EAES recommendations for recovery plan in minimally invasive surgery amid COVID-19 pandemic

Vol.:(0123456789) 1 3 Surgical Endoscopy (2021) 35:1–17 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- 19) presents an unprecedented crisis to the surgical community globally [1, 2]. During the pandemic, elective surgical practice was forced to rapidly decrease or even put on hold completely. As a consequence, there is a backlog of patients requiring surgical services but with limited human and institutional resources [3–8]. While health care systems are calling to resume elective surgical practice where pandemic is under control [1, 2], uncertainty remains about the duration of the pandemic, the possibility of a second wave and the extent of its consequences on surgical services and patients [9, 10]. This leaves the surgical community with unanswered clinical questions on patient and staff safety. Various guidelines and recommendations have been published on issues pertaining to adapting surgical practice during the pandemic, often with conflicting recommendations, and Other Interventional Te chniques The members of the EAES group of experts for Recovery amid COVID-19 pandemic have been included in the Acknowledgements Section. Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s0046 4-020-08131 -0) contains supplementary material, which is available to authorized users. * Alberto Arezzo alberto.ar[email protected] Extended author information available on the last page of the article 2 Surgical Endoscopy (2021) 35:1–17 1 3 whereas many may not have been based on research evidence [11–14]. Preliminary guidelines recommended against performing laparoscopic surgery to avoid putative risks of SARS-CoV2 transmission via aerosolization due to pneumoperitoneum but were later revised recommending laparoscopic surgery under restrictions [15]. Several subsequent guidelines did not recommend against laparoscopic surgery; however, they advised strict precautions such as closed circuit smoke evacuation and the use of filtering system and personal protective equipment (PPE) [16–19]. The role of MIS has been argued to be more favourable in SARS-CoV-2 positive patients, as the potential benefits of MIS might exceed the risk of pneumoperitoneum on cardiovascular and respiratory systems [20]. Furthermore, there is substantial uncertainty with regard to specific questions related to laparoscopic procedures, and structured guidance pertinent to MIS procedures is lacking. There is an urgent need for practice-based recommendations in specific clinical situations with regard to safety precautions for patients and staff amidst the COVID-19 pandemic [21]. The purpose of this EAES initiative was to generate an updated and comprehensive set of management recommendations for MIS for each subspeciality of general surgery. This consensus was also designed to document the broader experts’ opinion on how to optimize the use of human and institutional resources including the use of MIS techniques for patient benefit. Methods A steering group (SG) was formed comprising of six experts from the EAES Executive Board (AA, NF, YM, SM, DP and AP) who organized the project and guided the data synthesis. IRB approval and informed written consent were not required. The steps of the consensus process are outlined below. Identification ofdomains andformulation ofquestions The clinical questions were divided into eight domains: (i) general (ii) Hepatobiliary & Pancreatic (HPB), (iii) Bariatrics (B), (iv) Abdominal Wall (AW), (v) Endocrine (E), (vi) Upper Gastrointestinal (UGI), (vii) Lower Gastrointestinal (LGI), (viii) technology and research. Domains (ii) to (vii) were divided into two subdomains: emergency and elective. Identification ofexperts toaddress questions Fifty-Five out of EAES board members accepted the task to contribute to this project and were divided into eight subgroups organized by the domain topics and led by a designated chair (Table1). In addition, key stakeholders were invited to provide expert input into the multidisciplinary aspects of this project including anaesthesiology, radiology and oncology and were allocated to a relevant group, based on their expertise. Search methods andinclusion criteria Based on the research questions, a literature search was 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 criteria were systematic and narrative reviews, commentaries, randomized clinical trials, cohort studies and case series on the subject of surgery during the COVID-19 and other pandemic published in the English language. Search syntaxes used was (COVID OR ‘SARS CoV 2′ OR coronavirus AND surgery). Table 1 Expert group members and topic allocations Topic Leader Experts General introduction Catalin Copaescu Emina 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- Stich George Hanna, Hans Fuchs, Miloš Bjelovic, Sheraz Markar, Philip Wai Yan, Chiu, Bang Wool 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 3Surgical Endoscopy (2021) 35:1–17 1 3 Formulation ofquestions andstatements Questions were drafted and submitted to the steering group, which approved them prior to sending them to the subgroups to formulate statements in response to these questions. Statements were generated by each subgroup in each topic question of their domain. Each group was advised to include any