Abstract
Introduction
The initial intercollegiate surgical guidance from the UK during the COVID-19 pandemic resulted in significant changes to practice. Avoidance of laparoscopy was recommended, to reduce aerosol generation and risk of virus transmission. Evidence on the safety profile of laparoscopy during the pandemic is lacking. This study compares patient outcomes and risk to staff from laparoscopic and open gastrointestinal operations during the COVID-19 pandemic.
Methods
Single-centre retrospective study of gastrointestinal operations performed during the peak of the COVID-19 pandemic. Demographic, comorbidity, perioperative and survival data were collected from electronic medical records and supplemented with patient symptoms reported at telephone follow up. Outcomes assessed were: patient mortality, illness among staff, patient COVID-19 rates, length of hospital stay and postdischarge symptomatology.
Results
A total of 73 patients with median age of 56 years were included; 55 (75%) and 18 (25%) underwent laparoscopic and open surgery, respectively. All-cause mortality was 5% (4/73), was related to COVID-19 in all cases, with no mortality after laparoscopic surgery. A total of 14 staff members developed COVID-19 symptoms within 2 weeks, with no significant difference between laparoscopic and open surgery (10 vs 4; p=0.331). Median length of stay was shorter in the laparoscopic versus the open group (4.5 vs 9.9 days; p=0.011), and postdischarge symptomatology across 15 symptoms was similar between groups (p=0.135–0.814).
Conclusions
With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic. The laparoscopic approach maintains an advantage of shorter length of hospital stay compared with open surgery.
Keywords: Gastrointestinal, Laparoscopy, Outcomes
Introduction
Laparoscopic surgery is an established approach for a variety of elective and emergency gastrointestinal (GI) operations. The advantages of laparoscopic over open surgery are well described and include less morbidity, faster restoration of bowel function, a shorter hospital stay and earlier resumption of normal activity.1–6 Conversely, laparoscopic surgery is associated with longer operative times.1,6
In the context of the current coronavirus disease (COVID-19) pandemic, the initial cautionary intercollegiate surgical guidance was to avoid laparoscopic surgery due to the potential risk of aerosol generation with pneumoperitoneum and risk to staff and patients.7,8
The evidence for risk of COVID-19 to staff as a result of laparoscopy is still lacking. This was echoed in the position statement from the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI).9 Furthermore, the outcomes of patients undergoing laparoscopic GI surgery during the pandemic remain undefined.
Aim of study
The aim of this study was to evaluate patient outcomes and risk to theatre staff after laparoscopic and open GI surgery during the initial peak phase of the COVID-19 pandemic in the UK.
Methods
A single-centre retrospective study was performed. Patients who underwent GI surgery at Basildon and Thurrock University Hospitals NHS Foundation Trust, Essex, UK, between 1 March 2020 and 27 April 2020, were identified from electronic theatre records. Patients undergoing hernia repair, vascular, urological, obstetric and gynaecological operations were excluded.
Variables of interest, including patient demographics, comorbidities, perioperative investigations for COVID-19, operation types and operating theatre timings were collected from electronic medical records. Staff sickness due to COVID-19 symptoms within 14 days of surgery was retrieved from theatre managers. Staff members included were surgeons and nonmedical staff (nurses, Operating Department Practitioners, and Support Workers). Anaesthetists were excluded from the analysis. If a staff member was sick with COVID-19 related symptoms and was involved in both open and laparoscopic cases, the sickness was assigned to the laparoscopic case. Patients were followed up by telephone consultation after discharge from hospital. The survival status of patients who were not contactable was ascertained via electronic medical records linked to regional hospitals.
Patients were divided into the laparoscopic and open groups for comparison. The outcomes of interest were: all-cause patient mortality, staff illness due to COVID-19-related symptoms, patient COVID-19 rates, length of hospital stay and patient symptomatology on follow up.
Analysis
Statistical analysis was performed using IBM SPSS v.24. Data are expressed as medians with absolute range, unless otherwise specified. Quantitative and ordinal data were compared using the Mann–Whitney test, whereas categorical data were compared using the Pearson chi-square test. Statistical significance was set at α=0.05.
