Steve Wexner

Steven Wexner, Director of the Digestive Disease Center at Cleveland Clinic Florida, speaks with Richard Brady about the US health system, COVID-19 guidance, online surgical education and more.

Professor Wexner, thank you for agreeing to speak to us on the subject of the current COVID-19 crisis in particular within US surgery.

Thanks Richard; as always delighted to collaborate with you.

The US and New York in particular seems to fast becoming one of the global hotspots for COVID infection, why do you think it has become so prevalent in NY?

I was born, raised, and educated in New York. New York shares many characteristics with Milan and with Madrid in that it is a high density urban area where there is a significant opportunity for virus acquisition while utilizing buses, trains, taxi and other cars, walking, riding elevators, and touching doorknobs and handrails. Although I am not an epidemiologist I believe that the population density is a major factor.

What is you reading of the preparedness and stability of the US health system for the COVID pandemic?

Several weeks ago every hospital in the USA began COVID-19 preparations. Those preparations include cancelling or postponing non-urgent surgery, endoscopy, and other interventional procedures. In addition dividing health care workers into teams to help with physical distancing (I agree with our Chief Wellness Officer Dr Mariana Berho that the term 'physical distancing' is more accurate and preferable to 'social distancing'), moving outpatient visits whenever possible to virtual visits, optimising space with intensive care capability, and ensuring optimal PPE and ventilator supply are all essential facets of preparation.

In addition policies and procedures for staff to care for their children who are no longer in school along with management of suspected and of COVID-19-positive staff are considerations.

What do you think of current plans in the US to relax social restriction policies by Easter and the so called 'treatment should not be better than cure' approach in regards to maintaining wider economic health?

Quarantines and physical distancing have been proven effective in Asia; I see no reason to tempt fate to prematurely relax restrictions. To the contrary, in my personal opinion we could do much more in terms of restricting domestic travel and federal 'shelter at home' orders as have been implemented in Italy, Spain, the UK, and elsewhere.

How has the current situation affected your own practice and are you taking any precautions in your social life?

Absolutely; I have reverted to the almost full-time administrative role similar to my schedule as chief of staff at Cleveland Clinic Florida from 1997-2008. The major difference is that my continuous meetings are now by video and or telephone rather than in person. Thankfully I have a superlative colorectal surgery team of Dana Sands, Eric Weiss, David Maron, Juan Nogueras, Giovanna Dasilva, Fabio Potenti and Stephen Sharp to provide excellent patient care in my absence. Socialisation in terms of travel, restaurants, and visiting friends has been eliminated for the last several weeks and for the foreseeable future. My socialisation is now by video and telephone calls with the leadership teams of the ACS and of Cleveland Clinic Florida.

What roles can surgeons play in these circumstances? Do you think the current crisis has irreversibly changed the life of surgeons?

We need to take care of ourselves and our families in order to best take care of our patients. Considerations include, trying to have healthy meals, exercise at home and try to have sufficient sleep each night. tremendous care must be taken to avoid bringing COVID-19 home by changing clothes, showering, and being fastidious. We can also learn other skills such as how to help our colleagues in the intensive care and acute care (emergency room/ A+E) areas as well as to perform nursing and or clerical functions as needed. I think that this pandemic will irreversibly change our lives much more so than the changes which were implemented during the onset of AIS/HIV disease.

You are heavily involved in US surgical leadership, can you explain some of the confusion about various guidelines that have been produced advocating open procedures versus laparoscopy during the pandemic?

I believe that you may be referring to are the guidelines jointly created by SAGES and EAES. I was President of SAGES from 2006-2007 and am proud to be an honorary member of EAES, but was not involved in drafting these guidelines. While the original version released March 21 advised against laparoscopy, the updated version seems more in line with the guidelines which, as Regent of the American College of Surgeons, I helped to develop.​ The intercollegiate statement of the four Royal Colleges with endorsement from ACPGBI, ASGBI, and AUGIS is very similar. My personal view is that the surgeon must ensure individual and team protection. Thus regardless of the operative approach selected, aerosolization must be avoided and full PPE should be properly donned and subsequently doffed by all operating room personnel. If laparoscopy is selected, for example in a patient in whom no suspicion of being actively infected with COVID-19 exists, great care must be taken to ensure proper use of sealed trocars and pneumoperitoneum maintenance and evacuation. A negative pressure operating room seems preferable.

What is your view on colonoscopy during the upcoming crisis and what level of protection should staff and endoscopists use?

