Discussion
This study provides a series of frames of the impact of the COVID-19 pandemic on the Italian surgical community and the response attitudes that surgeons have implemented to face this health crisis. The peculiarity of this survey is that it has taken three photographs of each of the three different phases of the pandemic: the first one, in correspondence with the first global pandemic wave (March–May 2020), the second (June–September 2020) in a period of relative calm in the spread of the virus and a third phase (October–December 2020) which saw the second wave of the pandemic in Italy.
The comparative analysis of what happened in the three phases allowed us to understand how surgeons have changed and evolved their practice, which recommendations have been adopted, and which ones could be modified.
In particular, this survey aimed to analyze three aspects. The first one, concerning the reorganization of surgical departments, the number of operations performed in elective and emergency settings, and the surgical technique used. The second one, regarding the COVID-19 screening methods, intending to improve their availability and reliability. The third aimed to explore how surgeons' attitudes in the operating room had changed: which and when PPEs were used, the use of SEDs for the safe management of the pneumoperitoneum during laparoscopy, and the use of HEDs.
This survey's first significant strength is the high response rate obtained: 50% of the departments invited to participate have signed up with their data. This makes us confident that the respondents reflect the attitudes of the Italian surgical population. A meta-analysis by Shih and Fan showed that the average response rate for email surveys is 33% [
13], and a recent report demonstrated that surveys administered on a surgical topic are expected to get a low response rate if given electronically (36.4%) and nationally (42%) [
14].
Our response rate vastly exceeds this limit. The answers obtained bring out the Italian surgical departments' reality and offer a realistic and reliable picture of how the surgical community has reacted to the COVID-19 pandemic.
A first important aspect that emerges from the analysis of the responses is that after nine months from the beginning of the pandemic, we are still far from returning to the volumes of surgical activity of the pre-COVID-19 era. Moreover, the survey showed that almost all Italian hospitals had maintained a mixed configuration in managing positive and negative COVID-19 patients. These data contrast with the recommendations to identify hospitals or defined pathways that are COVID-19-free, where it is possible to continue to manage all patients suffering from other diseases who need treatment. For surgical patients, the CovidSurg group demonstrated that postoperative pulmonary complication rates were lower for patients in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic [
15].
As already reported by previously published surveys [
16,
17], in the first pandemic phase, there was an apparent reduction in the activity of the surgical departments, primarily with the reduction in the number of effective beds dedicated to surgical activity: overall the 59% of surgical departments reduced their beds' availability, and 11.9% of them were closed during the phase I of the pandemic. The goal was to redirect nursing and medical-surgical staff to the management of COVID-19 patients, as demonstrated by the fact that about 50% of the departments had at least one member of their staff referred to the care of COVID-19 non-surgical patients.
It is worth noting that, although there has been an improvement in phase II, with the advent of the second pandemic wave, Italian surgical departments have experienced a return to a scenario that is similar to that of phase I: 7.7% of the surgical departments are still closed in phase III, 55.4% of the respondents declared that they still had fewer than 20 beds assigned to a surgical activity, and the range of 20–30 beds, the most represented in the pre-COVID-19 era (47.6%), remained stably reduced at 30%.
Consequently, in the first and third phases, there was a significant reduction in the elective surgical activity, which means that we are currently still not able to guarantee timely cures for a series of surgical pathologies, including tumors. Regarding emergency surgery, there was an even more significant contraction of the activity. The inevitable collateral damages that the pandemic brings are the diagnostic delays, the increase in the diagnosis-to-treatment interval for neoplastic diseases, and the delay between neoadjuvant treatment and surgery [
16,
18].
Since some studies [
19,
20] had investigated the possibility of viral aerosolization (HPV, HBV, HIV) by both pneumoperitoneum and surgical smoke during laparoscopic surgery, some had suggested not to use laparoscopy [
10,
21,
22], even if there is no evidence that SARS-CoV-2 could spread by aerosolization. As it is well known, laparoscopic surgery represents the best choice of treatment for many disease [
23,
24] and the standard rate of laparoscopic procedures in Italy ranges from 35% up to 60–80% in high-trained departments [
25‐
27]. The range of 50–80% of operations performed by laparoscopy in our survey had dropped to 22.3% in the first phase, highlighting that such recommendations had a strong impact during the first pandemic phase.
However, in phases II and III, Italian surgeons have resumed performing laparoscopic surgery more frequently. This is because during phase II, under the pressure of the surgical community, several published articles have reduced the strength of this recommendation [
28,
29].
