British Journal of Surgery

Di Marzo, F; Gemmi, F; Cennamo, R; Forni, S; Bachini, L; Collini, F; Cardi, M

doi: 10.1002/bjs.11832pmid: 32710547

Editor Postponing surgeries as a rapid response to SARS-CoV-2 pandemic was the clue to decrease disease spread in patients and health care professionals1,2. Non-urgent, non-cancer procedures were cancelled, and staff was reallocated to face the emergency, with most surgical departments closed or converted to COVID-19 medical wards3. Cancellation of elective operations creates a huge backlog of planned surgical patients, but no real data are currently available to assess the number of delayed operations and how this will be managed in the pandemic transition phase4,5. We conducted a retrospective study to compare the surgical volume (defined as the number of procedures performed during the index period) and characteristics of patients undergoing surgery in the period January–March 2019 and 2020. Data were retrieved from the Operating Room Logs of all private and public hospitals in Tuscany (Italy), a region with a population of 3·73 millions and 322 intensive care beds (8,63/100 K inhabitants). We considered demographics, Charlson index, urgent or elective admission, mortality and return to operating room within 7 days. Other variables recorded were median time from diagnosis to surgery, operative time and total time spent in the operating room area. Differences between groups were assessed by non-parametric tests (χ2 and Kolmogorf-Smirnow). The statistical software Stata 14 SE was used for data analysis. Between February 25th and May 19th, 9968 cases of Covid-19 were diagnosed and at the peak of the epidemic curve on April the 2nd, 91·3 per cent of the ICU beds (294) were used for SARS-CoV-2 patients. Regional government interrupted elective surgeries on March 6th, 1 week before WHO declaration of pandemic and Italian lockdown (Fig. 1). Between March 6th and 31th, a total of 4774 surgical procedures were performed, with a reduction of 68 per cent when compared to 2019 (14798). The reduction was higher for elective surgery (2796 vs. 11273) with a decrease of 75 per cent, while for urgent/emergency surgery the decrease was 30 per cent. Patients treated in 2020 were older (median age 67 vs. 63, p < 0·001) and the patients' rate with Charlson comorbidity index ≥2 was higher (36·4 per cent vs. 24·8 per cent). Admission to postoperative sub-intensive/intensive care was higher in 2020 (3·1 per cent vs. 2·8 per cent and 7·3 per cent vs. 6·2 per cent respectively). The median waiting time for elective surgery was shorter (6 vs. 23 days, p < 0·001). Median operative time and stay in the operating room area were both significantly higher (55 vs. 46 and 141 vs. 130 minutes respectively). Rate of patients with Clavien-Dindo 3b post-operative complications requiring a second procedure within 7 days was significant higher (5·8 per cent vs. 3·0 per cent, p < 0·001). Higher operative times and total operating room stay could be explained by the presence of SARS-CoV-2 related procedures. Open in new tabDownload slide Provision of surgical services will continue to be an essential aspect of our healthcare system throughout the pandemic, and surgical systems will have to adapt to a continuously changing situation. The results of our study provide important informations to define the impact of SARS-CoV-2 on elective surgery and set a benchmark to manage local planning and resource prioritization during the transition phase, ensuring quality standards and safety of patients and staff. References 1 Di Marzo F , Sartelli M, Cennamo R, Toccafondi G, Coccolini F, La Torre G et al. Recommendations for General Surgery Activities in a Pandemic Scenario (SARS-CoV-2) . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11652 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 2 Brindle ME , Gawande A. Managing COVID-19 in Surgical Systems . Ann Surg 2020 ; https://doi.org/10.1097/SLA.0000000000003923 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 3 Torzilli G , Vigano L, Galvanin J, Castoro C, Quagliuolo V, Spinelli A, Zerbi A, Donadon M, Montorsi M; COVID-SURGE-ITA group . A Snapshot of Elective Oncological Surgery in Italy During COVID-19 Emergency: Pearls, Pitfalls, and Perspectives . Ann Surg 2020 ; https://doi.org/10.1097/SLA.0000000000004081 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 4 CovidSurg Collaborative , Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11746. [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 5 Søreide K , Hallet J, Matthews JB, Schnitzbauer AA, Line PD, Lai PBS et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11670 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Maspero, M; Mazzola, M; Bertoglio, C L; Crippa, J; Morini, L; Magistro, C; De Martini, P; Gualtierotti, M; Lombardi, P M; Ferrari, G

