SYSTEMATIC REVIEW published: 07 May 2020 doi: 10.3389/fped.2020.00259 Management of COVID-19-Positive Pediatric Patients Undergoing Minimally Invasive Surgical Procedures: Systematic Review and Recommendations of the Board of European Society of Pediatric Endoscopic Surgeons Edited by: Alessio Pini Prato 1*, Andrea Conforti 2 , Markus Almstrom 3 , Wim Van Gemert 4 , Eugene S. Kim, Maria G. Scuderi 5 , Naziha Khen-Dunlop 6 , Isabela Draghici 7 , Mario Mendoza-Sagaon 8 , University of Southern California, Carlos Giné Prades 9 , Fabio Chiarenza 10 and Henri Steyaert 11 United States 1 Reviewed by: The Children Hospital, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy, 2 Department of Medical Tim Jancelewicz, and Surgical Neonatology, Ospedale Pediatrico Bambino Gesù, Rome, Italy, 3 Department of Pediatric Surgery, Astrid University of Tennessee Health Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden, 4 Department of Pediatric Surgery, Science Center (UTHSC), University Medical Center Maastricht, Maastricht, Netherlands, 5 Unit of Pediatric Surgery, Department GF Ingrassia, Hospital United States Policlinico, University of Catania, Catania, Italy, 6 University Hospital Necker-Enfants Malades, Paris, France, 7 Department of Christopher Gayer, Pediatric Surgery, Maria Sklodowska Curie Hospital for Children, Bucharest, Romania, 8 Department of Pediatric Surgery, University of Southern California, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland, 9 Digestive Pediatric Surgery, University Hospital Vall d’Hebron, United States Barcelona, Spain, 10 Division of Pediatric Surgery, San Bortolo Hospital, Vicenza, Italy, 11 Department of Pediatric Surgery, Queen Fabiola Children’s Hospital, University of Brussels, Brussels, Belgium *Correspondence: Alessio Pini Prato apini@ospedale.al.it; Introduction: Hospital response to the COVID-19 outbreak has involved the cancellation a.piniprato@gmail.com of elective, deferrable surgeries throughout Europe in order to ensure capacity for Specialty section: emergent surgery and a selection of elective but non-deferrable surgeries. The purpose This article was submitted to of this document is to propose technical strategies to assist the pediatric surgeons to Pediatric Surgery, a section of the journal minimize the potential aerosolization of viral particles in COVID-19 patients undergoing Frontiers in Pediatrics urgent or emergent surgical treatment using laparoscopic approaches, based on the Received: 05 April 2020 currently available literature. The situation and recommendations are subject to change Accepted: 27 April 2020 with emerging information. Published: 07 May 2020 Citation: Materials and Methods: The Scientific Committee and the Board of the European Pini Prato A, Conforti A, Almstrom M, Society of Pediatric Endoscopic Surgeons gathered together in order to address the Van Gemert W, Scuderi MG, Khen-Dunlop N, Draghici I, issue of minimally invasive surgery during this COVID-19 pandemic. A systematic Mendoza-Sagaon M, Giné Prades C, search through PubMed, Embase, and World Wide Web of the terms “COVID-19,” Chiarenza F and Steyaert H (2020) “Coronavirus,” and “SARS-CoV-2” matched with “pneumoperitoneum,” “laparoscopy,” Management of COVID-19-Positive Pediatric Patients Undergoing “thoracoscopy,” “retroperitoneoscopy,” and “surgery” was performed. Non-English Minimally Invasive Surgical language papers were excluded. A PRISMA report was performed. Criticalities were Procedures: Systematic Review and Recommendations of the Board of identified and a consensus was achieved over a number of key aspects. European Society of Pediatric Results: We identified 121 documents. A total of 11 full-text documents were assessed Endoscopic Surgeons. Front. Pediatr. 