Battling against the great disruption to surgical care in a pandemic: experiences of 11 South and Southeast Asian countries.

OBJECTIVES: The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic. DESIGN: Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis. RESULTS: The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions. CONCLUSION: This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption.

Disruption of joint arthroplasty services in Europe during the COVID-19 pandemic: an online survey within the European Hip Society (EHS) and the European Knee Associates (EKA).

PURPOSE: The aim of the present study was to evaluate the impact of the coronavirus (COVID-19) pandemic on joint arthroplasty service in Europe by conducting an online survey of arthroplasty surgeons. METHODS: The survey was conducted in the European Hip Society (EHS) and the European Knee Associates (EKA). The survey consisted of 20 questions (single, multiple choice, ranked). Four topics were addressed: (1) origin and surgical experience of the participant (four questions); (2) potential disruption of arthroplasty surgeries (12 questions); (3) influence of the COVID-19 pandemic on the particular arthroplasty surgeon (four questions); (4) a matrix provided 14 different arthroplasty surgeries and the participant was asked to state whether dedicated surgery was stopped, delayed or cancelled. RESULTS: Two-hundred and seventy-two surgeons (217 EHS, 55 EKA) from 40 different countries participated. Of the respondents, 25.7% stated that all surgeries were cancelled in their departments, while 68.4% responded that elective inpatient procedures were no longer being performed. With regard to the specific surgical procedures, nearly all primary TJA were cancelled (92.6%) as well as aseptic revisions (94.7%). In most hospitals, periprosthetic fractures (87.2%), hip arthroplasty for femoral neck fractures and septic revisions for acute infections (75.8%) were still being performed. CONCLUSION: During the current 2020 COVID-19 pandemic, we are experiencing a near-total shutdown of TJA. A massive cutback was observed for primary TJA and revision TJA, even in massively failed TJA with collapse, dislocation, component failure or imminent dislocation. Only life-threatening pathologies like periprosthetic fractures and acute septic TJA are currently undergoing surgical treatment. LEVEL OF EVIDENCE: V.

Massive cutback in orthopaedic healthcare services due to the COVID-19 pandemic.

PURPOSE: Due to the lack of evidence, it was the aim of the study to investigate current possible cutbacks in orthopaedic healthcare due to the coronavirus disease 2019 pandemic (COVID-19). METHODS: An online survey was performed of orthopaedic surgeons in the German-speaking Arthroscopy Society (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA). The survey consisted of 20 questions concerning four topics: four questions addressed the origin and surgical experience of the participant, 12 questions dealt with potential cutbacks in orthopaedic healthcare and 4 questions addressed the influence of the pandemic on the particular surgeon. RESULTS: Of 4234 contacted orthopaedic surgeons, 1399 responded. Regarding arthroscopic procedures between 10 and 30% of the participants stated that these were still being performed-with actual percentages depending on the specific joint and procedure. Only 6.2% of the participants stated that elective total joint arthroplasty was still being performed at their centre. In addition, physical rehabilitation and surgeons' postoperative follow-ups were severely affected. CONCLUSION: Orthopaedic healthcare services in Austria, Germany, and Switzerland are suffering a drastic cutback due to COVID-19. A drastic reduction in arthroscopic procedures like rotator cuff repair and cruciate ligament reconstruction and an almost total shutdown of elective total joint arthroplasty were reported. Long-term consequences cannot be predicted yet. The described disruption in orthopaedic healthcare services has to be viewed as historic. LEVEL OF EVIDENCE: V.

The Impact of the COVID-19 Pandemic on Corneal Transplantation in Brazil.