available evidence to support their statements and when evidence was not available, experts’ opinion was considered. Each group conducted a literature research and drafted statements and recommendations in response to their research questions. The literature review was reported in accordance with PRISMA statement standards for systematic reviews and meta-analyses [22]. Statements were then submitted to the steering group (SG) who did not participate in the formulation of these statements or in the voting process. After structural editing by the SG group, all questions were unanimously approved by all experts (Table1). Voting anddata analysis The statements received from each subgroup of experts was compiled by the SG and a modified Delphi methodology process was followed to reach agreement among all the experts on all statements and recommendations [23]. EAES board members voted to declare agreement or disagreement with the statements using closed-ended questions (agree or disagree), whereas there was an option to submit free text comments. The Delphi process was implemented through the SurveyMonkey electronic platform (https ://nl.s urv e ymonk ey.com). To reduce the possibility of bias among participants, the authors of the statements and the resultant votes/comments remained anonymous. Each statement was subjected to live voting by all experts including key stakeholders and excluding the steering committee. Consensus was achieved when a statement reached at least 70% expert agreement. Statements with less than 70% agreement in the first round were returned to the expert subgroup who modified them according to the comments. The subgroups had the option to revise statements based on feedback for further voting. The results of the consensus are summarized using descriptive statistics. The manuscript was then drafted with the recommendations following completion of all voting and statement formulation and sent to all members for revision, input and approval prior to submission for publication. Results Ninety-two statements were generated by the subgroups across the eight topics. The full text literature analyses and references used to generate statements and recommendations for all topics are included as Appendix1. Eighty-four out of 92 statements (91%) were approved in the first round and further 8 modified statements were approved in the second round. Overall, the Delphi process approved 92 statements (100%) for the consensus guidelines. The questions, final recommendations and respective approval rates in each step of the Delphi processes are summarized in Table2. Initial disagreement was regarded priorities depending on local resources, the use of energy dissection devices and the risk of aerosolization, the indication for stenting for obstructed colorectal cancer, the indication of laparoscopic lavage for diverticular disease, the indication of neoadjuvant treatment for early rectal cancer in order to postpone surgery, the management of undiagnosed pancreatic lesions, the indication for intragastric balloons to postpone bariatric surgery and the indication for endoscopic therapies for achalasia and reflux disease to postpone surgery. Discussion The study achieved its objective of formulating EAES evidence-based recommendations to provide guidance on the resumption of MIS across various general surgery specialities, taking into account the serious burden on our healthcare systems caused by the COVID-19 pandemic. These statements provided descriptive safety guidance measures that should be undertaken in the recovery plan for elective and emergency surgery across all subspecialties with specific measures for MIS. In a recent survey, over 28 million patients are awaiting treatment worldwide, a number which continues to grow in the setting of new restrictions on delivery of care and a pandemic that is still evolving [24]. As this progression is expected to continue, and given the uncertainty about the ongoing pandemic, adaptive changes are required in procedure-based specialties to include safety, logistic, service relocation, economic and ethical considerations [25–30]. Through this project, consensus was achieved on all the proposed statements by the expert across the different 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 4 Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 Questions and statements Topics Questions Statement 1st round % YES 2nd round % YES Introductory questions 1. What are the appropriate measures to mitigate the risks of general anaesthesia in patients during COVID- 19 pandemic? 1. All patients requiring surgery under general anaesthesia should be tested for COVID-19 by means of RT-PCR 79% Patient safety a. Asymptomatic b. Symptomatic 2. In case of PCR testing not available, imaging modalities such as CT or US lung scan can be used as a diagnostic tool before general anaesthesia 90% 3. Surgical procedures should be carefully prioritized based on local resources, theregionalcontrol of the COVID-19 pandemic andthe patients’ medical condition 65% 98% 4. When indicated, emergency surgery should be performed in all patients regardless of their COVID-19 status 94% 5. In COVID-19 positive patients, elective surgery for cancer and progressive diseases should be considered only after a negative PCR COVID-19 test 80% 6. In case of overutilization of hospital resources alternative/holding oncological therapies could be proposed to treat cancer in COVID-19 negative patients 80% 7. In case of symptomatic patients either suspected or confirmed COVID-19 positive, regional anaesthesia techniques should be considered when possible 92% Introductory questions 2. What is the optimal surgical approach during COVID- 19 pandemic in COVID + o symptomatic? 