Effect of the pandemic on surgical procedures in a tertiary care hospital: A retrospective review

Abstract

Objective: The aim of this study was to examine the impact of performing surgeries with necessary precautions and to evaluate demographic characteristics of operated patients during novel coronavirus-2019 (COVID-19) pandemic and the infection rates during hospitalization and within 14 days after surgery.

Material and Methods: Between March 15^th, 2020 and April 30^th, 2020, a total of 639 patients who had been operated on in our center were retrospectively analyzed. According to the triage system, the surgical procedures were classified as emergency, time-sensitive, and elective procedures. Data including age, sex, indication for surgery, the American Society of Anesthesiologists (ASA) class, pre- and postoperative symptoms, the presence and/ or absence of reverse transcriptase-polymerase chain reaction (RT-PCR) test result, type of surgery, surgical site, and documented COVID-19 infections during hospitalization and within 21 days after surgery were recorded.

Results: Of the patients, 60.4% were males and 39.6% were females with a mean age of 43.08 ± 22.68 years. Malignancy was the most common indication for surgery (35.5%), followed by trauma (29.1%). The abdominal area and head and neck region were the most frequent surgical sites in 27.4% and 24.9% of the patients, respectively. Of all surgical procedures, 54.9% were emergency and 43.9% were time-sensitive procedures. Of the patients, 84.2% were in ASA Class I-II while 15.8% patients were in ASA Class III, IV and V. General anesthesia was the most common anesthesia type in 83.9% of the patients. The overall rate of COVID-19 infection was 0.63% in the preoperative period. The rate of COVID-19 infection during and after surgery was 0.31%.

Conclusion: With similar infection rates to the general population, surgeries of all types can be performed safely taking preventive measures in the preand postoperative period. It would be wise to perform surgical treatment without delay in patients with an increased risk for mortality and morbidity in accordance with strict infection control principles.

Keywords: COVID-19, operative surgical procedure, demographic

Introduction

Pneumonia cases of unknown etiology were first reported in Wuhan, Hubei province of China in December 2019 and rapidly spread all over the world (1). The virus was identified as severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which was later named as novel coronavirus-2019 (COVID-19). The World Health Organization (WHO) declared COVID-19 a pandemic on March 11^th, 2020 with a public health emergency of international concern (2).

The COVID-19 pandemic has dramatically affected healthcare services in many ways worldwide, and there is an increased need for intensive care unit (ICU) beds and workforce. With the increasing number of infected patients requiring hospitalization, the working practices has dramatically changed, and non-urgent elective surgeries and procedures have been postponed in many centers in accordance with the Republic of Türkiye, Ministry of Health. From the beginning of the pandemic, surgical workforce has had to adopt new working practices to schedule both elective and emergency surgeries in a timely manner to utilize medical equipment and consumables, bed capacity, and workforce in the most effective way (3-7). Necessary measures have been implemented to minimize the risk of transmission in operating rooms, patient wards, and the other settings such as hallways, elevators, and stairs (8-10).

The impact of postponing elective surgeries during the pandemic has not yet been clearly understood; however, operation-related stress has been proposed to disrupt the immune system, making patients more vulnerable to infections and the decision-making process becomes more difficult, as the symptoms of the patient can overlap with potential COVID-19 infection (11). Nevertheless, emergency operations are time-sensitive and require prompt decisions. In previous studies, delayed treatment in cancer patients has been associated with adverse outcomes with reduced cure rates (12,13). In emergency operations, therefore, there is a consensus among surgeons that surgery should be planned without delay taking necessary precautions.

In the present study, it was aimed to examine the impact of performing surgeries with necessary precautions and to evaluate demographic characteristics of operated patients during the COVID-19 pandemic and the infection rates during hospitalization and within 14 days after surgery.

Material and Methods

This single-center, retrospective study was conducted at the Department of General Surgery, Neurosurgery, Aesthetic, Plastic and Reconstructive Surgery, Thoracic Surgery, Orthopedics and Traumatology, Urology, Ophthalmology, and Otorhinolaryngology of Marmara University, Pendik Training and Research Hospital, İstanbul, between March 15^th, 2020 and April 30^th, 2020. Prior to surgery, all patients were informed about the possible risks and benefits of surgery, and a written informed consent was obtained. The study protocol was approved by Marmara University, School of Medicine, Ethics Committee with the approval no: 09.2020.706. The study was conducted in accordance with the principles of the Declaration of Helsinki.