PURPOSE: The purpose of this study was to evaluate the impact of the coronavirus disease 2019 pandemic on corneal transplantation (CT) in Brazil. METHODS: Data from patients who underwent CT at the Hospital Oftalmológico de Sorocaba (HOS), Brazil, were analyzed. National and state numbers of keratoplasties, patients added to the CT waiting list, and total patients on the waiting list were also obtained. Baseline prepandemic (from January 1, 2019, to March 31, 2020) data were compared with 2 time frames of the coronavirus disease 2019 pandemic: elective CT suspension period (between April 1, 2020, and September 31, 2020) and after elective CT resumption (between October 1, 2020, and April 30, 2021). RESULTS: Despite elective CT resumption after the moratorium, the monthly CT rates did not return to baseline at HOS (-14.7%, P = 0.007), São Paulo state (-19.1%, P = 0.001), or Brazil (-30.1%, P < 0.001). The waiting list increased significantly regionally (P < 0.001) and nationally (P < 0.001). Among optical keratoplasties performed at HOS after resuming elective CTs, the proportion of endothelial keratoplasties declined from 38.2% to 30.0% (P < 0.001), whereas penetrating keratoplasties increased from 33.2% to 39.5% (P < 0.001) when comparing with prepandemic data. CONCLUSIONS: Keratoplasty numbers dropped significantly locally, regionally, and nationally. Hence, the CT waiting lists had a progressive increase, with significant long-term implications. An estimated increment on monthly CT rates of approximately 34% in São Paulo state, and 91% in Brazil, is required for the CT waiting list to get back to prepandemic numbers over the next 2 years.

Trends in US Surgical Procedures and Health Care System Response to Policies Curtailing Elective Surgical Operations During the COVID-19 Pandemic.

Importance: The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. Objective: To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19. Design, Setting, and Participants: This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. Exposures: 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. Main Outcomes and Measures: Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications. Results: A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = -0.00025; 95% CI, -0.0042 to -0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = -0.00034; 95% CI, -0.0075 to 0.00007; P = .11). Conclusions and Relevance: This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.

The ophthalmic surgical backlog associated with the COVID-19 pandemic: a population-based and microsimulation modelling study.

BACKGROUND: Jurisdictions worldwide ramped down ophthalmic surgeries to mitigate the effects of COVID-19, creating a global surgical backlog. We sought to predict the long-term impact of COVID-19 on the timely delivery of non-emergent ophthalmology sub-specialty surgical care in Ontario. METHODS: This is a microsimulation modelling study. We used provincial population-based administrative data from the Wait Time Information System database in Ontario for January 2019 to May 2021 and facility-level data for March 2018 to May 2021 to estimate the backlog size and wait times associated with the COVID-19 pandemic. For the postpandemic recovery phase, we estimated the resources required to clear the backlog of patients accumulated on the wait-list during the pandemic. Outcomes were accrued over a time horizon of 3 years. RESULTS: A total of 56 923 patients were on the wait-list in the province of Ontario awaiting non-emergency ophthalmic surgery as of Mar. 15, 2020. The number of non-emergency surgeries performed in the province decreased by 97% in May 2020 and by 80% in May 2021 compared with the same months in 2019. By 2 years and 3 years since the start of the pandemic, the overall estimated number of patients awaiting surgery grew by 129% and 150%, respectively. The estimated mean wait time for patients for all subspecialty surgeries increased to 282 (standard deviation [SD] 91) days in March 2023 compared with 94 (SD 97) days in 2019. The provincial monthly additional resources required to clear the backlog by March 2023 was estimated to be a 34% escalation from the prepandemic volumes (4626 additional surgeries). INTERPRETATION: The estimates from this microsimulation modelling study suggest that the magnitude of the ophthalmic surgical backlog from the COVID-19 pandemic has important implications for the recovery phase. This model can be adapted to other jurisdictions to assist with recovery planning for vision-saving surgeries.

Evaluation of Public Interest in Mohs Surgery and Other Elective Surgical Procedures During the COVID-19 Pandemic.

