Our challenge is to adapt the organization of our system to the six stages of the epidemic to go beyond the COVID-19 crisis

Editor

We thank Spinelli and Pellino¹ for describing their perspective of the experience in Italy. We have also published a paper on this subject². These perspectives focused on patient care and on caregiver protection.

Concerning this latter point, we also note a word of caution concerning laparoscopy. Laparoscopy has well known advantages, but in the setting of this infection, the most important thing for the patient is probably to reduce the negative impact on pulmonary function. However, there is a theoretical possibility that the virus can be found in circulating CO₂, with a risk of viral exposure. We agree fully with Spinelli and Pellino, laparoscopy should be performed only by well trained surgeons in compliance with all safety points.

The main pitfall when proposing recommendations for this crisis is that there are six consecutive stages: stage 1, calm before the storm; stage 2, the storm; stage 3, the peak; stage 4, the plateau; stage 5, the decline; and stage 6, return to normal. The strategy will be different at each stage.

During stages 1 to 3, surgeons have to review all scheduled elective procedures with a plan to minimize or postpone them. These are probably not the most difficult stages to deal with for surgeons. The strength of Spinelli and Pellino's writing is to anticipate management of the stages after the inflection point while we are still in the storm; they must be congratulated for this.

There will be a large amount of cancer surgery after the epidemic, and this could delay non-oncological intervention. We will have to take into account caregiver exhaustion. Spinelli and Pellino emphasize the need for strategies to prevent burnout among the caregivers.

Spinelli and Pellino have to be congratulated for taking the time to share with us their thinking about management beyond the storm.