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Table of Contents
INVITED COMMENTARY
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 41-45

Do's and don'ts for colorectal surgeons during pandemic time


1 Department of Surgery, Dr. B.S.A. Medical College and Hospital, Delhi, India
2 Department of Laparoscopic and General Surgery, Sir Ganga Ram Hospital, New Delhi, India
3 Department of General Surgery, Dr. B.S.A. Medical College and Hospital, Delhi, India

Date of Submission17-Jun-2020
Date of Acceptance18-Jun-2020
Date of Web Publication11-Aug-2020

Correspondence Address:
Jitendra Kumar
Department of Surgery, Dr. B.S.A. Medical College and Hospital, Sector - 6; Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_5_20

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  Abstract 

The whole world is reeling under coronavirus disease 2019 (COVID-19) pandemic due to highly infectious SARS CoV-2 virus. At this moment of global health crisis, all surgeons are facing difficult task to take care of their surgical patients and carrying a high risk of compromising their own safety. Among all surgical disciplines, colorectal surgeons are at higher risk as majority of surgical patients who require emergency surgical interventions are related to colorectal problems. Furthermore, after the respiratory tract, the digestive tract and fecal route of transmission are now being considered the next probable mode of transmission for SARS CoV-2 virus. In these circumstances, it has now become mandatory for all the colorectal surgeons to get well aware of the facts to counter the potential risk posed by COVID-19 pandemic. This is not only essential for their own safety but also for the safety of other health-care personnel and patients as well. They must know the measures to deal with all the challenges which could be encountered during the management of surgical patients at the current time of crisis created out of COVID-19 pandemic. The aim of this article is to prepare the brief note based on evidence-based literature and currently available recommendations to help our colorectal surgeons during the current pandemic time.

Keywords: Colorectal surgery, coronavirus, coronavirus disease 2019, impact of pandemic, noncoronavirus disease 2019 routine patients, pandemic


How to cite this article:
Kumar J, Agarwal BB, Khatana P S, Chaudhry S. Do's and don'ts for colorectal surgeons during pandemic time. Indian J Colo-Rectal Surg 2019;2:41-5

How to cite this URL:
Kumar J, Agarwal BB, Khatana P S, Chaudhry S. Do's and don'ts for colorectal surgeons during pandemic time. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 30];2:41-5. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/2/41/291871


  Introduction Top


At the moment, the whole world is fighting dangerous coronavirus disease 2019 (COVID-19) pandemic caused by highly contagious SARS CoV-2 virus. This pandemic is not only a global health crisis but also generated a lot of social, economic, and political turmoil across the world. In the current scenario, the main focus of every authority over the world is to contain the spread of COVID-19 virus and reduce the morbidity and mortality of the affected population. To achieve this, many compromises with other routine health-care deliveries are being done, which is considered as a collateral damage. To some extent, this sort of collateral damages is unavoidable, especially in the situation when the whole world is fighting a big war against this unprecedented global crisis created out of COVID-19 pandemic.

Since the outset of the current pandemic, surgeons are fighting in the forefront to reduce these collateral damages, of which their surgical patients are the main sufferers. With the time, the magnitude of this collateral damage is getting huge, especially for routine surgical patients. Among all specialties of surgery, colorectal surgeons are playing a major role, as situation in most of their patients demands urgent or early surgical intervention. Hence, in the current scenario, it is mandatory for all of us to be well aware of the relevant precautionary measures not only to safeguard our surgical team but also patients as well as other health-care workers.

SARS CoV-2 virus, causing the current pandemic, is novel, and many of their nature and behavior are still unfolding. Based on the knowledges available so far of the current pandemic along with the past experience of similar SARS CoV-1 and MERS virus, many recommendations and guidance have been issued by different stakeholders all over the world. All these recommendations guide us to take decision based on the individual need of patient and availability of resources in the hospital on day-to-day basis. The main purpose of writing this article is to provide an executive summary of important precautionary measure meant for colorectal surgeons to mitigate the associated high risk of COVID-19 infection at workplaces.


