THE IMPACT OF COVID – 19 ON THE
DIAGNOSIS AND MANAGEMENT OF
SURGICAL DISEASES
Dr. Neil Mendoza
Picture of how Covid 19 looks like
Covid 19 in general..
Its full name is SARS – COV 2 because of its
causative agent
• Causative agent: SARS– COV 2
• Highly transmissible
Despite all the factors that we have
established, we still continue to see
a rise in transmission of the
infection
• Spread efficiently from person to
person primarily through large
respiratory droplets
• Secondary mode of transmission:
touching of surfaces contaminated
by droplets containing the virus
• Infectious dose remains unknown
➢ Be conscious of how to do some
disinfecting of surfaces that have
potentially been exposed to a person
with Covid 19 virus. Ofc we don’t know
who these persons are. The only way
to protect yourself is to assume that
the person you are talking to is Covid
19 infected.
ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S
➢ Infectious dose refers to the VIRAL
LOAD or QUANTITY or amount of
virus that is known to produce a
virulent effect: If you get infected with
this quantity that means you are going
to exhibit signs and symptoms
(symptomatic case)
➢ Asymptomatic cases: wherein some
patient may harbor some virus and yet
they don’t have symptoms. We have to
be weary in this type of patients or
cases. And the potential of them
transmitting to another individual
which of course is mitigated or
addressed by wearing surgical masks
and face shields (mandatory by IATF)
Contact transmission
Droplet transmission
Aerosol Transmission
Blood, secretions and excretions transmission
Aerosolization of the virus:
***Aerosolization process: the main
route of entry of Covid – 19 is still through
RESPIRATORY TRACT.
But then again after entering the respiratory
tract it can be found in the GIT
|1
Impact on Surgery
• HCF prioritized covid19 cases
• Surgeries, especially elective ones
have been severely restricted
• Only emergency cases are
managed
• Other important surgical diseases
e.g. cancers need to be addressed
o Patients with malignancies are
high risk which will lead to
morbidity
• Surgical personnel act as backup
or become frontliners to augment
manpower
• Fear as healthcare workers are
infected and succumbed to the
disease
• PPE plays a central role in
protecting Healthcare workers
➢ When I made this slide, this was the
peak of pandemic. I would say that
now we are slowly opening in
performing elective surgeries. But then
again as I’ve said because hospital
resources are focus on managing
covid cases so therefore because of
the surge of covid – 19 patients we
tend to postpone operations and
surgeries that can wait. Only emergent
and urgent surgeries are performed
but then again elective surgeries are
slowly opening. The problem now is
that patients are still afraid to go to the
hospital.
➢ But the greatest impact of Covid – 19
on surgery is actually its restriction on
many cancer operations. Why?
1. Cancer patients with malignancy –
high risk for the development of
morbidity in covid – 19, If patient
has been infected with covid – 19.
➢ Philippines is one of highest
percentage where in health care
workers dying because of covid – 19.
ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S
➢ Psychological effect to health care
workers: Doctors, nurses, etc., they
are also battling real fear from getting
infected by patients but of course there
is no choice because this is their sole
duty and their profession to manage
their patients ♥. Let’s Pray for them!
➢ The ratio of medical provider and
patient is markedly disproportionate.
➢ PPE has been the game changer to
have the courage and not be afraid to
face patients who have been infected
with covid- 19.
• Covid - 19: GI complications
• Covid – 19: Outcomes of Surgery
• Covid – 19: The second surge of cancelled
surgery
➢ We are focused on covid being
respiratory but some studies initially
came out there’s been documented
GIT complications of covid – 19.
➢ Covid – 19 may impact the recovery of
patients whether patient will recover
fast and of course that deals with
comorbidity or whether they die with or
without covid are still a subject of
ongoing studies.
➢ What happens then to the surgical
cases that has been postponed? What
are we going to do with these
cancelled surgeries? How is it going to
play in these coming days? (this is the
entire scenario of the subsequent
scenario)
|2

