Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study

COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis

INTRODUCTION

To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery.

METHODS

PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19.

RESULTS

Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09).

CONCLUSIONS

Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

Asymptomatic viruses detectable in saliva in the first year of life: a narrative review

Viral infections are common in children. Many can be asymptomatic or have delayed health consequences. In view of increasing availability of point-of-care viral detection technologies, with possible application in newborn screening, this review aimed to (1) identify potentially asymptomatic viruses detectable in infants under one year old, via saliva/nasopharyngeal swab, and (2) describe associations between viruses and long-term health conditions. We systematically searched Embase(Ovid), Medline(Ovid) and PubMed, then further searched the literature in a tiered approach. From the 143 articles included, 28 potentially asymptomatic viruses were identified. Our second search revealed associations with a range of delayed health conditions, with most related to the severity of initial symptoms. Many respiratory viruses were linked with development of recurrent wheeze or asthma. Of note, some potentially asymptomatic viruses are linked with later non-communicable diseases: adenovirus serotype 36 and obesity, Enterovirus-A71 associated Hand, Foot, Mouth Disease and Attention-Deficit Hyperactivity Disorder, Ebstein Barr Virus (EBV) and malignancy, EBV and multiple sclerosis, HHV-6 and epilepsy, HBoV-1 and lung fibrosis and Norovirus and functional gastrointestinal disorders. Our review identified many potentially asymptomatic viruses, detectable in early life with potential delayed health consequences, that could be important to screen for in the future using rapid point-of-care viral detection methods. IMPACT: Novel point-of-care viral detection technologies enable rapid detection of viruses, both old and emerging. In view of increasing capability to screen for viruses, this is the first review to explore which potentially asymptomatic viruses, that are detectable using saliva and/or nasopharyngeal swabs in infants less than one year of age, are associated with delayed adverse health conditions. Further research into detecting such viruses in early life and their delayed health outcomes may pave new ways to prevent non-communicable diseases in the future.

UK Healthcare Workers' Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

METHODS

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.

RESULTS

Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.

CONCLUSION

Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.

Outcomes of patients undergoing elective liver and pancreas cancer surgery during the SARS-CoV-2 pandemic: an international, multicentre, prospective cohort study

BACKGROUND

The effect of SARS-CoV-2 infection upon HPB cancer surgery perioperative outcomes is unclear. Establishing risk is key to individualising treatment pathways. We aimed to identify the mortality rate and complications risk for HPB cancer elective surgery during the pandemic.

METHODS

International, prospective, multicentre study of consecutive adult patients undergoing elective HPB cancer operations during the initial SARS-CoV-2 pandemic. Primary outcome was 30-day perioperative mortality. Secondary outcomes included major and surgery-specific 30-day complications. Multilevel cox proportional hazards and logistic regression models estimated association of SARS-CoV-2 and postoperative outcomes.

RESULTS

Among 2038 patients (259 hospitals, 49 countries; liver n = 1080; pancreas n = 958) some 6.2%, n = 127, contracted perioperative SARS-CoV-2. Perioperative mortality (9.4%, 12/127 vs 2.6%, 49/1911) and major complications (29.1%, 37/127 vs 13.2%, 253/1911) were higher with SARS-CoV-2 infection, persisting when age, sex and comorbidity were accounted for (HR survival 4.15, 95% CI 1.64 to 10.49; OR major complications 3.41, 95% CI 1.72 to 6.75). SARS-CoV-2 was associated with late postoperative bleeding (11.0% vs 4.2%) and grade B/C postoperative pancreatic fistula (17.9% vs 8.6%).

CONCLUSION

SARS-CoV-2 infection was associated with significantly higher perioperative morbidity and mortality. Patients without SARS-CoV-2 had acceptable morbidity and mortality rates, highlighting the need to protect patients to enable safe ongoing surgery.

