Table 1 Summary of statements and recommendations

1-What is the diagnostic work-up in a suspected COVID-19 patient with an acute surgical condition?

 Statement 1.1

  Symptoms of COVID-19 infection are myriad and may include stroke or myocarditis as the first presentation. COVID-19 infection is suspected in patients presenting with fever, cough, dyspnoea and/or recent direct contact with a confirmed COVID-19 patients (QoE moderate B).

 Statement 1.2

  Characteristic laboratory findings for COVID-19 infection are leucopenia, lymphocytopenia, elevated aspartate aminotrasferase, inflammatory biomarkers such as C-reactive protein, erythrocyte sedimentation rate; elevated lactate dehydrogenase; creatinine; hypersensitive troponin I, fibrinogen and D-dimer (QoE moderate B).

 Statement 1.3

  The RT‐PCR test in respiratory samples (swab) is the current gold standard method for confirming the diagnosis of COVID‐19 (QoE moderate B).

 Statement 1.4

  The RT-PCR test result heavily relies on the presence of viral genome in sufficient amounts at the site of sample collection that can be amplified. An incorrect sample collection or missing the time-window of viral replication can provide false negative results and limits the usefulness of qPCR-based assay (QoE moderate B).

 Statement 1.5

  In the early stage of the disease the detection of SARS‐CoV‐2 viral RNA is better in nasopharynx samples than the oropharynx (QoE moderate B).

 Statement 1.6

  For individuals with a high clinical suspicion of SARS-CoV-2 infection with negative RT-PCR test, a combination of repeated naso-pharyngeal RT-PCR swab tests and chest imaging may be helpful to confirm early the diagnosis of COVID-19 disease and to evaluate the pneumonia’s severity (QoE moderate B).

 Statement 1.7

  In the COVID-19 screening, the chest-CT scan is the most accurate radiological tool to confirm the diagnosis above all in uncertain cases. The chest-XR can be helpful in case of unavailability of CT-scan (QoE moderate B).

 Statement 1.8

  The chest-CT scan may be useful to complete the COVID-19 screening in patients with a high clinical suspicion of SARS-CoV-2 infection but negative RT-PCR swab test (QoE moderate B).

 Statement 1.9

  For emergency physicians and emergency surgeons with excellent POCUS skills and limited access to CT, it is reasonable to use lung POCUS in COVID-19 screening, that can help in the diagnosis and at the same time rules out other acute respiratory illnesses (QoE low C).

 Statement 1.10

  Lungs US can be used as first COVID-19 screening tool and discriminate low-risk patients (lung US-negative, clinically stable patients that can wait for second level imaging) from higher-risk patients (such as those with abnormal lung US patterns), that might require second level imaging rapidly (QoE very low D).

 Statement 1.11

  Lungs US may be helpful for patients with a high clinical suspicion of COVID-19 but negative RT-PCR test to confirm the diagnosis, if they demonstrate typical lung ultrasound findings for COVID-19, if skills are available, in the unavailability of CT-scan (QoE moderate B).

 Recommendations/1

  We recommend screening for COVID-19 infection at emergency department, all surgical patients with clinical and epidemiologic features suspect for COVID-19 disease who are waiting for hospital admission and urgent surgery. The screening provides performing a RT-PCR naso-pharyngeal swab test and a baseline (non-contrast) chest CT or chest X-ray or lungs US, depending on skills and availability (Strong recommendation based on moderate level of evidence 1B).

2-Is it necessary to delay the surgical procedure for a suspected COVID-19 patient until RT-PCR swab test result is available?

 Statement 2.1

  All acute surgical patients should complete preoperative COVID-19 screening that includes RT-PCR naso-pharyngeal swab test and chest CT scan, when it’s available, or a Chest XR, or Lungs US in ED, whether they are symptomatic or not, to control the in-hospital spreading of SARS-CoV-2 (QoE moderate B).

 Statement 2.2

  Chest imaging such as a baseline CT scan or a Chest XR or a lungs US, depending on the availability, are useful diagnostic tool in the unavailability of RT-PCR swab test result to detect potentially infected patients (QoE moderate B).