doi: 10.1002/bjs.11892pmid: 32757214

Editor Table 1 Results . 2020 (n = 42) . 2019 (n = 44) . p value . Age (years) 69 ± 11 69 ± 12 0·983 ASA score 1 2 (5%) 5 (11%) 0·511 2 30 (71%) 29 (66%) 3 10 (24%) 10 (23%) Charlson Score 5 ± 2 5 ± 2 0·981 Diagnosis 0·959 Primary adenocarcinoma 33 (79%) 35 (79%) Recurrent malignancy 4 (9%) 5 (11%) Neuroendocrine tumor 3 (7%) 4 (9%) Lymphoproliferative disease 2 (5%) 0 Neoadjuvant treatment 18 (43%) 10 (23%) 0·070 Waiting time (days) 22 (IQT 17 – 33) 23 (IQT 16 – 37) 0·489 > 30 days 14 (33%) 10 (26%) 0·476 Type of surgery 0·431 Gastroesophageal 10 (24%) 6 (14%) Colorectal 18 (43%) 27 (61%) (5%) 3 (7%) Pancreatic 10 (24%) 7 (16%) Splenic 2 (5%) 1 (2%) Approach 0·382 Open 20 (48%) 16 (36%) Laparoscopic 22 (52%) 28 (64%) Conversion to open 2/22 (9%) 0/28 (0%) 0·198 Length of hospital stay (days) 7 (IQT 5 – 12) 7 (IQT 5 – 11) 0·674 Need for ICU admission 3 (7%) 5 (11%) 0·714 Length of ICU stay (days) 5 3 (range 1 – 6) Overall postoperative complications 16 (38%) 16 (36%) 1 CCI 29 ± 22 23 ± 11 0·347 Major morbidity 7 (17%) 8 (18%) 1 Reoperation rate 2 (5%) 4 (9%) 0·677 30-day readmission rate 2 (5%) 2 (5%) 1 30-day mortality 1 (2%) 0 (0%) 0·494 Interval between surgery and definitive pathology report (days) 14 (IQT 11 – 23) 16 (IQT 12 – 22) 0·885 R0 resection 41 (98%) 42 (95%) 1 Interval between discharge and first surgical follow up (days) 6 (IQT 5 – 10) 6 (IQT 3 – 16) 0·168 Interval between discharge and first oncological follow up (days) 27 (IQT 15 – 30) 43 (IQT 25 – 52) <.001 Indication to adjuvant CT 17 (41%) 16 (36%) 0·662 Interval between procedure and start of adjuvant CT (days) 51 (IQT 37 – 63) 63 (IQT 50 – 78) 0·103 . 2020 (n = 42) . 2019 (n = 44) . p value . Age (years) 69 ± 11 69 ± 12 0·983 ASA score 1 2 (5%) 5 (11%) 0·511 2 30 (71%) 29 (66%) 3 10 (24%) 10 (23%) Charlson Score 5 ± 2 5 ± 2 0·981 Diagnosis 0·959 Primary adenocarcinoma 33 (79%) 35 (79%) Recurrent malignancy 4 (9%) 5 (11%) Neuroendocrine tumor 3 (7%) 4 (9%) Lymphoproliferative disease 2 (5%) 0 Neoadjuvant treatment 18 (43%) 10 (23%) 0·070 Waiting time (days) 22 (IQT 17 – 33) 23 (IQT 16 – 37) 0·489 > 30 days 14 (33%) 10 (26%) 0·476 Type of surgery 0·431 Gastroesophageal 10 (24%) 6 (14%) Colorectal 18 (43%) 27 (61%) (5%) 3 (7%) Pancreatic 10 (24%) 7 (16%) Splenic 2 (5%) 1 (2%) Approach 0·382 Open 20 (48%) 16 (36%) Laparoscopic 22 (52%) 28 (64%) Conversion to open 2/22 (9%) 0/28 (0%) 0·198 Length of hospital stay (days) 7 (IQT 5 – 12) 7 (IQT 5 – 11) 0·674 Need for ICU admission 3 (7%) 5 (11%) 0·714 Length of ICU stay (days) 5 3 (range 1 – 6) Overall postoperative complications 16 (38%) 16 (36%) 1 CCI 29 ± 22 23 ± 11 0·347 Major morbidity 7 (17%) 8 (18%) 1 Reoperation rate 2 (5%) 4 (9%) 0·677 30-day readmission rate 2 (5%) 2 (5%) 1 30-day mortality 1 (2%) 0 (0%) 0·494 Interval between surgery and definitive pathology report (days) 14 (IQT 11 – 23) 16 (IQT 12 – 22) 0·885 R0 resection 41 (98%) 42 (95%) 1 Interval between discharge and first surgical follow up (days) 6 (IQT 5 – 10) 6 (IQT 3 – 16) 0·168 Interval between discharge and first oncological follow up (days) 27 (IQT 15 – 30) 43 (IQT 25 – 52) <.001 Indication to adjuvant CT 17 (41%) 16 (36%) 0·662 Interval between procedure and start of adjuvant CT (days) 51 (IQT 37 – 63) 63 (IQT 50 – 78) 0·103 Quantitative data are expressed as mean ± standard deviation or median (interquartile range), as needed. Categorical data are expressed as number (percentage). ASA = American Society of Anaesthesiologists. CCI = Comprehensive Complication Index. CT = systemic chemotherapy. ICU = Intensive Care Unit. IQT = interquartile range. Open in new tab Table 1 Results . 2020 (n = 42) . 2019 (n = 44) . p value . Age (years) 69 ± 11 69 ± 12 0·983 ASA score 1 2 (5%) 5 (11%) 0·511 2 30 (71%) 29 (66%) 3 10 (24%) 10 (23%) Charlson Score 5 ± 2 5 ± 2 0·981 Diagnosis 0·959 Primary adenocarcinoma 33 (79%) 35 (79%) Recurrent malignancy 4 (9%) 5 (11%) Neuroendocrine tumor 3 (7%) 4 (9%) Lymphoproliferative disease 2 (5%) 0 Neoadjuvant treatment 18 (43%) 10 (23%) 0·070 Waiting time (days) 22 (IQT 17 – 33) 23 (IQT 16 – 37) 0·489 > 30 days 14 (33%) 10 (26%) 0·476 Type of surgery 0·431 Gastroesophageal 10 (24%) 6 (14%) Colorectal 18 (43%) 27 (61%) (5%) 3 (7%) Pancreatic 10 (24%) 7 (16%) Splenic 2 (5%) 1 (2%) Approach 0·382 Open 20 (48%) 16 (36%) Laparoscopic 22 (52%) 28 (64%) Conversion to open 2/22 (9%) 0/28 (0%) 0·198 Length of hospital stay (days) 7 (IQT 5 – 12) 7 (IQT 5 – 11) 0·674 Need for ICU admission 3 (7%) 5 (11%) 0·714 Length of ICU stay (days) 5 3 (range 1 – 6) Overall postoperative complications 16 (38%) 16 (36%) 1 CCI 29 ± 22 23 ± 11 0·347 Major morbidity 7 (17%) 8 (18%) 1 Reoperation rate 2 (5%) 4 (9%) 0·677 30-day readmission rate 2 (5%) 2 (5%) 1 30-day mortality 1 (2%) 0 (0%) 0·494 Interval between surgery and definitive pathology report (days) 14 (IQT 11 – 23) 16 (IQT 12 – 22) 0·885 R0 resection 41 (98%) 42 (95%) 1 Interval between discharge and first surgical follow up (days) 6 (IQT 5 – 10) 6 (IQT 3 – 16) 0·168 Interval between discharge and first oncological follow up (days) 27 (IQT 15 – 30) 43 (IQT 25 – 52) <.001 Indication to adjuvant CT 17 (41%) 16 (36%) 0·662 Interval between procedure and start of adjuvant CT (days) 51 (IQT 37 – 63) 63 (IQT 50 – 78) 0·103 . 2020 (n = 42) . 2019 (n = 44) . p value . Age (years) 69 ± 11 69 ± 12 0·983 ASA score 1 2 (5%) 5 (11%) 0·511 2 30 (71%) 29 (66%) 3 10 (24%) 10 (23%) Charlson Score 5 ± 2 5 ± 2 0·981 Diagnosis 0·959 Primary adenocarcinoma 33 (79%) 35 (79%) Recurrent malignancy 4 (9%) 5 (11%) Neuroendocrine tumor 3 (7%) 4 (9%) Lymphoproliferative disease 2 (5%) 0 Neoadjuvant treatment 18 (43%) 10 (23%) 0·070 Waiting time (days) 22 (IQT 17 – 33) 23 (IQT 16 – 37) 0·489 > 30 days 14 (33%) 10 (26%) 0·476 Type of surgery 0·431 Gastroesophageal 10 (24%) 6 (14%) Colorectal 18 (43%) 27 (61%) (5%) 3 (7%) Pancreatic 10 (24%) 7 (16%) Splenic 2 (5%) 1 (2%) Approach 0·382 Open 20 (48%) 16 (36%) Laparoscopic 22 (52%) 28 (64%) Conversion to open 2/22 (9%) 0/28 (0%) 0·198 Length of hospital stay (days) 7 (IQT 5 – 12) 7 (IQT 5 – 11) 0·674 Need for ICU admission 3 (7%) 5 (11%) 0·714 Length of ICU stay (days) 5 3 (range 1 – 6) Overall postoperative complications 16 (38%) 16 (36%) 1 CCI 29 ± 22 23 ± 11 0·347 Major morbidity 7 (17%) 