Introduction: The COVID 19 pandemic has had a significant impact on surgical practice. This study aimed to capture all the changes suggested through advice and guidelines from professional organisations and understand how that has translated into day-to-day practice, as well understanding how patients were screened prior to surgery and the availability of PPE and mental health support.
Methods: An online questionnaire was sent to general surgeons via twitter, which then also sent three weeks later to members of ALSGBI to determine if there was any change in practice in the period of time.
Results: There were 158 responses to the initial twitter distribution and a further 44 responses from members of ALSGBI three weeks later. The majority of responders were consultants (50.5%). Of those that responded 60.8% were still performing urgent cancer procedures with 70.6% performing open surgery and 67.82% avoiding laparoscopic procedures, 92% of responders have managed appendicitis conservatively. Initially, only 45.54% responders indicated patients were being screened with swabs and radiographs in their organisation, this increased to 100% in the second group surveyed. 90.59% of respondents had appropriate PPE, however only 50% of responders had access to emotional or mental health support.
Conclusion: Availability of PPE for surgical teams has been high during this pandemic and should remain a priority as should increasing emotional support for front-line workers. The volume of surgical procedures has reduced and there has been a move to treat some surgical pathologies conservatively which should be monitored closely as this may inform future practice.

• Pandemic; COVID-19; Surgery; Mental Health; Guidelines

Thomas Herron JB, Ross E, Sandhu A, Brown A, Gilliam AD (2020) The Effect of COVID-19 Pandemic on UK General Surgical Practice. Arch Emerg Med Crit Care 4(1): 1047.

PPE: Personal Protective Equipment; RCS: Royal College of Surgeons of England; ALSGBI: Association of Laparoscopic Surgeons Great Britain and Ireland; SAGES: Society of American
Gastrointestinal and Endoscopic Surgeons; EAES: European Association for Endoscopic Surgery; ACPGBI: Association of Coloproctology of Great Britain and Ireland; CXR: Chest X-ray; CT:
Computer Tomography; AGP: Aerosol Generating Procedures; FIT: Faecal Immunochemical Test; ULPA: Ultra-low Particulate Air; AGE: Aerosol Generating Event

A novel strain of coronavirus (SARS-CoV-2) emerged from the Chinese region Wuhan in December 2019. With widespread transmission globally, the COVID 19 (Sars-CoV-2), pandemic is the biggest emergent public health threat since the Spanish flu [1]. There has already been changes in surgical practice with cancellation of elective surgery, reduction in NHS staff from sickness, shielding and self-isolation, reintroduction of retired healthcare professionals and redeployment of resources [2]. Surgical practice change guidance was designed to reduce viral exposure to the patient, healthcare workers and preserve the resilience of NHS resources. The introduction of additional personal protective equipment (PPE) [3], increases the interplay of human factors and thus the potential for mistakes [4]. There has been much publicity about PPE and its availability [3], however surgeons also have theatre instruments that can give additional protection such as Airseal© and diathermy with smoke evacuators among others [5], to reduce exposure to aerosolised virus. Many recommendations and guidelines have been published advising surgeons on how to prepare and reduce error4, which patients requires surgery and how the operation should be performed. This includes guidance from the Royal College of Surgeons of England (RCS) [6], Association of Laparoscopic Surgeons Great Britain and Ireland (ALSGBI) [7], the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) [8], European Association for Endoscopic Surgery (EAES) [9], the Association of Coloproctology of Great Britain and Ireland (ACPGBI) [10], and local guidance. Another looming crisis is the mental health burden which could cause psychological distress [11]. This paper aims to give a snap-shot of UK practice early in the COVID 19 pandemic and highlight any developments in practice over time as guidance changes.

A Survey Monkey® questionnaire consisting of ten questions (Table 1), was developed and sent to surgeons across Twitter® (13/04/2020), and after a three-week period (04/05/2020) to the ALSGBI™ membership via email to assess if there was any change in practice over time. Each participant was asked to only complete the questionnaire if they worked in the UK or Northern Ireland. Any participants who replied from outside the defined regions were excluded. Each question could only be answered once. Participation in the survey implied consent and the proforma was derived from the current guidance and research discussed below. All responses were anonymous.