 Statement 2.3

  If chest radiological evaluation by CXR, or chest CT scan or lungs US, is inconclusive and the patient needs for immediate surgery, he has to be treated as a COVID-19 patient to limit the risk of contagion and the spreading of the SARS-CoV-2 in the operating theatres (QoE moderate B).

 Statement 2.4

  After surgery, the uncertain patient has to be isolated as long as the RT-PCR test result is obtained, to be admitted in a COVID (+) or (-) ward. If it is positive, it is recommended repeating the swab test for confirmation. In patients with confirmed COVID-19 diagnosis, the laboratory evaluation should be repeated to evaluate for viral clearance prior to being released from isolation (QoE moderate B).

 Statement 2.5

  TACS classification system could be a valid tool to evaluate timing of surgery and severity of the surgical disease (QoE low C).

 Recommendations/2

  We recommend completing the COVID-19 screening (RT-PCR nasopharyngeal swab test + chest imaging) for all acute surgical patients before admission in the surgical ward or operating room. If the RT-PCR swab test result is not available to confirm the diagnosis, the patient needs to be isolated and treated such as COVID-19 (+) patients with all the mandatory precautions. The acute care surgeon is the only responsible for the decision of possible delaying of a surgical procedure in the emergency setting during the pandemic. TACS classification is a good tool to evaluate timing of surgery. According to this classification, surgery cannot be postponed for class1 (immediate surgery) and class 2 (surgery in 1 hour, as soon as possible) patients even if diagnosis of COVID-19 is not yet confirmed by RT-PCR swab test (Strong recommendation based on a moderate level evidence 1B).

3-In case of RT-PCR test unavailability and negative Chest CT Scan, suspected COVID-19 patients have to be operated using operating theatres’ procedures for overt COVID-19 patients?

 Statement 3.1

  RT-PCR test remains the reference standard to make a definitive diagnosis of COVID-19 infection and to manage the patient and resources in the correct way (QoE moderate B).

 Statement 3.2

  The emergency physician may identify high risk COVID-19 patients investigating the presence of typical clinical symptoms, laboratory test results and/or epidemiological risk factors as suggested byWHO, but RT-PCR test confirmation is mandatory to make diagnosis of viral infection (QoE moderate B).

 Statement 3.3

  Negative chest CT scan is not sufficient to exclude the diagnosis of COVID-19 infection, above all in the early phase of the infection (QoE low C).

 Statement 3.4

  In case of unavailability of the RT-PCR test, the surgical patient has to be considered potentially infected and managed like a COVID-19 (+) patient (QoE moderate B).

 Recommendations/3

  If it is not possible to confirm diagnosis of COVID-19 disease in an acute surgical patient by RT-PCR swab test, we recommend managing the patient such as he/she is COVID-19 (+) with all the mandatory precautions against viral infection, that include all the protective measures and a dedicated pathway for the operating room, to decrease the risk of environmental contamination and health personnel exposure. If a dedicated pathway for COVID-19 (+) patients is not available in the hospital, it should be an option to transfer hemodynamic stable suspected patient to the nearest COVID-19 HUB hospital for the appropriate management (Strong recommendation based on a moderate level of evidence 1B).

4-In case of RT-PCR swab test unavailability and chest CT scan unavailability, suspected COVID-19 surgical patients have to be operated using operating room procedure for overt COVID-19 patient?

 Statement 4.1

  Diagnosis of COVID 19 disease is confirmed through the RT-PCR test (QoE moderate B)

 Statement 4.2

  Each surgical patient might be considered suspected for COVID-19 disease if clinical signs, imaging features at CXR or/and lungs US or/and chest CT scan and laboratory tests results are compatible with a SARS-CoV-2 infection (QoE moderate B).

 Statement 4.3

  The COVID-19 screening includes RT-PCR swab test and a chest radiological imaging that could be CXR or lungs US in the unavailability of CT scan. (QoE moderate B).

