Obesity Surgery https://doi.org/10.1007/s11695-020-04678-y LETTER TO THE EDITOR Reply To The Article “Bariatric Surgical Practice During the Initial Phase of COVID-19 Outbreak.” by Aminian, A., Kermansaravi, M., Azizi, S. et al. Published in Obesity Surgery Ramon Vilallonga 1 & Ruth Blanco-Colino 2 & Manel Armengol Carrasco 2 # Springer Science+Business Media, LLC, part of Springer Nature 2020 COVID-19 has rapidly spread worldwide since its outbreak in viral hosting and propagation [4]. Moreover, there are several Wuhan, China in December 2019. Pandemic status was declared factors in which obesity can play a role in poor outcomes from by World Health Organization in March 2020 [2]. The authors COVID-19 infection. Some have proposed that obese patients report some of the cases that presented in Iran during the out- can present a metabolic dysfunction due to a pro- break from 24th February to 4th March. Being the first cases inflammatory state and also that adipose tissue can serve as declared from 19th to 25th February in Iran, there could be more a reservoir for some human viruses [5]. patients affected by COVID-19 that could have undergone bar- Clinical diagnosis of COVID-19 is heterogeneous among iatric elective surgery at that time without being noticed by sur- the 4 cases presented. Criteria for performing a chest CT or gical teams [3]. In fact, the same authors have reported previous- RT-PCR are not clearly stated. Case 4 misses RT-PCR, while ly a patient who died with morbid obesity, the day before and chest CT has not been done for case 2. This is a limitation for elective surgery for gastric bypass in Iran [4] .As most of those this early case series that will need to be explored in future affected countries in which systematic detection of COVID-19 perioperative protocols globally [6]. Also, it will be important by doing RT-PCR was not performed, means that we may be to take into consideration that some inflammatory parameters seeing the top of the iceberg by reporting only those cases who such as CRP, white blood cell count, and liver function alter- developed postoperative pneumonia. ations, as well as pulmonary pneumonia or thromboembolism The authors highlight that obesity patients are at greater and collapsed lung, can also be seen in patients presenting risk in presenting COVID-19 pulmonary complications due with bariatric surgery complications. Therefore, it is important to related comorbidities. From the 4 cases included, only the to do a complete differential diagnosis in those patients failing first seems to present with metabolic diseases and respiratory after gastric bypass or sleeve gastrectomy and to include previous pathology. However, usual treatments like 2- COVID-19 as one more possibility. angiotensin-converting enzyme inhibitors (ACEIs) and angio- The patients included received different treatments that tensin receptor blockers (ARBs) are not reported in the article. have already been described for COVID-19 pneumonia man- Although further evidence is needed due to controversy, agement, including hydroxychloroquine, antiretroviral ACEIs and ARBs have been proposed to increase expression (lopinavir and ritonavir), tocilizumab, and hemoperfusion. of ACE2 and therefore to make patients more susceptible to As there is many controversy and variability in pneumonia management across the globe [7], details on the dose and duration of the treatments should have been included to better * Ramon Vilallonga use these interesting data in the future. vilallongapuy@gmail.com Finally, short case series can help to have a picture of early experiences in bariatric surgery patients. In the meantime, we 1 Endocrine, Metabolic and Bariatric Unit, Vall d’Hebron Barcelona need to prepare for when normal activity return to surgical Hospital Campus, Universitat Autònoma de Barcelona. Center of centers. Some recommendations would be needed to be con- Excellence for the EAC-BC. Passeig de la Vall d’Hebron 119-129, 08035 Barcelona, Spain sidered with regards to bariatric surgery [8, 9]. However, it will 2 be key further evidence coming from larger cohort multicentric General Surgery Department, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona. Center of Excellence studies once the elective procedures are rescheduled after for the EAC-BC. Passeig de la Vall d’Hebron 119-129, COVID-19 pandemic. 08035 Barcelona, Spain OBES SURG Acknowledgments We thank Aminian A et al. for reporting their experi- of infection from Iran. Ann Intern Med. 2020. https://doi.org/10.7326/ ence in bariatric cases during COVID-19 outbreak [1]. We would like to M20-0696. highlight a few points and reservations. 4. Aminian A, Safari S, Razeghian-Jahromi A, et al. COVID-19 out- break and surgical practice. Ann Surg. 2020;216:1. Compliance with Ethical Standards 5. Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. What is the evidence? JAMA. 2020;11(8):875–9. Conflict of Interest The authors declare that they have no conflict of 6. Kassir R. Risk of COVID-19 for patients with obesity. Obes Rev. interest. 2020;194(March):10–1. 7. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR Ethical Approval Statement This article does not contain any studies testing in coronavirus disease 2019 (COVID-19) in China: a report of with human participants or animals performed by any of the authors. 1014 cases. Radiology. 2020;26:200642. 8. Chen X, Liu Y, Gong Y, et al. Perioperative management of patients infected with the novel coronavirus: recommendation from the joint References task force of the Chinese society of anesthesiology and the Chinese association of anesthesiologists. Anesthesiology 2020. https://doi. org/10.1097/ALN.0000000000003301. 1. Aminian A, Kermansaravi M, Azizi S, et al. Bariatric surgical prac- tice during the initial phase of COVID-19 outbreak. Obes Surg. 9. Yang W, Wang C, Shikora S, Kow L (2020) Recommendations for 2020; https://doi.org/10.1007/s11695-020-04617-x. metabolic and bariatric surgery during the COVID-19 pandemic 2. World Health Organisation(2020) WHO Director-General’s opening from IFSO. Obes Surg [internet]. 2020;1–3. Available from: http:// remarks at the media briefing on COVID-19 - 11 March 2020 www.ncbi.nlm.nih.gov/pubmed/32291701 [Internet]. Available from: https://www.who.int/dg/speeches/detail/ who-director-general-s-opening-remarks-at-the-media-briefing-on- Publisher’s Note Springer Nature remains neutral with regard to jurisdic- covid-19%2D%2D-11-march-2020 tional claims in published maps and institutional affiliations. 3. Tuite AR, Bogoch II, Sherbo R, et al. Estimation of coronavirus disease 2019 (COVID-19) Burden and potential for international dissemination