SAGES

Reimagining surgical care for a healthier world

Notes from the Battlefield - Coronavirus Global Surgical Collaborative (CVGSC)

An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, ELSA

A group of surgical leaders from affected countries have joined to discuss what they are learning during this COVID-19 global crisis. The following is a brief summary of what they feel may be useful information to disseminate to the surgical community:

General Disclaimer:

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

 

Notes from the Battlefield – May 14, 2020

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Coronavirus Global Surgical Collaborative (CVGSC)*
An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, and ELSA

A group of surgical leaders from affected countries have joined to discuss what they are learning during this Covid-19 Global crisis. The following is a brief summary of what they feel may be useful information to disseminate to the surgical community:

Impact of COVID-19 Pandemic on the Conduct of Surgical Research

The COVID impact on basic research has been extensive in certain areas of the world. Research labs have been affected and many times closed, except for those focused on COVID-19.  Clinical trials at institutions have been severely impacted and largely stopped.  Large streams of funding have been diverted away from non-COVID related research.  Adapting clinical research to the COVID-19 era is important and can be done incorporating COVID-19 testing and study protocol and using telehealth platforms.  For a useful guide on how to adapt research and clinical trials during this period, refer to the document prepared by the CVGSC

“Closing the Back Door” Protocol Helpful

Confidential reports from Italy and Spain confirm the efficacy of the “closing the back door protocol” in allowing an early detection of infected hospitalized surgical patients. Checking in house surgical patients twice a day – short interviews, temperature, and O2 saturation – led to several “suspected” infections. Standard operating protocol has been proven successful in identifying a few patients who later tested positive and were promptly isolated and managed accordingly. Although the early warning system increased the workload in the surgical wards, it definitely proved useful to limit in-hospital micro-outbreaks that potentially can affect other patients and staff health.

Preoperative Testing and Screening for Elective Surgery During the Pandemic to Restart Surgery

To minimize the spread and to plan appropriate protective measures for patients and OR staff, all patients should be tested prior to surgery.  The type and timing of testing remains controversial, however, and is highly dependent on local resources. Please see attached statement for further suggestions.

Participants:

Drs.  Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Davide Lomanto, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona, Suthep Udomsawaengsup

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at [email protected] if interested in being considered for participation.

General Disclaimer:

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

Did you find this information helpful?
Please consider joining SAGES or making a donation to the SAGES Education and Research Foundation so we can continue to bring content like this to the surgical community for free.

Notes from the Battlefield – April 23, 2020

by

Coronavirus Global Surgical Collaborative (CVGSC)*
An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, and ELSA

A group of surgical leaders from affected countries have joined to discuss what they are learning during this Covid-19 Global crisis. The following is a brief summary of what they feel may be useful information to disseminate to the surgical community:

Improving communication strategies for hospitalized COVID patients:

Because of the no visitor or restricted visitor policies in hospitals affected by the COVID-19 pandemic, communications between patients, families and their care teams have become extremely difficult. Understandably, clinical interactions are limited and preferentially conducted remotely, through glass doors, with in-person evaluations. Conversations are kept short and focused. Patients in isolation are particularly vulnerable to anxiety, fear of the unknown, and may have limited understanding of their condition and medical decision-making. A document on Communication Strategies during the COVID Pandemic is provided here and could be of valuable help in better understanding and addressing this issue.

Understanding COVID testing:

Several tests for the diagnosis of COVID infection have emerged. PCR, IgM and IgG are all valuable indicators at different stages of the disease. A comparison between the different tests, significance and potential pitfalls of the results are presented on the following document, courtesy of Surgery-AEC-COVID.

Transition back to surgical activities: When? How? by Whom?:

As we witness the decrease in cases in Europe and the plateau of the curve in certain parts of the US, a crucial question arises: How do we safely become operational and what will that look like? Since no one has a crystal ball to predict resurgence of the pandemic and prevalence of active infection, all answers to the question are based on predictions from expert opinion.  Clinicians and health care providers should have an important role in advising both policy makers, hospital administration and the public on the need for a thoughtful approach before calling for a full return to normal activities. A webinar on the subject will be held (link) which may shed some light on this difficult issue. At the same time, SAGES and EAES, in collaboration with several international surgical societies, are conducting a Delphi study with rigorous methodology with the goal of getting some valid information that will aid in answering this question.

Message from Italy, Spain & Netherlands to North America:

SAGES and EAES have joined forces during this crisis in creating initiatives like the CVGSC and multiple sources of information that have been of significant value to the global surgical community. It is from EAES that SAGES has received a heartfelt message of support and encouragement. SAGES thanks their European sister society for such a gesture of friendship. The letter clearly illustrates what the human spirit is and how difficult times brings people together to join forces and overcome adversity.

Participants:

Drs. Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Davide Lomanto, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona, Suthep Udomsawaengsup

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at [email protected] if interested in being considered for participation.

General Disclaimer:

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

Did you find this information helpful?
Please consider joining SAGES or making a donation to the SAGES Education and Research Foundation so we can continue to bring content like this to the surgical community for free.

