Impact of the SARS-CoV-2 pandemic on emergency surgery services—a multi-national survey among WSES members
World Journal of Emergency Surgery volume 15, Article number: 64 (2020)
The SARS-CoV-2 pandemic is a major challenge for health care services worldwide. It’s impact on oncologic therapies and elective surgery has been described recently, and the literature provides guidelines regarding appropriate elective patient treatment during the pandemic. However, the impact of SARS-CoV-2 pandemic on emergency surgery services has been poorly investigated up to now.
A 17-item web survey had been distributed to emergency surgeons in June 2020 around the world, investigating the impact of SARS-CoV-2 pandemic on patients and septic diseases both requiring emergency surgery and the time-to-intervention in emergency surgery routine, as well as experiences with surgery in COVID-19 patients.
Ninety-eight collaborators from 31 countries responded to the survey. The majority (65.3%) estimated the impact of the SARS-CoV-2 pandemic on emergency surgical patient care as being strong or very strong. Due to the pandemic, 87.8% reported a decrease in the total number of patients undergoing emergency surgery and approximately 25% estimated a delay of more than 2 h in the time-to-diagnosis and another 2 h in the time-to-intervention. Fifty percent make structural problems with in-hospital logistics (e.g. transport of patients, closed normal wards etc.) mainly responsible for delayed emergency surgery and the frequent need (56.1%) for a triage of emergency surgical patients. 56.1% of the collaborators observed more severe septic abdominal diseases during the pandemic, especially for perforated appendicitis and severe septic cholecystitis (41.8% and 40.2%, respectively). 62.2% had experiences with surgery in COVID-19-infected patients.
The results of The WSES COVID-19 emergency surgery survey are alarming. The combination of an estimated decrease in numbers of emergency surgical patients and an observed increase in more severe septic diseases may be a result of the fear of patients from infection with COVID-19 and a consecutive delayed hospital admission and diagnosis. A critical delay in time-to-diagnosis and time-to-intervention may be a result of changes in in-hospital logistics and operating room as well as intensive care capacities. Both reflect the potentially harmful impact of SARS-CoV-2 pandemic on emergency surgery services.
Since the World Health Organization declared SARS-CoV-2 as a worldwide pandemic in early 2020, the disease majorly influences political decisions, social life and especially health care services as well as daily therapeutic practices [1,2,3,4,5,6]. Recommendations from politics as well as respective medical societies aimed to postpone elective therapies, especially elective surgery aimed primarily to hold up bed, intensive care as well as operating room capacities available during the pandemic [3, 7,8,9,10]. The second goal was certainly to preserve patients from nosocomial infection with COVID-19 . Respective statements, how to proceed with those patients, had been published for oncologic therapy and cancer surgery [1, 2, 11,12,13]. Thereby, it is known that especially cancer patients are highly vulnerable for COVID-19 but a delay in cancer-specific therapy might cause severely impaired oncologic outcome [1, 2, 11,12,13]. Balancing the necessity of SARS-CoV-2 measures on the one hand and the urgent treatment of surgical emergency patients on the other hand made the SARS-CoV-2 pandemic an everyday challenge for emergency surgery worldwide. Since the rapid spread of the SARS-CoV-2 around the world in late 2019, a high amount of research had been published regarding the pandemic and the characteristics of COVID-19 disease, but only very little is known about the impact of the pandemic’s consequences on clinical daily routine in emergency surgery. Several structural changes were established in hospitals around the world to deal with (potentially) high numbers of severely and critically ill patients infected with COVID-19 [2,3,4,5]. There are the risk and the fear of patients of getting infected with SARS-CoV-2 and suffering from severe course of COVID-19 . Undoubtedly, all of these factors not only influence the entire spectrum of elective patient care but also might have a significant impact on daily routine patient care in emergency rooms and in particular emergency surgery around the world. Therefore, The WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on patients and their diseases requiring emergency surgery and on time-to-diagnosis and time-to-intervention in emergency departments as well as the causes for a delayed surgical therapy, following the aim to improve emergency surgical patient care during the pandemic.
An online survey was designed by a core group of investigators of the study. Google Forms (Google LLC, Mountain View, CA, USA) was used as the platform for the survey.
The survey consists of 16 single-choice items and one open-answer question. The items are organized in five sections: (1) recording the characteristics of collaborators and their affiliated hospitals—three items, (2) investigating the impact of SARS-CoV-2 pandemic on patients requiring emergency surgery—three items, (3) septic diseases requiring emergency abdominal surgery—three items, (4) structural problems driven by the pandemic and leading to a delayed emergency surgical treatment—six items, and, finally, (5) the experiences of the study group with emergency surgery in COVID-19-infected patients assessed by one item and one open-answer question.
