International Delphi Expert Consensus on Safe Return to Surgical and Endoscopic Practice

From the Coronavirus Global Surgical Collaborative

Horacio J. Asbun, MD, FACS; Mohammad Abu Hilal, MD, PhD, FACS, FRCS; Filipe Kunzler, MD; Domenech Asbun, MD; Jaap Bonjer, MD, PhD, MBA, FRCSC; Kevin Conlon, MD, FRCSI, FACS, FRCSG, FTCD; Nicolas Demartines, MD, FACS, FRCS; Liane S. Feldman, MDCM, FACS, FRCS; Salvador Morales-Conde, MD, PhD; Andrea Pietrabissa, MD, FACS; Aurora D. Pryor, MD, FACS; Christopher M. Schlachta, BSc, MDCM, FRCSC, FACS; Patricia Sylla, MD, FACS, FASCRS; Eduardo M. Targarona, MD, PhD, FACS; Yolanda Agra, MD, PHD, MHRs; Marc G. Besselink, MD, Msc, PhD; Mark Callery, MD, FACS; Sean P. Cleary, MD, FACS; Luis De La Cruz, MD; Philippe Eckert, MD; Chad Evans, BA; Ho-Seong Han, MD, MS, (Gen Surg), PhD; Daniel B. Jones, MD, MS, FASMBS; Tong Joo Gan, MD, MHS, FRCA, MBA; Daniel Koch, MD; Keith D. Lillemoe, MD, FACS; Davide Lomanto, MD, PhD, FAMS; Jeffrey Marks, MD, FACS; Brent Matthews, MD, FACS; John Mellinger, MD, FACS; William Scott Melvin, MD, FACS; Eduardo Moreno-Paquentin, MD, FACS; Claudio Navarrete, MD; Timothy M. Pawlik, MD, PhD, MPH; Patrick Pessaux, MD, PhD; Walter Ricciardi, MD, MPH, MSc; Steven Schwaitzberg, MD, FACS; Paresh Shah, MD, FACS; Joseph Szokol, MD; Mark Talamini, MD, FACS; Ricardo Torres, MD; Alessandro Triboldi; Suthep Udomsawaengsup, MD, FRCST, FACS; Federica Valsecchi, PhD; Jean-Nicolas Vauthey, MD, FACS; Michael Wallace, MD; Steven D. Wexner, MD, PhD, FACS, FRCS, FRCS; Michael Zinner, MD, FACS; Nader Francis, MBChB, FRCS, PhD


Annals of Surgery. 2021;274(1):50-56. 

In This Article

Abstract and Introduction


Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities.

Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers.

Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting.

Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements.

Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.


The rapid global spread of coronavirus disease 19 (COVID-19) presents an unprecedented crisis for the surgical and endoscopic community, which has forced to rapidly decrease or even halt elective surgical practices.[1,2] As a consequence there is a backlog of patients needing surgical care, along with increased financial hardships for healthcare workers and hospital systems.[3,4] There remains uncertainty about the duration of this pandemic and the extent of its consequences on surgical services and patients.[5]

The COVID19 pandemic presents immediate challenges to the surgical and endoscopic global community. Given the complexity of the growing issues, there is a need in healthcare communities for clear and structured guidance pertaining to when, where, and how to restart surgical practices amidst the COVID-19 pandemic.

Despite multiple position statements from prominent organizations with recommendations on when and how to resume elective surgical services,[3,4] there is a paucity of evidence-based techniques used to formulate these processes. Additional limitations of the published position statements are that either they are not specifically made for surgical and endoscopic settings or they are not detailed enough to serve as an effective and comprehensive guide. The acute nature of the pandemic has made it difficult to employ traditional sources of high-level evidence and stringent consensus methodology.

The Coronavirus Global Surgical Collaborative (CVGSC) in conjunction with a group of international experts from four continents representing a wide range of surgical, anesthesia, and endoscopic societies sought to formulate consensus recommendations. The group also included policymakers and patient representatives, and sought to apply validated, rigorous scientific methodology to formulate pertinent recommendations.

The CVGSC was formed with the purpose of sharing experiences and disseminating information related to the COVID-19 pandemic. It is an initiative sponsored by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in collaboration with representatives from the European Association for Endoscopic Surgery (EAES), Americas Hepato-Pancreato-Biliary Association (AHPBA), American Society of Anesthesiologist (ASA), the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), the Endoscopic and Laparoscopic Surgeons of Asia (ELSA), the Enhanced Recovery after Surgery Society (ERAS-UK), French Surgical Association (AFC), the International Consortium of Minimally Invasive Pancreatic Surgery (IMIPS), the Korean Society of Endoscopic and Laparoscopic Surgeons (KSELS), the Spanish Association of Surgeons (AEC), Society for Surgery of the Alimentary Tract (SSAT), and other international leaders in surgery.

This work aims not to provide expertise in the management of the COVID-19 disease, but to take advantage of the knowledge gained by internationally renowned surgical leaders in the handling of the COVID-19 crisis affecting the surgical community and on the safe resumption of surgical and endoscopic activities.