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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 6  |  Page : 279-285

A glimpse of unfolding surgical crisis amid the COVID-19 pandemic: Need urgent global attention and universal recommendation


1 Department of Surgery, Dr BSA Medical College and Hospital, New Delhi, India
2 Department of Anaesthesia and Intensive Care, Dr BSA Medical College and Hospital, New Delhi, India

Date of Submission11-Nov-2020
Date of Acceptance17-Nov-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Jitendra Kumar
Department of Surgery, Dr BSA Medical College and Hospital, Sector-6, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmrp.cmrp_53_20

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  Abstract 


The COVID-19 pandemic has resulted in serious consequences for all those patients who need treatment for any other routine ailments. The worst sufferers are the patients who need to undergo elective or non-emergency surgical procedures. But globally, no concrete steps have so far been taken to reduce the huge suffering of routine surgical patients either during or the aftermath of the pandemic. The aim of this study is not only to draw global attention by highlighting the magnitude of suffering faced by routine surgical patients but also to put the much-needed proposal for the urgent need of universal guidance to counter the huge challenges waiting ahead. In an attempt to find the scale of problems faced by patients in need of routine surgical procedures and their suggested solutions available to date, we did an extensive search online on different search engines and scientific databases. Unfortunately, no country is tracking or reporting the data of routine surgical patients affected by this pandemic. Whatever estimated data in this regard is projected, is catastrophic. The worst at the global level is that no step has so far been taken to look into any solution for this huge suffering faced by millions of people. The COVID-19 pandemic has posed a huge challenge for routine surgical patients across most of the affected parts of the world, and we cannot turn a blind eye for long time on this issue. All stakeholders at the global level must come forward with uniform guidance to handle this global emergency during and post-pandemic time.

Keywords: COVID-19, pandemic crisis, SARS-CoV-2, surgical crisis


How to cite this article:
Kumar J, Raina R. A glimpse of unfolding surgical crisis amid the COVID-19 pandemic: Need urgent global attention and universal recommendation. Curr Med Res Pract 2020;10:279-85

How to cite this URL:
Kumar J, Raina R. A glimpse of unfolding surgical crisis amid the COVID-19 pandemic: Need urgent global attention and universal recommendation. Curr Med Res Pract [serial online] 2020 [cited 2021 Jan 19];10:279-85. Available from: http://www.cmrp.org/text.asp?2020/10/6/279/304824




  Introduction Top


Andrew D. Gilman, the founder president and CEO of CommCore, once quoted that 'the secret of crisis management is not good vs. bad but it's preventing the bad from getting worse'. It is quite relevant in the current scenario when the whole world is endeavouring to reduce the impact of the crisis created out of the COVID-19 pandemic and the aim is the same – just to prevent this bad situation from getting even worse.

This coronavirus disease 2019 (COVID-19) pandemic is caused by the highly infectious severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus. When it first started in the city of Wuhan, China, in December 2019, most of the countries took it as an epidemic of China. Within months, the virus started taking a heavy toll all over the world which led to a knee jerk reaction worldwide. Probably, we did not learn from our history which has plenty of much worse pandemics on records when millions of people were wiped out and there are instances when some of the indigenous communities had been pushed to the brink of extinction.[1]

The WHO had declared the COVID-19 – a pandemic on 11 March 2020, and now it is just over the 5 months (on 4 September 2020) and the total number of cases globally has reached to 26,121,999 and the total number of deaths recorded due to this pandemic is 864,618 deaths.[2],[3] To overcome the demand and supply gap, most of the healthcare facilities have diverted all of their resources primarily to tackle the surge of patients due to COVID-19. The strong fear of spread of COVID-19 infection has further limited the healthcare deliveries to its minimal extent of emergency services only. Unfortunately, this sort of engagement has brought a serious consequence for all those patients who need treatment for any other routine ailments. Among all non-COVID-19 routine patients, worse sufferers are patients who need to undergo any kind of routine surgical or endoscopic procedures.

Ironically, no proper attention has so far been given to this serious issue of the unprecedented surgical crisis created out of the COVID-19 pandemic. Globally, neither any concrete step has been taken in terms of the formulation of a structured framework nor any uniform guidance has been framed to address this unforeseen exigency. The main purpose of writing this article is not only to assess and highlight the magnitude of suffering faced by routine surgical patients but also to draw the global attention and call for the urgent need of universal guidance for management of all the routine surgical patients both during and aftermath of this COVID-19 pandemic.