After the survey was approved by the World Society of Emergency Surgery (WSES) project steering committee, it was distributed to the multi-national mailing list of WSES members on June 9, 2020. The deadline to participate was June 26, 2020. After closing the survey, the results were checked for duplicates. Results are presented descriptively within the present manuscript. All 17 items of the survey as well as the assignment of items to figures in the present manuscript are depicted in Table 1.
Characteristics of the participants
Ninety-eight members of the WSES from 31 countries around the world and four continents, respectively, responded to the survey (see Table 2). Most of the participants were health care specialists, including board-certified surgeons, senior consultants and heads of their department (see Fig. 1). Among them, 11 (11.2%) participants stated that their hospital does not treat any patients suffering from COVID-19 and, vice versa, emergency surgery was suspended in hospitals of 5 (5.1%) participants of the survey during the SARS-CoV-2 pandemic (see Fig. 2). The answers of participants, whose hospitals did not treat COVID-19 patients, are indicated in the figures.
Impact of SARS-CoV-2 pandemic on capacities for emergency surgery
The majority of participants estimate the impact of the SARS-CoV-2 pandemic on emergency surgical patient care as being strong or very strong (n = 64, i.e. 65.3%). Notably, even seven participants working in those hospitals, where no COVID-19 patients were treated, also estimated the impact of the pandemic on emergency surgical patient care as being strong or very strong (see Fig. 3).
To evaluate the reasons why the SARS-CoV-2 pandemic impacts on emergency surgery, the collaborators of the study group were asked for factors being critical in the therapy of emergency surgical patients during the pandemic: general caseload in emergency surgery, diagnostic (“time-to-diagnosis”), therapeutic (“time-to-intervention”) and intensive care capacities in their respective hospitals. Therefore, most of the participants reported a decrease in the total number of patients undergoing emergency surgery in their hospitals (n = 86, i.e. 87.8%) to a reduction ranging between 21 and 60% of the cases in 54.7% of their hospitals during the pandemic (see Fig. 4).
In the emergency room workflow, no delay in the time-to-diagnosis was stated by 58 (59.2%) of the participants, whereas one-fourth of the study group estimated a dramatical delay of more than 2 h in time-to-diagnosis by a computed tomography from entering the hospital for critical ill surgical patients (see Fig. 5 a). The same holds true for the time from diagnosis to intervention. Therefore, a critical delay of even more than 2 h was estimated in hospitals of almost one-fourth of the study group during the SARS-CoV-2 pandemic for patients requiring any emergency surgical intervention (see Fig. 5 b). Beneath a lack of operating room staff (n = 7, i.e. 7.1%) and operating room as well as intensive care unit capacities (n = 15, i.e. 15.3% as well as n = 12, i.e. 12.2%, respectively), structural problems with in-hospital logistics (e.g. transport of patients, closed normal wards etc.) were seen as the most important factors for a delay in surgical emergency patient treatment from 50% of the study group (n = 49, see Fig. 6). All of those structural problems and limited capacities culminate in the urgent need for a triage of emergency surgical patients reported by 55 (56.1%) participants of the study group, which may furthermore worsen the resources of surgical emergency patient care during the SARS-CoV-2 pandemic (see Fig. 7).
Impact of SARS-CoV-2 pandemic on diseases requiring emergency surgery
The study group was asked for their subjective observation, if a higher severity was more prevalent during the SARS-CoV-2 pandemic in patients suffering from frequent septic diseases requiring abdominal emergency surgery, including appendicitis, cholecystitis and diverticulitis. Overall, 56.1% of the study group observed more severe septic abdominal diseases during the pandemic, especially for appendicitis and cholecystitis (41.8% and 40.2% of the study group, respectively), which make a rapid time-to-surgical-intervention mandatory (see Fig. 8). Interestingly, even 7 (63.6%) collaborators from hospitals, where no COVID-19 patients were treated, observed this trend. Finally, the majority of participants (n = 61, i.e. 62.2%) performed any kind of emergency surgery in patients infected with COVID-19. Thereby, the study group had the most experiences with appendectomies, cholecystectomies and laparotomies for trauma, intestinal perforation and any kind of bowel resection (see Table 3).
This study proves a severe impact of the SARS-CoV-2 pandemic situation and it´s consequences on emergency surgical patient care around the world. Interestingly, even collaborators from hospitals, where no COVID-19 patients were treated described that the pandemic at least strongly affects their emergency surgical patient care. In the opposite to elective medical treatment or elective (oncologic) surgery, emergencies do frequently not tolerate even small postponement; otherwise, the disease rapidly progresses, gets more severe, more complicated and potentially ends fatal.
