1444 Letters to the Editor / Surgery 171 (2022) 1443e1447
1. Is the overall benefit for surgery confirmed in rectal poorly
differentiated neuroendocrine neoplasms?
2. In patients who experienced chemotherapy with or without
radiotherapy followed by surgery, did they experience a better
disease-free and overall survival than those who underwent
surgery alone in a curative intent?
3. It would be helpful for readers to present the subgroup analysis
of neuroendocrine neoplasms based on location.
Funding/Support
All authors have no funding sources to declare.
Conflict of interest/Disclosure
All authors have no conflict of interest to declare.
References
1. Thornblade LW, Warner SG, Melstrom L, et al. Does surgery provide a survival
advantage in non-disseminated poorly differentiated gastroenteropancreatic
neuroendocrine neoplasms? Surgery. 2021;169:1417e1423.
2. Pellat A, Cottereau AS, Terris B, Coriat R. Neuroendocrine carcinomas of the
digestive tract: what is new? Cancers. 2021;13:3766.
3. Strosberg JR, Coppola D, Klimstra DS, et al. The NANETS consensus guidelines for
the diagnosis and management of poorly differentiated (high-grade) extrapul-
monary neuroendocrine carcinomas. Pancreas. 2010;39:799e800.
4. Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and sur-
vival outcomes in patients with neuroendocrine tumors in the United States.
JAMA Oncol. Published online April 27, 2017. https://doi.org/10.1001/jamaoncol.
2017.0589
5. Brieau B, Lepe
re C, Walter T, et al. Radiochemotherapy versus surgery in nonme-
tastatic anorectal neuroendocrine carcinoma: a multicenter study by the Associ-
rologues Oncologues. Medicine. 2015;94.
ation des Gastro-Ente
Claire Sabat, MD*
Lola-jade Palmieri, MD, MSc
Catherine Brezault, MD, MSc
Gastroenterology and Digestive Oncology Unit
Ho^pital Cochin, APHP Centre, Paris, France
Claire Ginestet, MD
Antoine Assaf, MD
Romain Coriat, MD, PhD
Gastroenterology and Digestive Oncology Unit
Ho^pital Cochin, APHP Centre, Paris, France
Unit
e INSERM, Universit
e de Paris, Paris, France
* ing the COVID-19 outbreak. These complications need to get
Corresponding author.
E-mail address: clairesabat@free.fr (C. Sabat).
Accepted 27 August 2021
https://doi.org/10.1016/j.surg.2021.08.050
0039-6060/© 2021 Elsevier Inc. All rights reserved.
The surgeon’s dilemma: Performing cholecystectomy
during COVID-19
To the Editor:
We read with interest the article titled, “Impact of Coronavirus
Disease (COVID-19) on In-Hospital Mortality and Surgical Activity
in Elective Digestive Resections: A Nationwide Cohort Analysis”
by Challine et al.1 We would first congratulate the authors for an
insightful read. The COVID-19 pandemic led to the postponement
of elective surgeries, and the article suggests that elective surgeries
during the period did not have any implication on in-hospital mor-
tality rate. It also states that elective procedures should be advo-
cated during the pandemic for patients with cancer. However, the
results varied for low- and middle-income countries (LMICs) and
also depended on the lockdown measures employed by every
nation. Only emergency procedures were performed in most LMICs
to ensure the effective use of manpower and resources. This article
collates the postoperative outcomes, adaptations, and suggestions
by surgeons in LMICs during the COVID-19 pandemic, particularly
for emergency cholecystectomy.
Conventionally, one of the most common operative proced-
ures performed globally is cholecystectomy. The gold-standard
method for gallstone-related pathologies is still laparoscopic
cholecystectomy.2 Kabir et al noted that understanding the new
critical view of safety by surgeons during the pandemic is impor-
tant. These 3 points include: (1) absence of SARS-CoV in bile, (2)
evidence favoring safe laparoscopic surgery in COVID-19 infected
patients, and (3) implementation of rigorous preoperative
screening measures.3 Vigneswaran et al recommended using
smoke evacuation, minimizing use of energy devices, and low
pneumoperitoneum pressure to improve outcome and reduce
transmission.4 However, few opponents believe that percuta-
neous cystostomy is a better approach than laparoscopic chole-
cystectomy amidst the pandemic.5 To date, the dilemma
continues, and very few studies noted the postoperative outcome
of emergency cholecystectomy done during the COVID-19
outbreak period in LMICs.
