International guidelines and recommendations for surgery during Covid-19 pandemic: A Systematic Review

Outcomes after emergency abdominal surgery in COVID-19 patients at a referral center in Brazil

Purpose

COVID-19 is associated with high morbidity and mortality in patients undergoing surgery. Contrary to elective procedures, emergency operations should not be postponed. We aim to evaluate the profile and outcomes of COVID-19 patients who underwent emergency abdominal surgery.

Methods

We performed a retrospective analysis of perioperative data of COVID-19 patients undergoing emergency surgery from April 2020 to August 2020.

Results

Eighty-two patients were evaluated due to abdominal complaints, yielding 22 emergency surgeries. The mean APACHE II and SAPS were 18.7 and 68, respectively. Six patients had a PaO₂/FiO₂ lower than 200 and more than 50% of parenchymal compromise on chest tomography.

The most common indications for emergency surgery were hernias (6; 27.2%). The median length of stay was 30 days, and only two patients required reoperation. Postoperatively, 10 (43.3%) patients needed mechanical ventilation for a mean of 6 days. The overall mortality rate was 31.8%.

Conclusion

Both postoperative morbidity and mortality are high in COVID-19 patients with respiratory compromise and abdominal emergencies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01007-5.

Humanitarian Surgical Missions in Times of COVID-19: Recommendations to Safely Return to a Sub-Saharan Africa Low-Resource Setting

Background

Since the declaration of the pandemic, humanitarian medicine has been discontinued. Until now, there have been no general recommendations on how humanitarian surgical missions should be organized.

Methods

Based on our experience in the field of humanitarian surgical missions to Sub-Saharan Africa, a panel of recommendations in times of COVID-19 was developed. The fields under study were as follows: (1) Planning of a multidisciplinary project; (2) Organization of the infrastructure; (3) Screening, management and treatment of SARS-COV-2; (4) Diagnostic tests for SARS-COV-2; (5) Surgical priorization and (6) Context of patients during health-care assistance. We applied a risk bias measurement to obtain a consensus among humanitarian health-care providers with experience in this field.

Results

A total of 94.36% of agreement were reached for the approval of the recommendations. Emergency surgery must be a priority, and elective surgery adapted. For emergency surgery, we established a priority level 1a (< 24 h) and 1b (< 72 h). For an elective procedure, according our American College of Surgeon adaptation score, process with more than 60 points should be reconsidered. Due to the low life expectancy in many African countries, we consider 45–50 years as age of risk. In case of SARS-COV-2 active infection or high clinical suspicion, the screening, management and treatment should be following the international guidelines adapted to duration of the stay, available infrastructure, size of the cooperation team and medical resources.

Conclusions

Humanitarian surgical mission in times of COVID-19 is a challenge that must extrapolate the established recommendations to the local cooperation environment.

Supplementary Information

The online version contains supplementary material available at (10.1007/s00268-021-06001-x).

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study

Objectives

Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units.

Results

The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019.

Conclusions

A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.

Postoperative complications and mortality following emergency digestive surgery during the COVID-19 pandemic: A multicenter collaborative retrospective cohort study protocol (COVID-CIR)

ABSTRACT

Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).

Impact of COVID-19 on small biopsy diagnostic procedures and cancer resection surgeries in the North-West of Ireland

AIMS

To quantify the impact of COVID-19 on small biopsy procedures and cancer resection surgeries in the North-West of Ireland.

METHODS

Data was obtained from the Histopathology Departments of University Hospital Galway (UHG) and Letterkenny University Hospital (LUH) Laboratory Information Systems to establish the impact of COVID-19 on both the small biopsy (coded P01) and cancer resection (coded P03) caseloads reported from January to June 2020, with comparison made to January to June 2019.

RESULTS

From January to June 2020 compared with January to June 2019, UHG had an overall decrease of 714 P01 cases (21.5%) and a decrease of 152 P03 cases (14.4%). In this time, LUH had an increase of 9 P01 cases (0.8%) but a decrease of 48 P03 cases (58.5%).

CONCLUSIONS

There has been a significant impact on the provision of both diagnostic and therapeutic services in North-West of Ireland due to the COVID-19 pandemic.

