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.
Sergio M Navarro, MD MBA, Kelsey A Stewart, MD, Hashim Shaikh, BS^, Matthew C, Bobel, MD, Evan J Keil, BS, Jennifer Rickard, MD MPH, Todd M Tuttle, MD MS
^ Department of Surgery, University of California San Francisco, San Francisco, CA, USA
* Department of Surgery, University of Minnesota, Minneapolis, MN, USA Please contact: Sergio M Navarro, MD MBA 420 Delaware St SE, Minneapolis, MN 55455 email@example.com
The Coronavirus disease 2019 (COVID-19) has rapidly evolved and impacted all aspects of health policy and healthcare delivery – including surgery. Recommendations to postpone and provide additional guidelines regarding ‘elective surgery’ has left surgeons, patients, and hospitals with questions on the definition of ‘elective,’ the proper type and use of personal protective equipment (PPE) in surgery, the ethics of delaying medically indicated procedures, and the health and psychological impacts on patients and families. Analysis of social media information enables examination of the impact of COVID-19 and associated policy changes in a unique way and gathering of real-time data more rapidly than traditional methods. [1–4]
From March 1 to March 31, 2020, we conducted a cross-sectional analysis of associated posts on Twitter to collect data related to COVID-19 and surgery. The public domain was queried by filtering for five hashtags: #covidsurg, #covid19surgery, #COVID-19, #Coronavirus and #surgery. A binary scoring system was used for media format, perspective of the author, tone, user and post content, based on 2-person review. Data underwent descriptive and statistical analysis. All specific author information was de-identified. Non-English and non-surgery related tweets were excluded from analysis.
890 posts met the inclusion criteria. Posts an average of 629 Likes, 95 Retweets, and 1.78 hashtags per post. Author categories included physicians (39.7%), news organizations (18.4%), institution/professional organization (13.6%), and patients (11.9%). The majority of posts occurred from Twitter users based in the US (51.3%), followed by the UK (25.3%), and Canada (4.4%). Content included the cancellation of surgery (24.9%), surgical guidelines (20.2%), commentary/other (18.2%), COVID-19 education (16.2%), and PPE availability (7.4%).
Physicians were more likely than patients or patient’s families to post content related to PPE shortages, COVID19 education, research dissemination, as well as commentaries. Patients and patient families emphasized postoperative recovery and postoperative complication. Businesses, media outlets, and institutions posted most frequently about surgery cancellations and surgical guidelines. Authors from low and middle-income countries (LMICs) accounted for 4.4% (33/755) of posts where location of the post was available.
This initial exploration of the impact of COVID19 on surgery worldwide using social media found different perspectives from physicians, patients, families, media outlets, and institutions on various topics including cancellation of surgery, types of ‘non-essential’ surgery, concerns about PPE, and dissemination of surgical guidelines and educational information.
Non-Essential Surgery Cancellations
The cancellation of ‘non-essential’ surgery was the primary focus of content among all groups (25%, 222/890) and 40% (76/191) of posts by patients and families. Physician posts on cancellation comprised only 14.8% of their overall content. Their discussion on cancellation revolved around complex decision making in the designation of ‘non-essential’ surgeries and the inevitable consequences. One healthcare professional in Italy posted about the likely morbidity following lack of access to care and a surgeon in Canada discussed the difficult but important decision to delay surgery to improve healthcare capacity and protect patients from COVID19 exposure. A Urologist in Brazil described a difficult treatment decision for a patient with poor quality of life in need of a ‘non-essential’ surgery, emphasizing just how difficult it is to define ‘essential.’
Subspecialty Surgery Cancellations
A portion of the surgical cancellation content highlighted the ethical and political consequences of possible delays in specific types of surgeries; namely cancer surgery, orthopedic surgery, surgical abortion, and transgender surgeries.[5–8] Twitter served as a platform to discuss these ethical considerations for both surgeons and their affected patients. In one tweet, attention was drawn to a 17-year-old in need of surgery and chemotherapy; however, after spiking a fever he was subject to a two-week delay in care due to awaiting COVID-19 testing results.
