during the COVID-19 pandemic General recommendations to the colorectalsurgeon Coloproctology Journal of

jcoloproctol(rioj).2020;40(3):192–195

w w w . j c o l . o r g . b r

Journal of

Coloproctology

Special Article

General recommendations to the colorectal surgeon during the COVID-19 pandemic

Fábio Guilherme Campos

, Henrique Sarubbi Fillmann

aUniversidadedeSãoPaulo,HospitaldasClínicas,DivisãodeCirurgiaColorretal,DepartamentodeGastroenterologia,SãoPaulo,SP, Brazil

bUniversidadePUCRS,FaculdadedeMedicina,DepartamentodeCirurgia,DivisãodeCirurgiaColorretal,PortoAlegre,RS,Brazil

a r t i c l e i n f o

Articlehistory:

Received1June2020 Accepted10June2020 Availableonline19June2020

Keywords:

Coronavirus COVID-19 Colorectalsurgery Coloproctologist

a bs t r a c t

TheCOVID-19 pandemichasshownourcountryinan unfavorablelight, asBrazilhas reportedthesecondhighestnumberofdeathstodate.Whenthesocialisolationphase isfinished,professionalactivities(includingthemedicalones)willresumetheirroutines andthespecialistmustbeupdatedinordertoprovideeffectiveandsafecare.Although manypublishedrecommendationsarebasedonlowlevelsofevidence,disclosingthemhas becomenecessary,sincethecoronavirusinfectionmayaffectoperativeoutcomes.Overall,it issuggestedthatphysiciansadoptpreventivemeasures,startingwiththemedicalappoint- ment,andextendingthemtothesurgicalprocedure.Furthermore,itisalsonecessaryto provisionallychangecriteriaforoperativeindicationsandconducts.Currently,postponing electivesurgeriesseemstobeauniversallyagreeddecision.Moreover,weneedtoestablish theearlydiagnosisoftheviralinfection,beforeorafterthesurgery.Severalsafetymeasures relatedtominimally-invasiveprocedureshavebeenreported,disclosingtherisksofaerosol disseminationbythepneumoperitoneumandsmokefromenergy-powereddevices.The presentarticleaimedtobringtothecolorectalsurgeonthecurrentrecommendationsand generalsafetymeasuresinordertopreventinfectiondissemination,toimprovesurgical planningintermsoftimingandspecifictechnicalaspects.

©2020SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Recomendac¸õesgeraisaocoloproctologistaduranteapandemiado COVID-19

Palavras-chave:

Coronavírus COVID-19 Cirurgiacolorretal Coloproctologista

r e su m o

Apandemia peloCOVID-19colocou oBrasilhojenumasituac¸ãode destaquenegativo, porquesomososegundopaíscommaiornúmerodecasosnomundo.Aofinalizarmos operíododeafastamentosocial,asatividadesprofissionais,incluindoasmédicas,serão

∗ Correspondingauthor.

E-mail:fgmcampos@terra.com.br(F.G.Campos).

https://doi.org/10.1016/j.jcol.2020.06.001

2237-9363/©2020SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

jcoloproctol(rioj).2020;40(3):192–195

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restabelecidas,eoespecialistanecessitaestaratualizadoafimdeproveromelhornível detrabalho,demaneirasegura.Apesardemuitasdasrecomendac¸õesestarembaseadas emopiniõeseestudossemmuitograudeevidência,suadivulgac¸ãonessemomentotorna- senecessária,umavezqueainfecc¸ãopelocoronavírusafetaosresultadosoperatórios.

