Safe management of surgical smoke in the age of COVID-19

Analysis and visualization of the research progress on surgical smoke

BACKGROUND

With the advancement of medical technology, tools such as electrosurgical equipment, laser knives, and ultrasonic scalpels have made modern medical procedures more convenient and effective. However, the generation of surgical smoke during these procedures poses significant health risks to medical personnel. Despite this, only a few studies have examined the literature systematically in this area. By analyzing bibliometric data on surgical smoke, we can gain insights into current research hotspots and forecast future trends.

METHODS

This study included literature related to surgical smoke from the Web of Science and China National Knowledge Infrastructure (CNKI) databases, covering the period from 2000 to 2024. We used VOSviewer, CiteSpace, and BioBERT to visualize research trends and hotspots.

RESULTS

In the early stages of research, the focus was mainly on the composition, generation mechanisms, and susceptible populations related to surgical smoke. In recent years, with the development of laparoscopic surgery and the global COVID-19 pandemic, research interests have shifted towards occupational protection of healthcare workers and public health. Currently, the research in this field primarily explores the promoting effects of surgical smoke on conditions such as inflammation and tumors, as well as occupational protection and health education for healthcare workers. Disease research focuses heavily on Smoke Inhalation Injury, Infections, Neoplasms, Postoperative Complications, and Inflammation.

CONCLUSION

We explored future research directions in the field of surgical smoke using VOSviewer, CiteSpace, and BioBERT. Our findings indicate that current research focuses on investigating the promoting effects of surgical smoke on conditions such as inflammation and tumors, as well as on occupational protection and health education for healthcare workers. We summarized existing preventive measures, aiming to facilitate further research advancements and the translation of research outcomes into clinical results. These efforts provide new insights for advancing research in occupational protection of healthcare workers.

Digestive and breast cancer patients managed during the first wave of COVID-19 pandemic: Short and middle term outcomes

BACKGROUND

The first wave of coronavirus disease 2019 (COVID-19) pandemic in Spain lasted from middle March to the end of June 2020. Spanish population was subjected to lockdown periods and scheduled surgeries were discontinued or reduced during variable periods. In our centre, we managed patients previously and newly diagnosed with cancer. We established a strategy based on limiting perioperative social contacts, preoperative screening (symptoms and reverse transcription-polymerase chain reaction) and creating separated in-hospital COVID-19-free pathways for non-infected patients. We also adopted some practice modifications (surgery in different facilities, changes in staff and guidelines, using continuously changing personal protective equipment…), that supposed new inconveniences.

AIM

To analyse cancer patients with a decision for surgery managed during the first wave, focalizing on outcomes and pandemic-related modifications.

METHODS

We prospectively included adults with a confirmed diagnosis of colorectal, oesophago-gastric, liver-pancreatic or breast cancer with a decision for surgery, regardless of whether they ultimately underwent surgery. We analysed short-term outcomes [30-d postoperative morbimortality and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection] and outcomes after 3 years (adjuvant therapies, oncological events, death, SARS-CoV-2 infection and vaccination). We also investigated modifications to usual practice.

RESULTS

From 96 included patients, seven didn't receive treatment that period and four never (3 due to COVID-19). Operated patients: 28 colon and 21 rectal cancers; laparoscopy 53.6%/90.0%, mortality 3.57%/0%, major complications 7.04%/25.00%, anastomotic leaks 0%/5.00%, 3-years disease-free survival (DFS) 82.14%/52.4% and overall survival (OS) 78.57%/76.2%. Six liver metastases and six pancreatic cancers: no mortality, one major complication, three grade A/B liver failures, one bile leak; 3-year DFS 0%/33.3% and OS 50.0%/33.3% (liver metastases/pancreatic carcinoma). 5 gastric and 2 oesophageal tumours: mortality 0%/50%, major complications 0%/100%, anastomotic leaks 0%/100%, 3-year DFS and OS 66.67% (gastric carcinoma) and 0% (oesophagus). Twenty breast cancer without deaths/major complications; 3-year OS 100% and DFS 85%. Nobody contracted SARS-CoV-2 postoperatively. COVID-19 pandemic-related changes: 78.2% treated in alternative buildings, 43.8% waited more than 4 weeks, two additional colostomies and fewer laparoscopies.

CONCLUSION

Some patients lost curative-intent surgery due to COVID-19 pandemic. Despite practice modifications and 43.8% delays higher than 4 weeks, surgery was resumed with minimal changes without impacting outcomes. Clean pathways are essential to continue surgery safely.

Bedside open tracheostomy in COVID-19 patients - a safe and swift approach

BACKGROUND

Tracheostomy can be performed as an open surgical procedure, percutaneous, or hybrid and forms an important step in the management of patients infected with coronavirus disease 2019 (COVID-19) requiring weaning from mechanical ventilation. The purpose of this article is to share our experience to performing bedside surgical tracheostomy in COVID-19 patients in a safe and effective manner, whilst minimising the risk of viral transmission, to optimise patient outcomes and reduce risk to healthcare professionals.

MATERIAL AND METHODS

As recommended by ENT UK, we prospectively established a COVID Airway Team within the ENT department at Birmingham Heartlands Hospital, consisting of four head and neck consultant surgeons to perform either open-bedside, open-theatre or percutaneous tracheostomy in COVID-19 patients. A specific stepwise method for bedside open surgical tracheostomy was based on ENT UK and British Laryngological Society recommendations.

RESULTS

Thirty patients underwent tracheostomy during the study period (14 bedside-open, 5 open-theatre, 11 percutaneous). Mean duration of mechanical intubation prior to bedside-open tracheostomy was 14.5 days. The average time for open-bedside tracheostomy was 9 minutes compared to 31 minutes for open-theatre. There were no significant tracheostomy related complications with bedside-open tracheostomy. No healthcare professional involved reported acute COVID-19 infection.

CONCLUSIONS

We describe our effective, safe and swift approach to bedside open tracheostomy during the COVID-19 pandemic. Our experience demonstrated a short mean procedural time, with no tracheostomy-related complications and no reported viral transmission amongst the healthcare members involved.

Use of current automatic smoke evacuation system in flexible gastrointestinal endoscopy: Its feasibility and potential usefulness

Objectives

Flexible endoscopy does not have a system that can automatically evacuate surgical smoke generated in the gastrointestinal lumen. We aimed to investigate the feasibility and potential usefulness of automatic smoke evacuation systems in flexible endoscopy.

Methods

[Bench] After surgical smoke generated in the stomach was evacuated by the evacuator, the degree of residual smoke and gastric luminal collapse were evaluated to optimize the evacuator settings. [Animal] Insufflation, suction, and total operation time to complete the protocol of 10 cauterizations of the gastric mucosa were measured in three groups: "manual suction only," "manual suction with automatic evacuation (50% force)," and "manual suction with automatic evacuation (70% force)." The stability of endoscopic visualization and operability was evaluated by 10 endoscopists blinded to those suction settings, and the number of manual suctions, insufflations, and total operation time were measured.

Results

[Bench] The degree of residual smoke and gastric luminal collapse were inversely correlated. [Animal] When the automatic evacuator was partially used, there was no difference in the insufflation time, but the suction time (vs 50%; p = 0.011, vs. 70%; p = 0.011) and total operation time (vs. 50%; p = 0.012, vs. 70%; p = 0.036) were significantly reduced compared to manual operation only. Furthermore, manual suction with automatic evacuation (50% force) significantly improved the stability of endoscopic visualization and operability compared to manual operation only (p = 0.041, p = 0.0085).