94% Surgical approach a. In elective vs. emergency cases b. in patients with moderately to severely compromised respiratory 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 pandemic in COVID – or unknow but not suspected? a. In elective vs. emergency cases 8. General preference for minimal invasive surgery (MIS) according to guidelines should not change both in COVID-19 negative and positive patients as well as in elective and emergency settings, unless otherwise contraindicated, if adequate equipment and expertise are available 9. No a priori contraindication to a minimally invasive approach should be stated in COVID-19 positive patients with normal, mild or moderately compromised respiratory function 92% Staff protection in OR 4. What is the optimal personal protection equipment (PPE) that should be used during abdominal surgery in? 10. The OR personnel should use standard PPE when operating on a tested COVID-19 negative patient 80% 5Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 (continued) Topics Questions Statement 1st round % YES 2nd round % YES a. asymptomatic patients during COVID- 19 pandemic b. symptomatic patients during COVID- 19 pandemic c. positive patients during COVID- 19 pandemic d. in symptomatic or positive patients and Aerosol Generating Procedures (Laparoscopy/Endoscopy) during COVID- 19 pandemic 11. When any aerosol generating procedure is indicated on a suspected or confirmed COVID-19 positive patient, symptomatic or asymptomatic, the OR staff should be reduced to 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 94% 12. It is of major importance that donning and doffing is performed under self-control or direct control of a colleague 85% Specific measures in OR 5. Which Specific Operative Risk Issues to consider during abdominal surgery in symptomatic or positive patients during COVID- 19 pandemic regarding? 13. The risk of infection during laparoscopic surgery should be controlled by reducing gas leaks, the generation of smoke and by the application of surgical smoke evacuating systems 98% a. Reduce the risk of aerosol contamination during laparoscopy b. Minimizing Staff personnel c. Type of OR – COVID + OR/cleaning OR after surgery/negative pressure OR 14. In order to control gas leaks, surgeons should: use low CO2 intraabdominal pressure, perform small incisions for the access ports, limit the exchange of surgical instruments and evacuate CO2 before any abdominal wall incision 94% 15. Inorder to reduce the smoke generation during surgery in 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 65% 87% 16. COVID-19 positive or suspected patients should be operated 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 90% 6. How should we change the design of the OR block to adapt to the risks of infections in the era of COVID- 19 pandemic? 17. Disposable devices (instruments, trocars, etc.) should be preferred in COVID-19 positive or suspected patients 76% a. Negative pressure b. Distinct paths for COVID + and – patients c. Design of equipment easily disinfected or disposable covers 18. All patients admitted should follow an initial screening triage, considering history of the patient, temperature, nasal swab and chest radiogram to detect COVID-19 status 73% 19. Based on screening at admission, patients should be addressed to the COVID-19 positive, COVID-19 negative or suspected unit, as for local organization 94% 20. Distinct and separated paths should be created in any hospital for COVID-19 positive, COVID-19 negative or suspected patients 98% Specific emergency operations in the immediate post-COVID-19 pandemic 6 Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 (continued) Topics Questions Statement 1st round % YES 2nd round % YES Hepatobiliary 7. What are specific measures in hepatobiliary disorders that should be considered during COVID-19 pandemic regarding? 21. Antibiotics should be attempted as the only treatment for COVID positive/ suspected patients with severe cholecystitis and the response to treatment should be reassessed rapidly (24h) 83% a. Role of a non-operative approach (antibiotics) in cholecystitis b. Role of a non-operative approach (transhepatic drainage) in cholecystitis c. Role of a Laparo-Endoscopic Rendez-Vous (LERV) approach (orotracheal intubation) in Jaundice for CBD obstruction d. Role of non-surgical/ non-endoscopic approach (only ERCP) in Jaundiced patients 22. Transhepatic drainage should be proposed for compromised patients with severe cholecystitis, refractory to medical treatment at 24h in COVID-19 positive patients 78% 23. In COVID-19 positive patients with common bile duct and gall bladder stones a sequential approach (ERCP followed by Laparoscopy) should be preferred to a Laparo-Endoscopic Rendez-Vous (LERV) approach to reduce the risk of a prolonged anaesthesia 84% 24. Patients with obstructive common bile duct stones should be treated according to the severity of cholangitis regardless of the COVID-19 status, favouring medical treatment 77% 25. Patients with a non-calcular obstructive jaundice should be referred to tertiary centres in order to choose the best treatment (PTBD-ERCP-upfront surgery) 84% 26. Upfront surgery should not be offered to COVID-19 positive patients with non-calcular obstructive jaundice 80% 27. Cholecystectomy should be indicated in severe cholecystitis that is not responsive to conservative or interventional treatment, even COVID-19 positive patients 89% Abdominal wall hernias 8. What are specific measures in abdominal wall hernia surgery that should be considered during COVID-19 pandemic regarding? 