Changes to practice
Another individual highlighted his mother’s breast cancer journey, sharing that instead of a partial mastectomy and reconstruction, an entire mastectomy without reconstruction would be performed – all due to changing guidelines regarding procedure safety. In terms of historically politicized surgeries, several state governments made decisions to limit access to abortion and gender affirming surgeries creating dissention within patients and physicians which was highlighted in over 10% of total tweet content where specific subspecialties were mentioned. 
Surgical Guidelines, Education, and Changes in Clinical Management
Throughout the analyzed tweets, several changes were recommended in the routine management of surgical conditions during the COVID-19 epidemic to conserve resources, limit exposure to the virus, and limit the use of PPE. These posts were primarily (46% in total) disseminated by academic institutions, other professional organizations, and media outlets. For example, the ACS and others have recommended limiting the use of laparoscopy which has the potential to aerosolize viral particles. Physicians worldwide have recommended alternate surgical techniques to reduce the risk of exposure to COVID19 including an Otolaryngologist in France who recommended the use of hammer and chisel in place of drilling. However, these changes are not without dissention, highlighted by a bariatric surgeon in the UK who struggled to follow a new guideline that he felt would worsen outcomes for patients.
Safety and Personal Protective Equipment
Surgeons, physicians, and other health professionals focused on commentaries and discussions about safety and PPE more than the other groups- giving insight that they see safety of patients and healthcare workers as the more important information surrounding the COVID-19 pandemic. One post from a trauma surgeon described lessons learned from performing emergency surgery on patients with COVID-19 and the need for clear guidelines and safety measures. The Columbia Chair of Surgery provided updates daily outlining the future need of PPE and justification for supplying a single mask per provider per day even at an early point in the COVID-19 outbreak.
Concerns surrounding the COVID-19 pandemic vary in different regions and countries given their specific burden of disease and capacity to mount a public health response to the disease.[10–13]. High-income countries (HICs) made up an overwhelming majority of the posts and thus a complete picture of the global burden of disease and changes to surgery across the globe may not be able to be formed. It is known that LMIC authors are often underrepresented in the global social media sphere in regard to global surgery which we further affirm here. Inclusion of LMICs in both the discussion and dissemination of global guidelines in regard to the COVID-19 pandemic ought to be a priority by the global surgical community. Some of the emphasized concerns from LMICs include internet outages that impact accessing surgical guidelines, hospital exposure of patients to the virus, as well as the dissemination of guidelines from other countries.
In this cross-sectional analysis, surgeons, physicians, and organizations expressed concerns about the impact of COVID-19 on surgical guidelines, the delay and cancellation of surgery, and the availability of PPE while disseminating COVID-19 education and information. We found minimal variation in the levels of mention regarding the impact of COVID-19 on surgical cancellations or delays, but the community of surgeons and physicians made more mention of PPE availability to conduct surgeries. These findings provide an indicative sampling of the key surgical perceptions of COVID-19 on these important populations.
1. Sorice SC, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social Media and the Plastic Surgery Patient. Plast Reconstr Surg. 2017;140: 1047–1056. doi:10.1097/PRS.0000000000003769
2. Navarro SM, Haeberle HS, Cornaghie MM, Hameed HA, Ramkumar PN. The Impact of Social Media in Medicine: An Examination of Orthopaedic Surgery. Social Media: Practices, Uses, and Global Impact. 2017.