Outcomes of elective cancer surgery in COVID‐19 survivors: An observational study

Background and Objectives

Guidelines recommend deferral of elective surgery after COVID‐19. Delays in cancer surgeries may affect outcomes. We examined perioperative outcomes of elective cancer surgery in COVID‐19 survivors. The primary objective was 30‐day all‐cause postoperative mortality. The secondary objectives were 30‐day morbidity, and its association with COVID‐19 severity, and duration between COVID‐19 and surgery.

Methods

We collected data on age, gender, comorbidities, COVID‐19 severity, preoperative investigations, surgery performed, and intra and postoperative outcomes in COVID‐19 survivors who underwent elective cancer surgery at a tertiary‐referral cancer center.

Results

Three hundred and forty‐eight COVID‐19 survivors presented for elective cancer surgery. Of these, 332/348 (95%) patients had mild COVID‐19 and 311 (89%) patients underwent surgery. Among patients with repeat investigations, computerized tomography scan of the thorax showed the maximum new abnormalities (30/157, 19%). The 30‐day all‐cause mortality was 0.03% (1/311) and 30‐day morbidity was 17% (54/311). On multivariable analysis, moderate versus mild COVID‐19 (odds ratio [OR]: 1.95; 95% confidence interval  [CI]: 0.52–7.30; p = 0.32) and surgery within 7 weeks of COVID‐19 (OR: 0.61; 95% CI: 0.33–1.11; p = 0.10) were not associated with postoperative morbidity.

Conclusions

In patients who recover from mild to moderate COVID‐19, elective cancer surgery can proceed safely even within 7 weeks. Additional preoperative tests may not be indicated in these patients.

Early Postoperative Complications in Total Hip and Knee Arthroplasty Before and During the COVID-19 Pandemic: A Retrospective Analysis of 38,234 Patients

Background

The outcomes of total joint arthroplasty during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We sought to compare early postoperative complications in total hip arthroplasty (THA) and total knee arthroplasty (TKA) prior to and during the COVID-19 pandemic.

Methods

Patients in the American College of Surgeons National Surgical Quality Improvement Program database who had THA or TKA in the latter halves (July to December) of 2019 and 2020 were identified. Patients were divided into pre-COVID-19 (2019) and during-COVID-19 (2020) cohorts. Propensity score matching and logistic regression were used to detect correlations between operative period and outcomes. Statistical significance was set at α = 0.05.

Results

A total of 38,234 THA and 61,956 TKA patients were included. There was a significantly higher rate of outpatient procedures in 2020 than that in 2019 for both THA (41.68% vs 6.59%, P < .001) and TKA (41.68% vs 7.56%, P < .001). On matched analysis, surgery in 2020 had lower odds of hospital stay for >1 day (THA: odds ratio [OR] 0.889; P < .001) (TKA: OR 0.644; P < .001) and nonhome discharge (THA: 0.655; P < .001) (TKA: 0.497; P < .001). There was also increased odds of superficial surgical site infection in THA (OR 1.272; P = .040) and myocardial infarction in TKA patients (OR 1.488; P = .042) in 2020 compared to those in 2019. There was no difference in the 15 other outcomes assessed.

Conclusions

Total joint arthroplasty surgery remains safe despite the COVID-19 pandemic. A statistically significant increase was detected in superficial surgical site infection and myocardial infarction risk during 2020 compared to 2019; however, the clinical significance of this is questionable. A shift away from inpatient stay was also present, possibly reflecting efforts to minimize nosocomial exposure to COVID-19.

Safe Surgery During the COVID-19 Pandemic

PURPOSE OF REVIEW

Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future.

RECENT FINDINGS

Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

The Efficacy of Pre-Operative Self-Isolation Guidelines for Safe Elective Orthopaedic Surgeries: A Prospective Pilot Study

Objectives

This study aimed to determine the efficacy of the self-isolation guidance for elective orthopaedic surgery. We aimed to evaluate the relationship between patient compliance with the self-isolation guidance and the resulting COVID-19 status. This would give planning strategies for managing elective orthopaedic lists.