8 (18%) 1 Reoperation rate 2 (5%) 4 (9%) 0·677 30-day readmission rate 2 (5%) 2 (5%) 1 30-day mortality 1 (2%) 0 (0%) 0·494 Interval between surgery and definitive pathology report (days) 14 (IQT 11 – 23) 16 (IQT 12 – 22) 0·885 R0 resection 41 (98%) 42 (95%) 1 Interval between discharge and first surgical follow up (days) 6 (IQT 5 – 10) 6 (IQT 3 – 16) 0·168 Interval between discharge and first oncological follow up (days) 27 (IQT 15 – 30) 43 (IQT 25 – 52) <.001 Indication to adjuvant CT 17 (41%) 16 (36%) 0·662 Interval between procedure and start of adjuvant CT (days) 51 (IQT 37 – 63) 63 (IQT 50 – 78) 0·103 Quantitative data are expressed as mean ± standard deviation or median (interquartile range), as needed. Categorical data are expressed as number (percentage). ASA = American Society of Anaesthesiologists. CCI = Comprehensive Complication Index. CT = systemic chemotherapy. ICU = Intensive Care Unit. IQT = interquartile range. Open in new tab After the first case of COVID-19 in Italy, all elective non-urgent surgical activities were interrupted in order to provide resources for the emerging epidemic and in fear of exposing patients to in-hospital SARS-CoV-2 infections. Our Institution, one of the largest public hospitals in Lombardy (Italy), was designated as a COVID hub by the regional government, and has so far treated more than one thousand COVID-19 patients. As smaller hospitals redirected cancer patients to designated Oncological hubs1, we kept performing major cancer surgery “in-house”, for ours being a tertiary oncological referral center with a high specialization in minimally invasive procedures. A dedicated pathway of care was designed based on three principles: multidisciplinary cooperation between clinical staff and health managers; systematic SARS-CoV-2 preoperative screening with RT-PCR on nasal swab; rigorous adherence to in-hospital COVID-19 regulations regarding clean pathways, use of personal protective equipment, and limitations of all unnecessary hospital accesses. To evaluate the efficacy of our model, we compared outcomes of major cancer surgeries performed from February 24th 2020 to May 8th 2020 with the same time period in 2019. The primary endpoint was waiting time, defined as the interval between the date of the first diagnostic investigation and surgery for newly diagnosed cancers, and as the interval between the date of the tumor board during which surgical indication was given and surgery for patients who received a neoadjuvant treatment (Table 1). While overall surgical activity underwent a 84 per cent reduction in volume (from 502 procedures in 2019 to 73 in 2020), major cancer cases remained stable (44 vs 42). Baseline characteistics of the patients were similar. Waiting time did not differ between the two cohorts (23 versus 22 days in 2019 and 2020, respectively). This was in contrast with a previous report from the COVID-SURGE-ITA group survey2, which showed an increase in time between tumor board and surgery. Distribution of procedures according to anatomical district showed a trend toward less colorectal operations in 2020 compared to 2019, with an increase in gastroesophageal and pancreatic operations. Several concerns have been raised on the use of laparoscopy during the COVID-19 pandemic3. The risk of SARS-CoV-2 transmission during laparoscopy has not been scientifically demonstrated4,5, while an increase in open procedures will have a detrimental effect on short-term outcomes. In our division, we continued performing laparoscopic operations, as all of our patients tested negative for SARS-CoV-2 before surgery. Thirty-day surgical outcomes were similar between the two time periods. This was unsurprising as patients were operated on by the same surgical staff and cared for following the same standardized enhanced recovery protocol. The potential need for postoperative ICU admission was a concern during the COVID-19 emergency. Scheduling major surgery in such situations requires collaboration between surgeons, anesthesiologists and healthcare managers. Our patients can rely on a dedicated high-care surgical ward with the presence of a multispeciality team; this also decreased the need for postoperative ICU admission. A strict adherence to protocols was critical to patient safety. No patients developed a postoperative SARS-CoV-2 infection in our division. Oncological surgical standards were equally maintained. The oncological pathway was not affected, as shown by the reduced interval from discharge to the first oncological follow up and to start adjuvant treatment. Our study shows that major cancer surgery during the COVID-19 pandemic was not discontinued and was carried out with similar short-term outcomes as in standard conditions in our cohort of patients from a tertiary care center in Northern Italy. Multidisciplinary cooperation between the clinical staff and health managers played a critical role in ensuring a safe pathway of care. References 1 Sorrentino L , Guaglio M, Cosimelli M. Elective colorectal cancer surgery at the oncologic hub of Lombardy inside a pandemic COVID-19 area . J Surg Oncol 2020 ; 122 : 117 – 119 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Torzilli G , Vigano L, Galvanin J, Castoro C, Quagliuolo V, Spinelli A et al. A Snapshot of Elective Oncological Surgery in Italy During COVID-19 Emergency: Pearls, Pitfalls, and Perspectives . Ann Surg 2020 ; https://doi.org/10.1097/sla.0000000000004081 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 3 Di Saverio S , Khan M, Pata F, Ietto G, De Simone B, Zani E et al. Laparoscopy at all costs? Not now during COVID-19 and not for acute care surgery and emergency colorectal surgery . J Trauma Acute Care Surg ; 2020 ; 88 : 715 – 718 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Schwarz L , Tuech JJ. Is the use of laparoscopy in a COVID-19 epidemic free of risk? Br J Surg 2020 ; 107 : e188 . Google Scholar Crossref Search ADS PubMed WorldCat 5 de Leeuw RA , Burger NB, Ceccaroni M, Zhang J, Tuynman J, Mabrouk M et al. COVID-19 and laparoscopic surgery, a scoping review of current literature and local expertise . JMIR Public Heal Surveill 2020 ; https://doi.org/10.2196/18928 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Rahmanzade, Ramin; Hashemian, Seyed MohammadReza

