Performing General Surgery Emergencies Safely during COVID-19 Outbreak

1. Introduction

Cases of pneumonia of undetermined etiology emerged in the city of Wuhan in China on 31 December 2019 [1]. The results of throat swabs indicated Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) as the causative agent. World Health Organization (WHO) then designated COVID-19 as the official name for the disease that arose from the novel coronavirus, and on 30 January 2020, and declared the COVID-19 epidemic a public health emergency [1, 2].

COVID-19 is a single-stranded RNA virus that is transmitted via droplets scattered from infected patients. It typically manifests with a dry cough, fever, dyspnea, joint pain, and malaise. Recent studies have also reported that anosmia/hyposmia are among the major symptoms [3]. On the other hand, the disease may also have an asymptomatic course. Although COVID-19 usually has a favorable prognosis, its consequences may be severe in the elderly population and people with chronic disorders [2, 4, 5]. Its imaging findings usually include bilateral infiltrations and ground glass appearances in the lungs. Its laboratory findings include leukopenia, lymphopenia, and mild elevation in liver function tests. A third of patients have an elevated D-dimer level [6]. Furthermore, troponin I elevation may also occur as infected patients may develop myocarditis. The inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), usually increased. The mortality rate is approximately 2% [4, 7]. The diagnosis of COVID-19 is based on the presence of all clinical symptoms, laboratory findings, the presence of the aforementioned signs of viral pneumonia on thoracic CT, and identification of viral nucleic acid real-time reverse transcription-polymerase chain reaction (RT-PCR) in swab samples taken from nasopharynx and oropharynx [7, 8].

The first case of COVID-19 in Turkey was a man from Istanbul who was diagnosed on 11 March 2020 during the examinations performed to investigate the etiology of fever of unknown origin. After the first case was announced on 11 March 2020, some hospitals were turned into pandemic hospitals across the country by the Coronavirus Scientific Advisory Board’s decision set up by the Ministry of Health in Turkey so as to manage treatment of patients infected with COVID-19 . From the first case to 11 May 2020, 139.771 cases have been diagnosed as of 11 March 2020, and 3841 deaths have been reported [9]. Approximately 60% of the total number of cases have been reported from Istanbul, where our hospital is located [10]. Our hospital has also been declared a pandemic hospital from the very first day of the pandemic.

Health systems and healthcare workers all around the world, including emergency surgery teams, have met serious difficulties due to the rapid spread of COVID-19 [5]. To prevent the crisis that arises from the pandemic, the emphasis has been given to assign intensive care units(ICUs) and mechanical ventilators to severely ill patients and to provide healthcare staff with adequate personal protective equipment. As a result, the guidelines have recommended postponing, and even cancelling, all elective and semi-elective interventions. However, little guidance has been provided “by surgeons for surgeons” concerning the preparation of perioperative media for planned emergency surgeries and interventions for general surgery and trauma patients [4, 7, 8, 11, 12]. On the other hand, general surgery patients and trauma patients requiring emergency surgery or intervention should be urgently evaluated and managed.

The management of patients requiring emergency surgery or intervention and trauma patients by the general surgery departments in light of those guidelines and recommendations has undergone pandemic-related changes. Herein, we aimed to investigate our emergency surgery approach and changes in our management and report our experience with emergency surgeries and interventions during the COVID-19 pandemic.

2. Materials and methods

The medical records of patients requiring emergency surgeries or interventions and trauma patients admitted to the general surgery Emergency Department clinic between 11 March 2020 and 11 May 2020 were retrospectively reviewed in this study. This study was approved by the Ministry of Health Science Committee and the local hospital ethics committee (No: 77106/2020). This study included patients older than 18 years who had signs of acute abdomen, required emergency intervention, had complete accessible laboratory data and underwent posterior-anterior (PA) chest radiography and/or thoracic computerized tomography (CT). Since the surgical evaluation of patients younger than 18 years is carried out by pediatric surgeons at our hospital, this group of patients was not included in this study. In addition, elective and semi-elective operations were excluded from this study since only patients who required emergency surgeries and interventions were included. The patients’ demographic data, comorbidities, smoking history, presence of fever, laboratory parameters, preoperative imaging techniques, surgical indications, presence of preoperative and postoperative suspicion of COVID-19, postoperative ICU need, presence of surgical site infection(SSI), America Society of Anesthesiologists(ASA) score, type of surgery and/or intervention, operative time, need for blood transfusion, length of hospital stay, and mortality rate were analyzed. All patients were evaluated for suspected COVID-19 before admission to the general surgery department and at the time of discharge. In addition, cooperation was made with the Department of Infectious Diseases for patients’ management.

