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
When the first cases of the disease that would have been later named COVID-19 (Coronavirus Disease 2019) caused by SARS-CoV2 were described in Wuhan approximately three months ago, it would have been difficult to predict the impact and the burden that the subsequent outbreak would have had globally. The first case was tracked back to November 2019, indeed the spread COVID-19 proved to be incredibly rapid, and is currently causing several challenges to most health systems.
Among European countries, Italy has been hit first and more deeply, the reasons for this still being analysed, and no agreed explanation available. Since the first cases were described on the 30th January 2020, two Chinese tourists, the outbreak showed a logarithmic growth, and by today (16/03/2020), the overall number of individuals who tested positive was 24 747 (20 603 still positive) with 1809 deaths. This would mean a mortality rate overall as high as 7.3%, and 43.6% of those who had an outcome. Of those currently infected, approximately 8% is in serious/critical conditions. Lombardy, considered the economic heart of Italy, where an ideal health system is in place, registered the highest number of COVID-19, exceeding 13 200 patients, more than half than all Italian cases. The outbreak is rapidly spreading to the entire peninsula, islands not being spared: almost 1000 cases between South and Islands (3.73%). Even if these figures might not seem worrisome, they actually are, as facilities and infrastructures might not be prepared to afford a similar outbreak as that observed in Northern Italy, and the system could collapse. Restrictive measures had to be taken, and the Italian Government ordered an unpreceded lockdown effective as the 12th March 2020, and its effect and meaning are well testified by the empty Italian cities. Florence’s Uffizi Gallery is closed; St. Peter’s Square in Rome is empty.
These images are self-explanatory. Similar measures are being taken in other European countries, even if the strategies to face COVID-19 were not consistent. Spain followed a similar pathway observed in Italy, with 7753 cases and 288 death as of today, mainly in Madrid, and adopted the same measures.
The impact of COVID-19 on our society is already immense, and some have suggested that the post-pandemic era is likely to blow away the world as we used to know it.
COVID-19 and Cancer
Liang et al. analysed the cases of COVID-19 in China, and found that patients with cancers were at higher risk of developing the symptoms from SARS-CoV2 infection. Out of 1590 COVID-19 cases analysed, an history of cancer was found in 1% of them, versus 0.29% observed in the general population. One out of four had received chemotherapy or surgery within 30 days from infection, whereas another 25% were on follow-up after treatment. This might suggest that cancer patients might be at increased risk, even after curative treatment of the disease, for reasons that are not completely understood. Liang et al. also suggested that severe events were more common in cancer patients with COVID-19, as more patients in this population required invasive treatment measures or died compared with patients without cancer (even [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher’s exact p=0·0003); the risk was even higher if chemotherapy or surgery were performed in the last month, administered. These findings raise concerns on the ideal care to provide to such patients and whether or not should chemotherapy be continued during the outbreak, or at least stopped or reduced in selected patients at higher risk of infection. Of note, the actual impact of COVID-19 on the outcome of cancer patients in this specific cohort remains to be clearly proven, as the age of this cohort was higher than that of non-cancer patients with COVID-19. Moreover, they were more frequently smokers, and more frequently had polypnea. These considerations advocate for prudence at the time of interpreting the findings of studies which are currently being published on the topic, due to the limited knowledge available and to the relatively low (yet) number of cases described in these publications, which might be underpowered to show clinically relevant findings.
Similar concerns are applicable to patients who are chronically immunodepressed and to those with chronic conditions that might expose them to an increased risk of contracting COVID-19, and with potentially detrimental outcomes.
COVID-19 and usual hospital routine
The effects on COVID-19 on patients with chronic diseases or cancers are more extensive than the risk of contracting the virus for carriers of these conditions. The health system is almost collapsing in several countries, with few available beds in intensive care units. Elective surgery has been stopped in many hospitals, giving priority to cancer patients and to emergency. The personnel is being shortened to the minimum necessary to deliver the basic services, and, while intensive care units and medical wards are saturated, the current appearance of surgical wards is appalling.