Method

For the study, 110 patients who underwent elective orthopaedic surgical procedures during a one-month period were identified. Patients scheduled for surgery were asked to take a SARS-CoV-2 PCR test three days prior to surgery and they were asked to follow the self-isolation guidance. On the day of admission, patients declared compliance with self-isolation regulations. Admission was refused in cases of non-compliance. After discharge, telephone calls were made to patients to determine the degree of compliance with the self-isolation guidance.

Results

Overall, 106 out of 107 patients that were compliant with the self-isolation guidance tested negative for COVID-19; 15 patients had their operation cancelled over the one-month period; of which one-third were cancelled by the patients themselves. Three patients were found to be non-compliant with the self-isolation guidance. Of these three non-compliant patients, one tested positive for COVID-19. Adherence to the self-isolation guidelines helped to prevent last-minute cancellations and manage the list effectively.

Conclusions

Compliance with our self-isolation guidance accompanied by PCR screening minimises the risk of testing positive for COVID-19 and is thus an effective system to safely perform elective orthopaedic surgery. Intentionally overbooking theatre lists by 10 to 12.5% may account for cancellations and improve theatre efficiencies during post-pandemic recovery plans for elective orthopaedic surgeries.

Estratégias organizacionais no centro cirúrgico diante da pandemia de COVID 19: uma revisão integrativa

Introdução: os sistemas de saúde foram desafiados a desenvolver estratégias organizacionais para a prestação de cuidados cirúrgicos. Objetivo: apresentar as estratégias dos serviços de saúde no que se refere às práticas de cuidados cirúrgicos em tempos de pandemia de COVID-19. Materiais e métodos: revisão integrativa, desenvolvida em seis etapas, cuja busca dos artigos ocorreu na Biblioteca Virtual de Saúde, SciELO, PubMed e ScienceDirect. Os descritores controlados em saúde adotados foram “Centros Cirúrgicos” e “Infecções por Coronavírus”, de acordo com os sistemas DeCS e MeSH Terms. Foram selecionados 60 artigos de 405 estudos encontrados. Resultados: as principais estratégias utilizadas pelos serviços de saúde foram: a suspensão e adiamento de cirurgias eletivas durante as ondas de contágio da doença; e a triagem cuidadosa dos pacientes para COVID-19 antes e após intervenções cirúrgicas. Discussão: a suspensão e o adiamento de cirurgias eletivas devem ser avaliados com cautela pela equipe de saúde, de forma individualizada, para cada paciente, visto que situações clínicas não urgentes podem agravar ao longo do tempo, aumentando as chances de morbimortalidade desses pacientes. Conclusão: a triagem dos pacientes e dos profissionais da saúde para COVID-19 são estratégias importantes para evitar a contaminação desses sujeitos. A suspensão e o adiamento de cirurgias eletivas, durante as ondas de contágio por COVID-19, são recomendados para aumentar a capacidade de leitos disponíveis para pacientes graves hospitalizados por essa doença. Essa recomendação também auxilia no remanejamento de profissionais desse setor para as unidades com a demanda de cuidados de saúde mais elevada.

Consent for orthopaedic trauma surgery during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has brought a series of new challenges to the management of surgical patients. The consent process relies on a foundation of open and non-coerced discussion between clinician and patient, which includes all the potential risks of surgery. This must be updated to incorporate the additional risks of surgery during the pandemic including infection with the SARS-CoV-2 and increased risks of complications with the potential requirement for intensive care support.

Aim

The aim of this multi-cycle quality improvement project was to ensure all patients were fully informed of the risks of developing COVID-19 and the possible need for intensive care unit (ICU) support.

Methods

We investigated the quality of the consent process for patients undergoing surgery for trauma at our major trauma centre. Our baseline data collection included a review of all orthopaedic trauma consent forms over a 4-week period in March 2020. We subsequently undertook three further Plan-Do-Study-Act (PDSA) cycles over separate 4-week periods. First, in June 2020, after education measures and presentation of baseline data, second in July 2020 after further education and regular digital reminders were sent to staff, and third in September 2021 after the implementation of an electronic consent form.

