Surgical Endoscopy (2021) 35:1–17 and Other Interventional Techniques https://doi.org/10.1007/s00464-020-08131-0 EAES RECOMMENDATIONS EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID‑19 Pandemic Alberto Arezzo1 · Nader Francis2,3 · Yoav Mintz4 · Michel Adamina5,6 · Stavros A. Antoniou7,8 · Nicole Bouvy9 · Catalin Copaescu10 · Nicolò de Manzini11 · Nicola Di Lorenzo12 · Salvador Morales‑Conde13 · Beat P. Müller‑Stich14 · Felix Nickel14 · Dorin Popa15 · Diana Tait16 · Cenydd Thomas17 · Susan Nimmo18 · Dimitrios Paraskevis19 · Andrea Pietrabissa20 · The EAES Group of Experts for Recovery Amid COVID-19 Pandemic Received: 26 September 2020 / Accepted: 22 October 2020 / Published online: 10 November 2020 © The Author(s) 2020 Abstract Background COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems. Keywords COVID-19 · Delphi consensus · EAES guidance · Priority · Minimally invasive surgery The rapid spread of the coronavirus disease 2019 (COVID- practice was forced to rapidly decrease or even put on hold 19) presents an unprecedented crisis to the surgical commu- completely. As a consequence, there is a backlog of patients nity globally [1, 2]. During the pandemic, elective surgical requiring surgical services but with limited human and insti- tutional resources [3–8]. While health care systems are calling to resume elective The members of the EAES group of experts for Recovery surgical practice where pandemic is under control [1, 2], amid COVID-19 pandemic have been included in the uncertainty remains about the duration of the pandemic, the Acknowledgements Section. possibility of a second wave and the extent of its conse- Electronic supplementary material The online version of this quences on surgical services and patients [9, 10]. This leaves article (https​://doi.org/10.1007/s0046​4-020-08131​-0) contains the surgical community with unanswered clinical questions supplementary material, which is available to authorized users. on patient and staff safety. Various guidelines and recommendations have been pub- * Alberto Arezzo alberto.arezzo@unito.it lished on issues pertaining to adapting surgical practice dur- ing the pandemic, often with conflicting recommendations, Extended author information available on the last page of the article 13 Vol.:(0123456789) 2 Surgical Endoscopy (2021) 35:1–17 whereas many may not have been based on research evi- required. The steps of the consensus process are outlined dence [11–14]. Preliminary guidelines recommended against below. performing laparoscopic surgery to avoid putative risks of SARS-CoV2 transmission via aerosolization due to pneu- Identification of domains and formulation moperitoneum but were later revised recommending lapa- of questions roscopic surgery under restrictions [15]. Several subsequent guidelines did not recommend against laparoscopic surgery; The clinical questions were divided into eight domains: (i) however, they advised strict precautions such as closed cir- general (ii) Hepatobiliary & Pancreatic (HPB), (iii) Bariat- cuit smoke evacuation and the use of filtering system and rics (B), (iv) Abdominal Wall (AW), (v) Endocrine (E), (vi) personal protective equipment (PPE) [16–19]. The role of Upper Gastrointestinal (UGI), (vii) Lower Gastrointestinal MIS has been argued to be more favourable in SARS-CoV-2 (LGI), (viii) technology and research. Domains (ii) to (vii) positive patients, as the potential benefits of MIS might were divided into two subdomains: emergency and elective. exceed the risk of pneumoperitoneum on cardiovascular and respiratory systems [20]. Identification of experts to address questions Furthermore, there is substantial uncertainty with regard to specific questions related to laparoscopic procedures, and Fifty-Five out of EAES board members accepted the task to structured guidance pertinent to MIS procedures is lacking. contribute to this project and were divided into eight sub- There is an urgent need for practice-based recommendations groups organized by the domain topics and led by a desig- in specific clinical situations with regard to safety precau- nated chair (Table 1). In addition, key stakeholders were tions for patients and staff amidst the COVID-19 pandemic invited to provide expert input into the multidisciplinary [21]. aspects of this project including anaesthesiology, radiology The purpose of this EAES initiative was to generate an and oncology and were allocated to a relevant group, based updated and comprehensive set of management recommen- on their expertise. dations for MIS for each subspeciality of general surgery. This consensus was also designed to document the broader Search methods and inclusion criteria experts’ opinion on how to optimize the use of human and institutional resources including the use of MIS techniques Based on the research questions, a literature search was for patient benefit. designed and performed by two independent EAES experts (AA, NF). The PubMed and Embase databases were queried for articles published before May 10th, 2020. Inclusion cri- Methods teria were systematic and narrative reviews, commentaries, randomized clinical trials, cohort studies and case series on A steering group (SG) was formed comprising of six experts the subject of surgery during the COVID-19 and other pan- from the EAES Executive Board (AA, NF, YM, SM, DP and demic published in the English language. Search syntaxes AP) who organized the project and guided the data synthe- used was (COVID OR ‘SARS CoV 2′ OR coronavirus AND sis. IRB approval and informed written consent were not surgery). Table 1  Expert group members and topic allocations Topic Leader Experts General introduction Catalin CopaescuEmina Letić, Silviu Daniel Preda, Alice Tsai, Ewelina Malanowska, Dusan Lesko, Wlodzimierz Majewski, Ludovica Baldari Hepatobiliary Nicolò de Manzini Luca Morelli, Andreas Shamiyeh, Gil Faria Bariatrics Nicola Di Lorenzo Francesco Maria Carrano, Piotr Mysliwiec, Gunnar Ahlberg Abdominal Wall Stavros Antoniou Elisa Cassinotti, Samir Delibegović, Lubomír Martinek Endocrine Nicole Bouvy Eugenia Yiannakopoulou, Marguerite Gorter-Stam, Hendrik Jaap Bonjer Upper GI Beat P. Müller- George Hanna, Hans Fuchs, Miloš Bjelovic, Sheraz Markar, Philip Wai Yan, Chiu, Bang Wool Stich Eom, Young-Woo Kim, Carmen Balagué Ponz, Marlies Schijven Lower GI Michel Adamina Luigi Boni, Thomas Carus, George Theodoropoulos, Antonello Forgione, Marco Milone, Wanda Luisa Rita Petz, Predag Andrejevic, Dejan