15/04/2020
Journal of Pediatric Endoscopic Surgery https://doi.org/10.1007/s42804-020-00054-w
EDITORIAL
SARS‐CoV‐2 pandemic and pediatric endoscopic surgery
Amulya K. Saxena1
© Springer Nature Singapore Pte Ltd 2020
The severe acute respiratory coronavirus 2 (SARS-CoV-2) also known as Coronavirus disease 2019 (COVID-19) outbreak started in December 2019 in Wuhan, China and declared as a pandemic by the World Health Organization (WHO) on 11th March 2020 [1]. The WHO statement stated that this was the first pandemic sparked by a coronavirus. With the global rise in infection and mortality, front line medical staff in many countries are being pushed to the lim- its in managing infected patients. The pandemic has also affected pediatric surgery and the approach to patients with minimal access surgery; as anesthetists, intensive care spe- cialists and nurses have been channeled to manage critical patients with SARS-CoV-2, depleting their numbers for pediatric surgical procedures.
The American College of Surgeons published the “COVID-19 Guidelines for Triage of Pediatric Patients” with the aim to optimize hospital resources and preserving the health of providers [2]. This guideline though not com- prehensive, has been extremely helpful as it divided the most common pathologies into three categories:
(a) Emergency cases (life threatening if delayed).
(b) Urgent cases (detrimental if delayed for days or weeks).
decision to categorize patients should always be based on sound surgical judgement.
With many hospitals not having dedicated pediatric sur- gical operating theaters during the pandemic and sharing theaters with adult patients, the operating environment to perform procedures requires special attention [3]. An operat- ing theater with separate access should be designated for all confirmed or suspected COVID-19 cases. The ideal situation would be to have the operating theater consisting of five interconnected rooms, of which only the waiting and anes- thesia induction rooms have negative atmospheric pressures, whereas the operating theater, preparation, and scrub rooms have positive pressures. Understanding the airflow within the operating theater is crucial to minimizing the risk of infec- tion. It is also important that the same operating theater and the same anesthesia machine solely be used for the COVID- 19 cases for the entire duration of the pandemic. Besides optimal theater setup, proper PPE for the teams involved in such procedures and strict following of hospital infectious disease protocols is mandatory.
As our focus remains on minimal access procedures, the Society of American Gastrointestinal and Endoscopic Sur- geons (SAGES) and European Association for Endoscopic Surgery (EAES) published a recommendation regarding “Surgical response to COVID-19 crisis” [4]. It strongly rec- ommended, that consideration be given to the possibility of viral contamination to staff during surgery either open, lapa- roscopic or robotic and that protective measures are strictly employed for operating room staff safety and to maintain a functioning workforce. It further added that there may be enhanced risk of viral exposure to the teams performing endoscopic and airway procedures. The practical measures recommended specifically for endoscopic surgery were: (a) Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports, (b) CO2 insufflation pressure should be kept to a mini- mum and an ultra-filtration should be used, if available and (c) all pneumoperitoneum should be safely evacuated via a filtration system before closure, port removal, specimen extraction or conversion to open. When these procedures are
(c)
Elective cases (minimal risk to patients if delayed).
As countries around the world face huge differences in the impact of SARS-CoV-2, decisions to use this guideline should be based on (a) institutional resources and (b) the national impact that has reallocated staff to alternative roles during the present crisis. Delaying of elective procedures is also important from other aspect, as such procedures will consume valuable personal protective equipment (PPE) that are presently limited in stocks worldwide. However, the
* Amulya K. Saxena amulya.saxena@nhs.net
1
Department of Pediatric Surgery, Chelsea Children’s Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, 369 Fulham Road, London SW10 9NH, UK
Vol.:(01233456789)
necessary, enhanced PPE should be considered as aerosol and fomite transmission of SARS-CoV-2 is plausible, as the virus can remain viable and infectious in aerosols for hours and on surfaces up to days [5].
SAGES and EAES have also published the “Resources for smoke and gas evacuation during open, laparoscopic, and endoscopic procedures”.[6] This outlines the practi- cal measures for use of filtration during laparoscopy: (1) to safely evacuate pneumoperitoneum through port attached filtration devices, (2) once placed ports should not be vented if possible, (3) all escaping CO2 should be captured with an ultra-filtration system using desufflation mode on insuffla- tor (if available), (4) in absence of desufflation feature on insufflators, close the work port valve before the flow of CO2 on the insufflator is turned off, (5) use of least dependent port for desufflation, (6) removal of specimens only after all CO2 gas is evacuated, (7) surgical drains should be utilized only if absolutely necessary, (8) fascia closure after desfuf- flation and (9) avoiding hand-assisted surgery. SAGES and EAES have also provided a list of commercially available products that could potentially be used to filter CO2.