Results
Between 1 March 2020 and 27 April 2020, 1,108 procedures were performed at Basildon and Thurrock University Hospitals NHS Foundation Trust, including 247 General Surgery cases, of which 134 were elective and 113 were emergencies. In parallel, 668 COVID-19 cases were diagnosed by reverse transcription polymerase chain reaction (RT-PCR) across all departments. Figure 1 presents the operating activity and COVID-19 cases across the Trust on a weekly basis.
Figure 1 .
Surgical activity and COVID-19 cases at Basildon and Thurrock University Hospitals NHS Foundation Trust.
Preoperative and intraoperative data
A total of 73 eligible patients were identified. The median age at the time of operation was 56 years (range: 7–83 years) and 39 patients (53%) were female. The indications, urgency and approaches to operations performed are presented in Table 1.
Table 1 .
Indication, urgency and approach to operations
| Indication | Elective/emergency | Laparoscopic/open | Total* |
|---|---|---|---|
| Cancer | 12 (50%)/12 (50%) | 22 (92%)/2 (8%) | 24 (33%) |
| Acute appendicitis | 0/23 (100%) | 19 (83%)/4 (17%) | 23 (32%) |
| Small bowel obstruction | 1 (14%)/6 (86%) | 3 (43%)/4 (57%) | 7 (10%) |
| GI perforation | 0/3 (100%) | 2 (67%)/1 (33%) | 3 (4%) |
| IBD | 1 (33%)/2 (67%) | 3 (100%)/0 | 3 (4%) |
| Restoration of GI continuity | 3 (100%)/0 | 1 (33%)/2 (67%) | 3 (4%) |
| Diverticular disease | 0/2 (100%) | 0/2 (100%) | 2 (3%) |
| GI bleeding | 0/2 (100%) | 1 (50%)/1 (50%) | 2 (3%) |
| Large bowel obstruction | 0/2 (100%) | 1 (50%)/1 (50%) | 2 (3%) |
| Abdominopelvic abscess | 1 (100%)/0 | 1 (100%)/0 | 1 (1%) |
| Faecal incontinence | 1 (100%)/0 | 1 (100%)/0 | 1 (1%) |
| Non-specific colitis | 0/1 (100%) | 0/1 (100%) | 1 (1%) |
| Access for peritoneal dialysis | 1 (100%)/0 | 1 (100%)/0 | 1 (1%) |
| Total * | 20 (27%)/53 (73%) | 55 (75%)/18 (25%) | 73 (100%) |
GI = Gastrointestinal; IBD = Inflammatory bowel disease
*Percentages with respect to total cohort (n=73)
Of the 73 patients, 20 (27%) underwent elective operations and 53 (73%) underwent emergency operations. The laparoscopic and open groups consisted of 55 (75%) and 18 (25%) patients, respectively. Three laparoscopic cases were converted to open (conversion rate: 3/55; 5%). The median time in the theatre suite (ie from arrival in anaesthetic room until departure from recovery ward) was 298min (117–1,015min). The median number of staff (excluding anaesthetists) involved was 6 (4–10).
Preoperative RT-PCR tests for SARS-CoV-2 were performed for five patients (7%), all of which were negative. Of the 22 (30%) patients who underwent a preoperative chest radiograph, 1 result (1%) was deemed indeterminate for COVID-19, and 21 results (29%) deemed negative. Among 28 (38%) patients who underwent preoperative computed tomography (CT) thorax, there was 1 (1%) indeterminate result and 27 (37%) negative results. In summary, there were no preoperative diagnoses of COVID-19.
In comparing laparoscopic vs open cases, there was no statistically significant difference in terms of median age (p=0.853), sex (p=0.835), American Society of Anesthesiologists (ASA) status (p=0.876), urgency of operation (p=0.074), time in theatre suite (p=0.163) or number of theatre staff involved (p=0.831). Open cases were more likely to involve benign disease (p=0.024). Table 2 presents a detailed preoperative and intraoperative comparison of laparoscopic and open cases.
Table 2 .