Demaneirageral,omédicodeveassumirmedidaspreventivasdesdeomomentoemque agendaumaconsultaatéarealizac¸ãodoprocedimentocirúrgico.Alémdisso,énecessário consideraranecessidadedemudarprovisoriamenteoscritériosdeindicac¸ãocirúrgica,e atéascondutasoperatórias.Pareceexistirumpensamentouniformenosentidodeadiar cirurgiaseletivas.Damesmaforma,devemosreconhecerainfecc¸ãoviralprecocemente, antesouapósacirurgia.Diversasmedidaspreventivasrelacionadasaosprocedimentos minimamenteinvasivosjáforamdescritas,realc¸andoopoderdedisseminac¸ãopeloaerossol geradonessesprocedimentosenousodeinstrumentosdeenergia.Opresenteartigovisou apresentaraocoloproctologistaasrecomendac¸õesatuaisecuidadosgeraisparaprevenir disseminac¸ãodainfecc¸ão,ecomoplanejarotratamentocirúrgicocommaisseguranc¸aem termosdemomentodacirurgiaeaspectostécnicosespecíficos.

©2020SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este

´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Inhumans,coronaviruses(fromtheRNAfamily)causeres- piratoryinfections, suchas influenzaor severe syndromes (MERS,MiddleEastRespiratorySyndrome;SARS,SevereAcute Respiratory Syndrome). Since its appearance in China, in Decemberoflastyear,theinfectioncausedbythenewcoron- avirus,SARS-CoV-2(knownasCOVID-19),hasspreadrapidly andwasdeclaredapandemicbytheWorldHealthOrganiza- tion(WHO)inMarchofthisyear.¹

The disease spreads from person-to-person through dropletsfromthenoseormouth throughspeech,coughing orsneezing,orwhenpeoplecomeintocontactwithcontam- inated objects andputs their handson their eyes,noseor mouth.Otherformsoftransmissionarebeingstudied.Once infected,theaverageincubationperiodis5.2days(2–14days), andtheindividualmayremainasymptomaticordevelopflu- like,generalsymptoms(weaknessandbodypain),digestive andothersymptoms.Whilethevastmajorityrecoverwith- outdifficulties,around1/6ofthepatientscanhavethesevere formofthedisease,especiallyelderlyindividualsorthosewith comorbidities.²

Itiscurrentlyknownthat,inadditiontotheprofoundpul- monaryeffects,there aredigestive, neurological,renal and otheralterationsassociatedwiththeviremia.Morethanthe infectionitself,thehealthsystemisdeeplyaffected,andthe economicconsequencesareestimatedtobedevastatinginthe shortterm.

InBrazil,thepandemicreachednumberscompatiblewith ourlargepopulation,makingitoneofthefivecountrieswith thehighestnumberofdiagnosedcases.Duringthecourseof thepandemicandsoonafterithaswaneddown,itisexpected thatpracticalactivitieswillberoutinelyreestablishedinall specialties. Consequently, several medicalCollegiates have beenconcernedaboutdiscussinggeneralrecommendations fordailypractice,evenifitisbasedonthesmallnumberof publishedstudieswithalowlevelofscientificevidence.This

attitudearisesfromthespecialists’needtofeelminimallysafe andinstructedtodeveloptheiractivities.^3–8

Therefore,colorectalsurgeonsneedtoadapttheirpractical activitiestothenewreality,consideringtheconcernsrelated tothepossibilityoffecaltransmissionofthevirus.⁹Inviewof theseveralanticipatedandexpectedchangesinpatientcare, this reportaimed todiscuss the several recommendations publishedsofarinourspecialty.

Suggested adaptations in outpatient care

Many publications have suggested that when making an appointment,thepatientshouldbeaskedaboutsymptoms andcontactswithpossiblecarriers.Whenthereisanycause forsuspicion,theappointmentshouldbepostponedorcar- riedoutbytelemedicine,reducingtheriskofcross-infection.

Patientsshouldbeadvisedtocomewithoutcompanions,if possible, and appointmentsshould be scheduledat longer intervals,toavoidcontactwithmanypeople.Alcoholgelmust bemadeavailableintheenvironment,whichmustberegu- larlyventilatedandcleaned.

Thecontactwithpatientsshouldbemadewiththe use ofgloves,and boththedoctorandthepatientshouldwear facialmasks,inviewofthepossibilityofoccupationalexpo- sureand cross-infectionevenbyasymptomaticcarriers.^4,6,7 Inspiteofthecriticisms,theuseoftelemedicinehasreceived supportduetothefactthatitminimizestheriskofcontact andexposureofthepatient.