Correlation between bioactive lipids and novel coronavirus: constructive role of biolipids in curbing infectivity by enveloped viruses, centralizing on EPA and DHA

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) belongs to the family coronaviridae. It is spherical and possesses proteins called spikes, which can clamp onto the human cells. Once in close interaction with the human cells, these viruses undergo structural change and can fuse with the cell membrane. The virus enters the host and starts the process of translation and transcription in the cells and uncoated genome, respectively. Due to the rapid transmittable nature of the virus, extant actions should be taken. The fatty acids administrated orally, or intravenously, could help us gear things up in providing resistance and preventing infection. Hence, the multiplication of the virus could be hindered by arachidonic acid, eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). In that context, the current review highlights the role of these unsaturated fatty acids and their derivatives such as lipoxins and resolvins in the inactivation of the enveloped coronavirus disease 2019 (COVID-19).

Perioperative SARS-CoV-2 infection among women undergoing major gynecologic cancer surgery in the COVID-19 era: A nationwide, cohort study from Turkey

OBJECTIVE

The objective of this study was to determine the rate of perioperative SARS-CoV-2 infection among gynecologic cancer patients undergoing major surgery.

METHODS

The database of the Turkish Ministry of Health was searched in order to identify all consecutive gynecologic cancer patients undergoing major surgery between March 11, 2020 and April 30, 2020 for this retrospective, nationwide, cohort study. The inclusion criteria were strictly founded on a final histopathological diagnosis of a malignant gynecologic tumor. COVID-19 cases were diagnosed by reverse transcriptase- polymerase chain reaction testing for SARS-CoV-2. The rate of perioperative SARS-CoV-2 infection and the 30-day mortality rate of COVID-19 patients were investigated.

RESULTS

During the study period, 688 women with gynecologic cancer undergoing major surgery were identified nationwide. The median age of the patients was 59 years. Most of the surgeries were open (634/688, 92.2%). There were 410 (59.6%) women with endometrial cancer, 195 (28.3%) with ovarian cancer, 66 (9.6%) with cervical cancer, 14 (2.0%) with vulvar cancer and 3 (0.4%) with uterine sarcoma. The rate of SARS-CoV-2 infections confirmed within 7 days before or 30 days after surgery was 46/688 (6.7%). All but one woman was diagnosed postoperatively (45/46, 97.8%). The rates of intensive care unit admission and invasive mechanical ventilation were 4/46 (8.7%) and 2/46 (4.3%), respectively. The 30-day mortality rate was 0%.

CONCLUSION

In the COVID-19 era, gynecologic cancer surgery may be performed with an acceptable rate of perioperative SARS-CoV-2 infection if the staff and the patients strictly adhere to the established infection control measures.

Impact of the COVID-19 pandemic on appendicitis treatment in Germany-a population-based analysis

PURPOSE

Acute appendicitis is one of the most common reasons for emergency medical consultation. While simple appendicitis can be treated with antibiotics or surgery, complex appendicitis including gangrene, abscess, and perforation requires appendectomy. During the COVID-19 pandemic in early 2020, an overall drop in emergency room consultations was observed. We therefore aimed to investigate the incidence and treatment strategies of acute appendicitis during that period.

METHODS

Data of insurance holders with the ICD code for "acute appendicitis" or OPS procedure of appendectomy of a major health insurance company in Germany were analyzed retrospectively. Groups were built, containing of the means of March-June of 2017, 2018, and 2019, defined as "pre-COVID group" with the "COVID group," defined as data from March to June of 2020. Data was analyzed by age, sex, comorbidities, length of hospital stay, diagnoses, and treatment. Data of the COVID group was analyzed for simultaneous COVID-19 infection.

RESULTS

During the COVID-19 pandemic of early 2020, an overall reduction by 12.9% of patients presenting with acute appendicitis was noticeable. These results were mainly due to decreased rates of uncomplicated appendicitis, while complicated appendicitis was scarcely affected. Especially in the group of females < 40 years, a drastic reduction was visible. Rates of extended surgery did not change. Likewise, the complication rate like appendix stump leakage or need for re-operation did not differ. In March 2020, 4.8% of acute appendicitis patients had concomitant COVID-19 infection.

