Management of non traumatic surgical emergencies during the COVID-19 pandemia

In December 2019, in Wuhan, China, the first cases of what would be known as COVID-19, a disease caused by an RNA virus called SARSCoV-2, were described. Its spread was rapid and wide, leading the World Health Organization to declare a pandemic in March 2020. The disease has distinct clinical presentations, from asymptomatic to critical cases, with high lethality. Parallel to this, patients with non-traumatic surgical emergencies, such as acute appendicitis and cholecystitis, continue to be treated at the emergency services. In this regard, there were several doubts on how to approach these cases, among them: how to quickly identify the patient with COVID-19, what is the impact of the abdominal surgical disease and its treatment on the evolution of patients with COVID-19, in addition to the discussion about the role of the non-operative treatment for abdominal disease under these circumstances. In this review, we discuss these problems based on the available evidence.


INTRODUCTION
C OVID-19 is a disease caused by the SARS-CoV-2 virus, an RNA virus. It was initially described in Wuhan, China, in December 2019. In January 2020, the World Health Organization understood the situation as an "international concern" and, on 3/11/2020, as a pandemic. At the time of writing this text (May 15, 2020) there are around 4.5 million cases in the world, and approximately 300,000 deaths. The first case in Brazil was documented on 2/25/2020, in the City of São Paulo. Although there is a characteristic curve for the evolution of the disease, it has developed differently in the various the states of Brazil, suggesting that each area may be at a different moment in its evolution 1,2 .
It is also known that non-traumatic abdominal surgical emergencies (NTSE) are very common and are likely to continue to appear in the emergency services during the COVID- 19

Conduta nas urgências e emergências cirúrgicas não traumáticas durante a pandemia COVID-19
incarcerated hernias, intestinal ischemia and even acute hemorrhagic abdomen. They are acute diseases with significant potential for complications and deaths, in a short period of time. There is a need for quick decision making so that the best results are achieved. • Offer the safest and least invasive treatment to the patient.
• Prevent contamination of the medical and assistance team.
• Preserve the use of Personal Protective Equipment (PPE).
• Reduce the use hospital and ICU beds.
• Minimize viral transmission as much as possible.
These priorities must not compete with each other. There has to be a balance, offering the best treatment to the patient, in association with the lowest risk of contamination for the team and the greatest possible preservation of resources.
In response to these circumstances, several positive RT-PCR also had positive chest CT 16 . Of the 308 who had negative RT-PCR, more than 80% were considered probable or highly probable for COVID-19.
Of great importance, it was also seen that more than 90% of patients who had initially negative RT-PCR, and who were positive during hospitalization, had a positive chest CT early at admission.
Negative chest CT does not rule out the presence of COVID-19. In these cases, there is no way to predict the patient's evolution. In the situation under discussion, the focus should be a positive CT, as, in this context, the case must be considered suspicious and treated as such.
In the "COVID-19 Prevention and Treatment Manual", edited by Liang in 2020, it is understood that the patient with a clinical history and CT suggestive of COVID-19 should be considered and treated as positive, even if the RT-PCR is negative 13 .
Once there is a definitive or suspected diagnosis of COVID-19, it is necessary to stratify its severity 13 . It is different to discuss operative treatment in a patient with images suggestive of COVID-19 on chest CT, but without significant hypoxia, and another with respiratory failure. There will be situations of critical patients, with extreme clinical derangements, severe hypoxia, under full anticoagulation therapy and with organic dysfunctions, for whom the operative risk is considerably high. In these cases, it should be considered an inter disciplinary discussion between the involved teams and family members, making the best decision for the patient, whether it be the attempt of operative treatment even with high risk of death, maintenance of clinical treatment or palliation, as long as everyone agrees.

