Early Experience: Bariatric Emergency During the COVID-19 Pandemic
by SABER GHIASSI, MD, MPH
Dr. Ghiassi is with the Division of Bariatric and Minimally Invasive Surgery, Department of Surgery at the Yale School of Medicine in New Haven, Connecticut.
Bariatric Times. 2020;17(4):19.
I checked the electronic medical records as soon as I received a call from the consult resident regarding a 59 year-old female patient with closed loop small bowel obstruction. The patient had undergone a laparoscopic Roux-en-Y gastric bypass at an outside hospital over a decade ago. She was brought to the emergency room (ER) by ambulance with 12 hours of worsening abdominal pain, nausea, and vomiting. She was tachycardic, but labs were within normal limits. A computed tomography (CT) scan showed classic findings of internal hernia, including dilated gastric remnant and biliopancreatic limb with midabdominal mesenteric swirl.
While asking the resident to book the patient for the operating room (OR), I glanced at a brief intake note by the ER nurse. The patient worked at a local community health center, and she had been told to isolate herself at home after a physician and a coworker at the center have been tested for COVID-19. She did not know their test results yet.I made sure that a COVID-19 polymerase chain reaction (PCR) was sent by the ER.
We have been preparing for such scenarios at Yale New Haven Health System. All elective cases have been postponed. Luckily, it was a Saturday, and the only other case in the operating room was for a gunshot wound handled by the trauma staff. I informed the OR staff and anesthesiologist that the patient is suspected of and should be managed as a COVID-19 infection. I donned the appropriate personal protective equipment (PPE), including N95 mask, cap, face shield, gown and shoe covers and asked the resident to wait outside the patient’s negative pressure room in the ER while I examined her. She appeared in distress with generalized abdominal tenderness and epigastric fullness on physical, consistent with gastric remnant dilation.
The patient was to be transferred directly from the ER to an OR furthest from the trauma room, and then directly to a negative pressure room
in the intensive care unit (ICU) to recover after surgery. We ensured that persons responsible for transport were in full protective gear as one led the way through the badge readers and doors without touching the patient or stretcher.
The OR staff was limited to anesthesiologist, who donned a hooded face shield on top of N95 mask, scrub technician, and a circulating nurse. I instructed the resident to enter the OR once patient was intubated and prepped. Everyone had the appropriate PPE, including N95 masks. We ensured that all necessary instruments and equipment were in the room with the plan to have someone deliver any other material to the scrub room outside the OR if necessary. The circulating nurse and myself assisted the patient from the stretcher to the OR table. Once the patient was intubated and prepped, I took off and placed my cloth gown in the appropriate bin, scrubbed and used the paper gown in the surgical pack and double gloved. The resident then entered the room and donned gown and gloves.
The laparoscopy was straight forward, as the entire small bowel was examined in a retrograde fashion from the ileocecal valve, which was pulled to the mid abdomen. The common channel, jejunojejunostomy, and the Roux limb were reduced from a defect in the transverse mesocolon. A massively dilated gastric remnant made the complete visualization of the mesocolic defect difficult. The remnant was decompressed by pushing a suction catheter through its thinned and stretched wall. The small gastrotomy was then repaired easily once the gastric remnant was decompressed. The mesenteric defects in the mesocolon and at the jejunojejunostomy were closed with permanent sutures. All intestinal limbs were examined again to ensure normal anatomy. Electrocautery and ultrasonic energy sources were not used during surgery due to the theoretical risk of tissue and virus aerosolization. Abdomen was evacuated of CO2 with trocars in place to prevent aerolization. To further prevent aerolization, you can also connect a smoke evacuator to remove CO2. The patient was transported to a negative pressure room in the ICU to recover, and she did well after surgery. The operating room was terminally cleaned and all material disposed of per system protocol for handling COVID-19 material.
Once home, I took off and left my clothes and shoes in the garage, disinfected my hands and put on a set of new clothes left in the garage for such scenario. Soon after, the patient’s PCR test resulted negative for COVID-19. I called the patient’s son, whom I had asked to self-isolate before surgery, for an update and the test result. I asked him to continue to practice hand washing and social distancing despite the negative result. While feeling relieved, I was happy to have had a dry run for possibility of operating on a COVID-19 positive patient.
Category: Letters to the Editor, Past Articles
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