An, Y

Bellato, V

Campanelli, M

Efetov, S

Franceschilli, M

Giuseppe Sica

Khanna, K

Konishi, T

Pellino, G

Piciocchi, A

Pirozzi, B M

Sensi, B

Siragusa, L

English

CorrespondenceImpact of asymptomatic COVID-19patients in global surgical practiceduring the COVID-19 pandemicEditorThe rapid spread of COVID-19 haschanged the global surgical care1-3.Patients infected with COVID-19 maypresent without typical symptoms,and such asymptomatic patients maypotentially trigger in-hospital outbreaksby transmitting the disease to healthcare providers and other hospitalizedpatients4, 5. Further, asymptomaticCOVID-19 patients have worse postop-erative outcomes with an unexpectedlyTable 1 Preoperatively asymptomatic COVID-19 patients by the countries’ risk groupCountries by risk groupOverall High risk Int. risk Low risk936 330 242 364 P ValueTesting policies before surgery. No. (%)aEveryone 155 (16⋅6) 91 (27⋅6) 43 (17⋅8) 21 (5⋅8) <⋅001All oncologic patients 42 (4⋅5) 24 (7⋅3) 14 (5⋅8) 4 (1⋅1) <⋅001All emergency patients 73 (7⋅8) 41 (12⋅4) 22 (9⋅1) 10 (2⋅7) <⋅001Symptomatic or suspicious radiological features 691 (73⋅8) 214 (64⋅8) 183 (75⋅6) 294 (80⋅8) ⋅03Experienced preoperatively asymptomatic patients tested positive aftersurgery. No. (%)Yes 257 (27⋅5) 170 (51⋅5) 66 (27⋅3) 21 (5⋅8) <⋅001No 679 (72⋅5) 160 (48⋅5) 176 (72⋅7) 343 (94⋅2)Experienced preoperatively asymptomatic patients tested positive aftersurgery with symptoms. No. (%)Yes 231 (24⋅7) 158 (47⋅9) 55 (22⋅7) 18 (4⋅9) <⋅001No 705 (75⋅3) 172 (52⋅1) 187 (77⋅3) 346 (95⋅1)Experienced preoperatively asymptomatic patients tested positive aftersurgery without symptoms. No. (%)Yes 157 (16⋅8) 108 (32⋅7) 39 (16⋅1) 10 (2⋅7) <⋅001No 779 (83⋅2) 222 (67⋅3) 203 (83⋅9) 354 (97⋅3)Preventive measures changed due to the asymptomatic patients? (2nd survey)No. (%)a,bYes, PPE use 40 (26⋅8)Yes, PPE availability 23 (15⋅4)Yes, preoperative patient testing 55 (36⋅9)Yes, staff testing 26 (17⋅4)Yes, staff rotation 16 (10⋅7)Yes, COVID-19 dedicated area 54 (36⋅2)Yes, stop elective surgeries 31 (20⋅8)No 27 (18⋅1)Did you observe a worse surgical outcome related to asymptomatic COVID-19patient? (2nd survey) No. (%)bYes 46 (30⋅9)No/I don’t know 103 (69⋅1)Int: intermediate. aPercentages do not add up to 100 because of the multiple choice question. bThe second survey respondents are the centers that answered‘yes’ in the question ‘Experienced preoperatively asymptomatic patients tested positive after surgery’ (n = 149). The data are not analyzed by countries’risk group.high morbidity and mortality, reaching20⋅5 per cent deaths6. However, wedo not have objective global data onthis issue. In an attempt to clarify thecurrent global surgical practice underthe COVID-19 pandemic particularlyfocusing on the preoperative screeningof asymptomatic COVID-19 patients,we conducted a cross-sectional onlinesurvey on surgical practice. The surveywas administered to surgeons worldwidethrough international surgical societies,social media and personal contacts dur-ing 2 April to 8 April. The results wereanalyzed by country’s cumulative deathsnumber by 8 April, 2020 (high risk,>5000; intermediate risk, 100-5000; lowrisk, <100) (https://covid19.who.int/).The survey was completed by a totalof 936 centres in 71 countries, involving5 high risk countries (330 centres), 20intermediate risk countries (242 centres)and 46 low risk countries (364 centres).Table 1 summarizes the results of thesurvey. The majority (73⋅8 per cent)of the centers performed preoperativeCOVID-19 testing based on symp-toms or suspicious radiologic findings.Universal COVID-19 testing for everypatient was performed in only 16⋅6© 2020 BJS Society Ltd BJS 2020; 107: e364–e365Published by John Wiley & Sons LtdCorrespondence e365per cent of the centers, and the pro-portion was less than 30 per cent evenin severely affected countries. Asymp-tomatic COVID-19 patients who testedpositive postoperatively were reportedfrom 27⋅5 per cent of the centres, withhigher rates in higher risk countries(high risk, 51⋅5 per cent; intermediaterisk, 27⋅3 per cent; low risk, 5⋅8 per cent;p< 0⋅001). To further clarify the clinicalimpact of asymptomatic COVID-19patients, the second survey was sentto 218 centres that experienced suchpatients and had contact information,and 149 responded. The median numberof asymptomatic COVID-19 patientstesting positive after surgery per centrewas 2 (range, 1 to 20). After experienc-ing the first asymptomatic COVID-19patients, most centers (81⋅9 per cent)changed testing policies and/or preven-tive measures in surgical practice. Worsesurgical outcomes in asymptomaticCOVID-19 patients were