Subjecting every emergency patient to triage and preoperative
screening required crucial hours. Evaluating both emergency and
elective patients would further burden the system. In India, a
single-center study noted that during lockdown, emergency chole-
cystectomy procedures and multiorgan dysfunction led to 4 times
increment in postoperative morbidity in patients.6
Martin Nnaji et al2 conducted a prospective study of complica-
tions seen in cholecystectomy patients during the COVID-19
outbreak period with indications of biliary colic, cholecystitis, chol-
angitis, gallbladder perforation, gallbladder polyp, and pancreatitis.
Postoperative complications noted were an approximate 2-fold in-
crease in bile leak, collection, hospital-acquired pneumonia, and
surgical site infections.
In conclusion, the patients after cholecystectomy are at
increased risk of bile leak, intraabdominal collection, hospital-
acquired pneumonia, and surgical site infection, especially dur-
assessed in follow-up patients and outcomes require proper au-
dits to improve further practice. Segregating patients requiring
conservative management during triage with those needing
emergency cholecystectomy can reduce the overall workload.
Further studies are needed to create a set of uniform practical
guidelines on the type, procedure, pre and postoperative consid-
erations of GI and hepatobiliary surgeries. They should consider
unique socioeconomic and geopolitical considerations of
different nations during the pandemic, which can be further
tailored by every institution regularly after practical consider-
ations. This will reduce subjectivity and ensure better implemen-
tation of guidelines worldwide.
Funding/Support
None declared.
 Letters to the Editor / Surgery 171 (2022) 1443e1447
Conflict of interest/Disclosure
None declared.
Acknowledgments
We would like to thank the Peer Research Mentorship Program
started by the International Society for Chronic Illnesses for their
support.
References
1. Challine A, Dousset B, de’Angelis N, et al. Impact of coronavirus disease 2019
(COVID-19) lockdown on in-hospital mortality and surgical activity in elective
digestive resections: a nationwide cohort analysis. Surgery. 2021;170:1644e1649.
2. Nnaji M, Murcott D, Salgaonkar H, Aladeojebi A, Athwal T, Cheruvu CV. Cholecys-
tectomy during COVID-19: a single-center experience. Dig Dis Intervent. 2021.
3. Kabir T, Kam JH, Chew M-H. Cholecystectomy during the COVID-19 pandemic:
current evidence and an understanding of the “new” critical view of safety: cor-
respondence. Int J Surg. 2020;79:307e308.
4. Vigneswaran Y, Prachand VN, Posner MC, Matthews JB, Hussain M. What is the
appropriate use of laparoscopy over open procedures in the current COVID-19
climate? J Gastrointest Surg. 2020;24:1686e1691.
5. Çiyiltepe H, Yıldırım G, Fersahog lu MM, et al. Clinical approach to patients
admitted to the emergency room due to acute cholecystitis during the COVID-
19 pandemic and percutaneous cholecystostomy experience. TJTES. 2021;27:
34e42.
6. Rahul, Verma A, Yadav P, Sharma VK, Sanjeev OP. Non-COVID surgical emergency
during the nationwide lockdown due to corona pandemic: a critical appraisal.
Indian J Surg. 2021;83:268e272.
Surobhi Chatterjee, MBBS*
Department of Surgery, King George’s Medical University, Lucknow,
Uttar Pradesh, India
Deepak Bethineedi, MBBS Student
Department of Surgery, Andhra Medical College, Vishakhapatnam,
Andhra Pradesh, India
* over “standard” management in 4 clinically relevant outcomes
Corresponding author.
E-mail addresses: surochat98@gmail.com,
surobhichatterjee@kgmcindia.edu (S. Chatterjee);
Twitter: @SurobhiChatter1
Accepted 11 September 2021
https://doi.org/10.1016/j.surg.2021.09.004
0039-6060/© 2021 Elsevier Inc. All rights reserved.
Letter to the editor: “Decision points in
pancreatoduodenectomy: Insights from the
contemporary experts on prevention, mitigation and
management of postoperative pancreatic fistula.”
