COVID-19 and Laparoscopic Surgery: Scoping Review of Current Literature and Local Expertise

Trends among patients with endometriosis over a 7-year period and the impact of the COVID-19 pandemic: experience from an academic high-level endometriosis centre in Germany

PURPOSE

Endometriosis is known to be an underestimated disease. Lately the awareness of the disease seems to have improved. Aim of this analysis is to provide an overview of the development of treatment of patients diagnosed with endometriosis. This includes a special scope on implications of the COVID-19 pandemic since in multiple settings postponed treatments resulting in negative impact on prognosis were reported.

MATERIALS AND METHODS

We analysed the development of numbers of patients treated for endometriosis in an academic centre within a 7-year period, 01/2015-12/2021, performing a systematic analysis of ICD-10-Codes from our computer system used in clinical routine.

RESULTS

Treatment numbers increased over the past 7 years, i.e., 239 treated cases in 2015 vs. 679 in 2021. Following restrictions for outpatient evaluation and surgical capacity at our centre, during COVID-19 pandemic the numbers of treated patients were reduced, especially in the first lockdown period (03/22/2020-05/05/2020 vs. same period in 2019: outpatient clinic (9 vs. 36; p < 0.001), patients surgically treated (27 vs. 52; p < 0,001)). The comparison of 2020 to 2019 showed a reduction in April 2020 of - 37% in outpatient department and up to - 90% for surgically treated patients. Comparing to 2019, we found a reduction of surgical interventions in 2020 by - 9% and an increase by 83% in 2021.

CONCLUSIONS

Raising numbers of patients treated for endometriosis point to a new awareness for the disease. After the decline during the lockdown period numbers raised again, leading to a delay, but not an omission of treatment. A certified endometriosis centre with established and well-organized structures is required to improve not only treatment results but also quality of life of those affected.

Nurses' role in the management of persons with chronic urogenital pelvic pain syndromes: A scoping review

BACKGROUND

Pelvic pain has cognitive, behavioral, sexual, and emotional consequences. Nurses involved in pelvic floor rehabilitation clinics have contacts with patients reporting chronic pain and should know the most appropriate service for patient referral, to submit the problem to professionals capable of correctly assessing and managing the condition. Furthermore, in some countries nurses can use conservative methods to treat the painful symptoms inside a multidisciplinary team such as breathing retraining, biofeedback, and noninvasive neuromodulation. This paper aims to provide an overview of the literature regarding the role of rehabilitation nurses in dealing with patients suffering from chronic urogenital pelvic pain or urogenital painful syndromes, inside a multidisciplinary team.

METHODS

Scoping review on Pubmed, CINAHL, Embase, Scopus, Web of Science including trials, reviews, case studies or series, and other descriptive studies regarding the role of nurses inside the multidisciplinary team in the management of males and females presenting chronic pelvic pain (CPP) or chronic pelvic pain syndrome (CPPS).

RESULTS

The 36 papers included in this review allowed answering research questions in four areas of nursing: collecting basic information, referring the person to appropriate services, evidence-based nursing interventions for CPP and CPPS, and proper documentation. Clinical history and assessment of breathing pattern, Muscular assessment and research of trigger points are the main points of data collection. Techniques for muscular relaxation and breathing retraining are important aspects of treatment, as well as biofeedback and noninvasive neuromodulation where the law allows nurses to practice such techniques. The McGill pain questionnaire and the pain inventory of the International Pain Society allow systematic data collection and handover.

CONCLUSION

Rehabilitation nurses work inside multidisciplinary teams when dealing with persons suffering from pelvic pain; further research is needed as our comprehension of the underlying pathophysiological mechanisms of CPP and CPPS evolve.

Psychological Health of Surgeons in a Time of COVID-19: A Global Survey

OBJECTIVE

To assess the degree of psychological impact among surgical providers during the COVID-19 pandemic.

SUMMARY OF BACKGROUND DATA

The COVID-19 pandemic has extensively impacted global healthcare systems. We hypothesized that the degree of psychological impact would be higher for surgical providers deployed for COVID-19 work, certain surgical specialties, and for those who knew of someone diagnosed with, or who died, of COVID-19.

METHODS

We conducted a global web-based survey to investigate the psychological impact of COVID-19. The primary outcomes were the depression anxiety stress scale-21 and Impact of Event Scale-Revised scores.

RESULTS

A total of 4283 participants from 101 countries responded. 32.8%, 30.8%, 25.9%, and 24.0% screened positive for depression, anxiety, stress, and PTSD respectively. Respondents who knew someone who died of COVID-19 were more likely to screen positive for depression, anxiety, stress, and PTSD (OR 1.3, 1.6, 1.4, 1.7 respectively, all P < 0.05). Respondents who knew of someone diagnosed with COVID-19 were more likely to screen positive for depression, stress, and PTSD (OR 1.2, 1.2, and 1.3 respectively, all P < 0.05). Surgical specialties that operated in the head and neck region had higher psychological distress among its surgeons. Deployment for COVID- 19-related work was not associated with increased psychological distress.

