The WHO has estimated that 1.9 billion adults worldwide are overweight and 650 million are obese (1). In Italy, as reported by Global Obesity Observatory, the overall percentage of patients with body mass index (BMI) > 30 kg/m² is across 12 and 10% for men and women over 18 years old, respectively (2). Despite it being a high percentage, it is lower than the mean value of European states (2). In particular, in Molise, a small region of Italy, the overall percentage of obesity is over 14% in both genders: one of the highest national values (3). In literature, it is clearly described a link among obesity and hormonal, endothelial and inflammatory level alterations (4, 5), and pieces of evidence regarding the association between the increased BMI and carcinogenesis (6–8).

The metabolic and bariatric surgery (BS) showed to be the most successful treatment for weight loss and to reduce the patients' comorbidities due to obesity (9, 10).

Bariatric surgery and many other elective surgical services had to deal with the widespread postponements in many parts of the world during the Coronavirus Disease-2019 (COVID-19) pandemic (11, 12). Nevertheless, the surgical treatment of obesity cannot be defined as “elective” (13), because nowadays it is considered a life-changing intervention and a life-saving surgery, improving health, quality of life, and long-term survival (11).

Therefore, “A. Cardarelli Hospital” in Campobasso (Molise) started a “Teaching/Learning Model of Hub and Spoke Collaboration” among some referral centers for bariatric, colorectal, and liver surgery (14), in order to reduce patient migration offering the best standard of care to people for all the surgical specialties. The learning programs allow to guarantee effective treatment and safety procedures in patients with morbid obesity also during the critical pandemic period as reported in minimally invasive approaches performed in complex surgery (15–18).

Hub and Spoke Programs have already demonstrated a great impact on regional health programs avoiding health migration, reducing costs, and decreasing the waiting times for surgery (15, 19, 20).

Our study aimed to evaluate the safety and effectiveness of the Hub and Spoke Bariatric Learning Program in a small Italian region analyzing all the peri-, intra-, and postoperative outcomes and the BMI reduction, Total Weight Loss (%TWL), and Excess Weight Loss (%EWL) after 30 and 90 days from surgical procedures, in order to reduce the health system costs and patients migration.

A total of 13 (3 men and 10 women) patients who were included in our study underwent BS between February 2020 and August 2021.

The mean age was 47.08 years ± 7.54 with a mean BMI, before surgery, of 41.79 ± 6.02.

Regarding ASA score 7 (53.84%), patients were ASA II and 6 (46.16%) patients were ASA III.

The most frequent comorbidities were hypertension (84.81%), gastritis (84.61%), and diabetes mellitus (30.76%). No patient was found positive at SARS-CoV-2 molecular swab. Baseline characteristics of patients are depicted in Table 1.

All procedures were performed laparoscopically. Twelve (92.31%) procedures were sleeve gastrectomies (LSG) and 1 (7.69%) patient underwent endoscopic BIB placement. One (8.33%) LSG was associated to gastric band removal.

All surgical operations were performed under general anesthesia, except for the placement of BIB.

Mean surgical time was 110.14 ± 23.54 min. No hiatal hernia was found or repaired. No Intensive Care Unit (ICU) admission was reported.

Clavien-Dindo I-II complications were observed in 4 out of 13 patients: we reported 3 (23.07%) cases of PONV and 1 (7.69%) patient, after LSG, required Total Parental Nutrition (TPN) during hospitalization.

The mean length of stay was 4.07 ± 2.40 days. No mortality was reported.

Surgical characteristics and postoperative course are shown in Tables 2, 3.

The follow-up rates were 100% at 30 and 90 days.

BMI, %TWL, and %EWL trends are shown in Figure 1.

Our study demonstrates the safety and the efficacy of the bariatric procedures, mainly LSG, performed in a peripheric center when involved in a Hub and Spoke Program.

Analyzing our results concerning preoperative patient characteristics, they are superimposable to other relevant casistics from referral centers for BS (35). All the patients have at least one comorbidity in addition to obesity. The most common comorbidities were hypertension and diabetes as reported in the literature (36–39).