Ignjatovic, Thanjakumar Arulampalam, Kenneth Campbell, Manish Chand, Mark Coleman, Christos Kontovounisios Technology & Research Felix Nickel Chen Sagiv, Fanny Ficuciello, Stefania Marconi, Pietro Mascagni, Kiyokazu Nakajima, Francisco Miguel Sánchez Margallo, Tim Horeman, George Mylonas, Pietro Valdastri 13 Surgical Endoscopy (2021) 35:1–17 3 Formulation of questions and statements Results Questions were drafted and submitted to the steering group, Ninety-two statements were generated by the subgroups which approved them prior to sending them to the subgroups across the eight topics. The full text literature analyses and to formulate statements in response to these questions. State- references used to generate statements and recommendations ments were generated by each subgroup in each topic question for all topics are included as Appendix 1. of their domain. Each group was advised to include any avail- Eighty-four out of 92 statements (91%) were approved able evidence to support their statements and when evidence in the first round and further 8 modified statements were was not available, experts’ opinion was considered. Each group approved in the second round. conducted a literature research and drafted statements and rec- Overall, the Delphi process approved 92 statements ommendations in response to their research questions. The (100%) for the consensus guidelines. The questions, final literature review was reported in accordance with PRISMA recommendations and respective approval rates in each statement standards for systematic reviews and meta-analyses step of the Delphi processes are summarized in Table 2. [22]. Statements were then submitted to the steering group Initial disagreement was regarded priorities depending (SG) who did not participate in the formulation of these state- on local resources, the use of energy dissection devices and ments or in the voting process. After structural editing by the the risk of aerosolization, the indication for stenting for SG group, all questions were unanimously approved by all obstructed colorectal cancer, the indication of laparoscopic experts (Table 1). lavage for diverticular disease, the indication of neoadjuvant treatment for early rectal cancer in order to postpone surgery, Voting and data analysis the management of undiagnosed pancreatic lesions, the indi- cation for intragastric balloons to postpone bariatric surgery The statements received from each subgroup of experts was and the indication for endoscopic therapies for achalasia and compiled by the SG and a modified Delphi methodology pro- reflux disease to postpone surgery. cess was followed to reach agreement among all the experts on all statements and recommendations [23]. EAES board members voted to declare agreement or disa- greement with the statements using closed-ended questions Discussion (agree or disagree), whereas there was an option to submit free text comments. The Delphi process was implemented through The study achieved its objective of formulating EAES the SurveyMonkey electronic platform (https​://nl.surve​ymonk​ evidence-based recommendations to provide guidance ey.com). To reduce the possibility of bias among participants, on the resumption of MIS across various general surgery the authors of the statements and the resultant votes/comments specialities, taking into account the serious burden on our remained anonymous. Each statement was subjected to live healthcare systems caused by the COVID-19 pandemic. voting by all experts including key stakeholders and excluding These statements provided descriptive safety guidance the steering committee. measures that should be undertaken in the recovery plan Consensus was achieved when a statement reached at least for elective and emergency surgery across all subspecial- 70% expert agreement. Statements with less than 70% agree- ties with specific measures for MIS. ment in the first round were returned to the expert subgroup In a recent survey, over 28 million patients are awaiting who modified them according to the comments. The sub- treatment worldwide, a number which continues to grow groups had the option to revise statements based on feedback in the setting of new restrictions on delivery of care and a for further voting. pandemic that is still evolving [24]. As this progression is The results of the consensus are summarized using descrip- expected to continue, and given the uncertainty about the tive statistics. The manuscript was then drafted with the rec- ongoing pandemic, adaptive changes are required in pro- ommendations following completion of all voting and state- cedure-based specialties to include safety, logistic, service ment formulation and sent to all members for revision, input relocation, economic and ethical considerations [25–30]. and approval prior to submission for publication. Through this project, consensus was achieved on all the proposed statements by the expert across the differ- ent domains, providing specific guidance on how to safely resume MIS and implement adaptive changes in procedure specific manner. This project adhered to Delphi principles dictating anonymous voting. The selection of the steering group 13 4 Table 2  Questions and statements Topics Questions Statement 1st round % 2nd YES round % 13 YES Introductory questions 1. What are the appropriate measures to mitigate the risks of 1. All patients requiring surgery under general anaesthesia should 79% general anaesthesia in patients during COVID- 19 pandemic? be tested for COVID-19 by means of RT-PCR Patient safety a. Asymptomatic 2. In case of PCR testing not available, imaging modalities such 90% b. Symptomatic as CT or US lung scan can be used as a diagnostic tool before general anaesthesia 3. Surgical procedures should be carefully prioritized based on 65% 98% local resources, the regional control of the COVID-19 pan- demic and the patients’ medical condition 4. When indicated, emergency surgery should be performed in all 94% patients regardless of their COVID-19 status 5. In COVID-19 positive patients, elective surgery for cancer and 80% progressive diseases should be considered only after a negative PCR COVID-19 test 6. In case of overutilization of hospital resources alternative/hold- 80% ing oncological therapies could be proposed to treat cancer in COVID-19 negative patients 7. In case of symptomatic patients either suspected or confirmed 92% COVID-19 positive, regional anaesthesia techniques should be considered when possible