Keywords
COVID-19 - pandemic - elective - emergency - surgery
After the official documentation of cases of pneumonia of unknown etiology on December
31st, 2019 by Wuhan Municipal Health Commission, the offending virus identified was named
as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The World Health Organization (WHO) named this novel disease as coronavirus disease
2019 (COVID-19) on February 11, 2020 and declared it as a pandemic on March 11, 2020,
after the rapid spread of this disease globally.[2] Now more than 200 countries have been affected with its outbreak and it has become
a matter of public health concern as it is a highly contagious disease which spreads
via air droplet during speaking, sneezing, and coughing.[3]
On January 30, 2020 India became a part of this global carnage with the detection
of its first COVID case.[4] To curtail the infection and spread of disease, Government of India (GOI) declared
a nationwide lockdown of 21 days from March 24th, 2020. Since then every patient coming to hospital was being screened for COVID-19
before admission as per the institute's policy. On April 14th, GOI announced the extension
of the nationwide lockdown till May 3rd owing to the rising number of cases in the
country. It was further extended till May 17th (Lockdown 3.0) and subsequently till
May 30th (Lockdown 4.0) while giving successive relaxation.[5]
[6] As the priority of health care has changed to cater only emergency and semi-emergency
conditions, it has also affected the care provided by surgical disciplines. We report
our experience regarding the effect of COVID lockdown on the spectrum of surgical
diseases encountered, their management, clinical outcomes along with an emphasis on
the precautions taken to minimize the spread of infection to health care workers (HCWs).
Material, Method, and Statistical Analysis
Clinical data of all patients admitted in Department of Surgery from March 24th to
May 31st, was extracted from the medical records. Demographic profile of patients,
their diagnosis, management, and outcomes were analyzed by SPSS v.26.0. Length of
the hospital stay, morbidity (according to Modified Clavien-Dindo [CD] Classification),
and mortality were recorded. Descriptive analysis was done by calculating the arithmetic
mean, mode, and percentile.
Results
A total of 77 patients were admitted in the surgery ward out of which 54 were males
and 23 were females. The average age of the patients was 44.37 (SD) years with two
patients of more than 74 years of age. Total number of patients with associated comorbidities
were 29 (37.6%). ([Table 1])
Table 1
Sociodemographic profile of surgical patients
|
Number of patients (%)
|
|
Age groups (years)
|
|
18–59
|
56 (72.7%)
|
|
60–74
|
19 (24.6%)
|
|
> 74
|
2 (2.5%)
|
|
Gender
|
|
Male
|
54 (70.1%)
|
|
Female
|
23 (29.8%)
|
|
Co-morbidities
|
|
Coronary artery disease (CAD)
|
7 (9.1%)
|
|
Hypertension (HTN)
|
7 (9.1%)
|
|
Chronic obstructive pulmonary disease (COPD)
|
3 (3.8%)
|
|
Diabetes mellitus (DM)
|
8 (10.8%)
|
|
DM with HTN
|
4 (5.2%)
|
|
GI malignancies
|
|
Esophagus
|
1 (1.3%)
|
|
Stomach
|
1 (1.3%)
|
|
Duodenum
|
1 (1.3%)
|
|
Colon
|
1 (1.3%)
|
|
Hepatopancreatico-biliary malignancies
|
|
Gall bladder
|
5 (6.5%)
|
|
Cholangiocarcinoma
|
3 (3.8%)
|
|
Periampullary
|
1 (1.3%)
|
|
Head of pancreas
|
2 (2.5%)
|
|
Breast and endocrine
|
|
Breast
|
4 (5.2%)
|
|
Benign diseases
|
|
Hollow viscus perforation with peritonitis
|
14 (18.1%)
|
|
Sub-acute intestinal obstruction
|
5 (6.5%)
|
|
Koch's abdomen
|
1 (1.3%)
|
|
Enterocutaneous fistula
|
1 (1.3%)
|
|
Mesenteric Ischemia
|
1 (1.3%)
|
|
Acute pancreatitis
|
3 (3.8%)
|
|
Liver abscess
|
8 (10.3%)
|
|
Acute cholecystitis
|
2 (2.5%)
|
|
Cholelithiasis with choledocholithiasis
