key: cord-0916217-crecd66s
authors: Milone, Marco; Carrano, Francesco Maria; Letić, Emina; Shamiyeh, Andreas; Forgione, Antonello; Eom, Bang Wool; Müller-Stich, Beat P.; Ponz, Carmen Balagué; Kontovounisios, Christos; Preda, Daniel; Ignjatovic, Dejan; Cassinotti, Elisa; Yiannakopoulou, Eugenia; Theodoropoulos, George; Faria, Gil; Morelli, Luca; Gorter-Stam, Marguerite; Markar, Sheraz; Arulampalam, Thanjakumar; Velthoven, Therese; Antoniou, Stavros A.; Francis, Nader K.
title: Surgical challenges and research priorities in the era of the COVID-19 pandemic: EAES membership survey
date: 2020-08-04
journal: Surg Endosc
DOI: 10.1007/s00464-020-07835-7
sha: c53d151279c4b030d9610651b87ace1cd47a7918
doc_id: 916217
cord_uid: crecd66s

BACKGROUND: Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons’ experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities. METHODS: An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate. RESULTS: The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities. CONCLUSIONS: Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00464-020-07835-7) contains supplementary material, which is available to authorized users.

The COVID-19 pandemic has strongly influenced healthcare systems worldwide. The rapid spread of the coronavirus required adjustment and rearrangement of healthcare services within a short period of time [1] . These changes, along with public health, social, and economic factors, have greatly affected surgical practice [2] .

Surgeons were called to change their practice and assume extended roles, often not related to their primary expertise.

Furthermore, healthcare professionals have faced challenges on a social, personal, and psychological level. In this period of social introversion, the medical community was called to address these challenges according to professional and scientific principles. Among the initial abundance of empiric and often conflicting recommendations [3, 4] , national and institutional protocols on surgical practice [5, 6] , and the profound lack of research evidence, the surgical community was called to address functional, practice, and research challenges.

The European Association for Endoscopic Surgery (EAES) has identified a lack of systematic register of these challenges. The EAES Research Committee therefore aimed to evaluate the current situation as experienced by our members, to identify gaps in knowledge, to record shortcomings 

The study group consisted of members of the EAES Research Committee, an international panel of surgeons from 10 European countries. The steering group consisted of two Committee members (EL, MM) and the Committee chair (NKF) acted as coordinator.

The study group nominated candidate questions through email communication and the steering group shortlisted questions and refined the questionnaire through feedback of all Committee members. The questionnaire consisted of 69 items (Online Appendix) divided into the following sections:

(I) Participant demographics. (II) Burden of the pandemic in participants' institutions and management strategies/protocols. (III) Analysis of resource, knowledge, and evidence gaps.

The survey questions were organized into closed-ended questions with unordered choices, open-ended questions, and partially closed-ended questions, as considered appropriate. To assess knowledge gaps and research priorities, a 5-point Likert scale was used, 5 indicating the highest score.

The 3500 EAES members were invited to participate in the survey through: Two separate invitations were sent on March 25th and on April 16th. Participants were informed that data are anonymized and confidential, and were provided a web link directing to the survey instrument. Consent was implied upon acceptance to participate. The survey was hosted by SurveyMonkey, a secure web-based survey platform. Participants were required to respond to all questions for their responses to be registered.

No formal sample size calculation was performed due to time constraints and in order for the survey to be launched within reasonable time under consideration of the urgency of the situation and the need to make results made available in a timely manner.

No relevant actions were taken for the above reasons.

A tallied summary of the results for each question was generated. Data were analyzed using descriptive statistics (SPSS™ v20.0, IBM®, US). Frequencies were presented as % percentages and continuous variables were presented as medians, ranges, and interquartile ranges. Summary survey responses were presented regularly to the EAES Research Committee and to the EAES Executive Board to adjust its strategic plan and address priorities.

The survey took place between March 25th and April 16th. A total of 550 surgeons (16%) from 79 countries participated. The majority of participants were based in Europe (Italy, 29%; United Kingdom, 9%; Romania, 5%). There was representation from most European countries, although the number of participants from individual countries was variable (median 3; range 1-149; interquartile range 1-5). Geographical distribution of surveyed surgeons is shown in Fig. 1 .

