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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 30-34

Gastrointestinal surgery and COVID-19 in India


Department of HPB Surgery and Liver Transplant, BLK Superspeciality Hospital, Delhi, India

Date of Submission19-Jun-2020
Date of Acceptance03-Jul-2020
Date of Web Publication11-Aug-2020

Correspondence Address:
Sandeep K Jha
BL Kapur Superspeciality Hospital, Pusa Road, New Delhi - 11005
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_6_20

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  Abstract 

COVID crisis has significantly impacted the delivery of gastrointestinal (GI) surgery services. It may also adversely compromise the patient survival. Initially, COVID crisis lead to complete shutdown of all GI surgery cases. However, with time, we have learnt from global experiences and adapted them to our own institution to resume essential GI surgery cases. This narrative review chronicles the changes in our protocol and practices to navigate through these difficult times. These may act as roadmaps for other GI surgery centers to implement. Furthermore, the planned strategies to resume nonessential GI surgery cases have also been reviewed.

Keywords: Colorectal surgery, COVID-19, gastrointestinal surgery, pancreatic surgery, pandemic


How to cite this article:
Jha SK, Chaudhary A. Gastrointestinal surgery and COVID-19 in India. Indian J Colo-Rectal Surg 2019;2:30-4

How to cite this URL:
Jha SK, Chaudhary A. Gastrointestinal surgery and COVID-19 in India. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 30];2:30-4. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/2/30/291868


  Introduction Top


COVID-19 struck India on 30th of January with the first-reported case from an Indian student in Wuhan. Since then the pandemic gained a stronghold on the entire country notwithstanding the various phases of the lockdown. The worst of the pandemic is far from over; however, the lockdown did manage to flatten and curve as intended. Furthermore, the virulence of the virus is said to be on the decline since India has a reported a much lower number of cases and deaths per million population.

By the beginning of June, gradual opening up of lockdown has been ordered to rescue the economy, but it has resulted in significant increase in number of cases hinting toward a community spread. At the time of writing this article, the COVID number was as shown in [Figure 1]:
Figure 1: Current situation of COVID-19 in India

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Pandemic may be categorized as a disaster or mass casualty incident “when the destructive effects of natural or man-made forces overwhelm the ability of a given area or community to meet the demand for health care,”[1] COVID-19 had been declared a pandemic by the World Health Organization on March 11, 2020.[2]


  Gastrointestinal Surgery in India - Challenges in COVID ERA Top


COVID is expected to compromise the overall survival of patients; however, the readiness of the surgical teams globally suggests that its going to be a good fight. In the context of ongoing pandemic, gastrointestinal (GI) surgeons faced a challenge of careful crisis management. The importance of timely management had to be balanced with prudence of pandemic. After the initial chaos, it slowly became obvious that this pandemic was going to impact the services for 6–12 months. Elective abdominal surgery is not an optional surgery; it may seem nonurgent but definitely not unnecessary. Hence, clear strategies were required to navigate through the pandemic as well as postpandemic era.

The list of limiting factors were many starting with sanitizers, N95 masks, gloves, personal protective equipment (PPE) kits, visors, social-distancing protocols, etc. Once these issues were addressed the most crucial limiting factor to emerge was availability of ventilators and ICU capacity. The next most important limiting factors to emerge were staffing problems at all levels, for example, doctors, nurses, technicians, etc. Once these logistical issues were addressed then came the issue of triaging the patients. The first response was to put the malignant cases on neoadjuvant chemoradiotherapy; however, the futility of such an approach was quickly apparent and need for more formal and robust method of triaging was required. The parameters were decided and protocols formed on how to prioritize, postpone or refuse particular patients. Next was the need to establish clearly-worded, easy protocols for OPD consultations, OT movements, intubation protocols, surgical procedures including instrumentation, OT staffing and movements, postoperative protocols, and postdischarge protocols. As GI surgeons, these challenges were in front of us as also it was for multitude of surgical teams across the globes. Surgical teams globally have met this challenge head on and experiences and communications from teams across the world helped us to formulate our own path and navigate this pandemic tsunami. Here, we chronicle our experience in a GI surgery department at a quaternary center in Delhi. Moreover, although the pandemic is far from over, it seems we may have made the necessary adjustments to meet the demands of GI surgery case-load in these challenging times.