Therefore, the new recommendation is to use laparoscopy when there is a clear benefit for the patient, within a well-trained team, and with the adoption of every protective device, such as PPE and SEDs [
30,
31].
The present survey has also highlighted that surgeons have quite understood the need to protect themselves using the necessary PPE with the use of glasses/facial shield and FFP2 or FFP3 masks during the unfolding of the pandemic. In the first phase, there was a shortage in the availability of these PPE [
32], but even subsequently the increase in their use was mild and with no statistically significant difference.
Conversely, almost 40% of the respondents have never adopted SEDs in all three phases. This means that the recommendations on the appropriate way of managing the pneumoperitoneum and the surgical plume were not followed appropriately. In this scenario, it is unclear whether laparoscopic smoke represents a greater risk than that created during open surgery [
20]. Even in open surgery, there would be a dispersion of surgical plume, which has the same potential to carry viral transmission compared to laparoscopy [
33]. Therefore, even in open surgery, devices dedicated to surgical smoke aspiration should be adopted, and it becomes more complex to control rather than inside a closed abdomen [
34].
Likewise, little or nothing has been implemented by the advice to reduce the use of specific HEDs, reduce aerosolization of particles, and the potential risk of viral emission. On the contrary, our survey shows that in the development of the three phases, the percentage of those who followed this recommendation was increasingly lower. Italian surgeons have perceived that recommendations against the use of laparoscopy or some HEDs seem to be linked more to theoretical and physio-pathological considerations than to real data [
28,
35].
Regarding the screening policies, it is clear that there has been a progressive enhancement of testing the patient before entering the ward or operating room. The percentage of departments that performed molecular tests on a nasopharyngeal swab in phase I was 81% for elective patients and 77.9% for those admitted in an emergency setting. This percentage rose to 87.6% and 81.9%, respectively, in the second phase and even more in the third: 90.7% and 85.4%.
All departments currently perform screening tests on their incoming patients, but it should not be ignored that 10% of responders still do not use the molecular swab test to check patients' negativity. The ACIE Appy Study [
36] reported that, during the first pandemic wave, about half of the respondents screened surgical patients only in case of respiratory symptoms and that 12% did not test patients in emergency admission at all. This opens the debate not only on the surgeon's but also on the patient's safety, as the increased rate of postoperative complications for positive asymptomatic patients is well demonstrated [
37,
38].
This survey shows that the percentages of positive COVID-19 patients' interventions always remain low both in the elective and emergency settings. Knowing if the patient has contracted a COVID-19 infection is also crucial for deciding to proceed with conservative treatment, where possible, and to postpone surgery [
38,
39].
Despite response rate was among the highest for an online survey, the first limitation is that the kind of study does not allow us to gain strong evidences. Furthermore, there are no data collecting of the pre-COVID-19 situation that can be directly compared with the answers obtained. Similarly, the use of ranges instead of absolute numbers gave us a more approximate evaluation and sometimes not very representative data.
