By Consultant Surgeon Prof. G. Sivakumar
Elective surgery or elective procedure (from the Latin: eligere, meaning to choose) is the surgery that is scheduled in advance. All patients with life-threatening situations requiring surgery are operated as an emergency, while the dilemma during this viral pandemic is only for elective conditions.
Elective surgery includes surgeries which can wait. There are patients who have no increased risk by waiting. Some of the elective surgeries can change into life-threatening emergencies. A current estimate suggests that more than 50% of all elective surgical cases have the potential to inflict significant harm on patients if cancelled or delayed.
Most of the hospitals decided to cancel all elective procedures. Cancelling leads to various scenarios that you come across when treating elective cases. It is imperative to note that transparent and informed consent and discussion with the patient about postponement is vital.
COVID is basically a respiratory disease with systemic ramification. Cardiovascular and respiratory fitness and diabetes control need reassessment.
During viraemia, fitness parameters may dramatically change. Colorectal malignancies may progress slowly while pancreatic and liver cancers may spread and metastasize rapidly. Every cell is different and hence comparing two types of cancers and their doubling time is not reliable.
Predicting benignity is difficult, anecdotal and requires enormous clinical knowledge. The inherent risks of delaying surgery for different cancers must be analyzed in the tumour board and discussed with the patient. A reasonable period of wait will not upstage cancers and in certain situations can be treated with other modalities like neoadjuvant chemotherapy.
Pre-operative assessment should include a detailed history of travel abroad/ any region with potential COVID-19 cases, contact with any COVID-19 case or history of fever, cough, sore throat, myalgia or diarrhoea. If testing facilities are available, RT-PCR+/- ELISA test for COVID 19 should be done. However, the possibility of false negatives should always be kept in mind and all precautions should be taken considering every patient as potentially infected.
Medical resources needed to manage a potential surge of coronavirus cases like ventilators, ICU facilities pose a difficult situation. Elective procedures may contribute to crowding and the spreading of the coronavirus within departments. Surgical teams should consider waiting for COVID-19 test results for patients who may be infected.
Types of elective procedures:
Elective procedures are stratified into “essential“, which implies that there is a risk of adverse outcomes by delaying surgical care, and “non-essential” for an undetermined period of time like cosmetic surgeries, weight loss surgeries and certain orthopaedic procedures.
Based on surgical judgment and resource availability, patients should get appropriate and timely surgical care. Non-operative management is advised when it is clinically appropriate for patients. With anticipated staffing shortages, surgical procedures at night should be avoided.
Aerosol generating procedures such as intubation and electrocautery, increase the risk not only for the patient but also for the entire operating team. If aerosol-generating procedures are unavoidable, surgical staff should wear full personal protective equipment including an N95 mask or powered, air-purifying respirator designed for operating room use. Although there is emerging data to make recommendations regarding choosing open surgery vs. laparoscopic approach, surgical teams should pick an approach that reduces operating room time and increases the safety of patients and healthcare workers.
Patients should receive appropriate and timely surgical care, including operative management, based on sound surgical judgment and availability of resources.
For elective cases that have a high likelihood of postoperative ICU or ventilator utilization, it is imperative that the risk of delay to the individual patient is balanced against the imminent availability of resources for patients with COVID-19.
Others believe that the decision should be made on a case-by-case basis, taking into account a patient’s prognosis without the procedure. Elective surgeries and procedures often make up a significant percentage of healthcare provider revenue. Postponing these procedures will undoubtedly have significant financial ramifications.
The ‘co-morbids’ as they are referred to are the cardiorespiratory dysfunctions and poor major vital organs’ functional reserve. These raise the operative risk for all the major surgeries and anaesthesia performed during the present COVID-19 pandemic.
Research studies published have reviewed the literature on these considerations in relation to COVID-19. Elective surgeries for conditions like benign thyroid swellings, ortho corrective surgeries, cosmetic and obesity surgeries may be postponed.
Progressive surgical situations that require surgeries like CABGs, early malignancies, cesarean section etc need clinical wisdom. The increased work-related nosocomial infections and the availability of ICU facilities must be considered while planning elective surgeries.
Several guidelines have been issued from surgical societies across the globe, which essentially insist on avoiding/delaying elective cases, while emergency and semi urgent cases (selected malignancy) can be performed taking full safety precautions for the patient and the entire theatre team.