CONCLUSION

In line with the overall drop of emergency room visits during the COVID-19 pandemic of spring 2020 in Germany, a significantly lowered number of patients with uncomplicated appendicitis were noticeable, whereas complicated appendicitis did not differ. Also, treatment and complication rate of acute appendicitis did not change. These findings might be a hint that acute appendicitis is not a progressing disease but caused by different entities for uncomplicated and complicated appendicitis and therefore another clue that uncomplicated appendicitis can be treated with antibiotics or observation. Nevertheless provided data does not cover outpatient treatment; therefore, no statement observation or antibiotics in outpatients can be made.

Outcomes of major head and neck reconstruction during the COVID-19 pandemic: The St. Andrew's centre experience

Background

The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre.

Methods

A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri‑operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations.

Results

Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36–92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred.

Conclusion

Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri‑operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Urgent and emergency surgery for secondary peritonitis during the COVID-19 outbreak: an unseen burden of a healthcare crisis

The COVID-19 pandemic has raised concerns about the negative impact of the fear of contagion on people’s willingness to seek medical care and the subsequent effects on patients’ prognosis. To date, not much is known about the outcomes of acute surgical diseases in this scenario. The aim of this multicenter observational study is to explore the effects of COVID-19 outbreak on the outcomes of patients who underwent surgery for peritonitis. Patients undergoing surgery for secondary peritonitis during the first COVID-19 surge in Italy (March 23–May 4, 2020—COVID period group) were compared with patients who underwent surgery during the same time interval of year 2019 (no-COVID period group). The primary endpoint was the development of postoperative complications. Logistic regression analysis was conducted to identify predictors of complications. Of the 332 patients studied, 149 were in the COVID period group and 183 were in the no-COVID period group. Patients in the COVID period group had an increased frequency of late presentations to the emergency departments (43% vs. 31.1%; P = 0.026) and a higher rate of postoperative complications (35.6% vs. 18%; P < 0.001). The same results were found in the subset analysis of patients with severe peritonitis at surgical exploration. The ASA score, severity of peritonitis, qSOFA score, diagnosis other than appendicitis, and COVID period resulted independent predictors of complications. During the COVID-19 pandemic patients with peritonitis had a higher rate of complicated postoperative courses, weighing on hospital costs and assistance efforts already pressured by the ongoing sanitary crisis.

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

BACKGROUND

COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts' opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic.

METHODS

Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement.

RESULTS

A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus.

CONCLUSION

The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.

Directives of general surgical practice during the COVID-19 pandemic: A systematic review

The coronavirus disease 2019 (COVID-19) is a serious global pandemic that has extremely affected health-care systems. This article aimed to review the perspectives of general surgical practice during the COVID-19 pandemic. A systematic review of the literature addressing modification to general surgical practice during the COVID-19 pandemic indexed in PubMed, Scopus, Google, and Google scholar was carried out on June 19-20, 2020. The literature review yielded 577 articles. The exclusion of duplication, articles not in English, and specialized ones in various surgical disciplines precluded 398 articles. Finally, following checking for relevance and publication status, 114 papers were included. Recommendations for surgical practice during the COVID-19 pandemic revolved around mitigation of the risk of virus transmission to patients and health-care workers. The emerging themes of safety precautions were related to patient prioritization and testing, mindful consideration of the operative strategy, optimum use of personal protective equipment, operative room setup, and departmental organization. However, those recommendations were often diverging and bore on a dearth of evidence and personal opinions. Multidisciplinary work and cooperation among surgical specialties are required to establish and validate the protocols for safe surgical practice during the pandemic and perhaps similar crises in future. The COVID-19 pandemic has brought several challenges to the field of medicine, including the surgical specialty. The centrality of safety precautions emerging in this crisis requires surgeons to adopt the new roles and work standards and translate them into practice during the pandemic and perhaps longer.

Onco-Anaesthesiology and palliative medicine: Opportunities and challenges

Global cancer burden is on the rise and many more patients present for surgery or other oncological diagnostic or therapeutic interventions requiring anaesthesia. Oncology therapy is unique as it requires a multidisciplinary team of surgical, medical and radiation oncologists apart from palliative medicine (PM) specialists, and anaesthesiologists. Anaesthetic management can affect the outcome of oncology treatment both by ensuring early return to oncology treatment and some anaesthetic techniques being innately associated with recurrence. Hence, the time has come for a separate super-speciality of onco-anaesthesiology to cater to the complex unmet needs of cancer patients. PM is the fourth dimension of oncology care and so mandatory education and training should be included in the undergraduate curriculum.

