Shared experience from China - an interview with Xiaohua Jiang

Consultant colorectal surgeon and ESCP’s Communication Chair, Richard Brady, interviews Xiaohua Jiang MD, Ph.D, Professor of Surgery and Vice Dean at the Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University, as part of ESCP’s ongoing #COVID19ESCP campaign. Xiaohua Jiang shares his experience from China, discussing the treatment of patients and working procedures during this unprecedented time.

ESCP would like to thank Nick Crockatt and Frankenman in assisting with the delivery of this interview.

Firstly, can I ask, there are some reports that almost half of the patients who present have nausea, anorexia, abdominal pain or other gastrointestinal symptoms, and that in some this was the only symptom – did you experience this pattern in patients?

Yes, like other virus infection disease, patients infected by COVID-19 can have gastrointestinal symptoms including nausea, anorexia, abdominal pain and diarrhea,mainly because ACE2 receptor is also highly expressed in gastrointestinal organs. Report from three hospitals in Wuhan showed that 48.5% patients with COVID-19 had gastrointestinal symptoms and these symptoms included nausea (83.8%), diarrhea (29.3%), vomitting (0.8%) and abdominal pain (0.4%).

Actually in fever clinic of our Shanghai East Hospital, we experienced one patient with fever and diarrhea, but without respiratory symptoms, his COVID-19 PCR test was positive.

So now in our out-patient clinic, patients with fever and gastrointestinal symptoms will go to see fever clinic, despite of routine blood test including WBC, lymphocyte and CRP and routine stool test, chest CT scan will be checked and COVID-19 PCR will also be tested.

How did you approach surgical patients who presented with common surgical conditions during this time? For example, appendicitis - did you modify any management or make changes due to the COVID-19 pandemic surge and the implications of potential infection?

According to the condition of patients, emergency patients are divided into three situations: urgent emergency operation, emergency operation and conservative observation, with different diagnosis and treatment paths.

The urgency of emergency treatment in different general surgery is not the same. The longer the time from admission to operation is allowed, the more adequate preoperative preparation and the easier the work of protection will be carried out. According to the urgency of emergency surgical treatment, the emergency of general surgery can be divided into three situations: the need for emergency surgery as soon as possible, the need for emergency surgery and non-surgical conservative treatment. The cases that need emergency operation usually include abdominal parenchymal organ injury and active bleeding caused by traffic accident, abdominal penetrating firearm injury, various complex injuries, etc. First aid operations are usually life-saving. Patients may have been in shock and coma. There are some problems, such as lack of epidemiological data, difficulty in collecting medical history, and inability to perform COVID-19 PCR test before operation. Once surgeons encounter this kind of situation, we need to immediately report to the infection control management department. All medical staff who participate in the rescue should be well protected according to the regulations and then undergo emergency operation. During the epidemic period, more emergency patients in general surgery are usually acute appendicitis, incarcerated inguinal hernia, gastrointestinal perforation, mechanical intestinal obstruction, acute cholecystitis, etc. For such emergency patients, there is usually a certain time for preoperative preparation. We should carefully inquire about the epidemiological history, whether there is fever, the time sequence of abdominal symptoms and fever, whether there is respiratory symptoms, and complete necessary auxiliary examinations before operation, including blood routine, CRP, procalcitonin, electrolyte and liver and kidney functions, . COVID-19 PCR test and pulmonary CT examination should be done. Operation can be performed after excluding COVID-19 infection. The COVID-19 test is recommended for non operative treatment in the general surgical emergency. It is suggested that non-surgical treatment should be the first choice to reduce the risk of infection, such as ultrasound puncture and drainage of abdominal abscess, biliary PTCD puncture and drainage for acute suppurative obstructive cholangitis, PTGBD drainage for acute suppurative cholecystitis, and interventional embolization for acute abdominal bleeding.

How did surgical teams deal with other surgical conditions during this unfortunate time, such as cancers requiring operations?

Evaluate the risk of operation and carry out surgery carefully

The novel coronavirus pneumonia patients have high risk of death during perioperative period, and infection protection is very challenging during the operation, according to data from Wuhan Union Hospital gastrointestinal surgery. Therefore, surgical treatment should be extra cautious under current conditions. With the situation of epidemic control, in the process of operation in each center, we should pay more attention to the preoperative screening and isolation observation of patients. The pre-treatment screening should at least include body temperature, epidemiology, clinical manifestations and so on. The isolation observation time before treatment should be prolonged as appropriate. The chest CT Reexamination must be improved before operation. The basic screening should also be improved.