 Statement 4.4

  If a surgical patient cannot complete the screening for COVID-19 disease, and requires immediate surgical procedure, he/she should be managed with all the mandatory precautions against COVID-19 infection (QoE low C).

 Statement 4.5

  If the RT-PCR swab test is positive, the surgical patient has to be manage such as a COVID-19 patient. The chest imaging is useful to assess the severity of the pneumonia (QoE high A).

 Recommendations/4

  In case of RT-PCR test and chest CT scan unavailability, we recommend completing the COVID-19 screening with Chest XR or lungs US that can help assessing the severity of COVID-19 pneumonia, exactly such as chest CT scan, before surgery. If the naso-pharyngeal swab test is positive, the patient is a COVID-19 confirmed patient (Strong recommendation based on moderate level of evidence 1B).

5. Are emergency surgery indications for a confirmed COVID-19 patient different?

 Statement 5.1

  Indications for a surgical procedure are not different in confirmed COVID-19 patients. (QoE moderate B).

 Statement 5.2

  Current data about outcome of surgery in COVID-19 has shown a higher morbidity and mortality rate in comparison with negative patients (QoE moderate B).

 Statement 5.3

  The risk of environmental contamination and virus exposure in operating room related to the surgical management of a confirmed COVID-19 patient is high in the lack of trained health staff and personal protective equipments (QoE moderate B).

 Statement 5.4

  During COVID-19 pandemic, it is fundamental to carefully evaluate case by case the necessity for immediate surgical or non operative strategies, as recommended in international guidelines (QoE moderate B).

 Recommendations/5

  In evaluating the necessity to perform emergency surgery in COVID-19 (+), we recommend complying with international guidelines about immediate surgery or non operative strategies, evaluating case by case and resources. According to TACS classification, class 1 and 2 patients require surgical treatment in a very short delay (Strong recommendation based on a moderate level of evidence 1B).

6-Are emergency surgical procedures for confirmed COVID-19 patients different?

 Statement 6.1

  SARS-CoV-2 is presumed to spread primarily via respiratory droplets and aerosols and close contact, but the virus can be isolated also in the faeces and biological fluids of the infected patient (QoE high A).

 Statement 6.2

  Human coronaviruses can persist on inanimate surfaces such as metal, glass, or plastic for up to nine days (QoE high A).

 Statement 6.3

  Aerosol generated procedures (AGP) are considered responsible for the dissemination of the SARS-CoV-2 virus in the hospital (QoE moderate B).

 Statement 6.4

  Performing or being exposed to a tracheal intubation without adequate PPE is the main risk factor for health care workers SARS-CoV-2 infection (QoE high A).

 Statement 6.5

  Laparoscopic approach has been advocated such as a high risk AGP because of the artificial pneumoperitoneum and smoke generated from the surgical devices (QoE very low D).

 Statement 6.6

  Laparotomy such as laparoscopy should be considered a high risk procedure that can be implicated in the intra-hospital dissemination of the virus because of the higher exposure to biological fluids, surgical smoke generated with the use of electrocautery (QoE low C).

 Statement 6.7

  The laparoscopic approach could have the advantage of decreasing the length of hospital stay of an asymptomatic COVID-19 patient and the risk of in-hospital infection of a negative patient, in a period of limited availability of beds (QoE very low D).

 Statement 6.8

  The emergency surgeon has the responsibility to evaluate if a safe surgical procedure is possible considering the restricted access to resources and the safety of surgical staff and of patient (QoE high A).

 Recommendations/6

  If an immediate surgical procedure needs to be performed, whether laparoscopic or via open approach, we recommend doing every efforts to protect the operating room staff, in the safety of the patient (Strong recommendation based on low level evidence 1C). To perform a safe surgical procedure, we recommend having a trained staff, wearing the necessary PPEs and an established protocol for the preoperative, peri-operative and postoperative management of the COVID-19 surgical patient (Strong recommendation based on low level evidence 1C).We recommend being careful in the establishment and management of the artificial pneumoperitoneum, in the management of the hemostasis and of incisions to prevent any loss of biological fluids and contamination of the surgical staff (Strong recommendation based on low level evidence 1C).We recommend using of all available devices to remove smoke and aerosol during a laparoscopic procedure and a closed suction system for artificial pneumoperitoneum (Strong recommendation based on a low level evidence 1C).If it is not possible to perform surgery in a safe and protected environment, we recommend do not underestimating the highest risk of contamination and infection for health care workers and dissemination of the virus in the hospital and to consider transferring hemodynamically stable patients in a COVID HUB hospital for the appropriate management (Strong recommendation based on a low level evidence 1C).We recommend to not be present during the intubation and extubation maneuvers, if it is possible (Strong recommendation based on a moderate level evidence 1B).