Notwithstanding the effort put in treating as many cancer patients as possible, the timeliness of cures is inevitably delayed, and the outcomes of treatment might well be affected in the long-term. At the same time, screening is not being offered consistently. A delayed diagnosis is associated with worse outcome in cancer surgery. Sanjeevi et al. showed that potentially curable pancreatic cancers had 0% unresectability rate at surgery when the interval between imaging and resection was shorter than 23 days, highlighting the importance of acting within a window of opportunity to achieve optimal survival results. An analysis of a US National Cancer database with over 60 thousands patients with curable colon cancer, found that overall survival was longer in patients operated on within 16 days from diagnosis compared with those operated on after 37 days or more (5-year survival 75.4 vs 71.9%, 10-year survival 56.6 vs 49.7%, both p<0.001). Moreover, the long-term effects and associated indirect costs of cancer surgery include the assessment of lost work-hours due to sick leave after surgery. Postoperative recovery after colorectal cancer surgery might be slower than thought, and advanced disease further impair return to work, suggesting that delaying diagnosis and surgery impacts the economy further.
Many chronic conditions are likely to be affected by delayed treatment. Patients waiting for transplantation are another facet to consider. Discussions are ongoing globally in order to face these difficult situations, and how to deal with the current status of things still remains to be clarified.
Patients, family, and COVID-19
During crisis, priorities are being reorganized, meaning that priority is given to patients with more worrisome conditions or those more likely to benefit from a treatment. However, this generates a stressful environment and brings about nonnegligible consequences to individuals’ wellbeing. Surgical patients with conditions that are not being regarded as priority may feel let down by the doctors and the health system, and they need appropriate support to face this new condition, and their families to be cared for, and this will be much more relevant once the current acme of the outbreak has settled. Many societies and patients’ associations have made available for patients’ guidance and suggestions to help them during these difficult times.
Moreover, family visits to patients who are currently being hospitalized are being strictly controlled, so that the postoperative recovery or the in-hospital stay in general are made even more challenging by an overwhelming sense of loneliness.
Emergencies can bring to light the worst aspects of humanity, but they can also strengthen the spirit of collaboration against a common issue. Even if many have been forced in isolation or quarantined, even if travel is forbidden from and to several countries, social media proved again to be a powerful means to disseminate knowledge, to facilitate discussions, and to establish collaborative initiatives on a global scale.
The response to the fears of doctors and patients on how to deal with COVID-19 and how to act during the outbreak has been immediate, and several scientific societies have provided documents and platforms to be used as guidance. The Spanish Association of Surgeons (Asociación Española de Cirujanos, AEC) released on the 15th March a Position Statement that can be freely accessed on the measures to be taken for patients needing surgery during the pandemic, and a similar initiative has been announced by the Spanish Association of Coloproctology (Asociación Española de Coloproctología, AECP), with specific focus on patients needing surgery for colorectal conditions. These documents are being developed with an innovative format, meaning that they are solidly grounded on available evidence but they are dynamic, open to updating that can occur within hours.
This is relevant at a time when no agreed policy has been decided to face the COVID-19 pandemic. As of today, not all nations have decided to adopt the same stringent measures acting in Italy and Spain, and likely to be extended to France and other countries. For example, UK has announced a different strategy, relying on the development of an immunity against COVID-19, with no need for restrictive measures. Indeed, this was not agreed by the entire scientific community, and hundreds of UK scientists signed an open letter pressing the Government to enforce social distancing. It is difficult to identify which strategy is the more appropriate, but a common effort towards an agreed strategy is desirable in the following months.
A joint GI Society Message on COVID-19 was released on the 16th March by the American Gastroenterology Association, the American Association for Liver Disease, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy. The document deals with recommendations to provide care, including endoscopy, to patients with gastrointestinal conditions during the pandemic.
An initiative that rapidly captured the attention of the surgical community globally was the launch of an international prospective registry of patients operated on for whichever condition while positive for COVID-19. The initiative was launched by Aneel Bhangu on the 14th March on Twitter and is open for registration. A draft protocol is available to access and registration can be performed at this link.
