A critical review of the safety of minimally invasive surgery in the era of COVID-19

The pan - COVID - AGICT study. The impact of COVID-19 pandemic on surgically treated pancreatic cancer patients. A multicentric Italian study

BACKGROUND

In this article we aimed to perform a subgroup analysis using data from the COVID-AGICT study, to investigate the perioperative outcomes of patients undergoing surgery for pancreatic cancers (PC) during the COVID-19 pandemic.

METHODS

The primary endpoint of the study was to find out any difference in the tumoral stage of surgically treated PC patients between 2019 and 2020. Surgical and oncological outcomes of the entire cohort of patients were also appraised dividing the entire peri-pandemic period into six three-month timeframes to balance out the comparison between 2019 and 2020.

RESULTS

Overall, a total of 1815 patients were surgically treated during 2019 and 2020 in 14 Italian surgical Units. In 2020, the rate of patients treated with an advanced pathological stage was not different compared to 2019 (p = 0.846). During the pandemic, neoadjuvant chemotherapy (NCT) has dropped significantly (6.2% vs 21.4%, p < 0.001) and, for patients who didn't undergo NCT, the latency between diagnosis and surgery was shortened (49.58 ± 37 days vs 77.40 ± 83 days, p < 0.001). During 2020 there was a significant increase in minimally invasive procedures (p < 0.001). The rate of postoperative complication was the same in the two years but during 2020 there was an increase of the medical ones (19% vs 16.1%, p = 0.001).

CONCLUSIONS

The post-pandemic dramatic modifications in healthcare provision, in Italy, did not significantly impair the clinical history of PC patients receiving surgical resection. The present study is one of the largest reports available on the argument and may provide the basis for long-term analyses.

Robotic Abdominal Surgery and COVID-19: A Systematic Review of Published Literature and Peer-Reviewed Guidelines during the SARS-CoV-2 Pandemic

Background: Significant concern emerged at the beginning of the SARS-CoV-2 pandemic regarding the safety and practicality of robotic-assisted surgery (RAS). We aimed to review reported surgical practice and peer-reviewed published review recommendations and guidelines relating to RAS during the pandemic. Methods: A systematic review was performed in keeping with PRISMA guidelines. This study was registered on Open Science Framework. Databases were searched using the following search terms: ‘robotic surgery’, ‘robotics’, ‘COVID-19’, and ‘SARS-CoV-2’. Firstly, articles describing any outcome from or reference to robotic surgery during the COVID-19/SARS-CoV-2 pandemic were considered for inclusion. Guidelines or review articles that outlined recommendations were included if published in a peer-reviewed journal and incorporating direct reference to RAS practice during the pandemic. The ROBINS-I (Risk of Bias in Non-Randomised Studies of Intervention) tool was used to assess the quality of surgical practice articles and guidelines and recommendation publications were assessed using the AGREE-II reporting tool. Publication trends, median time from submission to acceptance were reported along with clinical outcomes and practice recommendations. Results: Twenty-nine articles were included: 15 reporting RAS practice and 14 comprising peer-reviewed guidelines or review recommendations related to RAS during the pandemic, with multiple specialities (i.e., urology, colorectal, digestive surgery, and general minimally invasive surgery) covered. Included articles were published April 2020—December 2021, and the median interval from first submission to acceptance was 92 days. All surgical practice studies scored ‘low’ or ‘moderate’ risk of bias on the ROBINS-I assessment. All guidelines and recommendations scored ‘moderately well’ on the AGREE-II assessment; however, all underperformed in the domain of public and patient involvement. Overall, there were no increases in perioperative complication rates or mortalities in patients who underwent RAS compared to that expected in non-COVID practice. RAS was deemed safe, with recommendations for mitigation of risk of viral transmission. Conclusions: Continuation of RAS was feasible and safe during the SARS-CoV-2 pandemic where resources permitted. Post-pandemic reflections upon published robotic data and publication patterns allows us to better prepare for future events and to enhance urgent guideline design processes.

The Impact of COVID-19 on Surgical Training: the Past, the Present and the Future

The COVID-19 pandemic and infection control measures had an unavoidable impact on surgical services. During the first wave of the pandemic, elective surgery, endoscopy, and 'face-to-face' clinics were discontinued after recommendations from professional bodies. In addition, training courses, examinations, conferences, and training rotations were postponed or cancelled. Inadvertently, infection control and prevention measures, both within and outside hospitals, have caused a significant negative impact on training. At the same time, they have given space to new technologies, like telemedicine and platforms for webinars, to blossom. While the recovery phase is well underway in some parts of the world, most surgical services are not operating at full capacity. Unfortunately, some countries are still battling a second or third wave of the pandemic with severely negative consequences on surgical services. Several studies have looked into the impact of COVID-19 on surgical training. Here, an objective overview of studies from different parts of the world is presented. Also, evidence-based solutions are suggested for future surgical training interventions.

Presentation and outcomes of acute appendicitis during COVID-19 pandemic: lessons learned from the Middle East-a multicentre prospective cohort study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had a striking impact on healthcare services in the world. The present study aimed to investigate the impact of the COVID-19 pandemic on the presentation management and outcomes of acute appendicitis (AA) in different centers in the Middle East.