28. Laparoscopic approach to incarcerated ventral and inguinal hernia may be safe in COVID-19 positive patients if laparoscopy is not otherwise contraindicated 80% 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 incarcerated ventral and inguinal hernia to obtain test results may not be justified 89% d. Role of techniques that might increase intraabdominal pressure 30. The use of mesh for hernia repair may not increase the risk of complications in COVID-19 positive patients 89% e. Surgical approach if a bowel resection is needed 31. Laparoscopic approach to incarcerated hernia requiring bowel resection may be safe for COVID-19 positive patients if not otherwise contraindicated 80% 7Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 (continued) Topics Questions Statement 1st round % YES 2nd round % YES Upper GI 9. What is the role for flexible endoscopy mitigating the risk of surgery during COVID-19 pandemic in the following situations? 32. Flexible endoscopic therapy should be the first attempt to treat upper GI bleeding even in patients affected by COVID-19 93% a. Acute gastric volvulus b. Obstructing gastric cancer c. Obstructing esophageal cancer d. Esophageal perforation e. Surgical leaks f. Bleeding 33. COVID-19 positive patients with an obstructing esophageal or gastric cancer should be treated first by endoscopic stenting if possible, in order to delay surgery until conditions are more favourable to operate 81% 10. What is the role for surgical endoscopy during COVID-19 pandemic in the following situations? 34. COVID-19 positive patients with an immediate presentation of benign esophageal perforation (of less than 24h) should be treated first by flexible endoscopy means, while those perforated present after 24h should undergo immediate surgery 83% a. Esophageal perforation b. Gastroduodenal perforation c. Bleeding 35. In patients suffering from an upper GI anastomotic leak, initial endoscopic therapy should be attempted regardless the COVID-19 status 88% 36. Emergency surgery should be recommended after failure of conservative/endoscopic management in symptomatic upper GI perforation or leak in COVID-19 positive patients 98% 37. Laparoscopy should be the preferred approach in patients with perforated gastroduodenal ulcer if not otherwise contraindicated in COVID-19 positive patients 84% Lower GI 11. What is the role for flexible endoscopy mitigating the risk of surgery during COVID-19 pandemic in the following situations? 38. Endoscopic stenting for obstructing colorectal carcinoma should be considered for palliation in malignant obstruction regardless of the COVID-19 status 67% 87% a. Stenting for obstructing colorectal carcinoma b. Decompression of acute sigmoid volvulus c. Management of acute perforation d. Management of anastomotic leaks 39. Endoscopic decompression should be the first line of treatment of uncomplicated sigmoid volvulus, regardless the COVID-19 status 91% 40. In patients suffering from a leak of a low rectal anastomosis, all endoscopic means which proved effective should be attempted regardless the COVID-19 status 81% 8 Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 (continued) Topics Questions Statement 1st round % YES 2nd round % YES 12. What is the role for laparoscopy during COVID-19 pandemic in the following situations? 41. Emergency surgery should be recommended after failure of conservative/endoscopic management in symptomatic lower GI perforation or leak in COVID-19 positive patients 93% a. Acute diverticulitis (lavage/HP/Primary Resection anastomosis with stoma) b. Small bowel obstruction c. Appendicitis (with/without abscess/abdominal collection) 42. The indication for laparoscopic lavage for Diverticular Disease can be considered in COVID-19 positive patients when local expertise and protective measures are available 65% 87% 43. Primary resection with or without anastomosis can be considered in COVID-19 positive patients with acute diverticulitis, providing that this is performed by an experienced surgeon 86% 44. Percutaneous drainage and/or targeted defunctioning stoma can be considered in unstable COVID-19 positive patients with acute diverticulitis 88% 13. Should damage control surgery be performed in COVID + / suspected COVID-19 patients? 