When to indicate the non-operative treatment?
In cases where there is no clear indication of operative treatment such as those described above, it is appropriate to discuss non-operative treatment for abdominal urgency, in a time of pandemic.
A few studies that report the evolution of patients with COVID-19 who underwent surgery justify such decision. To date, the study by Lei et al., published in 2020, serves as a reference 18  Three out of these 4 patients died 19 .
Adding to this the fact, there is the potential risk of contamination of the team (anesthetic, surgical and circulating) 1,4-10 . This contamination can occur due to the most common forms such as contact and droplets, but the main concern is at the time of tracheal intubation and during the operation, by the production of aerosols. Therefore, although non-operative treatment seems like an option, it is not so simple to predict its evolution. Table 1 shows the weighting of therapeutic options in this pandemic moment.

Operative treatment
Non-operative treatment Benefits -Direct approach to surgical disease, maintaining the proposal considered as the gold standard for the treatment of diseases such as acute uncomplicated appendicitis and acute calculous cholecystitis.
-Greater chance of resolving surgical disease, with consequent shorter hospital stay and complications.
-Less use of resources in general, complementary tests and antibiotics to control treatment.

Benefits
-Less chance of contamination of the anesthesiology and surgery team.
-Possible protection of the evolution of COVID-19 to more serious forms.
-Possibility of outpatient treatment in the simplest cases.
-Savings on PPE, in cases where outpatient treatment is possible, considering that there will be no complications. With these possibilities in mind, the results on non-operative management in some of the most frequent diseases will be evaluated.

Non-operative management (NOM) protocols
It is of utmost importance to once again highlight that the literature available proposals for nonoperative treatment should not be applied without criteria in COVID-19 patients, as they have been studied in other contexts. However, considering a pandemic situation, the information provided by previous studies is important to evaluate the expectation about the results.

a. Acute appendicitis
Nonoperative treatment for cases of acute appendicitis can be analyzed in two different groups of patients: those with periapendicular abscesses and those with uncomplicated acute appendicitis.
The diagnosis of periapendicular abscess should be considered when the patient has a longer history, usually more than seven days, and has localized pain and peritonitis. An inflammatory mass is often palpated in the region. In these cases, treatment with antibiotics and eventual percutaneous drainage of collections is -Possibly there is a greater chance of respiratory complications in patients undergoing surgical treatment.
-Greater chance of contamination by the anesthesiology team during orotracheal intubation.
-Greater chance of contamination of the surgical team in the operative act.
-Risk of surgical complications and need for ICU, with consequent longer hospital stay.

Disadvantages
-It is not the gold standard for some diseases such as acute uncomplicated appendicitis and acute calculous cholecystitis.
-Chance of local and systemic complications of these diseases, making surgical resolution at a later time more complicated.
-Real chance of death from sepsis of abdominal focus if the situation gets out of control.
-Loss of the "timing" of treatment: if the patient complicates with COVID-19, the operative treatment of abdominal disease may be rendered unfeasible.
-Longer time of antibiotics. that NOM was successful in approximately 75% of cases, while appendectomy was successful in more than 95% 29 . Since the vast majority of cases are resolved with appendectomy, it is our opinion that this is the best form of treatment.
However, in times of a pandemic, antibiotic only treatment can be considered, as it is known that 75% of the cases are successful, even without surgery.
In the Guidelines of the World Society of Emergency Surgery (WSES) of 2020, non-operative treatment for uncomplicated acute appendicitis is accepted in selected patients, as long as they are aware of and agree with the risks of this option 28    be considered, as well as the transfer of non-COVID-19 patients to other centers. If transfer is not possible, nonoperative treatment becomes the best option in cases where there is a possibility.

The decision…
Several points should be considered, which are summarized in table 2.

What if it is defined to operate?
There are several recommendations that need to be addressed, in order to preserve the safety of the

FINAL CONSIDERATIONS
Finally, it is worth mentioning that the number of publications in the last few months has been impressive. Many studies may be critized, but the fact is that a lot has been reported about COVID-19. Articles appear daily on the topic and new challenges are believed to emerge in the next months. We believe that this text is yet another invitation for reflection. Right now, although we don't have the best information, we will need to make decisions. Authors hope that the ideas presented here can help colleagues at this delicate moment.