Introductory questions 2. What is the optimal surgical approach during COVID- 19 94% pandemic in COVID + o symptomatic? Surgical approach a. In elective vs. emergency cases b. in patients with moderately to severely compromised respira- tory function (CPAP or endotracheal intubation) c. in patients with mild to moderately compromised respiratory function (requiring mask oxygen therapy only) d. in patients with normal respiratory function—Patients with either no symptoms or mild symptoms, without interstitial pneumonia or other pulmonary complications 3. What is the optimal surgical approach during COVID- 19 8. General preference for minimal invasive surgery (MIS) accord- pandemic in COVID – or unknow but not suspected? ing to guidelines should not change both in COVID-19 negative a. In elective vs. emergency cases and positive patients as well as in elective and emergency set- tings, unless otherwise contraindicated, if adequate equipment and expertise are available 9. No a priori contraindication to a minimally invasive approach 92% should be stated in COVID-19 positive patients with normal, mild or moderately compromised respiratory function Staff protection in OR 4. What is the optimal personal protection equipment (PPE) that 10. The OR personnel should use standard PPE when operating 80% should be used during abdominal surgery in? on a tested COVID-19 negative patient Surgical Endoscopy (2021) 35:1–17 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % YES a. asymptomatic patients during COVID- 19 pandemic b. symptomatic patients during COVID- 19 pandemic c. positive patients during COVID- 19 pandemic 11. When any aerosol generating procedure is indicated on a 94% d. in symptomatic or positive patients and Aerosol Generating suspected or confirmed COVID-19 positive patient, symp- Procedures (Laparoscopy/Endoscopy) during COVID- 19 tomatic or asymptomatic, the OR staff should be reduced to Surgical Endoscopy (2021) 35:1–17 pandemic minimum and should all wear high level of PPE, consisting of: medical hood, FFP2/FFP3 mask, eye protection/full-face shield, long sleeved fluid repellent gown / medical protecting coverall (ANSI/AAMI level 3–4), double disposable gloves, long waterproof leg cover 12. It is of major importance that donning and doffing is per- 85% formed under self-control or direct control of a colleague Specific measures in OR 5. Which Specific Operative Risk Issues to consider during 13. The risk of infection during laparoscopic surgery should be 98% abdominal surgery in symptomatic or positive patients during controlled by reducing gas leaks, the generation of smoke and COVID- 19 pandemic regarding? by the application of surgical smoke evacuating systems a. Reduce the risk of aerosol contamination during laparoscopy 14. In order to control gas leaks, surgeons should: use low C ­ O2 94% b. Minimizing Staff personnel intraabdominal pressure, perform small incisions for the access c. Type of OR – COVID + OR/cleaning OR after surgery/nega- ports, limit the exchange of surgical instruments and evacuate tive pressure OR ­CO2 before any abdominal wall incision 15. In order to reduce the smoke generation during surgery in 65% 87% COVID-19 positive or suspected patients, the application of energy devices should be minimized, whereas ligatures/clips and/or stapling devices should be considered instead 16. COVID-19 positive or suspected patients should be operated 90% in a dedicated OR equipped with laminar air flow, negative pressure and downward evacuation system which should be cleaned by a dedicated specifically trained 24/7 team 6. How should we change the design of the OR block to adapt to 17. Disposable devices (instruments, trocars, etc.) should be 76% the risks of infections in the era of COVID- 19 pandemic? preferred in COVID-19 positive or suspected patients a. Negative pressure 18. All patients admitted should follow an initial screening triage, 73% b. Distinct paths for COVID + and – patients considering history of the patient, temperature, nasal swab and c. Design of equipment easily disinfected or disposable covers chest radiogram to detect COVID-19 status 19. Based on screening at admission, patients should be 94% addressed to the COVID-19 positive, COVID-19 negative or suspected unit, as for local organization 20. Distinct and separated paths should be created in any hospital 98% for COVID-19 positive, COVID-19 negative or suspected patients Specific emergency opera- tions in the immediate 13 5 post-COVID-19 pandemic 6 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % 13 YES Hepatobiliary 7. What are specific measures in hepatobiliary disorders that 21. Antibiotics should be attempted as the only treatment for 83% should be considered during COVID-19 pandemic regarding? COVID positive/ suspected patients with severe cholecystitis and the response to treatment should be reassessed rapidly (24 h) a. Role of a non-operative approach (antibiotics) in cholecys- 22. Transhepatic drainage should be proposed for compromised 78% titis patients with severe cholecystitis, refractory to medical treat- b. Role of a non-operative approach (transhepatic drainage) in ment at 24 h in COVID-19 positive patients cholecystitis 23. In COVID-19 positive patients with common bile duct and 84% c. Role of a Laparo-Endoscopic Rendez-Vous (LERV) gall bladder stones a sequential approach (ERCP followed by approach (orotracheal intubation) in Jaundice for CBD Laparoscopy) should be preferred to a Laparo-Endoscopic obstruction Rendez-Vous (LERV) approach to reduce the risk of a pro- d. Role of non-surgical/ non-endoscopic approach (only ERCP) longed anaesthesia in Jaundiced patients 24. Patients with obstructive common bile duct stones should be 77% treated according to the severity of cholangitis regardless of the COVID-19 status, favouring medical treatment 25. Patients with a non-calcular obstructive jaundice should be 84% referred to tertiary centres in order to choose the best treatment (PTBD-ERCP-upfront surgery) 26. Upfront surgery should not be offered to COVID-19 positive 80% patients with non-calcular obstructive jaundice 27. Cholecystectomy should be indicated in severe cholecystitis 89% that is not responsive to conservative or interventional treat- ment, even COVID-19 positive patients Abdominal wall hernias 8. What are specific measures in abdominal wall hernia surgery 28. Laparoscopic approach to incarcerated ventral and inguinal 80% that should be considered during COVID-19 