Adjust treatment plan and waiting time

The treatment plan should be made according to the patients' wishes and combined with tumor type and disease stage. Generally speaking, the doubling rate of patients with early cancer is slow. Taking gastric cancer as an example, the median time from early development to advanced stage is 34-44 months, and the flexibility of delayed operation is large. For the patients whose waiting time has a great influence on the treatment outcome, we can adjust the treatment plan through MDT discussion, start chemotherapy and other anti-tumor treatment as early as possible, and achieve the purpose of delaying surgery and reducing risk. In the aspect of operation plan, considering the recovery , blood preparation and other supporting supplies, we should pay attention to control the scope of operation and shorten the operation time. If conditions permit, endoscopic intervention and other less invasive intervention methods can be given priority.

How did you investigate surgical patients in who you suspected COVID-19?

For patients who are going to be operated, novel coronavirus pneumonia should be understood: whether there is a history of residence / tourism within 14 days in Wuhan or other epidemic area, whether there is a suspected or confirmed history of contact with COVID-19 patients, whether it is one of the cases of clustering disease (over 2 cases, fever, respiratory symptoms and suspicious imaging changes).

We should carefully inquire about whether there is fever, respiratory symptoms or abdominal symptoms, especially diarrhea. Complete auxiliary examinations should be performed including blood routine, CRP, procalcitonin. COVID-19 PCR test and pulmonary CT examination should also be done.

What preparations or special conditions did you use in the operating theatre when operating on COVID-19 patients?

1. Operation room preparation
   The operation can only be carried out in a negative pressure operating room with a negative pressure value of less than 5 PA. Warning signs of "COVID-19" are hung outside the operating room. Remove the articles irrelevant to the operation from the operating room, and prepare protective articles: N95 mask, protective clothing, disposable surgical clothing, goggles, protective screen, long shoe cover, etc. According to the needs of operation, prepare necessary sterile instrument set, disposable sterile dressing set, disposable sterile medical supplies, etc. Special preparation of negative pressure smoke suction device. After the operation, the nurses in the buffer front room are responsible for delivering the required materials to the room, and at the same time, the second level protection is implemented. The surgeons, scrubbing nurses, anesthesiologists and patrol nurses enter the buffer front room, implement hand hygiene, and implement the third level protection.
2. Wear protective equipment
   It is an important measure to prevent cross infection for medical staff to wear medical protective equipment.
3. Equipment disinfection
   Transfer wheelchair, mobile bed and other equipment with special marks, and replace disposable bed sheet and quilt cover. After the equipment is used, the wipes and disposable articles after disinfection are discarded in the double-layer medical waste packaging bag and treated as infectious medical waste.
4. Intraoperative protection
   In addition to the personnel necessary for the operation, the access of personnel irrelevant to the operation shall be strictly restricted. Surgeons and scrubbing nurses should wear double-layer latex gloves. It is recommended to use stab proof needles during the operation and deliver sharp instruments without contact to avoid occupational exposure. During the operation, smoke should be drawn and discharged in time to avoid aerosol damage. If masks, goggles or protective screens are splashed by blood or body fluids, they should be replaced in time.
5. Final treatment in operation room
   The treatment of the operation room after operation is an important work to avoid cross infection. In addition to the treatment of all the things in the room and the ground, replace the return air and exhaust air filter screen and the internal filter of the purification unit. Do a good job of medical waste classification and standardized treatment.

Did you see any change in the surgical outcomes or infections of COVID-19 positive surgical patients compared to non-surgical patients?

The novel coronavirus pneumonia was diagnosed in six cases of gastrointestinal diseases in the Department of Gastroenterology, Tongji Medical College, Huazhong University of Science and Technology since mid January 2020. Among them, two cases died. Three out of six patients occurred fever occurred after radical operation of gastrointestinal tract. One case died of respiratory failure after fourteenth days of diagnosis. One case died of septic shock and MODS 11 days after admission.

After operation, the patients are easy to be infected because of trauma stress and immune defense. For patients with postoperative fever, we should attach great importance to and actively examine and differentiate them. Combined with novel coronavirus infection, the fever of patients, the changes in various inflammatory markers (leukocyte, neutrophils, lymphocytes, C-reactive protein and procalcitonin) and drainage tube were comprehensively judged as heat absorption or fever caused by anastomotic leakage, abdominal infection or COVID-19 infection. For patients with postoperative dyspnea, decreased blood oxygen saturation, etc., it should also be distinguished from pulmonary embolism and other complications. In addition, before the removal of abdominal drainage tube,despite routine abdominal and pelvic CT examination, it is recommended to add lung CT to know whether there is any relevant imaging changes of COVID-19. Before the diagnosis of the suspected cases, single room isolation treatment should be given, and the patients should be transferred to the isolation area as soon as possible after the diagnosis of nucleic acid test.

What ways did surgeons and their team protect themselves in theatre?