Acknowledgements
Collaborative Group: Adelmo Antonucci, Claudia Zanframundo, Fabio Cavallo, Giorgio Mazzarolo, Antonio Agrusa, Giuseppe Di Buono, Luca Aldrighetti, Guido Fiorentini, Alessandro Lucianetti, Stefano Magnone, Sergio Alfieri, Fausto Rosa, Donato F. Altomare, Arcangelo Picciariello, Amilcare Parisi, Antonio Di Cintio, Marco Francesco Amisano, Francesca Cravero, Michele Ammendola, Giorgio Ammerata, Alessandro Anastasi, Giuseppe Canonico, Andra Gattolin, Elisabetta Travaglio, Andrea Sartori, Massimiliano De Palma, Pierluigi Angelini, Francesco Galante, Angelo Benevento, Stefano Rausei, Angelo Serao, Francesca Abbatini, Mario Annecchiarico, Antonio Varricchio, Valerio Annessi, David Tumiati, Alfredo Annicchiarico, Antonello Mirabella, Marco V. Marino, Antonino Spinelli, Antonio Braun, Hong Tham Santi, Lucia Romano, Michele Antoniutti, Mariano Fortunato Armellino, Giulio Argenio, Augusto Verzelli, Andrea Budassi, Gianluca Baiocchi, Marie Sophie Alfano, Alessandro Balani, Marco Barone, Gianandrea Baldazzi, Diletta Cassini, Ruben Carlo Balzarotti Canger, Gianpietro Zabbialini, Andrea Belli, Francesco Izzo, Franco Bertolino, Marco Brunetti, Francesco Bianco, Antonio Cappiello, Luigi Boccia, Bernardo Boffi, Federico Perna, Stefano Bonilauri, Giuseppe Frazzetta, Pierpaolo Bordoni, Francesco Fleres, Felice Borghi, Giorgio Giraudo, Vincenzo Bottino, Alfonso Canfora, Fabrizio Briganti Piccoli, Luca Calligaris, Bruno Nipote, Aniello Gennaro Nasti, Andrea Bufalari, Francesca Bettarini, Massimo Buononato, Marco Greco, Pietro Giorgio Calò, Fabio Medas, Eugenia Cardamone, Pasquale Castaldo, Massimo Carlini, Domenico Spoletini, Carlo De Nisco, Fabio Pulighe, Carlo V. Feo, Nicolò Fabbri, Carmine Antropoli, Fabrizio Foroni, Maurizio Carnazza, Salvatore Ragazzi, Elisa Cassinotti, Luigi Boni, Fausto Catena, Mario Giuffrida, Gennaro Perrone, Christian Ccotsoglou, Stefano Granieri, Graziano Ceccarelli, Walter Bugiantella, Carla Cedolini, Luca Seriau, Maurizio Cesari, Alessandro Contine, Osvaldo Chiara, Stefania Cimbanassi, Eugenio Cocozza, Mattia Berselli, Corrado Fantini, Renato Costi, Lorenzo Casali, Andrea Morini, Francesco Crafa, Serafino Vanela, Giuseppe Currò, Vincenzo Orsini, Corrado Da Lio, Mario Biral, Piergiorgio Danelli, Claudio Guerci, Dario Scala, Graziella Marino, Luciano De Carlis, Andrea Lauterio, Donato De Giorgi, Gianluca Sciannamea, Nicolo De Manzini, Pasquale Losurdo, Maurizio De Palma, Nicola Sangiuliano, Maurizio Degiuli, Franco Caterina, Paolo Del Rio, Elena Bonati, Stefano Di Lernia, Marco Vittorio Rossi Ardizzone, Salomone Di Saverio, Caterina Franchi, Beatrice Di Venere, Rosanna Miglio, Diego Cuccurullo, Carlo Sagnelli, Ludovico Docimo, Salvatore Tolone, Mauro Longoni, Giuseppe Faillace, Fabio Rondelli, Francesca Pennetti Pennella, Vincenzo Colucci, Teresa Carfora, Irnerio Angelo Muttillo, Biagio Picardi, Rossi Stefano, Roberto Campagnacci, Angela Maurizi, Fausto Tricarico, Marco Montagna, Elio Amedeo, Michela C. Scollica, Enrico Lauro, Ernesto Laterza, Enrico Molinari, G. Berta, Dario Bono, Massimiliano Fabozzi, Mafalda Romano, Enzo Facci, Dario Parini, Roberto Farfaglia, Valeria Arizzi, Marco Farsi, Egidio Miranda, Landino Fei, Giordano Flavio, Felice Pirozzi, Antonio Sciuto, Alessandro Ferrero, Marco Palisi, Marco Filauro, Andrea Barberis, Antonio Azzinnaro, Valentino Fiscon, Silvia Vigna, Michele D'ambra, Emanuele Pontecorvi, Gabriele Anania, Cristina Bombardini, Gennaro Galizia, Annamaria Auricchio, Francesca Cardella, Michele Genna, Sergio Gentilli, Nikaj Herald, Giampaolo Castagnoli, Alberto Bartoli, Luca Gianotti, Mattia Garancini, Giovanni Bellanova, Paola Palazzo, Giovanni De Palma, Marco Milone, Giovanni Ferrari, Carmelo Magistro, Antonio