There were 158 responses from those who received the questionnaire via Twitter®, and a further 44 responses three weeks later from the ALSGBI network taking the overall response total to 202. Figure 1 shows the breakdown of respondents by region. Others included 9 respondents from London, 1 from East of England and 1 from Kent. Of the respondents 50.50% (102), were Consultant grade, 31.68% (64), Specialist Trainees, 6.93% (14), Core Trainees and 10.89% (22), were Trust Grade, Associate Specialists or Fellows. 68.32% (138), were still performing urgent cancer work. Of the 31.68% (64), surgeons not performing Urgent Cancer work 31 were consultants, 22 Specialist registrars, 3 were core trainees and 8 were Trust Grade, Associate Specialists or Fellows. Regionally 4 were in the South East, 25 in the Northern/ Yorkshire, 3 in Wales, 5 in Scotland, 8 in the Midlands, 8 in the Northwest, 6 in the South West, 2 in Northern Ireland, 1 in Kent, 1 in East of England and 1 in London which spanned all regions. There was no difference in the percentage of respondents over the time span performing urgent cancer operations.

Figure 1: Graph detailing the regions of the respondents in the UK 

When screening patients for COVID 19 prior to urgent cancer surgery 4.9% (10), were screened with imaging only, 15.35% (31), with swabs only, and 45.54% (92), had both imaging and swabs taken. 34.16% (69), selected N/A. Surgeons initially started to choose N/A, Imaging only or Swabs only in the first respondents, in the second cohort 100% responded both imaging and swabs or N/A.

The vast majority of surgeons performed open surgery (76.24%), with 67.82% (137), avoiding laparoscopy in favour of open approach, 8.42% (17), still predominantly performed open
surgery, 21.78% (44), still predominantly laparoscopic surgery and 1.98% (4), avoiding open surgery in favour of a laparoscopic approach (Figure 2).

Figure 2: A graph demonstrating how surgeons’ operative approach has changed with COVID 19.

The guidelines surgeons used were predominately the RCS and local guidelines. This question could have multiple answers however 80.20% (162) used RCS, 57.43% (116), used local guidance, 23.27% (47), used SAGES, 21.29% (43), ACPGBI, 18.81% (38), used ALSGBI (these results came exclusively from the ALSGBI membership), 6.93% (14), EAES and 2.97% (6), as other. Other answers included 1 evidence from Italy, 2 Public Health England, 1 Vascular society, 1 Northern Cancer Alliance and 1 Association of Breast Surgery (Figure 3).

Figure 3: Graph demonstrating which guidelines UK surgeons used.

90.59% (183) [X2 265.585, P < 0.0001] of surgeons had good access to PPE in theatre. 9.41% (19), of surgeons had inadequate access to PPE, every region in the UK was represented in this
cohort, except Northern Ireland where the sample size may have been too small. This improved as the weeks progressed.

Surgeons that only had access to an Airseal© or alternative represented 27.23% (55), of those surveyed, 56.93% (115), had only access to diathermy with built in smoke evacuator, 5.94%
(12), had access to both and 9.90% (20), had no access to a special device. London, Wales and Northern Ireland were not represented in those with no additional special devices.

The majority of surgeons 92.08% (186), [X2 285.441, P < 0.0001), tried to manage appendicitis and cholecystitis conservatively. 7.92% (16), were not managing patients conservatively and this represents all regions except Northern Ireland, Wales and Midlands. This has not changed over time significantly.

Only 51.49% (104), of participants had access to local emotional/mental health support. Of the 48.51% (98) respondents with no emotional/mental health support, there was no indication that surgeons from London or Northern Ireland were receiving any local emotional/mental health support. Across the other regions the figures were proportionately distributed.

There has been a significant mortality in both patients [12], and in healthcare professionals [3]. In order to protect patients and staff multiple guidelines were published throughout the pandemic. New information about the virus is being released regularly and surgical guidelines have been updated in order to incorporate this new knowledge and improve patient and staff safety. Many of the early guidelines has methodological weakness and neglected vulnerable groups [13]. A summary timeline of the release of the guidance is found in Table 2.

Table 2: showing the timing of the release of the guidance from various sources.

