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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 12-16

Impact of the COVID-19 pandemic on general surgical practice – An observational cross-sectional study


Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission09-Jan-2022
Date of Acceptance12-Apr-2022
Date of Web Publication20-May-2022

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jica.jica_2_22

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  Abstract 

Introduction: The study aimed to study the impact of the COVID-19 pandemic on surgical practice in a tertiary care setup in India and the future implications of the pandemic. Methodology: This observational cross-sectional study was conducted at a tertiary-care hospital. The case series consisted of a snapshot search of all operating theatre activity at AIIMS, Rishikesh between the 1st of March 2020, and 31st August 2020. Observations: A total of 790 patients were operated on in the first 6 months of the covid era while 5308 patients had undergone surgery in the 6 months preceding the onset of covid-19. In the precovid era, 73.71% of the cases were performed under General Anaesthesia while 62.6% of the cases were performed under general anaesthesia in the covid era. 18.83% of the cases in precovid era were performed under spinal anaesthesia and 3.5% under combined spinal and epidural anaesthesia in the precovid era. Conclusion: This study has shown the extent to which general surgical practice was affected during the covid pandemic. With the lessons learnt during this period, we can implement a more robust plan in the eventuality of another pandemic and be more thoroughly prepared the next time around.

Keywords: Anesthesia, coronavirus, COVID-19, elective surgery, emergency surgery


How to cite this article:
Suresh S, Gupta B, Kumar A, Mohanta J, Perween R, Singh AK. Impact of the COVID-19 pandemic on general surgical practice – An observational cross-sectional study. J Ind Coll Anesth 2022;1:12-6

How to cite this URL:
Suresh S, Gupta B, Kumar A, Mohanta J, Perween R, Singh AK. Impact of the COVID-19 pandemic on general surgical practice – An observational cross-sectional study. J Ind Coll Anesth [serial online] 2022 [cited 2022 Nov 30];1:12-6. Available from: https://www.jicajournal.in//text.asp?2022/1/1/12/345596


  Introduction Top


Coronavirus was declared a public health emergency by the World Health Organization on January 30, 2020. The detection of an unexpectedly large number of cases worldwide in the 1st week of March prompted the World Health Organization to declare COVID-19 a pandemic on April 10, 2020.[1] As the data on the virus was scant at the time, most hospitals directed their resources toward procuring masks and other personal protective equipment (PPE) for the health-care workers and the temporary suspension of all elective work. The lack of definitive treatment, high contagiousness of COVID-19 virus via respiratory droplets/body fluids, fear of airborne transmission via aerosols produced during various surgical procedures, and safety needs of health-care professionals have forced a change in current surgical practice. The experiences of the surgeons from Italy and China, the early epicenters of the pandemic, taught invaluable lessons on the safe conduct of surgery to the rest of the world. Experience with emergency and cancer surgery has also shown that workloads can be tackled safely in these challenging times. Surgical cases were categorized either as urgent or emergent cases, the latter which need to be operated on within 1 h. Urgent surgeries, defined as those which could cause loss of limb or life if not performed within 24 h, included appendicitis, cholecystitis, septic arthritis, open fractures, femur shaft fractures and hip fractures, acute nerve or spinal cord injuries, and surgical infections. Elective essential cases included cancer surgeries, biopsies, subacute cardiac valve procedures, hernia repair, hysterectomy, and reconstructive surgeries.

Surgical patients are classified into three risk categories for COVID-19: confirmed and suspected patients, high-risk patients, and low-risk patients which are defined as:

Confirmed and suspected patients

COVID-19 was confirmed when reverse transcription-polymerase chain reaction diagnostic panels or serological (immunoglobulin M and immunoglobulin G) test results were positive. The definition of suspected cases falls into two categories. The first category will have a contact history and meet any two of the clinical manifestations (fever and respiratory symptoms) with the typical findings of COVID-19 in the chest computerized tomography (CT) scan. The second category is without a clear epidemiological history and shows three of the clinical manifestations (fever and/or respiratory symptoms, with the typical findings in the chest CT.

High-risk patients

Patients who had traveled to high-risk areas or contacted patients with confirmed or suspected COVID-19 (who have developed a fever and/or symptoms of acute respiratory illness within 14 days).

Low-risk patients

Patients who had no history of close contact with confirmed and suspected COVID-19 patients and who did not have fever, respiratory symptoms and CT manifestations of COVID-19 within 14 days.

This study was planned in an attempt to understand the impact that the pandemic had on surgical practice at a tertiary care hospital in India.


  Subjects and Methods Top


Aims

The study aimed to study the impact of the COVID-19 pandemic on surgical practice in a tertiary care setup in India and the future implications of the pandemic.

Objectives

To study the details of the cases conducted in the COVID and pre-COVID era with regard to:

  1. Demographics
  2. Nature of surgery
  3. Department
  4. COVID status of the patient
  5. Type of anesthesia provided
  6. Perioperative adverse events.


