COVID-19 pandemic: perspectives on an unfolding crisis

Abstract

COVID-19 has been declared a pandemic by the World Health Organisation (WHO) as confirmed cases approach 200 000 patients with what will exceed 8000 deaths across over 160 countries1. After the initial description in Wuhan and China, Italy was hit first in Europe and the impact has been immense2. The virus spread very rapidly such that 2 weeks from the first cases diagnosed 1000 patients tested positive. One week later the number of positive cases exceeded 4600, reaching over 30 000 patients and 2500 deaths on the 18 March 20201,2. The region of Lombardy was the most profoundly affected, with local institutions forced to reset the entire healthcare system to face the challenges, while the Italian government ordered a nationwide lockdown4. Other nations followed, for example, Spain declared the state of emergency on 14 March and announced similar measures to be taken5. Most outpatient clinics have been suspended, and scheduled patients are called beforehand by hospital administration, asking for specific symptoms in the previous two weeks (for example, fever or cough), or direct exposure to COVID19-positive individuals. In such cases, the patient is asked not to come to the hospital and the visit is postponed. Checkpoints were set up to assess patients for symptoms and to provide each individual with surgical masks before entering hospitals. No visitors or accompanying persons are allowed in the hospital and all shops, restaurants, and facilities remain closed (including vending machines). Non-urgent, non-cancer procedures were stopped to reallocate the nurses and anaesthetists to face the COVID-19 emergency. This measure freed ventilators for patients with COVID-19 and converted surgical theatres into additional intensive care unit beds as needed. Patients with cancer were prioritized by clinical priority and availability of resources: patients in probable need of postoperative intensive care were corralled into specific, government-defined centres to free resources elsewhere. It is foreseeable that there will be a significant number of patients with benign conditions needing surgery after the surge in patients with acute viral illness falls. This will require extra resources to catch up on the backlog. The need to care for patients with emergency presentation still continues during a pandemic. Therefore, surgical staff and the available units have been modified to balance service provision, reducing infection risk, and specialist care. Most centres have reduced the number of consultant/attending surgeons on the ward, down to one or two with similar trainee numbers per day, with larger teams being used for covering emergency and accident services. This policy reduces the number of working units attending the hospitals and limits unnecessary exposure of patients and healthcare providers. Indications for surgery in patients tested positive for COVID-19 should not differ from those who have tested negative in emergency conditions. Some colleagues report a worse postoperative course after complications in elective COVID-19-positive patients, but data are lacking. There are some reports regarding patients with COVID-19 presenting with gastrointestinal symptoms that mimic surgical diseases, specifically a pancreatitis-like clinical presentation. There is no agreement of whether a dedicated COVID-19 staff should be allocated to infected patients needing surgery. Patients are not being tested for COVID-19 routinely as yet, especially if they are asymptomatic. Theoretically, this would imply that there should be the highest level of personal protection attire for surgical staff in every case. Due to the shortage of protection equipment hospital management tend to recommend use only in known COVID19-positive cases even though this stresses individuals6. Some professional bodies state that the evidence for guidelines is limited, recommending no more than standard surgical protection for the scrub team6. This policy differs from that followed in many afflicted zone centres where the highest protective measures are being taken. There are no agreed policies about testing staff routinely but it is intuitive that it would be desirable to test all patients and staff in a pandemic. It is not clear whether the virus can be found in circulating CO2 used for laparoscopic surgery or aerosol generating procedures. Some allow the use of laparoscopy but question transanal minimally invasive procedures, due to the increased risk of exposure to aerosolized biological fluids with the latter7. Laparoscopy may reduce intraoperative exposure to smoke compared with open surgery and devices for smoke evacuation and cleansing are recommended where feasible. Some suggested using the closed circuit of the pressurized intraperitoneal aerosol chemotherapy (PIPAC) if available, but cheaper and more readily available alternatives to reduce the contamination from aerosol from CO2 during laparoscopy have been proposed, such as connecting one of the