  Methods Top


To evaluate the overall impact of the COVID-19 pandemic on surgical patients and available guidance to manage this at the global level, an extensive search of information in English language, available online as of 25 July 2020, was performed. An electronic search was performed using online search engines such as PubMed, NCBI database, Embase, Google Scholar and the Cochrane library database. Initial keywords used for the search were covid19 pandemic, novel coronavirus, global outbreak, SARS-CoV-2, followed by impact of COVID-19 pandemic, global crisis created out of COVID-19 pandemic, non-COVID-19 routine patients amid COVID-19 pandemic, surgical patients and COVID-19 pandemic and guidance for management of surgical patients during pandemic.

Inclusion criteria were any information regarding the impact of the current pandemic on patients who needed any kind of surgical or endoscopic procedure and any guidance available so far to manage surgical patients during or after the pandemic. We have excluded all other articles that were not fitting into our inclusion criteria. Conference papers, correspondence and expert opinion, which were not based on evidence were also excluded.

A detailed flowchart of our review process is depicted in [Figure 1].
Figure 1: Flowchart of our review process

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  Results Top


Nine out of the total 22 articles selected were related to the impact of the current pandemic on surgical activities, four articles were related to the possible solution of the surgical crisis, while three articles have common information. Rest of the five articles have information regarding other related issues. We have selected a total of 11 advisories issued by different authorities over the world, which is relevant to the management of the current surgical emergency.

Rationale behind the postponement of elective or routine procedures

To counter the threat of the COVID-19 pandemic, authorities and surgical societies across the world have advised to postpone or delay all kinds of non-essential elective surgeries with some exception of certain life-threatening malignancies.[4],[5],[6],[7],[8],[9],[10] All these decisions are based on an aim to prevent the spread of highly contagious SARS-CoV-2 virus and to make the limited hospital resources readily available for a sudden surge of patients due to the COVID-19 pandemic.[11],[12] Threat perception of COVID-19 has further been augmented by the fact that so far, there is no treatment available for this highly contagious disease.

All kinds of surgical procedures have a risk of associated complications and deterioration of immunity, which makes the surgical patients more vulnerable for COVID-19 infection and related complications. In this regard, few reports based on experiences during the pandemic have been published.[13],[14] They have highlighted the exponential rise of complications and mortality among the unsuspecting surgical patients who have been found positive for COVID-19 during the due course of treatment.

Magnitude of impact

Unfortunately, so far, no official data is available in terms of the exact magnitude of the surgical patients who got affected due to the COVID-19 pandemic.[15] As per the estimated data, published and approved by the WHO, the global volume of major surgeries performed in the year 2012 was between 266.2 and 359.5 million (average 312.9 million).[16] This is a rough estimate from the data available from 66 member countries among a total of 194 WHO member states. In India, it is estimated between 9,801,319 and 12,556,488.[16]

In the USA, as per the national health statistic report based on ambulatory surgery data collected in 2010 (National Hospital Ambulatory Medical Care Survey), 48.3 million surgical and non-surgical procedures were performed in a year.[17] In the UK, according to one of the reports published in August 2017 (based on data collected between 1 April 2009 and 31 March 2014), the total number of surgical procedures performed per 100,000 population per year was 23,024.[18] As per the data available on the website of Royal College of Surgeons, the total estimated surgical admissions in 2013–2014 was about 4.7 million.[19]

All the data mentioned above are inclusive of both emergency and routine cases. We can get a rough idea about the number of non-emergent surgery on the basis of one of the studies published in 2018.[20] Accordingly, the median ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries, was 14.6 (interquartile range 5.5–62.6). However, this value was found to have a direct relationship with per capita healthcare spending of the country. Hence, poorer countries have higher Ee ratio.

As per the estimated data in a recently published paper, a total of 28,404,603 surgical procedures would be cancelled or postponed during the peak 12 weeks of disruption due to the COVID-19 pandemic (2,367,050 operations per week), which is the 72.3% of the total elective surgeries performed during this period.[21] As per this report, it would take at least 45 weeks to clear the backlog of surgical procedures which were postponed during the outbreak even if countries would increase their surgical volume by 20%.

