JULY 2022 | The Surgical Technologist | 321 CONCLUSION The pathophysiological derangements of patients infected with SARS-CoV-2 require an understanding of the fundamental endotheliitis and immunothrombotic crosstalk causing fibrinolytic shutdown. For the surgeon who must confront an acutely ill patient with COVID-19, important decisions must be made regarding not just the timing of surgery, but also the nature of anticipating the thrombohemorrhagic complications of CAC and whether the patients are fully or prophylactically anticoagulated (205). For those patients who require elective surgery, a large study suggests a delay of up to seven weeks for elective surgery following SARS-CoV-2 infection, a guideline which has recently been adopted by specialty-specific societies (10). Yet, other studies have found abnormal hypercoagulability biomarkers up to six months after COVID-19 recovery, indicating potentially increased risk for some patients past seven weeks (81, 89–93). Refined use of these biomarkers for risk-benefit analysis can help to determine the most favorable time for surgery (7). In regard to the administration of thromboprophylaxis and full anticoagulation in the convalescent COVID-19 postoperative patient, certain biomarkers can potentially be used in a personalized-based medicine approach (77). More studies are needed to analyze biomarkers and physiologic derangements in COVID-19 recovery patients focusing on how these profiles forecast postoperative outcomes. VHAs have historically been used to profile postoperative patients at risk for VTE, and may help guide surgeons with timing of elective surgery, thromboprophylaxis, and full anticoagulation in this patient population (113–116). As the pandemic evolves, one can anticipate changing guidelines that may vary based on the COVID variant with accruing data on managing elective and acute surgery in this unique group of patients. ETHICS STATEMENT Ethical clearance for microclot analysis was obtained from the Health Research Ethics Committee (HREC) of Stellenbosch University (South Africa): N19/03/043, project ID 9521. Confirmation of omicron variant: N20/04/008_COVID-19. Ethics approval for the inclusion of the microclot micrographs in this review paper was received from the Ethics committee of Stellenbosch University (HREC2-2022-24525). AUTHOR CONTRIBUTIONS Conceptualization, CMB, EEM, HBM, AVT, NZ, DF, WH, RM, BSB, and MMW; Writing – Original Draft Preparation, CMB, AVT, NZ, JZ, SZ, TJB, MB, HB, RM, BSB, and MMW; Writing – Review & Editing, CMB, EEM, HBM, MDN, AVT, NZ, JZ, SZ, TJB, MB, HB, GW, DF, WH, HCK, GL, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK, MDF, LG, RZK, CNM, RM, RM, BSB, and MMW; Visualization, AVT, MMW; Supervision, AVT, MMW; Project Administration, CMB, AVT, NZ, and MMW; Funding Acquisition, MMW, EP. Patient recruitment, fluorescent microscopic and viral sequencing analysis, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK. All authors contributed to the article and approved the submitted version. FUNDING DBK: Novo Nordisk Foundation for support (grant NNF20CC0035580) (Project Code 96825). MJK and TGM: Research reported this article was supported by the South African Medical Research Council with funds received from the Department of Science and Innovation (Project Code 96825). The content and findings reported and illustrated are the sole deduction, view and responsibility of the researchers and do not reflect the official position and sentiments of the funders. ACKNOWLEDGMENTS In honor of the late Michael P. Chapman MD; mentor, colleague, and friend. We thank Dr. Arneaux Kruger for the blood sample collection of the patient diagnosed with Omicron. REFERENCES 1. Mattingly AS, Rose L, Eddington HS, Trickey AW, Cullen MR, Morris AM, et al. Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic. JAMA Netw Open. (2021) 4(12):e2138038. doi: 10.1001/ jamanetworkopen.2021.38038 2. Collaborative, Irish Surgical Research, Italian Society of Colorectal Surgery, Association of Surgeons in Training, and Transatlantic Australasian Retroperitoneal Sarcoma Working Group. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. Lancet Oncol. (2021) 22(11):1507–17. doi: 10.1016/S1470-2045(21)00493-9 3. American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. Chicago: ACOS (2020). 