TheGastrointestinalTract(TGI)isanothertargetofSARS- CoV-2, a fact recognized by digestive symptoms and the presence ofthe virus inthe stool. This isprobably dueto thehighexpressionofACE2(angiotensin-convertingenzyme) receptorsbyenterocytes,alsopresentinthetypeIIalveolar epithelium.¹⁰

SymptomsinthehighandlowGITarecommon,although diagnosedlater,withwaterydiarrheabeingthemostfrequent one(20%),evenintheabsenceofcough,shortnessofbreath,

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sorethroator fever.Diarrhea canoccur beforeorafterthe respiratorysymptoms,especiallyamongwomen,andlastsan averageof5days(1–14).Othercomplaintsarenausea,vom- iting and abdominal pain. The presenceof GITsymptoms increasesthechanceoftestingpositiveforCOVID-19andthe diseaseduration.¹¹

Asmuchaspossible,wemustdifferentiatebetweenunin- fected, potentially infected individuals and sick patients, aiming to differentiate treatment strategies. In COVID+

patients,thetreatmentofrespiratorysymptomsmustprecede theoncologicaltherapy(exceptinemergencies).Patientswith suspecteddiseasemustbeobservedandkeptinisolation.The managementofnon-infectedindividualsmustincludepro- tectionfortheteam,consideringtheincubationperiodofthe disease.Thus,thepreoperativescreeningprocessisessential toavoidnosocomialinfectionandtoreduceindividualrisks.

Should elective surgeries be delayed?

While there is an increasing number of new cases and deaths, there is a recommendation to delay elective surg- eries (including selected cancer cases) in order to provide medicalresourcesandbeds(includingICUs),increasethehos- pitalareas thatcanbeused,concentratehospitalactivities foremergencycareand,mainly,reducethechancesofcross- infectionofdoctors,patientsandvisitors.⁵

Thebig questionofthe moment is:whento operateor when to delay? If the doctor and patient decide to have an elective procedure, an analysis should be made about the risk of acquiring an infection during the hospitaliza- tionperiod,whether aneventualCOVID-19infectionmight haveanimpactonthepostoperativeevolutionandthecon- sequences of longer hospital length ofstay (contracting a secondaryinfection,isolationfromthefamily,etc.).Likewise, weshoulddiscussthebesttimetorescheduletheprocedure andthepossibilityofdiseaseworseningduetothisreschedul- ing. A multicenter study carried out in patients from 235 hospitalsshowedthatpulmonarycomplicationsdevelopin 50%ofthosewithperioperativeinfection,leadingtosignifi- cantmortality.¹²

Dependingonhospitalconditions,thetreatmentofperi- analabscesses,selectedcasesofhemorrhoidalthrombosis, infectedpilonidalcystandanalfissureassociatedwithalotof painareproceduresthatcanbeconsideredwithoutgreatrisks.

Analternativeistoperformoutpatientsurgeryunderlocal anesthesia.¹³Inanycase,RT-PCRswabtestsshouldalwaysbe performed.Insuspectedpatients,utmostcareshouldbetaken whenhandlingstoolintherectalampoule.TheuseofN95 masksanddevicestoevacuatesmokeinallanorectalproce- duresarerecommended.¹⁴Someprofessionalsrequestachest computedtomography24–48hpriortolargerprocedures.¹⁵

General recommendations and care measures during surgical procedures

Any procedure performed on a COVID-19-positive or sus- pected patient must be performed in a specific room.

AppropriatePPE(N95masks,caps,gloves,facialprotection,

eyewear)mustbeusedbytheteam,whomustbetrainedto removeitattheendofthesurgery.

TooperateonCOVID+orsuspectedpatients,itisrecom- mendedthatpatientshaveanexclusiveaccesstoenterand leavetheoperatingroom.Aminimumnumberofpeopleinthe operatingroomisrecommended,andorotrachealintubation andextubationshouldbeperformedbytheanesthetistwith- outthepresenceofthesurgicalteamintheoperatingroom, preferablyundernegativepressure.