Conclusions

The automatic smoke evacuation in flexible gastrointestinal endoscopy was potentially feasible and useful by improving the device setting.

Perioperative considerations for acute appendicitis in patients with COVID-19 infection: two case reports

We report considerations related with surgery through 2 cases of acute apendicitis with COVID-19 infection. In November and December 2020, two patients infected with COVID-19 developed acute apendicitis and underwent emergency surgery. In case 1, an 84-year-old woman was asymptomatic and diagnosed with acute apendicitis on the 20th day of infection. She was discharged after surgery without complication. In contrast, case 2 was a 69-year-old male patient with pneumonia treated with antibiotics, steroids and remdesivir. After surgery, he was hospitalized for a long duration due to persistent pneumonia and wound complications. We should perform appendectomy in well-established negative pressure operating rooms, personal protective equipment, and protocols. Since the physical examination and blood tests were limited, image examination like computed tomography scan should be considered if acute apendicitis is suspected. If the patient has pneumonia before surgery, it can get worse after surgery, and complications such as wound infections can occur.

Surgical smoke: A hidden killer in the operating room

Surgical smoke is a byproduct of aerosols containing several components produced by energy equipment. The characteristics of surgical smoke components produced by different types of tissues or using different kinds of energy devices vary. For example, the average diameter of smoke particles produced by electrocautery is smaller, and the possibility of viable cells and pathogens in surgical smoke produced by an ultrasonic knife is higher. According to the characteristics of its composition, surgical smoke may be an important risk factor affecting the health and safety of operating room staff and patients. The use of surgical masks, suction devices and portable smoke evacuation systems can reduce this risk to some extent. However, most operating room staff members do not implement corresponding measures to protect themselves. In this paper, the characteristics of surgical smoke and the research progress in protective measures are briefly reviewed.

Two-year outcomes of conservatively managed appendicitis during the COVID-19 pandemic-a multicentre cohort study

PURPOSE

During the COVID-19 pandemic, the new RCSEng guidelines resulted in appendicitis being more commonly managed conservatively to avoid aerosol-generating procedures. This resulted in shorter hospital stays without increased short-term complications. The 2-year outcomes of this change, specifically recurrence and re-admission rates remain unknown.

METHODS

We conducted a multicentre, prospective, observational study including all adult patients treated as appendicitis after the implementation of the new surgical guidelines during the COVID-19 pandemic. Outcomes included initial management failure, re-admission rate, appendicitis recurrence, and interval appendicectomy. A historical cohort prior to the COVID-19 pandemic was used for comparison. Patients were followed up for 2-years post index admission. Categorical and continuous variables were compared using Fisher's exact test and Student's T or Mann-Whitney U tests as appropriate.

RESULTS

Sixty-three and 79 patients with appendicitis were included from four NHS trusts, before (A) and after (B) the new intercollegiate guidelines respectively. Operative management was used less frequently in cohort B (28/79 vs 52/63; p<0.001). More patients re-presented in cohort B (14/79 vs 3/63; p=0.020), but not when comparing only those managed conservatively (2/11 vs 13/52; p=1.000). A similar trend was observed for appendicitis recurrence although without statistical significance (2/63 vs 9/79; p=0.112); with loss of trend when comparing those managed conservatively-only (2/11 vs 9/52; p=1.000). Among all patients, four (2.8%) were found to have underlying neoplasia of which three were initially managed conservatively (3/63; 4.8%).

CONCLUSION

Conservative management of appendicitis has previously been shown to have short-term benefits in expedited hospital discharge without early complications. The present study shows it has a higher readmission and appendicitis recurrence rates. The risks of this alongside missed/delayed management of neoplasia needs to be considered alongside the benefits including avoidance of aerosol-generating general anaesthesia and laparoscopy during the COVID-19 pandemic or similar future health crises. Small case numbers limit analysis.

Impact of COVID-19 Pandemic on Management and Outcomes of Acute Cholecystitis at US Academic Centers

BACKGROUND

The COVID-19 pandemic has had wide-ranging effects on management of medical conditions. Many hospitals encountered staffing shortages, limited operating room availability, and shortage of hospital beds. There was increased psychological stress and fear of contracting COVID-19 infection, leading to delay in medical care for various disease processes. The objective of this study was to examine changes in management and outcomes attributed to the COVID-19 pandemic in patients presenting with acute calculus cholecystitis at US academic centers.

STUDY DESIGN

Using the Vizient database, patients with the diagnosis of acute calculus cholecystitis who underwent intervention during the 15 months before the pandemic (prepandemic, October 2018 to December 2019) were compared with 15 months during the pandemic (pandemic, March 2020 to May 2021). Outcomes measures included demographics, characteristics, type of intervention, length of stay, in-hospital mortality, and direct cost.

RESULTS

There were 146,459 patients with acute calculus cholecystitis identified (prepandemic: 74,605 vs pandemic: 71,854). Patients in the pandemic group were more likely to undergo medical management (29.4% vs 31.8%; p < 0.001) or percutaneous cholecystostomy tube placement (21.5% vs 18%; p < 0.001) and less likely to undergo laparoscopic cholecystectomy (69.8% vs 73.0%; p < 0.001). Patients in the pandemic group who underwent procedural intervention had longer length of stay (6.5 days vs 5.9 days; p < 0.001), higher in-hospital death (3.1% vs 2.3%; p < 0.001), and higher cost ($14,609 vs $12,570; p < 0.001).

CONCLUSIONS

In this analysis of patients with acute calculus cholecystitis, there were distinct changes in the management and outcomes of patients due to the COVID-19 pandemic. Changes in the type of intervention and outcomes are likely related to delayed presentation with increases in the severity and complexity of the disease.

Synergic evacuation device helps smoke control during endoscopic thyroid surgery

BACKGROUND

Surgical plumes in small cavities, such as transoral endoscopic thyroid surgery, have never been satisfactorily resolved. We aimed to study the use of a smoke evacuation system and evaluate its efficacy, including the field of view and operating time.

STUDY DESIGN

We retrospectively reviewed 327 consecutive patients who underwent endoscopic thyroidectomy. They were separated into 2 groups based on whether the smoke evacuation system was used. To reduce the possible experience bias, only patients 4 months before and after implementing the evacuation system were included. Recorded endoscopic videos were evaluated, including the field of view, the incidence of scope clearance, and time spent during air-pocket creation.

RESULTS

Overall, there were 64 patients with a median age of 43.59 years and a median body mass index of 22.87 kg/m², including 54 women, 21 thyroid cancers, and 61 hemithyroidectomies. The operative duration was comparable between the groups. The group where the evacuation system was used scored more as good in terms of endoscopic views (8/32, 25% vs 1/32, 3.13%, P = .01), fewer incidences of endoscope lens pull out for clearance (3.5 vs 6.0 times, P < .01), less time for clear view after energy device activation (2.67 vs 5.00 seconds, P < .01), and less time spent (8.67 vs 12.38 minutes, P < .01) during air-pocket creation.