4. American College of Surgeons. COVID-19: elective case triage guidelines for surgical care. Chicago: ACOS (2020). 5. Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective surgery in the time of COVID-19. Am J Surg. (2020) 219(6):900–2. doi: 10.1016/j. amjsurg.2020.04.014 6. American College of Surgeons. Joint statement: roadmap for resuming elective surgery after COVID-19 pandemic. Chicago: ACOS (2020). 7. Silvapulle E, Johnson D, Darvall JN. Risk stratification of individuals undergoing surgery after COVID-19 recovery. Br J Anaesth. (2021) 128(1): e37–9. doi: 10.1016/j.bja.2021.09.026 8. Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. (2020) 396(10243):27–38. doi: 10.1016/S0140-6736(20) 31182-X Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.frontiersin.org 17 2022 | Volume 9 | Article 889999 CONCLUSION The pathophysiological derangements of patients infected with SARS-CoV-2 require an understanding of the fundamental endotheliitis and immunothrombotic crosstalk causing fibrinolytic shutdown. For the surgeon who must confront an acutely ill patient with COVID-19, important decisions must be made regarding not just the timing of surgery, but also the nature of anticipating the thromboh morrhagic complications of CAC and whether the patients are fully or prophylactically anticoagulated (205). For those patients who require elective surgery, a large study suggests a delay of up to seven weeks for elective surgery following SARS-CoV-2 infection, a guideline which has recently been adopted by specialty-specific societies (10). Yet, other studies have found abnormal hypercoagulability biomarkers up to six months after COVID-19 recovery, indicating potentially increased risk for some patients past seven weeks (81, 89–93). Refined use of these biomarkers for risk-benefit analysis can help to determine the most favorable time for surgery (7). In regard to the administ ation of thromboprophylaxis and full anticoagulation in the convalescent COVID-19 postoperative patient, certain biomarkers can potentially be used in a personalized-based medicine approach (77). More studies are needed to analyze biomarkers and physiologic derangements in COVID-19 recovery patients focusing on how these profiles forecast postoperative outcomes. VHAs have historically been used to profile postoperative patients at risk for VTE, and may help guide surgeons with timing of elective surgery, thromboprophylaxis, and full anticoagulation in this patient population (113–116). As the pandemic evolves, one can anticipate changing guidelines that may vary based on the COVID variant with accruing data on managing elective and acute surgery in this unique group of patients. ETHICS STATEMENT Ethical clearance for microclot analysis was obtained from the Health Research Ethics Committee (HREC) of Stellenbosch Universit (South Africa): N19/03/043, project ID 9521. Confirmation of omicron variant: N20/04/008_COVID-19. Ethics approval for the inclusion of the microclot micrographs in this review paper was received from the Ethics committee of Stellenbosch University (HREC2-2022-24525). AUTHOR CONTRIBUTIONS Conceptualization, CMB, EEM, HBM, AVT, NZ, DF, WH, RM, BSB, and MMW; Writing – Original Draft Preparation, CMB, AVT, NZ, JZ, SZ, TJB, MB, HB, RM BSB, and MMW; Writing – Review & Editing, CMB, EEM, HBM, MDN, AVT, NZ, JZ, SZ, TJB, MB, HB, GW, DF, WH, HCK, GL, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK, MDF, LG, RZK, CNM, RM, RM, BSB, and MMW; Visualization, AVT, MMW; Supervision, AVT, MMW; Project Administration, CMB, AVT, NZ, and MMW; Funding Acquisition, MMW, EP. Patient recruitment, fluorescent microscopic and viral sequencing analysis, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK. All authors contributed to the article and approved the submitted version. FUNDING DBK: Novo Nordisk Foundation for support (grant NNF20CC0035580) (Project Code 96825). MJK and TGM: Research reported this article was supported by the South African Medical Research Council with funds received from the Department of Science and Innovation (Project Code 96825). The content and findings reported and illustrated are the sole deduction, view and responsibility of the researchers and do not reflect the official position and sentiments of the funders. ACKNOWLEDGMENTS In honor of the late Michael P. Chapman MD; mentor, colleague, and friend. We thank Dr. Arneaux Kruger for the blood sample collection of the patient diagnosed with Omicron. REF R NC S 1. Mattingly AS, Rose L, Eddington HS, Trickey AW, Cullen MR, Morris AM, et al. Trends in US Surgical Procedures and Health Care System Response to Policies Curtaili g Elective Surgical Ope ations During the COVID-19 Pandemic. JAMA Netw Open. (2021) 4(12):e2138038. doi: 10.1001/ jamanetworkopen.2021.38038 2. Collaborative, Irish Surgical Research, Italian Society of Colorectal Surgery, Association of Su ge ns in Training, and Transatlantic Australasian Retroperitoneal Sarcoma Working Group. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. Lancet Oncol. (2021) 22(11):1507–17. doi: 10.1016/S1470-2045(21)00493-9 3. American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. Chicago: ACOS (2020). 4. American College of Surgeons. COVID-19: elective case triage g idelines for surgical care. Chicago: ACOS (2020). 5. Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective surgery in the time of COVID-19. Am J Surg. (2020) 219(6):900–2. doi: 10.1016/j. a jsurg.2020.04.014 6. American College of Surgeons. Joint statement: roadmap for resuming elective surgery after COVID-19 pandemic. Chicago: ACOS (2020). 7. Silvapulle E, Johnson D, Darvall JN. Risk stratification of individuals undergoing surgery after COVID-19 recovery. Br J An esth. (2021) 128( ): e37–9. doi: 10.1016/j.bja.2021.09.026 8. Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. (2020) 396(10243):27–38. doi: 10.1016/S0140-6736(20) 31182-X Bunch et al. COVID-19 Immuno-Thrombosis and Surgery Frontiers in Surgery | www.fr nti rsin.org 17 2022 | Volume 9 | Article 889999 CONCLUSION The pathophysiological derangements of patients infected with SARS-CoV-2 require an understanding of the fundamental endotheliitis and immunothrombotic crosstalk causing fibrinolytic shutdown. For the surgeon who must co front an acutely ill patient with COVID-19, important decisions must be made regarding not just the timing of surgery, but also the nature of anticipating the thrombohemorrhagic complications of CAC and whether the patients are fully or prophylactically anticoagulated (205). For those patients who require elective surgery, a large study suggests a delay of up to seven weeks for elective surgery following SARS-CoV-2 infection, a guideline which has ecently been ad pted by specialty-specific societies (10). Yet, other studies have found abnormal hypercoagulability biomarkers up to six months after COVID-19 recovery, indicating potentially increased risk for some patients past seven weeks (81, 89–93). Refined use of these biomarkers for risk-benefit analysis can help to determine the most favorable time for surgery (7). In regard to the administration of thromboprophylaxis and full anticoagulation in the convalescent COVID-19 postoperative patient, certain biomarkers can potentially be used in a personalized-based medicine approach (77). More studies are needed to analyze biomarkers and physiologic derangements in COVID-19 recovery patients focusing on how these profiles forecast postoperative outcomes. VHAs have historically been used to profile postoperative patients at risk for VTE, and may help guide surgeons with timing of elective surgery, thromboprophylaxis, and full anticoagulation in this patient population (113–116). As the pandemic evolves, one can anticipate changing guidelines that may vary based on the COVID variant with accruing data on managing elective and acute surgery in this unique group of patients. ETHICS STATEMENT Ethical clearance for microclot analysis was obtained from the Health Research Ethics Committee (HREC) of Stellenbosch University (South Africa): N19/03/043, project ID 9521. Confirmation of omicron variant: N20/04/008_COVID-19. Ethics approval for the inclusion of the microclot micrographs in this review paper was received from the Ethics committee of Stellenbosch University (HREC2-2022-24525). AUTHOR CONTRIBUTIONS Conceptualization, CMB, EEM, HBM, AVT, NZ, DF, H, RM, BSB, and MMW; Writing – Original Draft Preparation, CMB, AVT, NZ, JZ, SZ, TJB, MB, HB, RM, BSB, and MMW; Writing – Review & Editing, CMB, EE , HBM, MDN, AVT, NZ, JZ, SZ, TJB, MB, HB, GW, DF, WH, HCK, GL, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK, MDF, LG, RZK, CNM, RM, RM, BSB, and