The MIS-COVID-AGICT Study: Trend of Minimally Invasive Surgery for Gastrointestinal Cancer Treatment During the First Waves of the COVID-19 Pandemic in Italy. Subgroup Analysis from the COVID-AGICT Study: COVID-19 and Advanced Gastrointestinal Cancer Surgical Treatment.

Background: A preliminary analysis from the COVID-Advanced Gastrointestinal Cancer Surgical Treatment (AGICT) study showed that the rate of minimally invasive surgery (MIS) for elective and urgent procedures did not decrease during the pandemic year. In this article, we aimed to perform a subgroup analysis using data from the COVID-AGICT study to evaluate the trend of MIS during the COVID-19 pandemic period in Italy. Methods: This study was conducted collecting data of MIS patients from the COVID-AGICT database. The primary endpoint was to demonstrate whether the SARS-CoV-2 pandemic scenario reduced MIS for elective treatment of gastrointestinal cancer (GIC) in Italy in 2020. The secondary endpoint was to evaluate the impact of the pandemic period on perioperative outcomes in the MIS group. Results: In the pandemic year, 62% of patients underwent surgery with a minimally invasive approach, compared to 63% in 2019 (P = .23). In 2020, the proportion of patients undergoing elective MIS decreased compared to the previous year (80% versus 82%, P = .04), and the rate of urgent MIS did not differ between the 2 years (31% and 33% in 2019 and 2020 - P = .66). Colorectal cancer was less likely to be treated with MIS approach during 2020 (78% versus 75%, P < .001). Conversely, the rate of MIS pancreatic resection was higher in 2020 (28% versus 22%, P < .002). Conversion to an open approach was lower in 2020 (7.2% versus 9.2% - P = .01). Major postoperative complications were similar in both years (11% versus 11%, P = .9). Conclusion: In conclusion, although MIS for elective treatment of GIC in Italy was reduced during the COVID-19 pandemic period, our study revealed that the overall proportion of MIS (elective and urgent) and postoperative outcomes were comparable to the prepandemic period. ClinicalTrial.gov (NCT04686747).

Changes to same day discharge after minimally invasive hysterectomy throughout COVID-19 pandemic.

BACKGROUND: Minimally invasive hysterectomy is a common gynecologic procedure. Numerous studies have found that a same day discharge (SDD) is safe following this procedure. Research has found that SDDs decrease resource strain, nosocomial infections, and financial burden for both the patient and healthcare system. Due to the recent COVID-19 pandemic, the safety of hospital admissions and elective surgeries was called into question. OBJECTIVE: To assess the rates of SDD among patients who underwent a minimally invasive hysterectomy before and during the COVID-19 pandemic. STUDY DESIGN: A retrospective chart review was performed from September 2018 to December 2020 on 521 patients, who met inclusion criteria. Descriptive analysis, chi-square tests of association, and multivariable logistic regression were used for analysis. RESULTS: There was a significant difference between rate of SDDs pre-COVID-19 (12.5%) versus during the COVID-19 period (28.6%) (p < 0.001). Surgical complexity was predictive of not being discharged the same day of surgery (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 2.2-8.8), as was surgical completion time after 4 p.m. (OR = 5.2, 95% CI = 1.1-25.2). There was no difference in readmissions (p = 0.209) and emergency department (ED) visits (p = 0.973) between SDD and overnight stay. CONCLUSION: Rates of SDD for patients undergoing minimally invasive hysterectomy were significantly increased during the COVID-19 pandemic. SDDs are safe; the number of readmissions and ED visits did not increase among patients who were discharged on the same day.

Safety and Feasibility of Telehealth Only Preoperative Evaluation Before Minimally Invasive Robotic Urologic Surgery.