The study group observed on the one hand a lower number of patients who underwent emergency surgical procedures, but on the other hand a higher rate of perforated or more severe septic abdominal diseases in patients conducted to emergency surgery. A decrease in absolute numbers of patients with surgical complaints in the emergency department during the SARS-CoV-2 pandemic had been previously described [15,16,17]. This might be an effect of the worldwide lockdown policies as well as the fear of the patients from COVID-19 and might result in delayed diagnosis and therapy. Also Snapiri et al. observed a high rate of complicated appendicitis with abscess or perforation in their patient cohort during the pandemic . They discussed changes in medical evaluation and decision-making processes of the patients, their relatives and treating physicians as possible reasons for a diagnosis in later stages of the disease . Thereby it is well known that complications frequently occur as late as 36–48 h after onset of symptoms of acute appendicitis [14, 18,19,20,21]. As discussed by Patriti et al., the negative impact of the SARS-CoV-2 pandemic on surgical activities is multifactorial . Results of their survey among local surgeons during the SARS-CoV-2 outbreak in Italy remained that changing daily practice, shifting working plans, and reduction in personnel resources through allocating surgeons to non-surgical departments, high sickness and quarantine rates among surgeons during the pandemic led to a lower quality of surgical patient care . Furthermore, the diffuse symptomatology of COVID-19 patients including gastrointestinal symptoms and abdominal pain, reported in the current literature, may disguise the real cause and may delay the adequate (surgical) therapy of affected patients during the pandemic [22, 23]. As for patients with delayed diagnosed appendicitis, the same might be true for cholecystitis and diverticulitis. Nevertheless, the COVIDSurg Collaborative recently described a high rate of mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection . These results led the COVIDSurg Collaborative to their conclusion that preventively postponing of non-urgent surgical procedures or non-operative treatment options should be considered . However, several diseases presenting in the emergency department require urgent or emergency surgical therapy; thus, among others, Campanile et al. declare in their multi-society position statement the laparoscopic cholecystectomy still as the therapeutic standard-of-care in patients with acute cholecystitis even in the SARS-CoV-2 pandemic situation .
The long delay (more than 2 h) in time-to-diagnosis and furthermore in time-to-intervention observed in emergency situations by approximately one-fourth of the participants during the SARS-CoV-2 pandemic are the most critical results of the present study. Unfortunately, these items of the survey were kept very generally; thus, the underlying diseases, for which the delays were estimated and if there are differences, e.g. in trauma or septic patients, were not the objective of the survey. However, the responses of The WSES COVID-19 emergency surgery survey collaboration group give important implications on the structural problems and barriers, which emergency surgeons and their patients are faced with. The COVID-19 outbreak severely impairs our society, health care systems and especially in-hospital infrastructure; barriers arising from extensive preventive measures during the pandemic situation might by an underlying cause for processing emergency patients into routine diagnostic and therapeutic pathways [6, 10]. Nevertheless, a rapid surgical therapy is mandatory for a high percentage of acute care patients, including trauma and septic diseases, still in the pandemic situation [15, 26]. It is well known that delayed emergency surgery results in high morbidity rates and worsens survival for the patients, whereby the risk of death increases per hour [26, 27]. Furthermore, The WSES COVID-19 emergency surgery survey study group, consisting of specialists in emergency surgery around the world, estimates the most important factors, leading to the critical impairment in diagnostic and therapeutic work-up of emergency surgical patients. The present study proves that this is not a local but more of a worldwide issue. To solve these problems and to improve emergency surgical patient care during the pandemic, policies, respective medical societies and local health care providers should define tailored solutions and provide resources to enhance medical staff, operating room capacities, intensive care capacities and—in particular—in-hospital logistics.
Although The WSES COVID-19 emergency surgery survey collaboration group consists of some highly experienced and specialized associates in emergency surgery, the study has some strong limitations. The collected data presented in this present work are based on subjective feelings, observations and estimations of the collaboration group. Thus a “hard” data basis, e.g. by big data analysis during the SARS-CoV-2 pandemic, is currently lacking. Furthermore, data were collected in a small period of time, in which parts of the world were currently suffering from SARS-CoV-2 outbreaks, whereas others were beyond the outbreak. However, the estimation about the impact of the pandemic on emergency surgery was homogenous.