8:259. to address all concerns related to the adoption of minimally invasive surgery. All doi: 10.3389/fped.2020.00259 aspect of pediatric minimally invasive surgery, including elective surgery, urgent surgery, Frontiers in Pediatrics | www.frontiersin.org 1 May 2020 | Volume 8 | Article 259 Pini Prato et al. Pediatric Laparoscopy During COVID-19 Pandemic laparoscopy, thoracoscopy, retroperitoneoscopy, and pneumoperitoneum creation and maintainance were extensively addressed through systematic review. A consensus regarding urgent laparoscopic procedures, setting and operation techniques was obtained within the Committee and the Board. Conclusions: The ESPES proposes the following recommendations in case minimally invasive surgery is needed in a COVID-19 positive pediatric patients: (1) consider conservative treatment whenever safely possible, (2) dedicate a theater, columns and reusable laparoscopic instrumentation to COVID-19 pediatric patients, (3) prefer disposable instrumentation and cables, (4) use low CO2 insufflation pressures, (5) use low power electrocautery, (6) prefer closed-systems CO2 insufflation and desufflation systems, and (7) avoid leaks through ports. These recommendations are subject to change with emerging information and might be amended in the near future. Keywords: COVID 19, minimally invasive surgeries (MIS), pneumoperitoneum, safety, outbreak, pediatrics BACKGROUND The purpose of this document was to propose technical strategies to assist the pediatric surgeons to minimize the The World Health Organization (WHO) recommendations to potential aerosolization of viral particles in COVID-19 patients contain the coronavirus (COVID-19) outbreak include social undergoing urgent or emergent surgical treatment using distancing, avoidance of crowding and staying at home. Reducing laparoscopic approaches, based on the currently available the flow of people within countries also increases the likelihood literature. The situation and recommendations are subject to of successful infection control. Restrictions implemented in change with emerging information. Italy on the 7th of March 2020 included limitations on all personal activities. Similar limitations were implemented by other countries during the following weeks. METHODOLOGY Most hospitals have been involved in treatment of COVID-19 Systematic Literature Review patients. In areas where the virus outbreak has been particularly PubMed and Embase were searched for the terms severe, hospital infrastructure has been acutely remodeled to “COVID-19,” “Coronavirus,” and “SARS-CoV-2” matched enable the direction of resources toward the care of COVID-19 with “pneumoperitoneum,” “laparoscopy,” “thoracoscopy,” patients. The need to contain the outbreak, treat cases and protect “retroperitoneoscopy,” and “surgery” with all possible healthcare personnel have featured as prime considerations. combinations. Non-English language papers and documents In spite of this scenario, ordinary illnesses, trauma, and were excluded. diseases requiring surgery continue to prevail alongside COVID- 19. For reasons that are not yet understood, children appear to World Wide Web Search be less susceptible and generally the course of the disease is less Guidelines, recommendations or statements published by severe (1). scientific societies, including adult societies and their websites Hospital response to the outbreak has involved the were searched using a combination of the same terms as above. cancellation of elective, deferrable surgeries throughout Europe in order to ensure capacity for emergent surgery and a selection of elective but non-deferrable surgeries. This has been regarded Preferred Reporting Items for Systematic as essential to avoid the complications of time-dependent Reviews and Meta-Analyses (PRISMA) diseases in terms of survival and functional results. These This schematic methodology was used to report significant and have included certain pediatric liver conditions, malignancies, homogeneous results of the systematic review. congenital malformations, and functional disorders amongst other acute problems that cannot be postponed for a reasonable Identification of Criticalities amount of time to pass safely through the pandemic. The papers and documents extracted from the web were Patients suffering from these diseases will continue assessed with regard to indications on elective surgery, on urgent to be treated according to the COVID-19 infection and emergent surgery using laparoscopy, thoracoscopy, and prevention strategies of their local institutions. In procedures retroperitoneoscopy as well as on the risk of aerosolization during involving laparoscopy and thoracoscopy, the possibility CO2 insufflation with regard to these