Management of non traumatic surgical emergencies during the COVID-19 pandemia

PARREIRA, JOSÉ GUSTAVO; CAMPOS, TERCIO DE; ANTUNES, PEDRO DE SOUZA LUCARELLI; PERLINGEIRO, JACQUELINE ARANTES GIANNINNI; ASSEF, JOSE CESAR

doi:10.1590/0100-6991e-20202614

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Review article • Rev. Col. Bras. Cir. 47 • 2020 • https://doi.org/10.1590/0100-6991e-20202614 copy

Management of non traumatic surgical emergencies during the COVID-19 pandemia

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARS-CoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.

Keywords:
Emergencies; Pandemics; Coronavirus Infections; General Surgery

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[1] Mailing address: José Gustavo Parreira E-mail: jgparreira@uol.com.br/lucarelli_2007@yahoo.com.br

Operative treatment	Non-operative treatment
Benefits - Direct approach to surgical disease, maintaining the proposal considered as the gold standard for the treatment of diseases such as acute uncomplicated appendicitis and acute calculous cholecystitis. - Greater chance of resolving surgical disease, with consequent shorter hospital stay and complications. - Less use of resources in general, complementary tests and antibiotics to control treatment.	Benefits - Less chance of contamination of the anesthesiology and surgery team. - Possible protection of the evolution of COVID-19 to more serious forms. - Possibility of outpatient treatment in the simplest cases. - Savings on PPE, in cases where outpatient treatment is possible, considering that there will be no complications.
Disadvantages - Unpredictability of the evolution of COVID-19 in these cases. - Possibly there is a greater chance of respiratory complications in patients undergoing surgical treatment. - Greater chance of contamination by the anesthesiology team during orotracheal intubation. - Greater chance of contamination of the surgical team in the operative act. - Risk of surgical complications and need for ICU, with consequent longer hospital stay.	Disadvantages - It is not the gold standard for some diseases such as acute uncomplicated appendicitis and acute calculous cholecystitis. - Chance of local and systemic complications of these diseases, making surgical resolution at a later time more complicated. - Real chance of death from sepsis of abdominal focus if the situation gets out of control. - Loss of the “timing” of treatment: if the patient complicates with COVID-19, the operative treatment of abdominal disease may be rendered unfeasible. - Need for second-stage operative treatment (e.g. cholecystolithiasis). - Longer time of antibiotics.

Factors in favor of operative treatment	Factors in favor of NON-operative treatment
Clear indication of operative treatment	No clear indication of operative treatment
Negative chest CT or minimal involvement	Frankly positive chest CT
Mild / moderate COVID-19	Severe / critical COVID-19
IgG positive	IgM / IgA positive
Acute uncomplicated appendicitis	Appendicular abscess
Complicated acute cholecystitis	Uncomplicated acute cholecystitis
NOM failure in Diverticulitis H I and II	Diverticulitis Hinchey I and II
Initial phase of the pandemic	Late stage of the pandemic
Available PPE	Lack of PPE