pandemic regard- hernia may be safe in COVID-19 positive patients if laparos- ing? copy is not otherwise contraindicated a. Laparoscopy in incarcerated ventral/incisional hernia b. Laparoscopy in incarcerated inguinal hernia c. Role of meshes in emergency 29. In COVID-19 unknown patients, delaying surgery of an 89% incarcerated ventral and inguinal hernia to obtain test results may not be justified d. Role of techniques that might increase intraabdominal pres- 30. The use of mesh for hernia repair may not increase the risk of 89% sure complications in COVID-19 positive patients e. Surgical approach if a bowel resection is needed 31. Laparoscopic approach to incarcerated hernia requiring bowel 80% resection may be safe for COVID-19 positive patients if not otherwise contraindicated Surgical Endoscopy (2021) 35:1–17 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % YES Upper GI 9. What is the role for flexible endoscopy mitigating the risk of 32. Flexible endoscopic therapy should be the first attempt to 93% surgery during COVID-19 pandemic in the following situa- treat upper GI bleeding even in patients affected by COVID-19 tions? a. Acute gastric volvulus b. Obstructing gastric cancer Surgical Endoscopy (2021) 35:1–17 c. Obstructing esophageal cancer d. Esophageal perforation e. Surgical leaks f. Bleeding 33. COVID-19 positive patients with an obstructing esophageal 81% or gastric cancer should be treated first by endoscopic stenting if possible, in order to delay surgery until conditions are more favourable to operate 10. What is the role for surgical endoscopy during COVID-19 34. COVID-19 positive patients with an immediate presentation 83% pandemic in the following situations? of benign esophageal perforation (of less than 24 h) should be treated first by flexible endoscopy means, while those perfo- rated present after 24 h should undergo immediate surgery a. Esophageal perforation 35. In patients suffering from an upper GI anastomotic leak, 88% b. Gastroduodenal perforation initial endoscopic therapy should be attempted regardless the c. Bleeding COVID-19 status 36. Emergency surgery should be recommended after failure of 98% conservative/endoscopic management in symptomatic upper GI perforation or leak in COVID-19 positive patients 37. Laparoscopy should be the preferred approach in patients 84% with perforated gastroduodenal ulcer if not otherwise contrain- dicated in COVID-19 positive patients Lower GI 11. What is the role for flexible endoscopy mitigating the risk of 38. Endoscopic stenting for obstructing colorectal carcinoma 67% 87% surgery during COVID-19 pandemic in the following situa- should be considered for palliation in malignant obstruction tions? regardless of the COVID-19 status a. Stenting for obstructing colorectal carcinoma b. Decompression of acute sigmoid volvulus c. Management of acute perforation 39. Endoscopic decompression should be the first line of 91% d. Management of anastomotic leaks treatment of uncomplicated sigmoid volvulus, regardless the COVID-19 status 40. In patients suffering from a leak of a low rectal anastomo- 81% sis, all endoscopic means which proved effective should be attempted regardless the COVID-19 status 13 7 8 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % 13 YES 12. What is the role for laparoscopy during COVID-19 pandemic 41. Emergency surgery should be recommended after failure of 93% in the following situations? conservative/endoscopic management in symptomatic lower GI perforation or leak in COVID-19 positive patients a. Acute diverticulitis (lavage/HP/Primary Resection anasto- 42. The indication for laparoscopic lavage for Diverticular 65% 87% mosis with stoma) Disease can be considered in COVID-19 positive patients when b. Small bowel obstruction local expertise and protective measures are available c. Appendicitis (with/without abscess/abdominal collection) 43. Primary resection with or without anastomosis can be con- 86% sidered in COVID-19 positive patients with acute diverticulitis, providing that this is performed by an experienced surgeon 44. Percutaneous drainage and/or targeted defunctioning stoma 88% can be considered in unstable COVID-19 positive patients with acute diverticulitis 13. Should damage control surgery be performed in COVID + / 45. Laparoscopic approach should be considered in COVID-19 91% suspected COVID-19 patients? positive patients with virgin abdomen and acute small bowel obstruction that is likely due to a single adhesion band, which is suspected at CT scan a. In Upper GI 46. Non-surgical approaches such as percutaneous drainage with 81%% b. In Lower GI antibiotic treatment should be considered as the first line of c. In Pancreas surgery treatment of acute appendicitis with peri-appendicular abscess in COVID-19 positive patients 47. In case of failed non-surgical approach for acute appendicitis 91% in COVID-19 positive patients, laparoscopic surgery should be considered 48. The principles of damage control surgery with adherence to 98% optimal seal of temporary abdominal closure should remain unchanged in COVID-19 positive/suspected patients Specific elective operations in the immediate post- COVID-19 pandemic Hepatobiliary 14. What indications for laparoscopic surgery in hepatobiliary 49. Elective cholecystectomy in patients COVID-19 negative 98% disorders should be considered during COVID-19 pandemic may be performed if hospital setting allows a safe pathway for regarding? COVID-19 negative patients and local resources are sufficient Surgical Endoscopy (2021) 35:1–17 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % YES a. Cholelithiasis/choledocholithiasis and adenomyoma 50. Elective cholecystectomy in patients COVID-19 positive 81% b. Hepatic cancer should be delayed until the post-pandemic period c. Liver metastases 51. Elective liver resection for primary or secondary cancer in 86% d. Pancreatic cancer COVID-19 negative patients should not be delayed e. Other indications 52. Elective liver resection for primary or secondary cancer in 93% Surgical Endoscopy (2021) 35:1–17 COVID-19 positive patients should be delayed until patients fully recover from COVID. Jaundice or infection should be first treated with PTBD or ERCP as a bridge therapy 53. Patients affected by unproven pancreatic lesion could be 69% 73% observed and intervention can be delayed until the post-pan- demic period 54. Elective pancreatic resection for cancer in COVID-19 nega- 90% tive patients should not be