Purpose: Telehealth utilization has increased dramatically over the past few years due to improvement in technology and the COVID-19 pandemic. To date, no study has examined whether a telehealth visit alone for preoperative evaluation is safe and sufficient before surgery. We examined the safety and feasibility of preoperative telehealth visits alone before minimally invasive urologic surgery. Materials and Methods: Single institution retrospective review of robotic prostate, kidney, and cystectomy procedures between April and December 2020. Cases were dichotomized into those who underwent preoperative evaluation by telehealth only vs traditional in-person visits. Outcomes included complications, blood loss, conversion to open surgery rates, and operative times. We assessed efficiency of care by measuring time from preoperative visit to surgery. Results: Three hundred fourteen patients were included in the study, with 14% of cases (n = 45) being performed after a preoperative telehealth visit. The majority of cases included in analysis were robotic surgeries of the prostate (56.1% of all cases, n = 176) and the kidney (35.0% of all cases, n = 110). Patients seen via telehealth alone preoperatively had no significant differences in any grade of complications, perioperative outcomes, blood loss, operative time, and length of stay. There was no difference in change in anticipated procedure between the groups, and there was no case of conversion to open surgery in the telehealth only group. Time from preoperative visit to surgery was significantly shorter for the telehealth group by 13 days. Conclusions: Our study is the first to analyze the safety of telehealth only preoperative visits before minimally invasive urologic surgery. We found no difference in perioperative outcomes including conversion to open surgery or change in planned procedure. Furthermore, telehealth preoperative visits appeared to facilitate shorter time to surgery. This study has important implications for expediting patient care and medicolegal considerations.

Minimally Invasive Surgery for Colorectal Cancer During the COVID-19 Pandemic in a Tertiary Medical Facility in Japan.

BACKGROUND/AIM: The coronavirus disease 2019 (COVID-19) pandemic has reduced hospital visits due to concerns regarding infection and also resulted in cancer screening delays. These changes may have had an impact on the progression of colorectal cancer (CRC). Therefore, the present study investigated the effects of the COVID-19 pandemic on minimally invasive surgery (MIS) for CRC using a correlation analysis of clinical outcomes before and during the COVID-19 pandemic. PATIENTS AND METHODS: The present study targeted CRC patients who underwent MIS between January 2018 and December 2019 (pre-COVID-19) and between April 2020 and March 2021 (COVID-19). A comparison analysis of clinical, surgical, and pathological findings between the pre-COVID-19 and COVID-19 groups was performed. RESULTS: Ninety-one patients underwent MIS for CRC pre-COVID-19 and 67 during COVID-19. The number of CRC cases detected by fecal occult blood tests was slightly higher in the pre-COVID-19 group than that in the COVID-19 group. Re-evaluations of laparoscopic videos revealed that the number of cases of surgical T4 CRC resected with the combined resection of the adjacent organs was significantly higher in the COVID-19 group than that in the pre-COVID-19 group (16.4 vs. 4.4%, p=0.010). Furthermore, surgical times were significantly longer in the COVID-19 group than those in the pre-COVID-19 group (p<0.001). Pathological findings showed that the number of pT4 cases was significantly higher in the COVID-19 group than that in the pre-COVID-19 group (p=0.026). CONCLUSION: The number of T4 CRC cases was higher during than before the COVID-19 pandemic, with increases in the surgical difficulty of MIS.

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.

Perspectives of Gynecologic Oncologists on Minimally Invasive Surgery During COVID-19 Pandemic: A Turkish Society of Minimally Invasive Gynecologic Oncology (MIJOD) Survey.

BACKGROUND: To evaluate gynecologic oncologists' trends and attitudes towards the use of Minimally invasive surgery (MIS) in active period of the COVID-19 pandemic in Turkey. METHODS: Online national survey sent to members of Turkish Endoscopy Platform consisting of six sections and 45 questions between the dates 1-15 June 2020 in Turkey to explore their surgical practice during the pandemic in three hospital types: Education and research hospital/university hospital, state hospital and private Hospital. Participants were gynecologic oncologists who are members of Turkish Endoscopy Platform. RESULTS: Fifty-eight percent of participants canceled all operations except for cancer surgeries and emergent operations. About a quarter of participants (28%) continued to operate laparoscopically and/or robotically. For the evaluation of the suspected adnexial mass (SAM) 64% used laparotomy and only 13 % operated by laparoscopy (L/S). For the management of low-risk early-stage endometrial cancer only fifth of the participants preferred to perform L/S. For endometrial cancer with high-intermediate risk factors more than half of participants preferred complete staging with laparotomy. For advanced stage ovarian cancer, one-fifth of the participants preferred to perform an explorative laparotomy, whilst 15 % preferred diagnostic laparoscopy to triage the patients for either NACT or cytoreductive surgery. On the contrary 41 % of participants chose to have cytology by paracentesis for neo-adjuvant chemotherapy (NACT). Gynecologic oncologists with >10 years L/S experience used MIS more for SAM. Furthermore, experienced surgeons used L/S more for endometrial cancer patients. In busy COVID hospitals, more participants preferred laparotomy over L/S. CONCLUSION: Use of MIS decreased during the pandemic in Turkey. More experienced surgeons continued to perform MIS. Surgical treatment was the preferred approach for SAM, early-stage endometrial cancer.  However, NACT was more popular compared to radical surgery.