Results

At baseline, only 2.6% of consent forms mentioned the risk of COVID-19 and none mentioned the risk of requiring ITU support. Through three PDSA cycles this increased to 97% of cases where consent forms displayed the additional risks of COVID-19 and the potential need for ITU admission.

Conclusion

Our quality improvement project improved the informed consent procedure at our trust. By incorporating these additional risks into the template of an electronic consent form, we hope to achieve sustained improvement in practice.

Effects of vaccination status in the United States on willingness to undergo surgery during a pandemic: A prospective survey study

PURPOSE OF THE RESEARCH

Modifiable and non-modifiable patient and hospital characteristics may affect willingness to undergo surgery during a pandemic. We hypothesized that vaccination of hospital staff and patients, type of surgery, and length of stay, would affect willingness to undergo a surgical procedure. 2006 adult participants in the United States were recruited electronically using Amazon's ® Mechanical Turk ® and answered a 26-item survey in English about hypothetical surgery, manipulating requirements for: staff vaccination, patient vaccination, surgical urgency, and time in hospital. They also answered questions about their opinions about vaccination, personal vaccination status, and demographics.

PRINCIPLE RESULTS

Participants are more willing to undergo surgery if they have been vaccinated, if staff vaccinations are required, and if surgery is lifesaving and outpatient.

MAJOR CONCLUSIONS

Willingness to undergo surgery varies with hospital staff and patient vaccination. This may inform policies for vaccination, boosters, and resource allocation.

Changes in Surgical Volume and Outcomes During the Coronavirus Disease 2019 Pandemic at Two Tertiary Hospitals in Ethiopia: A Retrospective Cohort Study

BACKGROUND

Limited data exist concerning how the coronavirus disease 2019 (COVID-19) pandemic has affected surgical care in low-resource settings. We sought to describe associations between the COVID-19 pandemic and surgical care and outcomes at 2 tertiary hospitals in Ethiopia.

METHODS

We conducted a retrospective observational cohort study analyzing perioperative data collected electronically from Ayder Comprehensive Specialized Hospital (ACSH) in Mekelle, Ethiopia, and Tibebe Ghion Specialized Hospital (TGSH) in Bahir Dar, Ethiopia. We categorized COVID-19 exposure as time periods: "phase 0" before the pandemic (November 1-December 31, 2019, at ACSH and August 1-September 30, 2019, at TGSH), "phase 1" starting when elective surgeries were canceled (April 1-August 3, 2020, at ACSH and March 28-April 12, 2020, at TGSH), and "phase 2" starting when elective surgeries resumed (August 4-August 31, 2020, at ACSH and April 13-August 31, 2020, at TGSH). Outcomes included 28-day perioperative mortality, case volume, and patient district of origin. Incidence rates of case volume and patient district of origin (outside district yes or no) were modeled with segmented Poisson regression and logistic regression, respectively. Association of the exposure with 28-day mortality was assessed using logistic regression models, adjusting for confounders.

RESULTS

Data from 3231 surgeries were captured. There was a decrease in case volume compared to phase 0, with adjusted incidence rate ratio (IRR) of 0.73 (95% confidence interval [CI], 0.66-0.81) in phase 1 and 0.90 (95% CI, 0.83-0.97) in phase 2. Compared to phase 0, there were more patients from an outside district during phase 1 lockdown at ACSH (adjusted odds ratio [aOR], 1.63 [95% CI, 1.24-2.15]) and fewer patients from outside districts at TGSH (aOR, 0.44 [95% CI, 0.21-0.87]). The observed 28-day mortality rates for phases 0, 1, and 2 were 1.8% (95% CI, 1.1-2.8), 3.7% (95% CI, 2.3-5.8), and 2.9% (95% CI, 2.1-3.9), respectively. A confounder-adjusted logistic regression model did not show a significant increase in 28-day perioperative mortality during phases 1 and 2 compared to phase 0, with aOR 1.36 (95% CI, 0.62-2.98) and 1.54 (95% CI, 0.80-2.95), respectively.