CONCLUSION

In conjunction with the synergy function of energy devices, evacuators enhance the field of view and optimize the time spent in the real clinical setting of low-pressure and small-space endoscopic thyroid procedures, in addition to the benefit of reducing smoke harm.

Temporal pattern of humoral immune response in mild cases of COVID-19

BACKGROUND

Understanding the humoral response pattern of coronavirus disease 2019 (COVID-19) is one of the essential factors to better characterize the immune memory of patients, which allows understanding the temporality of reinfection, provides answers about the efficacy and durability of protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and consequently helps in global public health and vaccination strategy. Among the patients who became infected with SARS-CoV-2, the majority who did not progress to death were those who developed the mild COVID-19, so understanding the pattern and temporality of the antibody response of these patients is certainly relevant.

AIM

To investigate the temporal pattern of humoral response of specific immunoglobulin G (IgG) in mild cases of COVID-19.

METHODS

Blood samples from 191 COVID-19 real-time reverse transcriptase-polymerase chain reaction (RT-qPCR)-positive volunteers from the municipality of Toledo/ Paraná/Brazil, underwent two distinct serological tests, enzyme-linked immunosorbent assay, and detection of anti-nucleocapsid IgG. Blood samples and clinicoepidemiological data of the volunteers were collected between November 2020 and February 2021. All assays were performed in duplicate and the manufacturers' recommendations were strictly followed. The data were statistically analyzed using multiple logistic regression; the variables were selected by applying the P < 0.05 criterion.

RESULTS

Serological tests to detect specific IgG were performed on serum samples from volunteers who were diagnosed as being positive by RT-qPCR for COVID-19 or had disease onset in the time interval from less than 1 mo to 7 mo. The time periods when the highest number of participants with detectable IgG was observed were 1, 2 and 3 mo. It was observed that 9.42% of participants no longer had detectable IgG antibodies 1 mo only after being infected with SARS-CoV-2 and 1.57% were also IgG negative at less than 1 mo. At 5 mo, 3.14% of volunteers were IgG negative, and at 6 or 7 mo, 1 volunteer (0.52%) had no detectable IgG. During the period between diagnosis by RT-qPCR/symptoms onset and the date of collection for the study, no statistical significance was observed for any association analyzed. Moreover, considering the age category between 31 and 59 years as the exposed group, the P value was 0.11 for the category 31 to 59 years and 0.32 for the category 60 years or older, showing that in both age categories there was no association between the pair of variables analyzed. Regarding chronic disease, the exposure group consisted of the participants without any comorbidity, so the P value of 0.07 for the category of those with at least one chronic disease showed no association between the two variables.

CONCLUSION

A temporal pattern of IgG response was not observed, but it is suggested that immunological memory is weak and there is no association between IgG production and age or chronic disease in mild COVID-19.

Relationships Between Job Satisfaction of Operating Room Nurses and Hospital's Compliance With Protective Guidelines During the Covid-19 Pandemic: A Cross-Sectional Study, Iran

PURPOSE

The Covid-19 pandemic is considered the biggest threat to human health in the recent century. During emergency surgeries, the possibility of infection of members of the surgical team with Covid-19 increases due to the direct contact with patients. The present study has been conducted aimed to investigate the relationships between job satisfaction of operating room nurses and the hospital's compliance with protective guidelines (guidance) during Covid-19 pandemic from the perspective of operating room nurses.

DESIGN

This was a descriptive and cross-sectional study conducted from September 22, 2020 to April 21, 2021.

METHODS

This study was conducted on 926 nurses working in operating rooms in 15 metropolises of Iran. The sampling method in this study was multistage clustering. The questionnaire was sent to the target group through social apps (WhatsApp and Telegram). The collected data were analyzed by SPSS software version 26 using descriptive and analytical statistics.

FINDINGS

The mean age and job satisfaction of the participants were 28.81 ± 5.64 years and 51.15 ± 11.45, respectively. Participants (n = 259; 27.97%) reported very good job satisfaction. Also, the mean hospital's compliance with protective guidelines during Covid-19 pandemic from the perspective of operating room nurses was 42.29 ± 7.11. The results of the present study showed a significant relationship between job satisfaction and hospital's compliance with protective guidelines during Covid-19 pandemic (P-value ≤ .001).

CONCLUSIONS

Optimization of infrastructure, improvement of management decisions and increasing human resources in a crisis can affect the quality of performance and job satisfaction of operating room nurses. The researchers suggest that health system managers can contribute to the safety and efficiency of the existing human resources by taking measures to increase job satisfaction.

Lingering SARS-CoV-2 in Gastric and Gallbladder Tissues of Patients with Previous COVID-19 Infection Undergoing Bariatric Surgery

BACKGROUND

Lingering severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in gut tissue might be a source of infection during bariatric surgery. This study aimed to confirm the presence of SARS-CoV-2 nucleocapsid in gastric and gallbladder tissues removed during bariatric surgery in individuals previously infected with coronavirus disease 2019 (COVID-19) who had negative polymerase chain reaction results prior to the surgery.

METHODS

Gastric and gallbladder specimens from 80 patients who underwent bariatric surgery between November 2021 and May 2022 and had a history of COVID-19 infection with gastrointestinal symptoms were examined for the presence of lingering SARS-CoV-2 nucleocapsid proteins using immunohistochemistry.

RESULTS

Gastric specimens from 26 (32.5%) patients and 4 (100%) cholecystectomy specimens showed positive cytoplasmic staining for the anti-SARS-CoV-2 nucleocapsid protein in surface mucosal epithelial cells. The mean age was 37.8 ± 10.3 years. The average body mass index was 44.2 ± 7.0 kg/m²; most of the patients were females (71.3%). The positive staining group was significantly younger than the negative staining group (p = 0.007). The full-dose vaccination rate was 58.8%, with a median of 91 days after the last vaccine dose. A positive serological anti-spike IgG response was observed in 99% of the patients. The median time between initial COVID-19 infection and surgery was 274 and 380 days in the positive and negative staining groups, respectively (p = 0.371).

CONCLUSION

Gastric and gallbladder tissues can retain SARS-CoV-2 particles for a long time after COVID-19 infection, handling stomach specimens from patients during an operation must be done with care, as we usually do, but now with the knowledge that in 1/3 of patients they can be present. Performing LSG on post-COVID patients did not seem to increase perioperative morbidity.

Distribution of surgical smoke particles within a simulated laparoscopic cavity utilizing an AirSeal® system

An exploratory study was performed to determine the distribution of surgical smoke particulate matter (SSPM) and evacuation times within an AirSeal® System and a traditional insufflation access system in various simulated surgical scenarios. Identified trends showed statistical significance when setting the AirSeal® System to Low smoke evacuation that it reduces the percentage of particulate matter at the Access Port opening. Additionally, it was observed that when utilising a laparoscopic tool a similar trend in particle distributions were seen between either insufflation and access system at the opening of the Access Port and trocar. Evacuation times for SSPM removal within the AirSeal® System showed an overall average to ≥95% reduction of 5.64 min within the surgical cavity, 3.69 min at the Access Port opening, and 3.61 min within the smoke evacuation line. The overall average for the traditional insufflation and access system was 9.38 min within the surgical cavity and 6.06 min at the trocar opening. Results showed that when using the traditional system compared to the AirSeal® System, it resulted in a percent change increase in evacuation times of 66.31% within the surgical cavity and 64.23% at the trocar opening.

