key: cord-0695632-qtlq7a6l
authors: Guraya, Salman Yousuf
title: Transforming laparoendoscopic surgical protocols during COVID-19 pandemic; big data analytics, resource allocation and operational considerations; a review article
date: 2020-06-23
journal: Int J Surg
DOI: 10.1016/j.ijsu.2020.06.027
sha: 3dcf6406a7addd81763cc31c5d3b0307a2271c25
doc_id: 695632
cord_uid: qtlq7a6l

The current dreadful pandemic of coronavirus disease (COVID-19) is playing havoc with humanity, socio-communal systems and economic reservoirs worldwide. Certain countries have managed to curtail COVID-19 crisis to some extent, however, a great majority still remains helpless in containing this outbreak. Rapidly evolving disease patterns and complex epidemiology of COVID-19 necessitate a tailored approach by medical experts in dealing with this devastating outbreak. Similar to other medical disciplines, surgical associations and societies have developed a tailored approach of patients’ selection and planning with improvised endolaparoscopic practice during the COVID-19 pandemic. Non-essential and non-urgent surgical procedures are deferred till this outbreak is abated. Benefits of delaying elective and non-urgent surgery outweighs the risk of performing surgical procedures on patients with asymptomatic or active COVID-19 disease. Laparoendoscopic procedures increase the risk of aerosol exposure, disease transmission and contamination. Limiting the number of operating room personnel, use of disposable instruments, small trocar incisions, negative pressure environment, and setting energy devices at low modes can help reduce disease transmission during laparoendocsopic procedures. This write up provides a brief account of the impact of the COVID-19, big data analytics of response of medical personnel in curtailing and understanding the disease process and the consensus guidelines for carrying out laparoscopic and endoscopic procedures.

As it stands, from January to May 2020, the ScienceDirect database has published approximately 6,202 documents about COVID-19 in medical and allied health sciences [4] . In the ScienceDirect repository, China has contributed by the largest number of publications, followed by United States, Italy and United Kingdom (Figure 1) . To some extent, this trend of proliferation of scientific documents reciprocates with magnitude of disease burden and associated morbidity and mortality in these countries. Further, breakdown of publications in medical disciplines in the Web of Science database has shown a highest number of documents published in the Journal of Internal Medicine, followed by surgery, imaging and infectious disease journals (Figure 3) . This includes all categories of articles such as editorial, review, original research, opinions, short communications, letters to editors and commentaries. This data reflects enormous response by the medical fraternity to COVID-19 pandemic by conceiving, conducting and publishing novel research findings in a wealth of publishing titles. Regrettably, despite this profound work, so far we have neither succeeded in drawing a unified contingency management protocol nor a vaccine for combating COVID-19 disease.

Generally, almost all age groups are susceptible to COVID-19 as approximately 86.6% of all patients, infected so far, were aged between 30 to 79 years with a median age of 47 years [5] . Though literature has not reported any significant gender preponderance, men are shown to exhibit a higher propensity for COVID-19 [6] . The major mode of transmission of SARS-CoV-2 is human-to-human and, according to the National Health Commission of China, SARS-CoV-2 spreads through respiratory aspirates, droplets, direct exposure, feces, and aerosols transmission [7] . There are sporadic reports about vertical transmission of SARS-CoV-2 but literature does not provide concrete evidence about this mode of spread [8] [9] . On the same note, Chen et al. did not find SARS-CoV-2 from the amniotic fluid, cord blood, neonatal throat swab, and breast milk samples of the pregnant women with COVID-19 in their third trimesters [10] .

Recent research has shown that cough and sneezes contains muco-salivary droplets resulting from short-range semi-ballistic emission trajectories [11] . These droplets are primarily composed of a complex cloud that embraces air, cluster of droplets and pathogens. Due to the forward thrust of the cloud, the virus-containing droplets are propelled much farther than if they were thrown without a heavy cloud. This biophysics of gas clouds and gas cloud dynamics bears significant implications in disease progression and provides the basis for a 2-meter social distancing and home-isolation. Though researchers have reported growth of SARS-CoV-2 RNA from blood and feces of COVID-19 patients (2, 3), Coccolini et al. have confirmed its presence in the peritoneal cavity of a 78-year-old man [12] . Using the real-time reverse transcriptasepolymerase chain reaction (RT-PCR), the investigators have detected the genome of SARS-CoV-2 RNA in the peritoneal fluid. This finding has significant implications for the abdominal surgeons and gastroenterologists as they invariably deal with GIT fluids and secretions during their clinical practices.

