Coronaviruses are a family of viruses that cause disease in people or that circulate among animals. The COVID-19 strain causing the current outbreak (elevated to the category of pandemic and health emergency by the WHO) was first identified in Wuhan, in the Chinese province of Hubei, in December 2019. With more than 500000 cases worldwide and 60000 in Spain in March 2020,1 this infection occurs in the form of fever, dry cough and mild dyspnea in most cases, although it can evolve into severe pneumonia and eventual acute respiratory distress. In this regard, it is very similar to severe acute respiratory syndrome (SARS) described in 2003 and the Middle East respiratory syndrome (MERS) of 2012.2,3 It is spread through respiratory droplets from coughing or sneezing, similar to how flu and other respiratory viruses spread.

Both the high rate of contagion observed and the pathogenesis of the disease itself depend on the anchoring of the virus to human cells (through the receptor-binding domain of transmembrane glycoprotein S), recognition of cellular receptors (specifically angiotensin-converting enzyme 2) and internalization into the cytoplasm using a host transmembrane serine protease (TMPRSS).4 As for involvement of the gastrointestinal tract, fecal–oral transmission has not yet been completely ruled out. Extrarespiratory involvement by COVID-19 is very rare and is usually restricted to nonspecific symptoms (nausea, vomiting, epigastric discomfort, etc.). Pancreatic involvement is exceptionally rare, as is hepatotoxicity, mainly due to some of the treatments used.5,6

Surgical teams must treat all patients with COVID-19 who require surgical treatment that cannot be delayed. It is recommended that the surgical teams designated to treat these patients should have extensive and appropriate training. Therefore, surgical teams should be created with surgical technologists, surgeons and anesthetists who are properly trained for any type of urgent surgery. These teams should receive extensive theoretical and practical training in simulated emergency situations, management of protective equipment and surgical protocol. Furthermore, healthcare institutions are obligated to provide the necessary resources for adequate prevention measures for their staff, which should be applied in accordance with current regulations and clinical protocols.

Patients are referred to the General Surgery Service from two branches: emergency department and hospital wards. Both settings will have a pre-established location for this type of patient in accordance with the protocols of each hospital.

It is essential to divide the patients into two groups: suspected COVID-19 group, and confirmed COVID19 group. Although the measures to be taken when evaluating these patients are very similar, a confirmed diagnosis can modify the therapeutic options. Table 1 summarizes important aspects to consider in the different stages.

According to the latest studies, it appears that COVID-19 basically causes diffuse alveolar damage associated with direct damage to pneumocytes, unlike other infections that cause damage due to inflammatory hyperresponsiveness and endothelial damage.7 Furthermore, it gives rise to a cytokine cascade similar to that found in bacterial sepsis or even hemophagocytic lymphohistiocytosis. All this translates into nonspecific respiratory symptoms with fever that appears frequently and especially in the severest cases. Up to 10% of patients may also experience digestive symptoms, such as diarrhea or nausea.5,8

In terms of analytical parameters, unlike bacterial sepsis, COVID-19 does not cause an elevated white blood cell count or classic neutrophilia. It has been associated with lymphopenia in approximately 80% of patients and mild thrombocytopenia in cases with a worse prognosis.2 Nonspecific elevated D-dimer levels are also frequent.

It is important to note that procalcitonin is not elevated in cases of COVID-19 infection according to the studies carried out to date, and procalcitonin levels less than 0.5ng/mL have been found in 95% of the patients analyzed. This point is important with regards to sepsis, where it is a fundamental marker, especially in systemic bacterial infections. However, C-reactive protein (CRP), as in the case of sepsis, can become elevated in a direct relationship with the prognosis and severity of the disease, as high levels are found in cases of hypoxemia and mortality.

Routine testing for COVID-19 is recommended before urgent or elective surgery.9Fig. 1 shows the proposed management for urgent and elective surgical patients. These recommendations are subject to the evolution over time of the pandemic and the resources of each geographic area.

Fig. 1.

Proposed management of urgent and elective surgical patients.

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Only preliminary data and some reported experiences are available, which are restricted to case reports or series of cases. The recommendations for surgery in patients with viral diseases that are highly transmissible through fluids recommend minimally invasive accesses to minimize the risk of infection of members of the surgical team.10 In the case of COVID-19, infection occurs by air and contact, although the fecal–oral route has not been ruled out. Thus, the risk of aerosolization of particles and fluids must also be considered, although until now the evidence related to the presence of viruses in the pneumoperitoneum during laparoscopy is restricted to the experience with hepatitis B virus.

During gastrointestinal surgery, the use of the scalpel and opening the digestive tract can generate aerosols. Laparoscopy involves the interposition of a physical barrier between the surgeon and the possible source of infection, avoiding occupational exposure and cross infection. The use of hand-assisted surgery through a properly sealed auxiliary port could be considered if the time of the procedure can be reduced without compromising the oncological/functional result. Equipment should be thoroughly checked before surgery. Attempt to minimize the number, size, and size-match of the incision for the trocars. Use central negative pressure systems, and try to evacuate the smoke only once. Constant pressure insufflation systems can be used, and complete exsufflation is recommended before making an assistance incision, if necessary.11,12 As for surgeries in which TaTME, TAMIS or TEM approaches have been used (which have been conducted with extreme precautions in China), the current situation discourages their use due to the high risk of aerosolization and prolonged direct exposure of the surgeon during the perineal stage.13 Likewise, it is essential to remember that the use of stomata (definitive and temporary) generates another possible source of transmission that must be taken into account when cared for by both health workers and family members.

