key: cord-0867346-rhm1ii3d authors: Kraft, Miquel; Pellino, Gianluca; Jofra, Mariona; Sorribas, Maria; Solís-Peña, Alejandro; Biondo, Sebastiano; Espín-Basany, Eloy title: Incidence, features, outcome and impact on health system of de-novo abdominal surgical diseases in patients admitted with COVID-19 date: 2020-08-28 journal: Surgeon DOI: 10.1016/j.surge.2020.08.006 sha: b1f782846bda84bda55d0c00896c8f04a1b1d7f5 doc_id: 867346 cord_uid: rhm1ii3d Objective to assess the epidemiology and features of de novo surgical diseases in patients admitted with COVID-19, and their impact on patients and healthcare system. Summary Background Data Gastrointestinal involvement has been described in COVID-19; however, no clear figures of incidence, epidemiology and economic impact exist for de-novo surgical diseases in hospitalized patients Methods This is a prospective study including all patients admitted with confirmed SARS-CoV-2 rT-PCR, between 1 March and 15 May 2020 at two Tertiary Hospitals. Patients with known surgical disease at admission were excluded. Sub-analyses were performed with a consecutive group of COVID-19 patients admitted during the study period, who did not require surgical consultation. Results Ten out of 3089 COVID-19 positive patients (0.32%) required surgical consultation. Among those admitted in intensive care unit (ICU) incidence was 1.9%. Mortality was 40% in patients requiring immediate surgery and 20% in those suitable for conservative management. The overall median length of stay(LOS) of patients admitted to ICU was longer in those requiring surgical consultation compared with those who did not (51.5 vs 25 days,p=0.0042). Patients requiring surgical consultation and treatment for de-novo surgical disease had longer median ICU-LOS (31.5 vs 12 days, p=0.0004). A median of two post-surgical complications were registered for each patient undergoing surgery. Complication-associated costs were as high as 38,962 USD per patient. Conclusions Incidence of de-novo surgical diseases is low in COVID-19, but it is associated with significant morbidity and mortality. Future studies should elucidate the mechanism underlying the condition and identify strategies to prevent the need for surgery. The outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) was initially detected in Wuhan, capital of Hubei, province of China in December 2019 1-3 as pneumonia of unknown origin. On January 8 th the novel Coronavirus was officially announced as the causative pathogen by the Chinese Centre for Disease Control and Prevention 4 and it was named Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) in February of 2020 5 . On March 12th the WHO declared COVID-19 a pandemic 6 . Currently, more than 16 million people have been infected, with over 646.000 deaths 7 . Hospitalized patients requiring ICU admission are calculated around a 25% 8 . In relation to surgery, poorer outcomes are associated after surgery in COVID-19-positive patients. Up to 44% of patients undergoing elective surgery during the COVID-19 incubation period might need postoperative Intensive Care Unit (ICU) care, with a mortality rate of 20.5% 9 . Hence, most surgical societies recommend conservative management of COVID-19positive patients presenting with some urgent surgical diseases 10, 11 . COVID-19 patients might develop de-novo surgical diseases during hospitalization, requiring surgical consultation and treatment. Spain is currently the second most affected country in Europe, following UK, with 272,421 confirmed cases and 28,422 death by the 26 th July 7,12 . Recent reports suggest that, in Catalonia Region, the toll of deaths related to COVID-19 exceeded 12,677 cases, when fatalities based on data from funeral services are taken into account 13 . Reporting on the Spanish experience could be useful at a time when some countries have not yet "flattened the curve" and new infection waves are predicted. This study aims to assess the epidemiology, features, economic burden and outcome of lateonset surgical diseases in patients treated for COVID-19 in two Catalan hospitals, one of the most affected regions in Spain. Univerity Hospital and Bellvitge University Hospital. Ethical Committee approval was obtained. All hospital admitted patients, 18-years-old or older, with confirmed COVID-19 were prospectively assessed for inclusion (March 1 -May 15). Patients who required surgical consultation/review during admission were identified. Patients who were admitted with a known surgical disease were not included, as well as patients without confirmed diagnosis of COVID-19. The primary endpoint was the incidence of late-onset surgical diseases in COVID-19 positive patients, the associated morbidity and outcome. All complications occurring after consultation and any therapies by the surgical team were used as outcome measures. The secondary endpoints included mortality and the estimated costs associated with the complications. Collected data included demographics, underlying comorbidities and medications, date of hospitalization and discharge, testing pathway and date, length of stay, length of ICU stay, medical