BACKGROUND: The reallocation of health care resources to focus on the acute care needs of COVID-19 patients leads to a delay and deferral of outpatient surgical procedures such as Mohs surgery. OBJECTIVE: Planning for the resumption of regular outpatient surgical care and preparing for future surges in COVID-19 cases requires identifying surrogate markers of health care demand. MATERIALS AND METHODS: United States national and state-based Google search data for "Mohs surgery" and other common elective surgical and cosmetic procedures were evaluated. These were compared with national and state-wide COVID-19 case number and death data from the Johns Hopkins University. Pearson correlation coefficients were generated to assess the association between COVID-19 cases and deaths with Google search trends. RESULTS: Search volume for "Mohs surgery" and other elective surgical and cosmetic procedures significantly decreased as the number of new deaths from COVID-19 increased. Statistically significant inverse correlation was noted between "Mohs surgery" search volume and new COVID-19 deaths on a national and state-based level. CONCLUSION: Search metric analysis may be used as part of a big data model to help predict health care demand during the reopening phase of the COVID-19 pandemic.

Effect of COVID-19 Pandemic Restructuring on Surgical Volume and Outcomes of Non-COVID Patients Undergoing Surgery.

OBJECTIVES: COVID-19 has caused significant surgical delays as institutions minimize patient exposure to hospital settings and utilization of health care resources. We aimed to assess changes in surgical case mix and outcomes due to restructuring during the pandemic. METHODS: Patients undergoing surgery at a single tertiary care institution in the Deep South were identified using institutional ACS-NSQIP data. Primary outcome was case mix. Secondary outcomes were post-operative complications. Chi-square, ANOVA, logistic regression, and linear regression were used to compare the control (pre-COVID, Mar 2018-Mar 2020) and case (during COVID, Mar 2020-Mar 2021) groups. RESULTS: Overall, there were 6912 patients (control: 4,800 and case: 2112). Patients were 70% white, 29% black, 60% female, and 39% privately insured. Mean BMI was 30.2 (SD = 7.7) with mean age of 58.3 years (SD = 14.8). Most surgeries were with general surgery (48%), inpatient (68%), and elective (83%). On multivariable logistic regression, patients undergoing surgery during the pandemic were more likely to be male (OR: 1.14) and in SIRS (OR: 2.07) or sepsis (OR: 2.28) at the time of surgery. Patients were less likely to have dyspnea with moderate exertion (OR: .75) and were less dependent on others (partially dependent OR: .49 and totally dependent OR: .15). Surgeries were more likely to be outpatient (OR: 1.15) and with neurosurgery (OR: 1.19). On bivariate analysis, there were no differences in post-operative outcomes. CONCLUSION: Surgeries during the COVID-19 pandemic were more often outpatient without differences in post-operative outcomes. Additional analysis is needed to determine the impact of duration of operative delay on surgical outcomes with restructuring focusing more on outpatient surgeries.

Survey of the Impact of the COVID-19 Pandemic on Ophthalmology Clinical Practice in Turkey

Objectives: To investigate the effect of the novel coronavirus disease 2019 (COVID-19) pandemic on the clinical practice of ophthalmologists in our country. Materials and Methods: A questionnaire consisting of 22 questions was delivered to 250 ophthalmologists via e-mail and a smartphone messaging application. A total of 113 ophthalmologists completed the survey. The questions included the participants' demographic data (age, years in practice, institution, and city), changes in their working conditions and institutional preventive measures implemented during the pandemic, their personal COVID-19 experiences, the prevalence of telemedicine applications, and their attitudes toward these practices. Results: Nearly half (47.8%) of the 113 ophthalmologists were 36 to 45 years old. In terms of years in practice, the largest proportion of respondents (28.3%) had 6-10 years of experience. Most of the participants worked in private/foundation universities (37.2%), while 22.1% worked in education and research clinics. Participants working at public universities most often reported that they or a close contact had to work in COVID wards (89.5%). Triage was performed in 51.5% of ophthalmology outpatient clinics, with 88.0% of these participants reporting that patients with fever, cough, or dyspnea were directed to the pandemic clinic without ophthalmological examination. All participants working in public hospitals, education and research clinics, and public university hospitals had postponed elective surgeries, whereas 12.5% of those working in private practice and 20.5% of those working in private/foundation universities reported that they continued elective surgeries. While 80.8% of the participants did not conduct online interviews or examinations, 40.4% stated that they considered telemedicine applications beneficial. Seventy-seven percent of participants expressed concern about a decrease in their income during the pandemic, with this being especially common among participants working in private practice (87.5%) and private/foundation university hospitals (85.7%). Conclusion: Ophthalmologists across our country have been affected by this pandemic at a level that will change their clinical approach. We think that ophthalmologists impacted by the difficulty of providing personal protective equipment and economic concerns should be supported more during the pandemic.