CONCLUSIONS

Analysis at 2 low-resource referral hospitals in Ethiopia during the COVID-19 pandemic showed a reduction in surgical case volume during and after lockdown. At ACSH, more patients were from outside districts during lockdown where the opposite was true at TGSH. These findings suggest that during the pandemic patients may experience delays in seeking or obtaining surgical care. However, for patients who underwent surgery, prepandemic and postpandemic perioperative mortalities did not show significant difference. These results may inform surgical plans during future public health crises.

Has the COVID-19 Pandemic Affected Breast Cancer Stage and Surgical Volume?

Background

This study investigates the effects of COVID-19 on the breast cancer stage and the volume of breast cancer surgery in a specialized breast institute.

Methods

Data of 332 patients who were diagnosed and treated for breast cancer between December 2019 and November 2020 were evaluated retrospectively according to periods of pandemic.

Results

A significant decrease in the number of operations, especially upfront surgeries rather than surgeries after neoadjuvant chemotherapy, was detected in the early period of the COVID-19 pandemic. It was found that patients with complaints were mostly admitted during this period (p = 0.024). No statistical significance was found for age, sex, side of the tumor, type of tumor, surgery to breast, and axilla. Following the early period of the pandemic, it was observed that patients with mostly luminal, early-stage, and less axillary nodal involvement (p < 0.05) were admitted, and as a result, it was founded that upfront surgeries increased, although no change in TNM staging was observed. However, it did affect the decision of initial treatment. Thus, the number of upfront surgeries was significantly higher than the NCT group (p = 0.027) following the early period.

Conclusion

Surgical volume is significantly affected in the early period of the COVID-19 pandemic. To overcome overload due to delayed surgeries related to pandemics, some hospitals should be spared for oncological treatments. Following the early period, mostly luminal type, early-stage patients were admitted, probably because of increased self-awareness and short wave duration, but the breast cancer stage was not affected.

Risk and Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Infection on Corneal Transplantation: A Case-Control Study

PURPOSE

The purpose of this study was to evaluate the risk of symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection after corneal transplantation surgery, with cataract surgeries as controls, and the impact of the novel coronavirus disease pandemic in the clinical and surgical complications of corneal transplantation and cataract surgeries.

METHODS

A retrospective matched case-control study of 480 consecutive individuals who underwent surgery at the Bascom Palmer Eye Institute between May 2020 and November 2020. A total of 240 patients who underwent corneal transplantation with tissue obtained from the Florida Lions Eye Bank were age, race, ethnicity, and sex matched with 240 patients who underwent cataract surgery during the same day and by the same surgical team. Only the first corneal transplant or cataract surgery during this period was considered for each individual. All donors and recipients were deemed SARS-CoV-2 negative by a nasopharyngeal polymerase chain reaction test before surgery. Postoperative SARS-CoV-2 infections were defined as previously SARS-CoV-2(-) individuals who developed symptoms or had a positive SARS-CoV-2 polymerase chain reaction test during the first postoperative month.

RESULTS

Mean age, sex, race, and ethnicity were similar between groups. There were no differences between the corneal transplant and cataract groups in the rates of SARS-CoV-2 infection before (5.8% vs. 7.5%, P= 0.6) or after surgery (2.9% vs. 2.9%, P = 1). The rates of postoperative complications did not increase during the pandemic, compared with previously reported ranges.

CONCLUSIONS

In this study, postoperative SARS-CoV-2 infection was similar for individuals undergoing corneal transplantation or cataract surgery. Further research is required to evaluate the transmission of SARS-CoV-2 through corneal tissue.