CONCLUSIONS

The COVID-19 pandemic may have a mental health legacy outlasting its course. The long-term impact of this ongoing traumatic event underscores the importance of longitudinal mental health care for healthcare personnel, with particular attention to those who know of someone diagnosed with, or who died of COVID-19.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

BACKGROUND

Acute appendicitis (AAp) is the most frequent cause of acute abdominal pain, and appendectomy is the most frequent emergency procedure that is performed worldwide. The coronavirus disease 2019 (COVID-19) pandemic has caused delays in managing diseases requiring emergency approaches such as AAp and trauma.

AIM

To compare the demographic, clinical, and histopathological outcomes of patients with AAp who underwent appendectomy during pre-COVID-19 and COVID-19 periods.

METHODS

The demographic, clinical, biochemical, and histopathological parameters were evaluated and compared in patients who underwent appendectomy with the presumed diagnosis of AAp in the pre-COVID-19 (October 2018-March 2020) and COVID-19 (March 2020-July 2021) periods.

RESULTS

Admissions to our tertiary care hospital for AAp increased 44.8% in the COVID-19 period. Pre-COVID-19 (n = 154) and COVID-19 (n = 223) periods were compared for various parameters, and we found that there were statistically significant differences in terms of variables such as procedures performed on the weekdays or weekends [odds ratio (OR): 1.76; P = 0.018], presence of AAp findings on ultrasonography (OR: 15.4; P < 0.001), confirmation of AAp in the histopathologic analysis (OR: 2.6; P = 0.003), determination of perforation in the appendectomy specimen (OR: 2.2; P = 0.004), the diameter of the appendix (P < 0.001), and hospital stay (P = 0.003). There was no statistically significant difference in terms of interval between the initiation of symptoms and admission to the hospital between the pre-COVID-19 (median: 24 h; interquartile range: 34) and COVID-19 (median: 36 h; interquartile range: 60) periods (P = 0.348). The interval between the initiation of symptoms until the hospital admission was significantly longer in patients with perforated AAp regardless of the COVID-19 or pre-COVID-19 status (P < 0.001).

CONCLUSION

The present study showed that in the COVID-19 period, the ultrasonographic determination rate of AAp, perforation rate of AAp, and duration of hospital stay increased. On the other hand, negative appendectomy rate decreased. There was no statistically significant delay in hospital admissions that would delay the diagnosis of AAp in the COVID-19 period.

The effects of COVID-19 pandemic on patients with acute appendicitis

BACKGROUND

The effects of the COVID-19 infection on the world's health system began to be reported in a short time, with the spread of the infection all over the world and it gained a global acceptance as a pandemic. It was predicted that patients who require urgent surgical procedures may not be able to access appropriate treatment during this period and may suffer from this process. In this process, we planned to report the effects of the pandemic process to this patient group by evaluating patients with acute appendicitis, which is the most common cause of acute abdomen among general surgery emergencies.

METHODS

In our study, we compared the patients who applied to the Training and Research Hospital we collaborated, whose clinics were compatible with acute appendicitis, between March 11, 2020, and May 21, 2020, with those applied within the same time period with the year before. We evaluated clinical and pathological findings of the patients and the treatment applied.

RESULTS

In this study, there were 103 patients diagnosed with acute appendicitis before pandemic and 61 in pandemic period. We found that during the pandemic period, patients with acute appendicitis were admitted to the hospital less often, and in a later period, and more complicated clinical pictures were determined. Complicated appendicitis patients were higher in pandemic period compared with previous year (33.96% vs. 8.00% of patients, respectively; p<0.05).

CONCLUSION

We emphasized that diseases that need to be treated urgently should not be left behind during the pandemic. Furthermore, we shared our clinical practice to ensure early discharge of patients with acute appendicitis during the pandemic process.

Maintaining a minimally invasive surgical service during a pandemic

PURPOSE

The safety of minimally invasive surgery (MIS) was questioned in the COVID-19 pandemic due to concern regarding disease spread. We continued MIS during the pandemic with appropriate protective measures. This study aims to assess the safety of MIS compared to Open Surgery (OS) in this setting.

METHODS

Operations performed during 2020 lockdown were compared with operations from the same time-period in 2019 and 2021. Outcomes reviewed included all complications, respiratory complications, length of stay (LOS) and operating surgeon COVID-19 infections (OSI).

RESULTS

In 2020, MIS comprised 52% of procedures. 29% of MIS 2020 had complications (2019: 24%, 2021: 15%; p = 0.08) vs 47% in OS 2020 (p = 0.04 vs MIS). 8.5% of MIS 2020 had respiratory complications (2019: 7.7%, 2021: 6.9%; p = 0.9) vs 10.5% in OS 2020 (p = 0.8 vs MIS). Median LOS[IQR] for MIS 2020 was 2.5[6] days vs 5[23] days in OS 2020 (p = 0.06). In 2020, 2 patients (1.2%) were COVID-19 positive (MIS: 1, OS: 1) and there were no OSI.