As a survey of GI surgeons[3] suggested a significant decrease in patient referral (~90%) and nearly 60% of them said that COVID had significantly impacted the ongoing treatment of patients. Complete lockdown was announced across India on 25th March, and implementation was exemplary. The impact on GI surgery was almost immediate. The OPD consultations and OT list were almost negligible compared to prepandemic era. This was attributed to apprehension, norms of social distancing, avoidance of person-to-person contact, and the general perception that hospitals are the hotspots for transmission that lead to lower referrals and footfalls. The much vaunted tele-consultations were unable to bridge the gap. Preoperative consultations, laboratory services, imaging services, multidisciplinary tumor, and transplant boards were all curtailed. The patient with GI malignancies was clinically evaluated but put on hold for at least 2 weeks and nonurgent cases were put on hold indefinitely. Routine follow-up consultations were discouraged including posttransplant patients. For close to 2 weeks, there was no operative activity as every vertical tried to gauze the impact and chart their crisis management strategy. Clinical staff on our team was then divided into two groups. One group was active for 3 days at a stretch and was responsible for all operative, clinical, and nonclinical work. The 2nd team would take over for the second half of the week. Even among the two groups, personnel for inpatient and outpatient were not allowed to intermingle. Operating surgeons and scrub staff protective checklist were decided and included FFP3 facial mask, long sleeve waterproof coats, gowns, double pair of nitrile gloves, protective goggles or visors, head caps, and long shoe covers. The PPE donning and doffing protocols were also institutionalized. Movement of personnel, trolleys, handovers, and preoperative patients had to be streamlined. Operational directives [Figure 2] published by Coccolini et al.[4] laid the foundations over which our own protocols were developed. Since COVID patients were expected at our center later during the COVID crisis, movement corridors were planned avoiding COVID areas and elevators.
Figure 2: COVID-19 surgical patient management flowchart[4]

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The idea was to create a “invisible barrier” between critical, immunocompromised, and elderly patients, from excess hospital foot traffic. All meetings were limited to five persons with 6 feet distance with adequate protective gears. Virtual platforms were recommended almost exclusively for departmental rounds and to maintain continuity of care. Daily ward rounds were scheduled on online meeting application for midday where all departmental personnel were present. Notwithstanding the initial glitches, it led to participation from all members of the team and more constructive inputs. With more experience, academic programs, multidisciplinary tumor, and transplant board meetings were also shifted to virtual meeting platform. Visitor restrictions culminating in a no-visitor policy were established quiet early during the COVID crisis.


  “to Delay or not to Delay”: Surgical Perspective Top


COVID crisis triggered a near-complete shutdown of elective surgical services in India. Suspending operative activity as part of the management of COVID crisis seemed rational. However, that lead to the delay of surgery for those who need it and the risk of progression which would lead to higher mortality in GI disease especially malignancies. For certain GI malignancies, progression can occur as early as 4–8 weeks, well within the expected delay of elective surgery due to the pandemic.

Delays in elective GI surgery would be also be on account of curtailed allied services such as radiology, endoscopy, biopsies, and pathology. Ethical questions such as beneficence, patient autonomy, informed consent, overtreatment, and withdrawal of care were intimately related to the decision to delay or not to delay.

The decision to delay or proceed with surgery was taken after complete evaluation of patient factors, surgery factors, and disease factors. Once our risk/benefit analysis through a multidisciplinary discussion led to a decision, it was communicated to the patient. However, the final decision was left to the patient wishes although assisting him all the while to arrive at a decision. Most of the times due to the lack of substantial evidence to advocate either ways, we went in accordance with a patient's wishes.

