Interview by Vittoria Bellato.

You may already know Professor Salomone Di Saverio from his tremendous work as a colorectal and general surgeon and as a brilliant researcher. Following a laparoscopic surgery fellowship in Bristol, he worked as a consultant surgeon in the Ospedale Maggiore di Bologna, Italy for eight years.

In January 2018 he moved to Addenbrookes Hospital in Cambridge working as a substantive consultant in one of the most renowned colorectal units in the UK, before finally coming back to Italy to work at Varese Hospital from March, where he has been appointed Aggregate Professor of Surgery and Director of the General Surgery 1st unit of the local university hospital in the northern Lombardy region.

Vittoria Bellato: Good afternoon, Professor Di Saverio and thank you for participating in this interview.

Salomone Di Saverio: Thank you for the kind invitation.

VB: You start working in Varese in the middle of the pandemic, can you describe us your experience and how your centre dealt with the COVID-19 emergency?

SD: I started working in Varese exactly at the beginning of the coronavirus outbreak; as a joke, my colleagues said I brought Coronavirus here, because in that period Varese hospital was helping the other provinces, especially the hardest hit, such as Brescia and Bergamo, to cope with COVID-19 hospitals' crisis.

Overall, the data that our Director Gianni Bonelli brought to the attention were: more than 1,200 critical patients were treated and admitted in Varese hospital, and 25% of them were transferred from secondary overwhelmed centres. The average age of these patients was just slightly over 67 years old and the average length of stay was roughly 17 days.

VB: How much has the pandemic affected the elective surgical activity in your centre?

SD: Elective surgery stopped completely just after the beginning of the lockdown. This was a sensible decision taken from the Directive Board of this hospital. All non-oncological elective surgery was fully interrupted while oncologic surgery has been highly selectively continued, prioritizing mainly the urgent cases or advanced cancers where there were no alternatives. Age of the patient was also a factor to be considered. In the first surgical unit I am now leading here in this hospital, we have done only six oncologic procedures between March and May 2020 compared to 92 procedures in the same period of 2019. So, 92 vs 6, roughly less than 10%.

VB: How and when have you resumed elective surgery?

SD: Actually, we're restarting very slowly with very careful and prudent pathways. All patients are screened with swabs and serology with a very strict protocol before being admitted in our hospital. If they tested positive their surgical schedule will be cancelled and operation will be delayed. Overall, from June we're restarting 30% of our normal surgical activity. The Board of Directors estimates to reach 70% of pre-COVID era surgical load not before October 2020; we won’t get back to 100% activity before next year if everything goes well.

VB: During the peak of pandemic most hospitals have banned visits from relatives, have these measures changed?

SD: During the peak of pandemic it was completely forbidden for patients to interact with relatives, which is sad but necessary to keep infection rates under control. This policy hasn’t changed, I think we must be strict and not break the rules, especially in this phase.

VB: Many hospitals are dealing with a huge backlog of outpatient clinic appointments, some institution in Italy are planning to open some services non-stop (Mon-Sun). How is your hospital organised regarding clinic activities?

SD: As far as I know, clinics have resumed with a normal schedule, but we can see one patient every 30 min, to clean and sterilise and do everything properly. I think this prudent pathway adopted in this hospital might sound quite strict but pays off in terms of infection and transmission rate of the disease, especially in term of infection rate of the staff (doctors, nurses and care assistants).

VB: I read that Varese Hospital was one of few hospitals in northern Italy that experienced no staff COVID-19 infection during the pandemic peak; in your opinion which were the measures that prevent the most in-hospital infections?

SD: This is exactly what everyone wants to find out! As a new member of this team I was pleasantly surprised by these results. Basically, the protocols adopted were very strict, also other strategies and technologies were used, for example the use of robots in the wards, in the ICU and even within the hospital for delivery of meals and other equipment. As you may well understand, the use of robots around different wards and repository is extremely important and has an extreme value, allowing to reduce human interaction and to reduce almost to zero risk of infection.

The use of robotic technology is important not only to substitute the porters in the hospitals but also the implementation of robotic surgery in these times might be a valuable tool to reduce surgeon's and surgical staff exposure to a COVID-19 positive patient. Thanks to robotic platform is possible to avoid close interaction between suspected COVID-19 positive patients and surgical staff during surgery and this could be a good strategy to decrease infection rates among the surgical staff. This is quite important to avoid the possibility of infecting surgeons and the loss of their skills if they get infected.

Robotic porters

VB: You previously mentioned that in your unit every elective patient is being tested with swabs for COVID-19, in your opinion how should we manage an oncologic patient who is tested positive for more than 30 days (either asymptomatic or with atypical presentation)?

SD: As a general and oncologic colorectal surgeon, if I have a patient with an advanced cancer that was tested positive more than twice in 30 days, I would discuss options with a multidisciplinary team, with patient and family and consider alternative non-surgical treatment as for example neoadjuvant therapy in case of rectal cancer. Afterwards I would reassess the patient. On the other hand, if we are dealing with an advance stage colorectal cancer that might develop complications as large bowel obstructions or such as bleeding or perforation obviously this patient will enter in the emergency surgery pathway that consist on dedicated theatres, ward, staff and PPE.

VB: First data from different studies (e.g. S. Lei et al and CovidSurg collaborative) showed us that patients tested positive for COVID-19 that underwent surgery have worryingly high rates of postoperative mortality and complications. On the other hand, consequences of delaying surgeries are mostly unknown but equally alarming…

SD: That is true. I am a member of the steering and writing committee of the Lancet paper of CovidSurg led by D. Nepogodiev and Aneel Bhangu, and I found the results of this multinational study quite alarming, with very high and unexpected complication and mortality rate. Nevertheless I think we cannot count only deaths and morbidity from COVID-19 but, now that we reached the COVID-19 peak, we have to acknowledge also the morbidity and mortality rates following coronavirus, as many oncologic patients had delayed diagnosis and treatment and will face subsequent increased morbidity and mortality; this is also sad and alarming.

VB: Do we have enough data to create guidelines regarding this point or should they be tailor made for each patient?

SD: It is a case-by-case discussion and assessment of pros and cons, risks and benefits, but I am convinced that pursuing and continuing these high quality multi-institutional studies, as CovidSurg is brilliantly doing, is of utmost importance as we need precise data to issue guidelines and recommendations.

VB: Since there was lack of evidence on COVID-19 and considering the large epidemiological variation on different geographical areas, most doctors and hospitals dealt with mixed indication and rapidly changing policies. In your opinion, in Italy, were most preventive policies in surgical departments guideline-driven, or were decisions made independently by hospital health management and regional health care?

SD: You're totally right, I think the challenge to issue guidelines that might be reasonable in each setting, in each region is mainly limited because of different epidemiology and different heath care burden in different region. Many surgical and endoscopic societies gave recommendations, some of them were slightly different and everyone was suggesting mostly what was their feelings as most of recommendations were not evidence-based. At the end of the day, I think in Italy each hospital, each region and each province made their own rules and in each institution every surgeon followed their local protocols.

VB: In your opinion, what is the most important lesson learned about management of surgery departments?

SD: The most important lesson learned about the management of surgical patients after pandemic and for the future that is ahead of us is the increasing role of robotics system and robotic platforms. I think this pandemic has taught us how technology can replace and help humans for some tasks that can be accomplished in effective way and with a lower margin of errors by robotic platforms.

VB: Thank you for your time, was a pleasure talking with you.

SD: Thank you! Best wishes to everyone within the colorectal international community and beyond. Stay safe and take care!

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