3. Results

Six of 54 patients were excluded from the study protocol due to unavailable laboratory data. Thus, 48 patients were included in this study. The number of patients who underwent emergency surgery during the same period last year (March-May 2019) was 110. In this study, 30 (62.5%) patients were male, and 18 (37.5%) were female. The mean age of patients was 50.3 $\pm$ 19 (range 13 - 93) years, with 13 (27%) patients being 65 years old or older. Nineteen (39.6%) patients had comorbidities (hypertension, diabetes mellitus, coronary artery disease). Table 1 shows the patients’ comorbidities, preoperative imaging findings, operative time, length of hospital stay, postoperative complications and mortality. Fifteen patients had more than one comorbidity, and one of them presented with suspected preoperative COVID-19. According to the ASA classification, 11 (22.9%) patients were in ASA I condition, 20 (41.7%) patients ASA II, 15 (31.3%) patients ASA III, and 2 (4.2%) patients ASA IV. Eight (16.7%) patients had a fever (body temperature $\ge$ 38${}^{\circ }$C). Only one patient with fever and suspicious signs of COVID-19 on preoperative thoracic CT had suspected COVID-19; that patient was underwent surgery for acute mechanical intestinal obstruction. Postoperative RT-PCR testing was administered from oropharynx and nasopharynx swab samples for suspected COVID-19 due to persistent fever in one of the four patients and suspected signs on thoracic CT in the rest. All RT-PCR tests were negative. However, as one of them was symptomatic, he was transferred to the COVID-19 ward. That patient was tested again; the result was negative. As his symptoms improved after that, he was discharged uneventfully following medical treatment. The other three patients were asymptomatic and discharged uneventfully. Eight (16.7%) patients needed postoperative ICU care. Five patients developed SSI. A patient who underwent primary repair for perforated peptic ulcer was operated with a second primary repair after developing a recurrent leak. No COVID-19 infection was detected in any of our healthcare team members during this study. Table 2 summarizes preoperative laboratory findings.

In Table 3, the diagnoses and the types of surgery are presented. The most common diagnoses were acute appendicitis (21 patients, 43%), bowel obstruction (11 patients 22%), peptic ulcer perforation (4 patients, 8%), trauma (3 patients, 6%) and acute cholecystitis (2 patients, 4%). All surgical procedures were performed with open technique. All appendices were complicated and had a mean Alvarado score of 8. Primary repair and omentoplasty were performed because of perforation due to peptic ulcer in the anterior aspect of the stomach in three patients and in the duodenum in one patient. Loop colostomy was performed in four patients due to mechanical ileus due to obstructive rectosigmoid tumors. While the right hemicolectomy was performed in one patient due to obstructive caecum tumor, one patient underwent low anterior resection and end colostomy due to rectosigmoid tumor perforation. Two patients had small bowel perforation due to adhesion, one of whom underwent loop ileostomy and the other adhesiolysis and primary repair.

Mortality occurred in five patients (10%) who had undergone surgery due to trauma (2), bowel perforation (2) and acute mesenteric ischemia (1). Both trauma patients died due to hypovolemic shock, two patients with GIS perforation due to septic shock, and the patient with acute mesenteric ischemia due to metabolic acidosis. In acute mesenteric ischemia, thrombus was present in the proximal jejunal and ileal branches originating from the superior mesenteric artery. Segmental small bowel resection and end ileostomy were performed. Mesenteric bypass procedure was not applied. None of the deceased patients had suspected COVID-19. No suspected case of COVID-19 occurred during the 14-day follow-up period after discharge.

4. Discussion

In the present study, we reported the general surgery cases that underwent emergency surgery in our institution, which was declared a pandemic hospital for two months since the report of the first COVID-19 case in Turkey. Multiple measures and actions have been taken during the pandemic, both to prevent the spread of the disease and to protect healthcare personnel. We demonstrated how the emergency surgeries and/or procedures were carried out at our hospital. The findings obtained in this study suggest that emergency and non-postponable surgical interventions can be carried out safely in a COVID-19 pandemic hospital. Moreover, this study showed that the number of emergency surgeries performed during this study reduced by half compared to emergency surgeries performed during the same period last year.

Multiple guidelines that have been published following the declaration of a pandemic by WHO have recommended postponing elective and semi-elective surgical procedures [4, 7, 13]. Besides, authors from many countries have reported their own experiences in emergency, unpostponable surgical procedures and interventions [5, 10, 14, 15]. As Lima et al. reported, all patients presenting to the emergency department with a presumed acute abdomen diagnosis were considered as having suspected COVID-19 even if they had no respiratory symptoms and/or fever [16]. Thus, each patient underwent a thoracic CT examination in conjunction with an abdominopelvic CT to determine the etiology of the acute abdomen. A study from China reported that RT-PCT had a sensitivity of 71%, whereas thoracic CT had a sensitivity of 98% [17]. In the light of the literature data, as RT-PCR test results were late, the preoperative RT-PCR test was performed, but patients were taken to emergency surgery before the test resulted. The possibility of COVID-19 was not excluded, even if thoracic CT imaging was negative.