reported from30⋅9 per cent of the centres.To our knowledge, this is one ofthe largest international surveys onCOVID-19 in the field of surgery.Acknowledging the biases caused byunintended selection of centres, unequalnumber of centres per country anduneven geographical coverage, this largesurvey captured the global surgical prac-tice under the COVID-19 pandemic andhighlighted the threat of asymptomaticpatients. Asymptomatic COVID-19patients who were tested positive post-operatively may represent insufficientpreoperative screening in the currentsurgical practice. The clinical impact ofasymptomatic COVID-19 patients forsurgeons is evident by the fact that thedetection of such asymptomatic patientsresulted in the change of testing policiesand/or preventive measures in most ofthe centres. We strongly believe that inthe coming phase of pandemic, duringwhich many medical centres will resumeelective surgeries, a call for action insurgical departments for more intensivescreening programs is needed in globalplans.AcknowledgementWe would like to thank all the collab-orators of “S-COVID CollaborativeGroup” (listed separately) for theircontribution to the study; the surgicalsocieties (European Society of Surgi-cal Oncology, Latin American Societyof Surgical Oncology, Russian Societyof Colorectal Surgeons and SocietàItaliana di Chirurgia Colo-Rettale)for distributing the survey; Dr. KrishnKhanna for English editing; andall the surgeons who translated theoriginal questionnaire into 13 lan-guages and shared the project in theircountries: A. Frontali, J. Carvas, L.Sanchez-Guillen, C. Blajut, M. Sbaih,E.Karbovnichaya, E. Samadov, N.Buchs, M. Ninkovic, T. Araki, G.Gallo, A. Sturiale. The study wasregistered with an analysis plan onClinicalTrials.gov (NCT04344197).V. Bellato1,*, T. Konishi2,* ,G. Pellino3,4 , Y. An5, A. Piciocchi6,B. Sensi1, L. Siragusa1, K. Khanna7,B.M. Pirozzi1 , M. Franceschilli1,M. Campanelli1, S. Efetov8, G.S. Sica1and on behalf of S-COVIDCollaborative Group∗Vittoria Bellato and Tsuyoshi Konishicontributed equally to this work as theco-first authors.Contributors of ‘S-COVID CollaborativeGroup’ are listed in Supporting Information.1Department of Surgery, MinimallyInvasive Unit, Università degli Studi diRoma “Tor Vergata”, Rome, Italy,2Department of GastroenterologicalSurgery, Cancer Institute Hospital of theJapanese Foundation for Cancer Research,Tokyo, Japan, 3Department of AdvancedMedical and Surgical Sciences, Universitàdegli Studi della Campania “LuigiVanvitelli”, Naples, Italy, 4Department ofColorectal Surgery, Vall d’HebronUniversity Hospital, Barcelona, Spain,5Department of General Surgery, BeijingFriendship Hospital, Capital MedicalUniversity, Beijing, China, 6GIMEMAFoundation, Rome, Italy, 7Department ofOrthopaedic surgery, Rush universitymedical center, Chicago, IL,and 8Department of Surgery, I.M.Sechenov First Moscow State MedicalUniversity, Moscow, RussiaDOI: 10.1002/bjs.118001 COVIDSurg Collaborative. Globalguidance for surgical care during theCOVID-19 pandemic. Br J Surg 2020;https://doi.org/10.1002/bjs.11646[Epub ahead of print].2 Soreide K, Hallet J, Matthews JB,Schnitzbauer AA, Line PD, Lai PBSet al. Immediate and long-term impactof the COVID-19 pandemic on deliveryof surgical services. Br J Surg 2020;https://doi.org/10.1002/bjs.11670[Epub ahead of print].3 Spinelli A, Pellino G. COVID-19pandemic: perspectives on an unfoldingcrisis. Br J Surg 2020; https://doi.org/10.1002/bjs.11627 [Epub ahead ofprint].4 Di Marzo F, Sartelli M, Cennamo R,Toccafondi G, Coccolini F, La TorreG, et al. Recommendations for generalsurgery activities in a pandemic scena-rio (SARS-CoV-2). Br J Surg 2020;https://doi.org/10.1002/bjs.11652[Epub ahead of print].5 Mowbray NG, Ansell J, Horwood J,Cornish J, Rizkallah P, Parker A et al.Safe management of surgical smoke inthe age of COVID-19. Br J Surg 2020;https://doi.org/10.1002/bjs.11679[Epub ahead of print].6 Lei S, Jiang F, Su W, Chen C, Chen J,Mei W et al. Clinical characteristics andoutcomes of patients undergoing surge-ries during the incubation period ofCOVID-19 infection. EClinicalMedicine2020; https://doi.org/10.1016/j.eclinm.2020.100331b [Epub ahead of print].Supporting informationAdditional supporting informationcan be found online in theSupporting Information section atthe end of the article.© 2020 BJS Society Ltd www.bjs.co.uk BJS 2020; 107: e364–e365Published by John Wiley & Sons Ltd

Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic

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Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic

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