"Door to Treatment" Outcomes of Cancer Patients during the COVID-19 Pandemic

Background

The novel coronavirus disease 2019 has become a worldwide threat. We aimed to explore reflections of these unexpected changes to newly diagnosed cancer patients.

Method

We searched the 2 months after the index case of our country. The first admission day and the first day of intravenous treatment of newly diagnosed patients were recorded.

Results

In the 60 days measured during the pandemic, the total number of patients on polyclinics was 159/weekdays, and the total applied chemotherapy cycles were 276/week. For comparison, the total numbers in the previous year were 267/weekday and 363/week for polyclinic and applied chemotherapy cycles, respectively. The total number of newly admitted patients in 2020 was 283. For comparison, the number of new patients in the same 60-day period in 2019 was 495. Patients who were admitted for adjuvant treatment required a median of 8 days for the first course, those who were admitted for neoadjuvant treatment required 12 days, and metastatic patients required 14 days; there were no significant differences between treatment types (p = 0.233). However, the median treatment time was 11.5 and 17 days, in 2020 and in 2019, respectively. A significant difference was observed between the 2 groups (p < 0.001).

Conclusion

The effective shift of workers and accurate regulations have not resulted in apparent delays in patient care. While a decrease in the number of patients has detected, faster healthcare service was introduced to newly diagnosed patients. The reason for the decrease in the number of patients should be investigated with new studies.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia

INTRODUCTION

Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19.

PRESENTATION OF CASE

This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination.

CONCLUSIONS

We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

COVID-19: The need for an Australian economic pandemic response plan

OBJECTIVES

Pandemics pressure national governments to respond swiftly. Mitigation efforts created an imbalance between population health, capacity of the healthcare system and economic prosperity. Each pandemic arising from a new virus is unknown territory for policy makers, and there is considerable uncertainty of the appropriateness of responses and outcomes.

METHODS

A qualitative approach was used to review mixed sources of data including Australian reports, official government publications, and COVID-19 data to discern robust future responses. Publicly available epidemiological and economic data were utilised to provide insight into the impact of the pandemic on Australia's healthcare system and economy.

RESULTS

Policies implemented by the Australian Government to mitigate the spread of COVID-19 impacted the healthcare sector and economy. This paper incorporates lessons learned to inform optimal economic preparedness. The rationale for an economic response plan concomitant with the health pandemic plan is explored to guide Australian Government policy makers in ensuring holistic and robust solutions for future pandemics.

CONCLUSIONS

In future, an Australian Economic Pandemic Response Plan will aid in health and economic system preparedness, whilst a strong Australian economy and strategic planning will ensure resilience to future pandemics.

What surgeons should know about emergency operation for COVID-19 confirmed patients: A case report

Introduction

This case is shared to reiterate and confirm the principles of ensuring the safety of the surgical team caring for COVID-19-confirmed patients, thus, preventing the spread of infection within the hospital.

Case presentation

A 54-year-old male, COVID-19-confirmed patient complaining of abdominal pain since two days prior was transferred to our hospital. Perforated appendicitis with a periappendiceal abscess was diagnosed by computed tomography. Laparoscopic appendectomy was performed in a negative-pressure operating room. The surgical team wore enhanced personal protective equipment. Electrocautery was not used during surgery and no other special instruments were applied to reduce aerosol generation. No special instruments or filters were used for the removal of intra-abdominal gas. The operation was completed successfully and no immediate surgical complications occurred. The patient advanced to a normal diet on the 4th postoperative day. The patient was treated with antibiotics for bacteremia and antiviral therapy for underlying pneumonia in the setting of COVID-19 with most symptoms dissipating by the 7th postoperative day. The patient was discharged on the 30th postoperative day without any complications.

Discussion

A well-designed manual, a well-trained surgical team, and a negative-pressure operating room are essential for safe laparoscopic appendectomies in COVID-19 patients.