Parallel with the evolving guidelines for combating COVID-19 outbreak in medical field, several international surgical societies and regulatory bodies have adopted a host of surgical protocols. These recommendations primarily aim to safeguard the surgical patients, surgeons and their surgical teams from adverse and fatal outcomes of COVID-19. The following section of this article provide major modifications in laparoendoscopic surgical practice and elective and emergency surgical procedures during the COVID-19 pandemic.

Similar to other medical fields, COVID-19 pandemic has substantially influenced the workplace policies and procedures in surgical disciplines. From a global perspective, the federal governments and health-care authorities have modified the protocols and guidelines for general and specialty surgical practices [13] . Elective surgery for benign disorders are deferred till COVID-19 pandemic is abated. This is mostly driven by the fact that laparoscopic surgery for benign and non-urgent illnesses may potentially lead to unwanted complications with poor surgical outcomes [14] . Healthcare professionals (HCPs) should inform the patients and their families about medical reasons for postponing surgery, particularly the collective community welfare of reserving hospital beds for critically ill patients with respiratory disorders. On the other hand, oncological surgery would continue during the COVID-19 crisis by adhering to the general principles of surgical practice [15] [16] . Delay in surgery for cancer patients will not only worsen the prognosis [17] , but also the estimated risk of surgical complications and morbidity and mortality would increase [18] [19] . Careful selection of patients and adherence to the revised and modified surgical principles during COVID-19 outbreak are essential.

a. Operating theatres should have a negative pressure flow below 4.7 Pa to prevent outward diffusion and contamination of personnel and external surfaces. b. Operating teams should have appropriate personal protection equipment (PPE) including face shields, gloves, masks, gowns and caps. c. Arrange separate contingency plans in operating theaters about entry-points of the patients with COVID-19 (symptomatic), suspected of COVID-19 (asymptomatic carriers) and for COVID-19 free (non-infected) patients [20] . d. All patients planned for endoscopic or surgical procedure must undergo a comprehensive pre-operative health screening protocol despite being asymptomatic. e. For patients with life-threatening conditions where results of RT-PCR are not available, consider them as infected and manage them with the protocol for infected cases [21] . f. Aerosol generating procedures (AGPs) such as intubation, extubation, bag masking, bronchoscopy, chest tube insertion, upper and lower GIT endoscopy, laparoscopy and electrocautery lead to a high risk of aerosol exposure of HCPs [22] . Special precautions should be observed and strictly followed during all AGPs. g. During AGPs, adjust devices to the lowest effective power settings in order to reduce the amount of surgical smoke emitting from operating areas.

h. During all endolaparoscopic surgeries, limit the number of HCPs in operating rooms and instruct them to leave room during AGPs and particularly during intubation and extubation processes. i. Separately clean all surgical equipment that was used during surgical procedures in patients with COVID-19 positive or persons under investigation (suspected COVID cases).

Laparoscopic surgery should be offered cautiously as the risk of exposure and contamination of personnel is high. There is an estimated risk of exposure of HCPs to SARS-CoV-2 due to its presence in the peritoneal cavity. The energy devices used during surgery and endoscopy such as electrocautery or ultrasonic shears produce surgical smoke (plume) during tissue dissection. Aerosolization of plume during endolaparoscopy is the most frequent deterrent to using laparoscopic surgery during COVID-19 outbreak [23] . The aerosol effect during surgery serves as potential leaks from trocars and post-surgery (exsufflation) can contaminate HCPs and surrounding surfaces by airborne transmission. a. Though there is inconclusive evidence about the relative risks of laparoscopic surgery as compared to conventional surgery during COVID-19 era, potential contamination of operating theatre, HCPs, and surroundings is possible. Therefore, strict protective measures should be in place during peri-operative period.

b. All laparoscopic procedures should be performed for life-threatening conditions only. Surgeons must ensure that all trocars are carefully introduced through abdominal opening without leakage and, preferably, by using balloon trocars.

c. Use disposable trocars and endoscopic instruments as cleaning the usable equipment adds risk of contamination.

d. Surgeons should use aspirator to remove smoke and to avoid leakage of smokes through trocars.

e. Maintain pneumoperitoneum at a lower pressure of 10-12 mm of Hg and low flow rate of insufflation.

f. Perform exsufflation and deflation of the peritoneum before trocar removal and specimen retrieval.

g. Due to the presence of SARS-CoV-2 virus in saliva, GIT secretions, stool and blood, set up energy devices at minimal level during all laparoendoscopic procedures.

h. Discourage long dissecting time at same point by laparoendoscopic electrocautery, which will reduce the amount of plume in operating field.

