Acute care surgery and post‐operative COVID‐19 pneumonia: a surgical and environmental challenge

COVID‐19 infection has emerged in China in December 2019 and has rapidly spread all over the world.1, 2 The need to fight the pandemic has lead to partial reorganization of the health care system. The majority of elective operations were cancelled.3, 4 A report from Iran about peri‐operative impact of COVID‐19 in patients undergoing elective benign surgery showed a high fatality rate.5 Emergency departments continue to take care of patients with acute diseases, some of those requiring urgent surgery.

We report the case of a 64‐year‐old female patient presenting to the emergency department on 4 March 2020. At admission, she complained of intense diffuse abdominal pain. She did not report any respiratory symptoms. She did not report any contact with patients affected by COVID‐19 infection nor people coming from endemic areas. At admission, temperature was 37.2° and heart rate 104 beats/min. Physical examination showed abdominal tenderness in all quadrants. Leucocytosis with 21 000 white blood cells was detected. Thoracic radiography did not show any anomaly. Abdominal computed tomography (CT) showed abundant abdominal fluid and distension of small bowel loops in the right iliac fossa suggesting volvulus (Fig. 1). A volvulus of the distal ileum close to the ileo‐caecal valve was found at laparotomy, with ischaemia of approximately 40 cm of the ileum. Ileocolic resection with hand‐sewn ileocolic anastomosis was performed. Large spectrum antibiotic therapy was started.

Figure 1.

Abdominal computed tomography scan at admission showing intra‐abdominal fluid and suspicious of small bowel volvulus.

Starting from post‐operative day (POD) 3, temperature >38° was detected without any other symptom. Blood white cells decreased to 14 300 at POD 1 and to normal values at POD 4. At POD 3, she had the firs flatus and at POD 5 the first stools. Since then, she had diarrhoea with five to six evacuations per day. Suspecting anastomotic leakage, at POD 7, a thoracic and abdominal CT scan was performed (Fig. 2). The CT scan did not show any abdominal complication. The fever persisted and at POD 14 thoracic CT scan detected bilateral consolidations mainly at the inferior lobes, with interstitial pattern, as showed in Figure 3, suggestive for COVID‐19 infection. The diagnosis was confirmed by microbiological investigation with reverse transcription‐polymerase chain reaction (RT‐PCR).

Figure 2.

Abdominal scan at post‐operative day 7, not showing any post‐operative complication.

Figure 3.

Thoracic computed tomography scan at post‐operative day 14 showing bilateral interstitial pneumonia.

This report highlights the possibility of COVID‐19 infection during the post‐operative course of patients admitted for emergency surgical procedures. Even if the hospitals organize specific pathways for patients with documented COVID‐19 infections, the virus is highly contagious and can spread to other patients, facilitated by the lower efficiency of the immune system in the post‐operative period. Another possibility is that some patients may be already infected at admission, but totally asymptomatic.

The presence of fever during the post‐operative period should be considered a warning sign, even in the absence of other symptoms. It should be noted that physicians might be confused by the possibility of other complication related to the surgical procedure (in the reported case, abdominal abscess or anastomotic leak have been suspected). Furthermore, other forms of respiratory complications may occur, including bacterial or aspiration pneumonia, pulmonary embolism, pulmonary oedema. COVID‐19 pneumonia is characterized by peripherally ground‐glass opacities with multilobe and posterior involvement, bilateral distribution and sub‐segmental vessel enlargement.6

A high grade of suspicious for COVID‐19 is needed during this period in the acute surgery departments, to avoid potential harm of the operated patients and health workers, and to allow an appropriate hospitalization of COVID patients in dedicated areas. Sensitivity of 71% has been reported for RT‐PCR in a large Chinese series, whereas CT scan had a sensitivity of 98%.7

COVID‐19 pneumonia may occur as a post‐operative complication, representing a diagnostic challenge in the post‐operative period, with potential adverse outcome. In the emergency setting, surgery obviously cannot be post‐poned. We suggest active surveillance with a liberal use of RT‐PCR test and thoracic CT scan in this setting, to rule out COVID‐19 infection, in the effort to offer prompt treatment to infected patients and to protect other patients and health workers.