CONCLUSION

Despite extensive use of MIS during the pandemic, there was no associated increase in respiratory or other complications, and no OSI. Our study suggests that, with appropriate protective measures, MIS can be performed safely despite high levels of COVID-19 in the population.

Impact of COVID-19 pandemic on Hepatobiliary and Pancreatic surgical services in Singapore: Experience Paper

Background

At the height of the COVID-19 pandemic, the hepatopancreatobiliary (HPB) unit had to reorganize its surgical case volume due to the rationing of health care resources. We report on a local audit evaluating the impact of COVID-19 on the HPB unit and the HPB surgical oncology practice.

Objective

The aim of this study was to review the impact of the COVID-19 pandemic on the HPB unit’s elective and emergency surgical cases. The secondary aims were to investigate the impact on the HPB surgical oncology operative case volume.

Methods

We performed a comparative audit of the HPB unit surgical case volume for January-June 2019 (baseline) and 2020 (COVID-19). Elective and emergency cases performed under general anesthesia were audited. Elective cases included hernia and gallbladder operations and liver and pancreatic resections. Emergency cases included cholecystectomies and laparotomies performed for general surgical indications. We excluded endoscopies and procedures done under local anesthesia. The retrospective data collected during the 2 time periods were compared. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000040265).

Results

The elective surgical case volume decreased by 41.8% (351 cases in 2019 compared to 204 cases in 2020) during the COVID-19 pandemic. The number of hernia operations decreased by 63.9% (155 in 2019 compared to 56 in 2020; P<.001) and cholecystectomies decreased by 40.1% (157 in 2019 compared to 94 in 2020; P=.83). The liver and pancreatic resection volume increased by 16.7% (30 cases in 2019 compared to 35 cases in 2020; P=.004) and 111.1% (9 cases in 2019 compared to 19 cases in 2020; P=.001), respectively. The emergency surgical workload decreased by 40.9% (193 cases in 2019 compared to 114 cases in 2020). The most significant reduction in the emergency workload was observed in March (41 to 23 cases, a 43.9% reduction; P=.94), April (35 to 8 cases, a 77.1% reduction; P=.01), and May (32 to 14 cases, a 56.3% reduction; P=.39); however, only April had a statistically significant reduction in workload (P=.01).

Conclusions

The reallocation of resources due to the COVID-19 pandemic did not adversely impact elective HPB oncology work. With prudent measures in place, essential surgical services can be maintained during a pandemic.

Trial Registration

Chinese Clinical Trial Registry (ChiCTR2000040265); https://tinyurl.com/ms9kpr6x

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.

COVID-19 and Gynecologic Oncology: What Have We Learned?

COVID-19 has transformed the care we provide to gynecologic oncology patients. In addition to directly impacting the diagnosis and treatment of women with gynecologic cancer, it has affected our patient’s ability to undergo recommended surveillance and has made an impact on every caregiver providing care during this time. Herein we review the current literature on the impact of COVID-19 on gynecologic oncology and highlight new approaches and innovations that have resulted in gynecologic cancer care as a result of the pandemic. The impact of COVID-19 on the field of gynecologic oncology has been profound. In addition to directly impacting the diagnosis and treatment of women with cancer, it has also challenged the very ethics with which we practice medicine. The equitable distribution of resources is paramount to upholding the Hippocratic Oath which we all invoke. The COVID-19 pandemic has stripped this oath down to its very core, forcing all medical practitioners to scrutinize who gets what resources and when. As the pandemic continues to unfold, the question remains — in the setting of a strained and overburdened healthcare system, how do we maximize beneficence to one group of patients, while maintaining non-maleficence to others? As gynecologic oncologists, we are responsible for advocating for our patients to ensure that the quality of their cancer care is not compromised, while also not overutilizing resources that are sorely needed for the care of COVID-19 victims, and not making them more likely to succumb to COVID-19 by the very nature of the treatment we provide. The effects of the pandemic are far-reaching and broad, and many of these are yet to be determined. Future studies are needed to analyze how the above-utilized strategies in GYN cancer care during the pandemic will impact the long-term outcomes of our patients.