Elective Colorectal Surgery Service Provision during SARS-CoV-2 Pandemic

The SARS-Cov-2 pandemic and its immediate public health impact has caused severe disruption of regular medical care provision. The morbimortality of other diseases continues to affect people regardless of the viral infection. Indeed, it would be reasonable to assume that they have been aggravated by the period of most restrictive public health measures that were adopted against the virus. Recovery and maintenance of healthcare provision is required despite the ongoing threat. Therefore, it is critical to resume services in a structured and safe way, otherwise greater harm could come to our patients and to ourselves. The present article proposes to be a broad guide to the recovery and maintenance of elective outpatient, surgical and lower endoscopic services, aiding the colorectal surgeon in identifying risks, assessing their multiple dimensions, and implementing risk management strategies in a pragmatic and efficacious way.

Impact of COVID-19 on the Mode of Presentation and Stage at Diagnosis of Colorectal Cancer

AIM

This study compares the stage at the presentation of patients with colorectal cancer (CRC) before and after introducing COVID-19 restrictions and the mode of presentation.

METHODS

This is a retrospective cohort study comparing the incidence of CRC, TNM stage and mode of presentation in the pre-COVID and COVID cohorts at a single UK Trust. All patients discussed at the CRC multidisciplinary team (MDT) from March 2017 to March 2021 were included and split into two cohorts; the pre-COVID group from 01/03/2017 to 29/02/2020 and the COVID group from 01/03/2020 to 28/02/2021. Percentages were used for descriptive statistics. Student's t-test was used for the comparison of demographic variables. Chi-squared test was used for the difference analysis for the categorical data, such as TNM and mode of presentation. P value ≤0.05 was significant.

RESULTS

In total, 1373 patients were diagnosed with CRC during the period from March 2017 to March 2021. The pre-COVID group (2017-2020) included 1104 CRC patients, compared to 269 patients in the COVID one (2020-2021). The mean age was higher in the pre-COVID group (p = 0.001). There was a statistically significant increase in the proportion of cases presenting with T4 disease (p = 0.023) and metastatic disease (p = 0.032) in the COVID group compared to the pre-COVID group. There was also a significant increase in the rate of emergency presentations (p < 0.0001).

CONCLUSION

We observed a statistically significant increase in rates of locally advanced (T4) and metastatic (distant) CRC in patients presenting after introducing the COVID-19 lockdown. There was also an increase in emergency presentations. There was no observed difference in nodal status. This may reflect disruption to cancer diagnostic services and the reluctance of patients to access medical care during a pandemic, particularly the elderly.

Impact of COVID-19 on Society of Urologic Oncology fellowship operative volumes

PURPOSE

The COVID-19 pandemic impacted all aspects of healthcare including surgical training. Our objective was to assess the impact of the pandemic on surgical case volumes of graduating Society of Urologic Oncology (SUO) fellows during the academic years 2019 to 2020 and 2020 to 2021.

MATERIALS AND METHODS

Deidentified case logs for graduating SUO fellows from 2017 to 2021 were obtained from the SUO Education Committee. Cases are stratified by category and minimally invasive surgery (MIS) or open approach. Graduates of 2017, 2018, and 2019 were combined into a pre-COVID cohort and compared to COVID-affected 2020 and 2021 cohorts. Total case volumes, case category volumes, and surgical approach type were compared with Kruskal-Wallis test.

RESULTS

A total of 173 graduating SUO fellow case logs were analyzed with 100, 38, and 35 in the pre-COVID and COVID-affected 2020 and 2021 cohorts, respectively. All fellow logs were obtained for 2017 to 2020 graduates while 5 of 40 were missing for the 2021 cohort. There was no statistical difference in median total cases across cohorts (P = 0.52). For the first COVID-affected cohort of 2020, they reported significantly fewer total MIS cases in 2020 compared to pre-COVID fellows (median 92.5 vs. 135 pre-COVID, P = 0.002). However, there were no significant differences among the tracked oncologic MIS categories except a statistically significant increase in MIS retroperitoneal lymph node dissection between 2020 and 2021 COVID-affected cohorts (0 vs. 2, P = 0.033) CONCLUSIONS: The oncologic case volumes of the initial SUO fellows graduating during COVID pandemic were minimally affected. This national deidentified data is reassuring that oncologic training has not been impacted by widespread decreases in case volume. However, impacts on individuals, programs or geographic regions may have varied.

Laparoscopic appendectomy for acute appendicitis in patients with COVID-19 confirmation: A case report

Introduction

Strategies to postpone elective surgeries were proposed to maintain the hospital capacity to cater for coronavirus disease 2019 (COVID-19) and emergency non-COVID cases. Non-operative management (NOM) was recommended when possible during the COVID-19 era. However, the optimal approach to acute appendicitis (AA) in patients with COVID-19 remains controversial.

Presentation of case

A 25-year-old man who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) was referred to our institution with a diagnosis of AA with appendicolith. Chest computed tomography did not detect evidence of pneumonia. Laparoscopic appendectomy was performed after strict infection prevention measures were taken. The postoperative course was uneventful. No respiratory symptoms such as cough or sputum production occurred postoperatively. No signs of infection in medical staff or spread in the operating room and infectious disease ward were observed.

Discussion

The treatment policy should fully consider the risk of COVID-19 infection to medical staff and the risk of aggravation in patients who tested positive for SARS-Cov-2. Surgery was chosen over NOM for AA with appendicolith because the presence of appendicolith was thought to indicate a high probability of treatment failure in NOM and possible perforation; thus, case more difficult measures were required for SARS-Cov-2-positive cases.

Conclusion

Careful assessment of the patient's condition and consideration of the treatment method is important, rather than choosing NOM over operative management based solely on SARS-Cov-2-positive status. Laparoscopic appendectomy with adequate infection control measures can be safely performed in SARS-Cov-2-positive cases.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery

The effect of the AirSeal^® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO₂), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal^®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO₂, peripheral capillary oxygen saturation (SpO₂), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO₂ was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined “positive respiratory and circulatory responses” (positive responses) as a decrease in EtCO₂ ≥ 3 mmHg in addition to decreases in SpO₂ ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO₂) embolism. The median EtCO₂ values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO₂ of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO₂ of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO₂ embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO₂ of hepatectomy was comparable to that of the other surgeries using the AirSeal^®, laparoscopic hepatectomy showed a tendency of CO₂ embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal^® insufflation system.

Measurement and Control of Surgical Smoke to Enhance Surgical Team Safety

Amid the coronavirus disease 2019 era, concern about the safety of surgical teams related to surgical smoke (SS) is rising. As simple ventilation improvement methods (SVIMs), we replaced 4 of the 8 supply diffusers with a direction-adjustable louver-type, closed 2 of the 4 exhaust grills, and strengthened the sealing of the doorway. Dynamic changes in the concentration of particulate matter (PM) with sizes of < 1.0 μm (PM1.0) were measured using low-cost PM meters (LCPMs) at eight locations in the operating room (OR). SS concentration up to 4 minutes at the location of the surgeon, first assistant, and scrub nurse before and after SVIMs application decreased from 65.4, 38.2, 35.7 µg/m³ to 9.5, 0.1 and 0.7 µg/m³ respectively. A similar decrease was observed in the other 5 locations. SVIMs could effectively control SS and the LCPM was also effective in measuring SS in the OR or other spaces of the hospital.

