“We are still learning. Every single day, there is more information coming out, and it’s really important that if we think we know something, to keep our ears and eyes open because our collective knowledge and understanding are progressing so quickly as to how we should optimally treat our patients,” said Clifford Ko, MD, MS, MSHS, the vice chair and a professor of surgery at the University of California, Los Angeles, and the director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

“A second thing to be cognizant of is that we should ‘localize’ many things since there are recognized high-prevalence areas and lower prevalence areas, different resource levels, different testing capabilities, etc. When statements, guidelines or suggestions are offered, everyone has to think about what it means for them locally, at their facility and in their community. What may be recommended for a high-prevalence area, for example, might not be the best thing for an area with a lower prevalence.”

Dr. Ko gave an overview of the ACS checklist of things to consider when thinking about reopening elective surgery. This guidance focuses on 10 issues in four main categories (Table 1) (www.generalsurgerynews.com/ COVID-19/ Article/ 04-20/ Return-to-Elective-Surgery-A-Road-Map-/ 58124). “In the document, we cite published considerations regarding when facilities might consider resuming elective surgery,” Dr. Ko said. “As we resume surgery, we need to constantly be aware of the possibility of a second wave.”

Finally, for facilities that participate in the ACS’s Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), the data registry will now include COVID-19–related variables.

Lessons Learned From China

Peng (Charles) Zhang, MD, PhD, the chief of metabolic and bariatric surgery at Beijing Friendship Hospital, Capital Medical University, discussed lessons learned from China, which halted elective surgery on Jan. 25, and resumed elective surgery with COVID-19 screening on March 16. Emergency procedures were allowed, and semi-elective procedures were conditionally allowed during this time period.

Patients are divided into three cohorts:

• suspected/confirmed COVID-19 patients;
• patients under quarantine due to close contact with CoV RNA–positive/suspected patients; and
• confirmed without coronavirus infection.

For patients with suspected/confirmed COVID-19, only emergency surgery is allowed; elective or semi-elective surgery is canceled or postponed. For patients confirmed without coronavirus infection, surgery is scheduled. For patients under quarantine due to close contact with CoV RNA–positive/suspected patients, semi-elective surgery candidates and elective surgery candidates undergo further COVID-19 testing (wait two weeks and rescreen); if patients are confirmed to have no infection, they continue to surgery, but if COVID-19 is detected, surgery is postponed. The COVID-19 screening protocol, Dr. Zhang said, includes travel history, symptoms (including fever, cough, shortness of breath), complete blood count and C-reactive protein tests, a chest CT scan, and a CoV RNA test.

China has defined three levels of personal protective equipment (PPE), with level 1 PPE consisting of normal everyday precautions (Table 2).

“The goals of protection are to protect our patients, protect ourselves, protect our coworkers, protect our family members and relatives, and protect our communities,” Dr. Zhang said. Close attention, he said, needs to be paid in the emergency room or fever clinic, while transferring patients to the operating room and in the OR, after the operation, during recovery and when patients are discharged. Dr. Zhang emphasized that hospitals should have a designated patient transporting route to the OR. Appropriate PPE should be used during transporting patients, including having the patient fully covered, with a surgical mask, face shield and disposable surgical cap. Transport personnel, he said, should use level 2/3 PPE, which includes a disposable protective coverall suit, shoe covers, double gloves, N95 mask and face shield/eye protection. Spraying disinfectant (500 mg/L chlorine-containing disinfectant) on the route is important, and elevators should be disinfected.

From the OR to Patient Discharge

Inside the OR, Dr. Zhang said, a negative-pressure system is strongly recommended, and hospitals should consider avoiding laparoscopy and endoscopy. Other considerations inside the OR include:

• having a minimal number of personnel in the OR;
• using level 2/3 protection;
• having surgeons and personnel not needed for intubation remain outside the OR until anesthesia induction and intubation are completed;
• minimizing the use of electrocautery and ultrasonic devices (low power setting and avoidance of long desiccation times);
• minimizing the use of drainage tubes, urinary catheter, nasogastric/orogastric tubes and feeding tubes.

For laparoscopic surgery, Dr. Zhang said, laparoscopic suction is recommended to remove the surgical plume and desufflate the abdominal cavity (do not vent pneumoperitoneum into the room). Other considerations for laparoscopic surgery include:

• using lower intraabdominal pressure (10-12 mm Hg), if feasible;
• avoiding rapid desufflation or pneumoperitoneum;
• performing specimen extraction with minimal carbon dioxide escape;
• minimizing blood/fluid droplet spray or spread;
• minimizing leakage of carbon dioxide from trocars (check seals).