These initiatives will hopefully help to clarify the actual impact of COVID-19 on surgical patients, and help to define the ideal pathways and perioperative management of these patients.
Impact on psychical well-being of healthcare professionals: who cares for the carers?
Last but not least, healthcare professionals are being exposed on the frontline. They are working in extremely difficult conditions, far different from what most of them were trained to work. The intensely stressful conditions in which doctors, surgeons and all healthcare professionals are called to work, is exposing them and their families to unpredictable consequences.
Not being able to treat everyone, the need to do extra shifts, wearing protective equipment during the entire shifts as well as the lack of protective devices, the fear of getting infected, all contribute to a potential burnout.
Doctors are choosing to isolate themselves from their relatives, in order to protect them, even if asymptomatic. The fear of being tested positive, apart from the fact that being affected already implies, brings about the necessity of being quarantined, and further reduces the number of available team members. This is further aggravated by the required quarantine for those colleagues who were in contact with the index healthcare professional tested positive.
Indeed, many institutions and entities are providing help to doctors struggling with the current crisis. The Physician Council of Barcelona (Colegio de Medicos de Barcelona, COMB), for example, established a telephone-based service to support doctors who are experiencing psychological stress and difficulties while in isolation, and a similar service was offered to struggling doctors at local hospitals (e.g. Hospital Vall d’Hebron in Barcelona). Similar initiatives are needed, and must not be limited to the emergency only, but should last long after this has been controlled.
Things are changing rapidly with COVID-19. A financial crisis is likely to occur, that will require to be faced jointly when the emergency has been resolved. It is however needed to maintain our focus on what we are doing every day with every single patient, and those of us who are isolated need not to forget that this is part of caring for the others. Doctors, surgeons, nurses, all the healthcare professionals need to feel backed by the institutions and by the people. In Italy and Spain, people under lockdown have started clapping their hands as a tribute to healthcare professionals. During such difficult times, similar spontaneous acts are fuel for our practice and help us to cope with the burden and the negativity that COVID-19 has spread, while scanning the horizon in search of the end of the current crisis.
Gianluca Pellino (@GianlucaPellino) and Antonino Spinelli (@AntoninoSpin) are surgeons from Italy.
A young surgeon’s experience as a patient with bowel cancer
If you ask any clinician, becoming a patient is an unusual experience. When you couple that with the naivety of youth, embracing the role of a patient is particularly challenging.
“We are taught that we when we hear hoof beats, we should think horses, not zebras.”
As part of surgical training, and even in medical school, there are specific red flags that are taught to all of us. ‘Bowel habit change’ and ‘per rectal bleeding’ are not a great combination. We are also taught that we when we hear hoof beats, we should think horses, not zebras. So when I developed these symptoms I just assumed that I probably had a benign cause of bleeding. I assumed this for six weeks while I worked in a high volume liver and kidney transplant unit until I decided it was bothersome. I picked up the phone to one of my mentors, a colorectal surgeon. She subsequently performed my low anterior resection.
My story is different. I class myself as one of the lucky ones. I was aged 33, with no significant family history, only stage 3. I underwent a low anterior resection, fertility treatment and then 6 months of adjuvant FOLFOX. FOLFOX was not very kind. I didn’t require neoadjuvant radiotherapy, had clear margins and only 2 positive nodes. It is amazing how different your perspective is after such an unexpected life interruption. My life changed completely in one single moment.
From the beginning I called myself a lucky unlucky person. I had encountered young people with colorectal cancer in my surgical training, however, in clinics with 30-50 people being followed up in our public health system, it was still a rarity. When I was diagnosed in 2018 I only really began to appreciate the growing trend of young people being diagnosed with colorectal cancer. People that are not considered at risk. People under the age of 50. Where screening programs exist, all of these people would be too young to be screened. The age for screening in the United States has recently been lowered. It is still not practical for many reasons to extend population based screening to include those who are even younger. While the figures are alarming us all and steadily climbing, they still don’t meet criteria to support population based screening.