Changes in the Emergency General Surgery Operations in the Setting of COVID-19 and Impact of Strategy of Non-Operative Management on Outcomes in Acute Appendicitis

Background: Coronavirus disease 2019 (COVID-19) has posed significant challenges to the provision of elective and emergency general surgical care. Patterns of presentation have changed and management pathways have also been adapted, moving to more non-operative management (NOM) for some conditions. We investigated how COVID-19 changed the volume of emergency general surgery operating in our district general hospital (DGH). We aimed to evaluate the impact of NOM on outcomes in acute appendicitis.

Methods: A retrospective case review of operating lists, patient handover lists, and patient notes was undertaken for patients presented between 1^st January 2020 and 3^rd June 2020. The study period was divided into two, with the period between 1^st January 2020 and 23^rd March 2020 representing the pre-COVID cohort.

Results: Some 393 emergency general surgery operations were performed in the study period. There was a clear reduction in operating volume after 23^rd March 2020. During that same period, 325 patients were assessed with right iliac fossa (RIF) pain. Median age was 21 (range 5-87) and 201 patients were female (61.8%). The rate of NOM for suspected acute appendicitis was 8.8% in the pre-COVID group, which increased to 36.4% in the COVID group. The incidence of normal histology following appendicectomy did not change with this difference in management (16.1% compared to 17.9%, p = 0.78).

Conclusions: This study summarizes the changes brought to the provision of emergency general surgery in the setting of a DGH by the COVID-19 pandemic. In particular, NOM was the preferred option for acute appendicitis but this did not alter the negative appendicectomy rate.

Impact of Covid-19 pandemic on upper gastrointestinal cancer services: Experience from an oncosurgical unit

Background The Covid-19 pandemic continues to affect the delivery of cancer care across the world. We evaluated the impact of the pandemic on the delivery of cancer care, to patients diagnosed with upper gastrointestinal (UGI) tract malignancies, during the first 4 months of the pandemic in India. Methods We retrospectively analysed a database of patients with UGI malignancies discussed in the Multidisciplinary Tumour Board (MDTB) between 24 March and 24 July 2020. The results in the study group were compared to that of a similar group of patients from the corresponding period in 2019. Results A total of 117 and 61 patients were discussed in the MDTB in 2019 and 2020, respectively, thereby showing a 48% reduction in the number of new cases seen in 2020. The reduction in the number of new cases was huge for oesophageal cancer (53-13; 75.5% reduction), compared to gastric cancer (53-43; 18.9%). The proportion of patients with metastatic disease at presentation was significantly higher in 2020, compared to 2019 (39.3% v. 23.1%; p=0.023). In 8 (13.1%) patients, the pre-existing treatment protocol had to be modified to suit the prevailing pandemic situation. Two patients with gastric cancer acquired asymptomatic Covid-19 infection during the treatment, which delayed the delivery of further therapy. Oncosurgeries were less in 2020 compared to 2019 (25 v. 63). The rate of 30-day major postoperative complications in 2020 was comparable with that in 2019 (12% v. 6.3%; p=0.4). Conclusions The number of new patients with UGI cancer, seeking elective cancer care and the number of oncosurgical procedures reduced during the Covid-19 pandemic. Continuous delivery of UGI cancer services was ensured during the pandemic through clinical prioritization, the adaptation of specific care pathways and selective modification of protocols, to suit the prevailing local conditions.

Attitude, preventive practice and perceived barriers among perioperative and anesthesia nurses toward surgical smoke hazards during the COVID-19 outbreak

Background

Surgical smoke (SS), which is produced by the use of high-temperature devices for cutting and coagulation of tissue during surgical procedures, is considered a serious threat to the health of operating room (OR) staff due to the presence of hazardous substances and possibility of transmitting various infections such as HPV, HIV, COVID-19 and so on. This study was conducted to determine the Attitude, preventive practice and perceived barriers among perioperative and anesthesia nurses toward surgical smoke hazards.

Methods

In this cross-sectional descriptive study, conducted at hospitals of Tabriz University of Medical Sciences (Iran) in 2021, 262 perioperative and anesthesia nurses were included by stratified random sampling. Data were collected using a demographic questionnaire and an SS questionnaire consisting of questions on attitude (17 item), practice (8 item), and barriers (13 item). Collected data were analyzed using SPSS16.

Results

The mean attitude and preventive practice scores (49.52 ± 12.36 and 15.8 ± 2.05, respectively) of the operating room nurses were reported at moderate and weak levels, respectively. There was a direct and significant relationship between attitude and practice scores (r = 0.129, P = 0.019). The main barriers to the prevention and dealing with the hazards of SS in ORs were reported in management (3.68 ± 1.06) and equipment (3.24 ± 0.66) dimensions, respectively.

Conclusion

It is recommended to adopt strategies to improve the attitude of OR staff regarding the preventive measures against surgical smoke hazards. Moreover, appropriate equipment and support of managers should be provided by explaining the policies and guidelines to prevent the complications of surgical smoke.

Investigating surgical smoke in otolaryngology operating rooms

Surgical smoke is a common chemical hazard produced from the use of electrocautery, laser, or ultrasonic scalpels during surgery. It has been proved harmful to medical personnel. Thus, it is important to monitor surgical smoke concentrations in the operating room. In the past decade, many researches regarding surgical smoke were discussed in different professional healthcare fields, but few showed the correlation between surgical smoke and otolaryngology surgery. In this study, the concentrations of particulate matter and formaldehyde were measured during thirty cases of several types of otolaryngology surgery in a regional research hospital in Taiwan. The concentrations of 0.3 µm and 0.5 µm particulate matter raised rapidly in the main knife range at the beginning of the electrocautery knife used, and then decreased by half after 5-10 min of use. The concentrations of formaldehyde were ranged from 1 to 2 ppm during the surgery, which is higher than the permissible exposure limit. While many medical staffs are working in the operating room and are exposed to the smoke hazard, effective strategies for collecting and eliminating the smoke should be taken in all medical facilities.

COVID-19 pandemic changed the management and outcomes of acute appendicitis in northern Beijing: A single-center study

BACKGROUND

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, outcomes and management of many diseases have been affected. Acute appendicitis is a common acute abdomen. The incidence rate is 0.05%-0.5%. Studies reported that the number of patients with appendicitis admitted to emergency department significantly decreased since the pandemic. People avoided going to the hospital for fear of being infected. Different countries have different epidemic prevention measures that result in different treatment outcomes. The Chinese government also published some temporary measures in order to prevent the outbreak.

AIM

To explore the changes in management and outcomes of acute appendicitis during the COVID-19 pandemic in the North of Beijing.

METHODS

Patients with acute appendicitis admitted to Beijing Tsinghua Changgung Hospital between February and June 2019 and February and June 2020 were retrospectively reviewed. Cases were grouped according to admission year. The demographic characteristics, present illnesses, medical history, symptoms and signs, comorbidities, blood test results, imaging data, appendix pathology, and treatment details were compared.