Methods

This observational cross-sectional study was conducted at a tertiarycare hospital. The case series consisted of a snapshot search of all operating theater (OT) activity at the hospital between March 23, 2020, and August 2020. Scanned operating notes and anesthetic charts for all emergency procedures within the study timeline were reviewed, and age, demographics, type of anesthesia provided, indications of surgery, duration, blood loss, etc were noted. Duplicate entries were removed, as were those with inadequate documentation. Anonymized data were then entered into a secure database for the analysis. Paper-based searches were not employed due to current COVID-19 restrictions in getting access to paper notes. Cases with incomplete records were excluded from the study.


  Results Top


A total of 790 patients were operated on in the first 6 months of the COVID era, while 5308 patients had undergone surgery in the 6 months preceding the onset of COVID-19. The number of male patients was marginally higher in both the pre-COVID and the COVID eras [Figure 1].
Figure 1: Demographics of cases

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In the pre-COVID era, a majority of the cases were performed on an elective basis (71.23%), and emergencies constituted 16.9% of the total number of cases. In the COVID era, most of the cases were emergencies (45.4%) and semiemergencies (40.25%). Elective cases were only 14.05% of the total cases performed [Figure 2].
Figure 2: Indications of surgery in the COVID and Pre-COVID era

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[Figure 3] and [Figure 4] depict the distribution of cases among various specialties in the pre-COVID and the COVID era. In the pre-COVID era, the maximum number of cases was operated by the department of orthopedics (18.76%), followed by the departments of obstetrics and gynecology (12.84%) and neurosurgery (7.686%). In the COVID era, however, the department of obstetrics and gynecology performed the maximum number of surgeries (17%). The cases operated on by the department of orthopedics constituted 14% of the total number of cases, and those by the department of neurosurgery 15%.
Figure 3: Specialty-wise distribution of cases. OMFS: Oral and maxillofacial surgery; CTVS: Cardiothoracic and vascular surgery; DSA: distribution services agreement

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Figure 4: Specialty distribution of cases. OMFS: Oral and maxillofacial surgery; CTVS: Cardiothoracic and vascular surgery; DSA: distribution services agreement

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In the pre-COVID era, 73.71% of the cases were performed under general anesthesia, while 62.6% of the cases were performed under general anesthesia in the COVID era. About 18.83% of the cases in pre-COVID era were performed under spinal anesthesia and 3.5% under combined spinal and epidural anesthesia in the pre-COVID era. In the COVID era, 28.3% of the cases were under spinal anesthesia and 4.4% of the cases were under combined spinal and epidural anesthesia [Figure 5].
Figure 5: The preferred technique of anesthesia. GA: General anesthesia; SA: Spinal anesthesia, CSE: Combined spinal epidural; RA: Regional anesthesia (Peripheral nerve blocks); LA: Local anesthesia (without sedation); MAC: Monitored anesthesia care

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About 99% of the patients undergoing surgery in the COVID era were COVID-19 negative and 1% were COVID-19 positive [Figure 6].
Figure 6: COVID status of the patients undergoing surgery

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  Discussion Top


With this study, our aim was to assess the impact that the COVID-19 pandemic had on surgical practices in India. With the onset of the pandemic in March 2020, to prepare better for the onslaught of COVID-19 cases that was expected and to ensure the safety of both the patients and health-care personnel, a decision was taken to close down the outpatient departments and to postpone all electively undertaken procedures until such time as the pandemic was brought under control.

For the patients, while it implied that their surgeries would be postponed for the unforeseeable future if not emergent or urgent, it also meant that they would not be unnecessarily exposed to the virus. With the increase in the number of COVID-19 cases, the majority of the workforce of the hospital was shunted from the “nonCOVID” areas to the emergency department, the wards, and the intensive care units housing the patients infected with the coronavirus. A reduction in workforce necessitated the admission of patients not infected with the coronavirus on a priority basis, that is, to admit only those patients in whom any delay in intervention would lead to loss of limb or life or would worsen the prognosis of their disease. Patients admitted to the hospital for any complaint had to undergo mandatory isolation, with no visitors allowed until the COVID testing of both the patient and the relatives was reported negative. Even with all the precautions in place, the patients still faced the risk of contracting the virus in the hospital.

The surgeons had the added burden of having to prioritize the patients, of ensuring the safety of the operating team, risking exposure to the virus, having to learn to operate while using a PPE, which more often than not, caused visibility issues and, in a lot of places, they also had to deal with the shortage of PPE. They faced the risk of exposure to aerosols, to viral particles in the blood and other bodily fluids handled. Laparoscopic surgery required the smallest possible incision for the ports, minimal CO2 insufflation pressure, avoidance of sutures with extracorporeal knots which required the ports to be opened, ultrafiltration for smoke, and safe evacuation of the pneumoperitoneum before closure or conversion to open surgery. Open surgeries presented their own set of challenges. They had to be performed taking care to generate the minimal amount of aerosols by keeping the electrocautery settings at the minimum possible, by the judicious use of energy devices, lasers, and drills. Laparoscopic surgeries were to be performed only if absolutely essential.[2] Patients who were infected with the coronavirus and also required emergency surgical intervention, had to be assessed, keeping in mind the COVID-related illnesses that the patient might suffer from.