Notes from the Battlefield – April 15, 2020

by

Coronavirus Global Surgical Collaborative (CVGSC)*
An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, and ELSA

A group of surgical leaders from affected countries have joined to discuss what they are learning during this Covid-19 Global crisis. The following is a brief summary of what they feel may be useful information to disseminate to the surgical community:

Anticoagulation and high risk of thrombosis:

Many COVID-19 patients develop a pro-thrombotic state which places them at high risk of thrombosis and significantly worsens their prognosis. A wide range of approaches have been used, from the usual prophylactic DVT regimens to full therapeutic anticoagulation. The majority of institutions place hospitalized patients in some type of prophylactic regimens as soon as the diagnosis is confirmed. In some areas of Italy, patients receive anticoagulants even when treated as outpatient.  Stony Brook University has kindly shared their protocol that includes escalation of anticoagulation on the basis of D-dimer levels.

Primers on COVID-19 Deployment for Surgeons:

As expected, in high COVID areas an increasing number of surgeons find themselves on the front lines of the COVID-19 battlefield, with very little time to prepare for deployment.  A primer on what to expect, how to prepare and helpful hints has been put together by international members of this CVGSC group that have been, or currently are in the front lines. The purpose of these documents is to aid those who will be, or are currently deployed.

Avoiding injury/decreasing discomfort while wearing an N95 mask:

The need to use N95 masks has been widely emphasized. However, their use for prolonged periods of times may pose a problem related to discomfort and skin related issues. The CVGSC issued a statement on April 6 regarding re-sterilization of N95 masks.  We now would like to add a list of products for face protection under N95 masks that may be useful to the providers in the front line.

Participants:

Drs.  Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Davide Lomanto, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona, Suthep Udomsawaengsup

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at [email protected] if interested in being considered for participation.

*GENERAL DISCLAIMER:  

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

Did you find this information helpful?
Please consider joining SAGES or making a donation to the SAGES Education and Research Foundation so we can continue to bring content like this to the surgical community for free.

Notes from the Battlefield – April 6, 2020

by

Coronavirus Global Surgical Collaborative (CVGSC)*
An initiative sponsored by SAGES in collaboration with EAES, AEC, KSELS, and ELSA

Re-sterilization of N-95 masks

Given the shortage of PPE around the globe, much effort has been placed in extending the life of N95 masks ( https://www.sages.org/n-95-re-use-instructions/ ). The FDA has now approved at least two systems for sterilization of N95 masks which will likely be of significant impact while we await for a larger production of new masks. Both systems use vaporized hydrogen peroxide. The below links are informational of the systems that to our knowledge are currently approved.

Closing the backdoor

Many of the healthcare efforts are concentrated at the hospital’s front door, screening patients for COVID symptoms and triaging all patients to areas of the hospital according to their potential of having the disease. From the European experience, it became evident that there is a need to control the spread of the virus originating from the assumed “clean areas” within the hospital. While in an ideal situation all patients coming to a hospital be tested for Covid-19, it is currently occurring only at very few institutions. Despite prior recommendations, the testing of all patients undergoing surgery ( https://www.sages.org/notes-from-the-battlefield-march-30-2020/ ) is still not uniformly practiced because continuing limitations in availability of testing and quick turnaround time. Regular screening of patients in the “clean areas” is therefore essential for early identification and isolation of newly infected cases. This is better done through a formal process. EAES and SAGES have created a Standard Operating Procedure (SOP) document that may be of assistance.

Can the “cytokine storm” be curtailed?

SARS-CoV-2 infection induces an excessive and aberrant host immune response that is associated with an acute respiratory distress syndrome characterized by the plasma increase of many cytokines: the so-called “cytokine storm”. The use of anti IL 6 medications, traditionally used in bone marrow transplant patients, may offer potential benefit:

    • Chinese researchers (Xiaoling Xu1, Mingfeng Han, Tiantian Li et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. ChinaXiv: 202003.00026v1) treated 21 patients with severe or critical COVID-19 pneumonia with Tocilizumab obtaining a reduction in oxygen requirement (15/20), a resolution of CT lesions (19/21), a normalization of lymphocyte count (10/19), a reduction of C-reactive protein levels (16/19), leading to hospital discharge (19/21) with an average hospitalization duration of 13.5 days. These results are considered by the Chinese authors to be very positive and lead to the design of a randomized trial (Tocilizumab vs control) which will include approximately 190 patients and is expected to reach the planned accrual by mid-May 2020.
    • In Italy a national study is being conducted on the use of Tocilizumab which has already enrolled 300 patients. In particular, in Pavia University Hospital were 30 patients have been treated with non-homogeneous results.
    • The FDA has approved a randomized, double-blind, placebo-controlled phase III clinical trial to evaluate the safety and efficacy of intravenous (IV) Tocilizumab (Actemra) plus standard of care in hospitalized adult patients with severe coronavirus disease 2019 (COVID-19) pneumonia. Timing of administration of the medication may play a role in the variability of the observed results.