On 26/03/2020 the RCS developed a joint statement in which they advised that patients should undergo testing for COVID 19 and have a chest x-ray (CXR). For patients undergoing an abdominal computer tomography (CT), they advised a chest CT should also be obtained at the same time unless one had already been done within the previous 24-hours. They advised stoma formation to prevent complications of an anastomosis and that laparoscopy should only be considered in selected cases due to the risk of aerosol transmission of the virus [6]. Non-operative management of appendicitis and cholecystitis should be implemented where possible, and only emergency endoscopies should be considered. On 11/04/2020 the RCS released a joint statement with other Royal Colleges and the NHS giving a comprehensive breakdown of prioritisations of surgical treatment timelines, including cancer. In this statement they did not recommend either laparoscopic or open surgery [14]. This is the most comprehensive of the guidance and the guidance adopted by 80.20% of surgeons.

On the 26/03/2020, ACPGBI released a statement advising colonic stenting as a bridging therapy for obstructing cancers with a view of delayed resection, and radiological drainage of
contained perforation [10]. The statement continued that risk benefit discussions should take place regarding commencing chemotherapy and resection of metastatic cancers, with the latter only offered to those with the best chance of survival. It is known there is a low yield of confirmed cancer diagnosis of around 3-4% from the current urgent referral system [10]. With this in mind,
and the risk of viral transmission during aerosol generating procedures (AGP), the ACPGBI advised on the 09/04/2020 that only therapeutic emergency and essential endoscopy is carried out. Virtual colonoscopy was only advised if there was explicit agreement with all stakeholders and the capacity existed to continue this service [10]. They advised that delaying low risk cancer patients would be in the patient’s best interest, and suggested allowing only urgent patients with a high clinical suspicion of cancer to be seen using faecal immunochemical test (FIT) testing to assist with risk assessment. For high risk patients they suggested urgent CT abdomen and pelvis as the investigation of choice with supplementary CT chest (Figure 4).

Figure 4: Image showing the ACPGBI referral pathway

ALSGBI released a position statement on 22/04/2020 advising routine COVID 19 testing, and laparoscopic procedures to be carried out by senior laparoscopic trained surgeons in order to reduce potential aerosolisation [7]. A closed-circuit smoke evacuation / ultra-low particulate air (ULPA), filtration system was recommended for routine use, with technical handling and
insertion of port sites to minimise any risk. A low insufflation pressure (12mmHg or less), with a contained extraction system and minimal use of energy devices was also recommended, and routine closed evacuation of all gas at the end of procedure, prior to specimen & port removal was also suggested [7].

SAGES have released recommendations on the 11/04/2020 8 introducing a tier system to cancers and a ‘3 month rule’ indicating a delay for any cancers that would be unlikely to spread
by 3 months. SAGES recommendations encourage consideration to the individual patient with regards to laparoscopic surgery, outlining both risks and benefits over open surgery and based on resources, without coming to any conclusion of which was best. They highlight electrocautery as an Aerosol Generating Event (AGE). Testing prior to surgery is endorsed but imaging is not
mentioned. Much of this guidance is based on the similar EAES published guidelines for surgeons released on the 30/03/2020 [9]. This was reflected in their joint position statement [14].

The evidence for conservative management of uncomplicated appendicitis is growing, and it is now considered entirely reasonable to try antibiotic therapy rather than surgery in both adults [15], and children [16]. The conservative management of cholecystitis is also an accepted treatment strategy. Up to 87% of all cases can be successfully treated conservatively [17], and this number increases to 96% in mild disease. As with all surgery, the key factor is appropriate patient selection for surgical management. Whilst not all cases can be managed conservatively, there can be a significant reduction in those going on to require surgical intervention, an important consideration as no COVID 19 vaccine exists.

Laparoscopic surgery poses a theoretical risk to surgeons as an AGE [18], however this has yet to be proven. There is evidence to suggest that laparoscopic surgery may actually be safer than open surgery [19]. With the knowledge that level 3 PPE gives up to 99.5% protection against the virus when aerosolised3, were there to be any penetration of the PPE, the infective load would be
lower which has been linked to a reduced severity of the disease [20]. Airseal© can filter down to 0.01μm and maintains a closedcircuit insufflation, and a smoke evacuator device can be used at
the end of surgery to reduce risk. During OPERATION GRITROCK (Humanitarian assistance to the Ebola epidemic Sierra Leone 2014–2015), the British Military measures to prevent the spread
of Ebola were very successful, with only one UK armed forces medical personnel contracting Ebola [21]. These included a PPE supervisor, strict training prior to deployment and adhering
stringently to donning and doffing protocols.