A total of 639 patients who had been operated on in our center between the study period were included. Data including age, sex, indication for surgery, the American Society of Anesthesiologists (ASA) class, pre- and postoperative fever, dry cough, the presence and/or absence of reverse transcriptase-polymerase chain reaction (RT-PCR) testing, type of surgery (elective vs. emergency), surgical site, and documented COVID-19 infections during hospitalization and within 21 days after surgery were recorded. According to the triage system, surgical procedures were classified as follows: emergency procedures (a delay beyond four weeks would result in an increased risk of morbidity and mortality), time-sensitive procedures (a delay beyond four weeks to three months would result in an increased risk of morbidity and mortality), and elective procedures (deferrable for up to >3 months). Triage of the patients was carried out by the surgical departments included in the study in accordance with the national and international guideline recommendations. All healthcare workers complied with the donning/doffing procedures of personal protective equipment (PPE), including face mask, gloves, goggles, and face shields.

During the pandemic, cardiovascular surgeries were referred to an external center and obstetrics and gynecology procedures were carried out in a private center; therefore, these departments were excluded from the study.

Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive data were expressed in mean ± standard deviation (SD), median (min-max) or number and frequency, where applicable. Pairwise comparisons were performed using the non-parametric Mann-Whitney U test while the Kruskal-Wallis H test was used for multiple comparisons. A p value of <0.05 was considered statistically significant.

Results

Of a total of 639 patients included in this study, 60.4% were males and 39.6% were females with a mean age of 43.08 ± 22.68 (range, 0 to 97) years. Malignancy was the most common indication for surgery (35.5%), followed by trauma (29.1%). The abdominal area and head and neck region were the most frequent surgical sites in 27.4% and 24.9% of the patients, respectively. Of all surgical procedures, 54.9% were emergency and 43.9% were time-sensitive procedures. Of the patients, 84.2% were in ASA Class I-II while 15.8% patients were in ASA class III, IV and V. General anesthesia was the most common anesthesia type in 83.9% of the patients. Demographic and clinical characteristics of the patients and operative data are summarized in Table 1.

Table 1. Demographic and clinical characteristics of the patients and operative data

Of the 68 (10.6%) patients who needed ICU stay, 26.5% (n= 18) were operated from the head and neck region, 26.5% (n= 18) from the abdominal area, and 23.5% (n= 16) from the lower extremities. Majority of these patients were in ASA class I (33.8%) and class II (50%) and were operated under general anesthesia (85.4%). More than half of these patients (54.4%) were males.

In the preoperative period, four patients had fever and two patients had dry cough and underwent RT-PCR test. Of these patients, four tested SARS-CoV-2-positive. The overall rate of COVID-19 infection was 0.63% in the preoperative period. In addition, 4.4% (n= 28) of the patients including 2.5% (n= 16) with fever and 0.9% (n= 6) with dry cough in the postoperative period underwent RT-PCR test, and two patients tested SARSCoV-2-positive. The rate of COVID-19 infection during and after surgery up to 21 days was 0.31% (n= 2). Demographic characteristics and operative data of the COVID-19-positive patients both in the pre- and postoperative period are shown in Tables 2 and 3.

Table 2. Demographic characteristics and operative data of COVID-19-positive patients both in the pre- and postoperative period

Table 3. Pre- and postoperative COVID-19 symptoms

Mean ages of the patients who were scheduled for emergency surgery, time-sensitive surgery, and elective surgery were 41.08 ± 22.99 years, 45.31 ± 22.03 years, and 51.13 ± 26.07 years, respectively, indicating no statistically significant difference (p= 0.599). Surgery triage according to the age of the patients is presented in Table 4.

Table 4. Surgery triage according to the age of the patients

Discussion

The COVID-19 pandemic has swept through the world, placing an enormous strain on many aspects of life, including social life, work, school, and family. The rapid spread of the pandemic has mainly crippled healthcare services, and elective surgeries have been postponed to allow facilities to dedicate all available healthcare resources, including healthcare workers and equipment, to the treatment of infected patients and to protect patients from being infected with the deadly virus, which is also the subject of ethics and medicolegal problems. In a study, Di Martino et al. (14) have reported the rate of COVID-19 infection after surgery as 7% among the operated patients during the pandemic while Karayiannis et al. (19) have found this rate to be 5.6%. In our study, the rate of COVID-19 infection as confirmed by RT-PCR was quite lower than the previous studies and general population (n= 2, 0.31%) within 21 days of surgery. In addition, we observed no COVID-19-related mortality in our study while Karayiannis et al. (15) have reported the mortality rate from COVID-19 as 0.8%.