RESULTS

Overall, 74 patients received nonsurgical treatment and 113 patients underwent surgical treatment in group 2019, whereas 159 patients received nonsurgical treatment and 26 patients received surgical treatment in group 2020. Fever, thick appendix, nonsurgical management, and uncomplicated appendicitis (simple or supportive appendicitis) were more common in group 2020 (P < 0.05). Among the nonsurgical management cases, the neutrophil percentage, neutrophil-to-lymphocyte ratio, and recurrence rate were higher in group 2020 (P < 0.05). Among surgically managed cases, there were more cases with gastrointestinal symptoms, peritonitis, ascites in the image, and intraoperative adhesion or ascites in group 2020 (P < 0.05). The white blood cell count, time from diagnosis to surgery, surgical time, and intraoperative blood loss were higher in group 2020 (P < 0.05).

CONCLUSION

During the COVID-19 pandemic, patients suffering from acute appendicitis in Beijing tended to present with severe symptoms and opt for nonsurgical treatment. For patients who underwent surgical management, the operation was delayed and more difficult during the pandemic. Nevertheless, the hospital stay and the incidence of postsurgical complications did not change.

Characterisation of trocar associated gas leaks during laparoscopic surgery

BACKGROUND

During laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO₂) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures.

METHODS

A model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery.

RESULTS

Twenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage.

CONCLUSIONS

We propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO₂ leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

General surgery practice under the COVID-19 pandemic: The experience of a pandemic hospital in Istanbul

BACKGROUND

Although elective operations in general surgery clinics were postponed during the pandemic, non-deferrable operations such as emergency trauma, acute abdominal, and cancer surgeries continued. We aimed to present emergency and non-deferrable elective surgery cases in our hospital's general surgery clinic during the pandemic, to identify the general surgery patients that pose the greatest risk for healthcare workers who served these patients, and to share our experience in these situations.

METHODS

The study was designed as a retrospective cohort study. The study included patients admitted for emergency and non-deferrable elective surgeries in Kartal Dr. Lutfi Kirdar City Hospital in Istanbul between March 10, 2020, and May 23, 2020. The patients were tested before the operation for severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) infection. They were also routinely checked for fever and coronavirus disease 2019 (COVID-19) symptoms during dressing changes and outpatient follow-up visits after discharge as well as through the national health monitoring system (e-nabız) whether the patients were diagnosed with COVID-19 within the 15 days of discharge. Patients who tested positive in the reverse transcription-polymerase chain reaction (RT-PCR) tests in the first 15 days after discharge or had infiltration in thorax tomography were considered suspicious in terms of hospital transmission.

RESULTS

During the COVID-19 pandemic period between March 10, 2020, and May 23, 2020, a total of 195 patients were operated on. Of these, 96 (49.2%) were operated due to emergencies, and 99 (50.8%) were non-deferrable elective surgeries. At the time of admission, 13 patients were diagnosed with COVID-19 through RT-PCR and thorax tomography findings. A higher proportion of the patients with COVID-19 (n=12, 92.3%) were found to be operated for emergencies. Three patients with COVID-19 died on the 1st postoperative day. Mortality was significantly higher in this group than in those who tested negative (n=3, 23.1% vs. n=8, 4.4%). During the study, none of the healthcare workers in our clinic developed COVID-19 symptoms. Three patients who had elective surgery were found to be SARS-CoV-2 (+) in the follow-up period after discharge.

CONCLUSION

Maintaining functional surgery departments under challenging times, such as a pandemic, will continue to be an important aspect of health systems. We believe that the results of this study will help reduce in-hospital transmission, help prevent disease transmission to healthcare personnel, and allow the members of the surgical teams to know in which patient group they will be at higher risk of infection during the operation.

Coronavirus viability in surgical plume and methods for safe disposal: a preclinical model

Smoke generated by cautery devices used during surgery may contain infective particles and may cause transmission of airborne viruses. This study determines whether live viruses are present in surgical smoke and evaluates the effectiveness of several proposed methods of removal so as to improve safety of healthcare workers.

Detection of human coronavirus RNA in surgical smoke generated by surgical devices

BACKGROUND

Gaseous by-products generated by surgical devices - collectively referred to as 'surgical smoke' - present the hazard of transmitting infective viruses from patients to surgical teams. However, insufficient evidence exists to evaluate and mitigate the risks of SARS-CoV-2 transmission via surgical smoke.

AIM

To demonstrate the existence and infectivity of human coronavirus RNA in surgical smoke using a model experiment and to evaluate the possibility of lowering transmission risk by filtration through a surgical mask.

METHODS

Pelleted HeLa-ACE2-TMPRSS2 cells infected with human coronavirus were incised by electric scalpel and ultrasonic scalpel, separately. A vacuum system was used to obtain surgical smoke in the form of hydrosol. Reverse transcription-quantitative polymerase chain reaction was used to analyse samples for the presence of viral RNA, and infectivity was determined through plaque assay. Furthermore, a surgical mask was placed centrally in the vacuum line to evaluate its ability to filter viral RNA present in the surgical smoke.

FINDINGS

In this model, 1/10⁶ to 1/10⁵ of the viral RNA contained in the incision target was detected in the collected surgical smoke. The virus present in the smoke was unable to induce plaque formation in cultured cells. In addition, filtration of surgical smoke through a surgical mask effectively reduced the amount of viral RNA by at least 99.80%.

CONCLUSION

This study demonstrated that surgical smoke may carry human coronavirus, though viral infectivity was considerably reduced. In clinical settings, surgical mask filtration should provide sufficient additional protection against potential coronavirus, including SARS-CoV-2, infection facilitated by surgical smoke.

Impact of the first surge of the coronavirus disease pandemic on general thoracic surgery practices in Kanagawa: a questionnaire survey by the Kanagawa General Thoracic Surgical Study Group

Objectives

The first surge in severe acute respiratory syndrome coronavirus 2 infection had a significant impact on health care institutions. Understanding how the pandemic affected general thoracic surgery would provide valuable data for establishing a health care protocol for upcoming surges.

Methods

A questionnaire survey on coronavirus disease-related patient statistics and health care was conducted between February 2020 and June 2020 across 14 facilities affiliated with the Kanagawa General Thoracic Surgery Study Group.

Results

The average number of newly referred patients from February to June 2020 was 65% of that during the same period in 2019. Six facilities placed restrictions on medical care services, among which four restricted surgeries. At all institutions and those placed on surgical restriction, the total number of surgeries under general anesthesia was 92% and 78%, the total number of primary lung cancers was 94% and 86%, and the total number of surgeries for pneumothorax was 71% and 77% of that in the preceding year, respectively. Infection control and insufficient resources of the medical material were the most influential factors impacting the medical institutions’ decision to restrict the services provided.

Conclusions

Restrictions on surgery had a significant impact on the care provided by general thoracic surgery departments. To avoid patient inconvenience, establishing a collaborative system that refers patients to operational medical institutions in case of medical treatment restrictions may be useful.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11748-021-01724-z.

BJS commission on surgery and perioperative care post-COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence.

METHODS

In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them.

RESULTS

BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training.

CONCLUSION

The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.