Conclusion

When surgery is performed in a negative-pressure operating room by a well-trained surgical team, a laparoscopic appendectomy can be successfully performed under the principles of obtaining optimum clinical outcomes while faithfully ensuring the safety of healthcare providers and the hospital environment.

Effective management of a firearm injury with multiple intestinal perforation in a COVID 19 positive patient: A rare case report

INTRODUCTION

A challenging situation lies in front of every surgeon to perform emergency surgeries in a pandemic scenario. Gunshot injuries in a COVID-19 affected individual increases the chances of post-operative morbidity and mortality. Such cases require multidisciplinary approach with an advanced COVID care for the satisfactory outcome.

CASE PRESENTATION

We present a case of 30-year-old male with an alleged history of an accidental fire arm injury. His rapid antigen for COVID was positive. Contrast enhanced computed tomogram (CECT) abdomen was suggestive of multiple bowel injuries. Emergency exploratory laparotomy confirmed multiple bowel perforations with no associated solid organ injury. Perforated sites were sealed by primary repair and loop ileostomy was performed. Patient was discharged on post-operative Day 17 with satisfactory clinical improvement.

DISCUSSION

Deleterious effects of COVID-19 has questioned the reliance on health care system across the globe. Pulmonary complications affect the post-operative course in patients undergoing surgery. However not every patient with peri operatively detected COVID-19 will have complicated post-operative course. Managing such patients with perioperative COVID-19 is an uphill task. Hemodynamic instability and clinical signs of peritonitis mandates the operative management. Multidisciplinary approach with advanced post-operative COVID care is required for satisfactory outcome.

CONCLUSION

Management of patients undergoing emergency procedure with peri-operative COVID 19 is challenging for the attending surgeon. Consider all surgical emergencies as COVID positive unless proved otherwise. Multidisciplinary approach for management of COVID-19 infection along with good post-operative care is required.

The impact of COVID-19 on gastric cancer surgery: a single-center retrospective study

BACKGROUND

The coronavirus disease 2019 (COVID-19) has been declared a global pandemic by the World Health Organization. Patients with cancer are more likely to incur poor clinical outcomes. Due to the prevailing pandemic, we propose some surgical strategies for gastric cancer patients.

METHODS

The 'COVID-19' period was defined as occurring between 2020 and 01-20 and 2020-03-20. The enrolled patients were divided into two groups, pre-COVID-19 group (PCG) and COVID-19 group (CG). A total of 109 patients with gastric cancer were enrolled in this study.

RESULTS

The waiting time before admission increased by 4 days in the CG (PCG: 4.5 [IQR: 2, 7.8] vs. CG: 8.0 [IQR: 2,20]; p = 0.006). More patients had performed chest CT scans besides abdominal CT before admission during the COVID-19 period (PCG: 22 [32%] vs. CG: 30 [73%], p = 0.001). After admission during the COVID period, the waiting time before surgery was longer (PCG: 3[IQR: 2,5] vs. CG: 7[IQR: 5,9]; p < 0.001), more laparoscopic surgeries were performed (PCG: 51[75%] vs. CG: 38[92%], p = 0.021), and hospital stay period after surgery was longer (7[IQR: 6,8] vs.9[IQR:7,11]; p < 0.001). In addition, the total cost of hospitalization increased during this period, (PCG: 9.22[IQR:7.82,10.97] vs. CG: 10.42[IQR:8.99,12.57]; p = 0.006).

CONCLUSION

This study provides an opportunity for our surgical colleagues to reflect on their own services and any contingency plans they may have to tackle the COVID-19 crisis.

The longitudinal impact of COVID-19 pandemic on neurosurgical practice

•

All neurosurgical procedures decreased in number during the COVID-19 pandemic.

•

Surgical complication rates remained within the acceptable range.

•

Emergency procedures numbers remained the same throughout the study period.

•

Neurosurgical oncology cases were the highest in frequency.

•

There is a decline in hospital length of stay as we progressed during the study period.

Objective

This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice.

Methods

We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time.

Results

During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5–8). The number of cases declined from 72 in the first week and plateaued at the 30′s range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4–18) to 6 (IQR: 3–13) to 5 days (IQR: 2–8). There was no significant among-period difference with respect to institution type, complications, or mortality.