Endometriosis Surgery during the First Wave of the COVID-19 Pandemic: A Brazilian Single Institution Experience

Introduction. Early in the 2020 Coronavirus pandemic stay-at-home guidelines, there were public health orders that elective surgeries be deferred to prioritize hospital beds for critically ill COVID-19 patients. Besides, several reasons led to the postponement of consultations, diagnostic tests, and elective therapeutic procedures. As a result, some women with endometriosis faced chronification of their pain and decreased prospects for pregnancy. The aim of this study was to describe individual responses to minimally invasive complete excision of endometriosis through 40 days of follow-up of women whose endometriosis was considered severe enough to proceed with surgery during the fourth, fifth, and sixth months of constraints imposed by the pandemic. Preventive strategies and safety measures employed to protect patients and staff from acquiring or transmitting Coronavirus infection are presented. Case Presentation. This case series report enrolled 11 consecutive Brazilian women (ages 22 to 47 y) who underwent minimally invasive surgical treatment of endometriosis between June 26 and August 17, 2020. Cases of endometriosis requiring more urgent surgery were promptly identified and considered individually. The strict safety measures were well accepted by patients. No women developed any flu-like or COVID-19-related symptoms (cough, dyspnea, fever, or anosmia) in the 40 days of postoperative follow-up. One of the most praised measures reported by patients was the routine testing of the patient, the person who would accompany her in the hospital, and all medical staff and employees. Discussion. It is feasible to safely perform elective endometriosis surgery in selected cases during a pandemic.

Impact of COVID-19 on management of urogynaecology patients: a rapid review of the literature

INTRODUCTION AND HYPOTHESIS

The coronavirus (COVID-19) pandemic has impacted health systems worldwide. There is a continuing need for clinicians to adapt practice to facilitate timely provision of medical care, whilst minimising horizontal transmission. Guidance and recommendations are increasingly available, and this rapid review aimed to provide a timely evidence synthesis on the current recommendations surrounding urogynaecological care.

METHODS

We performed a literature review using PubMed/Medline, Embase and Cochrane and a manual search of national and international societies for management recommendations for urogynaecological patients during the COVID-19 pandemic.

RESULTS

Nine guidance documents and 17 articles, including 10 reviews, were included. Virtual clinics are recommended for new and follow-up patients, to assess and initiate treatment, as well as triage patients who require face-to-face appointments. Outpatient investigations such as urodynamics and cystoscopy for benign indications can be deferred. Prolapse and continence surgery should be suspended, except in specific circumstances such as procidentia with upper tract complications and failed pessaries. There is no evidence to support a particular route of surgery, but recommendations are made to minimise COVID-19 transmission.

CONCLUSIONS

Urogynaecological patients face particular challenges owing to inherent vulnerabilities of these populations. Behavioural and medical therapies should be recommended as first line options and initiated via virtual or remote clinics, which are integral to management during the COVID-19 pandemic. Expanding the availability and accessibility of technology will be increasingly required. The majority of outpatient and inpatient procedures can be deferred, but the longer-term effects of such practices are unclear.

Developing paediatric endoscopic surgery skills for trainees in the era of COVID-19: narrative review from trainee perspective

Since the outbreak of Coronavirus 2019 (COVID-19) pandemic, paediatric endoscopic surgery training has taken a backseat. Simulation and virtual learning have become cornerstones in educating trainees across different surgical specialties. Paediatric minimal access surgery is an exceptionally challenging field due to the extreme variations in the size of the patients, ranging from newborns to adolescents. Finding possible solutions to continue training in this field during the pandemic will require focused efforts from the educators and leaders of paediatric endoscopic societies and universities.

Impact of the Global COVID-19 Pandemic on the Incidence, Presentation, and Management of Pediatric Appendicitis: Lessons Learned from the First Wave

The fast-evolving nature of the coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented clinical, logistical, and socioeconomical challenges for health-care systems worldwide. While several studies have analyzed the impact on the presentation and management of acute appendicitis (AA) in the adult population, there is a relative paucity of similar research in pediatric patients with AA. To date, there is some evidence that the incidence of simple AA in children may have decreased during the first lockdown period in spring 2020, whereas the number of complicated AA cases remained unchanged or increased slightly. Despite a worrying trend toward delayed presentation, most pediatric patients with AA were treated expediently during this time with comparable outcomes to previous years. Hospitals must consider their individual capacity and medical resources when choosing between operative and non-operative management of children with AA. Testing for severe acute respiratory syndrome coronavirus type 2 is imperative in all pediatric patients presenting with fever and acute abdominal pain with diarrhea or vomiting, to differentiate between multisystem inflammatory syndrome and AA, thus avoiding unnecessary surgery. During the further extension of the COVID-19 crisis, parents should be encouraged to seek medical care with their children early in order that the appropriate treatment for AA can be undertaken in a timely fashion.

The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access

Background

The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March–May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March–May 2020, group 2).

Methods

A comparison (groups 1 versus 2) and subgroup analysis were performed between patients’ demographic, medical history, surgical, clinical and management characteristics.

Results

Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08–4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33–5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89–11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05–25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01–63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11).

