Emergency Abdominal Laparoscopic Surgery During the Coronavirus Disease 2019 Pandemic: Experience in a Private Center in Peru

Introduction

According to the World Health Organization, 27,973,127 cases have been reported to date of September 11, 2020 and in Peru there are a total of 702,776 positive cases with a total of 30,236 deaths, being the fifth country in the world and the second in Latin America with confirmed cases of coronavirus disease 2019 (COVID-19).^1,2

In Peru, on March 5, 2020, the first imported case was registered and subsequently, on March 11, 2020, National Sanitary Emergency was declared initially for a period of 90 calendar days (March 11, 2020 until June 8, 2020). The Ministry of Health of Peru pronounces on March 16, 2020 declaring the suspension of outpatient care and subsequently the Ministerial Resolution was issued where elective surgeries are suspended. ³

Regarding the surgical approach for emergency abdominal surgery during the pandemic, there are various recommendations to avoid laparoscopic surgery in the absence of adequate biosecurity measures. There is currently no scientific evidence to show that laparoscopic surgery can transmit COVID-19 infection. However, conservative management was considered an alternative during the pandemic. In case this is not possible, laparoscopic surgery is indicated following the safety recommendations, due to the benefits it presents compared with open surgery.^4,5

Different protocols recommend that during the laparoscopic approach, the incision for the ports should be as small as possible to avoid pneumoperitoneum leaks, as well as the use of carbon dioxide (CO₂) filters. Regarding insufflation with CO₂, it must be kept at a minimum pressure (10–12 mmHg). Finally, evacuation of the pneumoperitoneum must be done through a filtration system before performing the closure, removal of trocars, or conversion of the surgery to open. Ideally, it is recommended that operating rooms have a negative pressure system.^4,6,7

In contrast, it is important to consider the impact of severe acute respiratory syndrome (SARS)-CoV-2 in the postoperative stage; according to studies before the pandemic, postoperative pulmonary complications were up to 10% (Ref. ⁸ ). In the collaborative study COVIDSurg, it was evidenced that more than half of the patients (51.2%) with perioperative SARS-COV-2 infection had pulmonary complications. ⁹ In addition, a mortality of 23.8% was evidenced, this being higher than a previous study carried out in several countries in which a mortality of 14.9% was found.^10,11

In a survey performed to surgeons in Italy, it was reported that surgical interventions found a greater degree of severity of surgical pathologies, possibly due to the delay in diagnosis. This would be explained since many patients waited several days to go to the hospital. In addition, it was related to a longer stay in the emergency room, due to the lack of beds in hospitalization and the implementation of protocols to discard COVID-19 infection. ¹²

During the Health Emergency, laparoscopic surgeries continued to be performed in the private center where the study was carried out, following the protocols and recommendations mentioned earlier. Currently, there is little information in Peru, so this study proposes to compare the degree of severity of the main gastrointestinal surgical pathologies managed with a laparoscopic approach in patients who were admitted during the National Health Emergency 2020 and the patients who underwent surgery in the same period of the year 2019. Likewise, to determine the incidence of surgical pathologies and postoperative complications during the state of Health Emergency.

Materials and Methods

A retrospective cohort-type analytical study was conducted in which patients of any age who were admitted due to the need for emergency laparoscopic gastrointestinal surgery were identified during the National Health Emergency of Peru from March 11, 2020 to June 8, 2020 (group exposed to the COVID-19 pandemic) and compared with the period from March 11, 2019 to June 8, 2019 (group not exposed to the COVID-19 pandemic). The study protocol was approved by the Institutional Ethics Committee of the Cayetano Heredia Hospital and the Medical Director of the El Golf Clinic.

After obtaining approval, data were collected from the medical records using an ad hoc file. Demographic and perioperative data such as age, gender, American Society of Anesthesiologists (ASA) classification of physical status, comorbidities, postoperative diagnosis, abdominal surgical procedure, disease severity, and postoperative complications were collected. The main variable of the study was the degree of severity of abdominal surgical pathology, which was obtained through the classification “Emergency General Surgery Anatomic Severity Tables” of The American Association for The Surgery of Trauma. Secondary variables such as comorbidities were assessed using the Charlson comorbidity index score, the ASA was categorized into grades 1, 2–3, 4–5, and the Clavien and Dindo classification was used for postoperative complications. Regarding continuous variables, age, time of illness (hours) and hospital stay (days) were considered.

With the information obtained, the database was built on a spreadsheet of the “Microsoft Excel 2019” program where only the researchers had access. Subsequently, the data were analyzed in the Stata software version 2016. First, the clinical, demographic, and perioperative conditions of the general study population were described to assess whether the exposed and unexposed cohorts were similar. The chi-squared test and Fisher's exact test were used to evaluate the categorical variables. With respect to continuous variables, to compare two means; first, it was evaluated whether the variables had a normal distribution with the Shapiro–Wilk test. If the variables had a normal distribution, the t-test or the Student's t-test was used to compare the means. If it did not have a normal distribution, the Wilcoxon rank sum test was used.

Results

A total of 104 patients were identified in the study, 59 patients correspond to the year 2020 (group exposed to the COVID-19 pandemic) and 45 patients to the year 2019 (group not exposed to the COVID-19 pandemic). Regarding the global population of the study, the mean age was 36.83 ± 17.46 (3–83) years; regarding gender, 50% were women, and the most frequent abdominal emergency pathology was acute appendicitis, with a total of 55 cases (52.88%).

