RBGO Revista Brasileira de Ginecologia e Obstetrícia Rev Bras Ginecol Obstet 0100-7203 1806-9339 Federação Brasileira das Sociedades de Ginecologia e Obstetrícia 00601 10.61622/rbgo/2024rbgo24 Letter to the Editor Letter to Editor: In response to existence of SARS-CoV-2 in the peritoneal fluid 0000-0002-9762-3698 Romero-Velez Gustavo 1 0000-0003-0735-148X de Leon-Ballesteros Guillermo Ponce 2 0000-0003-4158-4893 Barajas-Gamboa Juan 3 0000-0001-8659-0934 Dang Jerry 4 0000-0001-8664-244X Strong Andrew 4 0000-0003-3604-7938 Kroh Mathew 4 United States of America Endocrine and Metabolism Institute Cleveland Clinic Cleveland OH America Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH, United States of America. Hospital Angeles Morelia Department of Surgery Morelia Mexico Department of Surgery, Hospital Angeles Morelia, Morelia, Mexico. United Arab Emirates Cleveland Clinic Abu Dhabi Digestive Disease Institute America Digestive Disease Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates United States of America Digestive Disease and Surgery Institute Cleveland Clinic Cleveland OH America Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States of America. Corresponding author Gustavo Romero-Velez E-mail: romerog4@ccf.org

Conflicts to interest: none to declare.

 09 04 2024 2024 46 e-rbgo24 22 06 2023 04 07 2023 © 2023. Federação Brasileira de Ginecologia e Obstetrícia. All rights reserved. 2023 Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited.

We read with great interest the article recently published by Ilgen et al.(1) in which the authors prospectively collected peritoneal samples of patients positive for SARS-CoV-2 undergoing cesarean section. Their study increases the understanding of SARS-CoV-2 and the risk of infection while performing surgery, however, we would like to caution the authors in their conclusion. The authors findings are that none of the eight patients were positive for SARS-CoV-2 in their peritoneal samples and thus conclude that the exposure due to aerosolization of surgical fumes does not seem to be likely. Although the majority of case reports and case series have not been able to identify the presence of SARS-CoV-2 in the peritoneum, our recent systematic review on the topic found that 5.9% of the cases are likely to be positive, which is even higher for patients with severe disease.(2the virus responsible for COVID-19, in the abdominal cavity as well as in other abdominal tissues which surgeons are exposed has been investigated in several studies. The aim of the present systematic review was to analyze if the virus can be identify in the abdominal cavity.\nMethods We performed a systematic review to identify relevant studies regarding the presence of SARS-CoV-2 in abdominal tissues or fluids. Number of patients included as well as patient's characteristics, type of procedures, samples and number of positive samples were analyzed.\nResults A total of 36 studies were included (18 case series and 18 case reports) Thus, there is a theoretical risk of exposure to healthcare providers while performing surgery in infected patients. In a similar way, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines in the topic recommends protective measures to prevent the exposure in the era of COVID-19.(3) or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved.\nMethods Systematic literature reviews were conducted for 2 key questions (KQ)

References Ilgen O Ozgozen ME Appak O Ertan B Tımur HT Dogan OE Existence of SARS-Cov-2 in the peritoneal fluid Rev Bras Ginecol Obstet 2023 45 5 261 265 10.1055/s-0043-1770129 1 Ilgen O, Ozgozen ME, Appak O, Ertan B, Tımur HT, Dogan OE, et al. Existence of SARS-Cov-2 in the peritoneal fluid. Rev Bras Ginecol Obstet. 2023;45(5):261-5. doi: 10.1055/s-0043-1770129 Romero-Velez G Ponce de Leon-Ballesteros G Al Zubaidi M Barajas-Gamboa JS Dang J Corcelles R Presence of SARS-CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review Surg Endosc 2023 37 7 5011 5021 10.1007/s00464-023-10130-w 2 Romero-Velez G, Ponce de Leon-Ballesteros G, Al Zubaidi M, Barajas-Gamboa JS, Dang J, Corcelles R, et al. Presence of SARS-CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review. Surg Endosc. 2023;37(7):5011-21. doi: 10.1007/s00464-023-10130-w Collings AT Jeyarajah DR Hanna NM Dort J Tsuda S Nepal P SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19 Surg Endosc 2022 36 5 2723 2733 10.1007/s00464-022-09133-w 3 Collings AT, Jeyarajah DR, Hanna NM, Dort J, Tsuda S, Nepal P, et al. SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19. Surg Endosc. 2022;36(5):2723-33. doi: 10.1007/s00464-022-09133-w Original Article Reply to: Existence of SARS-CoV-2 in the peritoneal fluid 0000-0002-0296-8504 Ilgen Orkun 1 0000-0003-3395-3222 Ozgozen Mehmet Eyuphan 1 0000-0003-1810-8346 Appak Ozgur 1 0000-0002-0370-7509 Ertan Begum 1 0000-0002-1250-8579 Tımur Hikmet Tunc 1 0000-0002-5688-2300 Dogan Omer Erbil 1 0000-0001-5010-5204 Posacı Cemal 1 Dokuz Eylul University School of Medicine Department of Obstetrics and Gynecology Izmir Turkey Department of Obstetrics and Gynecology, School of Medicine, Dokuz Eylul University, Izmir, Turkey. Corresponding author Hikmet Tunc Timur Urla State Hospital, Obstetrics and Gynecology Clinic, Urla, Izmir, Turkey. E-mail: tunctimur@gmail.com

Conflicts to interest: none to declare.

We are gratified to note the international interest our article has sparked among medical practitioners. Romero-Velez et al.(1) recently presented an article entitled "Presence of SARS-CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review"; highlighting the substantial risk of viral particle dispersion during abdominal surgery, particularly in severe disease cases. Our research focuses on cases from the earlier stages of the pandemic when our understanding of the virus was not as advanced as it is today. Another Italian study by Fabbri et al.(2) stated that all their samples tested negative for SARS-CoV-2 RNA. Still, like other researchers, they emphasized that the risk could not be entirely ruled out and advised appropriate precautions. We concur that further research is necessary to shed more light on this issue.(3) Our primary goal should be to minimize the surgical team exposure to surgical fumes and other patient-derived substances, regardless of the specific pathogen. SARS-CoV-2 has undoubtedly brought more attention to this concern. We align ourselves with the guidelines of the Society of American Gastrointestinal and

Endoscopic Surgeons (SAGES)(4) and recommend implementing protective measures, even though numerous studies have failed to detect the virus in peritoneal samples. We extend our gratitude once more to Romero-Velez et al.(1) for maintaining the relevance of this discussion.

References Romero-Velez G Ponce de Leon-Ballesteros G Al Zubaidi M Barajas-Gamboa JS Dang J Corcelles R Presence of SARS- CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review Surg Endosc 2023 37 7 5011 5021 10.1007/s00464-023-10130-w 1 Romero-Velez G, Ponce de Leon-Ballesteros G, Al Zubaidi M, Barajas-Gamboa JS, Dang J, Corcelles R, et al. Presence of SARS- CoV-2 in abdominal tissues and biologic fluids during abdominal surgery: a systematic review. Surg Endosc. 2023;37(7):5011-21. doi: 10.1007/s00464-023-10130-w Fabbri N Pesce A Ussia A D’Urbano F Pizzicotti S Greco S Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: a prospective cross-sectional study from an Italian COVID center BMC Surg 202 22 1 119 119 10.1186/s12893-022-01571-6 2 Fabbri N, Pesce A, Ussia A, D’Urbano F, Pizzicotti S, Greco S, et al. Swab test in biological fluids as predictor of COVID-19 transmission risk during surgery: a prospective cross-sectional study from an Italian COVID center. BMC Surg. 202;22(1):119. doi: 10.1186/s12893-022-01571-6 Ilgen O Ozgozen ME Appak O Ertan B Tlmur HT Dogan OE Existence of SARS-Cov-2 in the peritoneal fluid Rev Bras Ginecol Obstet 2023 45 5 261 265 10.1055/s-0043-1770129 3 Ilgen O, Ozgozen ME, Appak O, Ertan B, Tlmur HT, Dogan OE, et al. Existence of SARS-Cov-2 in the peritoneal fluid. Rev Bras Ginecol Obstet. 2023;45(5):261-5. doi: 10.1055/s-0043-1770129 Collings AT Jeyarajah DR Hanna NM Dort J Tsuda S Nepal P SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19 Surg Endosc 2022 36 5 2723 2733 10.1007/s00464-022-09133-w 4 Collings AT, Jeyarajah DR, Hanna NM, Dort J, Tsuda S, Nepal P, et al. SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19. Surg Endosc. 2022;36(5):2723-33. doi: 10.1007/s00464-022-09133-w