doi: 10.1002/bjs.11799pmid: 32757206

Editor Coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented patient turnover and overuse of the limited resources1. This resulted in the re-definition of the method-of-choice in surgical procedures2. Tracheostomy is commonly performed in patients requiring long-term mechanical ventilation. The percutaneous dilatational tracheostomy (PDT) is the technique of choice in the elective setting. The difficult identification of anatomical landmarks in patients with morbid obesity or those with a short, thick neck puts this population at increased risk of peri-procedural complications following PDT. Therefore, surgical tracheostomy (ST) is generally considered superior to PDT due to offering a better anatomical visualization3. In 2015, we introduced the mini-surgical PDT (msPDT) as an alternative to the ST when PDT is contraindicated or difficult to perform4. We discontinued the use of bronchoscopy, the indispensable part of PDT techniques. The benefit of bronchoscopy has been debated5. It also may increase the risk of intra-procedural hypoxemia and transmission of COVID-194. In msPDT, tracheal puncturing occurs upon appearance of tracheal rings after vertical and horizontal retraction of overlaying tissues. To prevent a posterior wall laceration, the catheter introducer needle is conducted at a 45 angle. Correct positioning of the needle's tip is confirmed by bubbles formation following aspiration of a pre-filled syringe4. In a large randomized trial, we previously showed that msPDT is superior to the modified PDT and ST in terms of duration and complications2. Being less time-consuming, it may put the practitioners not as much as PDT or ST at the risk of COVID-19. Employment of msPDT instead of ST obviates the need for sector change from ICU to the operation theatre, which could contribute to COVID-19 propagation. In addition to patient's safety, the safety of practitioners should also be taken into account in the risk–benefit evaluation of different tracheostomy techniques during viral pandemics. References 1 Ives J , Huxtable R. Surgical Ethics During a Pandemic: Moving into the Unknown? Br J Surg 2020 ; 107 : 1089 – 1090 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Di Saverio S , Pata F, Khan M, Ietto G, Zani E, Carcano G. Convert to open: the new paradigm for surgery during COVID-19? Br J Surg 2020 ; 107 : e194 . Google Scholar Crossref Search ADS PubMed WorldCat 3 De Leyn P , Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y et al. Tracheotomy: clinical review and guidelines . Eur J Cardiothorac Surg 2007 ; 32 : 412 – 421 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Hashemian SM , Digaleh H; Massih Daneshvari Hospital Group . A Prospective Randomized Study Comparing Mini-surgical Percutaneous Dilatational Tracheostomy With Surgical and Classical Percutaneous Tracheostomy: A New Method Beyond Contraindications . 2016 ; 95 : e208e . 5 Gadkaree SK , Schwartz D, Gerold K, Kim Y. Use of Bronchoscopy in Percutaneous Dilational Tracheostomy . JAMA Otolaryngol Head Neck Surg 2016 ; 142 : 143 – 149 . Google Scholar Crossref Search ADS PubMed WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Wang, Lin; Lu, Xiaohuan; Zhang, Jinxiang; Wang, Guobin; Wang, Zheng

doi: 10.1002/bjs.11886pmid: 32749672

Editor SARS-CoV-2 has caused an ongoing pandemic of COVID-19, and brought a worldwide crisis to society and economy1. With lockdown being lifted in Wuhan in April, our hospital has thus far effectively cleared a huge backlog of operations accumulated during COVID-19 pandemic. Given over 20 per cent mortality rate associated with COVID-19 infection during perioperative periods2, surgeons still need to adapt standard procedures against COVID-19. Here, we introduce strategies for perioperative management based on our experiences in the post-COVID-19 pandemic era. Strategies for preoperative management. The prioritization of surgical interventions should be rationalized to effectively manage a large volume of patients with different conditions. For these patients, preoperative assessment should be focused on detection of COVID-19 infection, stage of disease, and operation types (emergent, elective, or selective). Patients who need emergent surgery should be prioritized as the first. The second level priority is given to cancer patients whose elective surgery has been delayed beyond recommended optimal waiting windows. The third level priority is rendered to patients who have advanced cancer and / or a high risk of metastasis and recurrence. Patients who need surgery but are asymptomatic or at the early stage of illness with a low risk of rapid deterioration can be prioritized as the fourth level. The fifth level priority should be placed for patients who need selective surgery, such as inguinal hernia repairs and hemorrhoidectomy. Of note, the above operation prioritization should be carefully determined with necessary multi-disciplinary consultation. Additionally, during the time period of preoperative preparation, viral nucleic acid testing and serologic antibody testing are mandated to be performed for patients every seven days. Strategies for intraoperative management. Surgeons should wear appropriate personal protective equipment (PPE) according to relevant regulations. For endotracheal intubation that is considered as an aerosolizing procedure with high infection risk, the top level of PPE is necessary with as less staff involved as possible. For laparoscopic or robotic surgeries, the release of positive pressure pneumoperitoneum gas from trocars might transmit aerosolized viral particles. It is recommended to keep low insufflation pressure, use closed suction to remove generated gas / smoke within abdominal cavity, and consider open surgery for high-risk patients3. Strategies for postoperative management. Since immunocompromised and elderly patients are at a high risk of COVID-19 infection4, postoperative protection of patients should be strictly implemented. Moreover, it is important to actively prevent and effectively treat postoperative complications in order to shorten hospitalization time towards accommodating the large volume of pandemic-delayed medical demands. Patients suspected of nosocomial SARS-CoV-2 infection should be isolated and receive clinical tests and CT scanning as early as possible. With the help of advanced technology, autonomous robots can be applied to deliver drugs, clean and patrol wards for reducing close contact and risk of nosocomial infection. In summary, we hope that our experience can help peers in perioperative management of general surgery, and ensure medical safety in the post-COVID-19 pandemic era. Contributions Conception and design: Z. Wang, L. Wang, G. Wang, J. Zhang, X. Lu. Drafting: L. Wang, X. Lu, Z. Wang. Revising critically: Z. Wang, L. Wang, X. Lu, J. Zhang, G. Wang. Final approval: L. Wang, X. Lu, Z. Wang, J. Zhang, G. Wang. References 1 Spinelli A , Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis . Br J Surg 2020 ; 107 : 785 – 787 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Lei S , Jiang F, Su W, Chen C, Chen J, Mei W et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection . EClinicalMedicine 2020 ; https://doi.org/10.1016/j.eclinm.2020.100331 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 3 Emile SH Should we continue using laparoscopy amid the COVID -19 pandemic? . Br J Surg 2020 ; 107 : e240 – e241 . Google Scholar Crossref Search ADS PubMed WorldCat 4 COVIDSurg Collaborative . Global guidance for surgical care during the COVID-19 pandemic . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11646 [Epub ahead of print]. OpenURL Placeholder Text WorldCat Author notes these authors contributed equally to this work. © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Macdonald, N; Clements, C; Sobti, A; Rossiter, D; Unnithan, A; Bosanquet, N