Conclusions

This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a “filter effect” induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

Impact of Surgical Wait Time on Survival in Patients With Upper Urinary Tract Urothelial Carcinoma With Hydronephrosis

Background and Objectives

Due to the inevitability of waiting time for surgery, this problem seems to have become more pronounced since the outbreak of COVID-19, and due to the high incidence of preoperative hydronephrosis in upper urinary tract urothelial carcinoma (UTUC) patients, it is particularly important to explore the impact of preoperative waiting time and hydronephrosis on upper urinary urothelial carcinoma.

Methods

316 patients with UTUC who underwent radical surgery at a high-volume center in China between January 2008 and December 2019 were included in this study. We retrospectively collected the clinicopathologic data from the medical records, including age, sex, smoking history, ECOG performance status (ECOG PS), body mass index (BMI), tumor location and size, number of lesions, T stage, N stage, surgical approach and occurrence of hydronephrosis, lymph node invasion, lymph node dissection, surgical margin, tumor necrosis, infiltrative tumor architecture, lymphovascular invasion and concomitant bladder cancer. Surgical wait time was defined as the interval between initial imaging diagnosis and radical surgery of UTUC. Hydronephrosis was defined as abnormal dilation of the renal pelvis and calyces due to obstruction of the urinary system. Firstly, all patients were divided into short-wait (<31 days), intermediate-wait (31-90 days) and long-wait (>90 days) groups according to the surgical wait time. The clinicopathological characteristics of each group were evaluated and the survival was compared. For patients with hydronephrosis, we subsequently divided them into two groups: short-wait (≤60 days) and long-wait (>60 days) groups according to the surgical wait time. Univariate and multivariate COX regression analysis were performed to evaluate the prognostic risk factor for patients with hydronephrosis.

Results

A total of 316 patients with UTUC were included in this study with a median surgical wait time of 22 days (IQR 11-71 days). Of the 316 patients, 173 were classified into the short-wait group (54.7%), 69 into the intermediate-wait group (21.8%) and 74 into the long-wait group (23.5%). The median follow-up time for all patients was 43 months (IQR 28-67months). The median surgical wait times of the short-wait, intermediate-wait and long-wait group were12 days (IQR 8-17days), 42days (IQR 37-65days) and 191days (IQR 129-372days), respectively. The 5-year overall survival (OS) of all patients was 54.3%. The 5-year OS of short-wait, intermediate-wait and long-wait groups were 56.4%, 59.3% and 35.1%, respectively (P=0.045). The 5-year cancer-specific survival (CSS) of short-wait, intermediate-wait and long-wait groups were 65.8%, 70.9% and 39.6%, respectively (P=0.032). In the subgroup analysis, we divided 158 UTUC patients with hydronephrosis into short-wait group (≤60 days) and long-wait group (> 60 days), 120 patients were included in the short-wait group and 38 patients in the long-wait group. The median surgical wait times of the short-wait and long-wait group were 14days (IQR 8-28days) and 174days (IQR 100-369days), respectively. The 5-year OS of long-wait group was significantly lower than the OS of short-wait group (44.2% vs. 55.1%, P =0.023). The 5-year CSS of long-wait and short-wait group were 49.1% and 61.7%, respectively (P=0.041). In multivariate Cox regression analysis of UTUC patients with hydronephrosis, surgical wait time, tumor grade, pathological T stage, and tumor size were independent risk factors for OS and CSS. Lymph node involvement was also a prognostic factor for CSS.

Conclusion

For patients with UTUC, the surgical wait time should be limited to less than 3 months. For UTUC patients with hydronephrosis, the OS and CSS of patients with surgical wait time of more than 60 days were relatively shorted than those of patients with surgical wait time of less than 60 days.

Pathogenesis of the inflammatory bowel disease in context of SARS-COV-2 infection

To date, the latest research results suggest that the novel severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) can enter host cells directly via the gastrointestinal tract by binding to the enterocyte-expressed ACE2 receptor, or indirectly as a result of infection of type II alveolar epithelial cells. At the same time, entry of SARS-CoV-2 through the gastrointestinal tract initiates the activation of innate and adaptive immune responses, the formation of an excessive inflammatory reaction and critical increase in the expression of proinflammatory cytokines, which, subsequently, can presumably increase inflammation and induce intestinal damage in patients suffering from inflammatory bowel disease (IBD). The aims of the present review were to reveal and analyze possible molecular pathways and consequences of the induction of an innate and adaptive immune response during infection with SARS-CoV-2 in patients with IBD. A thorough literature search was carried out by using the keywords: IBD, SARS-CoV-2, COVID-19. Based on the screening, a number of intracellular and extracellular pathways were considered and discussed, which can impact the immune response during SARS-CoV-2 infection in IBD patients. Additionally, the possible consequences of the infection for such patients were estimated. We further hypothesize that any virus, including the new SARS-CoV-2, infecting intestinal tissues and/or entering the host's body through receptors located on intestinal enterocytes may be a trigger for the onset of IBD in individuals with a genetic predisposition and/or the risk of developing IBD associated with other factors.