Again, I prefer to defer to consensus guidelines, in this case again using the resource of SAGES and EAES and of the ACS as above as well as the March 15 joint statement by ASGE/AGA/ACG/AASLD. Basically, the only endoscopic procedures which should be undertaken during the pandemic are urgent ones. Standard screening and follow up colonoscopy should be deferred. One of the reasons is for patient safety, another is health care worker safety and a third is preservation of precious PPE. An issue is that all personnel in the endoscopy room should doff and don full PPE for every endoscopy.

Can you tell me how treatment algorithm of common surgical conditions like appendicitis, diverticulitis has changed?

The ACS and intercollegiate guidelines indicate that if surgery can be deferred it be deferred. Thus, in the absence of diffuse peritonitis I believe that the majority of patients with these two inflammatory conditions will be treated with antibiotics and percutaneous drainage rather than surgery whenever possible

What is your institution doing to address colorectal cancer during this time?

Following the guidelines above we have deferred all non-urgent procedures and are seeking alternate therapies where possible including chemotherapy, radiation therapy, and stenting. However as our ACS colorectal cancer guidelines suggest, symptomatic lesions and some other cancers may require urgent intervention.

There are increasing reports of surgeons becoming infected, intubated or dying, can you clarify the US advice we should be following for PPE in surgical procedures (particularly colorectal procedures)?

We follow the advice and guidelines of the CDC ​which are also enumerated in our ACS guideline. ​Unfortunately, there appears to be a global shortage of PPE so that its use is limited to direct contact with patients known to be COVID-19 positive.

As you have mentioned, there is an increasing concern surrounding the availability of PPE to front line medical staff. There are reports of surgeons ignoring the threat and operating without necessary protection or being placed under duress to perform in these circumstances - what is your advice ?

I urge surgeons and all health care providers to follow the advice of the CDC and ACS and properly doff and don PPE whenever in contact with any infected patient. The media is replete with anecdotes of previously healthy health care workers who became critically ill and died after inappropriate protective measures were used. We must be diligent and vigilant to help ourselves or we will not be able to help our patients.

How do you think we can continue to provide surgical education during the upcoming months? Do you think the traditional medical conference has a future?

Like administrative meetings, surgical education has become a virtual electronic process. Grand rounds, morbidity and mortality conferences, journal clubs, tumour boards, and other conferences have all converted to on-line media.

I have worked with my very dear friend Professor Antonio Lacy on his AIS Channel since prior to its inception. We have already held one global COVID-19 colorectal surgery conference at which we interacted with participants at about 32,000 IP addresses in almost 150 countries. We have two upcoming conferences planned, one with Abe Fingerhut on April 9 on minimally invasive surgery during COVID-19, and one on April 16 with Mariana Berho, our Cleveland Clinic Florida CEO, Wael Barsoum, Julio Mayol, Scott Levin, Beth Sutton, Barbara Bass, Tracy Hull, Aurora Pryor, Heidi Nelson, Melina Kibbe, Neil Floch, Patricia Turner, Susan Galandiuk, Valerie Rusch, and others on surgical leadership during the COVID-19 pandemic. In addition, I inaugurated our series of ACS commissioned cancer ​webinars on cancer management during the COVID-19 pandemic​.

I think that traditional in-person meetings will be at least transiently more popular than ever as surgeons will be anxious to see their colleagues in person. Limitations may be both because of airline and hotel limitations as a consequence of the financial burdens of the pandemic and of the need to 'catch up' with all of the deferred elective surgery once the situation improves. I think that the future will include in person meetings but the electronic meetings will continue to endure much the way security checks for airports has not reverted to pre 9-11 levels.

Have you any words of wisdom for our members about how to cope with new pressures?

Take advantage of any time with your loved ones while preparing for your local surge and protect them during the surge. Physical distancing rather than social distancing should be practiced. The social media hobby/addiction which you and I share is a great way to both acquire and disseminate knowledge as well as to make new friends and interact with old ones.

Thank you for your time and insights Professor Wexner.

I hope that my across the ocean reflections/ramblings as an honorary member of the ESCP are of some value. Thanks for allowing me to share them.

Steven D. Wexner, M.D., PhD(Hon) is the Director of the Digestive Disease Center at Cleveland Clinic Florida and has been the Chairman of the Department of Colorectal Surgery since 1993. He is the Past President of the American Society of Colon and Rectal Surgeons Research Foundation (2014-2016), Past President of the American Society of Colon and Rectal Surgeons (2011-2012), and the Past President of the Society of American Gastrointestinal and Endoscopic Surgeons (2006-2007).

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