Surgical operations during the COVID-19 outbreak: Should elective surgeries be suspended?

Abstract

The current outbreak of coronavirus disease (COVID-19) which causes severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread since the end of 2019 from China. After the index case, increasing number of cases are being reported in many countries across the world [1,2]. The mortality rate of SARS-CoV-2 was 3.6% [3.5–3.7] in China and is 1.5% [1.2–1.7] in outside of China [3]. Safety of health workers and patients who are admitted to hospitals and health centers are of potential concern during SARS-CoV-2 outbreak [4]. The decision whether to suspend elective surgical operations during the current epidemic is a challenging topic in many centers. It is obvious that patients who need emergent surgical operations and trauma victims should be hospitalized and managed during the SARS-CoV-2 outbreak [5]. These patients may have symptomatic COVID-19 infection or be silent transmitters. In symptomatic cases, routine diagnostic and therapeutic measures should be applied and isolation should be conducted. In addition, it seems that patients who were in close contact with SARS-CoV-2 patients during the 14 days before their admission should be tested for COVID-19 [6]. The test can be performed either by chest computed tomography (CT) or real-time polymerase chain reaction (RT-PCR). The decision to suspend or cancel elective surgical operations should not only be made on the risk of COVID-19 spread. The surgical team should consider risks of cancer, vascular disease, organ failure and progression of the disease [7]. All reconstructive and cosmetic surgeries can be postponed to a time when COVID-19 crisis calms down. All surgeries of benign tumors in head and neck, breast, thoracic cavities and abdomen can be suspended. However, the benign condition should be proved by pathological report. The decision on suspending surgeries for malignancies should be assessed by the surgical team. Thyroid and parathyroid malignancies and other head and neck malignant tumors should not be suspended. Breast malignancies should be reviewed by the surgical teams. Neoadjuvant treatments should not be delayed. In addition, surgical operations should not be delayed in women who have completed their neoadjuvant courses. Gastrointestinal (GI) malignancies also should be reviewed by the surgical team and neoadjuvant treatments should be initiated based on evidence-based guidelines. Delaying surgical resection should be assessed considering the risk of COVID-19 spread, progression of the tumor and the risk of metastasis. Palliative procedures for GI obstructions should also not be suspended [8]. Many orthopedic and neurosurgical operations can be suspended. Urologic operations can also be suspended; however, renal and bladder cancers should be evaluated precisely. Access surgery for patients on dialysis is a potential concern. Patients with newly established end stage renal disease who require emergent dialysis should undergo catheter dialysis placement. Arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures can be postponed unless the risk of catheter failure or infection exists. Failed and infected catheters also should be managed by catheter irrigation or exchange. Thrombosed preexisting AVFs and AVGs should be managed by thrombectomy followed by venoplasty or other procedures based on evidence-based indications. Ruptured aortic and other arterial aneurysms should be operated emergently. However, non-ruptured aneurysms should be postponed unless the risk of rupture overweighs current risk of COVID-19 spread. Almost all venous and lymphatic procedures can be suspended. However, severe deep venous thromboembolisms (DVT) with phlegmasia may require emergent or urgent operations. Surgeries for aortoiliac occlusive disease and peripheral arterial disease can be postponed unless a progressive arterial ulcer necessitates an urgent operation to restore the arterial flow. Medical treatments should be kept in mind. It seems that endovascular techniques with local or spinal anesthesia may have lower risk because intubation and ventilation management are potential concerns during the current COVID-19 outbreak. However, elective endovascular procedures should be postponed [9]. Liver transplantation should also be limited to urgent cases in the epidemic areas. However, a more liberal allocation for patients outside the epidemic areas is recommended. All recipients should be screened to avoid transplantation in COVID-19 positive individuals. Post-transplant surveillance is also mandatory [10]. In conclusion, elective surgical operations should be suspended in current COVID-19 outbreak in epidemic areas unless the risks of the disease impose a potential risk, morbidity or organ failure in the patient. Ethical approval N/A. Sources of funding None. Author contribution The commentary has been written by SZ. Research registration number N/A. Guarantor SZ. Data statement This manuscript does not contain data. Provenance and peer review Not Commissioned, internally reviewed. Declaration of competing interest The author does not have any conflicts of interests.