|
4 (5.2%)
|
|
Biliary fistula
|
1 (1.3%)
|
|
Cholangitic abscess
|
1 (1.3%)
|
|
Acute appendicitis
|
1 (1.3%)
|
|
Foreign body ingestion
|
1 (1.3%)
|
|
Incisional hernia
|
2 (2.5%)
|
|
NSTI
|
4 (5.2%)
|
|
Surgical site infection (SSI)
|
2 (2.5%)
|
|
Peripheral vascular disease
|
2 (2.5%)
|
|
Psoas abscess
|
1 (1.3%)
|
Out of 77 patients, 58 (75.3%) presented with benign diseases, majority being hollow
viscus perforation (14 patients, 24.1%) and liver abscess (8 patients, 13.7%). The
number of patients presenting with malignancy were 19 (24.6%), out of which hepatopancreato-biliary
malignancy formed a major part, i.e., 11 patients (57.8%). Radiological intervention
was required in 28 patients that commonly included ultrasound-guided pigtail catheterization
and percutaneous transhepatic biliary drainage (PTBD). Surgical conditions requiring
pigtail catheterization included liver abscess, cholangitic abscess, deep space surgical
site infection, and sealed off perforation. PTBD was mainly done as a palliative procedure
for obstructive jaundice due to hepatobiliary and duodenal malignancies and in one
case of choledocholithiasis-induced severe cholangitis. Endoscopic retrograde cholangiopancreaticography
and stenting was done for biliary fistula, as a palliative procedure in metastatic
pancreatic cancer and for the removal of retained T-tube fragment. Endoscopic-guided
self-expandable metallic stenting was done for a patient with gastric outlet obstruction
due to local recurrence of carcinoma gall bladder infiltrating the first part of duodenum
and angio-embolization was done in a patient with post-pancreatitis gastroduodenal
artery aneurysm ([Fig. 1]). Twenty three out of 77 patients were operated for emergency and semi-emergency
conditions, out of which two cases were of breast malignancy. One patient with gastric
outlet obstruction due to metastatic duodenal adenocarcinoma was planned for palliative
surgery, but expired during initial resuscitation due to antecedent dyselectrolemia
and dehydration. All patients were classified under ASA grading on pre-anesthetic
check-up ([Table 2]). Patients requiring surgical intervention were taken up for surgery as per institutional
operative protocols. Out of 14 patients presenting with peritonitis due to hollow
viscus perforation, exploratory laparotomy was done in 13 patients while one patient
expired during initial resuscitation. Two patients presented with acute intestinal
obstruction due to postoperative adhesions and obstructed incisional hernia which
was managed by surgical intervention. Two out of four patients with obstructive jaundice
due to CBD stones required surgical intervention whereas one patient with severe cholangitis
was managed by PTBD and the other was discharged on request after resolution of symptoms.
One patient with wet gangrene of lower limb underwent below knee amputation.
Table 2
Surgical procedures and outcome of patients
|
Number of patients
|
|
ASA grade
|
|
I
|
6
|
|
II
|
14
|
|
III
|
3
|
|
IV
|
0
|
|
V
|
0
|
|
Surgical procedures
|
|
Modified GPR
|
8
|
|
Modified GPR with RD & FJ
|
2
|
|
Modified GPR with RD, gastrostomy & FJ
|
1
|
|
Exploratory laparotomy with double-barrel ileostomy
|
2
|
|
Exploratory laparotomy with adhesiolysis
|
1
|
|
Open cholecystectomy, CBD exploration with T-tube
|
2
|
|
Debridement and incision and drainage
|
3
|
|
Below knee amputation
|
1
|
|
Primary repair of hernia defect
|
1
|
|
Left MRM with LD flap
|
2
|
|
Modified Clavien-Dindo classification (postoperative outcome)
|
|
I
|
8
|
|
II
|
6
|
|
III
|
1
|
|
IV
|
5
|
|
V
|
3
|
Abbreviations: FJ, feeding jejunostomy; GPR, Graham's patch repair; LD flap, latissimus
dorsi flap; MRM, modified radical mastectomy; RD, retrograde duodenostomy.