delayed 55. Elective liver resection for cancer in COVID-19 positive 90% patients should be delayed until patients fully recover from COVID. Jaundice or infection should be first treated with PTBD or ERCP as a bridge therapy Bariatrics 15. What is the role for flexible endoscopy mitigating the risk of 56. In order to mitigate the risk of surgery during the recovery 70% surgery during COVID-19 pandemic in bariatrics? plan after the COVID-19 pandemic, all endoscopic techniques for morbid obesity should be preferred as bridge to surgery a. Should bariatric procedure be postponed? b. Role of bridging procedures (balloons and others) c. Treatment of complications of bariatric surgery 57. Intragastric Balloon placement can be a valid alternative to 68% 76% endoscopic sleeve gastroplasty in order to reduce procedure times and resources usage during the COVID pandemic 16. Is there a different timing for surgery during COVID-19 58. In patients experiencing a complication (bleeding or leak) 98% pandemic in bariatrics? following a bariatric procedure, all endoscopic means which proved effective should be put in place regardless of COVID-19 status a. Should bariatric procedure be postponed? 59. During the recovery plan after the COVID-19 pandemic, bari- 77% b. When should a redo procedure be performed? atric surgery should not be postponed further, nor the indica- tions limited in areas with a low incidence of SARS-CoV-2 infections 60. In case local regulatory authorities impose a reduction of 98% bariatric weekly case load, more complex metabolic patients should be prioritized Abdominal wall 17. What indications to surgery and what anaesthesia in abdomi- 61. Elective laparoscopic treatment for ventral and inguinal 90% nal wall disorders should be considered during COVID-19 hernias in COVID-19 negative asymptomatic or poorly sympto- pandemic regarding? matic patients may need to be postponed 13 9 10 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % 13 YES a. Ventral hernias b. Inguinal hernias c. Role of watch&wait policy 62. A watchful waiting management may be safe in asymptomatic 90% d. Should Spinal anaesthesia always be preferred? what will be patients and patients with abdominal wall hernia and minimal the indications? symptoms that do not substantially affect quality of life 63. Both general and spinal anaesthesia for hernia repair should 95% be considered safe in COVID-19 negative patients. The choice should follow local guidelines and patient’s preference Endocrine 18. What indications to laparoscopic surgery in endocrine 64. In the recovery plan after COVID-19 Pandemic indications 95% disorders should be considered during COVID-19 pandemic to laparoscopic surgery and priorities in endocrine disorders regarding? should not change a. Functional adrenal tumour 65. Elective adrenal resection for primary or secondary cancer in 98% b. Adrenal cancer COVID-19 negative patients should not be delayed c. Adrenal metastases 66. Elective adrenal resection for primary or secondary cancer 93% d. Thyroid goiter in COVID-19 positive patients should be delayed until patients e. Thyroid cancer (or suspected) fully recover from COVID f. P-Nets 67. Elective adrenal resection for functional tumours (pheochro- 93% mocytoma and severe Cushing) in COVID-19 negative patients should not be delayed 68. Elective adrenal resection for functional tumours (pheochro- 93% mocytoma and severe Cushing) in COVID-19 positive patients should be delayed until patients fully recover from COVID 69. Elective surgery for thyroid nodules Bethesda V and TIRADS 95% 5 or higher in COVID-19 negative patients should not be delayed 70. Elective surgery for thyroid nodules Bethesda V and TIRADS 95% 5 or higher in COVID-19 positive patients should be delayed until patients fully recover from COVID 71. Patients affected by thyroid goiter severely symptomatic 93% for dyspnea should not have surgery delayed regardless of the COVID status Upper GI 19. When and how should surgery for Upper GI disorders be 72. In COVID-19 positive patients who suffer from early esopha- 71% postponed during COVID-19 pandemic? geal or gastric cancer surgery should be delayed and neoad- juvant treatment should be considered even if not normally indicated a. Should we extend the indications for neoadjuvant treatment to early esophageal cancer? b. Should we extend the duration (cycles) of neoadjuvant treat- ment to esophageal cancer? Surgical Endoscopy (2021) 35:1–17 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % YES 20. What is the role for flexible endoscopy mitigating the risk of surgery during COVID-19 pandemic in upper GI functional diseases? a. Achalasia (including POEM)? b. Anti-reflux procedures (Esophyx/MUSE)? Surgical Endoscopy (2021) 35:1–17 21. Does surgical endoscopy still have a role during COVID-19 pandemic in the treatment of the following diseases? a. Esophageal cancer 73. Patients affected by benign Upper GI functional disorders 59% 93% b. Gastric cancer (total / subtotal gastrectomy) such as achalasia and GERD should be considered for flexible c. Hiatal hernia & reflux disease endoscopic intervention if not responding to medical treatment, after the COVID pandemic 74. Patients affected by neoplastic disease of the upper GI for 81% whom surgery is indicated, should be considered for an MIS approach, if not otherwise contraindicated, after the COVID pandemic 75. In COVID-19 positive patients with a surgical indication for 88% GERD, hiatal hernia or achalasia surgery should be delayed Lower GI 22. When and how should surgery for Lower GI disorders be 76. Prioritization of elective surgery for benign colorectal 95% postponed during COVID-19 pandemic? pathologies should be made taking into account the patient and disease characteristics, local COVID-19 burden and institu- tional and staff resources a. Should we extend the indications for neoadjuvant treatment to early rectal cancer? b. Should be opt for total neoadjuvant radiochemotherapy including upfront chemotherapy, for rectal cancer? c. How much should we wait after CRT? d. Role of watch&wait policy for rectal cancer with complete response e. Should we propose total neoadjuvant chemotherapy for colon cancer? f. Should we extend the indications for “liver first” and post- pone rectal resection? 