- Is that relevant? Well if we look at the
- But what about those occurring at the right
- Again, these are statistical data we don’t
GI symptoms:
- Anorexia
- Nausea/Vomiting
- Diarrhea
- Abdominal pain/discomfort
- Any GI symptoms
- Focus is on the prevalence of GI
involvement in Covid – 19. The majority of
general surgery operations involve the
abdomen
- Top 2 common non trauma related surgical
conditions
a. Acute appendicitis
b. Gall stone diseases / calculous
cholecystitis
- In this Meta-analysis study, they found out
that GI symptoms presents approximately
in 20 – 30% of the cases. Such as your non
specific signs and symptoms (listed above).
- Very significant when you think of
abdominal pain, anorexia, nausea are
actually if you just talk about of acute
appendicitis that is exactly the same sign
and symptoms, wherein you would consider
acute appendicitis. It actually very
significant in the time of covid – 19 so
therefore we can conclude that during the
pandemic that patients that would present
ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S
with such signs and symptoms before we
would think of covid – 19. And now we
should be weary that this patient MAY
actually have covid – 19 that is the
signifance of the data.
confidence interval those crossing the
midline (sa picture sa taas ung diamond
diamond) may not be significant at all.
of the mid line? These symptoms have
something to do with covid – 19.
know really but out of this study. We wanted
to prove really if there is any doubt in this
study probably some of doctors will begin to
question this. Because seemingly why do
we associate these symptoms (listed
above) with covid – 19 when they are
traditionally before the pandemic refer to
abdominal symptoms of common GI
problems for example Acute Appendicitis.
Why do we say that this patient may have
Covid – 19? This is answered by this data
below.
1. RNA in entire GI tract
2. 50% patients shred RNA in stool
3. Stool RNA lingers up to 4 weeks
4. e/o RNA replication
|3
Is there evidence of GI infection? ● (3) RNA Replication in the GI tract
○ Key Findings:
● (1) Geographic RNA distribution along
■ Subgenomic RNA (sgRNA)
GI tract (Lin e. al…)
present in stool samples
○ If it is true that the covid 19 is
suggestive of RNa
present in the Gi tract, where is
replication.
it predominating or where does
○ In this study, they have
the virus live? This is the first
concluded that:
question.
■ (1) RNA in entire GI tract
○ 6 patients underwent EGD
■ (2) 50% patients shed RNa
■ Esophagitis (n=1)
in the stool
■ Geographic RNA testing
■ (3) Stool RNA lingers up to
○ You may see that the number is
4 weeks
low but this is backed up by a
■ (4) evidence of RNA
strong RNA evidence.
replication
○ The virus was found to inhabit
Is the Alimentary Tract Vulnerable to
the esophagus, stomach,
Infection?
duodenum and rectum.
● (2) Prevalence of RNA in the GI tract
(Cheung et. al. Gastroenterology 2020
April 3)
○ 12 studies evaluated RNA
○ 138 patients
○ 48.1% (+) stool RNA
○ 70% (+) Stool RNA (-) Resp
RNA
■ Up to 33 days - particularly
true of kids
■ If we believe this data, we
know now that aside from
fever and the cough, loss of
smell, loss of taste, patients ● Yes, the entire alimentary tract is
may present diarrhea. vulnerable to infection.
■ This probably will explain ● The virus gains entry to the human
that up to a month, the virus system by attaching itself to the ACE2
will eventually manifest on protein receptors.
the respiratory tract which is ● The spikes on the corona appearance
particularly true of children. are the main means of attaching to the
● In this essence, the human cells.
children are restricted
from going out.

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S |4
 ● As you can see on this graph, a ● GI complications are divided in several
molecular study on the presence of groups:
COVID - 19 is established.
● The orange bars tell you that the virus
is predominating on the small bowel,
kidneys, testis, gallbladder, colon
rectum, liver, tongue and respiratory
tract.
○ This means that this validates that
the entire alimentary tract is
affected.
● In the early days of the pandemic, we
were focused on pneumonia.
○ The initial impression then was
that COVID virus is similar to the
SARS infection.
○ But now, it is proven that it also
can inhabit the GI tract.
○ The number of studied populations
○ The patient may die not only
may be small but what is important
because of pneumonia but also of
is that they were able to establish
something else.
data in 141 patients.
○ Still, there are a lot of things we do
GI Manifestations in the Critically Ill
not know about COVID - 19 but
there are a lot of ongoing studies
that we may see in the coming
months or days.
○ The most dreaded complication in
this table is bowel ischemia.

