The science of COVID-19

COVID-19 and surgery

Contributed by:
Dr. Navindranauth Rambaran, FCCS
DMT, MBBS, PGDip. Surgery (UG)
Trauma Surgery (u Ottawa)
Head Dept. General Surgery, GPHC
Associate Professor in Surgery
Chairman of the Medical Council of Guyana

Dr. Navindranauth Rambaran
Article submitted as part of the Ministry of Health’s COVID-19 public information and education programme
Severe acute respiratory syndrome Corona virus-type 2 (SARS Co-V-2), which causes the COVID-19 infection, was first documented in Wuhan Hubei Province, China after a number of cases of pneumonia of unknown origin occurred in late 2019.
A pandemic was subsequently declared by the World Health Organization (WHO) on March 11, 2020. The virus continued to spread rapidly throughout the world and, to date (November 12, at the time of writing), has infected 49.7 million and resulted in 1.2 million deaths globally.
No region or country has been spared, though infection and mortality rates vary among countries. Some countries, including New Zealand and Australia, have been successful in keeping rates of infection down, while America and parts of Europe, including Britain, have experienced significantly higher rates of infection and mortality.
The Caribbean picture has shown a mixed pattern, with many smaller territories, such as Barbados and St. Vincent and the Grenadines, being able to contain the disease relatively early in the pandemic, while others with larger populations, such as Trinidad and Tobago, Guyana and Jamaica, have experienced rising infection rates over several months.

Surgical services
The pandemic has impacted surgical services in several profound ways.
Importantly it has resulted in significant deployment of surgical resources to treat COVID-19 patients, and has increased the demand for other critical resources, including ventilators and blood components.
Together, with the increased risk of transmission to both patients and surgical staff within surgical institutions, the pandemic has resulted in:

• Reduced surgical staff to care for patients with surgical issues
• Reduced surgical bed space
• Shortage of blood components
• Increased surgical operative complications among COVID-19 patients
• Transmission of the disease to surgical staff
• A suspension of non-urgent surgeries

Classification of patients
Patients who need surgical services can be broadly categorised into two areas. First, there are electives; that is, those whose conditions require surgery for improved functioning and quality of life, but which are non life-threatening.
This category includes appearance augmentation surgeries. Thus, there is no danger when such surgeries are done on a schedule of over weeks to several months.
On the other hand, the second category, which is the emergent type of surgical conditions, does require urgent surgical intervention to prevent deterioration of health and, in many cases, to prevent death (reduce mortality).
This category includes patients with cancers, life-threatening infections and injuries.
Risks and non-operative management
Evidence has emerged which shows patients who undergo surgery and contract COVID-19, in some cases from -7 to +30 days of surgery, have increased respiratory complications and worse surgical outcomes than those who are uninfected.
Due to this risk, many surgeons have opted to operate on COVID-19 infected patients only if safe non-surgical options are unavailable.
During this period, surgeons carefully select patients for non-surgical management, including those with uncomplicated appendicitis, cholecystitis and diverticulitis. Of course, failure of conservative management would result in the surgical operation being conducted.
Suffice it to say that many COVID-19 patients who required emergency life-saving operations during the pandemic have been successfully operated on, while guarding against the potential for bad outcomes.

Risks to surgical staff
Due to the potential for increased aerosolisation of viral particles during operative procedures, there is a significantly higher risk of transmission to surgical staff when performing surgery on patients with COVID-19.
These risks can, however, be mitigated by improved safety protocols that have evolved during the pandemic.
These include the use special personal protective equipment (PPEs) by surgical staff, such as impervious surgical suits and goggles, and the refitting of operating rooms with air filters and new dynamic airflow systems.

Outpatient surgical services
New strategies have been utilised in the organization of surgical outpatient services to reduce the need for patients to visit surgical clinics, thereby decreasing the risk of COVID-19 transmission among patients and staff.
These new strategies to treat and follow up patients include:

• Telemedicine
• Virtual Clinics
• Telephone follow ups
• Call-in inquiry services for patients
A smaller number of patients with special needs or with deterioration of their surgical conditions are still required to visit the clinics in person.

Backlog of surgeries
The cancellation of routine/elective surgeries for the reasons already cited has resulted in an increased backlog of cases.
Since there is the risk of deterioration of surgical conditions, as the wait time for surgery increases, patients need to be re-assessed and other solutions sought, even as the pandemic persists.
One solution being looked at is the phased restart of certain types of non-urgent surgeries over the next several weeks and months. This process will prioritise patients based on the seriousness of their condition and also prioritise those surgeries that can be done in an ambulatory fashion, that is, surgeries which can be done as same-day admission and discharge.
This approach to restarting routine surgery keeps in mind the possibility of a resurgence in COVID-19 infection rates during the roll out, hence making any necessary scaling back less complicated.

Need for increased resources
Surgical facilities must now adopt new recommendations and emerging benchmark safety measures when conducting surgeries in the future.
These changes will likely result in an overall increase in the cost for surgical services that must be met by institutions, government and patients alike.

These changes include:
• New and more efficient surgical pathways for scheduling and conducting surgeries (same-day surgery being one key example)
• Perioperative screening and COVID-19 testing
• Purchase of special PPEs for surgical staff
• Redesign of surgical facilities and operating rooms

Minimally invasive surgeries
Before COVID-19, minimally-invasive procedures were on the increase and, in most modern surgical institutions, were the standard for many types of surgeries.
Laparoscopic cholecystectomy, appendectomy and colectomy are some examples of such surgeries. These surgeries were temporarily on hold in many institutions due to the perceived risk of increased aerosolisation of the virus during these procedures.
However, evidence-based reports which have now emerged suggest that surgical facilities can safely restart laparoscopic, endoscopic and other minimally invasive procedures by making simple adjustments to reduce the aerosolisation risks.

Second wave of COVID-19
From a surgical perspective, a return to full surgical operational capabilities is desired. While this author looks forward to a roll out of routine surgeries in the near future, the possibility of a second wave of COVID-19 infection must be kept in mind, and guarded against by all stakeholders.
Throughout the COVID-19 pandemic, and in this critical phase as we fight to further lower infection rates, surgical facilities through their staff will continue to do life-saving surgeries and offer other important surgical services, while at the same time planning for the next phase of routine surgical operations.