Operative Shutdown and Recovery: Restructuring Surgical Operations During the SARS-CoV-2 Pandemic

Background

During the 2020 SARS-CoV-2 outbreak in New York City, hospitals canceled elective surgeries to increase capacity for critically ill patients. We present case volume data from our community hospital to demonstrate how this shutdown affected surgical care.

Methods

Between March 16 and June 14, 2020, all elective surgeries were canceled at our institution. All procedures performed during this operating room shutdown (ORS) were logged, as well as those 4 weeks before (PRE) and 4 weeks after (POST) for comparison.

Results

A total of 2,475 cases were included in our analysis, with 754 occurring during shutdown. Overall case numbers dropped significantly during ORS and increased during recovery (mean 245.0 ± 28.4 PRE versus 58.0 ± 30.9 ORS versus 186.0±19.4 POST cases/wk, P< 0.001). Emergency cases predominated during ORS (26.4% PRE versus 59.3% ORS versus 31.5% POST, P< 0.001) despite decreasing in frequency (mean 64.5 ± 7.9 PRE versus 34.4 ± 12.1 ORS versus 58.5 ± 4.0 POST cases/wk, P< 0.001). Open surgeries remained constant in all three phases (52.2-54.1%), whereas laparoscopic and robotic surgeries decreased (-3.4% and -3.0%, P< 0.001). General and/or vascular surgery, urology, and neurosurgery comprised a greater proportion of caseload (+9.5%, +3.0%, +2.8%), whereas orthopedics, gynecology, and otolaryngology/plastic surgery all decreased proportionally (-5.0%, -4.4%, -5.9%, P< 0.001).

Conclusion

Operative volume significantly decreased during the SARS-CoV-2 outbreak. Emergency cases predominated during this time, although there were fewer emergency cases overall. General/vascular surgery became the most active service and open surgeries became more common. This reallocation of resources may be useful for future crisis planning among community hospitals.

Elective laparoscopic colectomy in a patient 3 weeks after coronavirus disease 2019 infection: a case report

BACKGROUND

According to previous reports, surgery is not recommended until at least 4 weeks after the symptoms of coronavirus disease 2019 resolve. However, strong evidence has not been established regarding the optimal timing and preoperative examination for elective laparoscopic colectomy for colorectal cancer in individuals with a previous coronavirus disease 2019 infection.

CASE PRESENTATION

A 63-year-old Asian man underwent elective laparoscopic colectomy for sigmoid colon cancer 3 weeks after asymptomatic coronavirus disease 2019. The postoperative course was good, and none of the surgical staff was infected with coronavirus disease 2019.

CONCLUSION

In this patient infected with coronavirus disease 2019 within 4 weeks of surgery, preoperative venous ultrasound of the lower extremities and a chest computed tomography scan were useful examinations for ensuring a safe surgical procedure for the patient and the staff. Surgery within 4 weeks may be possible with careful selection of cases based on thorough preoperative examination. This report may contribute to the development of a consensus on performing safe elective colectomy for colon cancer in persons previously infected with coronavirus disease 2019.

Neuromuscular blockade management in patients with COVID-19

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome, and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.

The PanSurg-PREDICT Study: Endocrine Surgery During the COVID-19 Pandemic

Background

In the midst of the COVID-19 pandemic, patients have continued to present with endocrine (surgical) pathology in an environment depleted of resources. This study investigated how the pandemic affected endocrine surgery practice.

Methods

PanSurg-PREDICT is an international, multicentre, prospective, observational cohort study of emergency and elective surgical patients in secondary/tertiary care during the pandemic. PREDICT-Endocrine collected endocrine-specific data alongside demographics, COVID-19 and outcome data from 11–3-2020 to 13–9-2020.

Results

A total of 380 endocrine surgery patients (19 centres, 12 countries) were analysed (224 thyroidectomies, 116 parathyroidectomies, 40 adrenalectomies). Ninety-seven percent were elective, and 63% needed surgery within 4 weeks. Eight percent were initially deferred but had surgery during the pandemic; less than 1% percent was deferred for more than 6 months. Decision-making was affected by capacity, COVID-19 status or the pandemic in 17%, 5% and 7% of cases. Indication was cancer/worrying lesion in 61% of thyroidectomies and 73% of adrenalectomies and calcium 2.80 mmol/l or greater in 50% of parathyroidectomies. COVID-19 status was unknown at presentation in 92% and remained unknown before surgery in 30%. Two-thirds were asked to self-isolate before surgery. There was one COVID-19-related ICU admission and no mortalities. Consultant-delivered care occurred in a majority (anaesthetist 96%, primary surgeon 76%). Post-operative vocal cord check was reported in only 14% of neck endocrine operations. Both of these observations are likely to reflect modification of practice due to the pandemic.