23. What is the risk in performing colorectal anastomoses during 77. Neoadjuvant therapy could be considered in early rectal 66% 82% COVID-19 pandemic? cancer in order to postpone surgery after the COVID pandemic, within registered studies a. Should we avoid anastomosis (HP?) 78. Patients with rectal cancer should not be offered chemora- 83% diotherapy including upfront chemotherapy as a sole treatment outside clinical trials 13 11 12 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % 13 YES b. Should always protect anastomosis with stoma? 79. Surgery for rectal cancer in patients COVID-19 positive 78% should be delayed beyond the standard 12 weeks following neoadjuvant chemoradiotherapy 24. What is the role for transanal surgery during COVID-19 80. A watch and wait policy for neoadjuvant treated rectal cancer 82% pandemic? should be proposed only in the setting of clinical trials and/or when surgery is contraindicated a. Cost/effectiveness of transanal surgery compared to flexible 81. During the COVID-19 pandemic and the recovery plan, 78% endoscopy in terms of risk for patient and operators? neoadjuvant chemotherapy can be proposed to patients affected b. Role of TaTME and ultra-low anastomosis? by stage II and III colon cancers 82. A liver first approach in locally advanced rectal cancer and 95% synchronous liver metastases cannot be recommended solely based on the pandemic situation 25. What is the optimal surgical approach during COVID- 19 83. In COVID-19 negative patients undergoing elective colorectal 98% pandemic for? resection, anastomosis should be considered if not otherwise contraindicated a. Colon cancer 84. Stoma formation should be preferred to an anastomosis in all 83% b. Symptomatic chronic diverticulitis patients medically unfit or COVID-19 positive c. Inflammatory Bowel Disease 85. Alternative strategies to TEMS/TAMIS for low rectal lesions, 72% d. Rectal prolapse (laparoscopy vs transanal approach) such as endoscopic mucosal resection and endoscopic submu- cosal dissection, should be considered in COVID-19 positive 86. Overall, taTME and ultra-low anastomosis are procedures 93% at higher risk of complications and should only be performed selectively in expert centres to minimize resource consumption during the pandemic 87. MIS approach should be considered to electively treat colon 88% cancer as well as benign conditions such as inflammatory bowel diseases and recurrent diverticulitis, due to its well proved benefits of reducing morbidity, during the pandemic New technologies demanded Technology 26. Which specific Operative Risk Issues to consider in case of 88. Research activity on digital technology and robotics should 98% abdominal surgery in symptomatic or positive patients during be encouraged to focus on reducing personnel in wards, inten- COVID- 19 pandemic? sive care unit and OR a. Use of active/passive smoke evacuator b. Use of reusable/disposable trocars c. Use specific type of reusable trocars (Ballon at the tip, blade- less, etc.…) d. Use of reusable/disposable instruments e. Use of advanced dissectors (Ultrasonic, Radiofrequency,…) vs standard mono & bipolar f. Use of cold knifes, scissors and ligatures/sutures Surgical Endoscopy (2021) 35:1–17 Table 2  (continued) Topics Questions Statement 1st round % 2nd YES round % YES 27. Is it time to use robotics technology to reduce the employ- ment of human beings and/or to keep social distance for… a. OR surgical instrumentation b. Scrub nurse and OR personnel c. Ward personnel Surgical Endoscopy (2021) 35:1–17 d. Other… 28. In the era of attention to climate changes and pollution, how to deal with technology solutions to limit quantity of waste dispersal? a. How to recycle PPE? b. How to recycle the increasing disposable material? c. How to be sure that reprocessing is effective? 29. While the COVID-19 pandemic is severely affecting educa- tional programs in surgery, can we envision technology solu- tions for training, such as …? a. Hands on courses on 3D printed organs / districts b. Virtual Reality simulators c. Consultation of selected Videolibrary d. Attending of Online Congresses e. Extensive webinar activity for education 89. Practical technological solutions including sustainable materi- 96% als and steam sterilization for PPE should be investigated in order to minimize production of waste f. Real time education via telesurgery for open and laparoscopic 90. Innovative solutions for training such as video-based educa- 96% operations tion in combination with box trainers should be promoted to mitigate the restrictions of face-to-face teaching Research 30. Should clinical research restart? 91. Non-COVID clinical research should restart as soon as pos- 98% sible in line with safety recommendations and procedures 92. Particular attention should be payed to research targeting 96% preventive and mitigation strategies of aerosol contamination in the OR and safety of MIS 13 13 14 Surgical Endoscopy (2021) 35:1–17 and the domains chairs was based on their peers’ recom- contaminated gas within a defined space, as it happens mendations and their leadership positions across different during laparoscopy, should provide a better control of specialties and of their expertise on the research methodol- risk, when compared to open surgery [11]. Regardless to ogy of consensus development. The steering group did not the mode of surgery, limiting the use of energy devices contribute to the voting process. in SARS-CoV-2 positive patients was also recommended The Delphi design allowed us to elicit the opinion of the and favouring ligatures/clips and/or stapling devices when EAES board members along with additional key stake hold- possible. This is also in line with other recommendations ers to complement the multidisciplinary and heterogeneous (EAES/SAGES) and with evidence suggesting gas escape nature of the international panel of experts. Although evi- through trocars [30–32]. General recommendations for dence synthesis was part of this project to generate evidence- personnel safety in the OR including characteristics of the based recommendations, there was no found evidence that environment and PPE were also confirmed [16]. can inform the statements, hence, relied on expert opinion. In the emergency setting, a number of recommendations A limited number of areas of continuing controversy were were proposed by the experts, supporting conservative identified at the first voting round with lack of consensus treatment for abscesses and collections in SARS-CoV-2 among members. Initial disagreement was encountered on positive patients, rather than offering immediate surgery, how to prioritize surgery, but ultimately