The challenge was to devise a model that despite current imbalances between demand and supply did not deviate from surgical indications guided by scientific evidence in GI malignancies. Falling back on worldwide experience, we utilized a prioritization study for malignancies emanating from Lombardi, Italy by Mazzaferro et al.[5] Learning from their experience with the COVID crisis, they developed a prioritization model balancing various disease and patient-related factors. The patients were categorized into four categories and surgery scheduled accordingly [Figure 3].
Figure 3: Model for prioritization for surgery in gastrointestinal malignancies[5]

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Various other guidelines have been published by surgical societies such as SSO,[6] SAGES, EAES,[7] and ACS[8] to provide the guidelines to surgeons and institutions globally. O'Leary et al.[9] have elaborated considerably management considerations in colorectal cancer during the COVID crisis. Oba et al.[10] have elaborated similarly about pancreatic malignancies based on a large, multi-institutional-based survey.


  Gastrointestinal Malignancies during COVID Crisis: Surgical Perspective Top


Reports from early on during the COVID crisis reported increased mortality (~20%) during routine elective surgery.[11] The prevalence of malignancies was also higher in COVID patients. Postoperative morbidity was also significantly higher in COVID patients with or without symptoms. With limited availability of PCR test, every surgical patient was considered to be asymptomatic carrier.[11] With more experiences from across the world, better availability of PCR testing and with more objective assessment of the situation, a more rational approach was developed. We started testing the asymptomatic patients planned for GI surgical procedure at initial presentation and once again 24 h before the elective surgery.

GI surgery is usually a major surgery requiring substantial resource and workforce utilization along with a long posthospital.[12] Operative times are longer with utilization of significant amount of disposable (PPE's, goens, masks, and shoe cover), and nondisposable resources. Personnel constituting a large surgical team, including multiple surgeons, nurses, operating room technicians, and anesthesia staff are required and procedures with high risk of aerosolization is routinely done such as intubation, extubation, and laparoscopy.[13] Peritoneal fluid, GI secretions, and ascites were isolated with high viral load and risk of aerosolization associated with the use of electrocautery and ultrasonic shear.[14],[15],[16]

During the postoperative course, early recovery after surgery protocols was implemented. However, 5–6 days of hospitalization was routine in most of the cases and even longer in case of complications. There were more intensive resource utilizations in patients with complications such as blood bank services, diagnostic and interventional radiology, critical care personnel, and reoperations. Due to the strict restrictions on visitations by attendants, the usual support systems of friends and family members were missing. Due to rationing of personnel, the patient had reduced access to their operating surgeons. Due to curtailment of traditional rounds to minimize person-to-person contacts, patients had lesser opportunity to voice their concerns and get re-assurance. However, the patients and attendants were encouraged to make liberal use of other tools of communications such as telephone, messaging, and online consultations to address their issues.

Patients were counseled and primed for early discharge beginning in the preoperative period. Close postoperative follow-up is required in such patients to diagnose the complications early. Careful counseling and setting reasonable expectations from the surgery help patients to go through the postoperative period smoothly. Ostomy education in the patient is begun preoperatively and established after the return of bowel functions. The patient and attendants are demonstrated about stoma care. Physiotherapy goals and expectations are established from the 1st postoperative day. Daily status of patient was monitored by telephonic conversation for the 1st week after discharge, and they were encouraged to call to update about any developments.

The decision to proceed or delay surgery arrived after a complex risk-benefit analysis consisting of patient, surgery, and disease factors in a multidisciplinary meeting. In case, the decision was taken to delay the surgery for a later date, the patient was put on a follow-up protocol to closely monitor and schedule the surgery or intervention according to development of the COVID crisis. The patient was also encouraged to utilize the online consultation or messaging services in case of any development or if he is reconsidering his decision.