● I would say this is a landmark study

which was published during the early
months of pandemic.

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S |5
Colonic Paralytic Ileus
● What is interesting about this is
that they found that bowel
ischemia is seen in relatively
young people between 30 to
60 y/o and patients with
minimal comorbidities.
● They also noted that it
develops about 2 weeks (10-
16 days) after initial admission.
● Mortality 40%

Bowel Ischemia in COVID 19

● Most dreaded complication

● Why are these patients developing

ischemia?
○ Because of the severe inflammatory
immune response of patients
against the virus - forming blood
clots that obstructs the capillary
vessels.
○ The capillaries is where oxygen
transfer occurs.
■ If (+) thrombosis or formation of
clots > occlusion of vessels >
hypoxemia > (+) anaerobic
metabolism > production of lactic
acid > lactic acidosis (hallmark of
septic process) > ischemia >
necrosis > danger of perforation

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S |6
 ■ if (+) perforation > leakage of
bowel contents > infection >
sepsis On top of ongoing
pulmonary infiltration of the virus,
now you have a GI problem
dealing with a septic bowel.
● Two major problems that the body will
endure.
■ The same microthrombosis also
happens on other organs such
as the lungs > increased
mortality and morbidity
○ Microthrombosis
■ Believed to be one of the
pathogenic mechanisms
of COVID - 19
■ In fact, one of the
management is giving
anti-thrombotics already
because of this new
concept.
• On a personal note, out of the doctors
who died of COVID - 19, a lot of them are
obese.
ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S
• Obesity is a risk factor where the virus
probably becomes more virulent.
• D dimer is a marker for sepsis (?). An
increased d dimer value points in a
septic focus.
CovidSurg Network
● Started in the US - connecting 2
surgeons with a single tweet evolved
into:
○ 1,500 hospitals
○ 120 countries
○ 48,000 patients
Mortality and pulmonary complications in
patients undergoing surgery with
perioperative SARS-CoV-2 infection
● International cohort study
● Published in The Lancet
● Diagnosis was done by CTscan, other
lab tests and clinical diagnosis
○ 24% pre-op diagnosis
○ 76% post-op diagnosis
● 24% overall 30-day mortality
● 51% of the patients developed post-op
pulmonary complications (pneumonia,
ARDS and unexpected post-op
ventilation)
○ 38% died within a month
○ 83% of the death of patients
were due to pulmonary post-op
complications
● Other risk factors for mortality in
patients undergoing surgery with
Covid-19:
○ Male sex
○ Age >70
○ ASA (American Society for
Anesthesiology) grade 3 and 4
|7
 - talks about physiologic status
of patients undergoing surgery;
higher grades 3-4 being highly
likely to die due to comorbidities
○ Cancer patients
○ Emergency surgery
○ Major surgery
● Conclusion: Post-op complications
and mortality is higher in patients
undergoing surgery than in the pre-
covid era. Surgeries must be
postponed and non-operative
management must be used whenever
possible. ● Males have higher risk of dying when
● This is the basis of existing surgical undergoing major or minor surgery if
guidelines: from postponement of they are <70 years old
operations shifting to testing with RT- ● For patients age >70 undergoing:
PCR for patients undergoing surgery ○ Minor surgery - risks in both
○ Protect the staff gender is equal
○ More importantly to avoid ○ Major surgery - male > female
complications and morbidity ● Conclusion: gender and type of
surgery matters with the risk of
mortality for covid+ patients
undergoing surgery

Impact of Covid-19 with surgeries all over the

world
● Over 28 million surgery cancellations
worldwide
○ 81.7% - benign surgeries
○ 37.7% - cancer surgeries

Summary and take-home messages:

● We have to use these figures for our
1. Much about Covid-19 remains
decision making when to proceed with
unknown
surgery
2. Science and data is what we need, not
● Conclusion: Do surgery when the
anecdotes and media stunts
patient is Covid-negative
3. Covid-19 is a systemic disease with GI
manifestations, most notably