Preoperative and intraoperative data
| Variable | Laparoscopic (n=55) | Open (n=18) | p-value* |
|---|---|---|---|
| Median age at time of surgery in years (range) | 53.0 (14–83) | 59.5 (7–79) | 0.853 |
| Sex (female/male) | 29/26 (53%/47%) | 10/8 (56%/44%) | 0.835 |
| Comorbidity | |||
| Hypertension | 14 (25%) | 5 (28%) | 0.845 |
| Ischaemic heart disease | 2 (4%) | 4 (22%) | 0.013 ** |
| Chronic heart failure | 1 (2%) | 0 | 0.565 |
| Cerebrovascular disease | 0 | 2 (11%) | 0.012 ** |
| Diabetes mellitus | 3 (5%) | 4 (22%) | 0.036 ** |
| Chronic kidney disease | 6 (11%) | 0 | 0.144 |
| Cancer | 24 (44%) | 4 (22%) | 0.105 |
| COPD | 1 (2%) | 0 | 0.565 |
| Asthma | 2 (4%) | 4 (22%) | 0.013 ** |
| Immunosuppression | 3 (5%) | 1 (6%) | 0.987 |
| Current smoker | 14 (25%) | 3 (17%) | 0.444 |
| ASA Physical Status | |||
| I | 14 (25%) | 5 (28%) | 0.876 |
| II | 27 (49%) | 7 (39%) | |
| III | 10 (18%) | 4 (22%) | |
| IV | 4 (7%) | 2 (11%) | |
| Indication for surgery | |||
| Benign disease | 33 (60%) | 16 (89%) | 0 . 024 ** |
| Malignant disease | 22 (40%) | 2 (11%) | |
| Urgency | |||
| Elective | 18 (33%) | 2 (11%) | 0.074 |
| Emergency | 37 (67%) | 16 (89%) | |
| Median time in theatre suite | 291min (121–820min) | 363min (117–1,015min) | 0.163 |
| Median number of theatre staff involved, excluding anaesthetists | 6 (4–10) | 6 (5–9) | 0.831 |
ASA = American Society of Anesthesiologists; COPD: chronic obstructive pulmonary disease
*Mann–Whitney test for quantitative and ordinal data, Pearson chi-square test for categorical data
**Statistical significance at α=0.05.
Outcomes
Over a median postoperative follow-up period of 49 days (10–70 days), there were four mortalities (5%). All four patients were above the age of 55, with ASA Physical Status ≥2, and had undergone an emergency open procedure for benign disease. All four patients were postoperatively diagnosed with COVID-19. There was no mortality in the laparoscopic group.
A total of 14 staff members (five surgeons and nine nonmedical staff members) developed COVID-19 symptoms within 14 days of surgery. There was no statistically significant difference between the laparoscopic and open groups with respect to total numbers of illness among staff members overall (10 vs 4; p=0.331), among surgeons (3 vs 2; p=0.410), or among nonmedical staff (7 vs 2; p=0.750).
Postoperatively, 10 patients (14%) underwent a SARS-CoV-2 RT-PCR test, with a positive result in five cases (7%). Of the 19 (26%) patients who underwent a postoperative chest radiograph, there were indeterminate results in 3 (4%) cases and negative results in 16 (22%). Nine patients (12%) underwent postoperative CT thorax, with three positive results (4%), four indeterminate results (5%), and two negative results (3%). Based on a positive result in either RT-PCR, chest radiograph or CT thorax, six patients (8%) were diagnosed postoperatively with COVID-19. All patients who developed COVID-19 postoperatively belonged to the open group.
The overall median length of hospital stay (Table 3) was 5.0 days (<1–57 days) and was significantly shorter in the laparoscopic vs the open group (4.5 vs 9.9 days; p=0.011).
Table 3 .