Corona Virus in the Gastrointestinal Tract

Covid-19 virus is known to mainly effect the respiratory system. However, there is rapid cumulative information that up to 29% of patients develop gastrointestinal symptoms. Viral RNA and viable virus have been identified in stools. The risk of contamination trough a fecal-oral route is not well known but the potential risk of the GI tract being a source of contamination is evident. Gastrointestinal surgeons and endoscopists should be aware and be vigilant about the possibility when performing endoscopic procedures, procedures were the bowel is entered or divided and during TATME and TEM procedures. Appropriate PPE should be used.

Follow-up on the good news from Italy

On our last week’s report, we stated that despite being too early to make any conclusions, there have been some signs that the slope of COVID-19 new cases in Italy may be starting to slow down and that Italian epidemiologists feel it is the result of the strict social isolation measures. This week it seems clear that indeed the peak is passing in Italy. Spain is now also experiencing positive results from social isolation measures which continue to look as the best preventive measure to emphasize, and possibly the only definite intervention currently available to overcome this epidemic.

Participants:

Drs. Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Davide Lomanto, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona, Suthep Udomsawaengsup

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at [email protected] if interested in being considered for participation.

*GENERAL DISCLAIMER:  

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.

Did you find this information helpful?
Please consider joining SAGES or making a donation to the SAGES Education and Research Foundation so we can continue to bring content like this to the surgical community for free.

Notes From the Battlefield March 30, 2020

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A group of surgical leaders from affected countries have joined to discuss what they are learning during this Covid-19 Global crisis. The following is a brief summary of what they feel may be useful information to disseminate to the surgical community from the week of March 22-29

  1. Aerosolization of virus during laparoscopic surgery

    Concerns for aerosolization of Covid-19 during laparoscopic surgery has created significant confusion. Even though there is no Level 1 evidence to prove its occurrence or lack thereof, SAGES and EAES have joined efforts resulting on a guiding statement based on valuable expert opinion and review of related literature:

    SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis:
    https://www.sages.org/recommendations-surgical-response-covid-19/ There is also an infographic:

    SAGES-EAES COVID-19 Infographic
    Click image to see full size.

    The publication is accompanied by a very useful summary entitled:

    Resources on Smoke & Gas Evacuation During Open, Laparoscopic and Endoscopic Procedures
    https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/.

  2. Testing for all patients undergoing surgery

    Based on the experience gained on the field, CVGSC recommends that in areas/institutions seeing high volumes of COVID-19 patients, all patients undergoing a surgical or interventional endoscopic procedure, receive some type of screening test, even if asymptomatic and without risk factors. When feasible and available, direct testing for COVID-19 is preferred. Alternatively, a chest ultrasound or a CT of the chest is advised. However cross contamination of CT equipment and patients is to be considered depending on the institutional availability of dedicated CT’s. Please see: https://www.sages.org/the-corona-virus-global-surgical-collaborative-cvgsc/ for more information and video.

  3. COVID plasma trial

    As the number of patients that recover from the disease is increasing, the FDA has approved the emergency use of investigational COVID-19 convalescent plasma to treat severely ill COVID-19 patients. While it will take months to years to develop an effective vaccine, convalescent plasma from recovered COVID-19 patients rich in antibodies may soon be available to boost immunity against the virus, theoretically reducing viral load and lowering mortality. A trial has been started at Mt Sinai,  New York and is expanding to other centers.  If results appear encouraging, SAGES will keep a list of sites that are actively screening volunteers for possible plasma donation.

  4. 3D printing of needed ventilation system parts

    As the number of patients requiring prolonged ventilator support increases, institutions have seen a shortage of ventilator parts contributing to the shortage when there is otherwise a functioning ventilator available. A document entitled Production of 3D printed components for ventilation systems: practical hints is kindly shared by San Matteo Hospital, Pavia. 3D printing for COVID-19

  5. Potential good news from Italy

    Despite that devastation from the disease still continues, and being too early to draw any definitive conclusions, there are some signs that the slope of COVID-19 new cases in Italy may be starting to slow down. Italian epidemiologists feel it is the result of the strict physical distancing measures. As health care provides, this appears to be the best preventive measure to emphasize and possibly the only intervention currently available to overcome this epidemic.

Participants:

Drs. Horacio Asbun (Lead), Mohammed Abu Hilal, Jaap Bonjer, Nicolas Demartines, Nader Francis, Ho-Seong Han, Salvador Morales, Andrea Pietrabissa, Aurora Pryor, Christopher Schlachta, Patricia Sylla, Eduardo Targarona

Other Surgical Societies/leaders are welcome to participate in future discussions. Please contact SAGES Executive Director, Sallie Matthews at [email protected] if interested in being considered for participation.

GENERAL DISCLAIMER

The following is intended to provide our members with information arising from the experience of our colleagues from Europe and Asia who experienced the pandemic first.  While the information provided is from very reliable sources, it is NOT evidence based data, since there was no time to test its validity on scientific grounds. It is merely an attempt to share practical advice based upon prior experience and current knowledge.