3. Ni hIci T, Archer M, Harrington C, Luc JGY, Antonoff MB. Trainee Thoracic Surgery Social Media Network: Early Experience With TweetChat-Based Journal Clubs. Annals of Thoracic Surgery. 2020. doi:10.1016/j.athoracsur.2019.05.083
4. Henderson ML, Adler JT, Van Pilsum Rasmussen SE, Thomas AG, Herron PD, Waldram MM, et al. How Should Social Media Be Used in Transplantation? A Survey of the American Society of Transplant Surgeons. Transplantation. 2019. doi:10.1097/TP.0000000000002243
5. Couloigner V, Schmerber S, Nicollas R, Coste A, Barry B, Makeieff M, et al. COVID-19 and ENT Surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2020. doi:10.1016/j.anorl.2020.04.012
6. Iyengar KP, Jain VK, Vaish A, Vaishya R, Maini L, Lal H. Post COVID-19: Planning strategies to resume orthopaedic surgery –challenges and considerations. Journal of Clinical Orthopaedics and Trauma. 2020. doi:10.1016/j.jcot.2020.04.028
7. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.02.017
8. Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020. doi:10.1002/bjs.11746
9. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic – Ensuring Access to an Essential Health Service. N Engl J Med. 2020. doi:10.1056/NEJMp2008006
10. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395: 1225–1228. doi:10.1016/S0140-6736(20)30627-9
11. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi:10.1016/S0140-6736(20)30566-3
12. Fauci AS, Lane HC, Redfield RR. Covid-19 – Navigating the uncharted. New England Journal of Medicine. 2020. doi:10.1056/NEJMe2002387
13. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020. doi:10.1016/S0140-6736(20)30567-5
14. Navarro SM, Mazingi D, Keil E, Dube A, Dedeker C, Stewart KA, et al. Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study. World J Surg. 2020. doi:10.1007/s00268-020-05553-8
Professor Steven R Brown, Sheffield Teaching Hospitals.
Based on the BJS Lecture at ACPGBI 2020
A success story
There is more and more convincing evidence that the number of patients undergoing surgery for Crohn’s disease is decreasing substantially (1,2). Of course this as a huge success story and testament to tremendous advances in medical therapy occurring particularly over the last 20-30 years, isn’t it? Not necessarily. Some would suggest the newer medications have made little to no difference in reducing the need for surgery (3,4). Other factors may be more pertinent. To give gastroenterologists credit, earlier recognition of disease and potential complications and better disease monitoring are likely to have played a role. On the other hand it may be nothing to do with medical care and there is a simple epidemiological explanation; for instance there are less smokers now than there was 30 years ago (5).
Or is it?
There is another more concerning explanation. The plethora of medical options for patients with Crohn’s disease continues to expand. As a simple surgeon it is difficult to keep up with the various biosimilars, protein kinase, IL , CAM and JAK3 inhibitors that are available or being developed. It is like a candy shop of choice for the physician and a huge temptation for the patient to at least try one or more of these cutting edge medical therapies. Give medical treatment ‘just one more go’ is an obvious impulsion. But the medical literature is consistent in suggesting over 70% of patients with Crohn’s Disease eventually come to surgery (6). This can only mean that an increasing proportion of those undergoing surgery have experienced protracted medical therapy and are likely to have more complex disease. Although difficult to confirm this is certainly the perception of many in the surgical community (7-9).
Naturally all clinicians strive for the ultimate goal of never requiring surgery for Crohn’s Disease, but we are not there yet. Indeed some argue that the trend for less surgery should be reversed and surgery offered for more patients much earlier in their treatment pathway.
Buying a car
I like to think that the choice of surgery or medical therapy is analogous to buying a car. When making such a decision there are various factors that should be considered. These include safety, comfort, reliability, cost and perhaps most important of all what your partner thinks. The car may seem perfect in terms of all of these factors but he/she does not like the salesman, the brand or the colour.
So when it comes to the choice of the medical or surgical ‘car’ option, safety is in some respects paramount. There is a justifiable fear of surgery and a dread by many for the need for a stoma. However, optimisation of the patient, use of minimally invasive techniques, minimal resection and enhanced recovery mean that many of these fears are unfounded in the majority of patients (10). Indeed there are not insignificant risks associated with the alternative long-term immunosuppression.
Car comfort translates to quality of life. We know from the LIRIC study that quality of life is pretty much equivalent when it comes to medical or surgical options (11). No obvious winner here. However, when it comes to reliability or the chance of needing surgery there is an outright winner. As mentioned earlier the universally consistent literature suggests a greater that 70% chance of Crohn’s patients eventually needing surgery despite enhanced medical therapy (6). The ‘shiny medical sports car’ is very likely to break down. Compare with the ‘banger’ that is the surgical car. This just keeps going.
Additionally, long-term studies suggest at least 50% of patients will be symptom free 10 years after resection and two thirds will avoid further surgery (6). If this were the data for a new drug it would undoubtedly become a best seller. Furthermore it may be possible to customize the surgical ‘banger’ to make it even more reliable and attractive to the discerning customer. The Kono-S anastomosis and more radical mesenteric resection have both been touted as techniques that may reduce recurrence even further (12,13).
