key: cord-309304-glcxrh7t
authors: Flemming, Sven; Hankir, Mohammed; Germer, Christoph‐Thomas; Wiegering, Armin
title: Author response to: Comment on: Abdominal fluid samples (negative for SARS‐CoV‐2) from a critically unwell patient with respiratory COVID‐19
date: 2020-09-19
journal: Br J Surg
DOI: 10.1002/bjs.11898
sha: 
doc_id: 309304
cord_uid: glcxrh7t

nan

We read the Comment by Coccolini et al. with interest and commend the authors for stressing the importance of surgical staff safety and protection during operations on COVID-19 patients. Since COVID-19 became pandemic, major research efforts have been directed towards understanding the pathophysiology and transmission of SARS-CoV-2. Initial recommendations were based on prior experience with the SARS-CoV and MERS-CoV outbreaks. Furthermore, recommendations for personal protection equipment for surgeons were influenced by experience with other viruses, such as human papillomavirus, hepatitis B virus (HBV) and human immunodeficiency virus (HIV), and their potential transmission during surgical procedures. International experts and medical societies have thus strongly encouraged that enhanced personal protective equipment including FFP2 or FFP3 facial masks be used, as well as laparoscopic approaches and the use of energy devices/electric instruments be re-considered during surgeries due to the increased potential risk of exposure to aerosolized viral particles 1,2 . Nevertheless, these recommendations should be critically challenged since only the transmission of human papillomavirus from patient to surgeon by surgical smoke (aerosols) has been reported in a very small number of cases. Further studies are therefore needed to increase the evidence of potential transmission by surgical smoke and pneumoperitoneum.

Several recent studies have shown that fecal samples of COVID-19 patients can be positive for SARS-CoV-2, suggesting potential fecal oral transmission and thus a higher risk for gastrointestinal surgeons 3 . A possible explanation for the detection of SARS-CoV-2 in fecal samples could be that ACE2, the receptor required for cell entry of SARS-CoV-2, is highly expressed in enterocytes of the small intestine and the colon 4 . Interestingly, ACE2 is also strongly expressed in the kidney 4 but PCR testing of urine samples were negative from patients suffering from COVID-19 5 . Similar observations have been made for other body fluid samples like cerebrospinal fluid, amniotic fluid and vaginal fluid.

The purpose of our case report was to share actual clinical observations and results from a critically ill patient suffering from COVID-19 pneumonia who required emergency surgical treatment. In our case, all intra-abdominal samples were negative for SARS-CoV-2. These results have since been supported by a second case report showing negative PCR of peritoneal fluid in a COVID-19 patient who needed emergency surgery due to acute appendicitis. However, we are acutely aware that SARS-CoV-2 progression varies from patient to patient, and that our understanding of COVID-19 pathophysiology is still at its infancy. As a result, emerging contradictory data that contribute to the ongoing scientific discussion are both welcome and essential. Coccolini et al. detected SARS-CoV-2 in peritoneal fluid, but without viral isolation suggesting that detection of SARS-CoV-2 by PCR in human body fluids does not necessarily mean that infectious transmission is possible.

We entirely concur that surgical staff protection and safety are of paramount importance when treating COVID-19 patients. Until the overall evidence of viral transmission through body fluids says otherwise, enhanced personal protective equipment is mandatory.

Global guidance for surgical care during the COVID-19 pandemic

Surgery in times of COVID-19-recommendations for hospital and patient management

COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission

Expression of the SARS-CoV-2 cell receptor gene ACE2 in a wide variety of human tissues

Detection of SARS-CoV-2 in Different Types of Clinical Specimens