specific techniques. of viral contamination through aerosolization during carbon dioxide (CO2 ) insufflation and electrocautery Proposed Statement has been raised as a concern that is being closely Pediatric surgeons belonging to the Scientific Committee of the reviewed worldwide. European Society of Pediatric Endoscopic Surgeons proposed a Frontiers in Pediatrics | www.frontiersin.org 2 May 2020 | Volume 8 | Article 259 Pini Prato et al. Pediatric Laparoscopy During COVID-19 Pandemic TABLE 1 | List of papers included in systematic review (rows) and areas of assessment (columns). References Age Elective surgery Urgent surgery Laparoscopy CO2 insufflation Other aspects Spinelli and Pellino (2) Adults Only oncologic Indications for surgery Might be safer Better than open provided NA surgery unchanged closed system is used Repici et al. (3) Adults NA NA NA NA Guidelines for endoscopy Pellino and Spinelli (4) Adults Warns delays over NA NA NA NA 90 days Iacobucci (5) Adults Suspended for 3 NA NA NA NA months since 15th of April 2020 Wang and Du (6) NA NA NA NA Highest risk if aerosol NA spreading is confirmed Zheng et al. (7) Adults Only oncologic Emergencies and Allowed Careful aerosolization in NA surgery cancer surgery closed cavity with eletrocauthery Lee et al. (8) NA NA NA NA NA Consider swab test for patients and parents/visitors Wen and Li (9) NA Canceled Emergencies with NA NA Recommend negative specific considerations pressure theaters, anesthesia with paralysis and avoid preoxygenation BAPES (10) Children NA NA Feasible with care Be careful on aerosolized CO2 NA American College of Children Postponed List of urgent and NA NA NA Surgeons section of semi-urgent procedures Pediatric Surgery (11) American College of Adults Postponed List of deferrable urgent NA NA Surgeons (12) procedures Society of American Adults Postponed to the Emergencies and Allowed Keep CO2 insufflation NA Gastrointestinal and end of peak cancer surgery pressure low Endoscopic Surgeons (13) pandemic summary of the evidence and technical strategies for laparoscopic including malignancy, it was identified that delaying surgery procedures to assist pediatric surgeons during this pandemic. would negatively influence the outcome and these therefore represented urgent surgical patients (4). The only document RESULTS addressing time-dependent diseases in pediatric population is that from the American College of Surgeons that divided diseases PRISMA according to emergencies, semi-urgent diseases and elective One-hundred and 16 papers were identified through PubMed deferrable diseases (11). and 61 through Embase searches. A further seven documents regarding reccomendations or position statements from Urgent Surgery Scientific Societies worldwide were identified with a web search. This aspect was addressed by 3 papers (2, 7, 9) and 3 documents After duplicate removal, a total of 123 papers were screened for (11–13) that agreed that urgent surgery should be performed. relevance. A total of 12 full-text documents [8 peer-reviewed Given the high risk of surgery (both for the patients and for papers (2–9) and 5 documents (10–14)] were assessed and turned the medical personnel) in case of COVID-19-positive patients, out to be eligible to address all concerns related to the adoption the American College of Surgeons has recommended that of minimally invasive surgery (involving pneumoperitoneum, conservative management should be followed when it is safely prenumoretroperitoneum, or pneumothorax creation) in possible (12). As stated above, the American College of Surgeons pediatric patients (Table 1). See Figure 1 for PRISMA details. (section of Pediatric Surgery) also identified pediatric diseases requiring urgent, semi-urgent or elective surgery on an empirical Addressed Criticalities and Issues basis (11). Local institutional infection control policies for Elective Surgery surgical theaters in confirmed or suspected COVID-19 patients This aspect was addressed by 5 papers (2, 4, 5, 7, 9) and 3 should be followed. documents (11–13) that underlined that all elective procedures should be postponed. Iacobucci in particular, stated that UK Laparoscopy stopped all elective surgery of at least 3 months since 15th This aspect was