treatment received for COVID-19, date of surgical consultation, treatment received for the surgical condition, treatment results, surgical complications, mortality cause and date. In all patients included in the analysis, ICU admission was needed for COVID-19. COVID-19 diagnosis was confirmed by SARS-CoV-2 reverse transcriptase-polymerase chain reaction (RT-PCR) testing with throat and nasal swab samples. In some patients, a chest CT was initially performed 14 , with posterior RT-PCR confirmation. Consultation and treatment for the following surgical diseases during hospitalization were included: bowel ischemia and/or perforation, bowel obstruction, appendicitis, cholecystitis, pancreatitis, peritonitis, and additional disease of surgical interest. All surgical treatments were assessed, including watchful monitoring, medical therapy (e.g. The complication costs were determined by CCI class for each procedure performed and patient age using the AssessSurgery tool (AssessSurgery.com). Categorical data are presented as absolute numbers and percentages, whereas continuous variables are presented as median with ranges. A descriptive analysis was performed to report on the incidence and outcomes of de novo surgical diseases. The overall incidence was computed by determining the rate of patients requiring surgical consultation among the entire number of patients who were admitted for COVID-19 at both Centers in the study period. Sub-analyses were performed to assess the LOS and outcomes in patients who needed ICU stay in the group who developed de-novo surgical disease during admission vs. a consecutive group of COVID-19 patients who did not require surgical consultation. For the control group, only patients with completely available data were considered. The Fisher's exact test was used to compare categorical data, whereas the Mann-Whitney U test was used for continuous data. A p value <0.05 was considered statistically significant. Between March the 1 st and May the 15 th 2020, 3089 patients were admitted with proven COVID-19 with no signs or symptoms of abdominal surgical diseases at both hospitals; of which 12 (0.39%) required surgical consultation. One patient was excluded from the final analysis because a CT scan ruled out appendicitis and another because surgical consultation was required because of an iatrogenic injury. Therefore, 10 patients required surgical consultation and treatment, accounting for 0.32% of admitted patients with COVID-19. When only patients already admitted to the ICU were considered, the incidence was 1.9% (8/409). Out of 10 patients who required consultation, four (40%, 4/10) were diagnosed with bowel ischemia and perforation, two (20%, 2/10) with acute cholecystitis, two (20%, 2/10) with acute pancreatitis, one (10%, 1/10) with perforated colon carcinoma, and one (10%, 1/10) with perforated diverticulitis. Flowchart of patient selection is represented in Figure 1 . Table 1 . A median of 18 (3-28) days passed between admission and surgical consultation. The reason for consultation is reported in Table 2 , along with therapeutic decisions and outcomes. Out of four patients with bowel ischemia, this occurred in the right colon/terminal ileum in two (50%, 2/4), and at the transverse colon in one (25%, 1/4), whereas one patient had massive small bowel ischemia due to mesenteric arterial thrombosis that could not be treated by interventional radiology. The latter patient was offered palliative treatment, whereas the other three were operated on. Overall, five patients had a bowel perforation, and all underwent open surgery with no anastomosis, because of clinical instability. One of them (20%, 1/5) died within 24 hours from surgery because of multi-organic sepsis. One patient (20%, 1/5) with perforated colon cancer died after myocardial infarction, five weeks after surgery. Two patients were diagnosed with acute cholecystitis and underwent cholecystostomy. Two patients were diagnosed with acute pancreatitis, one of them with a 16-cm collection. Watchful monitoring was decided, which proved successful, with clinical and radiological improvement in subsequent CT scans. The pathology report of the patient with the perforated colon cancer was consistent with a G2, pT3N0 adenocarcinoma with a 30% mucinous component. Perforation and invasion of small vessels was found. In two of the three ischemic perforations, involvement of small and medium vessels was observed, and micro-thrombosis in one. Thirteen complications occurred in the five patients who underwent surgery, with a median of two (range 1-4) complications per patient. These ranged from wound infection to multi-organ failure and death ( Table 2) . Each patient developed at least one complication. The overall median LOS was 44.5 (range 11-108), the median LOS in ICU was 28.5 (0-104) days. LOS and mortality of patients admitted to ICU who required surgical consultation were compared with a consecutive group of 272 patients who were admitted to ICU for COVID-19 and did not require surgical consultation. The overall median LOS of those admitted to ICU was longer in those who required surgical consultation, being 51. 