7-Confirmed COVID-19 patients have a different Low Molecular Weight Heparine (LMWH) prophylaxis ?

 Statement 7.1

  COVID-2019 infection can activate coagulation cascade through various mechanisms, leading to severe hypercoagulability. Early anticoagulation may block clotting formation and reduce microthrombus, thereby reducing the risk of major organ damages (QoE moderate B).

 Statement 7.2

  In confirmed COVID-19 patients, routine D-dimer testing on admission and serially during hospital stay should be considered to stratify the risk of venous thromboembolism (VTE). In the case of significantly elevated D-dimer levels (≥1.5–2.0 mg/L), pharmacological VTE prophylaxis should be initiated (QoE moderate B).

 Statement 7.3

  Prophylactic-dose LMWH should be initiated in all surgical patients with COVID-19 disease admitted to the hospital to decrease thromboembolic risk related to the infection and emergency surgery (QoE moderate B).

 Statement 7.4

  Prophylactic anticoagulation reduces the risk of VTE in acutely ill hospitalized medical patients when the risk of bleeding is acceptable (QoE moderate B).

 Statement 7.5

  Anticoagulant therapy mainly with LMWH appears to be associated with better prognosis in severe COVID‐19 patients, according to the risk of surgical bleeding (QoE moderate B).

 Statement 7.6

  If pharmacological VTE prophylaxis is indicated, LMWH should be given at a dosage approved for high-risk situations. In case of contraindications for anticoagulation, physical measures should be used (e.g., medical compression stockings) (QoE moderate B).

 Statement 7.7

 Intensified VTE prophylaxis (e.g. with an intermediate, half-therapeutic LMWH dosage once daily or with a high-risk prophylactic LMWH dosages twice daily) should be considered in patients with additional risk factors (e.g. body mass index > 30 kg/m2, history of VTE, known thrombophilia, active cancer) or requiring ICU admission or with rapidly increasing D-dimer levels, taking into account renal function and bleeding risk (QoE moderate B).

 Statement 7.8

  Following discharge from hospital, prolonged pharmacological VTE prophylaxis is reasonable in patients with persistent immobility, high inflammatory activity, and/or additional risk factors (QoE low C)

 Statement 7.9

  In hospitalized COVID-19 patients who develop VTE, especially in those requiring ICU admission, LMWH at therapeutic dosages may be considered the standard of care. In cases of severe renal insufficiency, unfractionated heparin should be administered (QoE moderate B).

 Recommendations/7

  We recommend administering prophylactic anticoagulation with LMWH as soon as possible in COVID-19 surgical patients to reduce thromboembolic risk related to the virus, sepsis and emergency surgery. The dosage of the anticoagulant therapy has to be adjusted according to the risk of surgical bleeding, renal function and weight of the patient (Strong recommendation based on a moderate level evidence 1B).If it is not possible to administer an antitromboembolic prophylaxis, think to the intermittent pneumatic compression, in case of immobilized patient, and to mobilize the patient as soon as possible (Strong recommendation based on moderate level of evidence 1B).

8-Is postoperative treatment for confirmed COVID-19 patients different?

 Statement 8.1

  COVID-19 surgical patient requires a multidisciplinary approach, above all if he/she is admitted in ICU for mechanical ventilation and presents with signs of septic shock (low level of evidence C).

 Statement 8.2

  Specific pharmacological treatment for COVID-19 disease is not available but when an empirical treatment is administered, it is mandatory to monitor for early detection of complications (moderate level of evidence B).