Conclusion

Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

Laparoscopic Surgery in COVID-19 Era-Safety and Ethical Issues

(1) Background: The paper aims to review the available evidence regarding the health risk of the aerosolization induced by laparoscopy induced and impact of the COVID-19 pandemic upon minimally invasive surgery. (2) Materials and methods: A systematic review of the literature was performed on PubMed, Medline and Scopus until 10 July. (3) Results: Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. However, the only evidence of viral transmission through surgical smoke to medical staff is post-laser ablation of HPV-positive genital warts. The reports of SARS-CoV-2 infected patients who underwent laparoscopic surgery revealed the presence of the virus, when tested, in digestive wall and stools in 50% of cases but not in bile or peritoneal fluid. All surgeries did not result in contamination of the personnel, when protective measures were applied, including personal protective equipment (PPE) and filtration of the pneumoperitoneum. There are no comparative studies between classical and laparoscopic surgery. (4) Conclusions: Previously published data showed there is a possible infectious and toxic risk related to surgical smoke but not particularly proven for SARS-CoV-2. Implementing standardized filtration systems for smoke evacuation during laparoscopy, although increases costs, is necessary to increase the safety and it will probably remain a routine also in the future.

Management of appendicitis during COVID-19 pandemic; short-term outcomes

Background and aim

COVID-19 pandemic has predisposed patients undergoing surgery to post-operative infection and resultant complications. Appendicitis is frequently managed by appendicectomy. After the onset of the pandemic, selected cases of appendicitis were managed with antibiotics which is a recognised treatment option. Our objective was to compare the management of appendicitis and post-operative outcomes between pre- and post-COVID-19.

Methods

Ninety-six patients were identified from before the onset of the pandemic (November 2019) to after the onset of the pandemic (May 2020). Data were collected retrospectively from electronic records including demographics, investigations, treatment, duration of inpatient stay, complications, readmissions and compared between pre- and post-COVID-19 groups.

Results

One hundred percent underwent surgical treatment before the onset of pandemic, compared with 56.3% from the onset of the pandemic. A greater percentage of patients were investigated with imaging post-COVID-19 (100% versus 60.9%; p < 0.00001). There was no significant difference in the outcomes between the two groups.

Conclusion

CT/MRI scan was preferred to laparoscopy in diagnosing appendicitis and conservative management of uncomplicated appendicitis was common practice after the onset of pandemic. Health boards can adapt their management of surgical conditions during pandemics without adverse short-term consequences. Long term follow-up of this cohort will identify patients suitable for conservative management.

Potential impact of COVID-19 on colorectal disease management

The current recommendations for management of colorectal diseases are still evolving, due to the limited experience on this issue. As the new coronavirus can be transmitted through breath droplets, by contact and orofecally, there is no consensus of how this fact may affect the investigation and treatment of anorectal diseases. Thus, high-quality multicenter studies are urgently needed to provide better information to both patients and the multiprofessional team, in order to build an effective pandemic response plan in our specialty. As a greater operative risk for infected patients has already been demonstrated, the next step lies on the identification of new therapeutic strategies that could minimize this effect on an individual basis. There is a present understanding that the COVID-19 pandemic should change some traditional practices. Therefore, the surgical treatment of suspected or known COVID-19 case demands specific insights. This article analyses potential influences regarding the treatment of patients with Colorectal Cancer (CRC) and Inflammatory Bowel Diseases (IBD). At present, elective surgery must be avoided, and the colorectal surgeon must carefully evaluate the risks and benefits of such decision. Within this context, a change toward nonsurgical and less aggressive modalities of CRC treatment may help to postpone definitive treatment. We also discuss the concerns regarding the viral infection among the population, the influence on clinical symptoms and the proposed modifications on therapeutic schemes.