SARS-CoV-2 Prevalence in Laparoscopic Surgery Filters. Analysis in Patients with Negative Oropharyngeal RT-qPCR in a Pandemic Context: A Cross-Sectional Study

Objective: Surgical societies of different specialties have lately demonstrated a growing concern regarding the potential risk of SARS-CoV-2 transmission during surgery, mainly via aerosols carrying SARS-CoV-2 particles during laparoscopy smoke evacuation. Since there is not sufficient scientific evidence to rule out this hypothesis, our study aimed to evaluate the prevalence of the appearance of SARS-CoV-2 genetic material in the in-filter membrane of the smoke filter systems, used in laparoscopic surgery, in a tertiary referral hospital during the peak phases of the pandemic. Methods: During the highest incidence of the pandemic outbreak, 180 laparoscopic smoke evacuation systems were collected from laparoscopies performed between April 2020 and May 2021 in University General Hospital of Castellón. As part of the safety protocol established as a result of the pandemic, an oropharyngeal reverse-transcription polymerase chain reaction (RT-PCR) was performed before surgery. We performed RT-qPCR tests for the detection and quantification of SARS-CoV-2 genetic material in the in-filter membranes extracted from the smoke evacuation systems. Results: We found two RT-qPCR positive in-filters from a sample of 128 patients with SARS-CoV-2-negative results in their oropharyngeal RT-qPCR, i.e., 1.6% (95% CI: 0.5–5.5%). From this estimation, the predictive posterior probabilities of finding n cases of negative oropharyngeal COVID-19 patients with positive filters increases with the increasing number of surgeries performed. Conclusions: This cross-sectional study provides evidence suggesting that airborne transmission of SARS-CoV-2 particles from smoke evacuation of aerosols carrying viral particles during laparoscopy should not be ruled out.

Rapid redesign and effect on clinical workload of a supra-regional burns and plastic surgery service during the COVID-19 pandemic

Introduction

In March 2020, South Wales experienced the most significant COVID-19 outbreak in the UK outside of London. We share our experience of the rapid redesign and subsequent change in activity in one of the busiest supra-regional burns and plastic surgery services in the UK.

Methods

A time-matched retrospective service evaluation was completed for a 7-week “COVID-19” study period and the equivalent weeks in 2018 and 2019. The primary aim of this study was to evaluate plastic surgery theatre use and the impact of service redesign. Comparison between study periods was tested for statistical significance using two-tailed t-tests.

Results

Operation numbers reduced by 64% and total operating time by 70%. General anaesthetic cases reduced from 41% to 7% (p<0.0001), and surgery was mainly carried out in ringfenced daycase theatres. Emergency surgery decreased by 84% and elective surgery by 46%. Cancer surgery as a proportion of total elective operating increased from 51% to 96% (p<0.0001). The absolute number of cancer-related surgeries undertaken was maintained despite the pandemic.

Conclusion

Rapid development of COVID-19 SOPs minimised inpatient admissions. There was a significant decrease in operating while maintaining emergency and cancer surgery. Our ringfenced local anaesthetic Plastic Surgery Treatment Centre was essential in delivering a service. COVID-19 acted as a catalyst for service innovations and the uptake of activities such as telemedicine, virtual MDTs, and online webinars. Our experiences support the need for a core burns and plastic service during a pandemic, and show that the service can be effectively redesigned at speed.

Surgical Infection Society Guidance for Restoration of Surgical Services during the Coronavirus Disease-2019 Pandemic

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. The need to accommodate growing numbers of hospitalized patients has led facilities in affected areas to suspend anew or curtail normal hospital activities, including elective surgery, even as earlier-affected areas normalized surgical services. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit. Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion. Results: The "second-wave" of serious infections is placing the healthcare system under renewed stress. Surgical teams likely will encounter persons harboring the virus, whether symptomatic or not. Continued vigilance and protection of patients and staff remain paramount. Reviewed are the impact of COVID-19 on the surgical workforce, considerations for operating on a COVID-19 patient and the outcomes of such operations, the size and nature of the surgical backlog, and the logistics of resumption, including organizational considerations, patient and staff safety, preparation of the surgical candidate, and the role of enhanced recovery programs to reduce morbidity, length of stay, and cost by rational, equitable resource utilization. Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Aerosols, airflow, and airspace contamination during laparoscopy

Laparoscopic surgery has been undermined throughout the COVID-19 pandemic by concerns that it may generate an infectious risk to the operating team through aerosolization of peritoneal particles. There is anyway a need for increased awareness and understanding of the occupational hazard for surgical teams regarding unfiltered escape of pollutants generated by surgical smoke and other microbials. Here, the aerosol-generating nature of this access modality was confirmed through repeatable real-time methodology both qualitatively and quantitively to inform best practice and additional engineering solutions to optimize the operating room environment.

Providing safe perioperative care in cardiac surgery during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients - and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients' exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.

Observance of preventive standards against COVID-19 transmission in operating rooms: A cross-sectional study

Background

Due to the highly contagious innate of the novel coronavirus, the surgical team is exposed to the disease during surgical care of patient with confirmed covid-19. Therefore, the necessary measures should be taken to protect surgical caregivers. This study was conducted to determine the status of compliance with the preventive standards against covid-19 transmission in the operating room.

Methods

This cross-sectional descriptive study was conducted on 183 surgical team members working in hospitals affiliated to Tabriz university of medical sciences in 2020. Participants were selected by stratified random sampling. The required data were collected by a researcher-made questionnaire according to the standard protocols of SAGES, EAES and AORN. In the first part of this questionnaire, the level of compliance with the standards of using personal protective equipment (PPE) was evaluated and in the second part, the level of compliance with the preventive strategies in the operating room was evaluated in three phases of Pre, Intra and Post-operative. The data was analyzed using SPSS16.

Results

preventive standards observance against COVID-19 was in moderate (55.3 ± 10.5) level and The level of compliance with the standards of using PPE by the surgical team was favorable (61.8 ± 8.1). There was a statistically significant relationship between the level of compliance with the standards of using PPE and the type of specialty (P = 0.004).

Conclusion

According to the results, the level of compliance with the principles of standards in applying protective measures against covid-19 was not favorable, so the operating room personnel is exposed to COVID-19 and the necessary measures and improvements should be considered in compliance with standards in operating room.

Has the time to reinstate elective orthopedic procedures come?

BACKGROUND

The coronavirus pandemic changed how we manage and operate patients in orthopaedic practice. Although elective orthopaedic procedures were halted to prevent spread of the disease as well as sustain supplies of essential protective equipment and healthcare workers, trauma services were continued. We studied the orthopaedic trauma cases operated over 6 months of the pandemic, and discuss the protocols used to minimize disease spread.

METHODS

Data was collected for all orthopaedic emergency cases operated at our centre from 1 st March - 10 th August 2020. During this time specific protocols were used for first aid, pre-operative care, inside the operation theatre, post-operative stay as well as for follow ups.

RESULTS

A total of 851 patients were operated. A sharp decline in surgeries was seen during the lockdown. Average stay in the hospital was 4 days. Only 44% of the patients came for follow-up visits. None of the contacted patients or their relatives developed symptoms or tested positive for COVID after discharge.

CONCLUSION

Multiple waves and various mutant strains of COVID-19 have made this pandemic longer than expected. Elective orthopaedic cases cannot be ignored for forever, as it leads to poor quality of life and an increasing burden of such patients. We suggest, that using the protocols used at our centre, we have successfully operated on cases without risking spread of the virus. Thus, we believe it's time to reinstate elective orthopaedic procedures, in a phased manner.

