Authors: Kenneth A McLean, Sivesh K Kamarajah, James C Glasbey
Early in the pandemic, it was recognised that patients had a higher rate of death associated with pulmonary complications if they become infected with SARS-CoV-2 in the perioperative period 1. However, the key question is why? Was this solely down to SARS-CoV-2 infections, was this due to differences in who was prioritised for surgery, or due to some other reason? These are difficult questions to answer, especially without comparable data from the pre-pandemic period.
To address this, our paper published in the BJS pools together two large-scale, prospective and multi-specialty international cohorts 2: one from the pre-pandemic period from the STARSurg Collaborative 3 and another from during the pandemic from the COVIDSurg collaborative 4. Since these projects both included elective abdominal cancer surgery patients, and collected similar data on them and their postoperative outcomes, we were able to make a fair comparison between these cohorts.
Overall, there was only a minority of patients with a perioperative SARS-COV-2 infection (4.3%), which is reassuring that most patientsundergoing surgery during this period were safeguarded. Interestingly, when postoperative outcomes were compared between the periods, the pulmonary complication rate observed was relatively similar (7.1% [before] vs 6.3% [during], p=0.158) but the 30-day mortality was much higher (0.7% [before] versus 2.0% [during], p<0.001). This was perhaps due to more “severe” pulmonary complications during the pandemic, e.g. a higher proportion of patients with acute respiratory distress syndrome.
Overall, we estimated the number of deaths related to pulmonary complications (the “population attributable fraction”) increased from 37.0% (95% CI: 14.6% – 64.1%) pre-pandemic to 66.0% (95% CI: 48.6% – 79.3%) during the pandemic. This is (perhaps unsurprisingly) difficult to tease out the exact role of SARS-COV-2 infection in this – not least because SARS-COV-2 infections didn’t exist in the pre-pandemic group. We also found some major differences in patient selection and surgical practice during the pandemic. For example, while patients operated during the pandemic tended to have an overall lower baseline risk of pulmonary complications, they still had higher rate of open operations (this may be at least in part due to uncertainty at the time whether or not laparoscopic surgery was high-risk for COVID-19 transmission 5). To allow us to account for these differences in the cohorts, we used a technique called “mediation analysis”, which allows us to estimate exactly how much SARS-COV-2 infection contributed to (“mediated”) 30-day postoperative mortality during the pandemic.
We found that even after adjustment, there was still an almost 3-times higher likelihood of death when being operated on during the pandemic, compared to pre-pandemic (OR: 2.72, 95% CI: 1.58 to 4.67, p<0.001). However, we estimated that over half of excess deaths (54.8%) during the pandemic were explained by the presence of a SARS-CoV-2 infection. If in a parallel universe these patients were operated on pre-pandemic (e.g. with no risk of SARS-CoV-2 infection) there would still have likely been a higher rate of death than expected (perhaps due to a collateral impact on other hospital services from the pandemic that reduced capacity to rescue). However, overall, there would have been no significant difference in postoperative mortality during the pandemic (OR:1.57, 95% CI: 0.91 to 2.73, p=0.108), compared to pre-pandemic.
In the first pandemic wave, despite attempts by care providers to continue safe elective surgery by operating on lower-risk patients, a significantly higher risk-adjusted mortality was observed. Whilst over 50% of excess deaths were explained by SARS-CoV-2 infection, the remainder may indicate a collateral impact on other hospital services that reduced capacity to rescue. The COVID-19 pandemic isn’t over yet, and upscaling elective surgery safely to meet the backlog is one of the major challenges facing health systems going forward. This study highlights the ongoing need for governments to ensure hospitals have Covid secure pathways 6 and to take appropriate and timely measures to ensure hospitals services aren’t overwhelmed. Several million patients have had their cancer surgeries delayed or cancelled 7, and there are serious concerns that despite best efforts to prioritise care this may lead to reductions in cancer survival in the long-term 8. It is likely to be several years until universal vaccination is available, and so until then strategies to mitigate risk of SARS-COV-2 infection must be implemented to continue surgery safely.