After the operation, for patients who fall into the cohort who are under quarantine due to close contact with CoV RNA–positive/suspected patients, retesting and waiting for CoV RNA results is recommended. If negative, these patients can be transferred back to the ward; if positive, they should be transferred to a designated room or hospital. Dr. Zhang recommended changing PPE when exiting the OR, containing the disposables and using a minimal number of transport personnel.

During recovery and going home, a single isolated patient room should be used, and designated personnel should use level 2 PPE. Dr. Zhang recommended an enhanced recovery after surgery protocol.

“Do not discharge [a patient] until CoV RNA becomes undetectable for at least two consecutive days,” Dr. Zhang said. As physicians continue to take care of patients, online seminars, teleconsultations and nonsurgical weight loss approaches should be prioritized, he said.

The U.S. Perspective: Prioritizing Patients

Eric DeMaria, MD, the director of bariatric surgery at East Carolina University, in Greenville, discussed considerations for restarting bariatric/metabolic surgery in the United States. Many bariatric surgeons were upset to find that the bariatric procedures including gastric bypass, sleeve, duodenal switch and gastric band fell into the elective surgery category in the ACS guidance. “The ASMBS strongly disagrees with the concept that bariatric surgery is an elective procedure,” Dr. DeMaria said. “We resent the underlying implication that it is a type of cosmetic procedure. It is only elective in the sense that there is flexibility in scheduling. Bariatric surgery is lifesaving surgery, with survival benefit for patients treated by surgery over those treated without surgery.”

Dr. DeMaria said during the pandemic, bariatric surgeons have responded admirably to the crisis and prioritized cases based on whether or not harm would occur if delayed, with more urgent cases being triaged ahead of less urgent cases. “However, once we start operating on the ‘flexible scheduling’ category of procedures, how do we prioritize patients?” Dr. DeMaria asked. For cases such as transplant candidates and pseudotumor cerebri, the clock may be ticking and they may need to move forward more rapidly, he said.

In terms of surgical risk, surgeons should consider moving forward sooner with patients who are optimized after months of preparation. In terms of COVID-19 risk, according to Dr. DeMaria, obesity, diabetes, hypertension and heart disease increase the risk for bad outcomes. “Do we prioritize the low-risk, low/zero-comorbidity patient?” Dr. DeMaria said. “We have gotten so good at what we do, how would we justify a bad outcome in such a patient when there was no urgency to move forward with surgery? Or do we prioritize the higher-risk/higher-comorbidity patient? This is usually the group we prioritize for treatment because we know they have higher risk without surgery. However, they are more likely to have a bad outcome if COVID infection occurs.”

In one study of 34 surgical cases in the early asymptomatic phase of COVID-19 who were unintentionally scheduled for elective surgeries in Wuhan, China, 44.1% of them required admission to the ICU during disease progression and 20.5% died after ICU admission (EClinicalMedicine 2020;100331. doi: 10.1016/j.eclinm.2020.100331). In another study of four gastric bypass cases in Iran during the initial phase of the COVID-19 outbreak, three required readmission to the hospital (two to the ICU), but ultimately survived (Obes Surg 2020 Apr 20;1-4. doi: 10.1007/s11695-020-04617-x). Presenters noted that the gastrointestinal tract is affected by COVID-19, and this presents challenges also for GI surgery.

Similar to Dr. Ko, Dr. DeMaria emphasized that local conditions should be the driving factor in restarting elective bariatric operations, including COVID-19 curve flattening; testing status for preoperative patients; hospital status, such as availability of the ICU and ventilators; PPE status; and health care worker status. The likelihood of needing an ICU postoperatively varies depending on surgical site: abdominopelvic minimally invasive surgery (<5%); abdominopelvic open surgery, infraumbilical (5%-10%); abdominopelvic open surgery supraumbilical (10%-25%); and head and neck surgery/upper GI thoracic (≥25%) (J Am Coll Surg 2020;S1072-7515[20]30317-3).

Other factors that may come into play as surgeons ramp up their procedures include that patients may have less money for copays and deductibles because of the economic downturn, unemployment which may change health insurance status, challenges completing pre-op requirements, difficulty obtaining new insurance authorization for rescheduled patients who were previously approved, and the fear that some patients may have of COVID-19 infection. “Unfortunately, we may not have as many cases to do as we think,” Dr. DeMaria said.