 Statement 8.3

  Currently there are no data about the use of antimicrobial in COVID-19 patients to prevent secondary health-care infections (low level of evidence C).

 Statement 8.4

  Initial prompt antibiotic therapy for intra-abdominal infections in surgical patients is typically empirical and depends on the underlying severity of infection, the pathogens presumed to be involved, and the risk factors indicative of major resistance patterns. Antimicrobial treatment should be targeted to results from cultures from the site of infections or hemocultures with de-escalation of treatment as early as possible, in according with WSES guidelines (moderate level of evidence B).

 Statement 8.5

  Empirical antifungal treatment should only be considered in critically COVID-19 patients, presenting fever of unknown origin, with new pulmonary infiltrate superimposed on a viral pneumonitis pattern, with the aim of confirming the diagnosis by invasive techniques and/or the use of fungal biomarkers (moderate level of evidence B).

 Recommendations/8

  We recommend carefully administering antibiotics in COVID-19 surgical patients for the high risk of selecting resistant bacteria, especially in patients admitted in ICU for mechanical ventilation. Early empirical antibiotic treatment should be targeted to results from cultures, with de-escalation of treatment as soon as possible (Strong recommendation based on a moderate level of evidence 1B).

9-Is it necessary to create an overt COVID-19 patient surgical ward?

 Statement 9.1

  Patients needing for a surgical procedure or undergone urgent surgery with confirmed SARS-CoV-2 infection require a multidisciplinary approach and management and they need to be isolated from negative patients to decrease the in-hospital risk of virus transmission and environmental contamination (very low level of evidence D).

 Statement 9.2

  Confirmed COVID-19 patients need to be cared by a trained and skilled workforce with adequate PPEs (e.g N95 masks, goggles, double gloves, face mask and protective gowns) to preserve negative surgical patients from contagion, because the high risk to come in contact with droplets and biological fluids (very low level of evidence D).

 Recommendations/9

  After an emergency surgical procedure, we recommend re-admitting in Covid-ICU patients with severe pneumonia for management and monitoring.For stable asymptomatic or mild symptomatic COVID-19 patients, it would be better to create a surgical dedicated ward with the aim to avoid any contamination of negative patients and to limit the in-hospital exposure to the virus to a dedicated and trained team (Strong recommendation based on a very low quality evidence 1D).

10-Is it necessary to create a suspected COVID-19 patient surgical ward ?

 Statement 10.1

  Insufficient precaution in managing a false negative COVID-19 patient could cause the contagion of nurses, surgeons and negative patients (QoE moderate B).

 Recommendations/10

  Considering the high infectivity related to SARS-CoV-2, we suggest that suspected/uncertain patients should be isolated to ensure the limiting of exposure and contagion. If suspected/uncertain COVID-19 patient needs to undergo immediate surgery, he/she has to be managed like a confirmed COVID-19 patient, till diagnosis is confirmed by RT-PCR test, that has to be performed twice in uncertain patients.If the swab test is negative, but CT scan showed signs of COVID-19 pneumonia, the patient can’t be considered COVID-19 (-) and the RT-PCR swab test has to be repeated; if RT-PCR is positive, the patient is considered COVID-19 (+) and addressed to Covid-ICU or Covid-Surgical unit (Strong recommendation based on low level of evidence 1C).

11-Are there different discharge policies for suspected/overt Covid patients?

 Statement 11.1

  Current data reported that several patients meeting criteria for hospital discharge, could show positive RT-PCR test after the established quarantine of 14 days (low level of evidence C).

 Statement 11.2

  There aren’t data proving the contagiosity of a recovered patient who keeps to intermittently eliminate SARS-CoV-2 after 14 days from the onset of symptoms or positive RT-PCR test.

 Recommendations/11

  We suggest that after hospital discharge, all the confirmed surgical COVID-19 patients should be kept in isolation for at least 2 weeks have passed since the date of their first positive naso-pharingeal swab test and until negative RT-PCR nasofaringeal swab test is obtained (Weak recommendation based on very low quality of evidence 2D).