1. Cai M, Wang G, Zhang L, Gao J, Xia Z, Zhang P, et al. Performing abdominal surgery during the COVID-19 epidemic in Wuhan, China: a single-centred, retrospective, observational study. Br J Surg. 2020;107(7):e183-e5.
2. STARSurg Collaborative and COVIDSurg Collaborative. Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic: a comparative analysis of two prospective international cohort studies. BJS. 2021;[in press].
3. STARSurg Collaborative. REspiratory COmplications after abdomiNal surgery (RECON): study protocol for a multi-centre, observational, prospective, international audit of postoperative pulmonary complications after major abdominal surgery. British Journal of Anaesthesia. 2020;124(1):e13-e6.
5. Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. British Journal of Surgery. 2020;107(7):785-7.
6. Glasbey JC, Nepogodiev D, Simoes JFF, Omar O, Li E, Venn ML, et al. Elective Cancer Surgery in COVID-19–Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study. Journal of Clinical Oncology. 2020:JCO.20.01933.
7. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. The British journal of surgery. 2020;107(11):1440-9.
8. COVIDSurg Collaborative. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. The Lancet Oncology. 2021.
J Osorio, Z Madrazo, S Videla, B Sainz, A Rodríguez-González, A Campos, M Santamaría, A Pelegrina, C González-Serrano, A Aldeano, A Sarriugarte, C J Gómez-Díaz, D Ruiz-Luna, A García-Ruiz-de-Gordejuela, C Gómez-Gavara, M Gil-Barrionuevo, M Vila, A Clavell, B Campillo, L Millán, C Olona, S Sánchez-Cordero, R Medrano, C A López-Arévalo, N Pérez-Romero, E Artigau, M Calle, V Echenagusia, A Otero, C Tebe, N Pallares, S Biondo, COVID-CIR Collaborative Group Members of the COVID-CIR Collaborative Group
Emergency surgeons may find ourselves attending patients who are potential candidates for emergency surgery and have a COVID-19 infection, with or without evident symptoms. What should we do with these patients?
The purely descriptive studies published to date show that these patients have a much higher than usual postoperative mortality. Considering these results, avoidance or postponement of surgery has been advised in COVID-positive patients.
However, postponing an emergency surgery may also have its risks. In each individual case, the risk of operating must be weighed against the risk of a non-surgical treatment. Therefore, it is very important to fully understand how and to what extent COVID-19 infection increases postoperative mortality.
Or in other words, is the high mortality observed in COVID-positive patients undergoing surgery entirely due to COVID-19 infection?
If we look closely at these descriptive non comparative studies, most of the COVID-positive patients were older than usual, with many underlying pathologies, and in poor general condition at the time of surgery. Could these factors, rather than the COVID-19 infection itself, explain their bad postoperative outcomes?
Additionally: During the lockdown, patients might have had fear or difficulty of going to the hospital and might therefore be diagnosed in a more advanced stage of their surgical pathologies. Moreover, the collapse of the pandemic could also cause hospitals to have difficulties in rescuing patients with postoperative complications.
If we can measure the true impact of these 3 factors involved (the patient’s context, the lockdown effect and the effect of hospital collapse) we will be able to assess how COVID-19 infection increases the mortality of patients undergoing emergency surgery. And that will allow us to make decisions based on evidence about whether, in each specific case, it is more reasonable to operate or to try not to do so.
The COVIDCIR project was born with the objective of answering that question. From the Bellvitge University Hospital, in Barcelona, we led a registry with 25 participating Spanish hospitals including all emergency general and gastrointestinal surgeries performed during the first wave of the pandemic (from March to June 2020) and during the same period of 2019 . More than 5,000 patients were included.