By drawing on lessons learned from the military, paying careful attention to human factors and employing the correct PPE, laparoscopic surgery may be more beneficial than open surgery to both patients and staff. As this study has shown most surgeons (90.59%), have access to PPE in theatre, it is suggested that laparoscopic surgery should be the surgery of choice.

Chest radiographs have been shown to be more sensitive than a COVID 19 rRT-PCR swab [22]. Pre-trained ResNet50 model combined with a chest radiograph demonstrated up to 98%
accuracy in diagnosis. This is particularly important when there is a shortage of COVID 19 rRT-PCR swabs. Chest CT has been shown have a sensitivity of 67-97% and specificity 93-100% for COVID
19 [23]. Chest CT can also show improvement before a PT-PCR swab will turn negative [24]. The rRT-PCR swabs can take up to 48 hours to return and are around 70% sensitive [25]. rRT-PCR remains the gold standard however as there have been incidences of rRT-PCR positive patient with negative chest CT images [26]. An even higher standard of practice would be the combination
of high-resolution imaging and swabs. However, with the limited availability of swabs initially, and the contamination of radiology departments, a case for single modality of screening could be made. This seems to have been the trend as imaging and swabs tended to be used as time progressed through the study. 

It is known that healthcare staff are likely to suffer from mental health issues due to ‘moral injury’ as demonstrated in pandemic medicine [27], and in military practice [28]. Although national support is available to everyone, local support is needed to reduce avoidance and ultimately mental health injury or illness. With one in five healthcare professionals more likely to quit after the pandemic due to mental health issues this must be addressed as a matter of urgency [29]. The military have used OPSMART (Optimising Performance through Stress Management and Resilience Training), the Army’s mental health resilience program [30], to good effect and there are lessons that can be applied to NHS practice with many others identified including engagement of healthcare managers early [27]. Ways to identify those who are likely to suffer from mental health issues need to be implemented, such as the military’s Trauma Risk Management (TRIM) and other resilience factors [28]. This study has identified that 48.51% of surgeons have no local mental health support and presents an opportunity for regain before injury translates to illness.

There has been no change in surgical approach between the two study periods, however, surgeons cite the ALSGBI guidelines as their reference but this practice is not reflected. There has been an increase in both radiographic imaging and swabs which may reflect an increase in resources. This also highlights the importance of getting the guidance correct first time, with agreements from all stakeholders, in a joint position statement as practice is more difficult to change once routine is established. 

Some limitations include the sample sizes in some regions are particularly small and may not reflect their practice, however, lack of response could also be due to an outlier position with regards to PPE or testing. Conversely, the high respondent rate from the North East may represent the authors twitter network. There are a limited number of core trainees represented in the results, however this could be because many have been redeployed as part of the COVID 19 response. The study did not indicate how many cancer surgeries, if any. Surgeons who were not performing cancer surgeries prior to the pandemic may feel a perceived lack of relativity and fail to submit answers. There was no option available to surgeons who did not screen for COVID 19 and the questionnaire assumed that all patients had at least some form of screening. The study did not address the reasons why surgeons chose to perform a particular type of screening and if this was limited by resources or directed by their local organisation. The study did not examine how often surgeons reviewed guidance statements or if evidence is independently reviewed and decisions made based on risk and resources.

As the vast majority of surgeons have access to PPE in theatre, laparoscopic surgery may present a more beneficial approach compared to open because of its reduced recovery time in hospital and decreased impairment of respiratory function postoperatively. Mental health of all staff must be made a priority and rapid regains may prevent progression through stages of mental illness and promote recovery. Guidelines should have early consensus and change as little as possible unless new information requires a change, as practice is slow to change. Delay in cancer surgery is appropriate during the peak of the pandemic and will require a catch-up period, however conservative management of other pathologies could represent a new change in practice for the future. PPE availability must remain a priority with ALL staff having access to the required level 3 standard, and planning for any future pandemic requirements should be revisited and appropriate lessons-learned measures implemented.

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