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S |8
 mesenteric ischemia due to
thrombosis leading to death of
segments -> mortality
4. Surgery should be avoided, when
possible, in Covid-19 patients
5. The second surge might be surgical
that of cancelled surgery

MeNTS Score / Medically Necessary

Treatment Score
• decision making algorithm to follow
whether the surgery should proceed
since resources are somehow directed
to COVID-19
• 25 score - proceed with surgery
• 105 score - defer/postpone surgery
Favorable surgical risk -
minor surgery, no
comorbidities, (-) COVID-19
Proceed
Favorable risk to personnel -
availability of PPEs
Favorable resource
utilization - available hospital
resources e.g. blood, PPEs
Not justified Worse outcomes - (+)
COVID-19, major surgery,
with comorbidities
Excessive risk to personnel -
doctors and other hospital
personnel
Excessive resource
utilization
General Recommendations
Main Strategies to prevent or limit
transmission:
1. Efficient triaging - e.g. QR code tracing
2. Early recognition and source control
3. Applying standard and specific
isolation precautions - negative
pressure rooms (one way direction of
air), reconstruction / retrofitting of
operation rooms and ICUs
4. Implementing administrative controls
5. Using engineering controls
Necessary Personal Protective Equipment
(PPE) in the Operating Room during the
COVID-19 Pandemic
• Surgical masks
• N95 masks
• Sterile, water-impermeable surgical
gowns
• Sterile surgical gloves
• Goggles or face shields
• Head caps
• Shoe covers (optional)

Reserved For Emergent/Urgent Cases

OR
Capacity Will depend on the nature of
the case

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S |9
 • Alcohol or alcohol-based
hygiene solution(s)
hand 2. High risk procedures (e.g.
aerosol-generating procedures
or AGP, surgeries involving the
aerodigestive tract) on patients
who tested positive on RT-PCR
for SARS-COV-2
-cutting through the GIT using
cautery devices generates
plume which potentially
contains the virus
List of High-risk/Aerosol-
Generating Procedures (AGP)

• Airway surgeries e.g. ENT /

thoracic / trans-sphenoidal
• Autopsies
• Bronchoscopy - unless carried out
through a closed-circuit ventilation
system
• Cardiopulmonary resuscitation
• Dental procedures
• Endotracheal intubation and
extubation
• Evacuation of pneumoperitoneum
during laparoscopic procedures
• Gastrointestinal endoscopy
• High frequency oscillatory
RISK STRATIFICATION FOR COVID-19
ventilation
TRANSMISSION
• Non-invasive ventilation e.g.
• Stratify patients based on the risk BiPAP, CPAP, high nasal flow
• Perform surgery now vs. Delay the oxygen
• Open suctioning of airways
surgery
• Manual ventilation
• Nebulization
A. HIGH RISK for transmission • Sputum induction
1. Emergency procedures. • Surgical procedures using high
Emergency procedures during speed/ high energy devices - e.g.
the pandemic require the high speed cutters and drills,
patients should be treated as powered instrumentation,
potentially infectious. Due to suction, microdebrider
exigency, these procedures • Tracheotomy / Tracheostomy
would have to be done
regardless of any symptom
screening or SARS-COV-2
testing

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 10
 3. Low risk procedures on SARS COV 2 AND THE OPERATING
symptomatic patients who ROOM
tested positive on RT-PCR for
SARS-COV-2 -equipment/devices to filter the circulating air
4. Patients in whom RT-PCR is
recommended but cannot be
done or results are unavailable
at the time of intended surgery.