doi: 10.1002/bjs.11817pmid: 32779749

Editor The current Covid-19 pandemic faced by the healthcare system is unprecedented in the modern health care setting. The NHS has been re-tasked to treat a large number of Covid-19 patients, suspending the usual business of elective surgery1. There is no current estimate to the size of the backlog being generated. Calculating the scale of the backlog It is impossible to tell the exact scale of the cancellations ongoing as NHS statistics have ceased to record this data during the current Covid-19 pandemic2. However, a rough estimate can be made from comparison of the statistics from 2019 for the same period. Using emergency admissions to calculate non-emergency admissions, the percentage of finished consultant episodes (FCE's) requiring a procedure can produce an estimate of the number of non-emergency admissions with procedure each month (Table 1). This data tallies with the known data of finished admission episodes (FAE's) by admission method. This gives an estimate of between 505 146 - 574 353 admissions per month. Using the data from the hospital admission by specialty and eliminating all non-surgical specialties and paediatric specialties we can see that there were 4 871 276 admissions that were ‘planned’ (1 335 565) or ‘waiting list’ (3 535 711). This gives us an estimate of 405 939 admissions per month for the surgical specialties, with an average bed stay of 4·3 days3. Even if we use a low end estimate of ∼400 000 cases per month, this will still lead to a back log of 1 200 000 cases over a 3-month period. Table 1 Provisional monthly hospital episode statistics: admitted patient care data with addition of non emergency admissions requiring a procedure estimate6,3. 2019 . Finished consultant episodes . FCEs with a procedure . % FCEs with a procedure . Ordinary episodes . Day case episodes . Day case episodes with a procedure . % Day case episodes with a procedure . Finished admission episodes . Emergency admissions . Non emergency admission with procedure . Oct 19 1,840,455 1,009,412 54.8% 1,166,818 673,637 600,033 89.1% 1,525,178 565,326 526,438 Sep 19 1,725,979 1,015,939 58.9% 1,105,315 620,664 582,690 93.9% 1,428,181 535,056 525,708 Aug 19 1,713,472 1,012,009 59.1% 1,108,339 605,133 568,563 94.0% 1,414,682 532,720 520,903 Jul 19 1,846,274 1,101,264 59.6% 1,172,130 674,144 633,149 93.9% 1,526,850 563,945 574,353 Jun 19 1,709,597 1,010,989 59.1% 1,102,241 607,356 571,396 94.1% 1,414,451 531,335 522,240 May 19 1,800,193 1,060,876 58.9% 1,161,064 639,129 601,609 94.1% 1,483,667 560,004 544,326 Apr 19 1,725,301 1,004,293 58.2% 1,121,169 604,132 569,322 94.2% 1,413,927 546,124 505,146 2019 . Finished consultant episodes . FCEs with a procedure . % FCEs with a procedure . Ordinary episodes . Day case episodes . Day case episodes with a procedure . % Day case episodes with a procedure . Finished admission episodes . Emergency admissions . Non emergency admission with procedure . Oct 19 1,840,455 1,009,412 54.8% 1,166,818 673,637 600,033 89.1% 1,525,178 565,326 526,438 Sep 19 1,725,979 1,015,939 58.9% 1,105,315 620,664 582,690 93.9% 1,428,181 535,056 525,708 Aug 19 1,713,472 1,012,009 59.1% 1,108,339 605,133 568,563 94.0% 1,414,682 532,720 520,903 Jul 19 1,846,274 1,101,264 59.6% 1,172,130 674,144 633,149 93.9% 1,526,850 563,945 574,353 Jun 19 1,709,597 1,010,989 59.1% 1,102,241 607,356 571,396 94.1% 1,414,451 531,335 522,240 May 19 1,800,193 1,060,876 58.9% 1,161,064 639,129 601,609 94.1% 1,483,667 560,004 544,326 Apr 19 1,725,301 1,004,293 58.2% 1,121,169 604,132 569,322 94.2% 1,413,927 546,124 505,146 Open in new tab Table 1 Provisional monthly hospital episode statistics: admitted patient care data with addition of non emergency admissions requiring a procedure estimate6,3. 2019 . Finished consultant episodes . FCEs with a procedure . % FCEs with a procedure . Ordinary episodes . Day case episodes . Day case episodes with a procedure . % Day case episodes with a procedure . Finished admission episodes . Emergency admissions . Non emergency admission with procedure . Oct 19 1,840,455 1,009,412 54.8% 1,166,818 673,637 600,033 89.1% 1,525,178 565,326 526,438 Sep 19 1,725,979 1,015,939 58.9% 1,105,315 620,664 582,690 93.9% 1,428,181 535,056 525,708 Aug 19 1,713,472 1,012,009 59.1% 1,108,339 605,133 568,563 94.0% 1,414,682 532,720 520,903 Jul 19 1,846,274 1,101,264 59.6% 1,172,130 674,144 633,149 93.9% 1,526,850 563,945 574,353 Jun 19 1,709,597 1,010,989 59.1% 1,102,241 607,356 571,396 94.1% 1,414,451 531,335 522,240 May 19 1,800,193 1,060,876 58.9% 1,161,064 639,129 601,609 94.1% 1,483,667 560,004 544,326 Apr 19 1,725,301 1,004,293 58.2% 1,121,169 604,132 569,322 94.2% 1,413,927 546,124 505,146 2019 . Finished consultant episodes . FCEs with a procedure . % FCEs with a procedure . Ordinary episodes . Day case episodes . Day case episodes with a procedure . % Day case episodes with a procedure . Finished admission episodes . Emergency admissions . Non emergency admission with procedure . Oct 19 1,840,455 1,009,412 54.8% 1,166,818 673,637 600,033 89.1% 1,525,178 565,326 526,438 Sep 19 1,725,979 1,015,939 58.9% 1,105,315 620,664 582,690 93.9% 1,428,181 535,056 525,708 Aug 19 1,713,472 1,012,009 59.1% 1,108,339 605,133 568,563 94.0% 1,414,682 532,720 520,903 Jul 19 1,846,274 1,101,264 59.6% 1,172,130 674,144 633,149 93.9% 1,526,850 563,945 574,353 Jun 19 1,709,597 1,010,989 59.1% 1,102,241 607,356 571,396 94.1% 1,414,451 531,335 522,240 May 19 1,800,193 1,060,876 58.9% 1,161,064 639,129 601,609 94.1% 1,483,667 560,004 544,326 Apr 19 1,725,301 1,004,293 58.2% 1,121,169 604,132 569,322 94.2% 1,413,927 546,124 505,146 Open in new tab These patients who wait may have a significant reduction in quality of life. Patients who have had multiple attacks of cholecystitis end up staying in hospital a week longer4 whereas those who wait too long for a joint replacement see a significant reduction in benefit5. The scale of the backlog should not just be seen as an increased waiting list but a ticking cluster bomb throwing off explosions of poor patient outcomes as time progresses. Conclusions Resumption of service to approaching normal will take months if not years and will result in a large backlog of elective cases. Strategies for resumption of work differ between college and specialty with new guidelines being produced on a weekly basis. We estimate across the NHS circa 400 000 procedures are backlogging per month. Resumption of services will be slow and less time efficient than pre-pandemic. Unless the government recognizes this paradigm shift in treatment and responds appropriately the current measures will result in large fines being levied on NHS trusts and poor outcomes for patients left waiting. We believe the large backlog of elective cases which will have a real impact on patient care and wellbeing. Ongoing waiting times must be adjusted to provide reasonable expectations to patients and allow critical cases such as cancer diagnostics to proceed in a timely manner. Strategies to reduce waiting times include continued investment in private hospital capacity, expansion of the workforce and increase in conservative management strategies. Finally, a national level response is needed to prevent ‘post code lotteries’ and could be used to redistribute workload evenly amongst the workforce. References 1 Iacobucci G . Covid-19: all non-urgent elective surgery is suspended for at least three months in England . BMJ 2020 ; https://doi.org/10.1136/bmj.m1106 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 2 NHS England . COVID-19 and the production of statistics . 2020 ; https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2020/07/COVID-19-and-the-production-of-statistics-2020-07-07.pdf 3 NHS Digital . Hospital Admitted Patient Care and Adult Critical Care Activity . https://files.digital.nhs.uk/F2/E70669/hosp-epis-stat-admi-summ-rep-2018-19-rep.pdf 4 De Mestral C , Rotstein OD, Laupacis A, Hoch JS, Zagorski B, Alali AS et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecystitis: A population-based propensity score analysis . Ann Surg 2020 ; 259 : 10 – 15 . Google Scholar Crossref Search ADS WorldCat 5 Ghomrawi HMK , Mushlin AI, Kang R, Banerjee S, Singh JA, Sharma L et al. Examining Timeliness of Total Knee Replacement Among Patients with Knee Osteoarthritis in the U.S.: Results from the OAI and MOST Longitudinal Cohorts . J Bone Joint Surg Am 2020 ; 102 : 468 – 476 . Google Scholar Crossref Search ADS PubMed WorldCat 6 NHS Digital . Provisional Monthly Hospital Episode Statistics: Admitted Patient Care data . https://digital.nhs.uk/data-and-information/publications/statistical/hospital-episode-statistics-for-admitted-patient-care-outpatient-and-accident-and-emergency-data/april-2019---october-2019-m07 © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Zanus, G; Romano, M; Santoro, G A; Rossi, S; Grossi, U