Impact of the SARS-CoV-2 (COVID19) pandemic on the morbidity and mortality of high risk patients undergoing surgery: a non-inferiority retrospective observational study

Background

During the COVID-19 crisis it was necessary to generate a specific care network and reconvert operating rooms to attend emergency and high-acuity patients undergoing complex surgery. The aim of this study is to classify postoperative complications and mortality and to assess the impact that the COVID-19 pandemic may have had on the results.

Methods

this is a non-inferiority retrospective observational study. Two different groups of surgical patients were created: Pre-pandemic COVID and Pandemic COVID. Severity of illness was rated according to the Diagnosis-related Groups (DRG) score. Comparisons were made between groups and between DRG severity score-matched samples. Non-inferiority was set at up to 10 % difference for grade III to V complications according to the Clavien-Dindo classification, and up to 2 % difference in mortality.

Results

A total of 1649 patients in the PreCOVID group and 763 patients in the COVID group were analysed; 371 patients were matched for DRG severity score 3-4 (236 preCOVID and 135 COVID). No differences were found in relation to re-operation (22.5 % vs. 21.5 %) or late admission to critical care unit (5.1 % vs. 4.5 %). Clavien grade III to V complications occurred in 107 patients (45.3 %) in the PreCOVID group and in 56 patients (41.5 %) in the COVID group, and mortality was 12.7 % and 12.6 %, respectively. During the pandemic, 3 % of patients tested positive for Covid-19 on PCR: 12 patients undergoing elective surgery and 11 emergency surgery; there were 5 deaths, 3 of which were due to respiratory failure following Covid-19-induced pneumonia.

Conclusions

Although this study has some limitations, it has shown the non-inferiority of surgical outcomes during the COVID pandemic, and indicates that resuming elective surgery is safe.

Trial registration

Clinicaltrials.gov identifier: NCT04780594.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01495-3.

Safety of elective abdominal and vascular surgery during the COVID-19 pandemic: a retrospective single-center study

BACKGROUND

Patients with coronavirus disease 2019 (COVID-19) who undergo surgery have impaired postoperative outcomes and increased mortality. Consequently, elective and semi-urgent operations on the increasing number of patients severely affected by COVID-19 have been indefinitely postponed.in many countries with unclear implications on disease progression and overall survival. The purpose of this study was to evaluate whether the establishment of a standardized screening program for acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sufficient to ensure high-quality medical and surgical treatment of COVID-19 and non-COVID-19 patients while minimizing in-hospital SARS-CoV-2 transmission.

METHODS

The screening program comprised polymerase chain reaction (PCR) testing of nasopharyngeal swabs and a standardized questionnaire about potential symptoms for SARS-CoV-2 infection. All elective and emergency patients admitted to the surgical department of a tertiary-care hospital center in Lower Franconia, Germany, between March and May 2020 were included and their characteristics were recorded.

RESULTS

Out of the study population (n = 657), 509 patients (77.5%) had at least one risk factor for a potentially severe course of COVID-19 and 164 patients (25%) were active smokers. The average 7-day incidence in Lower Franconia was 24.0/100,000 during the observation period. Preoperative PCR testing revealed four asymptomatic positive patients out of the 657 tested patients. No postoperative SARS-CoV-2 infection or transmission could be detected.

CONCLUSION

The implementation of a standardized preoperative screening program to both COVID-19 and non-COVID-19 patients can ensure high-quality surgical care while minimizing infection risk for healthcare workers and potential in-hospital transmission.

Safe Elective Surgical Practice During COVID-19 Pandemic - A Prospective Observational Study of 303 Elective Surgeries in the UK

Aim During the COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial viral transmission and peri-operative complications. With the unfolding situation, there is a definite need for an exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plans for elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during the pandemic. Methodology This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust's COVID-free environment at the Birmingham Treatment Centre between May 19 and July 14, 2020. Data were collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 reverse transcription polymerase chain reaction (RT-PCR) testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during the pandemic. Results A total of 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to the American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. Ninety-six percent (96%) of patients were discharged on the same day. Hundred percent (100%) compliance with pre-operative COVID-19 RT-PCR testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help provide safe elective surgical services if the community transmission is under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures.