To assess the impact of COVID infection, we compared COVID-positive patients with COVID-negative patients operated on during the pandemic. This comparison was made using a statistical method called propensity-score matching, which consists of matching COVID-positive patients with COVID-negative controls of similar age, underlying pathologies and general condition at the time of surgery, thus achieving two comparable groups.
We observed that the mortality of these two matched comparable groups was not statistically different. Or, put another way, that the high mortality observed in COVID-infected patients undergoing surgery is more due to their age, underlying pathology and preoperative condition than to a hypothetical COVID risk-multiplier effect.
Thus, the fact that a patient is COVID-positive should not be seen as an absolute impediment to perform an emergency surgery. In each individual patient, the assessment of the risk of performing or postponing surgery should be based, as has always been done, on her or his individual anesthetic risk and its state at the time of diagnosis.
Second, to understand the effect of lockdown, to see if patients were diagnosed too late due to fear or difficulty in accessing, we compared surgical pathologies of COVID-negative patients operated on during the pandemic with those operated during the previous year. We saw that in the pandemic, patients did not present with more advanced peritonitis and that the inflammatory parameters of their laboratory tests were not higher. Thus, the increased mortality observed during the pandemic cannot be attributed to the effect of lockdown.
And finally, to understand the consequences of hospital collapse, we assessed what is called Failure to Rescue of patients: that is, what percentage of patients who present postoperative complications could not be rescued and died as a consequence of the complication. We compared Failure-to-Rescue of COVID-negative patients operated during the pandemic with those operated before the pandemic. Also on this occasion we carried out the propensity-score matching comparison, matching patients from both groups from the same hospital and of similar age, underlying pathologies and severity of surgical pathology.
We found that COVID-negative patients operated on during the COVID-19-pandemic had the same risk of postoperative complications, but a greater Failure-to-Rescue than before. This fact was evident in the 25 participating hospitals and is probably explained by the hospital collapse in the pandemic context.
By Hannah Javanmard-Emamghissi (@hannahjavanmard), NELA Research Fellow and RCSEng Research fellow on behalf of the COVID:HAREM Collaborative
Keyhole surgery (laparoscopic appendicectomy) has been the mainstay of adult appendicitis treatment in Europe and the United States for the last several decades. In spite of this numerous trials have been ongoing exploring if there is a role for non-operative management of appendicitis with antibiotics. The APPAC and CODA trials both demonstrated that antibiotics were effective at treating simple appendicitis that was not perforated, gangrenous or associated with an abscess in the majority of patients.(1,2) However, it remained an underutilised treatment strategy.
This all changed during February and March of 2020, when the Sars-COV-2 virus (COVID-29) swept across much of the globe. Healthcare providers were forced to make contingency plans for hospitals that faced being overwhelmed by patients infected with COVID-19. Much of the anaesthetic workforce had been redeployed to intensive cares and there was uncertainty of the safety of general anaesthesia for patients with peri-operative COVID-19 and of the safety of the theatre teams exposed to virus aerosols during laparoscopy.(3,4) Non-operative management strategies were implemented recommended by surgical professional bodies across many surgical disciplines as a way of mitigating for these uncertainties.(5)
Our collaborative’s report, just published in BJS, represents the first time non-operative management of appendicitis has been implemented on a wide scale in the United Kingdom. We collected data on patients over the age of 18 presenting during the first wave of the COVID-19 pandemic presented with signs and symptoms suggestive of acute appendicitis, whether they were managed operatively and non-operatively. These patients were followed up for 90 days for length of hospital stay, complications, representation to hospital and appendicitis recurrence. Patients managed non-operatively were matched with similar patients managed operatively using propensity score matching, and their outcomes were compared.
Patients from 97 hospitals across the United Kingdom and Republic of Ireland were included in our study. Three thousand four hundred and twenty patients were included, of which 41% had initially been treated with antibiotics. When they were matched using propensity score matching with similar patients who had non-operative management, the group treated with antibiotics spent less time in hospital and had fewer complications than those who had an operative management. Non-operative management was successful in 80% of the patients managed in this way, with 20% going on to have an appendicectomy in the 90 days after their first attendance.