addressed in detail by only 2 papers (2, of April 2020 thus postponing all elective procedures in the 7) and 2 documents (10, 13) and therefore the evidence second half of July 2020 (5). However, in certain circumstances, regarding laparoscopy was very limited and of low quality. Frontiers in Pediatrics | www.frontiersin.org 3 May 2020 | Volume 8 | Article 259 Pini Prato et al. Pediatric Laparoscopy During COVID-19 Pandemic FIGURE 1 | PRISMA module for systematic review. None contraindicated the use of laparoscopy in COVID-19- suggested that COVID-19 may transmit through aerosol directly positive patients, but all underlined a risk of aerosolization making prevention and control much more difficult (6). Based of viral particles during CO2 insufflation. This aspect was on this incertitude, all supported the use of the highest degree supported by a recent paper by Li and colleagues who reported of dedicated and adequate Personal Protection Equipment (PPE) a higher concentration of 0.3 and 0.5 µm particles in laparoscopy in order to contain the risk of contamination, according to local compared to laparotomy after 10 min of electrosurgical treatment institutional infection control policies for surgical theaters in (14). All papers supported the use of closed systems (i.e., confirmed or suspected COVID-19 patients. Stryker Pneumoclear Smoke Evacuation High Flow Tube R sets or ConMed Airseal R delivery system) and filters for CO2 evacuation. Zheng and co-workers suggested low pressure ESPES Consensus on Laparoscopic CO2 insufflation, low-power electrocautery use, minimize Procedures in Children During COVID-19 Trendelenburg and avoid leakage from trocar sites as much Outbreak as possible (7). Finally, the use of intracorporeal anastomoses Indications (Level of Agreement—High) has been advocated by some in order to minimize the risk of Whenever a COVID-19-positive patient can have their surgery dangerous fecal aerosolization (2). Particular concern is raised in safely delayed until the patient has fully recovered from the case of combined laparoscopic/endoscopic procedures as those infection, this should be preferred. In acute surgical conditions, required in case of symptomatic choledocholithiasis requiring if a conservative management (i.e., uncomplicated appendicitis) urgent surgery (3). Of note, Spinelli and colleagues suggested is safely possible and does not negate the outcome for the patient, that open surgery could be even worse in terms of contamination this should be considered. Ideally, patients should be tested for when diathermy, electrosurgery and ultrasonic sealing device are COVID-19 before procedures, if this is practically feasible. used (2). Setting (Level of Agreement—High) Thoracoscopy and Retroperitoneoscopy Dedicated theater facilities (including laparoscopic column None of the papers focused on this aspect in details. camera and cables) for suspected or confirmed COVID-19- positive patients should be arranged, if possible. Appropriate CO2 Insufflation filtering and ventilation are important, and negative pressure This aspect was addressed by 3 papers (2, 6, 7) and 2 documents rooms may also be useful. Unnecessary night-time operating (10, 13). All Authors suggested that the risk of aerosolization should be avoided in order to decrease the workload of was palpable. In particular, a paper by Wang and colleagues, anesthesiologists and nurses likely to be needed to reinforce based on a peculiar transmission modality reported in Mongolia, adult teams. Frontiers in Pediatrics | www.frontiersin.org 4 May 2020 | Volume 8 | Article 259 Pini Prato et al. Pediatric Laparoscopy During COVID-19 Pandemic Procedure and Operation Technique (Level of the translation of these considerations to COVID-19 setting is Agreement—High) over-reaching and should be avoided. As time being there is In case of thoracoscopy, retroperitoneoscopy, or laparoscopy we lack of strong scientific evidences on which to support one recommend, whenever possible: approach over the other. As a matter of facts, we can provide recommendations based on reasonable hypothesis, common • Dedicate to COVID-19-positive patients a laparoscopic sense, and shared feelings. Based on these limitations, we strongly column (see