  General Measures Top


During the period of pandemic, the safety of health-care workers and the patients is equally important. For this, we need to make a proper plan and develop an infrastructure in the hospital so that the risk potential of highly infectious SARS CoV-2 virus could be mitigated. Every entry gate must have a facility for screening of all entrants to the hospital. Every working area of the hospital should have an arrangement to maintain the social distancing among visitors. For an unavoidable diagnostic procedure such as digital rectal examination (DRE) and proctoscopy, there should be a proper designated area in isolation with a separate changing room for doffing and donning. Negative pressure operating room with exclusive ventilatory system and a dedicated pathway for the transfer of patients depending on their risk potential is mandatory.[1]


  Role of Telemedicine Top


In the current scenario of pandemic apart from postponement of nonessential elective surgery, all other routine screening and diagnostic procedures also have been canceled. This is causing catastrophic consequences for patients of colorectal symptoms who are not getting timely intervention and finally succumbing to their colorectal malignancy.[2] In this situation, telemedicine can play a vital role as surgeon can advise and call the patients to the hospital on the basis of history and warning symptoms. This will also further reduce the need of physical attendance of the patients during the preoperative period as well as follow-up during the postoperative time.[3],[4],[5]


  Selection of Patients for Surgery Top


There is consensus around the world that no nonessential elective surgery should be performed during the outbreak of the pandemic, and this is justified too.[5],[6],[7] There is also clear guidelines that all urgent and emergency surgeries which are required for lifesaving within the first 24 hours must be done immediately after taking all safety precaution measures.[5],[6],[7] For rest of other patients who do not require urgent surgery, triage should be done. Every patient must be evaluated on individual basis, and at no circumstances, first come first serve basis should be applied.[8]

Most of the suggestions for triage of the patients requiring colorectal surgery are based on the availability of hospital resources, load of COVID-19 patients at the time, and possible harm to the patient in the event of postponement of surgery.[6],[7],[8],[9],[10] However, most of the authorities and surgical societies have now agreed upon that, in event of continuous decline of COVID-19 transmission in the given population for more than 2 weeks, elective surgeries can be started.[5],[7]


  Risk Stratification Before Surgery Top


During the pandemic, every surgeon must stratify their patients before surgery in terms of risk probability of COVID-19 infection in them. This can be done on the basis of prevalence of COVID-19 in the residing area of the patient, history of contacts with suspected or confirmed case of COVID-19, presence of respiratory symptoms or fever, finding in chest X-ray or computed tomography (CT) scan, travel history, etc.[11] On the basis of the risk level of the patients and proper evaluation of risk versus benefit (if surgery is postponed), one can decide to take up the case and proceed accordingly. Level of precautions, overall protection measure in terms of keeping the patients in isolation, separate pathways for transportation, and operation room etiquettes can be decided based on the probable risk level of the patients.[8],[11]


  Preoperative Reverse Transcription-Polymerase Chain Reaction Testing for Coronavirus Disease 2019 Top


Most of the recommendations are in favor of getting the reverse transcription-polymerase chain reaction test done before surgery except in circumstances where lifesaving surgery cannot wait for the test report.[5],[6],[7],[8] Only problem is the chances of false-negative report in more than 30% of cases.[5],[12] In this situation, it is now preferable if possible, to get other radiological investigations preferably CT of the chest done which is now considered as a better option for confirmation of diagnosis of COVID-19.[13] Some laboratory parameters such as higher level of lactate dehydrogenase, C-reactive protein, alanine aminotransferase, and neutrophil count can be used for predicting the COVID-19 in suspected individuals.[14] In these situations of confusion, better idea is to take every patient as COVID-19 positive case and use all protection gears and possible precautions in every case.


  Recommendations for Use of Safety Measures for Colorectal Surgeons Top


Works of colorectal surgeons demand more close contacts with their patients and frequent need of interventional diagnostic and screening procedures in their daily clinical practice. Due to the urgent nature of most of the diseases of colorectum which cannot be avoided even during the peak of the pandemic, all colorectal surgeons are at higher risk.[15] In view of all of these, they must be very careful and take all the possible precautionary measures at every level during the delivery of patient's care.

