Antonio LacyRichard Brady interviews Antonio Lacy about AIS Channel, the world's leading online surgery platform, and the challenges for surgery in the COVID-19 era. Dr Lacy is a pioneer in the use of laparoscopy in colorectal cancer surgery.

Can you tell me how COVID19 is affecting healthcare in Barcelona? When did you know this was a major problem?

The current situation in Spain is one of the most serious worldwide. A state of emergency has been declared. An action plan has been put in place in Barcelona to give full priority to the care of COVID19 patients. ICU equipment has been tripled, private healthcare facilities and hotels have been made available, field hospitals have been set up and surgical activity is being minimised, where possible.

What impact have you noticed on your surgical practice and patient care?

One key change has been that only non-delayable interventions are being carried out - that is, emergencies and preferential cases. We are naturally concerned about cancer patients, but with the shortage of ICU beds, the risk of transmission to surgical teams and the terrible rate of respiratory complications observed, we are compelled to do this. Many patients may be COVID19 positive but asymptomatic. These patients often present the manifestations of infection in an 'explosive' manner in the context of response to surgical aggression.

Are you implementing any changes within your personal/social life as a result of COVID-19?

In compliance with the state of emergency declared by the government, I only travel to treat patients or to perform management tasks in my department. We play very close attention to matters of hygiene, minimise social contact, hold all meetings online and treat patients with the utmost protection. In addition, in the event of having to operate on COVID19 patients, we make sure to use appropriate personal protection equipment.

AIS's high quality, user-friendly content and events have never had a more important time to shine to replace the traditional medical congresses.

How have you been preparing for this change?

The commitment to free surgical education at AIS is as strong as ever. In addition to offering our usual content, we have implemented three key lines of action:

  • A repository of reliable and proven information on COVID-19 and surgery that includes the translation of texts written by surgeons in Wuhan, China into Spanish and English.
  • The creation of a platform so that all the conferences and courses that were to be held during these months can be held online - an initiative that is completely in line with our philosophy.
  • Holding online conferences with world experts so that we can share experiences and questions about the care of surgical patients during this pandemic. It is of paramount importance that we learn from surgeons in both Wuhan and Beijing; being able to count on their experience in treating Covid19 patients, is extremely valuable.

What is the status of AIS at present, how big is the membership and how many people work on the channel?

AIS remains the world's leading online surgery platform. We have more than 130,000 users from more than 145 countries. AIS has grown a lot and diversified in recent times - in addition to content, we are increasingly involved in developing solutions for surgeons in many aspects of their education. In the last two years, AIS has become a giant thinktank of teaching solutions for surgeons. Our relationship with the world of telecommunications allows us to be leaders in innovation in areas such as remote learning or the use of 5G in the surgical field. We are growing not just in the numbers of surgical staff we have on board – we are also growing our capabilities with the addition of experts in online education, engineers, bioinformaticians, graphic designers, audio-visual personnel, etc.

What role will AIS aim to play in the coming months for global surgical education?

We will have two key roles. Firstly, we will ensure that the entire surgical community has access to the best information about coronavirus: its prevention, treatment and the attitude to take in the surgical environment.

We will also play our part in making sure that surgical education does not grind to a halt. We have to guarantee that surgeons from all over the world can continue in their education. That’s why we want to ensure that the key conferences take place virtually online.

Are there other innovations planned on the AIS channel and do you plan to expand into other areas?

As I mentioned previously, AIS plans to participate in very ambitious projects in order to improve surgical practice. One key project will be the application of AI to improve not only the way we operate, but also the way in which we teach how to operate. We will also implement technologies that, like 5G, allow virtual learning systems to be truly safe and effective.

Tell us about the upcoming conference on COVID19. Did it take long to arrange, how did you choose your speakers, what are the highlights and how many people will it reach?

The design of the meeting was quick as my idea was developed in a matter of hours by our team. We decided to contact world experts like Prof. Wexner and mainly surgeons who had experience in colorectal surgery in areas where there were high rates of Covid-19 infections, such as China and Italy. I was impressed that, from the outset, the response of the speakers was really positive. There has been an excellent willingness to help in this problem that, unfortunately, is global.

Can you tell me about your talk this Friday, what is your message? What is your view on colorectal cancer care during the crisis?

The current situation involves making complex decisions, including prioritizing patient care. Covid patients are the top priority. However, there are patients with neoplasms that unfortunately will have to be operated on during these months. The teachings of Wuhan's surgeons are proving to be key. Minimize risks, try to solve immediate problems with minimal invasion and prepare for the worst. I believe there are three factors that determine our performance:

  1. The tumour itself - the early stages must be deferred and, in the case of advanced or complicated neoplasms, offer treatments that are as resolving as possible. We will put stents in place, but we will probably not operate on that patient for a few months.
  2. The patient's general condition - elderly patients, without autonomy or with severe comorbidities should NOT be operated on at this time.
  3. The virus itself - no patient should be operated on without knowing if they are infected or not. And if this cannot be determined, assume that the patient is positive. The secondary inflammatory response to surgery combined with the presence of the virus can be lethal. We know that the respiratory picture is secondary to an extremely intense inflammatory response that destroys the lungs. We must not let surgery be the trigger for such an immunological catastrophe. It is also not acceptable for patients to become infected during admission or for professionals to become infected either: detecting the presence of the virus before operating is mandatory.

You are known as an innovator in surgery. What are the challenges you see for surgery during the COVID19 era?

The immediate challenge is knowing who we should operate on, or rather, whether we should continue to operate at all. The problems we now have are logistical as we minimize the consequences of performing surgery on COVID-19 positive patients.

It is time to innovate in management and protection. We must seek imaginative solutions that will allow us to continue performing excellent surgery with minimum risk. In this respect, the evacuation of gas and the development of energy sources that minimise the generation of aerosols are key.

You have a well-documented reputation in TaTME. Can you tell me about the role of TATME in the COVID era? Will indications change?

I think that the different modalities of transanal surgery (TaTME, TAMIS, TEM…) should be avoided. The colon is the second reservoir of the virus and gas insufflation, possible leaks and the direct exposure of the surgeon in the perineal time are all risk factors. Similarly, robotic surgery minimizes some of the surgeon's exposure, but I have serious doubts about maintaining the optimal disinfection of the equipment.

What do you think of laparoscopy in the COVID19 era?

The use of laparoscopy should be minimized. We have no evidence of the virus spreading through the gas used in the surgery. However, previous experience with HPV or HBV tells us that the risk exists. Safety must be a priority. Gas evacuation must be carried out in a very controlled manner using valves, filters or water seals. The timing of assist incisions is particularly dangerous. Similarly, aerosolisation is highly dependent on the smoke generated by the electric or ultrasonic scalpel and must be minimised.

What is your message to ESCP members and AIS channel viewers regarding the worrying months ahead?

We are living the most important health challenge that the West has experienced in 20 years. The current situation involves joining forces, working collaboratively and being disciplined. The current COVID-19 is due to an aggressive virus with a previously unknown rate of infection. However, never before has medical research advanced so quickly or has information been able to be shared so readily. In the face of virulence, we have the ability to work together extraordinarily effectively. It is generosity that will get us out of this situation.

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