In a large-scale, multi-center, cohort study, operated patients with COVID-19 infection diagnosed within seven days before or 30 days after surgery have been evaluated (16). In that study, mortality rate has been found as 23.8% in these patients and male sex, ≥70 years of age, ASA class III-V, cancer surgery, and emergency surgery have been found to increase mortality rates. In a systematic review and meta-analysis, Wang et al. (17) have reported that COVID-19-positive patients with hip fractures scheduled for surgery had ≥5 times higher risks of early mortality than COVID-19-negative patients with hip fractures. In the current study, six patients who tested COVID-19 positive in the pre- or postoperative period needed ICU stay; however, none of the patients died. Of note, these patients were in ASA Class IV, leading to an increased rate of morbidity.

In our country, all elective surgical procedures were postponed or cancelled to prevent devastating consequences of the pandemic in accordance with the Republic of Türkiye, Ministry of Health guidelines, resulting in a rapid decline in the number of surgeries (18). Initially, healthcare workers and facilities faced many unknows and confusion regarding the prioritization of cases for emergency and elective. Later, however, the societies of each specialty issued relevant guidelines (19). In our study, surgical procedures were classified based on the triage system as emergency, time-sensitive, and elective procedures. According to the guidelines and general medical practice in pandemics, epidemics, and outbreaks, emergency surgeries are prioritized. In the present study, majority of the patients (54.9%) underwent emergency operations. Although therapeutic modifications for emergency cases were recommended, emergency procedures were performed, when indicated. Altogether, the COVID-19 pandemic forced surgeons to reschedule elective surgeries and adopt a “new normal” work schedule in order to minimize the time spent in the hospital setting and to protect patients from being infected (20). In our study, the rate of elective surgical procedures was only 1.3%, and these patients were operated within the first week of pandemic and elective procedures were postponed during the ongoing pandemic.

Timing of time-sensitive surgical procedures are still controversial. During the pandemic, hospital administrators and healthcare providers have faced certain challenges on how to utilize critical resources most effectively (i.e., hospital and ICU beds, mechanical ventilators, PPE, and blood transfusion capacity), which are all of utmost importance to protect healthcare workers and patients from viral exposure and to minimize in-hospital transmission of COVID-19. Among those scheduled for time-sensitive surgical procedures, a considerable rate of the patients (43.9%) was operated in our study. According to the triage system, time-sensitive procedures were defined as procedures which could be slightly delayed, but not beyond three months; otherwise, such a delay could result in worsening morbidity and mortality for the patient. In this group of patients, the majority of them (35.5%) were operated for malignant diseases. In particular, immunosuppressed patients, such as cancer patients, are at a higher risk for more severe forms of COVID-19 and, therefore, hospital admission of these patients should be minimized as much as possible. In our country, telemedicine technology has been in use to protect patients from being infected and to utilize healthcare resources in the most optimal way. However, time-sensitive and emergency, invasive procedures that need to be done in the operating room setting have been performed to avoid adverse consequences. Surgeons discuss the possible risk of infection with their patients and decide to treat or delay the existing pathology. In the literature, psychological distress has been reported in cancer (21) and epileptic patients (22), compared to healthy individuals, due to serious concerns about their cancelled and/or postponed surgeries. It has been well established that stress reduces the ability of the immune system to fight against infections and such a psychological stress may lead to increase the infection rates and disease progression in these patients. In a study, Rivera et al. (23) have reported that the all-cause mortality rate among cancer patients infected with COVID-19-was significantly higher than the general population (17% vs. 2-7%, respectively). In our study, however, none of the patients with cancer tested COVID-19-positive. Consistent with our results, in another study conducted by Ji et al. (24) to investigate the incidence of COVID-19 in patients undergoing elective cancer surgery, a total of 621 elective cancer surgeries from different specialties have been examined, and none of the patients has been found COVID-19-positive after surgery as confirmed by RT-PCR test during minimum 30-day follow-up period. Although this finding cannot be fully explained, one of the reasons may be the fact that the first case of COVID-19 in Türkiye was identified after a couple of weeks and months than many European, Middle East, and Far East countries, and prompt measures were taken after the first case in accordance with the global precautions and strategic plans for the pandemic. Additionally, high-risk cancer patients themselves or their relatives may have refrained from consulting a physician and being operated to avoid infection. Finally, as ICU beds have been mostly occupied by COVID-19 patients in many facilities during the pandemic, surgical treatments may have been abandoned or the patients may have been referred to an external center with available ICU beds. In our study, two patients in the time-sensitive category with COVID-19 positivity were operated for tracheal stenosis (n= 1) and sarcoidosis (n= 1). None of the patients undergoing emergency or elective surgery had COVID-19 infection.