Fig. 1 Radiological interventions done in surgical patients.
Postoperative outcome of patients was categorized according to Modified CD classification.
Out of 23 operated patients, one patient required USG-guided pigtail catheterization
(CD grade III) and five patients needed intensive care unit (ICU) care (CD grade IV).
Three cases operated for ileal perforation, prepyloric peptic perforation, and anterior
abdominal wall NSTI succumbed to their illness due to septicemia and multiorgan failure.
Two out of 77 patients were confirmed as COVID positive, out of which one was diagnosed
with severe acute pancreatitis with septic shock and multiorgan dysfunction while
the other was a case of acute chronic pancreatitis. The former succumbed to her illness
while the latter was discharged after 30 days with a negative COVID report.
The average length of hospital stay during this period was 10.7 days. This was due
to the long waiting period for COVID-19 test result and mandatory quarantine. Eight
mortalities were noted in this duration which included two patients of carcinoma breast
and one patient with metastatic cholangiocarcinoma, both of which succumbed to the
terminal stage of the disease while five patients expired due to septicemia and multiorgan
failure. These five included three postoperative patients, one patient with severe
acute pancreatitis with COVID positive status and one with cholangitic abscess.
Discussion
During national lockdown, the Ministry of Health and Family Welfare issued guidelines
for hospitals to ensure resource preservation and safety of HCWs on account of rapid
spread of COVID infection.[7] Resource preservation was necessary to handle the worsening pandemic situation so
that its allocation could be done to frontline health workers in emergency department
and ICU, if required. Various principles were adopted by general surgeons in this
pandemic phase:
-
Postponement of elective surgeries except the diseases which were time-sensitive like
malignancy or limb salvage surgery.
-
Only emergency cases to be catered and prompt management to be done by the designated
surgical team, that too with adequate personal protective equipment (PPE).
-
Mandatory COVID testing for all cases before surgery by reverse transcription polymerase
chain reaction (RT-PCR) test.
-
Avoiding aerosol generating procedures like laparoscopy, endoscopy, and robotic surgeries.
When mandatory, full PPE including N95 respirators must be worn by surgeons and operating
room (OR)/endoscopy staff.
-
Minimum possible staff must be kept to reduce the consumption of PPE and exposure
to high-risk procedures.
-
Risk stratification of patients is important to avoid over-depletion of PPE supplies.[8]
[9]
[10]
Our institute was focused on catering the emergency and semi-emergency cases during
the lockdown period. All outpatient services and elective surgeries were suspended
immediately. Only patients needing COVID testing and acute care were allowed to enter
the hospital premises. High-risk individuals were sampled via nasopharyngeal and oropharyngeal
swab and were advised home-based quarantine for 14 days.[11] Patients requiring acute medical or surgical care and patients with malignancy were
scrutinized by the institute's screening team, along with their attendants, for symptoms
related to COVID-19. If the COVID screening test (based on symptoms and associated
risks of COVID-19) was negative, the patients were allowed to consult the non-COVID
emergency department for the evaluation and further management. All COVID suspects
were admitted in the COVID emergency ward where initial treatment was given and a
nasopharyngeal swab was taken for RT-PCR test.[12]
[13] The waiting period for COVID test result was approximately 24 hours. If the test
result was negative for COVID, patients were shifted to general ward of respective
departments for further evaluation and management while COVID positive patients were
kept in COVID ward or ICU according to the need and were managed accordingly. Retesting
of COVID positive patients was done after 13 days of the first sample during the same
hospital admission. Follow-up of patients was done telephonically via telemedicine
OPD and the follow-ups of patients with time sensitive diseases requiring surgery
were planned accordingly. However, many patients faced difficulty in traveling due
to lockdown constraints and thus, were lost to follow-up.