What does the data say?
Two recent publications back up these observations. A recent meta-analysis comparing early surgery with medical therapy decreases the risk of overall relapse (OR 0.53) , surgical relapse (OR 0.47) and the need for biological maintenance therapy (OR 0.24) whilst showing no difference in morbidity (14). Perhaps more significantly, long term analysis of the LIRIC data suggests nearly half of those treated with biological end up having surgery within 5 years and the rest remain on medication, switch or escalate treatment. Compare that with the surgical group were although about a quarter of the group required medical therapy for symptomatic recurrence, no one has required further surgery (15) Add to that cost, another clear winner for the surgical ‘banger’. Data again from LIRIC suggests it is €9000 cheaper than the medical option and almost 100% likely to be cost effective (16).
Therefore, it seems that the surgical car is cheaper, more reliable and, despite the looks, is as comfortable and safe as the shiny new medical sports car. However, the unpredictable factor is of course what your partner (patient) thinks. A study by Scott and Hughes (17) suggested about 80% of patients who underwent iloecaecal resection for Crohn’s disease said they ‘wished they had had surgery sooner’. Whilst a pre-biological era study and full of potential bias, many surgeons would be familiar with this phrase from the happy patient sitting in front of them, having undergone successful resection.
How do we proceed?
So there is a quandary here. Every doctor, regardless of specialty, wishes to reduce the need for surgery in Crohn’s but I would argue the evidence points to this being a less favorable option in many. The solution in my view lies in the underlying principle of good care for IBD, a multidisciplinary approach. Patients with Crohn’s Disease who require escalation of treatment should be fully informed of the risks and benefits of both medical and surgical options and make their own mind up. The only way this can be done fully and in an unbiased fashion is by meeting the surgeon earlier, preferably together with the physician in a joint clinic.
Kalman TD, Everhov ÅH, Nordenvall C, et al. Decrease in primary but not in secondary abdominal surgery for Crohn’s disease: nationwide cohort study, 1990-2014 [published online ahead of print, 2020 May 26]. Br J Surg. 2020;10.1002/bjs.11659.
Beelen EMJ, van der Woude CJ, Pierik MJ, et al. Decreasing Trends in Intestinal Resection and Re-Resection in Crohn’s Disease: A Nationwide Cohort Study [published online ahead of print, 2019 Jun 10]. Ann Surg. 2019;10.1097/SLA.0000000000003395.
Lakatos PL, Golovics PA, David Get al. Has there been a change inthe natural history of Crohn’s disease? Surgical rates and medicalmanagement in a population based inception cohort from Western Hungary between 1977–2009. Am J Gastro2012;107: 579–88.
Jeuring SF, van den Heuvel TR, Liu LY, et al. Improvements in the Long-Term Outcome of Crohn’s Disease Over the Past Two Decades and the Relation to Changes in Medical Management: Results from the Population-Based IBDSL Cohort. Am J Gastroenterol. 2017;112(2):325-336.
Cosnes J. Smoking and diet: impact on disease course? Dig Dis. 2016;34:72–77
Latella G, Caprilli R, Travis S. In favour of early surgery in Crohn’s disease: a hypothesis to be tested. J Crohns Colitis. 2011;5:1-4.
Buskens CJ, Bemelman WA. The surgeon and inflammatory bowel disease. Br J Surg. 2019;106:1118-1119
Macfie J. Commentary: Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:208.
Mege D, Garrett K, Milsom J, Sonoda T, Michelassi F. Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:200-207.
2015 European Society of Coloproctology (ESCP) collaborating group. Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate. World J Gastrointest Surg. 2019;11:261-270.
Ponsioen CY, de Groof EJ, Eshuis EJ, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial Lancet Gastroenterol Hepatol. 2017;2:785-792.
Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn’s disease: a systematic review [published online ahead of print, 2020 May 17]. Colorectal Dis. 2020;10.1111/codi.15136.