5 Overall, mortality was 30% (3/10). Among those who needed immediate surgery, mortality was 40% (2/5) and 20% (1/5) in those suitable for conservative management. Mortality in patients who required surgical consultation during their ICU stay was 37.5% (3/8), which was higher but not statistically different from mortality in the control group of patients who did not require surgical consultation (20.22%, 55/272, p=0.369). Overall, the costs associated with the surgical complications were as high as 311,703 USD, with median costs of 38,962 (range 27,365 -80,871) USD for each operated patient. In this study, the overall incidence of de-novo surgical disease in hospitalized patients for COVID-19 was 0.32% in two tertiary hospitals during the peak phase of the pandemic, which increased to 1.9% when only considering patients already admitted in ICU for COVID-19. Mortality in those who required surgery was twice as high as that previously reported in COVID-19 patients presenting with abdominal diseases. The onset of de-novo surgical diseases negatively impacts on hospital resources, increasing the overall LOS and stay in ICU, and postoperative complications, which are frequent in this group of patients. This significantly increases the care associated costs. Previous studies on non-COVID-19 patients reported that approximately 1-1,5% of patients in ICU develop an ICU-acquired abdominal sepsis 17 . It has been suggested that late-onset abdominal sepsis accounts for 15% of all cases of abdominal sepsis in ICU 18 . We found that the incidence of abdominal complications not present at the time of admission is overall negligible in confirmed COVID-19-patients; however, in the subgroup of patients admitted to ICU, the rate is higher. A study on 141 critically-ill COVID-19 patients, found that five needed surgery for abdominal conditions (3.5%), mainly represented by bowel ischemia 19 ; when only cases with no signs/symptoms of abdominal disease at admission are evaluated, the rate might be lower. Gastrointestinal involvement is common in COVID-19 patients in ICU, and may be managed with conservative approach depending on the involved pathology and the diseases progression 19 . Involvement of small vessels and viral entero-neuropathy has been suggested to occur in COVID-19 patients, and might be responsible for the relatively high number of patients with bowel ischemia and ileus 19 . In our series, all patients with bowel perforation had involvement of small vessels at pathology, suggesting that the virus itself might be responsible for the condition rather than the treatments delivered. Discussing care-associated cost might be useful, given the resource shortage that has been reported during the mitigation phase, and the backlog of procedures that need to be performed in the upcoming months 21 . It has been estimated that COVID-19 will cause 654.0 USD billion in direct costs in the US over the course of the pandemic should 8% of the population be infected 22 . Early predictions in Spain suggested that 1,800 billion Euros would be required to face the pandemic 23 . Mechanical ventilation is associated with incremented costs, which are already high in COVID-19 patients. The first two days are usually the most expensive as mechanical ventilation is often needed, whereas costs become more stable from day 3 of ICU stay (mechanical ventilation, 3,968 USD; no mechanical ventilation, 3,184 USD) 24 . In our series, the LOS in ICU was in median almost 3 weeks longer in patients with de novo surgical disease compared with patients who did not need surgical consultation (p=0.0004). This generate much higher costs than can be predicted, since -after surgery -patients may need prolonged use of ventilators. Postoperative complications add to the aforementioned costs. A median of two complications per patient occurred in the patients who underwent surgery, meaning that the costs for each patient increased by approximately 38,962 USD. The relatively small sample size requires that findings are interpreted with caution. The cost estimates were approximated and might have been higher in the context of the pandemic. However, this study was conducted prospectively on patients from two of the larger tertiary centres in Spain, with high volume of COVID-19 patients treated. Incidence could be reliably estimated, and the morbidity and complication-associated costs might be useful in managing patients with such presentation. The incidence of de-novo surgical disease is low in COVID-19, similar to non-COVID-19 critically ill patients. However, clinical symptoms should be detected and surgical review obtained, due to unacceptably high associated morbidity and mortality. Surgical treatment prolongs admission in ICU and increases costs of care. Conservative treatment is a safe option, when possible. Future studies should elucidate the mechanism underlying the condition, e.g. hypercoagulability and thrombo-inflammation in COVID-19 patients [25] [26] [27] , and identify strategies to prevent the need for surgery. 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