Anesthesiologist behavior and anesthesia machine use in the operating room during the COVID-19 pandemic: awareness and changes to cope with the risk of infection transmission

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease [coronavirus disease 2019 (COVID-19) infection] first appeared in December 2019 in China and is now spreading worldwide. Because SARS-CoV-2 can be transmitted via aerosols and surface contaminations of the environment, appropriate use of anesthesia machines and appropriate behavior in the operation room (OR) are required specifically in relation to this disease. The use of high-performance hydrophobic filters with a high rate of virus rejection is recommended as the type of viral filter, and surgical team behaviors that result in aerosol splashes should be avoided. Appropriate hand hygiene by the anesthesiologist is crucial to prevent unexpected environmental contamination. When the anesthesia machine is used instead of an intensive care unit ventilator, it is important to keep the fresh gas flow at least equal to the minute ventilation to prevent excessive humidity in the circuit and to monitor condensation in the circuit and inspiratory carbon dioxide pressure. In addition, both the surgical smoke inherent in thermal tissue destruction and the surgical team's shoe soles may be factors for the presence of SARS-CoV-2 in the operating room. Ensuring social distancing-even with a mask in the OR-may be beneficial because healthcare providers may be asymptomatic carriers. After the acute crisis period of COVID-19, the number of cases of essential but nonurgent surgeries for waiting patients is likely to increase; therefore, optimization of OR scheduling will be an important topic. Anesthesiologists will benefit from new standard practices focusing on the prevention of COVID-19 infection.

COVID-19 Emergency and Post-Emergency in Italian Cancer Patients: How Can Patients Be Assisted?

Italy and worldwide are experiencing an outbreak of a new coronavirus-related disease, named COVID-19, declared by the WHO COVID-19 a pandemic. The fragility of cancer patients is well-known, with many cases affecting aged patients or those with several comorbidities that frequently result in a loss of independency and functionality. Therefore, cancer patients have been greatly affected by this health emergency and, due to their vulnerability to COVID-19, oncologic patient visits have been often delayed or canceled leading to possible under-treatment. Different solutions can be adopted for reducing travels to cancer screening centers and the overall impact of cancer screening visits. As a consequence, it has been recommended that, when possible, the follow-up visits for cancer patients treated with oral anticancer drugs could be performed telematically. Furthermore, many patients refuse hospital visits, even if necessary, because of fear of contagion. Moreover, in some regions in Italy even the very first non-urgent visits have been postponed with the consequent delay in diagnosis, which may negatively affect disease prognosis. For these reasons, new approaches are needed such as the telemedicine tool. Throughout organized and appropriate tools, it would be possible to manage patients' visits and treatments, to avoid the dangerous extension of waiting lists when the standard activities will resume. In this context, a number of hospital visits can be substituted with visits at small local health centers, and general practitioners'office, taking in turn, advantage of well-defined telemedicine path which will be developed in the post-emergency phase.

Compliance and perception about personal protective equipment among health care workers involved in the surgery of COVID-19 negative cancer patients during the pandemic

BACKGROUND

Health care workers (HCWs) are at risk of getting infected while at work, for example, operating room (OR), hence it is pertinent that they don all the appropriate personal protective equipment (PPE) to minimize the chance of getting infected.

METHODS

A COVID-19 specific briefing and debriefing form was created and used in the OR along with the World Health Organization surgical safety checklist to reinforce the use of appropriate PPE. An audit was subsequently done to understand the compliance to PPE use, followed by a survey based on the findings of the audit to understand the issues related to noncompliance.

RESULTS

The form was used in 183 out of the 238 (77%) surgeries performed during a months' time. The overall compliance for PPE usage was 96.3%. Noncompliance was seen most often for eye protection (45/567) (P = .01). The survey revealed that this was mostly among surgeons mainly due to discomfort, poor visibility, and frequent fogging.

CONCLUSIONS

Our HCW were adapting well to the new normal of donning appropriate PPE in the OR, except for the eye protection due to discomfort and visibility related issues. This is important to know so that necessary changes could be introduced to better the compliance.

Facial Trauma Management during the COVID-19 era: a primer for surgeons

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has caused more than 6.1 million confirmed cases of COVID-19 in more than 188 countries, and has caused more than 370,000 deaths globally as of June 1, 2020. In addition, thousands of healthcare workers have also got infected with the virus. COVID-19 patients release large amounts of infectious viral particles in form of droplets from cough, sneeze and respiratory secretions. These droplets are the main modes of transmission of COVID-19. This mode of transmission puts the healthcare professionals at an increased risk of infection, especially from asymptomatic patients. As a result, during the current pandemic, most routine surgeries all around the world have been suspended, and only emergency surgeries are being performed. Facial trauma surgery is one such emergency surgery that cannot be delayed or suspended even in this pandemic. This review focuses on precautions surgeons have to take while managing facial trauma patients in the emergency department and while performing emergency surgeries on these patients during the current COVID-19 pandemic.