above) suggest Institutions and Scientific Societies keep monitoring • Maintain low pressure CO2 and/or use of emerging evidence. suspension techniques The choice of approach, whether laparoscopic or open should • Keep power settings of electrocautery as low as possible be based on careful consideration of the balance between the • Use disposable insufflation cables with high-capacity filters benefits and risks specific to the procedure, and the risk of viral • Use customized or commercially available closed CO2 contamination/aerosolization to the staff. The proven benefits of evacuation systems with filters minimally invasive surgery in certain procedures (i.e., reduced • Avoid leaks through trocar length of stay and complications) should be considered, as well • Avoid the use of trocars without valves as the capacity for ultrafiltration of any aerosolized particles that • Favor the use of disposable trocars, best if with sealing balloons may also pose a similar or greater risk if an open approach is • Prefer staplers instead of loops (appendectomy) to minimize adopted (2, 3, 6, 7, 9). the risk of leaks through the ports • Use disposable trocars in the context of a COVID-19-positive patient, if available. If reusable trocars are used, they should be CONCLUSIONS cleaned separately from other surgical equipment As a summary, as pediatric surgeons belonging to the European • Aspiration of the residual CO2 at the end of the operation in a Society of Pediatric Endoscopic Surgeons (ESPES) we suggest closed system with filters. the following concerning laparoscopic, thoracoscopic, and Strict use of PPE and infection prevention strategies as for retroperitoneoscopic procedures in COVID-19 positive patients: conventional open surgery and anesthesia for aerosol producing • Dedicate a theater to perform urgent procedures, avoid maneuvers should be followed. It is strongly recommended to unnecessary night-time operating follow the guidelines for droplet and airborne precautions of local • Consider conservative treatments, whenever safely possible institutions. This is particularly true for airway and endoscopic • Dedicate minimally invasive columns and procedures. For specific detailed guidelines we recommend reusable instrumentation WHO as well as local institutional guidelines. • Prefer disposable instrumentation and cables • Use low-pressure CO2 insufflation DISCUSSION • Use low-power electrocautery • Prefer closed-systems CO2 insufflation and In order to contain COVID-19 outbreak and to support the desufflation systems requirements of various European Health Systems in order to • Avoid leaks through ports (valved and/or balloon ports, small deal with this dramatic pandemic, it is necessary to adhere to a skin incisions). number of indications that apply to pediatric surgery and have been addressed by most governments. The aims of this document are to provide optimal patient care, maintain safety for all perioperative staff, and, as much as 1. Postpone all elective surgery according to institutional or possible, help contain the COVID-19 pandemic. The situation local guidelines and recommendations are subject to change with emerging 2. Consider a number of time-dependent diseases requiring information and might be amended in the near future. elective non-deferrable surgery 3. Prepare to encounter COVID-19-positive patients requiring urgent surgical treatment. DATA AVAILABILITY STATEMENT On the ground of these considerations, it is likely that a number The original contributions presented in the study are included of COVID-19-positive pediatric patients will require some sort in the article/supplementary materials, further inquiries can be of urgent surgical treatment. For this aspect, institutions will directed to the corresponding author/s. need to set procedures and protocols in order to be prepared to cope with all critical issues. Of note, some papers addressed AUTHOR CONTRIBUTIONS the issue of viral spreading during CO2 pneumoperitoneum creation during laparoscopy in case of Hepatitis (15) or Human AP performed the Systematic Review. AP, AC, MA, and Immunodeficiency Viruses (16), both in adults and children. WV drafted the paper. MS, NK-D, ID, MM-S, CG, FC, and They found laparoscopy to be safe, even