The results of The WSES COVID-19 emergency surgery survey are alarming. An estimated decrease in numbers of emergency surgical patients and an observed increase in more severe septic diseases may be a result of the fear of patients from infection with COVID-19 and a consecutive delayed hospital admission and diagnosis. A critical delay in time-to-diagnosis and time-to-intervention may be a result of changes in in-hospital logistics and operating room as well as intensive care capacities. Both reflect the potentially harmful impact of SARS-CoV-2 pandemic on emergency surgery services. Based on these investigations, further measures are necessary to develop optimized clinical pathways for a reduction in the time-to-diagnosis and time-to-intervention in emergency departments around the world. These should aim not only to prevent medical staff as well as emergency surgical patients from infection with COVID-19 and to protect infected patients from a perioperative exacerbation of the disease with consecutive severe morbidities and mortality [9, 24], but also to prevent the need for triage of emergency surgical patients and to provide a timely surgical therapy in all (infected or non-infected) urgent and emergency patients.
The WSES supports all efforts to fight for an optimized treatment of our surgical emergency patients both in cases of local COVID-19 outbreak and also the worldwide setting!
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
World Society of Emergency Surgery
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The authors sincerely thank all collaborators of the study for participation in the survey.
The WSES COVID-19 emergency surgery survey collaboration group:
Abakar Abdullaev, Department of Abdominal Surgery, Vladimir City Emergency Hospital, Vladimir, Russia
Adrian Camacho-Ortiz, Hospital Universitario Dr. José Eleuterio Gonzalez, Mexico
Adriana Toro, General Surgery, Augusta Hospital, Augusta (SR), Italy
Alain Chichom-Mefire, Faculty of Health Sciences, University of Buea, Cameroon
Aleix Martínez-Pérez, Department of General and Digestive Surgery, Doctor Peset University Hospital, Valencia, Spain
Alfie J Kavalakat, Jubilee Mission Medical College & RI, Thrissur, India
Ali Yasen Y Mohamedahmed, General Surgery, Sandwell General Hospital, Birmingham, UK
Andrey Litvin, Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Regional Clinical Hospital, Kaliningrad, Russia
Antonio Brillantino, Department of Surgery, A. Cardarelli Hospital, Naples, Italy
Antonio Pesce, Policlinico Abano Terme, Padua, Italy
Arda Isik, General Surgery Department, Erzincan University Hospital, Erzincan, Turkey
Aristotelis Kechagias, Department of Gastrointestinal Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
Azzain M H Ismail, Department of Trauma & Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, UK
Baris Mantoglu, General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
Basil Ibrahim, Speciality Registrar in Colorectal surgery, University hospital of north Durham, UK
Birgit Hecker, Department of Anesthesiology, St. Josefs Hospital, Gießen, Germany
Boris Sakakushev, Research Institute at Medical University Plovdiv, University Hospital St George, Plovdiv, Bulgaria
Charalampos Seretis, George Eliot Hospital NHS Trust, UK
Dimitrios Manatakis, Department of Surgery, Athens Naval and Veterans Hospital, Athens, Greece
Edgar Fernando Hernández García, Cirugía General y Laparoscópica, Cirugía de trauma, Hospital Central Militar, Mexico
Elif Çolak, University of Health Sciences Turkey, Samsun Training and Research Hospital, Turkey
Elmin Steyn, Division of Surgery, Tygerberg Hospital, Stellenbosch University, South Africa
Emrah Akin, Department of General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
Emre Gonullu, General Surgery, Sakarya University Educating and Research Hospital, Sakarya, Turkey
Fabio Cesare Campanile, General Sugery, San Giovanni Decollato /Andosilla Hospital, Civita Castellana VT, Italy
Francesco Pata, Department of Surgery, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy
Francesco Roscio, Department of General Surgery, ASST Valle Olona, Busto Arsizio, Italy
Fredrik Linder, Gävle county Hospital, Gävle, Sweden
Gia Tomadze, Surgery Department, Tbilisi State Medical University, Tiblisi, Georgia
Gianluca Pellino, Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
Gianmaria Casoni Pattacini, Department of General Surgery, Emergencies and New Technologies, Baggiovara Civil Hospital, Modena, Italy
Giovanni Pirozzolo, Dell'Angelo Hospital, Venice, Italy
Gustavo M. Machain, Jefe de Catedra y Servicio de Cirugia General, II Catedra, Hospital de Clinicas, FCM, Universidad Nacional de Asuncion, Paraguay
Gustavo P. Fraga, School of Medical Sciences (SMS), University of Campinas (Unicamp), Campinas, Brazil
Hazim Abdulnassir Eltyeb, St4 General Surgery, Northumbria Healthcare NHS Foundation Trust, UK
