May 17, 2020: Posted by Ankit Raj
The CovidSurg collaborative study estimates that over 28 million operations could be cancelled or postponed during the peak 12 weeks of COVID-19 related disruptions (2,367,050 operations per week). Breaking this down, this includes 81.7% of benign surgery, 37.7% of cancer surgery, and 25.4% of elective caesarean sections globally.
Even if countries increase their normal surgical volumes by 20% in the post-pandemic period, it would take an approximate 45 weeks to just clear the backlog from COVID-19 disruptions. Surgical systems will have to be substantially funded to clear this backlog with an estimate cost of over 2 billion GBP just for the United Kingdom to just clear the backlog of their surgical volumes. (COVIDSurg Collaborative 2020)
This may just be the tip of an iceberg and as the crisis unfolds and the pandemic grows, we may learn more about the direct and indirect effects of COVID-19 pandemic on surgical ecosystems worldwide.
Alongside elective and non-essential surgical services being delayed or cancelled in light of the pandemic situation, emergency and essential surgical services also get affected in more ways than one. In many places, due to a limited set of resources, both material and human resources from surgical units are redirected to fighting the COVID-19 pandemic on the frontline. These include re-routing ventilators, previously available in operating rooms and post-op care to critical care support of COVID-19 patients and the transferring surgeons and nurses from surgical units to emergency and COVID-19 ward services. For emergency and essential surgeries that do get performed, newer difficulties arise in terms of high quality protection of surgical personnel from COVID-19.
The surgical crisis surrounding COVID-19 pandemic is accentuated in lower- and middle-income countries and in regions with limited resources.(Ma X et al 2020) These places which were already functioning on thin resources will have to face devastating consequences in the long run. Morbidity and mortality figures resulting from the ripples of COVID-19 pandemic indirectly on surgical services and ecosystem remains unestimated and beyond current comprehension.
As the COVID-19 crisis is estimated to continue for a while now, or at least as long as a definite vaccine or treatment arrives, its impact on surgical services will also continue to bear ramifications. Many of the erstwhile guidelines, norms and protocols will clash with newer guidelines related to COVID-19. For instance, positive pressure maintained in many operating rooms are now considered as a potential airborne generating source. Similarly, many equipment and devices in operating rooms will have to be studied for their surface stability of COVID-19 virus. There may also be interests from patients, their attendants and the doctors themselves to minimize the surgical treatments and instead shift to medical management as much as possible. Screening of COVID-19 may become part of mandatory pre-operative list of investigations and may lead to an additional delay in surgeries without the advent of a faster screening test.
What makes the situation more interesting is that screening may need to be done for both the patients and their team of surgeons and nursing staff. Much smaller and often missed issues like longer time in donning and doffing PPEs and recommendation to include Rapid Sequence Intubation by anesthesia teams will have additional impact on how surgery is delivered at many places globally.
As many nations emerge from their worst period of pandemic and either flatten the curve or cross their peak of the curve, it is essential to discuss the continuing ramifications of this pandemic on the surgical ecosystem. It will take additional set of resources and a long time to mitigate the impact of COVID-19 on surgical services around the world. The role of advocacy and research in global surgery will also become heavily important as much of the ground gained on improving access to surgical services will be lost in the due process.
1.COVIDSurg Collaborative, Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. British Journal of Surgery. 2020. doi:10.1002/bjs.11746
2.Ma X, Vervoort D, Reddy CL, Park KB, Makasa E, Emergency and essential surgical healthcare services during COVID-19 in low- and middle-income countries: A Perspective, International Journal of Surgery, https://doi.org/10.1016/j.ijsu.2020.05.037
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