doi: 10.1002/bjs.11856pmid: 32725825

Editor Covid-19 pandemic is affecting more than 200 countries around the world with a case fatality rate of 6 per cent1. More than 28 million procedures would be cancelled or postponed during the 12-week peak according to a recent global expert-response study2. Furthermore, it has been shown that COVID-19 infection may complicate the course of patients undergoing elective surgery3. In this scenario, it is difficult to estimate the consequences of COVID-19 on global health systems, but concerted efforts are being made to avoid detrimental effect on oncologic outcomes and limit surgical morbidity4. After February 21, 2020, Italy became the hardest-hit country, with the highest death toll of 17,127 (>5 times as much as China) and 135,586 confirmed cases on April 7, 20205. Between February 26th and May 3rd (the day before all measures restricting movement within the regional territory ceased to have effect), 161 operations were performed by our unit from a tertiary teaching hospital in Veneto, the second-hit Italian region by the COVID-19 outbreak. Among these, 56 (35 per cent) were urgent cases. In 2019, 322 operations were performed during the same time period, with 76 (24 per center) in the emergency setting. Following hospital directions, a 50 per cent decrease in theatre slots has led to halving the number of operations compared to last year. During both years, most urgent cases related to lower gastrointestinal surgery (61 per cent [46/76] in 2019 and 64 per cent [36/56] in 2020). However, compared to the previous year these were performed in a significantly higher number of patients with active cancer (7/56 [12·5 per cent] vs. 1/76 [1·3 per cent]; P = 0·018). Moreover, a higher number of referrals for bowel obstruction resulting from incarcerated umbilical and inguinal hernias were observed during the pandemic. Forthcoming guidelines will inform the optimal timing and type of surgery, especially for cancer patients during an unrelated pandemic, and a joint international effort is advisable to establish pathways for crisis management. Author Contributions GZ and MR equally contributed to this article. References 1 WHO . Coronavirus disease (COVID-19) pandemic . https://www.who.int/emergencies/diseases/novel-coronavirus-2019. 2 COVIDSurg Collaborative . Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11746 [Epub ahead of print]. OpenURL Placeholder Text WorldCat 3 Aminian A , Safari S, Razeghian-Jahromi A, Ghorbani M, Delaney CP. COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period . Ann Surg 2020 ; 272 : e27 – e29 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Spinelli A , Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis . Br J Surg 2020 ; 107 : 785 – 87 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Grossi U , Zanus G, Felice C. Coronavirus disease 2019 in Italy: The Veneto model . Infect Control Hosp Epidemiol 2020 ; https://doi.org/10.1017/ice.2020.225 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Zhao, Y; Xu, X