Giuliani, Giuseppe Di Natale, Giuseppe Brisinda, Giuseppe Cavallaro, Giuseppe Sammarco, Gaetano Gallo, Orlando Goletti, Daniele Macchini, Vincenzo Greco, Vincenzo Amoroso, Gianluca Guercioni, Michele Benedetti, Guglielmo Guzzo, Francesco Pata, Ildo Scandroglio, Francesco Roscio, Elio Jovine, Raffaele Lombardi, Francesco La Rocca, Francesca Di Capua, Carmine Lanci, Renzo Leli, Andrea Borasi, Pasquale Lepiane, Andrea Balla, Edoardo Liberatore, Luca Morelli, Gregorio Di Franco, Andrea Lucchi, Laura Vittori, Luigi Bonavina, Emanuele Asti, Dario Maggioni, Gerosa Martino, Giuseppe Manca, Antonella Delvecchio, Manfredo Tedesco, Denise Gambardella, Salvatore Marafioti, Maria Luisa De Marco, Marco Azzola Guicciardi, Massimo Motta, Marco Calgaro, Vincenzo Adamo, Mario Guerrieri, Pietro Coletta, Monica Ortenzi, Gennaro Martines, Giuliano Lantone, Mario Martinotti, Giuseppe Fassardi, Maurizio Castriconi, Simone Squillante, Maurizio De Luca, Maurizio Pavanello, Carlo Di Marco, Maurizio Ronconi, Silvia Casiraghi, Vincenzo Mazzaferro, Carlo Battiston, Michele Perrotta, Carmine Ripa, Micheletto Giancarlo, Valerio Panizzo, Paolo Millo, Riccardo Brachet Contul, Valentina Ferraro, Carlo Molino, Enrico Crolla, Gianluigi Moretto, Matilde Bacchion, Mario Morino, Marco Ettore Allaix, Enrico Motterlini, Michele Petracca, Andrea Muratore, Mario Musella, Antonio Vitiello, Bruno Nardo, Veronica Crocco, Giuseppe Navarra, Salvatore Lazzara, Giuseppe Giovanni Navarra, Manuela Cuoghi, Stefano Olmi, Alberto Oldani, Matteo Uccelli, Enrico Opocher, Marco Giovenzana, Paolo De Paolis, Mauro Santarelli, Paolo Delrio, Fabio Carbone, Paolo Pietro Giampaolo Bianchi, Formisano, Patrizio Capelli, Edoardo Baldini, Patrizio Festa, Arianna Mottola, Michele Perrotta, Giovanni Merola, Nicola Perrotta, Marta Celiento, Eraldo Personnettaz, Stefania Muzio, Tommaso Petitti, Antonietta Melchiorre, Micaela Piccoli, Francesca Pecchini, Alice Frontali, Piergiorgio Danelli, Anna Maffioli, Pietro Maida, Pasquale Tammaro, Giusto Pignata, Jacopo Andreuccetti, Vincenzo Pilone, Michele Renzulli, Salvatore Pintaldi, Andrea Pisani Ceretti, Nicolò Maria Mariani, Adolfo Pisanu, Roberto Polastri, Fabio Maiello, Alberto Porcu, Teresa Perra, Felice Mucilli, Mirko Barone, Roberto Troisi, Roberto Montalti, Fabrizio Scognamillo, Daniele Delogu, Raffaele Galleano, Michele Malerba, Raffaele Salfi, Marcello Pisano, Raffaele Sechi, Nicola Cillara, Salvatore Ramuscello, Eugenio De Leo, Enrico Restini, Rocco Tumolo, Pasquale Cianci, Sabino Capuzzolo, Maurizio Rizzo, Alfonso Recordare, Roberto Santoro, Pietro Maria Amodio, Aldo Rocca, Giuseppe Cecere, Raffaele Romito, Luca Portigliotti, Riccardo Rosati, Ugo Elmore, Domenico Russello, Saverio Latteri, Salvatore Maria Costarella, Salvatore Massa, Lorenzo Capasso, Michele Santangelo, Maurizio Sodo, Giuliano Sarro, Umberto Rivolta, Stefano Scabini, Davide Pertile, Federico Selvaggi, Selene Rossi, Francesco Selvaggi, Gianluca Pellino, Gabriele Sganga, Pietro Fransvea, Silvio Testa, Clemente De Rosa, Walter Siquini, Cristian Tranà, Mario Solej, Stefano Bolzon, Enrico Guerra, Marco Stella, Francesco Ferrara, Francesco Stipa, Enrico Stringhi, Andrea Celotti, Lucio Taglietti, Roberto Del Giudice, Carlo Alessandro Talarico, Michele Ruggiero, Giuseppe Tirone, Uberto Fumagalli Romario, Wanda Petz, Valerio Caracino, Valentina Rossetti, Luca Andrea Verza, Fabio Cavallo, Lorenzo Vescovi, Michele Marini, Nereo Vettoretto, Emanuele Botteri, Leonardo Vincenti, Giusy Giannandrea, Tiziana Viora, Lorenzo Maganuco, Paolo Veronesi, Bruno Zani, Giacomo Zanus, Marco Brizzolari, Federico Zanzi, Anna Guariniello, Marco Antonio Zappa, Elisa Galfrascoli, Sandro Zonta, Luigi Oragano, Walter Zuliani, Damiano Chiari.