Coffey CJ, Kiernan MG, Sahebally SM, et al. Inclusion of the Mesentery in Ileocolic Resection for Crohn’s Disease is Associated With Reduced Surgical Recurrence. J Crohns Colitis. 2018;12:1139-1150.
Ryan ÉJ, Orsi G, Boland MR, et al. Meta-analysis of early bowel resection versus initial medical therapy in patient’s with ileocolonic Crohn’s disease. Int J Colorectal Dis. 2020;35:501-512.
Stevens TW, Haasnoot ML, D’Haens GR, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastro hepatol. 2020 Available on line 30 June.
de Groof EJ, Stevens TW, Eshuis EJ, et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn’s disease: the LIR!C Trial. Gut. 2019;68(10):1774-1780.
Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn’s disease–the patient’s view. Gut. 1994;35:656-657.
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.
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.
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.
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.
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.
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.
BJSOpen is a fully-online and open access journal & is proud to publish high-quality surgical research. This month, papers span surgical oncology, methdology, benign disease, and global surgery. The full table of contents is here.
This month features two interesting clinical reviews on conditions of interest to all general surgeons.
The first of these addresses the role of prophylactic mesh reinforcement in prevention of incisional hernia after midline laparotomy in a predominantly elective cohort. It showed reduction in mesh use vs suture closure, regardless of where the mesh was placed. The authors also undertook a trial sequential analysis which suggested that more than enough information was available to reach this conclusion. Rates of seroma were higher with onlay mesh vs suture, and there was no difference in the rates of surgical site infection. Will this change your practice?
Oesophagectomy is a high stakes operation, and is technically challenging. This paper from Birmingham in the UK, examines the outcomes of 430 patients who underwent oesphagectomy over an 11 year period. They show that increasing severity complications are associated with worse overall AND worse disease free survival, particularly when Clavien Dindo II or greater.
A paper from Cardiff, Wales, looked at the effect of systemic inflammatory response in oesophageal cancer. Specifically, it looked at the relationship between neutrophil:lymphocyte ratio (NLR) and survival. Lower NLR was associated with poor response to neoadjuvant chemo, and also with worse overall survival. Read it here.
Pancreatic fistula is a recognised complication of pancreatic surgery. This cohort study reviewed outcomes of 108 patients undergoing pancreatoduodenectomy or distal pancreatectomy. They found that enterobacter was frequently found in drain fluid of patients with pancreatic fistula after surgery. Where enterobacter or multidrug resistant organisms were found, this was associated with higher grade complications.
Other studies include a study of en bloc resection of the retropancreatic portal vein in patients undergoing surgery for pancreatic adenocarcinoma. Whilst a cohort study, it suggests benefit in terms of longer disease free and overall survival compared to standard resection approaches.
What’s the role of Liver Transplant in patients with unresectable colorectal liver mets? This was investigated as part of the SECA II ‘D’ arm. Median disease‐free and overall survival was 4 and 18 months respectively.
Anastomotic leakage is a popular topic in journals, often due to its importance to patients and clinicians. This Italian study of 1500 patients undergoing resection compared the performance of the Dutch Leakage Score, CRP alone, and Procalcitonin in predicting anastomotic leakage (amongst other things). It showed good negative predictive value of all tools on day 2,3, and 6 (approx 97%). The positive predictive value was poor (around 10-20%).
This really neat study looked at potential early biomarkers of sepsis (of varying degrees) in surgical patients. It looked at a panel of biomarkers of endothelial dysfunction, neutrophil degranulation, and granulopoesis. They noted that markers of endothelial dysfunction were higher in patients with sepsis vs infection, suggesting this is an early event in the development of sepsis. Definitely worth a read!
This is not all the papers from this issue, but a selection which we think will have particular appeal to a broad part of our readership. We hope you enjoy them, and look forward to discussing them with you online!
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.
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.
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
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
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.
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.
The aim of Young BJS is to nurture the future leaders of surgical academia by
Providing early-career researchers with an opportunity to gain editorial experience
Encouraging national and international collaborative efforts
Acting as an educational forum for surgeons-in-training
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.
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.
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.
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 firstname.lastname@example.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)
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
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.
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.
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
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.
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.
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
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
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.
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.
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
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
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.
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.
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.