Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: A prospective cross-sectional study from an Italian COVID center

Background. The contamination of body fluids by Severe Acute Respiratory Syndrome Coronavirus 2 during surgery is current matter of debate in the scientific literature concerning CoronaVIrus Disease 2019. Surgical guidelines were published during the first wave of the COVID-19 pandemic and recommended to avoid laparoscopic surgery as much as possible, in fear that the chimney effect of high flow intraperitoneal gas escape during, and after, the procedure would increase the risk of viral transmission.Aim. The aim of this study was to evaluate the possibility of SARS-CoV-2 transmission during surgery by searching for viral RNA in serial samplings of biological liquids.Methods. This is a single center prospective cross-sectional study. We used a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) test to perform swab tests for the qualitative detection of nucleic acid from SARS-CoV-2 in abdominal fluids, during emergency surgery and on the first post-operative day. In the case of thoracic surgery, we performed a swab test of pleural fluids during chest drainage placement as well as on the first post-operative day. Results. A total of 20 samples were obtained: 5 from pleural fluids, 13 from peritoneal fluids and two from biliary fluid. All 20 swabs performed from biological fluids resulted negative for SARS-CoV-2 RNA detection.Conclusion. To date, there is no scientific evidence of possible contagion by laparoscopic aerosolization of SARS-CoV-2, neither is certain whether the virus is effectively present in biological fluids.

290 Quality of Clinical Practice Guidelines for Laparoscopic Surgery: Systematic Review

Aim Guidelines on laparoscopic surgery are essential for providing guidance to achieve safe and effective treatments. In this systematic review, we investigated the true extent of the grades of recommendation which were supported by evidence in the guidelines and whether this extent depended upon the quality of the guidelines. Method We searched PUBMED and EMBASE for laparoscopic surgical guidelines published between 1st March 2016 and 1st March 2019.To determine the extent of the grades of recommendation supported by evidence, we determined the disagreement in the grading between the guideline author and independent evaluation. We used the AGREE-II Tool ‘rigour of development’ and ‘clarity of presentation’ domains to assess the quality of guidelines. We performed a mixed effects generalised linear regression modelling using binary distribution and logit link in the GLIMMIX procedure of Statistical Analysis System (SAS) software. Results We analysed 1905 guideline statements from the 63 guidelines retrieved. The median of the scores for the ‘rigour of development’, ‘clarity of presentation’, the ‘editorial independence’ domains in the guidelines were 0.43, 0.72 and 0.63. The interquartile ranges were 0.094, 0.25 and 0.38. The ‘rigour of development’ domain was the only determinant of disagreement in the grades of recommendation guideline statements between the guideline authors and independent evaluation. Conclusions There is variation in the grades of recommendation in the guidelines. The ‘rigour of development’ domain can be used to predict quality of the guidelines. Guideline users should use the ‘rigour of development’ domain to assess the quality of the laparoscopic guidelines before developing local clinical policies.

Pressure ulcers

Pressure ulcers are a problem worldwide with social and cost implications. Patients at special risk are paraplegics, those in intensive care units who are critically sick, and older patients having prolonged bed rest for whatever reason. The important extrinsic factors are pressure, shear, and friction. There are a number of charts, which endeavour to identify patients at risk, and institute appropriate preventative measures thereby avoiding the long-term sequelae and burden of pressure ulcers. In patients with established pressure ulcers, an accurate patient and wound evaluation is vitally important. The long-term success of management of these ulcers is dependent on good patient rehabilitation and optimization of the wound. Reconstructive success is improved by following surgical guidelines. Use of fasciocutaneous flaps, designed in a V–Y configuration, is the preferred method of reconstruction with muscle flaps reserved as a back-up option. Conscientious postoperative care is equally important at ensuring a successful surgical outcome and minimizing complications

Prophylactic colectomy and rectal preservation in FAP: systematic endoscopic follow-up and adenoma destruction changes natural history of polyposis

Background and study aims Prophylactic surgery of familial adenomatous polyposis (FAP) includes total colectomy with ileorectal anastomosis (IRA) to proctocolectomy with ileoanal anastomosis (IAA). Surgical guidelines rely on studies without systematic endoscopic follow-up and treatment. Our aim was to report our experience based on a different approach: therapeutic follow-up, comparing in this setting IRA and IAA in terms of oncological safety and quality of life. Patients and methods Between January 1965 and November 2015, all patients who underwent prophylactic surgery for FAP with therapeutic endoscopic follow-up in Lyon University hospital: systematic endoscopic treatment of adenomas, were retrospectively and prospectively (since 2011) included. Results A total of 296 patients were analyzed: 92 had proctocolectomy with IAA (31.1 %), 197 total colectomy with IRA (66.5 %), and seven abdominoperineal resections (2.4 %). Median follow-up was 17.1 years (range, 0–38.1). Incidence of secondary cancer (IR vs. IAA) was 6.1 % vs. 1.1 % (P = 0.06; 95 %CI 0.001–0.36). The 15-year cancer-free and overall survival (IR vs. IAA) were 99.5 % vs 100 % (P = 0.09) and 98.9 % vs. 98.8 % (P = 0.82), respectively. Postoperative morbidity occurred in 44 patients: 29 (14.7 %) in the IRA and 15 (16.3 %) in the IAA group (P = 0.72). The mean number of stools per day in the respective groups were 4.4 (2.5) vs. 5.5 (2.6) (P = 0.001). Fecal incontinence occurred in 14 patients (7.1 %) in the IRA vs. 16 (17.4 %) in the IAA group (P = 0.03). Conclusions A combination of therapeutic endoscopic treatment and extended rectal preservation appears to be a safe alternative to ileoanal J-pouch anastomosis.