The Impact of the Coronavirus Disease 2019 Pandemic on Neurosurgical Practice and Feasibility of Safe Resumption of Elective Procedures During this Era in a Large Referral Center in Tehran, Iran: An Unmatched Case-Control Study.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has considerably affected surgical practice. The present study aimed to investigate the effects of the pandemic on neurosurgical practice and the safety of the resumption of elective procedures through implementing screening protocols in a high-volume academic public center in Iran, as one of the countries severely affected by the pandemic. METHODS: This unmatched case-control study compared 2 populations of patients who underwent neurosurgical procedures between June 1, 2019 and September 1, 2019 and the same period in 2020. In the prospective part of the study, patients who underwent elective procedures were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection postoperatively to evaluate the viability of our screening protocol. RESULTS: Elective and emergency procedures showed significant reduction during the pandemic (59.4%, n = 168 vs. 71.3%, n = 380) and increase (28.7%, n = 153 vs. 40.6%, n = 115, respectively; P = 0.003). The proportional distribution of neurosurgical categories remained unchanged during the pandemic. Poisson regression showed that the reduction in total daily admissions and some categories, including spine, trauma, oncology, and infection were significantly correlated with the pandemic. Among patients who underwent elective procedures, 0 (0.0%) and 26 (16.25%) had positive test results on days 30 and 60 postoperatively, respectively. Overall mortality was comparable between the pre-COVID-19 and COVID-19 periods, yet patients with concurrent SARS-CoV-2 infection showed substantially higher mortality (65%). CONCLUSIONS: By implementing safety and screening protocols with proper resource allocation, the emergency care capacity can be maintained and the risk minimized of hospital-acquired SARS-CoV-2 infection, complications, and mortality among neurosurgical patients during the pandemic. Similarly, for elective procedures, according to available resources, hospital beds can be allocated for patients with a higher risk of delayed hospitalization and those who are concerned about the risk of hospital-acquired infection can be reassured.

Safety of elective abdominal and vascular surgery during the COVID-19 pandemic: a retrospective single-center study.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) who undergo surgery have impaired postoperative outcomes and increased mortality. Consequently, elective and semi-urgent operations on the increasing number of patients severely affected by COVID-19 have been indefinitely postponed.in many countries with unclear implications on disease progression and overall survival. The purpose of this study was to evaluate whether the establishment of a standardized screening program for acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sufficient to ensure high-quality medical and surgical treatment of COVID-19 and non-COVID-19 patients while minimizing in-hospital SARS-CoV-2 transmission. METHODS: The screening program comprised polymerase chain reaction (PCR) testing of nasopharyngeal swabs and a standardized questionnaire about potential symptoms for SARS-CoV-2 infection. All elective and emergency patients admitted to the surgical department of a tertiary-care hospital center in Lower Franconia, Germany, between March and May 2020 were included and their characteristics were recorded. RESULTS: Out of the study population (n = 657), 509 patients (77.5%) had at least one risk factor for a potentially severe course of COVID-19 and 164 patients (25%) were active smokers. The average 7-day incidence in Lower Franconia was 24.0/100,000 during the observation period. Preoperative PCR testing revealed four asymptomatic positive patients out of the 657 tested patients. No postoperative SARS-CoV-2 infection or transmission could be detected. CONCLUSION: The implementation of a standardized preoperative screening program to both COVID-19 and non-COVID-19 patients can ensure high-quality surgical care while minimizing infection risk for healthcare workers and potential in-hospital transmission.