Outcomes of preoperative real-time polymerase chain reaction testing for SARS CoV-2 in elective otolaryngology surgical patients during the pandemic: a prospective cohort study

Real-time polymerase chain reaction (RT-PCR) is used to rule out SARS-CoV-2 prior to surgery, however few studies have evaluated patients with negative testing after surgery. Some 499 patients with negative tests were followed for 14 days after surgery, 39 were retested but none developed positive RT-PCR after operation. The risk of developing a positive RT-PCR after surgery was 0.74 per cent.

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening

Background

The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.

Methods

This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/−]) or negative throughout (COVID[−/−]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.

Results

Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[−/−] to be 8.4 (C.I. 4.9–14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.

Discussion

Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.

Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and <1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), <1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

SARS-CoV-2 infection, COVID-19 and timing of elective surgery: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, the Centre for Peri-operative Care, the Federation of Surgical Specialty Associations, the Royal College of Anaesthetists and the Royal College of Surgeons of England

The scale of the COVID‐19 pandemic means that a significant number of patients who have previously been infected with SARS‐CoV‐2 will require surgery. Given the potential for multisystem involvement, timing of surgery needs to be carefully considered to plan for safe surgery. This consensus statement uses evidence from a systematic review and expert opinion to highlight key principles in the timing of surgery. Shared decision‐making regarding timing of surgery after SARS‐CoV‐2 infection must account for severity of the initial infection; ongoing symptoms of COVID‐19; comorbid and functional status; clinical priority and risk of disease progression; and complexity of surgery. For the protection of staff, other patients and the public, planned surgery should not be considered during the period that a patient may be infectious. Precautions should be undertaken to prevent pre‐ and peri‐operative infection, especially in higher risk patients. Elective surgery should not be scheduled within 7 weeks of a diagnosis of SARS‐CoV‐2 infection unless the risks of deferring surgery outweigh the risk of postoperative morbidity or mortality associated with COVID‐19. SARS‐CoV‐2 causes either transient or asymptomatic disease for most patients, who require no additional precautions beyond a 7‐week delay, but those who have persistent symptoms or have been hospitalised require special attention. Patients with persistent symptoms of COVID‐19 are at increased risk of postoperative morbidity and mortality even after 7 weeks. The time before surgery should be used for functional assessment, prehabilitation and multidisciplinary optimisation. Vaccination several weeks before surgery will reduce risk to patients and might lessen the risk of nosocomial SARS‐CoV‐2 infection of other patients and staff. National vaccine committees should consider whether such patients can be prioritised for vaccination. As further data emerge, these recommendations may need to be revised, but the principles presented should be considered to ensure safety of patients, the public and staff.

COVID-19 in Women's health reducing the risk of infection to patients and staff during acute and elective hospital admission for gynaecological surgery

The novel coronavirus SARS-Cov-2 has changed healthcare on a worldwide scale. This highly contagious respiratory virus has overwhelmed healthcare systems. Many staff were redeployed, and there was widespread cessation of non-urgent outpatient clinics and surgery. Outpatient clinics and theatre areas were converted to COVID-19 wards and intensive care units. Following the first peak, services began to recommence with new triaging and prioritisation guidance to safeguard patients and staff. Different countries and healthcare systems produced differing guidance and, in particular, variation in the best approach to continuing acute and elective surgical procedures. This chapter collates and evaluates the increasing international literature concerning the surgical management of gynaecological conditions during the pandemic, such that clear inferences, recommendations and guidance can be generated to aid clinical practice and safeguard against further major disruption arising from further COVID-19 peaks. The available data are assessed within the context of the current phase of the COVID-19 pandemic.