It is worth mentioning the impact of the current pandemic on the cases of malignancy. Most of the malignancies are diagnosed either during routine clinical examination or routine screening such as mammography and colonoscopy. As per the data obtained by the International Agency of Research on Cancer, WHO, the total number of new cases of malignancies diagnosed in 2018 was 18,078,957 and for colorectal cancer, it was 1,849,518 per year.[22]

A lot of malignancies of colorectum detected during screening colonoscopy have all now been postponed due to the COVID-19 outbreak. The prognosis and outcome of colorectal malignancies depends on the timing of intervention after the diagnosis and most of the diagnoses are done during routine screening, which is not possible in the current scenario of the COVID-19 pandemic.[23] All these extended sufferings due to denial of due routine surgical or diagnostic procedures have started affecting mental health and causing immense psychological trauma to the affected population.[24]

Status of healthcare workers

Healthcare deliveries are largely dependent on healthcare workers (HCWs), and reviewing the situation of our HCWs is equally important. A distressing number of HCWs who are fighting the pandemic globally, are falling prey to the COVID-19 infection. So far, most of the reports cited that the reasons for this large number of infected HCWs are lack of resources such as personal protective equipment (PPE) kits, lack of infection control training, long working hours and stressful environment and particular procedure with the potential of high aerosol generation.[25] One recent study has reported the significant rise of anxiety, depression and other mental health problems among surgical staffs.[26]

Unfortunately, no country around the world is tracking or reporting any data related to COVID-19 infection among HCWs. Most of the data are either based on media reports or published case series. On 11 April 2020, in its situation report, the WHO confessed that it is not getting any systematic report of the number of HCWs infected with COVID-19 from any country.[27] On 6 May 2020, the International Council of Nurses also raised a serious concern regarding the lack of data of COVID-19 infection and related deaths among HCWs and calls on governments to act immediately on this.[28]

Available guidance and recommendations for surgical services during the pandemic

Here, it is important to have a brief look at the guidelines and recommendations issued so far by government authorities and surgical bodies of different countries. We have included the only such guidance which is dealing with the current surgical crisis amid the COVID-19 pandemic.

It is now obvious by the fact that while this deadly pandemic has afflicted most of the countries around the world, only few among them have taken cognizance of the plight of surgical patients amid the COVID-19 crisis. There is no uniformity among all these guidelines as all of these have taken consideration of their own local situation, their resources and capability. As situation keeps changing rapidly, most of these guidelines are interim in nature and are being updated regularly. Definitely, this is not fair enough at least for the rest of the world.


  Discussion Top


Challenges

The main focus of every government is on the containment of the spread of virus in their community zone and minimise the morbidity and mortality of confirmed cases in the best possible manner. However, the problem in hand is so overwhelming that even best of the health infrastructure is not able to cope up with the situation. There is a severe gap in demand and supply in terms of workforce, infrastructure, equipment, consumables, etc., The bitter truth is that overnight, our healthcare delivery potential cannot match this sudden uncontrolled surge of patient load. Anaesthetists and intensive care facilities are an integral part of surgical team and at the peak of the pandemic they cannot be spared for non-lifesaving surgeries.

The nature and behaviour of COVID-19 are still evolving, so we cannot settle down with the available recommendations and guidance. The chances of getting false-negative and false-positive reverse transcriptase-polymerase chain reaction (RT-PCR) test reports for COVID-19 are further complicating the line of management for surgical patients.[29],[30] A lot of issues all over the world have been raised regarding the lack of PPE kits, but their 100% efficacy in preventing the COVID-19 infection is still doubtful.[31] Reports of high morbidity and mortality amongst surgical patients who acquired COVID-19 infection during the course of surgical treatment are also worrisome.[13],[14] Protecting the HCWs who are largely being infected with COVID-19 during healthcare delivery is also a huge challenge.[25]

Solution area

Keeping in view of the grave danger created out of the COVID-19 pandemic, it is justified to postpone non-essential surgeries for a certain period of time. However, the solution of COVID-19 is not in sight in near future and the magnitude of the problem is much high, we must look for some solution. Not many suggestions to deal with the suffering of patients in need of surgery during this global crisis have come yet.