1. Operation should be done in a negative pressure operating room with separate pass. Operation observation is forbidden.
2. Operation sheets should be once used with waterproof.
3. Personal protective equipment shall be equipped in accordance with level III protection standards.
4. Wearing process of personnel on the operating table (wearing two-layer surgical cap, three-layer sterile gloves, two masks, two pairs of shoe covers, two disposable surgical gowns, one medical protective clothing, one goggles, one protective screen and one boot cover).
   • Step 1: Enter the operating room, disinfect hands, change protective slippers, and enter the dressing room. Wash hands in seven steps, change personal clothes, wear hand washing clothes, remove personal articles such as jewelry, watches, mobile phones, etc., and wear disposable surgical caps
   • Step 2: Wear medical protective mask and do tightness test
   • Step 3: Wear goggles, shoe covers and disinfect hands
   • Step 4: Enter the buffer zone after self-inspection. Hand disinfection, inspection of medical protective clothing (model, integrity, etc.), wearing disposable medical protective clothing
   • Step 5: Disinfect hands, wear the first layer of sterile gloves, cover the cuff of protective clothing, and use adhesive tape to fix the cuff if necessary
   • Step 6: Wear disposable surgical cap
   • Step 7: Wear disposable surgical mask
   • Step 8: Wear disposable surgical clothes
   • Step 9: Disinfect the hands, wear the second layer of sterile gloves, and cover the cuff of disposable surgical clothes
   • Step 10: Wear a protective screen
   • Step 11: Wear waterproof boot cover
   • Step 12: Wear outer shoe cover
   • Step 13: Disinfect the hands, confirm the wearing effect with the help of others, check whether all personal protective equipment is complete, intact and appropriate in size, ensure that the two layers of medical personnel are tightly protected and the body is not exposed, and enter the operating room after self-inspection by the mirror
   • Step 14: Disinfect surgical hands (disinfect hands and wrists with hand sanitizer, i.e. the scope of the second pair of gloves), and wear disposable sterile surgical clothes
   • Step 15: Wear the third layer of sterile gloves, and cover the cuff of sterile surgical gown.
5. Measures to prevent aerosol transmission
   • The electrosurgical smoke generated by the use of the electrosurgical equipment will form aerosols. During the operation, an aspirator can be used to absorb the smoke, but the suction operation can also cause the generation of aerosols. Therefore, it is recommended to reduce the negative pressure suction operation during the operation, and use the electrosurgical smoking device to reduce the diffusion of aerosols.
   • Closed negative pressure suction system shall be used. The disposable negative pressure suction bag shall be added with effective chlorine containing disinfectant of 5000mg/L~10000mg/L according to its volume before operation, sealed and sealed after operation, and treated as infectious medical waste.
   • Endoscopic surgery should be minimized, because there is no evidence to rule out whether the leakage of pneumoperitoneum pressure in endoscopic surgery belongs to aerosol transmission path, and whether there is the possibility of increasing the risk of infection of the operating personnel.

How did the hospital staff ensure that all staff remained healthy at the time - how did you avoid fatigue?

1. The hospital staff coming back from abroad and other Chinese provinces with COVID-19 key area should isolate themselves for 2 weeks.
2. The hospital staff should report to the hospital if there are family members coming back from abroad and other Chinese provinces with COVID-19 key area.
3. The hospital staff should report their own health status via Wechat Mini Program everyday including temperature, respiratory and gastrointestinal symptoms.
4. There is only one entrance for hospital staff to enter and temperature will be taken for each people everyday.
5. If the staff have high temperature and some other respiratory or gastrointestinal symptoms, they need to stop to work and go to see fever clinic.

Regarding avoiding fatigue, in the beginning of COVID-19 outbreak, because of critical shortage of hospital staff, to tell the truth, it was not possible to avoid fatigue, and with more and more hospital staff from other provinces to help Wuhan, it had change rapidly soon. The hospital staff can have 1-2 days of rest after 6-8 hours of work. The hospital also set up pressure monitor system and pressure management methods to help the hospital staff.The government and hospital provided quiet and pleasant places for the staff to rest. The meals also were provided. The last but not least, specialists for infectious control team monitor occupation exposure of hospital staff everyday to protect them from COVID-19 infection.

Did surgeons commonly undertake any other duties at the time of the COVID-19 surge?

Yes, in Feb 2020, some surgeons were sent to Wuhan for helping local doctors to treat patients with COVID-19 because of critical shortage of hospital staff. They not only worked in mobile cabin hospitals, some with experience of ICU care even worked in ICU for treating critically ill patients. In Shanghai, some surgeons also need to work in fever clinic. And Now, some are sent to work in isolated points for foreigners and Chinese citizens flying to Pudong international airport from other countries.