The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) have jointly provided a position statement [25] with the following salient feature;

a. COVID-19 can be effectively eradicated by commonly used disinfectants with virucidal activity. b. Gastroenterologists should not reuse disposable GI endoscopic devices. c. All HCPs and patients in the GI endoscopy unit should wear respiratory protective equipment. d. Standard personal protection equipment (PPE) should include gloves, hairnet, goggles or face shield, waterproof gowns, booties/shoe covers, and respiratory protective equipment. e. In terms of risk stratification, GI endoscopy should always be performed for; upper and lower GI bleeding and anemia with hemodynamic instability, foreign body in esophagus, acute ascending cholangitis and obstructive jaundice and capsule endoscopy for torrential bleeding. f. Low priority endoscopic procedures should be offered for conditions such as low grade GI dysplasia, duodenal polyp, ampullectomy, achalasia and biliary strictures. g. A case-by-case review and individualized decision is recommended.

-The COVID-19 pandemic is spreading with escalating morbidity and mortality worldwide. -Big data analytics has reflected enormous proliferation of research and publications about COVID-19 during 2020. -Surgical practice is rapidly evolving according to the needs analysis and disease burden across regions. -Laparoendocsopic surgery should be postponed for non-essential and non-urgent surgical cases. -Personal protection equipment should be used and aerosol generating procedures should be well planned and rigorously rehearsed. -Laparoendoscopic procedures have potentially increased risk of disease transmission by aerosol exposure and contamination. -Limiting the number of operating room personnel, use of disposable instruments, negative pressure air flow, and setting electrocautery energy devices at low modes can possibly reduce disease transmission during laparoendocsopic procedures.

Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China

The epidemiology, diagnosis and treatment of COVID-19

A pneumonia outbreak associated with a new coronavirus of probable bat origin

Real estimates of mortality following COVID-19 infection

Clinical characteristics of coronavirus disease 2019 in China

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan

The reproductive number of COVID-19 is higher compared to SARS coronavirus

Perinatal transmission of COVID-19 associated SARS-CoV-2: should we worry?

Vertical transmission of coronavirus disease 19 (COVID-19) from infected pregnant mothers to neonates: a review

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19

SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients

Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic

Incidence, correlation with serum cholesterol I and the role of laparoscopic cholecystectom

Malignant melanoma of the small bowel with unknown primary: a case report

Post appendectomy small bowel obstruction

Prognostic significance of circulating microRNA-21 expression in esophageal, pancreatic and colorectal cancers; a systematic review and meta-analysis

Carcinoid tumors of the appendix. Our experience in a university hospital

The mapping of preferred resources for surgical education: Perceptions of surgical trainees at the Advanced International Minimally Invasive Surgery Academy

Risks of viral contamination in healthcare professionals during laparoscopy in the Covid-19 pandemic

Infection Prevention Measures for Surgical Procedures during a Middle East Respiratory Syndrome Outbreak in a Tertiary Care Hospital in South Korea

COVID-19: Impact on Colorectal Surgery

COVID-19: Advice from the Canadian Association of Gastroenterology for Endoscopy Facilities

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic

ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic

No conflict of interests declared.Provenance and peer review Not commissioned, externally peer-reviewed

The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories, then this should be stated.

No conflict of interest is declared.

No source of funding for this research

This is a review article and my institution does not require ethical approval for such type of research.

Please enter the name of the registry, the hyperlink to the registration and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only.Not applicable as this is not a human study and covers review of the literature. Name of the registry:1. Unique Identifying number or registration ID: 2. Hyperlink to your specific registration (must be publicly accessible and will be checked):

Please specify the contribution of each author to the paper, e.g. study design, data collections, data analysis, writing. Others, who have contributed in other ways should be listed as contributors.SYG conceived the research concept, conducted initial and final search for literature review, and wrote the final draft. SYG is responsible for the originality of this research article.

The Guarantor is the one or more people who accept full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Please note that providing a guarantor is compulsory.Prof. Salman Guraya is responsible for the work and provides full guarantee for the academic integrity and originality of this work.

International Journal of Surgery