Sixty-five percent reported practicing gastrointestinal surgery in general, 15% oncological surgery and 10% upper gastrointestinal surgery. More than half reported working in academic hospitals (59%), followed by local (26%) and private hospitals (12%).

Eight percent of the surgeons surveyed, maintained normal surgical practice for both elective and emergency surgery, 58% cancelled elective non-cancer surgery and 23% cancelled all elective surgery. One-third (35%) of the participants have been asked to help out in other specialties; out of those, 46% were asked to help in the emergency department and 62% did not receive relevant training.

Most respondents (85%) reported that their institution performed COVID-19 tests in patients with suspected symptoms; out of those, 61% reported that the tests were performed upon admission and 37% on the ward after admission. A dedicated ward for COVID-19-positive patients was reported by 82% to be available and COVID-19-positive surgical patients had to be admitted in such ward in 69%.

Half (47%) of the surgeons reported their hospital having treated COVID-19-positive patients with a median number of 50 (range 1-1800, interquartile range 10-160). Emergency surgery in COVID-19-positive patients was reported having been performed by 118 respondents, with a median of 3 patients (interquartile range 1-5). Out of those, 41% reported using minimally invasive surgery, with a median of 3 (range 1-43, interquartile range 1-5) ( Table 1) .

Sixty percent reported applying measures for minimally invasive surgery when operating on COVID-19-positive patients; 62% of those used a CO 2 filter. Two-thirds (66%) reported using standard operating procedures for COVID-19-positive patients in their institution, including operatingroom-related (70%) and perioperative care (58%). Seventyfive percent of participants reported a reduced incidence of acute surgical conditions compared to the pre-pandemic era.

One-fourth (27%) of respondents reported having encountered COVID-19-positive patients with abdominal pathologies, most frequently acute appendicitis (47% of respondents). Eighteen percent reported having encountered more complications with COVID-19-positive patients, primarily respiratory (71% of respondents) and infective complications (18% of respondents).

Respondents have prioritized gaps in the area of surgical procedures and protective measures (median 4, IQR 3-5; on a 5-point Likert scale); virus-specific parameters (median 4, IQR 3-4); service redistribution (median 3, IQR 3-4); and diagnostic modalities for COVID-19-positive patients (median 3, IQR 3-4) (Fig. 2) .

With regard to current gaps in resource management and protective equipment, respondents prioritized operating room protective measures (median 4, IQR 3-5), endoscopy protective measures (median 4, IQR 3-5), filtering face piece (FFP) masks (median 4, IQR 3-5) and protective materials/ equipment (median 4, IQR 3-5), own recyclable protective measures (median 4, IQR 3-5), redirection of surgical staff (median 3.5, IQR 3-5), and surgical staff training (median 3, IQR 3-4) (Fig. 3) . Thirty-five percent of respondents reported enrolling COVID-19-positive surgical patients to a registry. Out of those who did not, 83% would be willing to enroll patients to an international dedicated registry.

Research gaps in the fields of the safety of surgery when using usual protective measures (median 4, IQR 3-5), the safety of minimally invasive surgery in COVID-19-positive patients (median 4, IQR 3-5), the effect and safety of pneumoperitoneum in COVID-19-positive patients (median 4, IQR 3-5), postoperative care of in COVID-19-positive patients (median 4, IQR 3-5), and the effects of conversion from minimally invasive to open surgery in COVID-19-positive patients (median 3, IQR 3-5) were prioritized (Fig. 4) .

Personal psychological support was not prioritized high among respondents with a median score of 2 (IQR 1-3) (Fig. 5) , whereas 68% reported no peer support in their institution. Psychologists to provide staff support in relation to the pandemic were reported by 57% to be available in their institution and 56% reportedly had access to this service.