  Minimal Invasive Surgery during COVID Times Top


Minimal invasive surgery offers the advantage of earlier discharge of patient with shorter hospital stay which is hugely beneficial in COVID times. However, it also involves longer operative times and higher risk of aerosolization due to the use of energy devices and generation of surgical smoke. As recommended by Vigneswaran et al.,[14] modifications are warranted in instrumentation and surgical technique to prevent aerosolization and exposure to OT staff. Among the important suggestions, we implemented were minimizing the use of energy devices and no use of ultrasonic shears. Lower energy settings minimize the generation of surgical smoke. For effective evacuation of smoke, we installed closed circuit-HEPA filter smoke evacuation device. The pneumoperitoneum was kept below 12 mm Hg whenever possible and abdomen was desufflated using a smoke evacuation device. Elaborate guidelines from SAGES and EAES[17] have been published regarding minimal invasive surgery.


  So When Do We Go Back to Normal? Top


Given the worldwide impact of COVID-19, its difficult to say when things will be back to normal. However, as surgeons resumption of elective surgery and busy OT schedules should feel like normal to us. While administrative authorities will authorize and announce resumption of normal activities, we need to be prepared to handle increased case-loads post the pandemic.[18] This time should be utilized to procure appropriate number of ICU and non-ICU beds, PPE, ventilators, medications, anesthetics, and all medical surgical supplies. Anticipated personnel problems, including trained staffed and doctors to handle planned procedures and aligned with hospital resources, should be in place. The facility should check their preparedness to handle all patients that require hospitalization without landing into another crisis. Surgical team should have a ready list of deferred, cancelled, or postponed cases. These cases should be arranged on the basis of priority and called for consultations accordingly. Various tools are available to prioritize these patients and one of them is the MeNTS instrument that can be utilized.[19] Certain specialties will need consideration over others and these issues should be sorted out. Gradual opening up of operation theaters should be planned with gradual scaling up of operative case load along with proportional allocation of resources and workforce [Figure 4].
Figure 4: Model for resumption of surgical cases in phases

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Another dynamic plan of balancing the resource utilization with patient urgency was reported by Coleman et al.[20] from New York. They developed a Resource Intensity Class System that maps the requirement of each case and then combines it with the knowledge of immediately available resources assess the cases that can be reasonably accommodate. Later, they developed the Urgency Intensity Grid that maps the resource intensity on X-axis and urgency of the case on Y-axis. This provides a snapshot of waitlist and can be used for equitable division of resources across various cases. We are yet to implement this plan; however, the urgency intensity grid may ensure efficiency and optimal resource utilization even beyond the COVID crisis.


  Conclusion Top


GI surgery is resource intensive and patients with GI disease cannot be deferred indefinitely. COVID crisis has resulted in significant compromise in services leading to a negative impact on patient survival. However, we have learnt from experiences from around the world and managed to march toward normalcy. Clarity on protocols, responding to challenges, and triaging of patients with optimum utilization of resources has allowed us to maintain optimal services. COVID crisis is still on the upward curve and the ultimate impact is yet to be seen. However, a clear plan enacted by effective and motivated personnel will ensure optimal delivery of gastrointestinal surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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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;15:25.  Back to cited text no. 4
    
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Society of Surgical Oncology. Resource for Management Options of GI and HPB Cancers. Society of Surgical Oncology; 2020. Available from: https://www.surgonc.org/wp-content/uploads/2020/03/GIand-HPB-Resource-during-COVID-19-4.6.20.pdf. [Last accessed on 2020 Apr 06].  Back to cited text no. 6
    
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Society oq2'f American Gastrointestinal and Endoscopic Surgeons (SAGES). SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis. Available from: https://www.sages.org/recommendations-surgical-response-covid-19/. [Last accessed on 2020 Apr 11].  Back to cited text no. 7
    
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