safer than conventional HS reviewed the draft and contributed to the consensus. laparotomy. Nonetheless, as those viruses are not transmitted All authors reviewed and approved the final version of by droplets nor aerosolization (they are not respiratory viruses), the manuscript. Frontiers in Pediatrics | www.frontiersin.org 5 May 2020 | Volume 8 | Article 259 Pini Prato et al. Pediatric Laparoscopy During COVID-19 Pandemic REFERENCES facs.org/-/media/files/COVID19/guidance_for_triage_of_nonemergent_ surgical_procedures_pediatric.ashx 1. Ludvigsson JF. Systematic review of COVID-19 in children shows milder 12. American College of Surgeons. COVID 19: Elective Case Triage Guidelines for cases and a better prognosis than adults. Acta Paediatr. (2020) p. 1– Surgical Care. Emergency General Surgery. (2020). Available online at: https:// 8. doi: 10.1111/apa.15270 www.facs.org/COVID-19/clinical-guidance/elective-case/emergency- 2. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding surgery crisis. Br J Surg. (2020). doi: 10.1002/bjs.11627. [Epub ahead of print]. 13. SAGES and EAES Recommendations Regarding Surgical Response to 3. Repici A, Maselli R, Colombo M, Gabbiadini R, Spadaccini M, Anderloni A, COVID-19 Crisis. (2020). Available online at: https://www.sages.org/ et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy recommendations-surgical-response-COVID-19/ should know. Gastrointest Endosc. (2020). doi: 10.1016/j.gie.2020.03.019. 14. Li CI, Pai JY, Chen CH. Characterization of smoke generated during [Epub ahead of print]. the use of surgical knife in laparotomy surgeries. J Air Waste 4. Pellino G, Spinelli A. How COVID-19 outbreak is impacting colorectal Manage Assoc. (2020) 70:324–32. doi: 10.1080/10962247.2020.17 cancer patients in Italy: a long shadow beyond infection. Dis Colon Rectum. 17675 (2020). doi: 10.1097/DCR.0000000000001685. [Epub ahead of print]. 15. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B 5. Iacobucci G. COVID-19: all non-urgent elective surgery is virus in surgical smoke emitted during laparoscopic surgery. suspended for at least three months in England. BMJ. (2020) Occup Environ Med. (2016) 73:857–63. doi: 10.1136/oemed-2016-1 368:m1106. doi: 10.1136/bmj.m1106 03724 6. Wang J, Du G. COVID-19 may transmit through aerosol. Iran J Med Sci. 16. Banieghbal B. Minimally invasive surgery for children with HIV/AIDS. (2020). doi: 10.1007/s11845-020-02218-2 J Laparoendosc Adv Surg Tech A. (2009) 19:97–101. doi: 10.1089/lap. 7. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel 2008.0097 coronavirus outbreak: lessons learned in China and Italy. Ann Surg. (2020). doi: 10.1097/SLA.0000000000003924. [Epub ahead of print]. Conflict of Interest: The authors declare that the research was conducted in the 8. Lee IK, Wang CC, Lin MC, Kung CT, Lan KC, Lee CT. Effective strategies to absence of any commercial or financial relationships that could be construed as a prevent coronavirus disease-2019 (COVID-19) outbreak in hospital. J Hosp potential conflict of interest. Infect. (2020). doi: 10.1016/j.jhin.2020.02.022 9. Wen X, Li Y. Anesthesia procedure of emergency operation for Copyright © 2020 Pini Prato, Conforti, Almstrom, Van Gemert, Scuderi, Khen- patients with suspected or confirmed COVID-19. Surg Infect. (2020) Dunlop, Draghici, Mendoza-Sagaon, Giné Prades, Chiarenza and Steyaert. This is an 21:299. doi: 10.1089/sur.2020.040 open-access article distributed under the terms of the Creative Commons Attribution 10. BAPES statement. Available online at: https://static1.squarespace.com/static/ License (CC BY). The use, distribution or reproduction in other forums is permitted, 5c547dd3d7819e06b90a19ae/t/5e77f0e555c6b75f308db801/1584918761408/ provided the original author(s) and the copyright owner(s) are credited and that the BAPES$+$COVID19$+$2203.pdf original publication in this journal is cited, in accordance with accepted academic 11. American College of Surgeons. COVID 19: Elective Case Triage Guidelines practice. No use, distribution or reproduction is permitted which does not comply for Surgical Care. Pediatric Surgery. (2020). Available online at: https://www. with these terms. Frontiers in Pediatrics | www.frontiersin.org 6 May 2020 | Volume 8 | Article 259