Is Re-introducing Major Open and Minimally Invasive Surgery during COVID-19 Safe for Patients and Healthcare Workers? An International, Multi-centre Cohort Study in the Field of Oesophago-gastric Surgery.

INTRODUCTION: The COVID-19 pandemic has resulted in unparalleled changes to patient care, including the suspension of cancer surgery. Concerns regarding COVID-19-related risks to patients and healthcare workers with the re-introduction of major complex minimally invasive and open surgery have been raised. This study examines the COVID-19 related risks to patients and healthcare workers following the re-introduction of major oesophago-gastric (EG) surgery. PATIENTS AND METHODS: This was an international, multi-centre, observational study of consecutive patients treated by open and minimally invasive oesophagectomy and gastrectomy for malignant or benign disease. Patients were recruited from nine European centres serving regions with a high population incidence of COVID-19 between 1 May and 1 July 2020. The primary endpoint was 30-day COVID-19-related mortality. All staff involved in the operative care of patients were invited to complete a health-related survey to assess the incidence of COVID-19 in this group. RESULTS: In total, 158 patients were included in the study (71 oesophagectomy, 82 gastrectomy). Overall, 87 patients (57%) underwent MIS (59 oesophagectomy, 28 gastrectomy). A total of 403 staff were eligible for inclusion, of whom 313 (78%) completed the health survey. Approaches to mitigate against the risks of COVID-19 for patients and staff varied amongst centres. No patients developed COVID-19 in the post-operative period. Two healthcare workers developed self-limiting COVID-19. CONCLUSIONS: Precautions to minimise the risk of COVID-19 infection have enabled the safe re-introduction of minimally invasive and open EG surgery for both patients and staff. Further studies are necessary to determine the minimum requirements for mitigations against COVID-19.

The management of surgical patients in the emergency setting during COVID-19 pandemic: the WSES position paper.

BACKGROUND: Since the COVID-19 pandemic has occurred, nations showed their unpreparedness to deal with a mass casualty incident of this proportion and severity, which resulted in a tremendous number of deaths even among healthcare workers. The World Society of Emergency Surgery conceived this position paper with the purpose of providing evidence-based recommendations for the management of emergency surgical patients under COVID-19 pandemic for the safety of the patient and healthcare workers. METHOD: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) through the MEDLINE (PubMed), Embase and SCOPUS databases. Synthesis of evidence, statements and recommendations were developed in accordance with the GRADE methodology. RESULTS: Given the limitation of the evidence, the current document represents an effort to join selected high-quality articles and experts' opinion. CONCLUSIONS: The aim of this position paper is to provide an exhaustive guidelines to perform emergency surgery in a safe and protected environment for surgical patients and for healthcare workers under COVID-19 and to offer the best management of COVID-19 patients needing for an emergency surgical treatment. We recommend screening for COVID-19 infection at the emergency department all acute surgical patients who are waiting for hospital admission and urgent surgery. The screening work-up provides a RT-PCR nasopharyngeal swab test and a baseline (non-contrast) chest CT or a chest X-ray or a lungs US, depending on skills and availability. If the COVID-19 screening is not completed we recommend keeping the patient in isolation until RT-PCR swab test result is not available, and to manage him/she such as an overt COVID patient. The management of COVID-19 surgical patients is multidisciplinary. If an immediate surgical procedure is mandatory, whether laparoscopic or via open approach, we recommend doing every effort to protect the operating room staff for the safety of the patient.

SARS-CoV-2 pandemic: implications in the management of patients with colorectal cancer

The SARS-CoV-2 pandemic has already reached 3,207,248 patients with more than 225,000 deaths all over the world. Colorectal cancer is the third most diagnosed cancer worldwide, and the healthcare system is struggling to manage daily activities for elective cancer surgery. This review integrates clinical, microbiological, architectural and surgical aspects to develop indications on strategies to manage colorectal cancer patients and ensure safety during the pandemic. Telephone or virtual clinics must be encouraged and phone follow-up should be implemented. Indications for surgery must be rigorous, balancing the advantage of early surgical treatment and risks of treatment delay. To decrease the occupancy rate of intensive care unit beds, elective surgical treatment should be delayed until local endemic control, according to stage of disease. Patients with SARS-CoV-2 infection should be treated only after clinical recovery, two consecutive negative oropharyngeal swabs and, if available, a negative stool sample. Before any elective oncologic procedure, a multidisciplinary oncologic team including an anaesthesiologist and an infectious disease specialist must assess every patient to evaluate the risk of infection and its impact on perioperative morbidity, mortality and oncologic prognosis. The hospital should organise to manage all elective oncologic patients in an 'infection-free' area or refer them to a non-SARS-CoV-2 hospital.

Emergency general surgery in Italy during the COVID-19 outbreak: first survey from the real life.

BACKGROUND: COVID-19 pandemic has rapidly spread in Italy in late February 2020. Almost all surgical services have been reorganized, with the aim of maintaining an adequate therapeutic path, especially for surgical emergencies. The knowledge of how surgeons dealing with emergency surgery have reacted to the epidemic in the real life can be useful while drafting clinical recommendations. METHODS: Surgeons from multiple Italian regions were invited answering to an online survey in order to make a snapshot of their current behaviors towards COVID-19-positive patients bearing urgent surgical diseases. Questions about institutional rules and personal approach for patient treatment and to limit epidemic spread were included in a 37-item questionnaire. RESULTS: Seventy-one questionnaires from institutions dealing with emergency surgery were accepted. Participating surgeons were equally subdivided from a geographical point of view, with a large proportion of public (97.2%) and non-academical (91.5%) centers. In 80.3% of cases, the hospitals treated COVID-19 patients; in 69.1% of centers, a change in work plan was necessary, and 33.8% of teams had almost a surgeon infected or in preventive quarantine. The vast majority of surgeons operated only on urgent cases (73.9%), but the number of interventions significantly dropped. Up to 40% of non-traumatic abdominal emergency cases had an unusual delayed treatment. The laparoscopic approach was used in 69.6% of interventions on COVID-19 patients. Strategies to protect health care workers against COVID-19 infection and to identify asymptomatic infected surgeons were suboptimal with respect to the WHO recommendations in 70.4% and 90.2% of centers, respectively. Advanced personal protective equipment for operating room workers was adopted for all surgeries in only 12.7% of centers. DISCUSSION: This survey confirms that the COVID-19 outbreak is dramatically changing the practice of emergency surgery centers in Italy. Despite the reduction in number, urgent cases were on average more challenging owing to diagnostic delay. Recommendations from the International Scientific Societies are frequently not complied concerning the use of laparoscopic approach, the availability of personal protective equipment in the operating rooms, and the testing of both asymptomatic physicians and patients scheduled for surgery. A further evaluation of the short-term results of these attitudes is warranted to modulate international recommendations.