doi: 10.1002/bjs.11867pmid: 32749670

Editor As of May 31, globally there have been about 6·10 million cases of COVID-19 with more than 51 thousand cases confirmed per day. Nasolaryngoscopy, endotracheal intubation and possible tracheostomy in thyroid surgery put medical staff at high risk. The elective surgery, for example, for most patients with thyroid tumors, is recommended to be postponed1–3. In the other hand, in many countries, such as China, Japan, Korea, Germany, France, and Italy, daily confirmed cases have continued to decline. In contrast, the surgery for patients with positive FNA, has been delayed for several months. The concerns about cancer progression have gradually surpassed those of COVID-19, and can no longer be relieved by online consultation. Systematic and adequate infection control measures could be effectiveness in COVID-19 prevention. Meng et al. reported that no COVID-19 infection was confirmed in 169 staff workers who treated more than 700 patients with emergent dental care since January 24 in Wuhan, China4. Furthermore, Lee et al. performed 2073 elective operations without none hospital-acquired infection in South Korea between 20 January and 19 March 20205. In our experience, some following principles need be followed. Firstly, patients should be managed with risk group analysis based on their prognostic features. Secondly, patients, their accompanying persons and healthcare workers, all should wear a medical mask, measure body temperature, and avoid unnecessary gathering. Last but not least, the screening measures for COVID-19 include precheck questions about the health status and history of contact or travel in past two weeks, together with CT imaging, nucleic acid tests on respiratory tract specimens and IgM-IgG testing. Compared with nucleic acid, the IgM-IgG test is more accurate and sensitive6. Some measures like reducing hospital stays, face shields in surgery and endotracheal intubation, and so on, should also be taken. Author Disclosure Statement The authors declare that they have no competing interests. Reference 1 American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) . New Recommendations Regarding Urgent and Nonurgent Patient Care . https://www.entnet.org/content/new-recommendations-regarding-urgent-and-nonurgent-patient-care. 2 Soreide K , Hallet J, Matthews JB, Schnitzbauer AA, Line PD, Lai PBS et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11670 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 3 COVIDSurg Collaborative . Global guidance for surgical care during the COVID-19 pandemic . Br J Surg 2020 ; 107 : 1097 – 1103 . Crossref Search ADS PubMed WorldCat 4 Meng L , Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine . J Dent Res 2020 ; 99 : 481 – 487 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Lee J , Choi JY, Kim MS. Elective surgeries during the COVID-19 outbreak . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11697 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 6 Xie J , Ding C, Li J, Wang Y, Guo H, Lu Z, et al. Characteristics of Patients with Coronavirus Disease (COVID-19) Confirmed using an IgM-IgG Antibody Test . J Med Virol 2020 ; https://dx.doi.org/10.1002%2Fjmv.25930 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Peckham-Cooper, A; Coe, P O; Clarke, R W; Burke, J; Lee, M J

doi: 10.1002/bjs.11907pmid: 32749699

Editor We read with interest the COVIDSurg Collaborative article, ‘Global Guidance for surgical care during the COVID-19 pandemic’1 and eagerly await the collaboratives initial report. It is clear, the SARS-CoV-2 pandemic has had a significant impact on emergency and elective surgical services. Concerns about surgical outcomes in COVID-19 positive patients and intra-operative transmission to healthcare workers meant that initial guidance from multiple surgical bodies recommended non-operative management options where possible. Specifically, for the management of acute biliary disease, the Intercollegiate General Surgery Guidance on COVID-192 recommended either non-surgical management or the utilisation of a cholecystostomy tube. This represents a major deviation from prior best practice where definitive treatment with early laparoscopic cholecystectomy was recommended within one week of index admission3,4 and the use of cholecystostomy drains reserved only for patients considered too high risk for surgery5. The White Rose Surgical Collaborative (WRSC) (UK) is undertaking a multicentre, retrospective cohort study to examine commonly utilised management strategies for acute cholecystitis in the UK. One of the primary objectives is to examine the use of cholecystostomy drains, their associated management and morbidity. Data collection is ongoing, but interim analysis of results may provide guidance on what we might expect with the increased use of this strategy throughout the pandemic. To date, 864 patients with a coded diagnosis of acute cholecystitis during the study period were submitted from five hospital trusts in the United Kingdom. Of these 63 (7·2%) had a cholecystostomy drain placed. This typically represented those with more comorbidities (Charlson comorbidity index median score 2 vs 4 for no drain and drained respectively, p < 0·001), and those with a greater inflammatory response at admission (mean admission CRP 87·5 vs 169 mg/L, p < 0·01). Of those receiving a cholecystostomy, 22 (35·2%) patients experienced a complication. Of these 3 (4·7%) were immediate (e.g. bleeding) and 19 were late; Complications were reported as wrong site placement in 2 (10·5%) patients, displacement of drain in 12 (63·2%) patients and chronic fistula formation was seen in 1 (5·3%) individual. Other non-specific complications were seen in 4 (21·1%) patients undergoing intervention. Following insertion of a cholecystostomy drain, 21 (41·4%) patients underwent a check tubogram before discharge. Interestingly, 42·9% of those patients post cholecystostomy drain required readmission to hospital, re-presenting acutely for admission mean of 0·55 times (Range 1 to 4 times each). With the anticipated move towards radiological drainage for a wider population group resulting from COVID-19 protocols, the burden of complications and readmissions can be expected to increase6. As the peri-operative risks of Covid-19 become clearer we must remember that whatever strategy we adopt now will have ramifications for patients. Avoiding repeated admissions to hospital through the provision of definitive treatment pathways should be a consideration in planning services. Where laparoscopic surgery in the acute setting can be safely delivered for patients with acute cholecystitis this should be considered given the morbidity associated with non-operative strategies. Avoiding unintended consequences and balancing the associated risks of any proposed strategy remain difficult goals to achieve. We are working to expedite the completion and analysis of the dataset to further contribute to the discussion. References 1 COVIDSurg Collaborative . Global Guidance for surgical care during the COVID-19 pandemic . Br J Surg 2020 ; 107 : 1097 – 1103 . Crossref Search ADS PubMed WorldCat 2 The Royal College of Surgeons of England. Intercollegiate General Surgery Guidance on COVID-19 . https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/ 3 National Institute for Health and Care Excellence . Gallstone disease, diagnosis and management . https://www.nice.org.uk/guidance/cg188 4 Okamoto K , Suzuki K, Takada T, Strasberg SM, Asbun HJ, Endo I et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis . J Hepatobiliary Pancreat Sci 2018 ; 25 : 55 – 72 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Turiño SY , Shabanzadeh DM, Eichen NM, Jørgensen SL, Sørensen LT, Jørgensen LN. Percutaneous Cholecystostomy Versus Conservative Treatment for Acute Cholecystitis: a Cohort Study . J Gastrointest Surg 2018 ; 23 : 297 – 303 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Lu P , Chan CC, Yang NP, Chang NT, Lin KB, Lai KR et al. Outcome comparison between percutaneous cholecystostomy and cholecystectomy: a 10-year population based analysis . BMC Surgery 2017 ; 17 : 130 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes There are no external sources of funding declarable for this research. It has been conducted as a trainee collaborative project. Article submitted as a revised correspondence to the editor. This letter is original and based on no previous communication to a society or meeting. © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Agrawal, Vikesh; Sharma, Dhananjaya

