Letter to the Editor     June 2020  

Urgent, Emergent, or Elective Surgery during the COVID-19 Pandemic

By Vasileios Karampelias1, Ypatios Spanidis1, Constantinos D. Zografos2,3

Affiliations

  1. Department of Surgery, School of Medicine, University of Patras, Patras, Greece
  2. Experimental, Educational and Research Centre ELPEN, Athens, Greece
  3. Department of Propaedeutic Surgery, Hippokratio Hospital, Athens, Greece

Sir,

Coronavirus-19 (COVID-19) pandemic warrants the mindful utilisation of available human and financial sources by the national healthcare systems.1 Undoubtedly, surgical care is in the frontline of this battle. Surgeons and surgical staff are invaluable specialised teams, especially during a pandemic; and should they become infected, the total effort against COVID-19 would be severely compromised. In this effort, the available medical resources should be managed carefully to ensure their availability for patients needing intensive care. Moreover, infection by COVID-19 may complicate the postoperative course of patients, even of those undergoing elective surgery; and it increase the fatality rate. Therefore, it appears that the risk of performing an operation could overshadow the benefits.2

Unfortunately, the evaluation of patient cases and performing only emergency surgeries is an inevitable decision that has already been implemented in China and Italy despite the fact that this aspect has met opposition and criticism in other countries.3 In line, the American College of Surgeons (ACS) published their recommendations earlier this year, suggesting that elective surgeries should be postponed and that each healthcare facility should be focused on emergency cases.4 Likewise, the surgeons should consider whether the delay of performing surgical procedure would prolong the patients hospital stay or worsen his/her condition.4 Those surgery that cannot be postponed should involve the minimal staff number to reduce their exposure to potentially infected patients and the possibility to become infected and, subsequently, self-isolated.5

Actually, the plan of each healthcare facility includes the clear distinction of emergency and elective cases considered for surgery, according to institutional resource availability and scheduling. Elective surgeries should be performed only in time-sensitive cases, such as cancers, limb salvage, or a benign disease with a risk of infection.3 In patients with cancer, treatment decisions are made on a case-by-case basis. Therefore, although a biopsy is an elective surgery, it must not be postponed, as a delay may worsen the patient’s condition. However, it has also been suggested that all patients should undergo pre-surgical health screening to screen for COVID-19 infection; and even the aforementioned elective surgery procedures should be postponed until infection clearance has been obtained for patients suspected COVID-19.2 Specially, in Singapore all patients, who are scheduled to undergo surgery, are obliged to provide a health and travel declaration; and those, who have travelled to affected areas, are advised to postpone their surgery.3

Recently, the ACS highlighted the following conditions as emergencies, and provided treatment options: acute hemorrhoidal thrombosis, perianal or perirectal abscesses, soft tissue infections, acute pancreatitis with necrosis, pneumoperitoneum, intestinal ischemia and obstruction, complicated appendicitis, choledocholithiasis, acute cholecystitis, cholangitis, and diverticulitis.4

In conclusion, the surgical teams should assess each case and decide according to the severity of each condition and the availability of the resources; and perform elective surgeries only after screening patients for COVID-19. The need for a clear strategy is urgent to respond to this health crisis.

CONFLICT OF INTEREST:
The authors have no conflicts of interest to disclose.

AUTHORS' CONTRIBUTION:
VK, CDZ: Drafting the work and final approval.
YS: Drafting, writing the article and final approval.

REFERENCES

  1. Coccolini F, Sartelli M, Kluger Y, Pikoulis E, Karamagioli E, Moore EE, et al. COVID-19 the showdown for mass casualty preparedness and management: The cassandra syndrome. World J Emerg Surg 2020; 15(1):26.
  2. Aminian A, Safari S, Razeghian-Jahromi A, Ghorbani M, Delaney CP. COVID-19 outbreak and surgical practice: Unexpected fatality in perioperative  period. Ann Surg 2020; 272(1):e27-9.
  3. Chew MH, Koh FH, Ng KH. A call to arms: A perspective of safe general surgery in Singapore during the  COVID-19 pandemic. Singapore Med J 2020. [Online ahead of print].
  4. Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): The epidemic and the challenges. Int J Antimicrob Agents 2020; 55(3): 105924.
  5. Coccolini F, Perrone G, Chiarugi M, Di Marzo F, Ansaloni L, Scandroglio I, et al. Surgery in COVID-19 patients: Operational directives. World J Emerg Surg 2020; 15(1): 25.