“Becoming a patient reveals so much more about patient care and management.”
What is practical and even more alarming is these people’s stories. Bowel Cancer Australia and Bowel Cancer UK frequently highlight individuals who I never thought I would relate to. I am one of many in a long list of patients who are only too happy to tell their story in hope that someone might not have to go through and live with the effects of cancer. Becoming a patient reveals so much more about patient care and management. The anxiety relating to waiting, having scans, and to having your first operation as such a major one. The knowing too much, from the very beginning. After I was told that my surgeon found a cancer, I know I asked where it was. I meant anatomically. I asked this as I knew what the next investigations would be and what treatment (if I wasn’t metastatic) was being considered. It’s not a normal opening question from any other patient.
It is really encouraging to see increasing attention being paid by researchers and surgical journal editors to the rising rate of colorectal cancer in young people, because it means that the message is being delivered regarding the need to investigate symptomatic people. This is separate to any screening argument. I have been part of the #Never2Young campaign and consider myself obliged to advocate for such awareness campaigns not only as a health professional, but as a colorectal cancer patient. I have become a statistic. I am one of those people diagnosed with a left sided colorectal cancer in the age group 20-49.
Publishing real data and real stories and disseminating them will reach our communities and our clinicians working on the front line, trying to sort through who to investigate further or not. The message is becoming clearer for them now. Symptomatic people need investigating. I have seen firsthand only too many young people who have dismissed their own symptoms or had them dismissed by all levels of care. There are barriers to appropriate investigation with colonoscopy for many reasons. We need to make sure patients are better supported.
“Cancer does not discriminate.“
I have completed treatment. I have had highs and lows within my surveillance already. I am lucky enough to have returned to work finishing my time in general surgical training. Navigating through life post treatment has days of uncertainty and sadness. I never stay sad too long. I constantly get reminders of just how lucky I am to still have this life that could have so easily been taken from me.
Cancer does not discriminate. It will choose anyone at any time. Anyone with symptoms needs to be investigated, as sometimes those hoof beats are actually zebras.
Katherine Goodall is a general surgical registrar from Queensland Australia
Randomized controlled trial of plain English and visual abstracts for disseminating surgical research via social media
BJS started with the aim of of being a medium through which surgeons “can make our voice intelligibly heard”, according to Sir Rickman Godlee, President of the Royal College of Surgeons of England in 1913.
The aim of a recently published paper in BJS was to increase the engagement (defined compositely as the total number of replies, retweets, or likes on Twitter) of clinicians and patients in the communication of surgical research – part of the core values of BJS.
Ibrahim et al. showed in the Annals of Surgery that visual abstracts increased engagement on Twitter in their case-control study, but plain English summaries have not previously been studied in the context of surgical research. Plain English summaries are becoming a real priority for funders (e.g. NIHR), as well as for clinical practice (BMJ, AoMRC). Patients are involved in the development of research, and need to have access to it.
This was a three-arm, randomized controlled trial with crossover of two intervention arms. Manuscripts that were eligible for inclusion were randomly allocated to three arms and disseminated via Twitter. The arms were standard tweets, plain English abstracts & visual abstracts.
Visual abstracts are a simplified graphical summary of a study’s scientific abstract. Plain English abstracts were developed according to NIHR INVOLVE ‘make it clear’ guidance and edited to satisfy a minimum readability index.
The primary outcome was online engagement by the public within 14 days of dissemination. The secondary outcome was online engagement by healthcare professionals.
The results can be seen in the visual abstract, with more details available in the paper. Overall: visual abstracts attracted a greater number of total engagements than plain English abstracts, and engagement by members of the public was low across all abstract types.
Note that this study only looked for the potential benefits from the point of view of the journal – not data from the perspective of patients, although a Twitter poll suggested that there was an appetite for informing the public about the findings of research studies.
More work needs to be done in collaboration with the public to understand how and in what format they prefer to engage with surgical research. We need to avoid soundbites of results, and instead provide a balanced & educated interpretation, to help to counter the avalanche of false information to which the public is exposed.