We also teamed up with a health economics team from the London School of Tropical Medicine to calculate the costs associated with each treatment method. We found that, even when accounting for the 20% of patients that had surgery within the 3 months of being treated with antibiotics, non-operative management was associated with a cost reduction of €1034 per patient compared to operative management.
This study proves that antibiotics are an effective management strategy for appendicitis and can be utilised on a large scale beyond trials for the first time ever. Patients may be keen to avoid surgery for a number of reasons and going forward surgeons should incorporate a discussion about the risks, benefits and uncertainties of non-operative management into conversations they have with patients about appendicitis management options. Our results have shown how reducing the number of operations we do for appendicitis can have benefits for the patient in terms of complications and days in the hospital away from work and home, but it may have wider benefits to the hospital and world. Not only is non-operative management cheaper for the hospital, but reducing the number of appendicectomies performed can free up theatre time so the most urgent surgical emergencies have less delay accessing theatre. All operations are associated with a significant amount of carbon emissions and single use plastic waste, but despite our best efforts to reduce the harm that surgery can cause to the environment the most effective strategy remains reducing the amount of unnecessary surgery performed.(6)
That is not to say that the study of non-operative management of appendicitis is over, there is still debate about the long-term efficacy of antibiotic management and concern that some cancers of the appendix may be missed by not removing the appendix at the first presentation, as well as questions about how acceptable patients find non-operative management. Our collaborative hopes to answer these questions and more in a one year follow up study and ongoing patient and public involvement work.
Conflicts of Interest
None to declare
No funding was received for this blog article
1. Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259–1265.
2. CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NL, Odom SR, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Nov 12;383(20):1907-1919.
3. Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet [Internet]. 2020 Jul 4 [cited 2020 Nov 5];396(10243):27–38. Available from: https://doi.org/10.1016/
5. Hettiaratchy S, Deakin D. Guidance for surgeons working during the COVID-19 pandemic from the Surgical Royal Colleges of the United Kingdom and Ireland. Intercollegaite Royal Colleges of Surgery. London; 2020.
6. MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planetary Health [Internet]. 2017 Dec 1 [cited 2021 Sep 5];1(9):e381–8. Available from: http://www.thelancet.com/article/S2542519617301626/fulltext
The CovidSurg collaborative have published a new paper in BJS showing that global prioritisation of pre-operative vaccination for elective patients could prevent an additional 58,687 COVID-19-related deaths in one year. Watch the video abstract above or read the paper for free.
Maria Picciochi (@MariaPicciochi), Hospital Prof Doutor Fernando Fonseca, Portugal
Dmitri Nepogodiev (@dnepo), University Hospital Birmingham, UK
Virtually all elective surgical services around the world suffered some form of shutdown due to the COVID-19 pandemic1. Now, patients and surgeons are desperately looking to re-start services. Efforts to re-start after the first waves faced multifactorial challenges, including patient safety and ensuring enough staff along the whole patient pathway to support operating theatre availablity.2,3
The impact of the reduction in surgical capacity is likely to be staggering. Initial estimates of 28 million cancelled operations likely escalated to 50 million towards Autumn 2020, and may now be in excess of 100 million. That is only one part of the story, since the many undiagnosed patients with surgical conditions sitting in the community over the last 12 months may never make it to a surgeon or waiting list. Without adequate surgical capacity, there will be a major global decline in population health due to the burden of a full range of inadequately treated non-communicable diseases.
There is no single factor or solution that will enable surgery to re-start at scale, quickly. There is no single set of solutions that will work across every region. Since every single hospital around the world functions differently, context specific and whole system solutions are needed.
Vaccination will hopefully provide solutions to the current pandemic, although the global rollout is occurring at different paces globally, meaning surgical recoveries will differ. Cultural challenges across countries are adding to this variation. Unlike acute major incidents which disable elective surgical but are quickly over (e.g. major trauma or bombings), this pandemic has exposed specific, longer-term weaknesses of current systems. Post-pandemic planning will now happen across all spectrums of society. Surgeons need to lead efforts to create resilient elective surgical services that are pandemic resistant for the future, advocating for hospital and political awareness.