Therefore, it is recommended to prioritize the approach that is most beneficial for the patient, regardless of their COVID-19 infection. In cases where the laparoscopic route is used, protection measures of the airway and mucous membranes should always be maximized, and special precautions will be taken to avoid direct exposure when gas is discharged (evacuations, final exsufflation, etc.). Likewise, although there is no evidence in this regard, the use of smoke filters in the cannulae of each of the laparoscopic ports would be advisable, when available.

In the case of a confirmed positive patient, personal protective equipment (PPE) should be used in conjunction with surgical clothing to ensure adequate protection of operating-room personnel. Even in unconfirmed cases, in the current context of a pandemic all patients should be assumed positive, taking the same protective measures to avoid unnecessary exposure of healthcare staff. There are different types of protective equipment, but the basic elements of protection necessary to be able to carry out a surgical operation under adequate safety conditions are described below.

We recommend the use of a checklist for the entire procedure that explicitly includes the patient's COVID-19 status. As for anesthesia, the AEC subscribes to the recommendations made in this regard by the Spanish Society of Anesthesiology, Resuscitation and Therapeutics of Pain (SEDAR).

It is suggested that an operating room and all its equipment (respirator, etc.) should be designated exclusively for COVID-19 patients for use throughout the epidemic. Ideally it should be independent or away from other operating rooms. An adequate circuit should be planned to transfer these patients from the corresponding isolation area (ICU, ward, etc.) to the designated surgical area. Fig. 2 shows the surgical area protocol for surgical procedures involving patients with COVID-19, adapted from Ti et al.14

Fig. 2.

COVID-19 case management in the surgical area.

SA: surgical area; PPE: personal protective equipment; OR: operating room.

Source: Modified from Ti et al.14

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No specific routine treatment is recommended. Antiviral treatment follows the same indications as for any patient infected with COVID-19. To date, only confirmed cases have been treated, recording in the medical record that a specific treatment has been proposed for which the patients have given their consent (at least verbally). Hydroxychloroquine and lopinavir/ritonavir are currently being used. In elderly and/or polymedicated patients, only hydroxychloroquine is preferred, although it should be avoided in case of liver disease. The most severe patients may also receive treatment with interferon β/tocilizumab, and even remdesivir has been considered.18–20 However, the degree of evidence for these treatments is very limited and based fundamentally on the experience accumulated to date.

Other recommended complementary measures are oxygen therapy and avoiding administering corticosteroids and nebulizers. Regarding the use of drugs that can alter the expression and/or function of the angiotensin-converting enzyme 2 (ACE2), the data are too preliminary to make any firm recommendations. In this case, the use of NSAIDs such as ibuprofen could be questioned, although there is no clear evidence in humans that it can favor the infection or worsen its course. Regarding the therapeutic management of a possible intra-abdominal infection, initially the recommended guidelines for this type of situation should not be modified, neither generally nor according to the protocols of each hospital.21 It is strongly recommended to check the interactions of antiviral drugs. There are currently online registries such as www.covid19-druginteractions.org where updated interactions can be easily consulted.

Any member of the healthcare staff who has had close contact with a patient under investigation with probable or confirmed of coronavirus infection should immediately notify the Preventive Medicine/Occupational Health/Occupational Risk Prevention Department of their hospital. This department will establish the approach to follow based on general and local recommendations as well as the corresponding hospital protocol. Depending on the presence of community transmission, active or passive surveillance protocols will be established.

Table 6 shows the definitions of epidemiological contacts and the approach to follow in each case. The hospital service in charge must carry out an individualized risk assessment, the result of which will be communicated to the Public Health services of the autonomous community. The evaluation must take into account the following aspects:

• A.

  Type of exposure (e.g., procedures that generate aerosols, such as aspiration of the respiratory tract, intubation or bronchoscopy, resuscitation maneuvers, laboratory accidents)

• B.

  Exposure time (more than 15min less than 2m away)

• C.

  Service in which they carry out their healthcare activity (units with especially vulnerable patients, such as hematology, ICU, oncology or burn units)

Thus, once the exposure has been reported and the situation assessed by the corresponding department at the workplace, if the member of the surgical team does not present symptoms and is considered low risk, the current recommendation is to continue normal activities, while monitoring body temperature twice a day. Therefore, it is possible to continue carrying out scheduled and urgent surgical activity using the recommended protection measures for each case. In the event that symptoms appear, the Occupational Risk Prevention Department should be notified as soon as possible, as established in each autonomous community of Spain. The professional will withdraw from healthcare activity, the protocol for notification to the Public Health Department will be activated, and it will be considered a case under investigation.

In the event of exposure without PPE to a patient under investigation, with probable or confirmed COVID19 infection, the exposed staff should be considered close contact and will be managed as such, depending on the specific indications of each hospital. All exposed medical professionals should immediately contact the Preventive Medicine/Occupational Health/Occupational Risk Prevention Department at their medical center and follow the instructions that are indicated. To date, there have been no specific studies of post-exposure prophylaxis (PEP) for COVID-19.9 A retrospective study by Park et al. from 2019 on PEP for MERS in a limited number of healthcare professionals showed good results using a combination of antivirals (lopinavir/ritonavir plus ribavirin).22 However, it is a study with several probable biases in favor of PEP. At the present time, there is no evidence to recommend PEP for COVID-19.