Patients who underwent BS in our center were all ASA II and III. It is clear that high-volume centers can report more variability patients' ASA scores due to the greater number of cases (40, 41). The absence of ASA I patients might influence the postoperative data analysis.

Concerning intra-operative courses, all the procedures were performed through a laparoscopic approach following the standard of care for referral bariatric centers in the USA (42). No conversion or re-intervention is reported.

It can also be speculated that the number of the complications reported is higher than reported by a referral center (30 vs. 5–15%, respectively) (43, 44), but we shall underline that we reported only Clavien-Dindo I or II complications treated in conservative approach.

Furthermore, the small sample size influenced the complication rate. No patient presented the complications reported as serious as an anastomotic leak, cardiac, genitourinary, hemorrhagic, neurologic injuries, obstruction, postoperative shock, pulmonary, splenic injury, thromboembolic event, wound infection, and reoperation (42, 45–48). No patients needed ICU stay.

Moreover, this finding may benefit from the small sample size, but it is also due to a careful selection of cases, which were always discussed with the Hub MDT.

Moreover, a proper step by step learning curve of the whole team was established to achieve the best results as described in Vitiello et al.'s experience (35).

The mean hospital stay is higher than the length of stay (LOS) reported in the literature for a high-volume center for LSG (35, 49–51). As known, LOS may be influenced by modifiable and non-modifiable factors (52).

In our case, most of the factors that affect LOS cannot be modified, such as age, BMI, ASA, and creatinine.

As reported by Tholey et al. (53), the ASA score > 2 was a significant predictor of an LOS longer than 48 h, probably due to the greater risk of even mild complications.

Among the non-modifiable factors, there are also the socio-economic conditions and the geographical distance between little towns and the Cardarelli Hospital.

In Molise, it might be difficult for many patients to undergo 1-day hospital service before and after surgery, forcing them to hospitalize these patients and frail and lonely patients (54).

We are aware that center volume correlates to results (55–58), but in a moment in which health migration constitutes a risk for the population due to the COVID19 pandemic (59, 60), a Hub and Spoke Program for elective BS may offer patients the chance to be treated in the safest and most effective way without the costs and risks of health migration (20).

The chance to be treated in their own region is also important for the families of the patients because in the COVID19 pandemic period, it was even more difficult to assist patients far from home (61).

Therefore, we can affirm that our approach has led us to guarantee effective treatment and safety procedures also during the critical pandemic period, as reported by Bonalumi et al. in cardiac and vascular surgery during the COVID19 pandemic (62). Moreover, Ceccarelli et al. have been experienced the safety of this program in liver surgery and concluded that it may allow patients to undergo a suitable standard of care for complex surgery (20).

Furthermore, our Hub and Spoke Learning Program aims precisely to improve the capacity and experience of the surgical team in order to best manage all the modifiable factors reported by Meneveau et al. with a consequent reduction of complications and hospital stay (52).

During the follow-up, our patients had a consistent reduction in BMI and our findings were in line with results from referral centers for BS (35, 51, 63).

Our aim is to share the first report of a successful Hub and Spoke Program, which allowed to best manage patients from a small region of Italy, where it is very difficult to reach all the standards of care for the most frequent surgical pathologies, but where health migration should be reduced respecting the rules of the best surgical practice.

Our pilot study has the aim to demonstrate the effectiveness of Hub and Spoke Learning Program to reduce migration and costs ensuring the standard of care in BS, especially in laparoscopic sleeve gastrectomy. Our program is still being continued and we are enrolling even more patients which can undergo BS for the first time in their region. Our further goals are represented by the improvement of outcomes, even more autonomous patient management and the possibility to propose all types of interventions in our hospital.

The raw data supporting the conclusions of this article will be made available by the authors, with undue reservation.

The studies involving human participants were reviewed and approved by University of Molise. The patients/participants provided their written informed consent to participate in this study.

AB, PA, and AR: conceptualization. PA and AR: methodology and writing—review and editing. PA, MC, and RV: software. PA, MC, AS, RV, MB, and AR: validation, writing—original draft preparation, and visualization. MC, AS, RV, GD, GG, CL, MB, DE, and LS: formal analysis and investigation, resources, and data curation. PM, BA, GG, and AR: supervision. All authors have read and agreed to the published version of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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