Addressing Concerns About Returning To Elective Surgery During The COVID-19 Pandemic

After almost 10 weeks of postponing elective surgery, I returned to the operating room two weeks ago. With mixed guidance from the state of Maryland on COVID-19 testing protocol prior to outpatient surgery, the proper way to proceed with cases at my preferred surgical center was confusing to me. 

My first case after our hiatus was a 15-year-old female who had isolated with her mother at home since schools closed in March. Though I assumed all patients having surgery would undergo preoperative testing for SARS-CoV-2, it was difficult to require testing on a healthy young person with no symptoms, no exposure to anyone with COVID-19 and no time in the world outside her home for over a month.  

Yet something about the continued realization that there is so much unknown about this virus made me uneasy about this approach. Since that time, I now require all my surgical patients to have testing for COVID-19 Patients seem perfectly willing to do this after I discuss the increased postoperative mortality rate reported in The Lancet through an international cohort study and the increased risk posed to health-care workers in the operating room.^1,2   

Initial recommendations for cancellation of elective surgery by governments and professional organizations intended to protect patients and health care workers, reduce burden on hospital bed capacity and ensure adequate supplies of personal protective equipment (PPE).¹ At present in my region of the country, hospital bed utilization has decreased so there is ample capacity. There is enough PPE. The move toward resuming elective procedures makes sense. However, the last piece pertaining to protection of patients and health-care workers seems hard to ensure without more information on adequate screening and testing.

Consider the findings from the COVIDSurg Collaborative report.³ Researchers assessed postoperative outcomes in 1,128 adults diagnosed with COVID-19 after surgery. These patients underwent a range of various procedures at 235 different hospitals with 24 countries participating in the study.³ There was an overall postoperative mortality rate at 30 days of 23.8 percent with pulmonary complications in 51.2 percent, accounting for 82.6 percent of the deaths. One should note that there was no control group for this study and data collection stemmed from cases identified by investigators on site. This could lead to bias since patients with a normal postoperative course were not likely to be tested for SARS CoV-2.  

In spite of this, the results are significant because the rate of poor outcomes is so much higher than those physicians usually seen with major surgery.^1,3 Mortality rates for patients having minor or elective surgery are typically under one percent, but the mortality rate in this particular study was 16.3 percent for “minor surgery” and 18.9 percent for “elective surgery.”³ This leads to the conclusion that postoperative outcomes in SARS-CoV-2-infected patients are exponentially worse than what physicians would expect for patients who do not have the virus.³

While patient history is helpful, this cannot be enough information to protect health care workers in the operating room and surgical facility, especially during aerosol-generating procedures. A population screening study in Iceland found that 43 percent of patients testing positive for SARS-CoV-2 were asymptomatic.⁴ Each of the four times I have now been at the surgical center, the anesthesiologist has mentioned the surprising number of positive tests in asymptomatic women in labor and delivery at the large hospital where he also works. Researchers have also documented this phenomenon in multiple New York hospitals.⁴   

While it may seem obvious that testing is the best answer to all of the uncertainty, there are variables in testing ability, with dependency on sampling technique, test performed, fluid sampled and the timing of test within the course of infection. Up to 30 percent of patients with infection can see false negatives due to these variables and sensitivity of SARS-CoV-2 testing.⁴ Detection of the virus usually uses polymerase chain reaction (PCR) to identify the viral RNA through nucleic acid amplification. The swabs for this are more sensitive when one takes them from the nasopharynx as opposed to the oropharynx. 

Detection through serology counts IgM, IgA, IgG or total antibodies caused by white blood cells in response to infection. This antibody response takes time and studies suggest that with SARS-CoV-2, seroconversion may be seven to 11 days after exposure to the virus. This type of testing is not helpful for the acute setting or in detection prior to outpatient surgery. It is unknown if patients with antibodies will experience protection in full or even partially from future infection with SARS-CoV-2.² 

Al-Muharraqi’s article in the June 2020 issue of the British Journal of Oral Maxillofacial Surgery is informative with a defined approach and testing recommendations for patients scheduled for surgery.2 Taking the facts available at present, the author worked with the assumption that all patients are potential carriers of the virus throughout their hospital stay. This is regardless of passing pre-assessment triage, having normal temperatures, not having travel or exposure history, and having no respiratory symptoms. Patients are screened via PCR and serology 24 hours prior to surgery. If the PCR test is positive, the patient must isolate and postpone surgery. If the patient has a negative PCR test and a positive antibody test, then the patient will not require more testing during his or her hospital stay. If the patient’s PCR and antibody test are both negative, then the patient will retest via PCR each week of his or her hospital stay.² 

Translating this into an algorithm for outpatient surgery can have some challenges. Access to testing is not always straightforward and the length of time to results can vary greatly. This puts the patient in the position of strict isolation from the time of testing until the surgical procedure. However, the evidence to date indicates that this is in the best interest of everyone involved. It is not enough to rely on pre-assessment screening questions and a lack of symptoms. The limited data currently available overwhelmingly points to the benefit in knowing if a patient is COVID-19-positive prior to choosing to perform elective surgery.³ 

Dr. Schwartz is the Scientific Conference Chair and a Past President of the American Association for Women Podiatrists. She is board-certified in foot surgery by the American Board of Foot and Ankle Surgery, and practices with Foot and Ankle Specialists of the Mid-Atlantic in Washington, DC and Chevy Chase, Md. 

References

1. Myles PS, Maswime S. Mitigating the risks of surgery during the COVID-19 pandemic. Lancet. 2020. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31256-3/fulltext . Published May 29, 2020. Accessed June 15, 2020.
2. Al-Muharraqi MA. Testing recommendation for COVID-19 (SARS-CoV-2) in patients planned for surgery- continuing the service and ‘suppressing’ the pandemic. Br J Oral Maxillofac Surg. 2020;58(5):503-505.
3. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020. Available at: https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31182-X.pdf . Published May 29, 2020. Updated June 9, 2020. Accessed June 15, 2020. //Dr. Schwartz is this reference okay? It directly references the COVIDSurg collaborative.//
4. American Society of Anesthesiologists, Anesthesia Patient Safety Foundation. The ASA and APSF Joint Statement on Perioperative Testing for COVID-19 Virus. Avaliable at: https://www.asahq.org/about-asa/newsroom/news-releases/2020/04/asa-and-apsf-joint-statement-on-perioperative-testing-for-the-covid-19-virus . Published June 3, 2020. Accessed June 15, 2020.