total agreement was if the general condition of patients allows this. On the achieved by recommending that decisions should be based contrary, for acute cholecystitis in SARS-CoV-2 positive on local resources, the regional control of the COVID-19 patients, cholecystectomy was recommended when not pandemic and the patients’ medical condition. This was responsive within 24 h rather than interventional treat- fundamental in deciding priorities also hereinafter for the ment such as percutaneous transhepatic drainage, with the rest of the consensus, but it is probably an area that requires exception of ASA 3 and 4 patients. fundamental research in the immediate future. In the field of abdominal wall surgery, laparoscopy was While there was also general agreement on the need to recommended for incarcerated ventral and inguinal hernia screen all patients undergoing surgery under general anaes- if not otherwise contraindicated and should not be post- thesia, by Reverse Transcription Polymerase Chain Reac- poned if clinically indicated. Emergency endoscopy (diag- tion (RT-PCR) or even by computer tomography (CT) or nostic and therapeutic) was supported in SARS-CoV-2 ultrasound (US) lung scan in symptomatic patients, the positive patients, as the first line to assess and possibly option of regional anaesthesia should always be considered to treat bleeding, neoplastic obstruction, perforation and in suspected or positive patients for whom surgery cannot anastomotic leak. Similarly, laparoscopic surgery should be postponed. Elective oncologic surgery should be only be considered after failure of conservative/endoscopic offered to SARS-CoV-2 negative patients or to previously management in symptomatic patients, as well as the in positive patients after conversion to a negative RT-PCR acute diverticulitis management according to the accepted COVID-19 test. algorithms. One of the main objectives of this project was to clarify Elective surgery for both malignant and benign disease the role of MIS, considering the conflicting information should be postponed in SARS-CoV-2 positive patients until from different guidelines. This was based on the theoretical they return negative. This is also the case for hepatobiliary risk of possible contamination due to aerosolization and the and pancreatic non-neoplastic diseases, as well as other gas leaks demonstrated during laparoscopy [31–33]. oncologic patients, in whom interim procedures should be Until high-level evidence will be available to provide an offered instead. For instance, drainage of the biliary tract answer about the direct link between SARS-CoV-2 con- by Percutaneous Transhepatic Biliary Drainage (PTBD) or tamination by pneumoperitoneum and its contagion to the Endoscopic Retrograde Cholangio Pancreatography (ERCP) operating team, the application of MIS across all surgical should be considered as a bridging therapy. specialities has been supported by the experts in this project, In the field of bariatric surgery, the expert group in this provided local expertise is available and safety procedures project supported postposing elective surgery until the are adhered to. Additionally, there was wide agreement recovery plan, and flexible endoscopic procedures such as that the general preference for MIS according to guidelines intragastric balloons was recommended as a bridge to sur- should not depend on the SARS-CoV-2 status or the indica- gery during the COVID-19 pandemic. Elective laparoscopic tion of surgery in terms of elective and emergency settings. treatment for ventral and inguinal hernia in SARS-CoV-2 These precautions are in line with the recent EAES/ negative patients may need to be postponed depending on SAGES recommendations to reduce gas leaks [34], the the local situation. Endocrine surgery should only be can- generation of smoke and by the use of surgical smoke celled in SARS-CoV-2 positive patients until they convert to evacuating systems [16]. These guidelines are also sup- negative. Otherwise, patients should be prioritized depend- ported by the argument that containing potentially ing on symptoms and oncological risk. 13 Surgical Endoscopy (2021) 35:1–17 15 For upper and lower gastrointestinal cancer, neoadjuvant this field. The selection of experts is another critical aspect therapy could be considered for early cancers in order to within consensus statements development. The expert group postpone surgery after the COVID-19 pandemic, but only involved in this research were all the EAES board members within registered studies, although difficult to arrange in representing the research, technology and educational com- short time. Functional disorders such as achalasia and reflux mittees as well as the members of the executive committee disease should be treated as usual and surgery can be consid- of the society. The response rate among the participants was ered if not responding to conservative treatment. The experts high across the entire process reflecting the hard work and recommend that surgery should be delayed only in SARS- commitment of the board members to undertake this pro- CoV-2 positive patients. Similarly, elective surgical treat- ject and complete the project in a timely manner given the ment of benign colorectal pathologies should be prioritized urgency and the need for the guidelines. based on patient and disease characteristics, local COVID-19 burden and institutional and staff resources. If not otherwise contraindicated, colorectal resections should be completed Conclusion with anastomosis, while stoma formation should be applied as usual only for high-risk patients. Particular attention The recommendations formulated by the EAES board create should be paid when Transanal Endoscopic Microsurgery a framework for resumption of surgery following COVID-19 (TEMS) or TransAnal Minimally Invasive Surgery (TAMIS) pandemic with particular focus on the role of MIS across procedures are indicated, including TransAnal Total Meso- all specialities. The statements have the potential for wide rectal Excision (TaTME), due to the particularly high risk application in clinical setting, education and research across of operator contamination. In fact, alternative strategies for different healthcare systems. low rectal lesions, such as endoscopic mucosal resection and endoscopic submucosal dissection, should be considered in Acknowledgements We would like to thank Muriel Van Eck and the SARS-CoV-2 positive. On the other hand, due to its