45. Laparoscopic approach should be considered in COVID-19 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 91% a. In Upper GI b. In Lower GI c. In Pancreas surgery 46. Non-surgical approaches such as percutaneous drainage with antibiotic treatment should be considered as the first line of treatment of acute appendicitis with peri-appendicular abscess in COVID-19 positive patients 81%% 47. In case of failed non-surgical approach for acute appendicitis in COVID-19 positive patients, laparoscopic surgery should be considered 91% 48. The principles of damage control surgery with adherence to optimal seal of temporary abdominal closure should remain unchanged in COVID-19 positive/suspected patients 98% Specific elective operations in the immediate post- COVID-19 pandemic Hepatobiliary 14. What indications for laparoscopic surgery in hepatobiliary disorders should be considered during COVID-19 pandemic regarding? 49. Elective cholecystectomy in patients COVID-19 negative may be performed if hospital setting allows a safe pathway for COVID-19 negative patients and local resources are sufficient 98% 9Surgical Endoscopy (2021) 35:1–17 1 3 Table 2 (continued) Topics Questions Statement 1st round % YES 2nd round % YES a. Cholelithiasis/choledocholithiasis and adenomyoma b. Hepatic cancer c. Liver metastases d. Pancreatic cancer e. Other indications 50. Elective cholecystectomy in patients COVID-19 positive should be delayed until the post-pandemic period 81% 51. Elective liver resection for primary or secondary cancer in COVID-19 negative patients should not be delayed 86% 52. Elective liver resection for primary or secondary cancer in 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 93% 53. Patients affected by unproven pancreatic lesion could be observed and intervention can be delayed until the post-pan- demic period 69% 73% 54. Elective pancreatic resection for cancer in COVID-19 negative patients should not be delayed 90% 55. Elective liver resection for cancer in 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 90% Bariatrics 15. What is the role for flexible endoscopy mitigating the risk of surgery during COVID-19 pandemic in bariatrics? 56. In order to mitigate the risk of surgery during the recovery plan after the COVID-19 pandemic, all endoscopic techniques for morbid obesity should be preferred as bridge to surgery 70% 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 endoscopic sleeve gastroplasty in order to reduce procedure times and resources usage during the COVID pandemic 68% 76% 16. Is there a different timing for surgery during COVID-19 pandemic in bariatrics? 58. In patients experiencing a complication (bleeding or leak) following a bariatric procedure, all endoscopic means which proved effective should be put in place regardless of COVID-19 status 98% a. Should bariatric procedure be postponed? b. When should a redo procedure be performed? 59. During the recovery plan after the COVID-19 pandemic, bariatric surgery should not be postponed further, nor the indications limited in areas with a low incidence of SARS-CoV-2 infections 77% 60. In case local regulatory authorities impose a reduction of bariatric weekly case load, more complex metabolic patients should be prioritized 98% Abdominal wall 17. What indications to surgery and what anaesthesia in abdominal wall disorders should be considered during COVID-19 pandemic regarding? 61. Elective laparoscopic treatment for ventral and inguinal hernias in COVID-19 negative asymptomatic or poorly symptomatic patients may need to be postponed 90% 16 Surgical Endoscopy (2021) 35:1–17 1 3 provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. References 1. 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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 Department ofSurgical Sciences, University ofTorino, Corso AM Dogliotti 14, 10126Torino, Italy 2 Department ofGeneral Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK 3 The Griffin Institute, The Northwick Park Institute forMedical Research, Northwick Park andSt Marks Hospital, Watford Road, Harrow, Middlesex, LondonHA13UJ, UK 4 Department ofSurgery, Hadassah, Hebrew University Medical Center, Jerusalem, Israel 5 Department ofSurgery, Clinic ofVisceral andThoracic Surgery, Cantonal Hospital Winterthur, Winterthur, 8401Zurich, Switzerland 6 Faculty ofMedicine, University ofBasel, 4051Basel, Switzerland 7 Medical School, European University Cyprus, Nicosia, Cyprus 8 Department ofSurgery, Mediterranean Hospital ofCyprus, Limassol, Cyprus 9 Department ofSurgery, Maastricht University Medical Centre, Maastricht, TheNetherlands 10 Department ofGastrointestinal andBariatric Surgery, Ponderas Academic Hospital, Bucharest, Romania 11 General Surgery Clinic, Department ofMedical, Surgical andHealth Sciences, University ofTrieste, University Hospital ofTrieste, Trieste, Italy 12 Department ofSurgical Sciences, University ofRome “Tor Vergata”, Rome, Italy 13 Unit ofInnovation inMinimally Invasive Surgery, Department ofGeneral andDigestive Surgery, University Hospital “Virgen del Rocio”, University ofSevilla, Sevilla, Spain 14 Department ofGeneral, Visceral andTransplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany 15 General Surgery, Linköping University Hospital, Linköping, Sweden 16 The Royal Marsden NHS Foundation Trust, London, UK 17 Department ofRadiology, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, UK 18 Department ofAnaesthesia, Critical Care andPain Medicine, Western General Hospital, Edinburgh, Scotland 19 Department ofHygiene, Epidemiology andMedical Statistics, Medical School, National andKapodistrian University ofAthens, Athens, Greece 20 Department ofSurgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy