Category Archives: BJS

Guest post: Angst among surgeons during the COVID-19 crisis

Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
 
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
 
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
 
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
 
on behalf of S-COVID Collaborative Group

The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,1which seems to be occurring again in countries that are being hit by the second wave.2

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The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.

Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.3 Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job. 

China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.4 The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.5

Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.6 Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.7 Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.8, 9

In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.10, 11

Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.

Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.12, 13 A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.14

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A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.

Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;15 a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.16During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.17

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A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group

Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,18 and additional supply strategies have been established,19 the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.20, 21

Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,22 the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.23

It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.24 However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.25 It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,26 and to help HCW who are struggling, left alone.  

References

1.         Con le nostre azioni influenziamo la vita e la morte di molte persone. https://www.ecodibergamo.it/stories/bergamo-citta/con-le-nostre-azioni-influenziamola-vita-e-la-morte-di-molte-persone_1344030_11/.

2.         Coronavirus pandemic: Tracking the global outbreak. https://www.bbc.com/news/world-51235105.

3.         Scalea JR. The Distancing of Surgeon from Patient in the era of COVID-19: Bring on the Innovation. Annals of surgery 2020.

4.         Wuhan hospitals resume regular services amid COVID-19. https://news.cgtn.com/news/2020-03-16/Wuhan-hospitals-resume-regular-services-amid-COVID-19-OTRxkICEr6/index.html.

5.         Fu D, Yu X, Wang L, Cai K, Tao K, Wang Z. Gearing back to normal clinical services in Wuhan: frontline experiences and recommendations from mental health perspective. The British journal of surgery 2020;Epub ahead of print. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11912

6.         Surgeon reveals fear of dying on frontline in coronavirus fight. https://www.examinerlive.co.uk/news/west-yorkshire-news/surgeon-reveals-fear-dying-frontline-18025220.

7.         Balasubramanian A, Paleri V, Bennett R, Paleri V. Impact of COVID-19 on the mental health of surgeons and coping strategies. Head & neck 2020.

8.         #COVID19ESCP TweetChat: Antonino Spinelli shares insights from the frontline in Italy. https://www.escp.eu.com/news/2069-covid19escp-tweet-chat-antonino-spinelli-shares-insights-from-the-frontline-in-italy.

9.         Doctors reveal they are moving into their garages and basements to isolate themselves from their own families while they fight coronavirus – as they urge others to stop going out. https://www.dailymail.co.uk/femail/article-8136037/Doctors-isolating-FAMILIES-prevent-spread-COVID-19.html.

10.       Fear, guilt, and a surgeon’s wait for Coronavirus. https://exponentsmag.org/2020/03/21/fear-guilt-and-a-surgeons-wait-for-coronavirus/.

11.       The second wave of COVID-19: another potential tsunami – prepare to avoid being swept away. https://www.escp.eu.com/news/2093-the-second-wave-of-covid-19-another-potential-tsunami-prepare-to-avoid-being-swept-away.

12.       Ielpo B, Podda M, Pellino G, Pata F, Caruso R, Gravante G, Di Saverio S. Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11999

13.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.

14.       Life as a vascular surgeon in Mexico during the COVID-19 pandemic. https://vascularnews.com/life-as-a-vascular-surgeon-in-mexico-during-the-covid-19-pandemic/.

15.       Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).

16.       Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).

17.       An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).

18.       Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.

19.       Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.

20.       Wuhan completes mass COVID-19 screening. http://www.chinadaily.com.cn/a/202006/03/WS5ed6f96ea310a8b24115a6a8.html.

21.       Xiong Y, Mi B, Panayi AC, Chen L, Liu G. Wuhan: the first post-COVID-19 success story.n/a(n/a).

22.       Collaborative C, Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. BJS (British Journal of Surgery). https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.11746

23.       Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).

24.       Kadhum M, Farrell S, Hussain R, Molodynski A. Mental wellbeing and burnout in surgical trainees: implications for the post-COVID-19 era. The British journal of surgery 2020. https://bjssjournals.onlinelibrary.wiley.com/doi/10.1002/bjs.11726

25.       Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

26.       Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.

Plain English Abstract: Trends in deaths from abdominal aortic aneurysms

Mortality from abdominal aortic aneurysm: trends in European Union 15+ countries from 1990 to 2017

Abdominal Aortic Aneurysm or AAA is an abnormal swelling of the aorta, the biggest artery in the body. It usually occurs people over 65, especially men. An AAA can occasionally burst, leading to life-threatening bleeding. An AAA can be easily detected using a simple ultrasound scan. AAA screening programmes are now available in a number of countries, such as the United Kingdom and the United States. These AAA screening programmes have allowed us to better understand how many people in society have an AAA. In the last decade, it has become apparent in some countries that the number of people who have an AAA is decreasing. Some research suggested that the number of people who die due to AAA is also dropping. This was, however, never assessed in European countries using data of high-quality. 

In this open access article, researchers accessed information from the “Global Burden of Disease Study Global Health Data Exchange”. This source allows us to understand how many people might be dying due to a certain medical problem. The researchers then reported how many people die due to AAA every year per country, also taking people’s age into account. The study found that between the years 1990 and 2017 the death rate from AAA decreased in all 19 European Union countries for women, and in 18 of 19 countries for men. An increasing death rate due to AAA was observed only for men in Greece. The largest decreases were observed in Australia and Canada. Interestingly, in the last few years (after 2012) there seem to be small increases again in the rates of death due to an AAA in most of these countries. Overall, this study shows that AAA has become a less common cause of death in most European and Western countries in the last 27 years. 

Visual Abstract: Clean Cut programme

A success story in global surgery

Recently published as open access in BJS, this prospective quality improvement study showed a reduction in surgical site infections using an adaptive, multimodal surgical infection prevention programme for low-resource settings. Further information can be found at the Lifebox website.

Plain English Summary: How the first COVID‐19 wave affected UK vascular services

Global overall mean service reductions, worldwide response, and service reduction scores in the UK and the Americas
Global overall mean service reductions, worldwide response, and service reduction scores in the UK and the Americas

The COVID-19 pandemic has impacted healthcare around the world. Patients who have vascular disease (problems with their arteries or veins), are at high-risk of having complications if they develop COVID-19. This is because patients with vascular disease usually have many medical problems. Some of them are also elderly and might be frail. We do not know how the COVID-19 pandemic might have affected the care of patients with vascular disease. 

The COVER study is an international study trying to assess how the COVID-19 pandemic changed the medical care of patients with vascular disease. The first part of the COVER study was an internet survey. In this survey, doctors and healthcare professionals were asked questions (every week) about the care of vascular patients at their hospital. The results were published in this article.

The results showed that the COVID‐19 pandemic had a major impact on vascular services worldwide. Most of the 249 hospitals taking part from 53 countries, reported big reductions in numbers of operations performed and the types of services they could offer to patients with vascular disease. Almost half of the hospitals stopped doing routine scans to detect artery problems and a third had to stop all clinics in the height of the pandemic. There were major changes in the resources available to treat blocked leg arteries. Most non-urgent operations, especially for vein problems, were cancelled.

In the months during recovery from the pandemic peaks, there will be a big backlog of patients with vascular disease needing surgery or review by vascular specialists.

Decision-making, regret and the surgeon

Claire Donohoe

It is a surgical aphorism that it is more difficult to decide when not to operate than when to operate.

In the study “Learning from Regret”1, surgeons contributing to Queensland’s Audit of Surgical Mortality were asked to reflect on deaths following surgery. They were asked whether they would have done anything differently in retrospect. The aim was to explore surgeon’s reflections on what might have been done differently for patients who died under their care. The secondary aim was to assess for the presence of regret – defined as the presence of personal responsibility and realisation that another decision could have been better.

Findings

Post-decision regret was explicitly identified in 16.9% of responses. One of the scenarios specifically referred to was regret surrounding with proceeding to surgery in cases where the likelihood of survival was slim (“the decision entailed the alternative of certain death rather than probable death”). The fields of behavioural economics and psychology give us several reasons why we shouldn’t reflexively regret decision-making in these types of charged scenarios – because regret is the de facto outcome of a decision to operate in this scenario.

Understanding regret

Firstly, the fact of operating rather than palliating in this scenario makes us more likely to regret it in retrospect when the outcome is poor by the mere fact of one having acted rather than not acted. Actions are more salient (i.e. easier to recall) than inaction and, therefore, more prone to regret upon reflection from a psychological perspective2. Humans also tend to regret action (acts of commission) more than inaction (acts of omission) because having acted, we then attempt to mitigate the cognitive dissonance that arises between our ideal and actual selves by reducing the dissonance by deriving lessons learned from the perceived error3.

The authors of “Learning from Regret”1 highlighted that surgical decision-making in cases associated with deaths were uncertain, complex and subject to situational pressures. In not operating, the surgeon would have to violate the norms of usual surgical behaviour4 that in the face of certain death without an operation, an operation should be performed.

Futility scenarios

In fact, in scenarios where treatment is highly likely to be futile, expected utility theory would tell us that our choices are very limited. In classical economics, expected utility theory is the theory of how rational actors make decisions. That is, that rational beings choose the option to maximise the risk: benefit ratio. When applying expected utility theory to medical decision-making, as the net treatment benefits increase, we become more uncomfortable withholding treatment even when the probability of a good outcome is relatively low and the risks are substantial. Therefore, when the counterfactual treatment outcome is certain death, if we apply traditional rational economic decision-making theory, then there are few circumstances in which the certainty of this poor outcome can outweigh the small possibility of a good outcome (especially where survival and not functional outcome is the primary outcome).

Furthermore, we increasingly recognise that medical decision-making employs dual-processing theory5. Rather than employing the neural pathways utilised in rational decision analysis, medical decision-making also draws from type 1 or emotional decision-making. This tends to make medical decision makers more risk-averse. Dual-processing of this nature also means that it is more challenging to apply rational thinking behaviours to decision involving how we must act, than it is to rationally decide how others should act6.

Summary

Clearly, aiming to avoid futile treatment that increases suffering at the end of life is an important goal in emergency surgery, however, making these types of decisions will always be difficult because surgeons are human and prone to all of the cognitive biases inherent to this state.

References

1.            Boyle FM, Allen J, Rey-Conde T, et al. Learning from regret. BJS 2020; 107(4):422-431.

2.            Gilovich T, Medvec VH. The experience of regret: what, when, and why. Psychological review 1995; 102(2):379.

3.            Gilovich T, Medvec VH, Chen S. Commission, omission, and dissonance reduction: Coping with regret in the” Monty Hall” problem. Personality and Social Psychology Bulletin 1995; 21(2):182-190.

4.            Nichols S. Norms with feeling: Towards a psychological account of moral judgment. Cognition 2002; 84(2):221-236.

5.            Djulbegovic B, Elqayam S, Reljic T, et al. How do physicians decide to treat: an empirical evaluation of the threshold model. BMC medical informatics and decision making 2014; 14(1):47.

6.            Nadelhoffer T, Feltz A. The actor–observer bias and moral intuitions: Adding fuel to Sinnott-Armstrong’s fire. Neuroethics 2008; 1(2):133-144.

Sign language for surgeons in the COVID-19 pandemic

Sign language might be a useful tool for when PPE affects communication
  • Francisco Alberto Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.
  • Eduardo Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.,
  • Fernando Leyva-Moraga Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México.
  • Abelardo Juanz-González Department of Surgery, Hospital General del Estado de Sonora, Hermosillo, México. ,
  • Jorge Arturo Barreras-Espinoza, Department of Surgery, Hospital General del Estado de Sonora, Hermosillo, México.,
  • Ahmed Soualhi, GKT School of Medical Education, King’s College London, London, UK.,
  • Jesús Antonio Ocejo Gallegos, Department of Medicine and Health Sciences, Universidad de Sonora, Hermosillo, México,
  • Martyn Urquijo, Department of Surgery, The University of Arizona Banner Health, Tucson, Arizona.
  • Jesús Martín Ibarra Celaya, Thoracic Surgery Department, Hospital +Querétaro, Querétaro, México.

A COVID challenge

One of the consequences of COVID-19 has been greater attention on the risks of infection to clinicians. Much has been made of the need for personal protective equipment, including FFP3 masks, visors, and respirator hoods. Unfortunately these can also impact on communication. This can be due to muffled speech, or loss of ability to read lips. This is important in an operating theatre, where clear communication is critical.

Experience suggests that surgeons probably use some gestures to aid communication when operating. The use of sign language in clinical settings has been previously addressed in the literature, mainly as a proposal to manage increased noise levels in the OR. Sign language has also been suggested as an alternative to handle language differences in surgical team members of varied nationalities, as well as to improve action response within a procedure.

A new sign-language?

To reduce verbal communication that may be limited by impaired speech or hearing, the authors have proposed a surgery-specific sign language. The vocabulary consists of technical information that is easy to learn and replicate and allows fluent communication in the OR. These are summarised in the video above.

A full version of this article can be found in special correspondence to the editor on the BJS website.

Key questions in the diagnosis and management of appendicitis

questions about treatment of appendicitis

James Ashcroft (@JamesAshcroftMD) Academic Clinical Fellow, Department of Surgery, Cambridge, UK;

Salomone Di Saverio (@salo75) Consultant General and Colorectal Surgeon, Professor of Surgery, University of Insubria, Regione Lombardia, Italy;

Justin Davies (@jdcamcolorectal) Consultant General and Colorectal Surgeon and Deputy Medical Director, Addenbrooke’s Hospital, Cambridge, UK.

Key questions in the diagnosis and management of appendicitis

Throughout my surgical training, decision making and risk prediction in patients with a clinical suspicion of appendicitis has been a prominent challenge. The accurate diagnosis of appendicitis should lead to improved healthcare provision to the patient, however there is still debate amongst the use of tools and imaging to assist this. The appropriate use of antibiotics to manage appendicitis, and the use of operative techniques to remove the appendix, have recently become a global debate.

Diagnosis of appendicitis

I have personally found the diagnosis of appendicitis to be challenging, with presenting history and examination of patients with right iliac fossa pain variable and often confounded. Clinical risk scores have recently been investigated through prospective international collaborative studies.1 The Alvarado score was one of the earliest scores demonstrating efficacy in appendicitis diagnosis when confirmed to histopathological diagnosis leading to its widespread uptake.2 However, this been superseded by the Appendicitis Inflammatory Response score (AIRS) in males and Adult Appendicitis Score (AAS) in females which have demonstrated improved performance in a pragmatic clinical setting.1

I have often been taught that appendicitis is a diagnosis made on clinical judgement alone and I feel this has become one of the most prominent dogmas present in surgical practice. The use of AIRS and AAS have been recognised to decrease negative appendicectomy rates in low-risk groups and reduce the need for imaging.1,3 I believe that the use of risk scoring should be taught to all surgical trainees routinely as a standard work up for the assessment of right iliac fossa pain.

Recent news reports have disseminated to the public that “Thousands of young women have their appendix removed unnecessarily”4 and although this may represent the appropriate conservative approach to imaging in females, it emphasises that we cannot justify ignoring the diagnostic tools at our disposal. Point of care ultrasound is recommended by the World Society of Emergency Surgery for decision making as a first point of call in both adults and children, however operator variability is noted.3

In my experience, and as per the general consensus of the departments I have worked in, ultrasound imaging is often useful in female patients to identify any ovarian cause of right iliac fossa pain and inconclusive for appendicitis. However, I can envision the use of ultrasound as part of clinical-radiological scores to enhance the sensitivity of diagnosis and could assist in avoiding radiation exposure through CT scan, which remains a pertinent research question.

Non-operative and operative management of appendicitis

Mirroring teachings in the diagnosis of appendicitis, in my experience it is taught that there is only one definitive management plan for simple appendicitis – an emergency appendicectomy. When considering modern sources of evidence, my belief is that the UK national normal appendicectomy rate (NAR) of around 20% is too high, when compared to countries such as Switzerland where the NAR has been found to be around 6%.5 The high NAR in the UK was again picked up by British media outlets who published headlines such as ‘Unnecessary appendix surgery performed on thousands in UK’.4

Antibiotic-first strategy has been found to be safe and effective in selected patients with uncomplicated acute appendicitis however, the risk of recurrence has been suggested to be up to 39% after 5 years.3 A 2019 meta-analytical review of 20 studies (7 prospective RCTs, 8 prospective cohort studies, 4 retrospective cohort studies and 1 quasirandomised study) investigated outcomes in non-operative management with antibiotics in appendicitis with an overall moderate quality of evidence when regarding complications and treatment efficacy.6 Overall antibiotic therapy achieved a significantly lower post-intervention complication rate including postoperative abscesses, surgical site infections, incisional hernias, obstructive symptoms, and other general operative complications at 5 years compared to index event surgery.6 However, there was a lower complication free treatment success rate and a non-significantly higher rate of complicated appendicitis with delayed surgery in patients receiving initial antibiotic therapy.6

I feel that the stratifying of patients by risk and utilisation of outpatient surgical ambulatory units with repeated history taking, observations, and blood tests could be effective in reducing the NAR in the UK with or without imaging. Accurate diagnostic imaging in the form of a CT scan could reduce the UK’s NAR further, improving patient outcomes, surgical planning, and healthcare service provision at an organisational level. This may outweigh the impact of radiation exposure of a CT abdomen scan which has been well described by Aneel Bhangu the lead director of the RIFT/West Midlands Collaborative as giving “the same radiation as flying to New York”.4 T

his is a risk which I believe many would not be concerned about when travelling. This view is in opposition to that of the recently updated World Society of Emergency Surgery guidelines which suggest that CT imaging may be avoided prior to laparoscopic operation, but it should be noted that there was debate regarding this within the writing committee.3

I believe that more care must be taken in patients with suspected appendicitis to undertake a discussion around imaging use, operative management, and non-operative management which is unbiased and evidence based. Those opting for conservative management should be warned of the possibility of failure and misdiagnosis of complicated appendicitis. In my training so far, conservative management has been discussed in those judged to be low-risk however this does not come without the risk of the on call surgeon’s bias seeping into conversation. Further research should be undertaken to identify precisely which cohort of patients are optimal for non-operative outpatient management.

wses diagram on management of appendicitis

Practical WSES algorithm for diagnosis and treatment of adult patients with suspected acute appendicitis.3

Appendicitis and COVID-19

Recent research into risk scoring in appendicitis has demonstrated a clear benefit in stratifying patients into risk categories to guide management plans.1,3 As highlighted I believe that all patients presenting with right iliac fossa pain should undergo scoring, by either AIRS or AAS. It has been suggested that due to local population characteristics and health systems, risk scores should be validated locally prior to routine adoption.7 It has further been emphasised that risk score models should not replace clinical judgement and should be used as an adjunct to enhance decision making.8

In the current COVID-19 pandemic the use of non‐operative management has been suggested to be increased for acute surgical conditions such as appendicitis9 and this has been the experience of my department. The evidence at present suggests that this is safe and feasible, and therefore the COVID-19 pandemic presents a unique period for investigation.10 It could be a valuable endeavour for all centres to perform local analyses of the impact of conservative management on patients presenting with right iliac fossa pain in the COVID-19 period.

This is also being undertaken on a national level in the COVID- HAREM Study: Had Appendicitis and Resolved/Recurred Emergency Morbidity/Mortality. Locally, one year clinical outcomes could be measured for those diagnosed with appendicitis pre-COVID and during the COVID period. Finally, with the restoration of normal patient pathways post-COVID, risk scoring could be introduced to local departments with a pre-COVID / post-COVID comparison to allow for the clear demonstration of any benefit to the patient.

References

1.            The RIFT Study Group and the West Midlands Research Collaborative. Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2019:73-86. doi:10.1002/bjs.11440

2.            Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med. 1986;15(5):557-564. doi:10.1016/S0196-0644(86)80993-3

3.            Di Saverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World J Emerg Surg. 2020;15(1):1-42. doi:10.1186/s13017-020-00306-3

4.            Davis N. Unnecessary appendix surgery “performed on thousands in UK” | Society | The Guardian. Guard. 2020:1-5. https://www.theguardian.com/society/2019/dec/04/unnecessary-appendix-surgery-performed-on-thousands-in-uk.

5.            Güller U, Rosella L, McCall J, Brügger LE, Candinas D. Negative appendicectomy and perforation rates in patients undergoing laparoscopic surgery for suspected appendicitis. Br J Surg. 2011;98(4):589-595. doi:10.1002/bjs.7395

6.            Podda M, Gerardi C, Cillara N, et al. Antibiotic treatment and appendectomy for uncomplicated acute appendicitis in adults and children: A systematic review and meta-analysis. Ann Surg. 2019;270(6):1028-1040. doi:10.1097/SLA.0000000000003225

7.            The RIFT Study Group and the West Midlands Research Collaborative. Author response to: Comment on: Evaluation of appendicitis risk prediction models in adults with suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11542

8.            The RIFT Study Group and the West Midlands Research Collaborative. Author response to: RIFT study and management of suspected appendicitis. Br J Surg. 2020:2020. doi:10.1002/bjs.11552

9.            Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056

10.          COVIDSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg. 2020;(March). doi:10.1002/bjs.11646

Young BJS

The Young BJS represents a community of early-career researchers with enthusiasm for surgical academia. The ethos is aligned with that of the BJS with a mission to promote excellence in clinical and scientific research. Specific goals of the group will be to network, educate, and innovate in surgical publishing on a global scale.

Young BJS has an international membership – dots show location of members.

Structure

The Young BJS is led by surgical trainees under the guidance and governance of the BJS and BJS Open Editorial teams and the BJS Society. Membership is free of charge and open to everyone from junior consultants to medical students. All specialties and countries are welcome to join such that the resultant spectrum of research experience, career stage, and geographic distribution will provide a welcomed diversity to the community. Members should have a reasonable command of English but this is not essential.

Aim

The aim of Young BJS is to nurture the future leaders of surgical academia by

  1. Providing early-career researchers with an opportunity to gain editorial experience 
  2. Encouraging national and international collaborative efforts
  3. Acting as an educational forum for surgeons-in-training

Editorial Experience

The Young BJS will provide members with the opportunity to complete formal certified training in reviewing journal manuscripts through the Young BJS Reviewer Mentoring Programme in collaboration with the Editorial team and board, the BJS Society, and the planned BJS Academy. Upon commendation trainees will enter the BJS reviewer database as certified Young BJS reviewers. They may then be invited by members of the BJS editorial team to review manuscripts.

Collaborative Work

The Young BJS will provide a platform to promote national and international collaborative projects. Members will have the opportunity to inform the community of studies involving multiple institutions, thereby encouraging connectivity among young researchers on a global scale. 

Education

The Young BJS will act as an educational forum for surgeons in training to develop a digital learning platform, complementing the aims of the BJS Academy. Members will be encouraged to complete BJS delivered or supported writing courses and workshops to develop their editorial skills.

Communication

The Young BJS will have a strong and vibrant social media presence through its own Twitter account and posts on the BJS Cutting Edge blog. One of the specific goals of the group is balancing global disparities through better access to published works.

There is huge scope as to what we can achieve as a group with plenty of opportunities for members to participate in all aspects of the initiative. So far we have over 200 students and trainees involved from over 40 countries and representing every inhabited continent in the world.  

So what can you do to get involved?

Enthusiasm is all that is required. Those interested in becoming part of Young BJS, please email your details including name, institution, career stage and specialty interest (if applicable) to admin@youngbjs.org. We will inform you of upcoming projects, educational opportunities, and collaborative efforts.

We look forward to welcoming you.

The Young BJS coordinating team

(On behalf of the BJS / BJS Open editorial teams and BJS Society)

A Review of Peri-operative Precautions While Managing the SARS-CoV-2 Infected Patient

Authors:

Michal Daniluk, Jagiellonian University Medical College, Krakow, Poland                                 

Antonio M. Lacy, Department of Surgery, Hospital Clinic, University of Barcelona     

Tomasz G Rogula, Case Western Reserve University School of Medicine & Jagiellonian University Medical College, Krakow, Poland

Antoni M. Szczepanik, First Department of General, Oncological and Gastroenterological Surgery, Jagiellonian University Medical College, Krakow, Poland

Background:

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the virus responsible for the 2019 Coronavirus Disease (COVID-19). The main route of transmission is through droplets and close contact.1,2 As a result of their mass, droplets spread in space is limited to 1-2 meters from the source of production. Aerosolized particles, on the other hand, are smaller in size (0.3 to 100 micrometers) and have been documented to linger in the air longer than droplets and travel up to hundreds of meters before settling on a surface.3 The role of aerosolized particles in the spread of SARS-CoV-2 in the community has yet to be proven, however, their presence in the hospital setting has been of greater concern.4–6

The earliest documentation of infection coming out of Wuhan, China showed that 40 out of the first 138 (29%) people infected by SARS-CoV-2 were healthcare workers.7 In an effort to help minimize the spread of SARS-CoV-2, several hospitals have published their approach to the surgical management of infected or suspected COVID-19 patients. A recent PubMed search for “COVID-19” and ”surgery” yielded 224 results, of which 13 papers proposed detailed precautions when surgically managing a COVID-19 positive or suspected patient. From setup to post-operative management, this review will draw from the suggestions of these papers and outline some of the most commonly mentioned precautions. As many institutions have never experienced such a dramatic shift from their day-to-day operations, this document may provide useful information with regards to safe practice.

Studies referenced in this review.

The Role of Hospital Management:

The majority of COVID-19 infected or suspected patients will not require surgical intervention throughout the course of their disease. Therefore, mainstream procedures and precautions focus on the management of respiratory distress, proper isolation of patients, safety of ICU personnel and emergency department organization.8 Senior surgeons should be heavily involved in the supervision of focused training and the development and update of protocols.9 All personnel should be familiarized with specific procedures related to 1) COVID-19 patient transport to the operating room (OR) 2) intra-operative, and 3) post-operative care.

Pre-Operative Precautions

A predesignated route should be the shortest possible distance from isolation to the OR. It should be cleared by security, use isolated elevators and have minimal contact with others.10 A recent study by van Doremalen et al. found that the survival time of SARS-CoV-2 on plastic and steel surfaces such as elevator buttons can last as long as 72 hours, thus supporting the notion of using separate lifts and routes for patient transportation.4

With Regards to operating theatres, all studies suggested the use of negative pressure environment to reduce the dissemination of viral particles.1,5,11–21 Van Doremalen et al. also found that in aerosolized form, SARS-CoV-2 can remain viable for up to three hours.4 Applicably, the use of a high frequency (25/hour) air exchange can significantly reduce viral load within the OR.17 All drugs and equipment should be prepared before the start of surgery to limit movement of staff in and out of the OR.17 Anaesthetic drugs should be placed on a tray to limit contact and potential contamination of the drug trolley. Hand washing and glove change should be performed in any case were additional supplies must be accessed from the trolley.20 Monitors, ultrasound machines and other devices that are difficult to disinfect, should be covered by transparent plastic wrap to decrease the risk of contamination.17

Personal Protective Equipment

Of the 13 studies reviewed, all recommended the use of eye protection in the form of goggles or a face shield as well as a filtered face-piece respirator (N95).1,5,11–21 Five out of 13 studies recommended the use of powered air purifying respirators (PAPRs)(protection factor of 25-1000) as a superior alternative to N95 respirators (protection factor of 10).1,11,17,18,20,22 In addition to the higher protection factor, PAPRs provide eye protection and unlike the N95 respirator, do not require fit testing.18,17 Finally, five out of 13 studies suggested the use of double gloves during intubation and/or surgery.12,17–19,23 Forrester et al. also recommended the implementation of a buddy system during donning and doffing to identify any breaches in protection which can be decontaminating using alcohol spray.5

Intra-Operative Precautions: Anaesthesia and Surgical Smoke

Five of the 13 papers analyzed were sent to anaesthesiology journals and focused mainly on the minimalization of viral aerosolization during induction of anaesthesia and extubation.1,15,17,19,20 Some suggestions include the use of shortest acting drugs at lowest possible dose, avoidance of awake intubation and aggressive post-operative antiemetic prophylaxis to avoid aerosol production during emesis.1,17 Four studies recommended that pre-assessment, induction and post-operative anaesthesia recovery should all take place within the procedure room.12,17,19,20 Patient documentation should be done electronically, if possible, on a tablet or iPad, which can be disinfected after handling.17

Previous studies have demonstrated that ultrasonic scalpels and electrocautery equipment produce surgical smoke or plume, capable of transmitting active viruses in aerosolized form.24–26 The risk of SARS-CoV-2 aerosolization via electrical surgical equipment has not yet been shown, however, several sources recommend the implementation of appropriate precautions. A recent publication by Zheng et al. suggested that the aerosol formed during laparoscopic surgery accumulates in the abdominal cavity.14 Sudden release of trocar valves and deflation of pneumoperitoneum may expose the healthcare team to aerosolized viral particles.21 Therefore, some collegiate bodies suggest the use of laparoscopy, only in select cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission to the environment and OR staff.27

Other committees indicate that the evidence of such viral transmission during minimally invasive surgery is weak, but nevertheless proper safety measures are recommended. The Society of Gastrointestinal and Endoscopic Surgeons (SAGES) and the American College of Surgeons recommend the liberal use of suction devices and smoke evacuators to limit surgical smoke release into the OR.14,16 Gas filtration systems such as the ultralow particulate air filter (ULPA) might potentially achieve COVID-19 purification of the surgical plume, but this has still to be confirmed.28

Post-Operative Precautions

When doffing PPE, the first pair of gloves must be removed first, followed by the surgical gown, shoe covers, cap and goggles. The face mask must then be removed by the ear laces, taking care not to touch the external side. The second pair of gloves must be removed last.29 Upon leaving the operating theatre, all staff should take a whole-body shower before changing into clean scrubs and returning to their clinical duties.12,16,17,20

With regards to disinfection, the United States Environmental Protection Agency (EPA) has created a list of products for use against SARS-CoV-2.30 The most commonly mentioned protocols suggest the use of sodium hypochlorite, chlorine containing disinfectant, wipes that contain quaternary ammonium and alcohol, hydrogen peroxide vaporization, and ultraviolet (UV-C) light (for inactivation of aerosolized viruses).15,17,19,20,31

A major constraint reported by several centers is the shortage of PPE such as masks and gowns. Dr. Peter Tsai, the inventor of the N95 respirator, has made several suggestions regarding the re-usability of his equipment. The first recommendation is air drying for 3-4 days.32 Alternatively, masks can be oven dried for 30 minutes at 70oC.32,33 More recently, a study out of Duke University evaluated the utilization of hydrogen peroxide vapor to decontaminate N95 respirators. This validation study concluded that N95 respirators still met performance requirements even after 50 disinfections.34 It is important to note, however, that these recommendations are constantly changing and it is of utmost importance that healthcare professionals regularly assess the most up-to-date guidelines regarding N95 re-usability and the disinfection process.

Conclusions:

The conclusions drawn from the present literature are limited by the novelty of this disease. Most of the studies presented in this review were viewpoints and recommendations based on personal experience. Due to limited experience of single institutions, efforts should be made to increase international collaboration in the era of this unprecedented pandemic. Specific data on the risk of infection among surgeons has not yet been documented, however, this should not undermine the importance of strong occupational safety. The included studies suggest a need to develop a universal, effective and affordable protocol for perioperative management of COVID-19 patients to ensure surgical staff wellbeing.

References:

1.        Rajan N, Joshi GP. The COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic. Anesth Analg. 2020. doi:10.1213/ane.0000000000004847

2.        CDC. How Coronavirus Spreads. Available at: https://www.cdc.gov/coronavirus/2019- ncov/prepare/transmission.html. Accessed April 7, 2020.

3.        Wang J, Du G. COVID-19 may transmit through aerosol. Irish J Med Sci (1971 -). 2020;(5):5-6. doi:10.1007/s11845-020-02218-2

4.        van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. March 2020:NEJMc2004973. doi:10.1056/NEJMc2004973.

5.        Forrester JD, Nassar AK, Maggio PM, Hawn MT. Precautions for Operating Room Team Members during the COVID-19 Pandemic. J Am Coll Surg. 2020. doi:https://doi.org/10.1016/j.jamcollsurg.2020.03.030

6.        Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2) From a Symptomatic Patient. JAMA. March 2020. doi:10.1001/jama.2020.3227.

7.        Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with, novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2019; DOI: https://doi.org/10.1001/ jama.2020.1585.

8.        Ahmed S, Wei T, Glenn L, Chong Y. Surgical Response to COVID-19 Pandemic: A Singapore Perspective. J Am Coll Surg. 2020.

9.        Lancaster EM, Sosa JA, Sammann A, et al. Journal Pre-proof Rapid Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for Patients, Surgeons, and the Community Rapid Response of an Academic Surgical Department to the COVID-19.

10.      Ti, LK, Ang LS, Foong TW, Ng BS. What we do when a COVID- 19 patient needs an operation: operating room preparation and guidance. Can J Anesth 2020; 67. DOI: https://doi.org/10.1007/ s12630-020-01617-4. 31.

11.      Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist – preliminary evidence-based review. Laryngoscope. 2020. doi:10.1002/lary.28672

12.      Di Saverio S, Pata F, Gallo G, et al. Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience. Colorectal Dis. 2020. doi:10.1111/codi.15056

13.      Pryor A. Pryor A. SAGES Recommendations Regarding Surgical Response to Covid-19 Crisis. SAGES. https://www.sages.org/recommendations-surgical-response-covid-19/.

14.      Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak. Ann Surg. 2020:1. doi:10.1097/sla.0000000000003924

15.      Chen R, Zhang Y, Huang L, Cheng B heng, Xia Z yuan, Meng Q tao. Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients. Can J Anesth. 2020. doi:10.1007/s12630-020-01630-7

16.      American College of Surgeons. COVID 19: Considerations for Optimum Surgeon Protection Before, During, and After Operation. 2020. https://www.facs.org/covid-19/ppe.

17.      Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anesth. 2020. doi:10.1007/s12630-020-01620-9

18.      Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck during the COVID-19 Pandemic. JAMA Otolaryngol – Head Neck Surg. 2020;1:1-6. doi:10.1001/jamaoto.2020.0780

19.      Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 Defense. Anesth Analg. 2020:1. doi:10.1213/ane.0000000000004829

20.      Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth. 2020:19-21. doi:10.1007/s12630-020-01617-4

21.      Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. Br J Surg. 2020:3-5. doi:10.1002/bjs.11627

22.      Institute of Medicine. The Use and Effectiveness ofPowered Air Purifying Respirators in Health Care: Workshop Summary. National Academies Press; 2015.

23.      Lui R, Wong S, Sánchez-Luna SA, et al. Overview of guidance for endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. J Gastroenterol Hepatol. 2020;2019(852):0-3. doi:10.1111/jgh.15053

24.      Choi SH, Kwon TG, Chung SK, Kim TH. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc. 2014, 28 (8): 2374-80.

25.      Kwak HD, Kim SH, Seo YS, et al. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med. 2016, 73:857––863.

26.      Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. Journal of Medical Virology. 1991;33(1):47-50.

27.      Anderson I, Fearnhead N, Toogood G. Updated Intercollegiate General Surgery Guidance on COVID-19. The Royal College of Surgeons of England. https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/. Published 2020. Accessed April 8, 2020.

28.      Morris S, Fader A, Milad M, Dionisi H. Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic. J Minim Invasive Gynecol. 2020.

29.      Coccolini F, Perrone G, Chiarugi M, et al. Surgery in COVID-19 patients: operational directives. World J Emerg Surg. 2020;15(1):25. doi:10.1186/s13017-020-00307-2.

30.      List N: Disinfectants for Use Against SARS-CoV-2. United States Environmental Protection Agency. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use- against-sars-cov-2. Accessed April 09/2020.

31.      Kim DK, Kang DH. UVC LED irradiation effectively inactivates aerosolized viruses, bacteria, and fungi in a chamber-type air disinfection system. Appl Environ Microbiol 2018; DOI: https:// doi.org/10.1128/AEM.00944-18.

32.      Bauchner H, Fontanarosa B, Livingston EH. Conserving supply of personal protective equipment: a call for ideas. JAMA. Published online March 20, 2020.

33.      APSF: Update: potential processes to eliminate coronavirus from N95 masks. https://www.apsf.org/news-updates/potential-processes-to-eliminate-coronavirus-from-n95-masks/. Accessed April 9, 2020.

34.      Schwartz A, Stiegel M, Greeson N, et al. Decontamination and Reuse of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide Personal Protective Equipment Shortages During the SARS-CoV-2 (COVID-19) Pandemic. Appl Biosaf. 2020;2:1535676020919932. doi:10.1177/1535676020919932

Surgical Resource Management during the COVID-19 Pandemic – Insights from Global Surgery

A guest blog by:

Joshua S. Ng-Kamstra, Fellow in Adult Critical Care Medicine – Department of Critical Care Medicine, University of Calgary,

Dhruvin H. Hirpara, Resident in General Surgery – Department of Surgery, University of Toronto,

John Meara, Professor of Global Surgery and Social Medicine – Program in Global Surgery and Social Change, Harvard Medical School, Boston & Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, &

Julie Hallet, Assistant Professor – Department of Surgery, Sunnybrook Health Sciences Centre & Department of Surgery, University of Toronto

Background

The COVID-19 pandemic poses an acute threat to human health that is unprecedented in our lifetimes. Many health systems still continue to grapple with the volume of critically ill patients suffering from the virus.. The impacts of this crisis on surgical systems are being felt worldwide by patients and surgical providers. The estimated 30% of the global burden of disease caused by surgical conditions does not pause during a pandemic.1 Each year, 16.9 million people die due to surgically treatable conditions,2 and 15.2 million new cancers are diagnosed, 80% of which will require surgery.3 The magnitude and immediacy of the threat from COVID-19 has led many jurisdictions to cancel elective surgery to preserve precious hospital and critical care beds and limit nosocomial spread of the virus. As local trajectories of the pandemic become clear, surgeons and policymakers need to determine an optimal approach to meet population-level surgical needs to avoid additional pandemic-related morbidity and mortality.

Surgical systems are logistically demanding and interconnected networks of services: adaptation to the realities of limited operating theater availability is therefore complex. Human resources will also be threatened;4 safeguarding healthcare workers despite finite availability of personal protective equipment further adds to service delivery challenges. High-volume surgical systems must have the flexibility to systematically scale back provision of surgical care in a way that makes optimal use of resources while minimizing impacts on patients, providers, and systems. Looking at structured ways to operationalize sudden reductions in resources quickly, all countries can learn from existing principles and frameworks in the global surgery literature. Indeed, in addition to advocating for the health and economic benefits of investment in surgical systems,2 the global surgery literature recognizes and addresses the challenge of working under constraint. 

Prioritization of Surgical Services 

Surgical societies have provided guidance to surgeons as to which procedures are essential during this crisis.5,6 Such determinations are based on acuity, complexity, and population burden of disease. In a “must do, should do, can do” procedural framework,2 most surgeons have found themselves limited to providing only the first category: high value procedures (i.e. some cancer surgery) where long-term outcomes may hinge on timely surgical intervention, and urgent life- or limb-saving procedures. Should-do procedures are important but not vital procedures that may be amenable to a temporary workaround and still add value in the long run. Finally, can-do procedures are ones that are often desirable but not necessary—they could be deprioritized first with a relatively smaller impact on patient outcomes. These categories ought to be reassessed as resources change, but this framework can support discussions at the system, institution, and service levels. Non-operative management of traditionally surgical conditions (eg. antibiotics for uncomplicated appendicitis or endoscopic management of an early-stage esophageal cancer) may also aid in resource conservation. Finally, trauma prevention campaigns can be implemented or scaled up to minimize the need for emergency surgery.7  

Mitigating Harm from Delays to Care 

Globally, increased delays in access to surgical care are likely. Breaking these delays down into their three constituent components may help to mitigate them.2,8 First, is the delay in seeking care. With travel restrictions or residential lockdowns, the threshold to seek answers to concerns unrelated to the pandemic will increase. Creating easy access to primary care and surgical expertise, via telehealth for example, will give populations a venue to triage health concerns. Barriers to telehealth including finance, technical considerations, and confidentiality should be addressed collectively by providers, payers, government, and regulatory colleges. Second, the delay in reaching care at an appropriate center where diagnostics and therapeutics can be applied is less amenable to a technological solution. Maintaining separate health facilities as designated non-COVID-19 centers is one strategy to allow surgical work to continue or resume shortly after the pandemic peaks. As the pandemic progresses, the number of non-COVID-19 centres are reduced proportional to need as more patients present with viral illness, expanding again once the pandemic’s initial peak has passed. Finally, mitigating the delay in receiving surgical care requires adaptive waitlist management at the hospital level when progressively narrower bottlenecks in operating room time are encountered. Managing staffing constraints and pandemic-related supply chain disruptions will be critical to ensure that the appropriate personnel and disposables are available to use operating theaters as efficiently as possible.