B. LOW RISK for transmission

1. Asymptomatic patients who will
undergo low risk surgery
2. Low risk procedures among Best practice for mitigating possible
symptomatic patients who infectious transmission during open,
tested negative for SARS-COV- laparoscopic and endoscopic procedures is
2 RT-PCR to use a multi-faceted approach
3. High risk procedure on
symptomatic patients but • Proper room filtration and ventilation
SARS-COV-2 RT-PCR is • Appropriate PPE
negative • Smoke evacuation devices with
suction and filtration system

Aerosol Boxes during Intubation

• To protect the anesthesiologist from
aerosolized particles

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 11
Portable ULPA Filter for Smoke • Surgical mask
LOW RISK for
Evacuation during Laparoscopy • Sterile, water-
transmission
-attached to trochars during laparoscopy; impermeable, surgical
gown
smoke gets into the trochar and gets filtered
• Face shield or goggles
• Sterile surgical
gloves*
• Head cap

*use double gloves if double gloving is part of

institutional policy when performing surgery

Personal Protective Equipment to be used

by Healthcare Workers in the Operating
Room during the COVID-19 Pandemic

HEALTHCARE PPE
WORKER

Surgeon(s) Based on risk (Low risk vs.

High risk)

OR nurse, Based on risk (Low risk vs.

technicians High risk)
Minimum recommended personal Anesthesiologist Follow PPE
protective equipment to be used based on recommendations for HIGH
risk of COVID-19 transmission during RISK for transmission
surgery
LOW RISK
-note that it does not say to postpone the
-use N95 and goggles, face
surgery, rather wear appropriate level of PPE
shield
RISK LEVEL MINIMUM PPE -use additional PPE as
necessary (gowns or
HIGH RISK for • Fit-tested N95 gloves when in contact with
transmission mask or any blood or body fluids is
equivalent filtering anticipated)
facepiece respirator
• Sterile, water- Important: Other personnel
impermeable, should leave the room
surgical gown during bag mask ventilation
• Face shield or or intubation for general
goggles anesthesia
• Sterile surgical
gloves* Operating Room Gown, gloves, face shield,
• Head cap Cleaners surgical mask

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 12
Administrative Control in the Hospital
-color-coded areas which signifies who are
the persons that need to be there and what
time of PPE is required
ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S
Definition of Terms
Personal Protective Equipment (PPE) -
includes any gear to protect against infection
(gloves, face masks, N95 mask/respirators,
goggles, face shield, gowns, scrub suits,
coveralls, shoes, booties/shoe covers)
Level Surgical mask, alcohol
1 handwash/spray, goggles or face
shield
Level Surgical mask, alcohol
2 handwash/spray, goggles or face
shield
Level N95 mask (or PAPR), goggles or
3 face shield, gloves, surgical cap,
scrub suits, gowns (or coveralls)
shoe cover
Level N95 mask (or PAPR), goggles or
4 face shield, double gloves, surgical
cap, scrub suits, gowns (or
coveralls), dedicated shoes, shoe
cover
Powered Air Purifying Respirator (PAPR) -
protects the user by filtering out contaminants
in the air and uses a battery-operated blower
to provide the user with clean air through a
tigh-fitting respirator, a loose-fitting hood, or a
helmet
| 13
*take note that there is no postponement of seeing patients, rather wear proper PPE
When in doubt, choose level 4 PPE

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 14
Followed / Recommended by WHO, CDC, and, Philippine College of Surgeons

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 15
Q&A specifically affect different
organs/systems.
1. How many days or weeks after the RT-
PCR do we schedule for surgery 8. Fecal-oral route of infection may be
possible
a. RTPCR is time sensitive,
patients are encouraged to 9. Hematologic spread may be the cause
isolate themselves. The result of the COVID19 virus in other organs.
of the test usually comes out 3-
5 days. There is enough time
between the initial swab for the
test and the time for the result
to come out for any
patient/person to be infected by
the virus. So an RT-PCR test is
only truly negative if the patient
isolated themselves after the
initial swab and had no contact
that could have exposed them
to the virus. If the patient
followed this, the surgery would
be done the day after or asap.
2. Not all patients would develop GI
complications.
3. There is still no absolute findings about
the relation between COVID19 and the
GIT.
4. The full spectrum of COVID19 would
end with the micro thrombosis, but it
does not mean all patients would
develop such condition. It depends on
the patients’ immune system, stage of
the disease, the time of treatment and
others.
5. There is no immunity to COVID19,
thus reinfection is possible.
6. 2 RTPCRs in a span of 5days with
negative results
7. At present, there is no data that would
imply that there are different strains of
the COVID19 virus that would

ririshinotsuka | m j r s | SiyangKita | H R Y M N W R | J A A S | 16