The COVIDSurg collaborative has taken a data driven approach to supporting safe surgery, and for 2021-2022 will provide further data to support re-starts globally. Data is needed across the whole system and patient pathway, that includes referrals, preoperative selection, perioperative testing and safety, postoperative risk reduction, and structural organisation of hospitals4–6.
Figure 1 – Centres enrolled in COVIDSurg studies
Learning from other non-medical disciplines, surgeons have little barometer of how secure their elective surgical services are compared to everyone else’s. COVIDSurg will deliver a validated Elective Surgery Resilience Index in the first half of 2021, allowing surgeons to test their systems and identify areas for immediate strengthening.
Re-starting surgery safely will be a complex interplay of these multiple factors. Not all resources will be available across all regions, and in some resource limited settings, surgery is at risk of being seen as a burden. To further support the re-start, an easily accessible, digital, online toolkit is needed that will provide key take-home messages and downloadable pathways for surgical teams to take and adapt. This will include the ability to self-certify individual department and hospital level of COVID Secure Surgery. This will provide the building blocks to provide ring-fenced, pandemic secure surgery by 2030.
Conflicts of interest: We have no conflicts of interest to declare.
Funding: No funding was received for this blog article.
1. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: An international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
3. COVIDSurg Collaborative. COVID-19-related absence among surgeons: development of an international surgical workforce prediction model. BJS Open. doi:10.1093/BJSOPEN/ZRAA021
4. COVIDSurg Collaborative. Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic. Color Dis. December 2020:codi.15431. doi:10.1111/codi.15431
5. COVIDSurg Collaborative. Elective cancer surgery in COVID-19–Free surgical pathways during the SARS-cov-2 pandemic: An international, multicenter, comparative cohort study. J Clin Oncol. 2021;39(1):66-78. doi:10.1200/JCO.20.01933
6. COVIDSurg Collaborative. Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic. Br J Surg. 2021;108(1):88-96. doi:10.1093/bjs/znaa051
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
1/ I may be repeating myself, but I want to fight this sense of security that I see outside of the epicenters, as if nothing was going to happen “here”. The media in Europe are reassuring, politicians are reassuring, while there’s little to be reassured of. #COVID19#coronavirus
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
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
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.
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.
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.
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).
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.
Exploring psychological consequences for BRCA+ women in the post-Covid era
by Grace Brough1, Douglas Macmillan2, Kristjan Asgeirsson2, and Emma Wilson1 1Division of Epidemiology and Public Health, University of Nottingham 2Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
Whilst the global female population has a 12.5% overall lifetime risk of developing breast cancer and a 1.3% risk of ovarian cancer (Howlader et al), the risk for those with a pathogenic BRCA1 or BRCA2 mutation is 60-70% and 10-20% respectively (van Egdom et al). BRCA1 mutation carriers have a particularly high incidence of triple-negative breast cancer (TNBC) (Greenup et al) for which treatment options are more limited and always include chemotherapy (Bianchini et al; Collignon et al).
In the NHS, asymptomatic women with at least a 10% estimated chance of having a BRCA mutation are offered testing (NICE). Knowing you are at high risk of breast cancer and the increased likelihood of TNBC is a well-documented cause of anxiety (Wenzel et al) and many women describe having a BRCA gene mutation as living with a ‘ticking time bomb’. Bilateral mastectomy with or without reconstruction is the only proven method of drastically decreasing risk and can improve quality of life (McCarthy et al) and decrease anxiety (Rebbeck et al) for correctly selected cases, despite its potential negative outcomes (Gahm et al).