Outcomes and follow-up period
| Variable | Laparoscopic (n = 55) | Open (n = 18) | p-value* |
|---|---|---|---|
| Mortality | 0 | 4 (22%) | <0 . 001 ** |
| No. of staff ill ≤14 days | |||
| Surgeons | 3 | 2 | 0.410 |
| Nonmedical staff | 7 | 2 | 0.750 |
| Combined† | 10 | 4 | 0.331 |
| Postoperative COVID-19 | 0 | 6 (33%) | <0 . 001 ** |
| Median length of stay in days | 4.5 (0–45) | 9.9 (2–57) | 0 . 011 ** |
| Median postoperative follow-up interval in days | 50 (12–66) | 33 (10–70) | 0.165 |
COVID-19 = Coronavirus Disease 2019
*Mann–Whitney test for quantitative and ordinal data, Pearson chi-square test for categorical data
**statistical significance at α=0.05
†Excluding anaesthetists
From the cohort of 73 patients, 59 (81%) were followed up by telephone consultation, 1 (1%) declined to participate in follow up, 7 (10%) could not be contacted and 2 were still in hospital (3%). Among the 59 patients who were followed up, and when comparing laparoscopic vs open surgery (47 vs 12 patients), there was no significant difference in the prevalence of abdominal pain (20 vs 8; 43% vs 67%; p=0.135), fatigue (16 vs 2; 34% vs 17%; p=0.243), diarrhoea (8 vs 3; 17% vs 25%; p=0.526), fever (7 vs 3; 15% vs 25%; p=0.405), dyspnoea (6 vs 1; 13% vs 8%; p=0.672), ageusia (5 vs 2; 11% vs 17%; 0.564), cough (6 vs 0; 13% vs 0; p=0.192), dizziness (5 vs 1; 11% vs 8%; p=0.814), headache (4 vs 2; 9% vs 17%; p=0.404), pharyngalgia (5 vs 1; 11% vs 8%; p=0.814), arthralgia (5 vs 0; 11% vs 0; p=0.238), myalgia (5 vs 0; 11% vs 0; P=0.238), rigors (2 vs 1; 4% vs 8%; p=0.566), anosmia (1 vs 1; 2% vs 8%; p=0.289) or chills (1 vs 1; 2% vs 8%; p=0.289).
Discussion
The ongoing COVID-19 pandemic has significantly changed our professional practice. From the start of the pandemic, guidelines have been published emphasising caution but are limited by a relative lack of clinical evidence. Providing clinical evidence during such a constantly evolving situation remains a challenge.10 In this retrospective study, we have addressed some of the concerns regarding minimally invasive GI surgery. Specifically, our results indicate that laparoscopic surgery is associated with a shorter hospital stay, lower postoperative COVID-19 infection rates, and a lower all-cause mortality rate compared with open surgery. It could be speculated that by shortening the hospital stay, laparoscopic surgery reduces the exposure of postoperative patients to pathogens such as SARS-CoV-2 which may be circulating in hospitals, and therefore leading to better outcomes.
Our study period was chosen to include the exponential growth and peak phase of the pandemic in a south-eastern English NHS Trust with close proximity to London. The first SARS-CoV-2 cases in England were detected in late January 2020, rising to a total of 86 by the beginning of our study period (1 March 2020), and to 119,165 by the end of our study period (27 April 2020), with London considered to be disproportionately affected.11 In our institution, the first patient with COVID-19 was diagnosed on 2 March 2020. In the next 3 weeks, the number of newly diagnosed COVID-19 cases increased, with a subsequent decline in the last 3 weeks of the study period (Figure 1).
Like many other institutions during the initial phase of the pandemic in the UK, our attention was directed towards maximising hospital capacity in anticipation of a surge in COVID-19 admissions. Local capacity was increased by expediting safe patient discharge, reducing elective activity and converting additional clinical areas to Critical Care Unit extensions. Staff members from various departments were redeployed to support COVID-19 teams. Additional changes included the implementation of new diagnostic pathways, centred on CT of the thorax for early and rapid diagnosis of COVID-19, with routine CT screening for patients due to undergo surgery (as of April 2020) and cohorting of patients according to degree of suspicion of COVID-19. Operating theatre changes included: minimisation of staff numbers, routine use of personal protective equipment (two surgical caps, FFP3 masks, visors or goggles, plastic aprons and fluid-resistant gowns, double gloving for surgeons and triple gloving for anaesthetists, and shoe covers), airway management in the operating theatre rather than the anaesthetic room, no entry into theatre within 20min after intubation/extubation, dual-Consultant operating where possible, reduction of pneumoperitoneum pressures to 12mmHg, use of balloon laparoscopic ports and filtered smoke extractors (LaproSurge ClearFlow™ Ultra, LaproSurge Ltd, Hertfordshire, UK), and closed-system aspiration of pneumoperitoneum prior to specimen retrieval or port removal. During this initial phase of the pandemic, a key consideration was that any patient or staff member may carry SARS-CoV-2 at any time.
