Tag Archives: covid-surg

Apple and Orange

Guest blog: Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic: how to compare apples and oranges?

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.  

Figure 1: Multivariable natural effects model of postoperative death associated with time period, mediated by SARS-COV-2 infection.

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. 

References:

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.

4.         COVIDSurg Collaborative. Outcomes of Elective Cancer Surgery During the COVID-19 Pandemic Crisis. 2020 [updated 12/05/20. Available from: https://clinicaltrials.gov/ct2/show/NCT04384926.

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.

Patients should receive COVID-19 vaccine before surgery to reduce risk of postoperative death – study

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.

Healthcare workers wearing PPE and surgical gown, Creative Commons image

Guest post: COVID Secure Surgery

Authors:
Aneel Bhangu (@aneelbhangu), University Hospital Birmingham, UK, a.a.bhangu@bham.ac.uk

Dhruv Ghosh, CMC Ludhiana, India 

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.

References:

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

Guest post: CovidSurg – The impact of COVID-19 on surgical patients and the provision of surgical services

Constantine Halkias on behalf of COVIDSurg

The chance to learn about this disease & impact on surgical patients is in our hands.
Photo by Valentin Antonucci from Pexels

Surgery in a pandemic

Policies and public health efforts have not addressed the impact of pandemics on the provision of surgical services and the effects on health-related outcomes on surgical patients. This also applies to the response to Coronavirus disease 2019 (COVID-19). There hasn’t been any related research or analysis despite the impact of the pandemic so far. Understanding the effects of COVID-19 on patients undergoing surgery along with the effects of this pandemic on the provision of surgical services is a fundamental step to understanding the various different effects of a healthcare emergency of that magnitude and to implement policies from the lessons learned.

Impact on surgical patients

Undoubtedly despite the global focus to encounter the pandemic itself and the need to improve provision of services and treatments related to the immediate effects of COVID-19, with intensive care playing a major role, there are still millions of patients who will need surgical treatment. Major focus should be the provision of emergency surgical care, cancer surgery and transplant surgery. There is little or no knowledge on the outcomes of surgical patients with COVID-19 related disease.

Low quality data from a case series of patients who underwent cardiac surgery and acquired Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) did show very high mortality of 83.33% (1). This has major direct implications on the management of emergency surgical patients during the pandemic as well as on the ongoing provision of organ transplantation and cancer related operations. Whether major cancer surgery and organ transplantation should be delayed and for how long, in view of the possible worse outcomes during the pandemic is one of the issues that should be investigated.

Impact on surgical services

We also need to address the effects of the current pandemic on surgical services provision. It is an unprecedented situation that has already changed the way surgeons and health systems worldwide are offering surgical services. There is also very low quality evidence available from the 2003 Hong Kong Severe Acute Respiratory Syndrome (SARS) epidemic that showed significant reduction in the colorectal surgical caseload that had a major negative impact on waiting times and training (2). Although it’s certain that the impact of the current COVID-19 pandemic will be of unprecedented severity, it’s actual consequences and the implications on resources, staff allocation and training are still uncertain. Understanding the effect of the pandemic would also inform future global policy around cancer and transplantation surgery during pandemics, and the provision of surgical services in general.

A new project

There is an urgent need to understand the outcomes of COVID-19 infected patients who undergo surgery. To address the above issues we designed CovidSurg, an international group of surgeons and anaesthetists, with representation from Canada, China, Germany, Hong Kong, Italy, Korea, Singapore, Spain, United Kingdom, and the United States. Our aim is to capture real-world data and share international experience that will inform the management of this complex group of patients who undergo surgery throughout the COVID-19 pandemic, improving their clinical care and to understand the effects of the pandemic on the provision of surgical services. 

References

  1. Outbreak of Middle East Respiratory Syndrome-Coronavirus Causes High Fatality After Cardiac Operations. Nazer RI, Ann Thorac Surg. 2017 Aug;104(2):e127-e129. doi: 10.1016/j.athoracsur.2017.02.072.
  1. Tales from the frontline: the colorectal battle against SARS. Bradford IM Colorectal Dis. 2004 Mar;6(2):121-3. doi: 10.1111/j.1462-8910.2004.00600.x