The strongest predictor for choosing to undergo risk reducing mastectomy is having a first or second degree relative die from breast cancer (Singh et al), a factor associated with fear, anxiety and vulnerability to this disease. Most women choosing it have clear and long-considered reasoning and have been prepared for it through well-established pathways guided by genetic counsellors, specialised surgeons and nurses. It is however, classified as elective surgery. As such, waiting lists for risk reducing mastectomies are impacted by other healthcare challenges and needs.
Being on NHS waiting lists causes anxiety across all specialities (Carr et al). With an estimated 10 million people on NHS waiting lists in the post-COVID era, levels of health-related anxiety within the population are anticipated to significantly increase. For BRCA mutation carriers, the prevailing fear is that they will develop breast cancer whilst on the waiting list. This reality is related to the length of time on the waiting list and represents potential conversion of a risk reducing scenario to one of chemotherapy and cancer surgery, often with other treatments, and all the life changing and life threatening implications of cancer diagnosis.
In pre-COVID times, there was a 18 week target time from referral to treatment for risk reducing mastectomy (UK GOV). Due to COVID, the majority of elective surgery has been put on hold and Breast Units now anticipate at least a 2-year waiting list for non-cancer surgery, such as risk reducing mastectomies, delayed reconstructions, and revisional surgery. Prioritisation is a difficult necessity.
In addition, breast screening services ceased or were significantly curtailed as a result of COVID related restrictions, and this adds to an already complex situation for BRCA mutation carriers. Not only may they now get breast cancer whilst on the waiting list, but they are denied the reassurance afforded by negative screening, or potentially a diagnosis may be delayed (Maringe et al).
Combining pre-existing anxieties of being a BRCA mutation carrier, new waiting list anxieties, and wider COVID general health anxieties, the post-COVID era has the potential to see significant levels of psychological burden in this population, which could negatively impact mental health and quality of life. Providing additional psychological support is likely to be the short-term solution, though this is also resource limited. In reality the collateral impact of pandemic related consequences for healthcare in this particular group may not be realised for some time.
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.
In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.
The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.
Cancer Surgery Priority
The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.
Priority level 1a
• Emergency: operation needed within 24 hours to save life
Priority level 1b
• Urgent:operation needed with 72 hours Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
Priority level 2
Elective surgery with the expectation of cure, prioritised according to: • Surgery within 4 weeks to save life/progression of disease beyond operability. Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers
NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
Priority level 3
Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery
However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;
The “Salford Score” simplifies this to:
Priority 1a = score (P)1
Priority 1b = score (P)2
Priority 2 = score (P)3
Priority 3 = score (P)4
A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).
Outcome in case of COVID infection
Vulnerability level 1
• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection
Vulnerability level 2
• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality
Vulnerability level 3
• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality
Table 2: Vulnerability score
A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.
A hypothesis paper on alternating population quarantine instead of lockdowns: a surgeon’s approach to the problem.
The Covid-19 pandemic is spreading quickly, threatening healthcare systems and the world economy. Test and tracing methods used efficiently in Asian countries are not feasible in countries with scarce test capacities. Current lockdown strategies are insufficient as not everyone can be quarantined for 2 weeks at the same time. An alternative strategy to extensive lockdown – namely an alternating home quarantine of half the population for 2 weeks at a time – is described in this post. This may be an efficient way to stop the spreading of the disease, buying time to establish test routines and a vaccine. At the same time it may prevent the economy and healthcare systems from collapsing.
As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is newly identified, the actual case fatality rate (CFR) and susceptibility in the population are uncertain. During the Chinese outbreak the CFR was calculated to be 2.9% in the Hubei province compared to 0.4% outside Hubei (overall 2.8%) . In Italy it is at the moment 8.5% . The actual CFR is probably closer to 1% with optimal treatment capacities and early and complete detection. No natural immunity against the SARS-CoV-2 has been shown. Post exposure immunity after sub clinic infection is however probable, which would explain why the Chinese outbreaks outside Wuhan were less intense. Neither a vaccine nor approved treatment are currently available, although there are ongoing trials with several drugs both for treatment and prophylaxis.