Only the patients which have been evaluated prior on telemedicine platform and in need of physical evaluation should be entertained in the outpatient department.[3],[4] Without screening, no patients should be allowed to enter the hospital premises, whereas relative of the patients must be avoided wherever possible. As far as possible, all diagnostic and endoscopic procedures should be avoided.[8] Even for minor diagnostic procedures, wearing of full personal protective equipment (PPE) kit (N95 mask, proper gloves, cap, face shields, eye goggles, and waterproof gown) is recommended.[11] PPE kit must be properly standardized and should be waterproof.


  Colorectal Cancer Top


Most of the recommendations have advised postponing all the surveillance colonoscopies till the time pandemic subsides.[3] The management of colorectal cancer during the pandemic has changed now to more conservative approach (e.g., chemo- or radiotherapy) and palliative procedures (e.g., stenting for obstruction) than protocol based on staging toward diseases.[16],[17] The treatment of colorectal cancer should be prioritized as an emergency, urgent (imminent emergent or oncologically urgent), and elective.[16] It further depends on the prevalent situation due to the pandemic and availability of resources in the hospital. As per the recommendation, surgical procedures in patient of COVID-19 must be avoided.[16],[17] Surgical procedures in emergent and imminent emergent cases should be decided on the basis of available resources and weighing the risk versus benefit out of it.[16],[17]


  Challenges for Colorectal Surgeons Top


On many occasion, colorectal surgeons need to work in association with a team of other disciplines and surgical specialties such as urologist, gynecologists, medical oncologist, radiotherapist, and radiologist, and in the current scenario of crisis, it may be difficult to assemble and coordinate with team member of other specialties easily on the time.[18] With the time, many evidence are now coming up that after the respiratory tract, the next mode of transmission of SARS CoV-2 is the digestive system and fecal matter.[19],[20] Colorectal surgeons cannot avoid the exposure of gastrointestinal contents even during routine DRE, proctoscopy, etc., so they are at higher risk and have to be more careful.

Laparoscopic surgery has made the life of most colorectal surgeons very easy, and they always prefer to perform their surgery laparoscopically. However, in the current situation of COVID-19 pandemic, it has become a serious issue of debate. So far available information, which is theoretical in nature, suggested that the release of intraperitoneal insufflated gas and smoke in the environment may be potential source for the spread of COVID-19 infection.[17],[21],[22] For safe laparoscopic surgery, it is mandatory to take care of air leak at the time of creation of pneumoperitoneum and also through the working ports during surgery. Other measures suggested are smoke filters, minimal use of electrocautery at lower setting, intracorporeal anastomosis, controlled and channeled exsufflation, and proper setting up of operating rooms.[21],[22]

Executive summary of do's and don'ts for colorectal surgeons during the pandemic time is listed in [Table 1].
Table 1: Executive summary of do's and don'ts for colorectal surgeons during the pandemic time

Click here to view



  Conclusions Top


In the current scenario of global emergency, health-care systems are overburdened and just endeavoring to prevent the bad situation from getting in to the worse. In this fight, colorectal surgeons are leading from the front as they cannot turn blind eye from suffering of their own patients. In the fight against invisible enemy, it is very important for every surgeon to take utmost precaution and safety measures to keep themselves safe and healthy.

All patients who need colorectal surgery must be prioritized after proper evaluation of their risk versus benefit of the intended procedures, and at the same time, consideration of the prevailing situation due to pandemic in the given population is also important. Colorectal surgeons must not make any compromise in terms of the provision of proper safety gears and creation of suitable designated facility. Even for senior surgeons, proper training to get well acquainted with the use of safety gears is a need of an hour. Most importantly, they must be fully aware and alert of the situation all the time.

Acknowledgment

We must salute the courage and dedication of all the warriors fighting the war against one of the deadly pandemics the world has ever seen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Kucirka LM, Lauer SA, Laeyendecker O, Boon D, Lessler J. Variation in False-Negative Rate of Reverse Transcriptase Polymerase Chain Reaction-Based SARS-CoV-2 Tests by Time Since Exposure [published online ahead of print, 2020 May 13]. Ann Intern Med. 2020;M20-1495. doi:10.7326/M20-1495.  Back to cited text no. 12
    
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21.
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22.
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  In this article
Abstract
Introduction
General Measures
Role of Telemedicine
Selection of Pat...
Risk Stratificat...
Preoperative Rev...
Recommendations ...
Colorectal Cancer
Challenges for C...
Conclusions
References
Article Tables

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