Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19.

INTRODUCTION: Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients. METHODS: A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK. RESULTS: Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19. CONCLUSION: With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

Adapting an emergency general surgery service in response to the COVID-19 pandemic.

INTRODUCTION: In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes. METHODS: Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge. RESULTS: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality. CONCLUSIONS: Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.

Challenges in providing surgical procedures during the COVID-19 pandemic: Qualitative study among Operating Department Practitioners in Pakistan.

The surgical theatre is associated with the highest mortality rates since the onslaught of the COVID-19 pandemic. However, Operating Department Practitioners (ODPs) are neglected human resources for health in regards to both professional development and research for patient safety; even though they are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs during the pandemic. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics. A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes. Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear. The public health sector, in Pakistan and other developing regions, needs to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwise.

Establishing a South African national framework for COVID-19 surgical prioritisation.

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.

[Management of elective surgical activity in a tertiary hospital during the SARS-CoV-2 pandemic]. / Gestión de la actividad quirúrgica electiva de un hospital terciario durante la pandemia por SARS-CoV-2.

INTRODUCTION: During the SARS-CoV-2 pandemic, elective surgical activity was reduced to a minimum. As both the number of cases and the hospitalization needs for this pathology decreased, we thought it appropriate to progressively recover scheduled surgical activity. This work describes how, even with the current alarm state, we were able to practically normalize this activity in a few weeks. METHODS: Two weeks before the intervention, the patients included in the waiting lists were contacted by telephone. After checking their health status and expressing their desire to undergo surgery, they were provided with recommendations to decrease the risk of coronavirus infection. Likewise, an exclusive circuit was established to carry out, 48 hours before the intervention, the detection of SARS-CoV-2 by means of exudates nasopharyngeal PCR. The results were evaluated by each surgical service and the anesthesiology service. In addition, asymptomatic Surgical Area professionals could undergo weekly screening for the early detection of coronavirus according to the recommendations of Occupational Health. RESULTS: In the midst of a pandemic, scheduled surgical activity was reduced by 85%. From the week of April 13, the operating rooms available were recovered, which allowed practically all surgical activity to be recovered the week of May 25. CONCLUSIONS: The creation of circuits and procedures to streamline surgical activity, still in full force of the state of alarm, has allowed us, in a few weeks, to recover almost all of it.

Organizational aspects of pediatric anesthesia and surgery between two waves of Covid-19.

BACKGROUND: The initial wave of the Covid-19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures-with the exception of urgent/emergent ones-between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars-CoV-2 in every case. METHODS: Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS-CoV -2 RT-PCR testing outcomes, and comparison to same period surgeries in 2019. RESULTS: An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33-2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43-2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi-squared P-value < .001). Sars-CoV-2-positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity. CONCLUSION: We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.

Surgical Support for Severe COVID-19 Patients: A Retrospective Cohort Study in a French High-Density COVID-19 Cluster.

Background. The COVID-19 epidemic has resulted in a massive surge in the need for intensive care unit (ICU) care. To avoid being overwhelmed, hospitals had to adapt and support the ICU teams in structured ICU care including involving surgical teams. This work aims at describing the collaborative efforts between the ICU care team and the Surgical Task Force (STF) during a surge of ICU activity in a University Hospital in a French high-density COVID-19 cluster. Study Design. This retrospective single center study analyzed the STF workflow and the ICU population. The study included 55 patients hospitalized in our ICU, ICU-converted step-down units, and post-anesthesia care units. The primary measure was the global daily STF activity. The secondary measure was the daily activity for each of the 5 tasks accomplished by the STF. Results. The STF attempted 415 phone calls for 55 patients' families, 237 mobilizations of patients requiring prone positions, follow-up of 20 patients requiring medevac, and contribution to ethical discussion for 2 patients. The mean (SD) daily number of successful phones calls, ethical discussions, mobilizations of patients requiring prone positions and medevac follow-up were 18 (7), .1 (.4), 10 (7), and 2 (3), respectively. No actions for discharge summaries writing were required. The maximum number of daily mobilizations for patients requiring prone positions was 25. The maximum number of daily attempted phone calls and successful phone calls were 37 and 26, respectively. Conclusion. Surgeons' technical and nontechnical skills represented an effective support for ICU teams during the COVID-19 pandemic.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

Re-organization of the Vascular Surgery Department During the Acute Phase of the COVID19 Outbreak: Lessons Learned and Future Perspectives.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection represents a serious threat to public health because it leads to a wide spectrum of clinical manifestations. The region Lombardia (Italy) has suffered from severe problems during the acute phase of the outbreak in Italy (March-April 2020). The aim of our analysis is to report the experience of the Department of Vascular Surgery of Pavia, including the learned lessons and future perspectives, considering that the COVID-19 outbreak is in its acute phase in other continents. MATERIAL AND METHODS: Single-center, retrospective, observational study based on extracted data from the medical records of all consecutive COVID-19 patients observed in our Vascular Department between March 1st and April 30th, 2020. We reviewed the records for demographic information, comorbidities, laboratory tests, and anticoagulation treatment at the time of hospital admission. RESULTS: We observed an important reduction in elective and urgent interventions compared to the same period of the previous year; in parallel, we observed an increase in the diagnosis of deep vein thrombosis (DVT) in hospitalized patients, especially with severe infection. In our department, four infections were reported among health workers. CONCLUSIONS: The impact of the COVID19 pandemic on health-care delivery has been massive. A wave of vascular-related complications is expected. Regular SARS-CoV-2 screening, adequate protection, and quick reorganization of health-care resources are still needed.