Reduction of admissions for urgent and elective pacemaker implant during the COVID-19 outbreak in Northern Italy.

AIMS: The coronavirus disease-19 (COVID-19) outbreak has been recently associated with lower hospitalization rates for acute coronary syndromes. Aim of the study was to investigate whether a similar behaviour is observed in admissions for urgent pacemaker implant. METHODS: This retrospective study included 1315 patients from 18 hospitals in Northern Italy with a high number of COVID-19 cases. Hospitalization rates for urgent pacemaker implant were compared between the following periods: 20 February to 20 April 2020 (case period); from 1 January to 19 February 2020 (intra-year control period); from 20 February to 20 April 2019 (inter-year control period). RESULTS: The incidence rate of urgent implants was 5.0/day in the case period, 6.0/day in the intra-year control period and 5.8/day in the inter-year control period. Incidence rate in the case period was significantly lower than both the intra-year [incidence rate ratio (IRR): 0.81, 95% CI 0.67-0.99, P = 0.040] and inter-year control periods (IRR: 0.79, 95% CI 0.66-0.95, P = 0.012); this reduction was highest after the national lockdown (IRR 0.68, 95% CI 0.52-0.91, P = 0.009). The prevalence of residents in rural areas undergoing urgent pacemaker implant was lower in the case period (36%) than in both the intra-year (47%, P = 0.03) and inter-year control periods (51%, P = 0.002). Elective pacemaker implants also decreased in the case period, with the incidence rate here being 3.5/day vs. 6.4/day in the intra-year (-45%) and 6.9/day in the inter-year period (-49%). CONCLUSION: Despite severe clinical patterns, the COVID-19 outbreak has negatively affected the population presentation to Emergency Departments for bradyarrhythmias requiring urgent pacemaker implant in Northern Italy. This mainly occurred after the national lockdown and concerned patients living in rural areas.

Assessment of outcomes of elective cancer surgeries in children during coronavirus disease 2019 pandemic: Retrospective cohort study from a tertiary cancer center in India.

ABSTRACT: To describe the outcomes of elective cancer surgeries and adverse consequences on the patients and medical staff due to the surgical interventions in children during the Coronavirus Disease 2019 (COVID-19) pandemic.The study included children younger than 15 years who underwent elective cancer surgeries from March 4, 2020 and December 3, 2020.A total of 121 patients (62% male; median age, 3 years) underwent surgery. The surgical procedures included nephrectomies (n = 18), neuroblastoma (n = 26) and soft tissue tumor resections (n = 24) and complex surgical procedures like extended liver resections (n = 2), intra-atrial thrombectomy under cardiopulmonary bypass (n = 2), pancreatoduodenectomy (n = 1), and free microvascular flaps (n = 7). Clavien-Dindo Grade III complications were 5% (n = 6), and there were no postoperative deaths. Preoperative COVID-19 testing was performed in 82% of children, and only 2% showed severe acute respiratory syndrome coronavirus 2 positivity. Postoperatively, 26 children were tested because of specific symptoms and, 6 tested positive for severe acute respiratory syndrome coronavirus 2. Except for a median delay of 23 days in treatment, none of the patients with COVID-19 required critical hospital management. None of the surgical residents or faculty acquired COVID-19, while 4 each medical and support staff were tested positive in the study period.COVID-19 was not a deterrent for continued cancer care, and surgeries could be safely performed adopting universal preventive measures without any added morbidity from COVID-19. Caregivers and centers dealing with childhood cancers can be encouraged to sustain or seek early healthcare.