doi: 10.1002/bjs.11860pmid: 32735700

Editor Ongoing COVID-19 pandemic has claimed hundreds of thousands of lives and as a collateral damage caused catastrophic socio-economic consequences for the whole world. One unsung collateral victim of ‘fear’ of this infection was Laparoscopic Surgery (LS). Theoretical potential of virus transmission during LS via surgical smoke and laparoscopy gas; coupled with high number of health care professionals (HCP) getting infected played on everybody's mind. This prompted authors and academic associations to err on the ‘side of safety’; and they labeled all LS procedures as high risk, and suggested avoiding laparoscopy in all COVID-19 positive or untested patients1–3. Proven sources of COVID-19 transmission are droplets and aerosol transmission; sources of theoretical risk (RNA presence but no proven transmission) are feces, blood, and urine, peritoneal and amniotic fluid. Similarly, there is no evidence of pathogen transmission via smoke and laparoscopic gas to HCPs; although bacterial/ viral fragments and chemicals have been isolated in surgical smoke. In the beginning of pandemic a ‘venturing into unknown’ - ‘safety-first’ approach was understandable; but, in the absence of substantial evidence of transmission risk to HCPs, more and more surgeons are now offering LS to their patients. Especially as safe management of surgical smoke is possible and frugal low-cost smoke filters are now easily available to assuage the unproven fears of LS4,5. There is no doubt that medical researchers rose to the occasion and responded swiftly to the pandemic with an unprecedented tsunami of publications; alas, all of them were not evidence-based. Our observation that initial suggestions were based more on caution and uncertainty than proof; is not meant as a criticism. However, only irrefutable evidence will make the scientific literature more reliable. The caveat by Nobel Laureate Professor Kaelin: “publish houses of brick, not mansions of straw” is more relevant today than ever. References 1 Spinelli A , Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis . Br J Surg 2020 ; 107 : 785 – 787 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Di Marzo F , Sartelli M, Cennamo R, Toccafondi G, Coccolini F, La Torre G et al. Recommendations for general surgery activities in a pandemic scenario (SARS-CoV-2) . Br J Surg 2020 ; 107 : 1104 – 1106 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Mayol J , Fernández Pérez C. Elective surgery after the pandemic: waves beyond the horizon . Br J Surg 2020 ; 107 : 1091 – 1093 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Mowbray NG , Ansell J, Horwood J, Cornish J, Rizkallah P, Parker A et al. Safe management of surgical smoke in the age of COVID-19 . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11679 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 5 Agarwal V , Sharma D. Frugal solutions for operating room during COVID-19 pandemic . Br J Surg 2020 ; 107 : e331 – e332 . Google Scholar Crossref Search ADS PubMed WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.

Merchant, J; Scarfe, M; Pandit, M; Cunningham, C

doi: 10.1002/bjs.11852pmid: 32725814

Editor The COVID-19 pandemic has significantly disrupted cancer treatment nationwide, despite NHS England urging Trusts to ensure cancer care continued1. Cautious clinical guidance2– avoiding anastomoses, reducing laparoscopy and deferring higher risk patients – coupled with the diversion of resources to manage the expected surge, caused UK cancer surgery numbers to plummet. The major concern was unwittingly performing surgery on COVID positive patients or patients becoming infected post-operatively. Early data from Wuhan suggested a 20 per cent mortality for COVID-19 positive elective surgery patients3. Unnecessarily endangering staff and other patients was also a key concern. Additionally, the potential reduction in ITU capacity and the possibility of litigation were prominent considerations4. In Oxford, we confined COVID-19 positive cases to our acute site, designated the Churchill Hospital the ‘clean’ site and commissioned support from the independent hospital. Since UK lockdown on 23rd March, we have conducted over 400 cancer procedures and extended our services to support more severely affected Trusts. We introduced 14 days preoperative shielding and minimised hospital visits using drive-through phlebotomy and swabbing services. CT chest was used for major procedures until routine pre-operative viral swab testing was available. All theatre staff used level II PPE and underwent robust simulation training. We use enhanced recovery protocols and where possible, early discharge with intensive telephone follow-up. Monitoring of the cohort continues, but to date we have no reported peri-operative COVID-19 infections. During the recovery phase, we must address the needs of patients whose treatment has been put on hold5. Firstly, we need to extend surgery to cancer patients with significant co-morbidities and patients with clinically urgent benign disease. Secondly, we must resume diagnostic services to avoid a peak of deaths due to delayed diagnoses. Teamwork, agile decision making and above all, systematic testing of staff and patients is essential to restore workforce confidence, improve efficiency and resource utilisation. References 1 NHS England and NHS Improvement . Letter to chief executives of all NHS trusts and foundation trusts, CCG accountable officers, GP practices and primary care networks, and providers of community health services . https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/urgent-next-steps-on-nhs-response-to-covid-19-letter-simon-stevens.pdf. 2 The Association of Coloproctology of Great Britain and Ireland. Considerations for Multidisciplinary Management of Patients with Colorectal Cancer during the COVID-19 Pandemic . https://www.acpgbi.org.uk/news/considerations-for-multidisciplinary-management-of-patients-with-colorectal-cancer-during-the-covid-19-pandemic/. 3 Lei S , Jiang F, Su W, Chen C, Chen J, Mei W et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection . EClinicalMedicine 2020 ; https://doi.org/10.1016/j.eclinm.2020.100331 [Epub ahead of print]. Google Scholar OpenURL Placeholder Text WorldCat 4 Spinelli A , Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis . Br J Surg 2020 ; 107 : 785 – 787 . Google Scholar Crossref Search ADS PubMed WorldCat 5 COVIDSurg Collaborative . Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans . Br J Surg 2020 ; https://doi.org/10.1002/bjs.11746 [Epub ahead of print]. OpenURL Placeholder Text WorldCat © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2020 BJS Society Ltd. Published by John Wiley & Sons, Ltd.