During the pandemic, necessary measures were implemented in our facility to minimize the risk of transmission in operating rooms, patient wards, hallways, elevators, and stairs. All healthcare staff were instructed to wear PPE. The patients undergoing surgery were taken to single-patient wards, and caregivers and/ or companions or visitors were not allowed. In addition, flexible working arrangements enabled surgeons of all specialties to do the same amount of work over a different period.

Nonetheless, there are some limitations to this study. First, mortality and morbidity rates were unable to be evaluated due to the relatively low number of patients with COVID-19 infection postoperatively. Second, asymptomatic cases may have been missed due to lack of RT-PCR screening from nasopharyngeal swabs on a regular basis. Third, besides patients, frontline healthcare workers are also at a high risk of infection. In our study, healthcare workers who collected nasopharyngeal swabs from six COVID-19-positive patients did not undergo RT-PCR testing to confirm the presence or absence of the infection. Further studies investigating differences in the demographic characteristics of the patients operated on during the pandemic compared to the previous year would provide additional information on this topic.

Conclusion

In conclusion, with similar infection rates to the general population, surgeries of all types (i.e., emergency or elective cancer surgery) can be performed safely taking preventive measures in the pre- and postoperative period. It would be wise to perform surgical treatment without delay in patients with an increased risk for mortality and morbidity in accordance with strict infection control principles. Further studies are needed to elucidate the true incidence of COVID-19 infection in frontline healthcare workers.

Cite this article as: Çavuş Özkan M, Saçak B, Kesimer MD, Şahin B, Uğurlu MÜ, Yamansavcı Sirzai E, et al. Effect of the pandemic on surgical procedures in a tertiary care hospital: A retrospective review. Turk J Surg 2022; 38 (3): 243-249.

The approval for this study was obtained from Marmara University, School of Medicine, Ethics Committee with the Decision no: 09.2020.706, Date: ????)

Externally peer-reviewed.

Concept - B.S., M.Ç.Ö.; Design - B.S., M.Ç.Ö.; Supervision - B.S.; Data Collection and/or Processing - M.D.K., B.Ş., M.Ü.U., E.Y.S., M.S., A.A., İ.Ç., A.C.Y.; Literature Search - M.Ç.Ö.; Writing Manuscript - M.Ç.Ö.; Critival Review - B.S.

The authors have no conflicts of interest to declare.

The authors declared that this study has received no financial support.