Surgical treatment of gastrointestinal tumors in a COVID-19 pandemic hospital: Can open versus minimally invasive surgery be safely performed?

PURPOSE: In order for patients with gastrointestinal cancer not to suffer the consequences of delayed treatment, they should be operated on in pandemic hospitals under adequate conditions. We aimed to discuss the outcomes of our gastrointestinal cancer surgery patients and to present our patient management recommendations to resume operative treatment during the ongoing COVID-19 pandemic while taking into account hospital facilities. MATERIALS AND METHODS: This study included 129 gastrointestinal cancer patients who underwent surgery between March 2020 and May 2021 in the gastrointestinal surgery clinic of our hospital, which was assigned as a pandemic hospital in March 2020. Patients' demographic characteristics and preoperative and postoperative findings were recorded. RESULTS: Among the patients, 42.6% (n = 55) were female and 57.3% (n = 74) were male. The mean age was 61.89 ± 3.4 years. The primary tumor organs were the stomach 37.2% (n = 48), pancreas 36.4% (n = 47), rectum 11.6% (n = 15), colon 8.5% (n = 11), and esophagus 6.2% (n = 8). The patients were treated with open (75.2%, n = 97) or minimally invasive surgery (24.8%, n = 32; laparoscopic 11.6%, n = 15; robotic 13.2%, n = 17). Eight patients tested positive for COVID-19 before surgery. No patients developed COVID-19 during postoperative intensive care or after being moved to the floor unit. There was no COVID-19-related morbidity or mortality. CONCLUSION: Failure to treat gastrointestinal cancer patients during the pandemic may result in undesirable consequences, such as stage shift and mortality. Cancer patients can be treated safely with conventional and minimally invasive surgery guided by current recommendations and experience.

Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study.

BACKGROUND: The COVID-19 pandemic forced a reconsideration of surgical patient management in the setting of scarce resources and risk of viral transmission. Herein we assess the impact of implementing a protocol of more rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication for patients undergoing brain tumor surgery. METHODS: A case-control retrospective review was undertaken at a community hospital with a dedicated neurosurgery and otolaryngology team using minimally invasive surgical techniques, total intravenous anesthesia (TIVA) and early post-operative imaging protocols. All patients undergoing craniotomy or endoscopic endonasal removal of a brain, skull base or pituitary tumor were included during two non-overlapping periods: March 2019-January 2020 (pre-pandemic epoch) versus March 2020-January 2021 (pandemic epoch with streamlined care protocol implemented). Data collection included demographics, preoperative American Society of Anesthesiologists (ASA) status, tumor pathology, and tumor resection and remission rates. Primary outcomes were ICU utilization and hospital length of stay (LOS). Secondary outcomes were complications, readmissions and reoperations. FINDINGS: Of 295 patients, 163 patients were treated pre-pandemic (58% women, mean age 53.2±16 years) and 132 were treated during the pandemic (52% women, mean age 52.3±17 years). From pre-pandemic to pandemic, ICU utilization decreased from 92(54%) to 43(29%) of operations (p<0.001) and hospital LOS≤1 day increased from 21(12.2%) to 60(41.4%), p<0.001, respectively. For craniotomy cohort, median LOS was 2 days for both epochs; median ICU LOS decreased from 1 to 0 days (p<0.001), ICU use decreased from 73(80%) to 29(33%),(p<0.001). For endonasal cohort, median LOS decreased from 2 to 1 days; median ICU LOS was 0 days for both epochs; (p<0.001). There were no differences pre-pandemic versus pandemic in ASA scores, resection/remission rates, readmissions or reoperations. CONCLUSION: This experience suggests the COVID-19 pandemic provided an opportunity for implementing a brain tumor care protocol to facilitate safely decreasing ICU utilization and accelerating discharge home without an increase in complications, readmission or reoperations. More rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication, layered upon a foundation of minimally invasive surgery, TIVA anesthesia and early post-operative imaging are possible contributors to these favorable trends.