Nineteen out of 77 patients presenting with acute surgical condition needed emergency
or urgent surgery (i.e., requiring surgery within 12 hours) and were operated in COVID
OR as their test results were awaited. These patients were shifted to general ward
or ICU after negative COVID test result. Four cases, two patients with carcinoma breast
and two with choledocholithiasis, were operated electively in routine OR with full
precautions as per institution protocol
Operative Protocol for Suspected or Confirmed COVID-19 Cases
A multidisciplinary team comprising of surgeons, anesthetists, physicians, critical
care specialists, and nursing supervisors formulated an Institutional operative protocol
which outlined ([Fig. 2]) the management and preventive measures to be taken during the perioperative period
in suspected or confirmed COVID-19 patients requiring surgery.[14]
[15]
[16]
Fig. 2 Algorithm used to define the management of patients requiring surgical intervention.
The following protocol was followed for operative patients
Preoperative Phase
After written and informed consent explaining the risk of contracting COVID infection
during the perioperative period, the patients were shifted to COVID ward or ICU for
initial resuscitation. The patients were transported via a predetermined, shortest
route with dedicated hospital staff after ensuring no hindrance during transportation.
The patients were required to wear a disposable head cap, three-layered mask and shoe
covers during transportation which was initiated only after confirming the preparedness
of surgical team.
Intraoperative Phase
A dedicated modular OR was designated for COVID patients with modifications to maintain
negative air pressure, thus minimizing the risk of transmission of COVID. The operating
team along with the anesthetists were kept to a minimum and unnecessary movement and
traffic were restricted ([Fig. 3]). Entry and exit information of every member of operating team was maintained for
contact tracing, if needed. Only essential equipment were allowed inside the OR. Use
of energy devices was kept to a minimum. Appropriate smoke and gas evacuation systems
were utilized for filtration of smoke and aerosols with possible viral particles.
Induction of anesthesia was performed with minimum personnel using disposable equipment
as per anesthesia guidelines, taking care that the production of aerosols was kept
to a minimum. The operating team was advised to keep out of the OR during induction
and to enter 15 minutes after intubation. Caution was taken to minimize spillage and
contamination by blood or body fluids during operation. The surgical specimen was
carefully packed and transported to the pathology department.
Fig. 3 Surgical team in personal protection equipment in operating room.
Postoperative Phase
Appropriate measures were taken to decrease the chances of aerosol formation during
extubation and the patient was shifted to the recovery room only after full recovery
from anesthesia. Transportation of patient out of the OR complex was done in a similar
manner as the preoperative transportation. Used PPE was removed in the doffing area
as per instructions for PPE removal before going to the clean area. It was mandatory
to change the scrubs after each procedure and take a shower, whenever possible. The
OR was kept vacant for 60 minutes to allow proper air exchange followed by cleaning
and fumigation as per the institutional protocol. Disinfection of OR and the surrounding
areas along with patient transit areas was done by dedicated staff in full PPE. For
waste disposal, separate containers were placed inside the OR and in the doffing area.
All contaminated material and PPEs were sent immediately to a collection point for
proper disposal as per protocol.
As directed by the GOI, all government and private hospitals were allowed to provide
health care during lockdown after ensuring proper safety measures. But several patients
suffered delay in treatment due to lockdown constraints, unawareness about provision
of essential health services by hospitals, the perceived fear of contracting COVID-19,
or reluctance of private hospitals to provide care. This resulted in increased morbidity,
chance of mortality, and longer length of hospital stay.
Special Consideration for Minimal Invasive Surgeries
At most surgical centers, management during this pandemic comprised of open surgical
approach with total abandonment of minimally invasive surgeries (MIS) due to higher
presumed risk of transmission of the virus. But there has been a constant debate among
the surgeons primarily due to the lack of a definitive evidence regarding the spread
of the virus.[17]
[18]
Opponents of MIS have been arguing on the basis of the assumption that aerosol formation
will be relatively more due to pneumoperitoneum and the leaks through port site during
transference of the instruments, which cannot be completely eliminated. Proponents,
on the other hand, are defending the rationality of minimal access surgery during
this pandemic with the argument that it has a potential for filtration of confined
aerosolized particles in the peritoneal cavity which is difficult in open surgery.
So, in spite of less aerosol generation expected in open surgery, the chances of exposure
are more due to free dispersion.[19]
[20]
[21]
[22]
Various surgical organizations like SAGES and ACS and teaching institutions have released
amended recommendations and guidelines for surgical care during this pandemic.[23]
[24] Our institution is currently following the mentioned guidelines:
-
Avoidance of hand-assisted laparoscopic surgery.