Conclusion

The COVID-19 pandemic has affected endocrine surgical decision-making, case mix and personnel delivering care. Significant variation was seen in COVID-19 risk mitigation measures. COVID-19-related complications were uncommon. This analysis demonstrates the safety of endocrine surgery during this pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06099-z.

Changes in children's surgical services during the COVID-19 pandemic at a tertiary-level government hospital in a lower middle-income country

Objective

The aim of this study was to quantify the changes that occurred in the surgical services of children during the COVID-19 pandemic from the perspective of a low/middle-income country.

Design

A case-control study was conducted at a large referral centre in Bangladesh among patients aged ≤12 years. Comparisons were made between cases admitted during a period of 'April to September 2020' (Pandemic period) and controls during a similar period in 2019 (Reference period). The number of admissions and outpatient department (OPD) attendances, age and sex distribution, diagnosis, number and types of surgeries performed (elective vs emergency), variations in treatment of acute appendicitis, types of anaesthesia and mortality were compared.

Results

Admissions were only 41% of previous year (635 vs 1549), and OPD attendances were only 28% of previous year (603 vs 2152). Admission of children reduced by 65.8%, but neonatal admission reduced only by 7.6%. The median age of the admitted patients was significantly lower during the pandemic period (3 vs 4 years, p<0.01). Acute appendicitis (151, 9.8%) and trauma (61, 9.6%), respectively, were the the most common causes of admission during the reference and the pandemic period. Elective surgeries were only 17% and emergency surgeries were 64% of previous year (p<0.01). Appendectomy (88, 9.1%) and laparotomy (77, 17.6%), respectively, were the most common surgeries performed during the reference and the pandemic period. Conservative treatment of acute appendicitis was more during the pandemic period (47.5% vs 28.5%, p=0.01), but patients who underwent appendectomies had more complicated appendicitis (63.3% vs 42.1%, p=0.01). In all, 90.4% of surgeries were performed by resident doctors. There were no COVID-19- related deaths.

Conclusion

Trauma became the most common cause of admission during the pandemic, and neonatal surgical conditions remained almost unchanged with high mortality rates. Elective procedures and laparoscopy remained low and resident doctors played a major role in providing surgical services.

How to manage inflammatory bowel disease during the COVID-19 pandemic: A guide for the practicing clinician

Managing inflammatory bowel disease (IBD) during the coronavirus disease 2019 (COVID-19) pandemic has been a challenge faced by clinicians and their patients, especially concerning whether to proceed with biologics and immunosuppressive agents in the background of a global outbreak of a highly contagious new coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2). The knowledge about the impact of this virus on patients with IBD, although it is still scarce, is rapidly evolving. In particular, concerns surrounding medications' impact for IBD on the risk of acquiring SARS-CoV-2 infection or developing COVID-19, and potentially exacerbate viral replication and the COVID-19 course, are a current thinking of both practicing clinicians and providers caring for patients with IBD. Managing patients with IBD infected with SARS-CoV-2 depends on both the clinical activity of the IBD and the occasional development and severity of COVID-19. In this review, we summarize the current data regarding gastrointestinal involvement by SARS-CoV-2 and pharmacologic and surgical management for IBD concerning this infection, and the COVID-19 impact on both the patient's psychological functioning and endoscopy services, and we concisely summarize the telemedicine roles during the COVID-19 pandemic.

Advantages of, and Adaptations to, Enhanced Recovery Protocols for Perioperative Care during the COVID-19 Pandemic

Objective

This review formulates the rationale for using enhanced recovery protocols (ERPs) to standardize and optimize perioperative care during this high-risk time to minimize poor outcomes owing to provider, patient, and system vulnerabilities.

Data Sources

n/a

Methods of Study Selection

A literature review using key Medical Subject Headings terms was performed—according to methods described by the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines—on studies that described enhanced recovery and coronavirus disease (COVID-19).

Tabulation, Integration, and Results

Modifications to our existing ERPs related to the COVID-19 pandemic should include new accommodations for patient education, preoperative COVID-19 testing, prehabilitation, and intraoperative infection as well as thromboembolism risk reduction.

Conclusion

ERPs are evidence-based, best practice guidelines applied across the perioperative continuum to mitigate surgical stress, decrease complications, and accelerate recovery. These benefits are part of the high-value–care equation needed to solve the clinical, operational, and financial challenges of the current COVID-19 pandemic. The factors driving outcomes on ERPs, such as the provision of minimally invasive surgery, warrant careful consideration. Tracking patient outcomes and improving care in response to outcomes data are key to the success of clinical care protocols such as ERPs. Numerous emerging clinical registries and reporting systems have been activated to provide outcomes data on the impact of COVID-19. This will inform and change surgical practice as well as provide opportunity to learn if the advantages that surgeons, patients, and the healthcare system might gain from using ERPs during a pandemic are meaningful.

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.