The anesthesiologists had to be well versed in the latest guidelines while handling the patient's airway, ensuring that the airway is secured with extra protective measures in place to minimize exposure to the aerosols which are inevitably generated during the procedure. The risk of transmission of the virus through fomites warranted the proper cleaning and sterilization of the anesthesia equipment and the anesthesia workstations. The massive amount of aerosols generated during intubation prompted the anesthesiologist to perform as many cases under regional anesthesia as possible. New safety checklists had to be adhered to and they had to keep themselves updated with the changing guidelines as new discoveries were made.

In order to prevent the iatrogenic transmission of the coronavirus to patients, the hospitals which had the facilities to do so had to have a dedicated OT for patients who were COVID positive. Apart from this, various other measures had to be put into place to ensure the safety of the patients and the health-care workers, which included the proper sanitization of the OTs in between cases, having a negative pressure system in the OT, effective smoke extraction, performing the surgery with the minimum number of persons required, use of disposables as much as possible and ensuring the proper sanitization of those materials which were not disposable. A separate area had to be provided for donning and doffing the PPE, and routes had to be marked for the transport of the patients.

The lockdown resulted in a decrease in both elective and emergency procedures undertaken at the hospital, with a greater decrease in the number of elective procedures as compared to emergency surgeries. Most of the surgeries performed during the COVID era were emergencies or semiemergencies (time-limiting surgeries). A study by Wade et al. at a tertiary care hospital in the UK showed similar findings.[1]

There was a drastic decrease in the number of cases operated by both the department of orthopedics and the department of trauma surgery during the lockdown period. This can be attributed to the reduction in the number of people venturing outside their homes and probably also due to the closure of liquor shops during this period. A similar decrease in the trauma and orthopedic caseload was observed by Dass et al.[3] and Wade et al.[1] at two hospitals in the United Kingdom.

Interestingly, it was noticed that no procedure was undertaken at the cardiac catheterization laboratory during the lockdown period. Ullah et al.[4] reported a similar decrease in the number of procedures performed in the cardiac catheterization laboratory during a 10-week period in England. The reasons for this dramatic decrease are unclear – we have no data from the emergency department from the time to assess whether there was an actual decrease in the number of patients presenting with cardiac emergencies or not.

While most of the surgeries were still performed under general anesthesia, even in the COVID era, the proportion of cases that were performed under regional anesthesia was higher than in the pre-COVID era. These findings are comparable to the observations made by Wade et al.[1] in the tertiary care hospital in the UK.

An increase in the number of perioperative adverse events was observed during the COVID era (6.32%) as compared to the pre-COVID era (1.38%) [Table 1]. As most of the patients who were operated on in the COVID era were tested negative for COVID, a possible explanation for this seemingly significant increase in the perioperative adverse events could be the fact that the majority of the surgeries (45.4%) undertaken in the COVID era were emergencies. Wade et al. observed in their cohort study that a number of general surgical patients presented at a later and more advanced stage of the disease, which could also explain the increase in perioperative complications.
Table 1: Comparison of adverse events

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The hospital management had to ensure adherence to the guidelines in place for the testing of patients and health-care workers and the adequacy of resources. In a developing country such as India, resource limitation was a major problem in the health-care sector even before the pandemic. The soaring number of coronavirus cases required judicious allocation of the limited resources by the management. They also had to provide good quality PPE to the health-care workers and monitor them for signs and symptoms of COVID-19. In the event of the health-care workers contracting the disease, adequate facilities had to be prepared for their isolation and treatment.

The observations of this study show that elective surgical practice is quite significantly affected by the pandemic. With new variants of the virus spearheading the second and third waves of the pandemic and the uncertainty about the endpoint of this pandemic, it would not be practical to keep postponing the elective procedures indefinitely. A plan of action should be made to tackle the pandemic while ensuring that elective procedures do not suffer.


  Conclusion Top


This study has shown the extent to which general surgical practice was affected during the covid pandemic. There was a decrease in the number of elective surgeries performed and with an increase in the number of emergency surgeries, an increase in the perioperative adverse events was also noted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wade S, Nair G, Ayeni HA, Pawa A. A cohort study of emergency surgery caseload and regional anesthesia provision at a tertiary UK hospital during the initial COVID-19 pandemic. Cureus 2020;12:e8781.  Back to cited text no. 1
    
2.
De Simone B, Chouillard E, Di Saverio S, Pagani L, Sartelli M, Biffl WL, et al. Emergency surgery during the COVID-19 pandemic: What you need to know for practice. Ann R Coll Surg Engl 2020;102:323-32.  Back to cited text no. 2
    
3.
Dass D, Ramhamadany E, Govilkar S, Rhind JH, Ford D, Singh R, et al. How a pandemic changes trauma: Epidemiology and management of trauma admissions in the UK during COVID-19 lockdown. J Emerg Trauma Shock 2021;14:75-9.  Back to cited text no. 3
  [Full text]  
4.
Ullah A, Fraser DG, Fath-Ordoubadi F, Holt CM, Malik N. Decrease in cardiac catheterization and MI during COVID pandemic. Am Heart J Plus 2021;1:100001.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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