An Intercollegiate General Surgery Guidance on COVID- 19 update issued jointly by the Association of Surgeons of Great Britain and Ireland, Association of Coloproctology of Great Britain and Ireland, Association of Upper Gastroin- testinal Surgeons, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow and Royal College of Surgeons in Ireland has also advised considerable caution as laparoscopy is considered to carry some risks of aerosol- type formation and infection [7]. This level of risk has not been clearly defined and it is likely that the level of PPE deployed may be important. The guidance warrants con- sideration of laparoscopy only in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission. The guidance recom- mends to look into appropriate non-operative treatment or open alternatives. For emergency procedures, it also recom- mends to treat all patients as COVID-19 positive and to add a computed tomography of thorax done in the past 24 hours in the preoperative assessment.
Clinical manifestations of SARS-CoV-2 in children are less severe than adults, but it appears that children of all ages are susceptible, with infants in particular being more vul- nerable to infections [8]. Although studies have shown that there were no clinical findings or investigations suggestive of SARS-CoV-2 in neonates born to affected mothers [9], a recent publication has suggested that the vertical mater- nal–fetal transmission cannot be ruled out [10]. Reports are now emerging over f***l–oral transmission of SARS-CoV-2, pointing to the fact that asymptomatic children and adults may be shedding infectious virus that could be transmitted [11]. Further evidence shows that children have persistently
tested positive on re**al swabs even after nasopharyngeal testing was negative [12]. In order to maintain safety of operation room personnel, all these transmission sources and factors should be borne in mind when performing pro- cedures in neonates, asymptomatic children or children with negative nasal swabs,
In context of COVID-19, with consideration given to (a) variations in universal access to specific filtera- tion equipment and recommended operating room set-up, (b) concerns about reliability and speed of various avail- able SARS-CoV-2 detection tests, (c) lack of comprehensive data regarding aerosol based virus transmission to operat- ing room personal and (d) guidelines and recommendations from adult endoscopic societies, it would be judicious to curtail pediatric endoscopic surgery procedures during the present SARS-CoV-2 pandemic. On the other hand, sound surgical judgement with maximum precautions should be implemented in the few selected cases where benefits would outweigh risks of performing endoscopic surgery.
Amulya K. Saxena Editor-in-Chief
References
1. WHO Director-General’s opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/dg/speec hes/detail/who-director-general-s-opening-remarks-at-the-media -briefing-on-covid-19---11-march-2020
2. COVID-19 Guidelines for Triage of Pediatric Patients. https:// www.facs.org/covid-19/clinical-guidance/elective-case/pediatric- surgery?fbclid=IwAR28d_VDVKDqGU7yUpW60OO3eg9nd5N JjeH6U5tFy0JJjXCAyf5icjirsIo
3. Ti LK, Ang LS, Foong TW et al (2020) What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth/J Can Anesth. https://doi.org/10.1007/ s12630-020-01617-4
4. SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis - SAGES. https://www.sages.org/ recommendations-surgical-response-covid-19/?fbclid=IwAR2 M139pV3bwWp9XYB2cfWyYgrnxbks0W3GZ_sZ0GrGXVuc ZQULXqOf7Jfk
5. van Doremalen N, Bushmaker T, Morris DH et al (2020) Aerosol and surface stability of SARS-CoV-2 as compared with SARS- CoV-1. N Engl J Med. https://doi.org/10.1056/NEJMc2004973
6. Resources for Smoke & Gas Evacuation During Open, Laparo- scopic, and Endoscopic Procedures - SAGES. https://www.sages .org/resources-smoke-gas-evacuation-during-open-laparoscopic- endoscopic-procedures/
7. Intercollegiate General Surgery Guidance on COVID-19 UPDATE | The Royal College of Surgeons of Edinburgh. https://www.rcsed .ac.uk/news-public-affairs/news/2020/march/intercollegiate-gener al-surgery-guidance-on-covid-19-update
8. D**g Y, Mo X, Hu Y et al (2020) Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. https://doi.org/10.1542/peds.2020-0702
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A. K. Saxena
SARS-CoV-2 pandemic and pediatric endoscopic surgery
9. Chen H, Guo J, Wang C et al (2020) Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infec- tion in nine pregnant women: a retrospective review of medical records. Lancet 395(10226):809–815. https://doi.org/10.1016/ S0140-6736(20)30360-3
10. Zeng L, Xia S, Yuan W et al (2020) Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID- 19 in Wuhan, China. JAMA Pediatr. https://doi.org/10.1001/jamap ediatrics.2020.0878
11. Hindson J (2020) COVID-19: faecal–oral transmission? Nat Rev Gastroenterol Hepatol. https://doi.org/10.1038/s4157 5-020-0295-7
12. Xu Y, Li X, Zhu B et al (2020) Characteristics of pediatric SARS- CoV-2 infection and potential evidence for persistent f***l viral shedding. Nat Med. https://doi.org/10.1038/s41591-020-0817-4
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Children infected with the COVID-19 outbreak coronavirus, SARS-CoV-2, show mild symptoms but prolonged shedding of viral RNA in f***s, suggesting that the f***l–oral route might play a role in virus transmission.