METHODS

This multicenter cohort study compared the presentation and outcomes of patients with AA who presented during the COVID-19 pandemic in comparison to patients who presented before the onset of the pandemic. Demographic data, clinical presentation, management strategy, and outcomes were prospectively collected and compared.

RESULTS

Seven hundred seventy-one patients presented with AA during the COVID pandemic versus 1174 in the pre-COVID period. Delayed and complex presentation of AA was significantly more observed during the pandemic period. Seventy-six percent of patients underwent CT scanning to confirm the diagnosis of AA during the pandemic period, compared to 62.7% in the pre-COVID period. Non-operative management (NOM) was more frequently employed in the pandemic period. Postoperative complications were higher amid the pandemic as compared to before its onset. Reoperation and readmission rates were significantly higher in the COVID period, whereas the negative appendicectomy rate was significantly lower in the pandemic period (p = 0.0001).

CONCLUSION

During the COVID-19 pandemic, a remarkable decrease in the number of patients with AA was seen along with a higher incidence of complex AA, greater use of CT scanning, and more application of NOM. The rates of postoperative complications, reoperation, and readmission were significantly higher during the COVID period.

Surgical plume from tissue infected with human hepatitis B virus can contain viral substances

INTRODUCTION

Evidence on the biological danger associated with surgical plume is lacking. We examined whether surgical plume, generated by the energy devices ultrasonically activated scalpel (US) or electrocautery (EC) contains virus-related substances.

MATERIAL AND METHODS

Experiment 1, ex-vivo model: Tumor mass of a hepatocellular carcinoma line was prepared in a Nod/SCID mouse. Surgical plume generated on the mass by US or EC was collected and detection of HBs gene fragment and antigens (HBsAg or AFP) was conducted. Experiment 2, clinical specimen: Detection of HBV-DNA and HBsAg was conducted following the collection of surgical plume generated from clinically obtained liver specimens from six HBV-associated hepatocellular carcinoma patients.

RESULTS

Experiment 1: HBs gene fragment was detected in the solutions regardless of the device used. HBsAg was detected in US and EC solutions and AFP was also detected in a US solution. Experiment 2: HBV-DNA was detected in both devices, in all three cases whose preoperative serum HBV-DNA was positive. In the other serum-negative cases, HBV-DNA was not detected. While serum HBsAg was positive in five of six cases, it was not detected in any solution.

CONCLUSIONS

DNA fragments or antigens of virus can exist in the surgical plume generated by EC or US.

Rate of Application and Outcome of Non-operative Management of Acute Appendicitis in the Setting of COVID-19: Systematic Review and Meta-analysis

BACKGROUND

Non-operative management (NOM) of acute appendicitis has been assessed in several studies before COVID-19 pandemic. This systematic review aimed to assess the extent of adoption, efficacy, and safety of NOM of acute appendicitis in the setting of COVID-19.

METHODS

This was a PRISMA-compliant systematic review of the literature. Electronic databases and Google Scholar were queried for studies that applied NOM of acute appendicitis during COVID-19. The main outcome measures were the rates of NOM application during the pandemic as compared to the pre-pandemic period, failure and complication rates of NOM. Failure was defined as the need for appendectomy during NOM and complications included development of appendicular mass or abscess.

RESULTS

Fourteen studies (2140 patients) were included. The male to female ratio was 1.44:1 and median age was 34. Nine hundred fifty-nine (44.8%) patients had a trial of NOM. The weighted mean rate of NOM application was 50.1% (95%CI: 29.8-70.5%). The application of NOM during the pandemic was significantly more likely than its application before COVID-19 (OR = 6.7, p < 0.001). The weight mean failure rate of NOM was 16.4% (95%CI: 9.4-23.4). NOM failure was more likely in children and patients with complicated appendicitis. The weighted mean complication rate after NOM was 4.5% (95%CI: 1.4-7.7). NOM had significantly lower odds for complications than appendectomy (OR = 0.36, p = 0.03). There was no mortality after application of NOM.

CONCLUSION

NOM of acute appendicitis in the setting of COVID-19 may be a safe, short-term alternative to surgery with acceptably low failure and complication rates.

Robots Under COVID-19 Pandemic: A Comprehensive Survey

As a result of the difficulties brought by COVID-19 and its associated lockdowns, many individuals and companies have turned to robots in order to overcome the challenges of the pandemic. Compared with traditional human labor, robotic and autonomous systems have advantages such as an intrinsic immunity to the virus and an inability for human-robot-human spread of any disease-causing pathogens, though there are still many technical hurdles for the robotics industry to overcome. This survey comprehensively reviews over 200 reports covering robotic systems which have emerged or have been repurposed during the past several months, to provide insights to both academia and industry. In each chapter, we cover both the advantages and the challenges for each robot, finding that robotics systems are overall apt solutions for dealing with many of the problems brought on by COVID-19, including: diagnosis, screening, disinfection, surgery, telehealth, care, logistics, manufacturing and broader interpersonal problems unique to the lockdowns of the pandemic. By discussing the potential new robot capabilities and fields they applied to, we expect the robotics industry to take a leap forward due to this unexpected pandemic.