Management of urologic cancers during the pandemic and potential impact of treatment deferrals on outcomes

The COVID-19 pandemic-related constraints on healthcare access have raised concerns about adverse outcomes from delayed treatment, including the risk of cancer progression and other complications. Further, concerns were raised about a potentially significant backlog of patients in need of cancer care due to the pandemic-related delays in healthcare, further exacerbating any potential adverse outcomes. Delayed access to surgery is particularly relevant to urologic oncology since one-third of new cancers in men (20% overall) arise from the genitourinary (GU) tract and surgery is often the primary treatment. Herein, we summarize the prepandemic literature on deferred surgery for GU cancers and risk of disease progression. The aforementioned data on delayed surgery were gathered in the context of systemic delays present in certain healthcare systems, or occasionally, due to planned deferral in suboptimal surgical candidates. These data provide indirect, but sufficient insight to develop triage schemas for prioritization of uro-oncological cases. Herein, we outline the extent to which the pandemic-related triage guidelines had influenced urologic practice in various regions. To study the adverse outcomes in the pandemic-era, a survey of urologic oncologists was conducted regarding modifications in their initial management of urologic cancers and any delay-related adverse outcomes. While the adverse effects directly from COVID-19 related delays will become apparent in the coming years, the results showing short-term outcomes are quite instructive. Since cancer care was assigned a higher priority at most centers, this strategy may have avoided significant delays in care and limited the anticipated negative impact of pandemic-related constraints.

[Surgical care during the new coronavirus (Covid-19) pandemic]

Safe and reasonable surgical care in the context of COVID-19 pandemic is difficult task. The main current issues are selection of patients for surgical treatment, principles of surgical treatment in cancer patients, possibilities of endoscopic surgery, organization of surgical department and operating theatre, surgical strategy in infected patients. Own experience and rational implementation of the recommendations developed by international research and practical communities are extremely important for optimizing surgical treatment of patients in a pandemic, as well as for ensuring the safety of patients and medical staff.

Rapid Scoping Review of Laparoscopic Surgery Guidelines During the COVID-19 Pandemic and Appraisal Using a Simple Quality Appraisal Tool "EMERGE"

The theoretical danger of virus transmission during laparoscopic surgery (LS) via surgical smoke and laparoscopy gas has led to the formulation of many guidelines during the COVID-19 pandemic. This rapid scoping review of these guidelines was done to assess the quality of their evidence and appraise them for their impact on surgical services from the global south. A simple quality appraisal tool was constructed which can be used to evaluate rapidly emerging guidelines for evidence as well as for the needs of the global south. This rapid scoping review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol. Electronic databases were searched with predefined strategy and retrieved papers were screened according to relevant criteria. A simple objective tool to assess the quality of rapidly emerging guidelines including evidence, methodology, ease, resource optimization, geography, and the economy was constructed. Twenty studies met the inclusion criteria. None of the guidelines qualified to be evidence-based clinical practice guidelines as the level of evidence was uniformly rated “low”. A newly constructed tool showed good validation, reliability, and internal consistency. This rapid scoping review found two major research gaps: lack of systematic review of evidence during their development and insufficient weightage of their impact on surgical services from the global south. These significant issues were addressed by constructing a simple and more representative tool for evaluating rapidly emerging guidelines which also gives the rightful importance of their impact on surgical services from the global south.

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.

Outreach and Influence of Surgical Societies' Recommendations on Minimally Invasive Surgery During the COVID-19 Pandemic-An Anonymized International Urologic Expert Inquiry

Objective

To assess the outreach and influence of the main recommendations of surgical governing bodies on adaptation of minimally invasive laparoscopic surgery (MIS) procedures during the coronavirus disease 2019 (COVID-19) pandemic in an anonymized multi-institutional survey.

Materials and Methods

International experts performing MIS were selected on the basis of the contact database of the speakers of the Friends of Israel Urology Symposium. A 24-item questionnaire was built using main recommendations of surgical societies. Total cases/1 Mio residents as well as absolute number of total cases were utilized as surrogates for the national disease burden. Statistics and plots were performed using RStudio v0.98.953.

Results

Sixty-two complete questionnaires from individual centers performing MIS were received. The study demonstrated that most centers were aware of and adapted their MIS management to the COVID-19 pandemic in accordance to surgical bodies’ recommendations. Hospitals from the countries with a high disease burden put these adoptions more often into practice than the others particularly regarding swabs as well as CO2 insufflation and specimen extraction procedures. Twelve respondents reported on presumed severe acute respiratory syndrome coronavirus 2 transmission during MIS generating hypothesis for further research.

Conclusion

Guidelines of surgical governing bodies on adaptation of MIS during the COVID-19 pandemic demonstrate significant outreach and implementation, whereas centers from the countries with a high disease burden are more often poised to modify their practice. Rapid publication and distribution of such recommendation is crucial during future epidemic threats.