As recommended by the guidelines [8], three patients who were hemodynamically unstable were examined using thoracic and abdominopelvic CT and operated without delay; two of them underwent splenectomy, and the other patient underwent packing. Although the most commonly performed procedure was open appendectomy (43%), patients with a high Alvarado score (score:8-9) [18] and complicated appendicitis were taken to surgery. The studies about the performance of the laparoscopic technique during the pandemic are controversial and small in number. The use of devices to filter CO2 from inhaled particles during laparoscopic procedures is strongly recommended. Moreover, central aspirator systems should be used to evacuate smoke [4, 8]. An Italian study has reported that laparoscopy can only be performed if these precautions are taken, and the devices are supplied. In the same study, the open surgical technique has been recommended for perforated appendicitis [19]. Due to all these concerns, in this study, all appendectomies were performed with the open technique to shorten the operation time and to maximally protect the operating room team since the measures related to laparoscopy mentioned above could not be taken. Uncomplicated acute appendicitis cases were followed up with medical treatment on an outpatient basis, and they were checked by phone calls day to day.

On the other hand, all uncomplicated acute cholecystitis were treated with intravenous (i.v) or per oral antibiotherapy. Two elderly patients with complicated cholecystitis, who did not benefit from medical treatment and had a high ASA score, were managed with percutaneous cholecystostomy according to Tokyo guideline [20]. Both patients underwent RT-PCR testing and thoracic CT before the procedure. Percutaneous cholecystostomy can be used as an alternative treatment method in cases where laparoscopic and open surgery cannot be performed [21]. Campanile et al. reported that laparoscopic cholecystectomy could be safely performed for uncomplicated cases even during the COVID-19 pandemic; they also added that percutaneous cholecystostomy might be considered for patients who are unfit for surgery [22]. Although it was mentioned that laparoscopic cholecystectomy could be performed safely, medical treatment was applied to patients diagnosed with uncomplicated acute cholecystitis since there were no filtering devices in our center. Complicated cholecystitis was managed by percutaneous cholecystostomy. Therefore, acute cholecystitis cases were managed with medical treatment or percutaneous cholecystostomy, and as no complications developed, the cholecystectomy procedure was postponed to an elective period due to pandemic.

Concern exists that postponement of elective procedures may lead to a possible increase in the rate of emergency department admissions for colorectal tumors showing signs of obstruction and perforation. As stressed by a comprehensive review [7], four patients in our study underwent a loop colostomy opening for an obstructive colon tumor, and another patient underwent right hemicolectomy. Similarly, another patient with perforation due to a rectal tumor was operated with low anterior resection and Hartmann colostomy. All procedures were completed as rapidly as possible by a minimum number of medical staff. The operating room was sterilized as early as possible after each operation.

No death was related to COVID-19 disease. Patients with suspected preoperative or postoperative COVID-19 disease were discharged uneventfully thanks to our institution’s compliance with the current guidelines. Our results showed that performing emergency surgical procedures as early as possible by taking strict measures and implementing a surgical management system adapted to the conditions of the pandemic are sustainable and do not adversely affect healthcare staff and even the most sensitive patients at risk of COVID-19 disease.

This study has some limitations. First, the present study has a small number of patients and a single-center design. Randomization is lacking, and this study is retrospective. Another limitation of our study is the inability to perform laparoscopic surgery as we lack specific devices in the operating room to prevent COVID-19 infection during laparoscopic surgery.

5. Conclusion

Cases needing emergency surgery should be managed without delay during the pandemic. COVID-19 should be suspected, and a thoracic CT should be taken in each patient. Preoperative preparations should be carried out with a multidisciplinary approach involving infectious diseases and anesthesia departments. All procedures should be performed with the smallest number of medical staff possible, each wearing PPE. The decision to perform laparoscopic surgery should be made after its advantages and disadvantages are weighed. We believe that patients should be admitted to single-person isolation rooms whenever possible, and be discharged as soon as possible. Additionally, patients should be informed about COVID-19 disease, and their condition should be checked via telephone calls and/or control visits during the 14-day follow-up period.

Acknowledgements

We would like to thank expert statician Mehmet Bilge Ozakcaoglu for his contribution.

Conflict of interest

The authors have declared that there is no conflict of interest.