well entire EAES Office for supporting us in this survey activity. proved benefits, a minimally invasive approach should be Members of the EAES group of experts for Recovery amid COVID- 19 pandemic: Emina Letić, Silviu Daniel Preda, Alice Tsai, Ewelina considered to treat colorectal cancer as well as benign con- Malanowska, Dusan Lesko, Wlodzimierz Majewski, Ludovica Bal- ditions such as inflammatory bowel diseases and recurrent dari, Luca Morelli, Andreas Shamiyeh, Gil Faria, Francesco Maria diverticulitis. Carrano, Piotr Mysliwiec, Gunnar Ahlberg, Elisa Cassinotti, Samir Finally, we focused on technology, education and research Delibegović, Lubomír Martinek, Eugenia Yiannakopoulou, Margue- rite Gorter-Stam, Hendrik Jaap Bonjer, George Hanna, Hans Fuchs, in the time of pandemic. The team of experts outlined how Miloš Bjelovic, Sheraz Markar, Philip Wai Yan, Chiu, Bang Wool Eom, research activity on digital technology and robotics should Young-Woo Kim, Carmen Balagué Ponz, Marlies Schijven, Luigi Boni, be encouraged to focus on reducing the numbers of working Thomas Carus, George Theodoropoulos, Antonello Forgione, Marco personnel in wards, intensive care unit and the operating Milone, Wanda Luisa Rita Petz, Predag Andrejevic, Dejan Ignjatovic, Thanjakumar Arulampalam, Kenneth Campbell, Manish Chand, Mark rooms. In fact, this pandemic highlighted the importance of Coleman, Christos Kontovounisios, Chen Sagiv, Fanny Ficuciello, Ste- technology advancement in remote teaching and mentorship. fania Marconi, Pietro Mascagni, Kiyokazu Nakajima, Francisco Miguel Innovative solutions for training such as video-based educa- Sánchez Margallo, Tim Horeman, George Mylonas, Pietro Valdastri. tion in combination with box trainers should be promoted to mitigate the restrictions of face-to-face teaching. The experts Funding Open access funding provided by Università degli Studi di Torino within the CRUI-CARE Agreement. outlined certain areas of further research targeting robotics, Artificial Intelligence, advanced imaging and energy devices Compliance with ethical standards that could have a positive impact in times of pandemic and restrictions due to social distancing. At the same time practi- Disclosures Alberto Arezzo has financial disclosures unrelated to this cal technological solutions including sustainable materials manuscript being consultant for Karl Storz, BBraun and Medrobot- and steam sterizilation for PPE should be investigated in ics. Nader Francis has financial disclosures unrelated to this manu- order to minimize production of waste. script being consultant for Pharmacozmos, Fisher & Paykel Health- care, Medtronic and Olympus. Yoav Mintz, Michel Adamina, Stavros Overall, this project highlighted interesting trends and A Antoniou, Nicole Bouvy, Catalin Copaescu, Nicolò de Manzini, controversies related to surgeons’ willingness to overcome Nicola Di Lorenzo, Salvador Morales-Conde, Beat P Müller-Stich, this difficult time, but it holds a number of limitations. There Felix Nickel, Dorin Popa, Diana Tait, Cenydd Thomas, Susan Nimmo is a lack of empirical data to support many of the underlying Dimitrios Paraskevis Andrea Pietrabissa have no conflict of interest or financial ties to disclose. statements, hence weaknesses inherent to these guidelines include the reliance on expert opinion and discussion to formulate recommendations. Despite the limited evidence, Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- this project highlighted a number of clinically relevant ques- tion, distribution and reproduction in any medium or format, as long tions that provide an agenda to stimulate future research in as you give appropriate credit to the original author(s) and the source, 13 16 Surgical Endoscopy (2021) 35:1–17 provide a link to the Creative Commons licence, and indicate if changes D’Ambrosio G, Cuccurullo D, Bergamini C, Allaix ME, Cara- were made. 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Colorectal Dis. https​://doi.org/10.1111/codi.15215​ Affiliations Alberto Arezzo1 · Nader Francis2,3 · Yoav Mintz4 · Michel Adamina5,6 · Stavros A. Antoniou7,8 · Nicole Bouvy9 · Catalin Copaescu10 · Nicolò de Manzini11 · Nicola Di Lorenzo12 · Salvador Morales‑Conde13 · Beat P. Müller‑Stich14 · Felix Nickel14 · Dorin Popa15 · Diana Tait16 · Cenydd Thomas17 · Susan Nimmo18 · Dimitrios Paraskevis19 · Andrea Pietrabissa20 · The EAES Group of Experts for Recovery Amid COVID-19 Pandemic 1 11 Department of Surgical Sciences, University of Torino, General Surgery Clinic, Department of Medical, Surgical Corso AM Dogliotti 14, 10126 Torino, Italy and Health Sciences, University of Trieste, University 2 Hospital of Trieste, Trieste, Italy Department of General Surgery, Yeovil District Hospital 12 NHS Foundation Trust, Yeovil, UK Department of Surgical Sciences, University of Rome “Tor 3 Vergata”, Rome, Italy The Griffin Institute, The Northwick Park Institute 13 for Medical Research, Northwick Park and St Unit of Innovation in Minimally Invasive Surgery, Marks Hospital, Watford Road, Harrow, Middlesex, Department of General and Digestive Surgery, University London HA1 3UJ, UK Hospital “Virgen del Rocio”, University of Sevilla, Sevilla, 4 Spain Department of Surgery, Hadassah, Hebrew University 14 Medical Center, Jerusalem, Israel Department of General, Visceral and Transplantation 5 Surgery, Heidelberg University Hospital, Heidelberg, Department of Surgery, Clinic of Visceral and Thoracic Germany Surgery, Cantonal Hospital Winterthur, Winterthur, 15 8401 Zurich, Switzerland General Surgery, Linköping University Hospital, Linköping, 6 Sweden Faculty of Medicine, University of Basel, 4051 Basel, 16 Switzerland The Royal Marsden NHS Foundation Trust, London, UK 7 17 Medical School, European University Cyprus, Nicosia, Department of Radiology, Yeovil District Hospital NHS Cyprus Foundation Trust, Higher Kingston, Yeovil, UK 8 18 Department of Surgery, Mediterranean Hospital of Cyprus, Department of Anaesthesia, Critical Care and Pain Medicine, Limassol, Cyprus Western General Hospital, Edinburgh, Scotland 9 19 Department of Surgery, Maastricht University Medical Department of Hygiene, Epidemiology and Medical Centre, Maastricht, The Netherlands Statistics, Medical School, National and Kapodistrian 10 University of Athens, Athens, Greece Department of Gastrointestinal and Bariatric Surgery, 20 Ponderas Academic Hospital, Bucharest, Romania Department of Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy 13