Regarding the demographic and intraoperative characteristics of the cohorts of exposed and unexposed patients, it was evidenced that there was a statistically significant difference between both groups in the ASA classification where there was a greater proportion in category “2–3” than category “1” in—the exposed group (63.01% versus 41.94%; [P = .047]). The rest of variables such as the patient's age (P = .5458), gender (P = .322), time of illness (P = .2123), and Charlson comorbidity index (P = .844) did not have a significant difference (Table 1).

The most frequent emergency abdominal pathologies in times of pandemic were acute appendicitis (50.85%), acute cholecystitis (42.37%), hernias (3.39%), including 1 inguinal and 1 diaphragmatic, gastric perforation (1.69%), and intestinal obstruction (1.69%). Similarly, in the group of patients not exposed to the pandemic, acute appendicitis (55.56%), acute cholecystitis (37.78%), and hernias, including 2 inguinal and 1 complex abdominal (6.67%), were observed (Table 2).

Regarding the time of hospital stay, the patients in the group exposed to the pandemic had a longer stay (2.74 ± 2.80 versus 1.73 ± 1.07; [P = .0237]). When comparing variables such as the degree of severity of surgical pathologies (P = .224) and postoperative complications according to the Clavien and Dindo classification (P = .481), no significant difference was found (Table 3).

At the time of study, none of the 12 surgeons who participated in the surgeries of the studied patients were infected with the COVID-19 virus. The 59 patients in the group exposed to the COVID-19 pandemic underwent chest tomography as a diagnostic support imaging study, showing baseline laminar atelectasis in 6 of them and 1 patient presented bilateral pleural thickening; however, none of these patients had computed tomography findings of COVID-19. The only patient with this virus infection who had no pulmonary alteration in his chest tomography; the infection was confirmed by molecular testing.

Discussion

The coronavirus is a broad family of viruses that can affect both animals and humans. This can lead to respiratory infections, from the common cold to serious illnesses such as Middle East Respiratory Syndrome and SARS. On December 31, 2019 in Wuhan, China, the first cases of pneumonia were reported due to the new virus SARS-CoV-2 (coronavirus), which was later called COVID-19. ¹³

The impact of the COVID-19 virus pandemic in Peru caused a great modification in surgical activity as elective surgeries were suspended to reinforce emergency care and optimize the use of hospital beds for patients infected with the COVID-19. ³ Owing to this change, the Peruvian Society of Endoscopic Surgery published recommendations on the management of the main emergency surgical abdominal pathologies; one of them was the conservative management in case of acute appendicitis and acute cholecystitis, which were the most frequent emergencies of acute surgical abdomen. In the case of no response to conservative management, surgical management could be performed, either open or laparoscopic, as long as the hospital center has the necessary resources for the safety of the patient and the health personnel. ⁷

The use of laparoscopy during times of the pandemic was a subject of discussion and controversy by different societies and surgical care departments, since it is not certain whether the virus can be transmitted by the aerosolization of electrosurgical smoke. There is also no knowledge of the ability of CO₂, by itself, to aerosolize particles in the abdomen. ¹⁴ Likewise, other recommendations were given such as making small incisions for the laparoscopic ports, CO₂ filters, and the use of minimum pressure for insufflation of the abdomen. In this study, it has been observed that the care of these emergency surgical pathologies has remained constant and the laparoscopic approach was not suspended. This can be contrasted with another Italian study, where the surgical attitude did not change despite the fact that the patients had COVID-19 infection, even 1 of 3 patients were operated under minimally invasive techniques and the laparoscopic approach was used. ¹⁵

Regarding the degree of severity of surgical pathologies, it was evaluated using the “Emergency General Surgery Anatomic Severity Tables” of The American Association for The Surgery of Trauma, which consists of certain criteria such as a brief description of the pathology, clinical criteria, images, operative finding, and pathological finding. Before the beginning of the study, it was suspected that the severity of these pathologies would increase due to the immobilization that was experienced in Peru due to quarantine and the fear of this new virus, causing patients not to go quickly to emergency services, prolonging the sick time and a more severe admission diagnosis. This idea was supported by a study, where it was evidenced that urgent interventions were significantly reduced due to mobility restriction measures and an unusual delay was observed in the presentation of nontraumatic abdominal emergencies. This delay is related to the patient's choice to stay home until symptoms worsen and the increased waiting time to obtain a COVID-19 ruling out test. In this study, with respect to the variable of degree of severity, there was no significant difference and this may be associated because the time of illness was not different in both study groups. ¹²

It can be seen that the complications in this study, according to the Clavien and Dindo scale in both study groups, were minimal and during the pandemic there were only 3 patients, who were not infected with COVID-19, who had multiorgan dysfunction; and the only 1 patient with COVID-19 infection had a residual abscess, did not present respiratory complications. This result is supported by a study carried out in Italy where postoperative morbidity and mortality were evaluated after some emergency abdominal surgery during an observational period of 3 months and the absence of serious respiratory complications was found despite being in times of pandemic. ¹⁶

Finally, the Medical College of Peru in June reported 1713 infected nationwide, of which 41 were in intensive care units and 60 doctors died from this virus. ¹⁷ During the study period (March 11, 2020 to June 8, 2020), none of the 12 surgeons of the institution who performed the surgical procedures contracted such infection that may be explained because the hospital center has biosafety measures such as CO₂ filters in the cannulas of laparoscopy ports, negative pressure operating room, and complete personal protective equipment for health personnel, recommendations that have been stipulated by different guides and protocols.^4,7,18

Conclusions

The degree of severity of emergency abdominal surgical pathology in times of pandemic has not increased compared with the previous year, with minimal postoperative complications. Likewise, the use of the laparoscopic approach was not suspended in the hospital center where the study was carried out due to the fact that it had the appropriate security resources, so no surgeon contracted the infection.