One recommendation is for the categorisation of the cases of elective surgery into – (1) 'essential'– increased risk on the event of delayed surgery, (2) 'non-essential' or 'discretionary' – not much risk and (3) equivocal (neither essential nor non-essential) categories, based on the risk involved in case if that surgeries are postponed.[32] Further, they have proposed a decision-making algorithm to categorise the elective surgical procedures on the basis of predicted resource utilisation in terms of post-operative intensive care unit (ICU) admission, prolonged ventilation and blood transfusion requirement during or after surgery.[32]

The ACS (USA), RCS (England) and ASI (India) have suggested a time period of 14–21 days of continuous decline in the local transmission of COVID-19 to start non-essential elective surgeries [Table 1] and [Table 2]. Few of other governmental authorities and surgical societies also now have started advising to start elective surgeries based on the level of local community transmission of COVID-19 and available healthcare facilities [Table 1] and [Table 2].
Table 1: Guidance from different governmental authorities for surgeries during the COVID-19 pandemic

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Table 2: Guidance from different surgical societies and associations during the COVID-19 pandemic

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Proposals

It is worth here to mention the famous quote by Benjamin Franklin – by failing to prepare, you are preparing to fail. When we discuss about the gigantic problems related to the sufferings of surgical patients during the current COVID-19 pandemic, so far, no steps have been taken at global level. The WHO is also mute spectator on the issue of management of all those patients who are in a dire need of surgery. So far, only few countries in the world have taken the initiative to sort out the problem of surgical patients during current pandemic with the help of formulation of recommendations and guidelines. All these recommendations are prepared as an interim measure based solely on the local situation and circumstances and are being updated regularly.

There are instances when in spite of the lack of resources some countries are faring better in managing the crisis than others, and unless all such experiences of success and failure will be brought into a common global platform, it is not possible to fight this global surgical crisis in an effective manner.[33],[34] There is a huge backlog of patients who are in need of surgery and for every nation, it would not be possible to deal such huge surge altogether once the pandemic ends and it will lead to chaos and will further enhance the suffering of humankind who is already under a huge stress.[21]

We are in an urgent need of formulation of a universal structured framework on starting surgeries after the pandemic, which should be prepared after taking into consideration of every geopolitical area of the world.[34] After analysing the available information in terms of surgical crisis amid the COVID-19 pandemic and the measures so far taken to manage this problem, the following proposals need an urgent consideration at the global level:

  • COVID-19 is going to stay here and we cannot ignore the huge suffering of our surgical patients for so long. Hence, long-term measures in the form of uniform standard operating procedures to manage patients in need of elective surgery must be framed at the global level
  • Every nation must constitute their own national surgical review committee consisting of all the stakeholders who will prepare future plans based on the local prevailing situation to deal the patients in need of surgery during and aftermath of the pandemic
  • Whether it is an issue of dedicated non-COVID-19 hospitals with an exclusive surgical team or the need of extended healthcare infrastructures and workforce to manage the huge surge of postponed surgical patients after the pandemic, every affected country of the world cannot afford it. In this case, global bodies must come forward with a proposal to provide them supports for a larger interest of humanity
  • The issue of false-negative COVID-19 RT-PCR testing is yet to be sorted out. The surgical community must seek ways out for screening of the patients before surgery as relying only on RT-PCR test will just create a false sense of security
  • There is no data related to COVID-19 infection among HCWs that has been released from any country of the world.[27],[28] Unless we maintain transparency in record keeping related to COVID-19 infection and death among HCWs, we cannot analyse and prevent it further.



  Conclusion Top


Taking care of the sufferings of non-COVID-19 routine patients who are getting neglected due to the burden of the pandemic is not undermining the gravity and the huge threat posed by the current COVID-19 pandemic. Right now, we are fighting a war against the pandemic, but we cannot win the war at a cost of lives of a significant number of people. All concerned organisations or authorities involved in decision-making should look into this matter on an urgent basis and take some decisive actions so that suffering of the masses at the global level could be avoided.

Acknowledgements

We acknowledge all those patients, whether of COVID-19 or non-COVID-19, whom we are witnessing daily in our hospital or silently watching in media reports. They inspire us to write this article in the hope of some solution for their betterment. We must salute the courage and dedication of all the warriors fighting the war against one of the deadly pandemics the world has ever seen.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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