Poke before cut

Monika More, 24, who underwent a 16-hour double hand transplant procedure successfully on August 28, 2020, is training to be independent after losing her hands in a train accident six years ago. Pic/Getty Images

A Grieving Toronto man, who lost his wife to cancer recently, is now speaking out about the devastating toll that pandemic-related surgery cancellations are taking. "There are a lot of people dying of COVID-19, and a lot of people dying indirectly because of it," he told local news channels last week, seeking anonymity to respect his deceased wife's privacy. She was diagnosed with renal cancer and was awaiting surgery last year, as Ontario's second COVID-19 wave continued to wreak havoc in the country. The 72-year-old woman's operation was postponed five times - twice because she was too weak, and then due to the lack of ICU beds that were full with COVID-19 patients. He says he will never know for sure if the delay contributed to her death, but worries that many others find themselves in the same position.

On March 20, 2020, India's central government directed hospitals and medical institutions to postpone non-essential elective surgeries [a procedure that can be scheduled in advance but is not necessarily optional] up to March 31, to reduce the risk of patients being exposed to the novel Coronavirus, and in turn infecting the surgical staff. The wait lasted till May 31. An international research consortium, which includes surgeons from multiple Indian institutions, estimated that around 5,05,800 non-emergency or benign surgeries, 51,100 cancer surgeries, and 27,700 obstetric surgeries could be delayed across the country during the three-month period before and after the peak. The CovidSurg Collaborative, a 77-country research initiative set up to analyse the impact of COVID-19 on surgeries, also estimated that over 28 million surgeries could be cancelled or delayed worldwide as a result of the pandemic.

Dr Vaibhav Kapoor, Dr Devananda NS, Dr Pradeep Rao and Prof Dr Somashekhar SP

Professor Dr Somashekhar SP, Chairman and HOD - Surgical Oncology, Manipal Hospitals, Bengaluru, explains, "The pandemic was divided into two phases - the first wave started in April 2020 and lasted until October 2020, while the second wave started in early March 2021. During the first wave, we had stopped all elective surgeries for two months. We had to postpone 70 per cent of the procedures, and only 30 per cent of cancer patients, who could not be managed on video consultation, or chemotherapy medications, or chemotherapy or radiation therapy, were offered surgery."

His colleague at Manipal, Dr Devananda NS, head and consultant, cardiothoracic vascular surgery, says that fewer number of patients opted for cardiac operations in the first few months of the pandemic. "For about two months, we operated on 40 per cent patients. Gradually, the number increased, and by December 2020, it was about 50 per cent.

However, for the last 25 days, there is a decline in patients once again. If the patients do not receive timely care, the cure becomes palliation. Timing is key."
But how safe is it for patients to get operated during a peak? The answer could lie in a study that proposes a vaccination model for safe surgery. The study, published by the British Journal of Surgery on March 21, 2021, points out that patients need a COVID-19 vaccine before they go in for surgery. This group should be given a jab on priority before others. It adds that globally, prioritising preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58,687 (best case 1,15,007, worst case 20,177) COVID-19-related deaths in one year.

"Although elective surgery volumes have started to recover in many countries, ongoing disruption is likely to continue throughout 2021, particularly in the event of countries experiencing further SARS-CoV-2 waves. Prioritisation of vaccination for surgical patients could support safe reinitiation of elective surgery services, especially in regions where vaccinating the total population will take several years. In addition, SARS-CoV-2 vaccination is likely to decrease post-operative pulmonary complications, reducing intensive care use and overall healthcare costs," the study adds.

Dr Pradeep Rao is director and head of the department of urology at Global Hospital. He has noticed that several patients are diagnosed with COVID-19 right before admission for surgery. When this happens, they are compelled to postpone the surgery by at least two weeks. "Urologists like myself conduct surgeries of the kidney, bladder, ureter and prostate. Kidney failure patients have been putting off transplants for the last year. We even had a situation where two cadaver kidneys were refused by all patients across the state due to fear of contracting COVID. This was a shocking waste of a scarce resource. Patients on dialysis are risking the health of two family members each, three times a week, by bringing them along to a closed air-conditioned dialysis centre," he says.

Thankfully, because almost all healthcare workers are now fully vaccinated, the risk of catching the infection from a surgery patient is minimal. Most patients lined up for emergency operations are tested through the antigen-based test. For elective surgery, an RT-PCR rest is conducted to be doubly sure.

Adding to this thought, Dr Rao says, "During surgery, anaesthesiologists, surgeons and the staff take all precautions to avoid getting infected. We have been working similarly with much more lethal infections like HIV and Hepatitis B for the last 35-plus years, and procedures are already in place at quality hospitals to prevent transmission. The chances of a surgical patient contracting COVID-19 in a hospital is therefore, negligible."

Having said that, if a non-immunised patient undergoes surgery, s/he is exposed to developing surgical site infections and other complications. Validating the need to vaccinate surgical patients, Dr Somashekhar explains, "Post-operative infection is very common as the patient's adaptive immunity is severely impaired because of the surgery. This in turn increases the risk of developing a severe Coronavirus infection. Especially if a cancer patient, who is already immunocompromised due to medications, has developed COVID-19 infection, the chances of survival are very low. Therefore, it is crucial to consider cancer patients who are scheduled to undergo any type of cancer surgery under the high-risk category and get them vaccinated immediately."

Dr Somashekhar refers to a study by the University of Birmingham, to argue that vaccinating patients one to two weeks before surgery can decrease post-operative complications and may prevent deaths. "We are yet to develop the right protocol for vaccinating cancer patients needing surgery, using the data from such studies. At present, there is no formal policy in place [in India] or instructions from the government for prioritising patients undergoing elective procedures, for vaccination."

Amid the second wave of the pandemic, Pristyn Care, a healthcare start-up specialising in surgeries, claims to have recognised the problem and introduced a ‘single visit safe surgery' service for patients who cannot delay an operation. Their strategy is to perform minimally invasive surgery to reduce the patient's stay in the hospital.

Dr Vaibhav Kapoor, its co-founder, says 400-plus hospitals are registered with them. "Advanced medical technique such as Laser of diode 1470nm [finest laser available in the country] is used in performing ano-rectal diseases such as piles, anal fissures, anal fistulas, vascular diseases such as varicose veins, urology procedures such as circumcision. The treatment of gallbladder stones is done using mini-port laparoscopy and kidney stone removal with flexible ureteroscopes and holmium lasers," he shares.

58,687
No. of additional COVID-related deaths that can be prevented in a year if pre-operative vaccination of patients needing elective surgery is prioritised, according to the British Journal of Surgery study of March 2021