Theindicationofnegativepressureisbasedonahistory ofinfectionbyotherpathogens,allowingtheairflowtoenter theroom,butnotitsescapeintoneighboringareas.⁷

Regardingtheenergyunits,theuseofmonopolarscalpels, ultrasonicdissectorsandadvancedbipolardevicesshouldbe minimized,inadditiontousingthelowestpossiblepowerfor thedesirableeffect,aimingtoreducetheoccurrenceofpar- ticleaerosolization. Theuseofmonopolardiathermy pens, alongwithsmokeevacuation,canbehelpfultopreventinhal- ingbytheteammembersandassistance.⁶

Open,laparoscopicorroboticabdominaloperations

InaMinimallyInvasiveSurgery(MIS),thereisapotentialrisk ofaerosoldispersionalongwithviralparticles,whichiswhy thereiscontroversyaboutusingthisaccessrouteinpatients whomaybeinfected.However,thedetectionofthevirusin theperitonealfluidinaCOVID+patienthighlightstheneed forprotectionalsoinopensurgeries.¹⁶Thedecisionregard- ingsurgicalaccesswillthendependontheavailabilityofMIS equipmentandthedetectionofCOVID-19inagivenpatient.

Whileclosedproceduresaresafer,openonescandisseminate fluidsandsmokemoreeasily.Nevertheless,somebelievethat itisnecessarytoavoidlaparoscopiesduetotheriskofviral spread duringpneumoperitoneum. Asthis chance hasnot been wellevaluated,theinitialrecommendationsforaban- doningMISproceduresquicklyloststrength.⁶

IthasbeenrecognizedthatthebenefitsprovidedbyMIS (shorter hospital stay, reduced complications, less contact with abdominal organs) are very useful in patients with possible respiratory function impairment, if they become infected. Ontheother hand,therelease ofaerosolsduring or after the end ofthe surgery can contaminatethe envi- ronment.Even duringalaparotomy,caremust betakento completely evacuate all smoke resulting from the use of diathermy/electrocautery, including the use of rooms with negativepressure.⁵

Generically,themainrecommendationsandcaredefended sofararelistedhere:

- Provide informed consentonthe riskofexposure tothe virusanditsconsequences.

- Adoptprotectivemeasuresinopen,laparoscopicorrobotic procedures.

- Createpneumoperitoneumusingtheclosedtechniquewith Veressneedle.

- Maketightincisions forportalintroduction, toavoidthe inadvertentpassageofgasesthroughthewall.

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- Maintain minimum inflation pressure during the proce- dure,whichallowsthecreationofsufficientoperatingfield (8–12mm/Hg).

- TheMISproceduremustusedevicestoevacuateandfilter thereleasedCO₂thatmaycontainaerosolparticles(AirSeal iFS® SystemorLaparoshieldTMLaparoscopicSmokeFiltra- tionSystem).

Beforemakingtheassistanceincision(toremovethespec- imen), beforeasurgical conversionor beforeremovingthe trocarsattheendofthesurgery,thepneumoperitoneummust beemptiedbyafiltrationsystem,toavoidleaks.Thetrocarori- ficemustbeconnectedtothenegativepressuresuctionwith awaterseal.

Astheviruscanbepresentingastrointestinalcells(saliva, intestinalcontents,blood),endoscopic procedures must be consideredofhighriskandthesameenergyprecautionsmust beadopted.

ProceduresthatrequireadditionalCO2insufflation(endo- scopic mucosal resection and endoluminal procedures) shouldbeindicatedaccordingtostrictcriteriaandmaximum careuntiltheviralaerosolizationpropertiesarebetterknown.

Itisrecommendedtousenegativepressurealsoinendo- scopicrooms.Endoscopiesshould notbeperformedinthe medicalofficeduetotheriskofcontaminationoftheenvi- ronmentandtheneedforspecialprotectivematerials,andthe cleaningofsurgicalorendoscopicmaterialusedinapositive orsuspectedpatientshouldbedoneseparatelyfromothers.

Conflicts of interest

Theauthorsdeclarenoconflictsofinterest.

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