Video-assisted minimal access surgery for complicated mitral valve endocarditis, tricuspid valve insufficiency and progressive coronary disease after previous CABG - in the time of COVID-19: a case report.

BACKGROUND: The timing for heart surgery following cerebral embolization after cardiac valve vegetation is vital to postoperative recovery being uneventful, additionally Covid-19 may negatively affect the outcome. Minimally invasive methods and upgraded surgical instruments maximize the benefits of surgery also in complex cardiac revision cases with substantial perioperative risk. CASE PRESENTATION: A 68 y.o. patient, 10 years after previous sternotomy for OPCAB was referred to cardiac surgery on the 10th postoperative day after neurosurgical intervention for intracerebral bleeding with suspected mitral valve endocarditis. Mitral valve vegetation, tricuspid valve insufficiency and coronary stenosis were diagnosed and treated by minimally invasive revision cardiac surgery on the 14th postoperative day after neurosurgery. CONCLUSION: The present clinical case demonstrates for the first time that the minimally invasive approach via right anterior mini-thoracotomy can be safely used for concomitant complex mitral valve reconstruction, tricuspid valve repair and aorto-coronary bypass surgery, even as a revision procedure in the presence of florid endocarditis after recent neurosurgical intervention. The Covid-19 pandemic and prophylactic patient isolation slow down the efficacy of pulmonary weaning and mobilisation and prolong the need for ICU treatment, without adversely affecting long-term outcome.

Tracheostomy in the COVID-19 pandemic.

PURPOSE: The role of tracheostomy in COVID-19-related ARDS is unknown. Nowadays, there is no clear indication regarding the timing of tracheostomy in these patients. METHODS: We describe our synergic experience between ENT and ICU Departments at University Hospital of Modena underlining some controversial aspects that would be worth discussing tracheostomies in these patients. During the last 2 weeks, we performed 28 tracheostomies on patients with ARDS due to COVID-19 infection who were treated with IMV. RESULTS: No differences between percutaneous and surgical tracheostomy in terms of timing and no case of team virus infection. CONCLUSION: In our experience, tracheostomy should be performed only in selected patients within 7- and 14-day orotracheal intubation.

Continuous Negative Pressure Operative Field Barrier for Combined Open Tracheostomy and Percutaneous Endoscopic Gastrostomy Tube Placement During Coronavirus Disease 2019.

Respiratory failure in coronavirus disease 2019 (COVID-19) patients with prolonged endotracheal intubation may require a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement to facilitate recovery. Both techniques are considered high-risk aerosol-generating procedures and present a heightened risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for operating room personnel. We designed, simulated, and implemented a portable, continuous negative pressure, operative field barrier system using standard equipment available in hospitals to enhance health care provider safety during high-risk aerosol-generating procedures.

Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience.

INTRODUCTION: COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. MATERIAL AND METHODS: We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. RESULTS: The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. CONCLUSIONS: This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

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

BACKGROUND: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts' opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. METHODS: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. RESULTS: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. CONCLUSION: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.

Letter to the Editor: Robot-Assisted and Minimally Invasive Pediatric Surgery and Urology During the COVID-19 Pandemic: A Short Literature Review.

The COVID-19 outbreak has dramatically impacted our activities of pediatric surgeons and urologists over the past 3 months, especially in the field of minimally invasive surgery (MIS) and robotics. Analyzing the available literature, there is very scarce evidence regarding the use of MIS and robotics for treatment of pediatric surgical and urological pathologies during this pandemic. However, we found some useful information that we would like to share with other pediatric surgeons and urologists through this journal. Based upon the available data, we believe that surgery should only be performed in pediatric patients with emergent/urgent and oncological indications until resolution of the COVID-19 outbreak. Robotics and MIS may be safely performed in such selected children by adopting specific technical precautions such as prevention of aerosol dispersion using filters/suction or adapted systems and appropriate use of electrocautery and other sealing devices for reduction of surgical smoke, as reported in our recent experience. Another key point to manage this pandemic emergency is that all hospitals should provide health care professionals with adequate individual protections and perform universal screening in all patients undergoing surgery. Considering that this pandemic is a rapidly evolving situation with new information available daily, these data resulting from the analysis of literature focused on pediatric robotics and MIS may be further revised and updated.