-
Pneumoperitoneum should be created via closed technique and intra-abdominal pressure
should be maintained between 10 and 12 mm Hg.
-
Insufflation of CO2 should be done at a minimum flow rate.
-
The incision for ports should be just adequate for the passage of trocar to prevent
leaks around the ports.
-
Minimum number and size of ports should be used. Proper air seal must be ensured.
-
Pneumoperitoneum should be evacuated via a smoke evacuation and filtration system.
-
Specimen retrieval should be done using an endo bag. The bag should be kept below
the valve of the retrieval trocar and should finally be extracted after complete desufflation.
-
The insufflator port should be closed prior to the removal of tubing from the port.
-
Port site closure after complete desufflation of pneumoperitoneum.
Post Lockdown Period
Gradual unlocking of the country saw a rise in the number of COVID positive patients
and related deaths.[25] The main concern was how to restart general outpatient services and elective surgeries
without the risk of contracting or spreading infection to the HCWs. The national lockdown
resulted in postponement of elective surgeries which were planned to be rescheduled
after the resumption of normal OR function. With the resumption of elective OR, provisions
were made to tackle the backlog of the elective cases. Telemedicine consultation was
started for follow-up of the patients and rescheduling of elective surgeries. The
deployment of residents and staff to COVID areas and conversion of surgical facilities
to COVID-specific wards became a hindrance to resume a full-fledged surgical care.
Physical distancing became the utmost priority to prevent the spread of COVID infection
among the HCWs and patients even after resumption of hospital function. Minimal invasive
surgeries were performed only in select cases due to the possible risk of transmission
of COVID-19 via aerosol production, although a concrete evidence was lacking.[26]
[27]
Resurgence of “The Second Wave”
The end of the year 2020 saw a gradual decline in the number of COVID-19 cases and
resumption of routine surgeries. But the end of March 2021 saw an exponential rise
in the number of COVID-19 cases which was due to more transmissible mutants of SARS-CoV-2
virus. Despite the initiation of the COVID vaccination drive, this mutant variant
hit like a tsunami in India and had a variable presentation when compared with the
SARS-CoV-2 virus. It was due to the fact that this mutant virus showed a widespread
disregard to the “COVID appropriate behavior” and was majorly responsible for the
second hit. The second wave noted more cases with breathlessness, newer gastrointestinal
symptoms and affected the younger and pediatric population.
We implemented the same institutional protocol that was used during the first wave
which included emergency surgical care only, while deferring the elective and outpatient
cases. The response to the second wave was better than the first wave as the health
care system was well prepared this time. The well-trained and experienced HCWS managed
the COVID as well as the surgical cases in a better manner, without fear and stress.
Preparedness after the first wave like exclusive vaccination drive for HCWs, stocking
of the resources like PPE and medications related to COVID care, improving RT-PCR
testing facilities helped enormously in tackling the second wave. Minimal invasive
surgeries were continued during the second wave as per institutional protocol.
Conclusion
COVID-19 has taken a huge toll on the country's economy as well as the health care
system. With the implementation of nationwide lockdown, the hospitals were focused
primarily on dealing with the patients affected with COVID while suspending the outpatient
services. The surgical department at our institute was involved in performing lifesaving
procedures or selected cancer surgeries while postponing the elective surgeries. This
was done for the resource preservation for COVID patients and to decrease the risk
of exposure and transmission of COVID-19 to the HCWs. While it was a decent strategy
to control the spread of COVID-19, it also led to delay in the management of patients
not fulfilling the criteria for emergent care and led to upstaging or increased severity
of the disease. Thus the lockdown served as a double-edged sword in the face of health
care system. The phased unlocking revealed an enormous backlog of patients requiring
management which resulted in an added stress to the already strained health care system.
The major concern in post lockdown period was to effectively manage the backlog along
with the judicious use of heath care resources to maximize the benefit and reduce
the health care burden. Minimal invasive approaches were continued with additional
safety precautions, suitable equipment, and expertise. With the anticipation of the
“third wave,” preparedness remains the most essential aspect in dealing with a pandemic
as one may expect that the worse is yet to come.