Evidence, not eminence, for surgical management during COVID-19: a multifaceted systematic review and a model for rapid clinical change

BACKGROUND

Coronavirus (COVID-19) forced surgical evolution worldwide. The extent to which national evidence-based recommendations, produced by the current authors early in 2020, remain valid, is unclear. To inform global surgical management and a model for rapid clinical change, this study aimed to characterize surgical evolution following COVID-19 through a multifaceted systematic review.

METHODS

Rapid reviews were conducted targeting intraoperative safety, personal protective equipment and triage, alongside a conventional systematic review identifying evidence-based guidance for surgical management. Targeted searches of PubMed and Embase from 31 December 2019 were repeated weekly until 7 August 2020, and systematic searches repeated monthly until 30 June 2020. Literature was stratified using Evans' hierarchy of evidence. Narrative data were analysed for consistency with earlier recommendations. The systematic review rated quality using the AGREE II and AMSTAR tools, was registered with PROSPERO, CRD42020205845. Meta-analysis was not conducted.

RESULTS

From 174 targeted searches and six systematic searches, 1256 studies were identified for the rapid reviews and 21 for the conventional systematic review. Of studies within the rapid reviews, 903 (71.9 per cent) had lower-quality design, with 402 (32.0 per cent) being opinion-based. Quality of studies in the systematic review ranged from low to moderate. Consistency with recommendations made previously by the present authors was observed despite 1017 relevant subsequent publications.

CONCLUSION

The evidence-based recommendations produced early in 2020 remained valid despite many subsequent publications. Weaker studies predominated and few guidelines were evidence-based. Extracted clinical solutions were globally implementable. An evidence-based model for rapid clinical change is provided that may benefit surgical management during this pandemic and future times of urgency.

COVID-19 and the emergency presentation of colorectal cancer

AIM

The COVID-19 pandemic led to widespread disruption of colorectal cancer services during 2020. Established cancer referral pathways were modified in response to reduced diagnostic availability. The aim of this paper is to assess the impact of COVID-19 on colorectal cancer referral, presentation and stage.

METHODS

This was a single centre, retrospective cohort study performed at a tertiary referral centre. Patients diagnosed and managed with colorectal adenocarcinoma between January and December 2020 were compared with patients from 2018 and 2019 in terms of demographics, mode of presentation and pathological cancer staging.

RESULTS

In all, 272 patients were diagnosed with colorectal adenocarcinoma during 2020 compared with 282 in 2019 and 257 in 2018. Patients in all years were comparable for age, gender and tumour location (P > 0.05). There was a significant decrease in urgent suspected cancer referrals, diagnostic colonoscopy and radiological imaging performed between March and June 2020 compared with previous years. More patients presented as emergencies (P = 0.03) with increased rates of large bowel obstruction in 2020 compared with 2018-2019 (P = 0.01). The distribution of TNM grade was similar across the 3 years but more T4 cancers were diagnosed in 2020 versus 2018-2019 (P = 0.03).

CONCLUSION

This study demonstrates that a relatively short-term impact on the colorectal cancer referral pathway can have significant consequences on patient presentation leading to higher risk emergency presentation and surgery at a more advanced stage. It is therefore critical that efforts are made to make this pathway more robust to minimize the impact of other future adverse events and to consolidate the benefits of earlier diagnosis and treatment.

Special surgical approaches during peri-COVID-19 pandemic: Robotic and transanal minimally invasive surgery

During the peri-coronavirus disease 2019 pandemic, the need of special care has raised, not only for our patients but also for health care workers. These needs are different regarding the procedure and the approach performed. This is a dynamic review in the use of robotics and transanal approaches for colorectal diseases. We searched PubMed and KSREvidence.com for studies related to coronavirus disease and robotic surgery/transanal mesorectal excision/transanal surgery (primary and systematic reviews). From 147 results in PubMed, 11 were selected for full text screening, and 11 were included in this paper. From 3 results in KSREvidence, no relevant systematic reviews were identified. We also checked the references in identified papers for further relevant studies. European Society of Coloproctology guidelines were including as part of the recommendations available. Robotic and transanal MIS can be performed safely during the pandemic, but particular characteristics of these procedure need to be taken into consideration.

An economical and available solution for surgical smoke in video-assisted thoracic surgery

During video-assisted thoracic surgery, surgical smoke can interfere with surgeons' vision and attention. In addition, the harmful substances in the surgical smoke also threaten the health of surgical staff. In practice, we designed an economical and available solution for the smoke in video-assisted thoracic surgery and got satisfactory results. This paper introduces the principle and procedure of this solution.

Knowledge about the effects of electrosurgery smoke among operating room nurses during COVID-19 Pandemic: A Cross-Sectional Study

Background

Electrosurgery smoke is the smoke emitted from tissue cauterization when using the electrosurgery device. Accordingly, in this smoke, more than 80 harmful toxins have been discovered. In the current study, we aimed to investigate the level of knowledge reported by the operating room nurses on the effects of electrosurgery smoke during the current COVID-19 pandemic.

Methods

This descriptive, survey-based cross-sectional study was performed on 533 OR nurses in all the referring hospitals of COVID-19 infection. The required information were collected using a questionnaire regarding the knowledge on the side effects of electrosurgery smoke. The obtained data were then analyzed using t-test and ANOVA by SPSS software.

Results

Most of the included participants (93.6%) had a low level of awareness and only a small number of them (0.4%) had a good level of knowledge on the effects of electrosurgery smoke. As well, a significant relationship (P˂0.05) was found between the level of knowledge reported by the OR nurses and the type of hospital (educational or private). Most of the studied hospitals used no electrosurgery smoke reduction equipment during electrosurgery.

Conclusion

The level of knowledge reported by the OR nurses was generally poor. It is recommended that managers and health officials try to increase the level of awareness of OR nurses during the COVID-19 pandemic by providing standard and protective equipment as well as holding some well-organized and related training courses.

The defects of lace-up surgical masks and related solutions in operating rooms

BACKGROUND

It is difficult to make a lace-up surgical mask fit tightly to the face with conventional wearing methods because of the strings' poor tension, resulting in some air flowing through the gap. We introduced two feasible new wearing methods and obtained satisfactory experimental results.

METHODS

The wearing of surgical masks by staff was investigated through observation and interview in operation rooms. The required time to don, close-fitting rates, and satisfaction of the conventional method and the two new recommended methods were counted and compared, according to the subjects' experience. The differences between the three wearing methods on the microbial contamination of the sterile area were explored in a mock operation.

RESULTS

In the subjects' experience, the close-fitting rates were 47.0%, 92.0% and 100.0% in the conventional, Three Knots, and Elastic Band groups, respectively (P<0.001); the satisfaction scores evaluated by numerical rating scale from 0 to 10 were 5.06 ± 2.22, 6.89 ± 1.86 and 7.10 ± 1.72, respectively (P<0.001); the required times were 14.32 ± 2.20, 25.76 ± 5.13 and 27.37 ± 5.11 s, respectively (P<0.001). In the mock operation, there were significant differences between the conventional and Three Knots groups (37.5 (13) vs 18 (8) cfu, P<0.001), as well as between the conventional and Elastic Band groups (37.5 (13) vs 17(10) cfu, P<0.001).

CONCLUSIONS

The recommended new wearing methods had the advantages of closer fit, higher satisfaction rates, were more comfortable, and resulted in lower contamination of the sterile area; however, the recommended two methods required more time.