Will the guidelines and recommendations for surgery during COVID-19 pandemic still be valid if it becomes endemic?

The current COVID-19 pandemic has impacted all the healthcare sectors all over the world. The WHO and various other health organizations have been issuing recommendations and guidelines for surgical practice and patient management during the current pandemic. Some of these guidelines include triaging of the patients, prioritizing emergency surgery and delaying the elective surgical procedures till the COVID-19 pandemic is over. However, it seems that COVID-19 might become endemic in the community and current guidelines might not hold true. Surgical practices cannot remain suspended forever as it will have a deleterious effect on surgeons and patients. Therefore we need novel guidelines so that the surgeons can resume their general surgical practice as soon as possible.

Ethics for surgeons during the COVID-19 pandemic, review article

The Covid-19 pandemic is a devastating global healthcare emergency with seismic impact on how modern surgical services function. Surgeons worry, that whilst healthcare-resources are directed against the pandemic, double effect may predict these benevolent public health efforts will cause unintended maleficent effects through delays to surgical treatment. Surgeons will make many challenging ethical judgements during this pandemic, here we conduct a narrative review of how medical ethics may help us make the best available choices.

A narrative review of all the relevant papers known to the author was conducted. We discuss the key aspects of medical ethics, and how they have applied to surgeons during the Covid-19 pandemic.

The four fundamental principles of medical ethics include: Beneficence, Nonmaleficence, Autonomy and Justice. Surgeons will face many decisions which shall challenge those ethical principles during the pandemic, and wisdom from medical ethics can guide surgeons, to do the right thing, make best available choices, and get the best available outcome for patients during the Covid-19 pandemic.

The practice of surgery is distinguished by good judgement in the face of uncertainty, we must strive to do the right thing, advocate for our patients, and be honest in the face of uncertainty. Medical Ethics can guide us to make the best available choices for our patients during the Covid-19 pandemic, afterwards, we must emerge wiser having learnt lessons and rebuilding trust in surgical care.

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The Covid-19 pandemic is a devastating global healthcare emergency with seismic impact on how modern surgical services function.

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Surgeons worry, that whilst healthcare-resources are directed against the pandemic, double effect may predict these benevolent public health efforts will cause unintended maleficent effects through delays to surgical treatment.

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Surgical practice is distinguished by good judgement in the face of uncertainty, we must strive to act ethically, be honest, do the right thing, and advocate for our patients.

The Impact of the COVID-19 Pandemic on Psychological Distress, Physical Activity, and Symptom Severity in Parkinson's Disease

BACKGROUND

The ongoing COVID-19 pandemic has many consequences for people with Parkinson's disease (PD). Social distancing measures complicate regular care and result in lifestyle changes, which may indirectly cause psychological stress and worsening of PD symptoms.

OBJECTIVE

To assess whether the COVID-19 pandemic was associated with increased psychological distress and decreased physical activity in PD, how these changes related to PD motor and non-motor symptom severity, and what frequency and burden of COVID-related stressors were.

METHODS

We sent an online survey to the Personalized Parkinson Project (PPP) cohort (n = 498 PD patients) in the Netherlands. In the survey, we distinguished between COVID-related stressor load, psychological distress, PD symptom severity, and physical activity. We related inter-individual differences to personality factors and clinical factors collected before the pandemic occurred.

RESULTS

358 PD patients completed the survey between April 21 and May 25, 2020 (response rate 71.9%). Patients with higher COVID-related stressor load experienced more PD symptoms, and this effect was mediated by the degree of psychological distress. 46.6% of PD patients were less physically active since the COVID-19 pandemic, and reduced physical activity correlated with worse PD symptoms. Symptoms that worsened most were rigidity, fatigue, tremor, pain and concentration. Presence of neuropsychiatric symptoms (anxiety, depression) before the pandemic, as well as cognitive dysfunction and several personality traits predicted increased psychological distress during the COVID-19 pandemic.

CONCLUSION

Our findings show how an external stressor (the COVID-19 pandemic) leads to a worsening of PD symptoms by evoking psychological distress as well as lifestyle changes (reduced physical activity).