749 Delivering Safe and Timely Cancer Care During COVID 19. Lessons and Successes from The Transition Period

Introduction Delivering timely cancer care during the COVID-19 pandemic was a major challenge. We analysed our success in addressing this. Method A key factor was the proximity of a private hospital (GN) to the primary trust. GN acted as a ‘clean site’. From 6th April 2020, two robots and dedicated staff were relocated to day surgery theatres with direct access to GN. Procedures and post-operative recovery happened in GN. National surgical guidelines were followed related to Covid-19. All theatre staff were swabbed weekly. Patients were risk stratified prior to admittance. Results We reviewed operations performed and cancer pathway data from March to June 2020 and compared it to data collected from August to November 2019. From March until June 2020 we performed 369 cancer operations; 120 robotic, 138 endoscopic and 7 open cases. From August to November 2019 we performed 407 cancer operations; 116 robotic, 175 endoscopic and 7 open cases. No elective patient developed symptomatic COVID-19 secondary to admission. Conclusions This study demonstrates that with rapid development of separate ‘clean’ and ‘COVID’ sites, we successfully delivered a comparable, safe and effective cancer service. As we potentially face a second wave we share our success to see if these changes can be replicated elsewhere.

O3 Forming a novel trainee-led research collaborative during times of crisis: Lessons learned from the COVID:HAREM collaborative

Introduction At the beginning of the COVID-19 pandemic, the effect it would have on our healthcare system was unknown. As a result, surgical guidelines shifted to recommend non-operative management despite uncertainty of its efficacy compared to standard operative management. Within general surgery, nowhere was this more relevant than with the management of appendicitis, the most common abdominal emergency worldwide. This novel research collaborative was set up during the COVID-19 pandemic to assess the outcomes of appendicitis patients managed with antibiotics compared to appendicectomy. Methods Without the time to obtain funding for the project, trainee-driven recruitment of sites was vital and used established trainee-led regional research networks and twitter (@Covidharem). Further backing was provided by surgical societies who published and promoted the study protocol on their platforms. The steering group used surgical networks and contacts to recruit sites who were not already involved and RedCap was used for data entry to allow for real time monitoring of data completion. Results In just twelve weeks, 471 individual collaborators were recruited from 101 sites across the United Kingdom and Ireland. The collaborative went from inception to 500 patients uploaded in 30 days. The collaborative to date has recruited nearly 3500 patients, published both the protocol and an interim analysis within 4 months, and hosted a highly successful webinar. Conclusion Quality research can be achieved in times of crisis, the key to successful projects is trainee driven and led, focussed “snapshots” that can be implemented rapidly during the dynamic environment of a crisis.

Use of Clinical Audits to Evaluate Timing of Preoperative Antimicrobials in Equine Surgery at a Veterinary Teaching Hospital

Based on human surgical guidelines, intravenous antimicrobials are recommended to be administered within 60 min of surgical incision. Achieving this target in horses is reportedly challenging and influenced by hospital policies. The objectives of this study were to evaluate and improve: (1) the timing of antimicrobial administration to surgical incision (tAB-INC), (2) contributions of anesthesia pre-induction (tPRI) and surgical preparation (tPREP) periods to tAB-INC, and the (3) completeness of antimicrobial recording. Two clinical audits were conducted before and after the policy changes (patient preparation and anesthesia record keeping). tPRI, tPREP, and tAB-INC were calculated and compared for elective arthroscopies and emergency laparotomies within and between the audits. The percentage of procedures with a tAB-INC <60 min was calculated. Antimicrobial recording was classified as complete or incomplete. A median tAB-INC <60 min was achieved in laparotomies (audit 1; 45 min, audit 2; 53 min) with a shorter tPREP than arthroscopies (p < 0.0001, both audits). The percentage of procedures with tAB-INC <60 min, tAB-INC, tPRI, and tPREP durations did not improve between the audits. There was a positive correlation between the number of operated joints and tPREP (audit 1, p <0.001, r = 0.77; audit 2, p < 0.001, r = 0.59). Between audits, antimicrobial recording significantly improved for elective arthroscopies (82–97%, p = 0.008) but not emergency laparotomies (76–88%, p = 0.2). Clinical audits successfully quantified the impact of introduced changes and their adherence to antimicrobial prophylaxis guidelines. Antimicrobial recording was improved but further policy changes are required to achieve a tAB-INC <60 min for arthroscopies.