Both South Korea and Singapore are conducting widespread testing of symptomatic patients combined with short-term lockdowns and tracing of close contacts to infected individuals. This strategy seems to have been very successful. Also China, where the virus originated, appears to have stopped the outbreak with combination of complete lockdown in hotspots, intensive testing and tracing, as well as restrictions in people’s mobility combined with partial lockdowns in other regions.
The rest of the world faces the challenge of widespread virus dissemination, which makes conventional containment measures as well as intensive test and tracing methods infeasible. Frankly, one doesn’t know where to look. In Italy, the European epicentre of the Covid-19 outbreak, a national lockdown was imposed the 9th of March. Several countries have introduced similar interventions with the aim “to flatten the curve”. The idea is to postpone and lower the peak of the epidemic curve to enable healthcare systems to cope, particularly with the high demand for mechanical ventilation. Another aspect of postponing instead of stopping the pandemic is the hope for so called “herd immunity” which will help to prevent later outbreaks.
All above-mentioned community interventions come at a very high cost. The world economy is starting to halt. As the current measures will need to be in place for a very long time, they may hinder sufficient supply of urgently needed equipment. Furthermore, it is uncertain whether the imposed actions are even close to slowing the pandemic sufficiently. The disease is highly contagious (R0 has been estimated between 2.4 and 3 in the Hubei Province and between 2.3 and 14.8 at the start of the Diamond Princess cruise ship outbreak) and even severe currently used community interventions will not entirely stop community transmission. Data from Italy for March 23rd show that the number of patients was still rising on average 14% the 10 preceding days; even in the region of Lombardy (first lockdowns February 27th) this figure was still 11% (down from 26% between Feb 23rd – Mar 3rd) although the number of new cases is finally declining. The Italian healthcare system is on the verge of collapse (Figure 1).
Currently, approximately 50,000 Italians are reported to have an ongoing Covid-19 infection. Even if the correct number was 20 fold (ascertainment in Wuhan was previously estimated to 5% (95%CI, 3.6–7.4)) that would be < 2% of the Italian population. One can only but imagine the consequences of 40% being infected. Currently, other European countries are struggling to prepare for the coming pandemic and consequently little aid is offered to Italy. The situation in the US is also currently escalating.
Hypothesis: A coordinated alternating nation- or region-wide quarantine of the whole population is an efficient way to stop the Covid-19 pandemic, with less impact on economies and on everyday life than the currently imposed partial lockdowns.
The idea is to divide the whole population in two groups (A and B) for a period of eight weeks. Both groups will stay in alternating home quarantine for two weeks at a time (quarantine length recommended by the WHO for Covid-19) while the other group attends to daily life. All symptomatic individuals during quarantine are either tested or need to remain in quarantine with their households. Positive tested individuals and their household members remain in home isolation until negative test result. Individuals in home-quarantine at the start of the first period are allocated to group A.
During this four-week period, other interventions should continue (cough and hand hygiene, social distancing, no public meetings, shut-down of cinema/theatres). Patients at risk should preferably be isolated for the whole period and some critical personnel might need to work the whole period (Figure2). The cycle may need to be repeated at the end of week 4 if there are many newly diagnosed patients in group A after the quarantine.
There are five prerequisites for this intervention to be effective:
It is essential that all members of one household are in the same group.
The group in home quarantine needs to stay at home and either buy all supplies for 2 weeks before the start of the period, or be supplied by the community (i.e. by the group that is not quarantined); this is to prevent new infections. Only few exceptions should be made (for example chronically ill or acutely unwell patients in need of hospital treatment and patients receiving home nursing or staying in institutions).
There should be as little contact as possible (preferably no contact) between the groups when switching quarantine periods. Non-avoidable contacts need to be traceable.
The start of the two periods needs to be coordinated for large areas, preferably whole countries, or country unions (for example the whole European Community).