This EAES-sponsored survey found that 81% of surgeons had to postpone non-urgent cases or suspend their practice and more than one-third assumed other functional roles within their institution. Furthermore, nearly 70% reported that COVID-19-positive surgical patients had to be transferred to a dedicated ward. Among other, these findings suggest tremendous changes in institutional infrastructures and surgical practices with potential implications to the quality of surgical services.

In addition, the results of this survey suggest substantial uncertainty with regard to potential risks of surgery in infected patients and the potential effect of protective measures. Practice recommendations were issued in the early phase of the pandemic in the West; however, they lacked background research evidence, and they were conflicting or were being updated within a short period of time. Anecdotal data suggest variable directives by policymakers among European countries, based on unknown, trivial, or no background evidence supporting their putative effect.

Notably, the safety of minimally invasive surgery has been questioned and directives have banned laparoscopic surgery in several countries. Substantial uncertainty with regard to operating and endoscopy room protective measures has been documented, whereas research in this field was prioritized. Indeed, the transmission potential of COVID-19 has not been addressed by animal studies and very limited evidence refers to patients with HIV, hepatitis, SARS, and MERS. It would be probably not appropriate to extrapolate this indirect evidence and assume similar effects for SARS-CoV-2.

Rearrangement of functions among healthcare staff and the reported lack of training to serve in alternate functions may constitute a threat to the quality of healthcare services. Further emphasis on training prior to assumption of functions would be a prudent practice. The current situation suggests an urgent need to exchange information on the outcomes of surgery in infected patients.

The vast majority of respondents would be willing to provide local data to a registry; however, 65% do not provide any data resulting in waste of valuable scientific information at a time when it is critically needed. International and intersociety collaboration and promotion of existing registries would allow centralization of data for research purposes.

Survey participants have prioritized the scientific need to investigate the effect of laparoscopy and pneumoperitoneum on COVID-19-positive patients, and the postoperative management of these patients. Under consideration of the crucial need for research evidence, it would be reasonable to make registry data available to multiple research groups, allowing simultaneous conduction of exploratory analyses to address research questions.

A limitation of this study was the response rate of 16%, which may undermine generalizability and be prone to response bias. The response rate, however, is comparable with previous surgical society membership surveys [7] [8] [9] . One inherit limitations of surveys in general are recall and While an argument could be made that a Delphi exercise would have been appropriate, we felt an initial broad grassroots approach would be more informative than an expert consultation. This project was developed within a few weeks in response to an urgent situation challenging surgeons on a global level and one may argue a repeat survey will be required to capture the members' views at the end of the pandemic.

This paper summarizes the current situation, perspectives and priorities of EAES members in the era of the COVID-19 pandemic. Stepwise approach to identify and generate evidence as a response to this global challenge is a prudent strategic goal and objective of the EAES community. 

WHO Director-General's opening remarks at the media briefing on COVID-19

Coronavirus pandemic and colorectal surgery: practical advice based on the Italian experience

Safe management of surgical smoke in the age of COVID-19

Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy

Intercollegiate General Surgery Guidance on COVID-19, first version and following updates

Spanish Society of Surgery (AEC) v1.0

Diagnosis and management of acute appendicitis. EAES consensus development conference 2015

Synchronous resection of colorectal cancer and liver metastases: comparative views of colorectal and liver surgeons

Uptake of enhanced recovery practices by SAGES members: a survey

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Marco Milone 1 · Francesco Maria Carrano 2,3 · Emina Letić 4 · Andreas Shamiyeh 5 · Antonello Forgione 6 · Bang Wool Eom 7 · Beat P. Müller-Stich 8 · Carmen Balagué Ponz 9 · Christos Kontovounisios 10 · Daniel Preda 11 · Dejan Ignjatovic 12 · Elisa Cassinotti 13 · Eugenia Yiannakopoulou 14 · George Theodoropoulos 15 · Gil Faria 16,17 · Luca Morelli 18 · Marguerite Gorter-Stam 19 · Sheraz Markar 20 · Thanjakumar Arulampalam 21 · Therese Velthoven 22 · Stavros A. Antoniou 23 · Nader K. Francis 24,25 1 Department of Clinical Medicine and Surgery, University of Naples "Federico II", via pansini 5, Naples, Italy