To the Editors:
We read with great interest the article by Casciani, Bassi, and
Vollmer, “Decision points in pancreatoduodenectomy: insights
from the contemporary experts on prevention, mitigation and
management of postoperative pancreatic fistula.”1 We congratulate
the authors for the enormous amount of work they have done to
prepare the questionnaires and to analyze the answers of 60 of
the 65 surgeons recognized as being contemporary leaders in the
pancreatic surgery domain.
The most interesting result of the article is the wide variability of
experts’ answers to each of the questions proposed that underlines
the uncertainty in choosing the best solution among those available
for each of the questions. This means, however, that even in such a
highly selected group of surgeons there are important differences
in managing “the 4 inclusive and sequential steps of the decision-
1445
making for postoperative pancreatic fistula (POPF): risk assess-
ment, operative technique for anastomotic construction, applica-
tion of mitigation strategies, and postoperative management.”
Thanks to these differences in patient management, the risk of clin-
ically relevant postoperative pancreatic fistulas (CR-POPF) can be
significantly different among centers for patients with the same
surgical risk. These risk differences may alter the results of random-
ized controlled trials with centralized randomization by concen-
trating most of the patients of 1 of the trial arms in 1 or more
centers with a low or high CR-POPF risk. Randomizing patients
within each participating center may prevent this risk.
The authors report a unanimous agreement among experts indi-
cating that percutaneous catheter drainage with appropriate anti-
biotic therapy should be the first intervention for severe
pancreatic fistula. Unfortunately, the questions about postoperative
drain management are mostly concentrated on early drain removal
and on prediction of CR-POPF, whereas almost nothing is required
for the management of long-term in situ drains due to a POPF. It
is quite strange that maintaining a drain in situ for 2 days longer
(from 3e5) will be very dangerous,2 but there are no problems
with drains left in situ for weeks for persisting POPF while fluid col-
lections are drained percutaneously. We would have expected that
the authors had performed a literature review before preparing the
questionnaire to be submitted to the experts. For example, they
would have found the possibility of an endoscopic drainage of peri-
pancreatic fluid collections3 and of replacing surgical drains under
radiologic control after studying the pathway of the fistula by
means of fistulography.4 In a systematic review and metanalysis
we compared the results of the “standard” treatment of POPFs,
like that reported by the authors, with the “draining-tract-tar-
geted” management, that performs an early fistulography with
drain exchange and eventually drain’s continuous lavage.5 “Drain-
ing-tract-targeted” management showed a significant advantage
out of 8 according to pool analysis and in one of them according
to meta-analysis. A comment of the 60 experts on these 2 issues
could have been an important contributory idea on how to proceed
in the study of best treatment for POPF.
Funding/Support
The authors have indicated that they have no funding)regarding
the content of this article.
Conflict of interest/Disclosure
The authors have indicated that they have no conflicts of inter-
est regarding the content of this article.
References
1. Casciani F, Bassi C, Vollmer Jr CM. Decision points in pancreatoduodenec-
tomy: insights from the contemporary experts on prevention, mitigation,
and management of postoperative pancreatic fistula. Surgery. 2021;170:
889e909.
2. Kawai M, Tani M, Terasawa H, et al. Early removal of prophylactic drains reduces
the risk of intra-abdominal infections in patients with pancreatic head resection:
prospective study for 104 consecutive patients. Ann Surg. 2006;244:1e7.
3. Fugazza A, Sethi A, Trindade AJ, et al. International multicenter comprehensive
analysis of adverse events associated with lumen-apposing metal stent place-
ment for pancreatic fluid collection drainage. Gastrointest Endosc. 2020;91:
574e583.
4. Pedrazzoli S, Liessi G, Pasquali C, Ragazzi R, Berselli M, Sperti C. Postoperative
pancreatic fistulas: preventing severe complications and reducing reoperation
and mortality rate. Ann Surg. 2009;249:97e104.
5. Pedrazzoli S, Brazzale AR. Systematic review and meta-analysis of surgical drain
management after the diagnosis of postoperative pancreatic fistula after pan-
creaticoduodenectomy: draining-tract-targeted works better than standard
management. Langenbecks Arch Surg. 2020;405:1219e1231.