There are different ways to allocate the population to the groups – community wise, according to where people work (for example a whole factory may pause for 2 weeks as long as household members of employees are allocated to the same group), by postal code or house number. The optimal way may differ between countries and communities. Group A may be larger than group B in order to get a quick control of the situation, especially in Hotspots. The whole 4-week circle needs to be followed by an active surveillance with intensive testing. A detailed plan by domestic health authorities for workers in critical positions who need to work throughout the whole period can minimize the chance of “contamination” of Group A and B after the home quarantine periods (for example home delivery of food to those working with Covid-19 patients). Figure 3 shows a very simplified model of the effect of social distancing and lockdowns compared to alternating quarantine.
The main strength of alternating population quarantine is that the risk of community acquired Covid-19 infection is reduced to a minimum already after week 2. Furthermore, this concept would enable countries to stop the pandemic quickly locally. The impact on economy would be minimalized as several businesses can run for a short period of time with half the workforce. Temporary working hour adjustments or reduction in activity may compensate for the loss of work force.
The concept has some drawbacks. It requires either complete compliance by the population or effective control mechanisms with law enforcement. However, when confronted with the alternative of a never-ending partial shutdown combined with a probable major recession or that of staying at home for a limited time, the choice should be easy and politicians should be able to motivate the majority of the public to stay at home for two weeks at a time.
Another aspect is the susceptibility of the population for a new outbreak due to lack of immunity. However, the cycle of home quarantine can be repeated if necessary until sufficient test capacities, vaccines or treatments are available which is still preferable to a never-ending partial lockdown. Asymptomatic Covid-19 positive patients may prevent the success of this method. The proportion of asymptomatic patients has been estimated to be 18% during the Diamond Princess cruise ship outbreak.
It is likely that asymptomatic individuals will often be in close relation to symptomatic ones. A double cycle could allow us to identify almost all; it is however even more difficult to conduct. Experience from Asian countries shows that quarantine and isolation measures do work and that it is sufficient to test those who are symptomatic in order to find asymptomatic transmitters. When new clusters are detected, the method may even be repeated in affected areas. Many adaptions of this method are possible. Advanced epidemiological models and increasing knowledge about the disease may help to optimize it. The main principle however remains: to reliably separate the infected population from the non-infected in space and time.
At the moment, many countries are expanding ICU capacities. In my own hospital, this is possibly to a six-fold of normal capacity, and this may not even be enough. Furthermore, the current pandemic already prevents elective patients from receiving care. In addition, the current situation causes major damage to the world economy. Although the number of newly infected patients in Italy has been falling the last two days, there may be a quick raise again once restrictions are lifted. We should therefore do whatever we can to stop the pandemic rather than postpone its peak. This is not only to protect the old and vulnerable, but also to save our healthcare systems and our societies from collapsing and to avoid a new era of Great Depression. To quote one principle of damage control surgery: “the treatment of bleeding is to stop the bleeding”. The current approach is similar to treating a bleeding patient with transfusions and a simple bandage to slow the bleeding.
One might argue that it is unethical to expose group B for transmission longer than group A. However, the risk of infection for group B will be reduced considerably compared to what it is now already in when group A is quarantined. Furthermore, the exposure for Group B could be minimized by increasing the Size of group A. Two weeks of strict home quarantine may also increase the risk of home violence; this is however not much different from lockdowns.
With the current knowledge about Covid-19, the current strategy of delaying the pandemic seems to hazardous. The present hypothesis of alternating home quarantine can only be tested by governments of countries or provinces, but time is precious.
I would like to thank my colleagues and family for critical discussions. I would also like to thank Sheraz Yaqub and Ørjan Olsvik for a critical review of the paper. Further, I thank my Italian colleagues Michela Monteleone and Dario Tartaglia for inside information from the epicenter of the European outbreak.
None other than a close bond to Italy, #tuttoandrabene! Funding: none.
Johannes Kurt Schultz is a surgeon at the Akershus university Hospital in Norway.