with the severity and mortality of the disease (KOČAR et al., 2021). Current knowledge suggests that low concentrations of HDL and high total cholesterol show an association with COVID-19 infections in patients. In summary, dyslipidemia, low HDL, and elevated triglyceride levels may be considered associated with the risk of developing complications in the future (GOLUCCI et al., 2018; SURMA et al., 2021). However, it is noted that despite analyzing the same biochemical parameters as the current research, it cannot be directly correlated due to differences in the study population, suggesting the need for further studies with this specific group.

In a study conducted at Brazil with 30 patients undergoing Roux-en-Y gastric bypass, there was a significant reduction in total cholesterol, LDL, and triglycerides (VIEIRA et al., 2015). The gradual weight reduction in patients undergoing bariatric surgery tends to make them more active, contributing to a reduction in serum lipid profile levels (VIEIRA et al., 2015). However, without the adoption of new healthy habits, there is a risk of weight gain and biochemical alterations.

According to the mentioned data, there was a statistical difference in gamma-glutamyl transferase (Gamma GT) levels six months before the diagnosis of COVID-19, although the levels were within the normal range. Gamma GT is an enzyme with higher concentration in renal tissue but is clinically important for liver and biliary diseases (especially cholestasis and inflammatory and toxic liver injuries) (ARAÚJO et al., 2005). Literature findings suggest a strong relationship between Gamma GT and increased BMI, indicating that higher body weight and high alcohol consumption may be the main factors for elevated serum levels of liver enzymes (PUUKKA et al., 2006).

Regarding high-density lipoprotein (HDL), a pandemic study associated it with disease severity and mortality. Our study found at a 95% significance level, statistically differences in triglycerides (TG), low-density lipoprotein (LDL) and Gamma Glutamyl Transferase (Gamma GT) levels six months before COVID-19 diagnosis. Elevated TG, LDL, and GGT are associated with hospitalization. Increased symptoms, including fever, dry cough, fatigue, pain, and difficulty breathing, speaking, or moving, were linked to hospitalization, suggesting a severe disease course. Individuals who underwent bariatric surgery but haven't achieved adequate weight loss and have elevated LDL, TG, and GGT levels deserve special attention in COVID-19 treatment due to their potential for hospitalization.

The present study has some limitations that deserve discussion. The first regards the observational and retrospective nature of the analysis, which limits the ability of the study to confirm the raised hypothesis. Moreover, the sample size was reduced, as only confirmed cases of COVID-19 were included in the final analysis.

According to the presented data and with a significance level of 95%, we can conclude that the main risk factors for hospitalization were elevated levels of triglycerides (TG), low-density lipoprotein (LDL), and Gamma Glutamyl Transferase (Gamma GT), compared to non-hospitalized patients in the six months leading up to the onset of the disease. Regarding self-reported symptoms, we identified pain and discomfort, difficulty breathing, speaking or moving, fever, and dry cough. The symptoms considered severe in our study, with a significance level of 95%, were difficulty breathing, speaking, or moving. Further studies are needed involving a larger number of patients, with greater control of preoperative comorbidities, and having a multicenter nature.

Conflict of interest: The authors declare that they have no conflicts of interests.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and the 1964 Helsinki declaration and its later amendments. This research project was approved by the Ethics Committee of our institution under the protocol CAAE 37991520.1.0000.8807

Informed consent: Informed consent does not apply.

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Evaluation of Patients Undergoing Bariatric Surgery Who Required Hospitalization Due to Covid-19

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