Ioannis Nikolopoulos, Lewisham and Greenwich NHS Trust
Isidoro Di Carlo, Department of Surgical Sciences and Advanced Technologies, General Surgery, University of Catania, Cannizzaro Hospital, Catania, Italy
Jae Il Kim, Department of Surgery, Inje University Ilsan Paik Hospital, Goyang, South Korea
Jesus-Manuel Saenz-Terrazas, Weapon Traumatology and Training Center, Dar Al-Chifae Hospital, Tripoli, Lebanon
Juan Carlos Rodriguez Sanjuan, Jefe de Servicio de Cirugía General, Hospital Universitario Marqués de Valdecilla (Santander), Universidad de Cantabria, Santander, Spain
Juliane Liese, Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital of Giessen, Giessen, Germany
Justin Davies, Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Kim Platte, Ziekenhuis Amstelland, Amstelveen, Netherlands
Lawrence Lottenberg, Department of Surgery, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA
Leonardo Pagani, Antimicrobial Stewardship Program, Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
Leonardo Solaini, General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
Lisa Miller, Western Michigan University Homer Stryker MD School of Medicine, USA
Lovenish Bains, Department of Surgery, Maulana Azad Medical College, New Delhi, India
Luis Buonomo, Hospital “Dr. Alberto Balestrini”, University of Buenos Aires, Argentina
Maciej Walędziak, Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, Warsaw, Poland
Mahir Gachabayov, Department of abdominal surgery, Vladimir City Emergency Hospital, Vladimir, Russia
Marc Maegele, Department of Trauma and Orthopedic Surgery, Institute for Research in Operative Medicine (IFOM), Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
Marco Catarci, General Surgery Unit, C.e G. Mazzoni Hospital, Ascoli Piceno, Italy
Marco Vittorio Rossi Ardizzone, Italy
Maria Grazia Alberio, Chirurgia generale d'urgenza, Ospedale di circolo – Varese, Italy
Massimiliano Veroux, General Surgery and Organ Transplant Unit, Azienda Policlinico University of Catania, Catania, Italy
Matteo Nardi, S. Giovanni Calibita Hospital-Fatebenefratelli Foundation, Rome, Italy
Mauro Podda, Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
Michael Sugrue, Department of Surgery, Letterkenny University Hospital and Centre for Personalised Medicine, Donegal, Ireland
Michele Pisano, General Surgery Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
Mihail Slavchev, Department of General Surgery, University Hospital Eurohospital, Plovdiv, Bulgaria
Mika Ukkonen, Department of Surgery, Tampere University Hospital, Tampere, Finland
Miklosh Bala, Trauma and Acute Care Surgery Unit, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
Mircea Chirica, Department of Digestive Surgery, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
Mouaqit Ouadii, Hassan II Hospital, Fes, Morocco
Orestis Ioannidis, 4th Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
Osvaldo Chiara, Trauma and Emergency Surgery, University of Milan, Milan, Italy
Pankaj Kumar, Department of General Surgery, Bhubaneswar,Odisha, India
Per Örtenwall, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
Pradeep Navsaria, Trauma Center, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
Raul Coimbra, Surgery, Loma Linda University School of Medicine, Riverside University Health System, Riverside, USA
Robert G. Sawyer, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
Saad Shebrain, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
Salomone Di Saverio, Surgery 1st unit, University Hospital of Varese, Varese, Italy
Sanjay Marwah, PGIMS Rohtak, Rohtak, India
Shahd Nour, North Bristol NHS Foundation Trust, UK
Stefano Magnone, General Surgery, Ospedale Papa Giovanni XXIII, Bergamo, Italy
Syed Muhammad Ali, Acute Care Surgery, Hamad Medical Corporation, Doha, Qatar
Tadeja Pintar, Abdominal Surgery Department, UMC Ljubljana Medical Faculty, Ljubljana, Slovenia
Tushar S Mishra, Department of Trauma & Emergency, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Valentina Tomajer, IRCCS San Raffaele Hospital, Milan, Italy
Varut Lohsiriwat, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
Vijay Shivpuje, Yashodhara Superspeciality Hospital, Solapur Maharashtra, India
Vladimir Khokha, City Hospital, Mozyr, Belarus
Yoshiro Kobe, Department of Surgery, Chiba Emergency Medical Center, Chiba, Japan
Zaza Demetrashvili, Surgery Department, Tbilisi State Medical University, Georgia
No funding was received for this research. Open Access funding enabled and organized by Projekt DEAL.
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Federico Coccolini and Fausto Catena are WSES project steering committee representatives.
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Reichert, M., Sartelli, M., Weigand, M.A. et al. Impact of the SARS-CoV-2 pandemic on emergency surgery services—a multi-national survey among WSES members. World J Emerg Surg 15, 64 (2020). https://doi.org/10.1186/s13017-020-00341-0