References

1. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020; 382(8): 727-33. https://doi.org/10.1056/NEJMoa2001017
2. Chan KW, Wong VT, Tang SCW. COVID-19: An update on the epidemiological, clinical, preventive and therapeutic evidence and guidelines of integrative Chinese-Western medicine for the management of 2019 novel coronavirus disease. Am J Chin Med 2020; 48(03): 737-62. https://doi.org/10.1142/S0192415X20500378
3. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair allocation of scarce medical resources in the time of COVID-19. N Engl J Med 2020; 382(21): 2049-55. https://doi.org/10.1056/ NEJMsb2005114
4. ACS. 2020. Guidelines for triage and management of elective cancer surgery cases during the acute and recovery phases of coronavirus disease 2019 (COVID-19) Pandemic. Available from: https://www.facs. org/media/xrspaqaz/acs_triage_and_management_elective_cancer_surgery_during_acute_and_recovery_phases.pdf (Accessed date: 25.04.2020).
5. Iacobucci G. COVID-19: All non-urgent elective surgery is suspended for at least three months in England. BMJ 2020; 368: m1106. https:// doi.org/10.1136/bmj.m1106
6. Topf MC, Shenson JA, Holsinger FC, Wald SH, Cianfichi LJ, Rosenthal EL, et al. Framework for prioritizing head and neck surgery during the COVID-19 pandemic. Head Neck 2020; 42(6): 1159-67. https://doi. org/10.1002/hed.26184
7. Flemming S, Hankir M, Ernestus RI, Seyfried F, Germer CT, Meybohm P, et al. Surgery in times of COVID-19-recommendations for hospital and patient management. Langenbecks Arch Surg 2020; 405(3): 359- 64. https://doi.org/10.1007/s00423-020-01888-x
8. Centers for disease control and prevention interim infection prevention and control recommendations for patients with known or patients under investigation for 2019 novel coronavirus (2019- nCoV) in a healthcare setting. Available from: https://www.cdc.gov/ coronavirus/2019-nCoV/hcp/infection-control.html (Accessed date: 21.02.2020).
9. World Health Organization Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. http://apps.who.int/iris/10665/112656 (Accessed date: 30.03.2021).
10. Collaborative CO. Global guidance for surgical care during the COVID-19 pandemic. Br J Surg 2020; 107(9): 1097-103. https://doi. org/10.1002/bjs.11646
11. Hogan A. COVID-19 and emergency surgery. Br J Surg 2020; 107(7): e180. https://doi.org/10.1002/bjs.11640
12. Kuderer NM, Choueiri TK, Shah DP, Shyr Y, Rubinstein SM, Rivera DR, et al. Clinical impact of COVID-19 on patients with cancer (CCC19): A cohort study. Lancet 2020; 395(10241): 1907-18. https://doi. org/10.1016/S0140-6736(20)31187-9
13. Tang LV, Hu Y. Poor clinical outcomes for patients with cancer during the COVID-19 pandemic. Lancet Oncol 2020; 21(7): 862-4. https://doi. org/10.1016/S1470-2045(20)30311-9
14. Di Martino M, García Septiem J, Maqueda González R, Muñoz de Nova JL, de la Hoz Rodríguez Á, Correa Bonito A, et al. [Elective surgery during the SARS-CoV-2 pandemic (COVID-19): A morbimortality analysis and recommendations on patient prioritisation and security measures]. Cir Esp 2020; 98(9): 525-32. https://doi.org/10.1016/j.ciresp.2020.04.029
15. Karayiannis PN, Roberts V, Cassidy R, Mayne AIW, McAuley D, Milligan DJ, et al. 30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic: A multicentre regional analysis of 484 patients. Bone Jt Open 2020; 1(7): 392-7. https://doi. org/10.1302/2633-1462.17.BJO-2020-0075.R1
16. 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. https://doi.org/10.1016/S0140-6736(20)31182-X
17. Wang KC, Xiao R, Cheung ZB, Barbera JP, Forsh DA. Early mortality after hip fracture surgery in COVID-19 patients: A systematic review and meta-analysis. J Orthop 2020; 22: 584-91. https://doi.org/10.1016/j. jor.2020.11.012
18. Republic of Türkiye, Ministry of Health, Patient Rights and Medical Social Services Department. Postponement of elective surgical interventions and other precautions to be taken. Available from: https:// shgmhastahakdb.saglik.gov.tr (Accessed date: 17.03.2020).
19. Surgens ACo. COVID-19: Elective case triage guidelines for surgical care. Available from: https://www.facs.org/for-medical-professionals/covid-19/clinical-guidance/elective-case/ (Accessed date: 24.03.2020).
20. Steward JE, Kitley WR, Schmidt CM, Sundaram CP. Urologic surgery and COVID-19: How the pandemic is changing the way we operate. J Endourol 2020; 34(5): 541-9. https://doi.org/10.1089/ end.2020.0342
21. Juanjuan L, Santa-Maria CA, Hongfang F, Lingcheng W, Pengcheng Z, Yuanbing X, et al. Patient-reported outcomes of patients with breast cancer during the COVID-19 Outbreak in the epicenter of China: A cross-sectional survey study. Clin Breast Cancer 2020; 20(5): e651-e62. https://doi.org/10.1016/j.clbc.2020.06.003
22. Hao X, Zhou D, Li Z, Zeng G, Hao N, Li E, et al. Severe psychological distress among patients with epilepsy during the COVID-19 outbreak in southwest China. Epilepsia 2020; 61(6): 1166-73. https://doi. org/10.1111/epi.16544
23. Rivera DR, Peters S, Panagiotou OA, Shah DP, Kuderer NM, Hsu CY, et al. Utilization of COVID-19 treatments and clinical outcomes among patients with cancer: A COVID-19 and cancer consortium (CCC19) cohort study. Cancer Discov 2020; 10(10): 1514-27. https://doi. org/10.1158/2159-8290.CD-20-0941
24. Ji C, Singh K, Luther AZ, Agrawal A. Is elective cancer surgery safe during the COVID-19 pandemic? World J Surg 2020; 44(10): 3207-11. https://doi.org/10.1007/s00268-020-05720-x