MMW; Visualization, AVT, MMW; Supervision, AVT, MMW; Project Administration, CMB, AVT, NZ, and MMW; Funding Acquisition, MMW, EP. Patient recruitment, fluorescent microscopic and viral sequencing analysis, GJL, PJL, EP, MJK, MSM, SS, TGM, DBK. All authors contributed to the article and approved the submitted version. FUNDI G DBK: Novo Nordisk Foundation for support (grant NNF20CC0035580) (Project Code 96825). MJK and TGM: Research reported this article was supported by the South African Medical Research Council with funds received from the Department of Science and Innovation (Project Code 96825). The content and findings reported and illustrated are the sole deduction, view and responsibility of the researchers and do not reflect the official position and sentiments of th funders. ACKNOWLEDGMENTS In honor of the late Michael P. Chapman MD; mentor, colleague, and friend. We thank Dr. Arneaux Kruger for the blood sample collection of the patient diagnosed with Omicron. REFERENCES 1. Mattingly AS, Rose L, ddington HS, Trickey AW, C ll n MR, Morris AM, et al. Trends in US Surgical Proc dures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic. JAMA Netw Open. (2021) 4(12):e2138038. doi: 10.1001/ jamanetworkopen.2021.38038 2. Collab rative, Irish Surgical Research, Italian Society of Colorectal Surgery, Associatio of Surgeons in Training, and Transatlantic Australasian Retrope itone l Sarcom Working Group. Effect f COVID-19 pandemic lockdowns n plan ed cancer surgery f 1 tumour types in 61 countries: an int rnati nal, prospective, cohort study. La cet Oncol. (2021) 22(11):1507–17. doi: 10.1016/S1470-2045(21)00493-9 3. American College of Surgeons. COVID-19: recommendations for management of elective surgical procedures. Chicago: ACOS (2 20). 4. American College of Surgeons. COVID-19: elective case triage guidelines for surgical care. Chicago: ACOS (2020). 5. Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective surgery in the time of COVID-19. Am J Surg. (2020) 219(6):900–2. doi: 10.1016/j. amjsurg.2020.04.014 6. American College of Surgeons. Joint statement: roadmap f r resuming electiv surgery aft COVID-19 pand mi . Chicago: ACOS (2020). 7. Silvapulle E, Johnson D, Darvall JN. Risk stratification of individuals und rgoing surgery after COVID-19 recovery. Br J Anaesth. (2021) 128(1): e37–9. doi: 10.1016/j.bja.2021.09.026 8. Nepo odiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. (2020) 396(10243):27–38. doi: 10.1016/S0140-6736(20) 31182-X Bunch et al. COVID-19 Immuno-Thr mbosis and Surgery Frontiers in Surgery | www.frontiersin.org 17 2022 | Volume 9 | Article 889999 9. Reuben Abel J, Andreani L, Aprile V, Balestri R, Benettini G, Berrettini S, et al. SARS-CoV-2 infection and venous thromboembolism after surgery: an international prospective coh rt study. Anaesthesia. (2022) 77(1): 28–39. doi: 10.1111/anae.15563 10. COVIDSurg Collaborative, GlobalSurg Collaborative. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. (2021) 76(6):748–58. doi: 10.1111/anae.15458 11. El-Boghdadly K, Cook TM, Goodacre T, Kua J, Blake L, Denmark S, et al. SARSCoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England. Anaesthesia. (2021) 76(7):940–6. doi: 10.1111/anae.15464 12. Groff D, Sun A, Ssentongo AE, Ba DM, Parsons N, Poudel GR, et al. Shortterm and Long-term Rates of Post cute Sequelae f SARS-CoV-2 Infection: A Systematic Review. JAMA Netw Open. (2021) 4(10):e2128568. doi: 10. 1001/jamanetworkopen.2021.28568 13. ASA and ASPF Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection: American Society of Anesthesiologists and Anesthesia Patient Safety Foundation; 2021. Available at: https://www. asahq.org/about-asa/newsroom/news-releases/2021/03/asa-and-apsf-jointstatement-on-elective-surgery-and-anesthesia-for-patients-after-covid-19infection-rv [updated March 9, 2021]. 14. Bui N, Coetzer M, Schenning KJ, O’Glasser AY. Preparing previously COVID-19-positive patients for elective surgery: a framework for preoperative evaluation. Perioper Med (Lond). (2021) 10(1):1. doi: 10. 1186/s13741-020-00172-2 15. Mankarious M, Massand S, Potochny J. Considerations for Elective Surgery in the Post-COVID-19 Patient. Aesthet Surg J. (2021) 41(10):Np1347–8. th 36 26. N A ht ag ut 20 27. T C SA e2 28. W C C (2 29. M cl im ja 30. Fo in C 31. K C do 32. Ja 19 C Bunch et al.
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