Recent evidence indicates that SARS-CoV-2 RNA can be detected in the peritoneal fluid of patients with COVID-19.12 In parallel, guidance from various professional bodies7–9 recommends cautious and selective use of laparoscopy due to concerns of SARS-CoV-2 virion aerosolisation. Although surgical smoke or plume has been associated with aerosolisation of blood-borne viruses (eg human papillomavirus and human immunodeficiency virus), reports of disease transmission through surgical smoke are rare and are not exclusive to laparoscopic surgery.13 To our knowledge, there is no evidence that SARS-CoV-2 can be transmitted from patient to staff through laparoscopic smoke, plume or in association with pneumoperitoneum. However, absence of evidence does not equal evidence of absence and for this reason we sought to study our local experience with the use of protective measures. As open surgery involves more manual contact with peritoneal fluid and exposes the peritoneum to the atmosphere, it could be argued that the risk of SARS-CoV-2 transmission in open surgery is relatively high. Conversely, laparoscopic surgery creates a contained environment and may thereby pose a lower risk to staff than previously thought. We believe that the institutional changes described above have synergistically minimised the risk of SARS-CoV-2 transmission between patients and staff. These measures are in line with European and American endoscopic surgery recommendations.14
Our study addresses pertinent issues regarding risk to patients and staff with open and laparoscopic surgery during the peak of the COVID-19 pandemic. However, there are several limitations to be acknowledged. Specifically, this is a retrospective study in an environment where daily practice and guidance have been subject to frequent change, and which describes a relatively small single-centre cohort of 73 patients. This cohort is heterogeneous in terms of indications and urgency of surgery. In particular, 19 of 55 laparoscopic procedures were performed for acute appendicitis, which may partly account for the shorter length of stay observed in laparoscopic versus open surgery. Performing subgroup analyses for each surgical indication would result in small subgroup sizes and would not permit confident conclusions. Furthermore, at the time of this study, perioperative SARS-CoV-2 RT-PCR testing was unfortunately not universally available due to limited testing resources and capacity. The limited sensitivity of available SARS-CoV-2 RT-PCR tests also meant that this could not be used as a standalone criterion for excluding SARS-CoV-2 infection. It should also be noted that during the first 2 weeks of March, no local COVID-19 theatre policy was available and that the protective measures mentioned above were not implemented for the entirety of our study. Anaesthetists were not included in the staff risk analysis as they performed endotracheal intubation for all cases, which remains the most high-risk aerosol generating procedure that can transmit SARS-CoV-2.15 Additionally, their regular COVID-19 Intensive Care Unit activities exposed them to areas considered to be of exceptional high risk. Finally, symptomatology was included in an attempt to provide a more complete picture of patient risk but is inherently prone to recall bias and is limited by the lack of pathognomonic COVID-19 symptoms. With the above limitations in mind, this study provides pragmatic evidence from the initial phase of the COVID-19 pandemic in a UK hospital.
Conclusions
With appropriate protective measures, laparoscopic surgery is safe for patients and staff during the COVID-19 pandemic and maintains an advantage in length of hospital stay vs. open surgery.
Acknowledgements
The authors wish to thank Ms Julie Plane (Theatre Systems Manager), Ms Denise Archer (Theatre Manager) and Ms Nicola Tunbridge (Clinical Lead, Theatres) for providing perioperative data, as well as Dr Mustafa Awad-El-Kariem (Consultant Microbiologist and Director for Infection Prevention and Control) for providing Trust-level COVID-19 data.
Author contributions
CH: Conception and design, data acquisition, analysis and interpretation, article drafting, revision and final approval.
SSS, AU, ZJA, PLA, RJF and KPP: Data acquisition, article revision and final approval.
BL: Conception and design, data acquisition and interpretation, article revision and final approval.
AA: Conception and design, data interpretation, article drafting, revision and final approval.
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