Stuff, staff, space, and systems and the perils of reopening

Governments are struggling to balance the devastating economic consequences of ongoing stay-at-home orders with the risk of an overwhelming second wave of infections.9 While the optimal timing and strategy for reopening the economy remain unclear, strategies to mitigate the hazard of disease resurgence include widespread testing, serological surveys to better understand community-level exposure, staged relaxation of distancing measures, and bolstering hospital capacity to manage potential new cases. What these strategies all require are staff, stuff, space, and systems, an alliterative list of necessities for global health delivery coined by Dr. Paul Farmer.10

When public health officials deem it safe to resume some elective surgery, surgical leaders can also use this model to ensure that surgery again becomes available. Staff may need to be remarshaled from deployments to other acute care services; ensuring their mental and physical health during a period of significant stress will be critical. Stuff includes not only robust supplies of the necessary personal protective equipment to safely assess, operate on, and provide postoperative care for patients, but also medications and other operating room disposables that may become scarce due to supply chain disruptions. Space implies not only physical operating room space, but also appropriate spacing between postoperative patients, ideally in individual rooms, to prevent outbreaks of COVID-19 on wards. Finally, systems are required to ensure that care pathways for infected and uninfected patients are developed, staff are trained in their implementation, and their logistics are feasible.

Integrating surgery and other acute care services into global health security

Global health security (GHS) implies global collaboration to ensure that all health systems are prepared to manage public health threats and emergencies. Historically, the GHS discourse has been focused on infectious diseases as the primary public health threat born of globalization.11 The Global Health Security Agenda is a growing community of nations and organizations formed in 2014 to respond to infectious disease threats.12 By strengthening public health systems and stopping outbreaks at their point of origin, the GHSA aimed to decrease the risk of global pandemic disease. When it comes to a pandemic, the aphorism that prevention is better than cure is true. But it is an aphorism that historically excluded surgery from the global health discourse—why invest in surgery when some surgical disease is preventable?

The Lancet Commission on Global Surgery demonstrated the scale of human suffering that results when prevention is preached to the exclusion of treatment, with five billion individuals unable to access safe, affordable surgical care when needed.2 Not all surgical disease is preventable, and not every pandemic is stopped. GHS must evolve to include health services like critical care and surgery to plan for effective treatment of patients after a pandemic has emerged. If plans to address global critical care needs were in place before COVID-19, would countries have better mobilized to support beleaguered hospitals in China, Italy, or New York? If countries had anticipated the impacts of a pandemic on surgical care, would the cancellation of all elective surgery have been necessary? While these counterfactuals are unknowable, what is clear is that health services leaders must sit at the global health security table alongside infectious disease epidemiologists and public health professionals.

Summary

COVID-19 has reached almost every country on earth, and many surgical systems have already responded to the challenges it poses. The choices made in surgical system design, both historically and recently, will determine patient outcomes in the coming weeks and months. The shock to surgical systems will not be a short one—until the majority of the population has been exposed to the virus via vaccine or illness,13 the virus will pose a unique barrier to accessing safe surgical care.

Now more than ever, we must emphasize interdisciplinary collaboration, knowledge exchange, and health equity in order to maximize the efficiency of surgical access in all jurisdictions.14 Global surgery frameworks can support adaptation to rapid shifts in resource availability. More importantly, they can be used to plan the post-pandemic delivery of surgical services, serve to reconceive routine surgical care delivery systems, and plan resource scaling strategies to build more flexibility into surgical delivery in the future.

National surgical crisis planning must become part of the health systems lexicon. Mitigating acute threats to surgical systems including natural disasters, economic downturns, workforce declines, supply chain disruptions, military conflicts, and pandemic disease is not optional: our patients’ lives depend on it.


References

1.         Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. The Lancet Global health 2015; 3 Suppl 2: S8-9.

2.         Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015.

3.         Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16(11): 1193-224.

4.         Bundu I, Patel A, Mansaray A, Kamara TB, Hunt LM. Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone. J R Army Med Corps 2016; 162(3): 212-6.

5.         Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet 2015; 385(9983): 2209-19.

6.         American College of Surgeons. Guidance for Triage of Non-Emergent Surgical Procedures. 2020. https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage?MessageRunDetailID=1509048893&PostID=12687687&utm_medium=email&utm_source=rasa_io (accessed March 20 2020).

7.         Kotagal M, Agarwal-Harding KJ, Mock C, Quansah R, Arreola-Risa C, Meara JG. Health and economic benefits of improved injury prevention and trauma care worldwide. PLoS One 2014; 9(3): e91862.

8.         Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38(8): 1091-110.

9.         Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 2020.

10.       Farmer P. Diary: Ebola. London Review of Books 2014; 36(20).

11.       Karan A. How Should Global Health Security Priorities Be Set in the Global North and West? AMA J Ethics 2020; 22(1): E50-4.

12.       Osterholm M. Global Health Security—An Unfinished Journey. Emerg Infect Dis 2017; 23(Suppl 1): S225-S7.

13.       Ferguson N, Laydon D, Nedjati-Gilani G, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand: Imperial College, 2020.

14.       Dare AJ, Grimes CE, Gillies R, et al. Global surgery: defining an emerging global health field. Lancet 2014; 384(9961): 2245-7.