Impact of COVID-19 on surgical IBD care
Michel Adamina, S-ECCO Chair on behalf of Christianne Buskens, Omar Faiz, Pår Myrelid, Hagit Tulchinsky
For the past year the COVID-19 pandemic has raged across the world, with wave after wave of the disease. No country has been spared and no end is in sight in the near future. A recent position paper from the ECCO COVID-19 Taskforce presented the ten ‘dos and don’ts’ when caring for IBD patients. S-ECCO Members are involved in the specialised surgical care of IBD patients in many countries and a variety of institutions. Hence, we are offering this opinion piece on the performance of IBD surgery during the pandemic.
Beyond urgent surgery, elective surgery may still be performed amidst the COVID pandemic. This entails a balancing act between the immediate additional risks for patients and healthcare workers, wise resource allocation during a major crisis and the real harm that can occur when a required procedure is postponed or a potentially detrimental surgical approach is selected. Needless to say, adequate personal protection measures are mandatory to protect staff and maintain operations.
The current pandemic exposes patients and caregivers to the additional risk of mutual contamination during outpatient and inpatient care. Furthermore, a detrimental loss of resource can result when scarce hospital staff and materials are allocated to perioperative surgical care. In order to optimise outcomes for individuals and society, it is therefore necessary to weigh all the relevant considerations carefully. The complexity of resource allocation is increased by the evolving dynamic of the pandemic, the lessons learned with each wave and the strain felt by staff and healthcare systems at the institutional, regional and national levels.
Delays to surgery should not happen in life-threatening situations, such as septic bowel perforation, closed loop obstruction, active bleeding not amenable to interventional therapy and medically refractory Acute Severe Colitis. When a postoperative ICU bed is not available, it may be necessary to transfer a patient to another institution following life-saving surgery. One of the common consequences of the pandemic has been the need for a tighter policy regarding ICU requests, so that many IBD and Non-IBD patients who would otherwise have been admitted to intermediate care or ICU units are now managed on a regular ward.
Non-urgent situations can still be addressed surgically to minimise restriction of care for IBD patients, assuming appropriate resources are available. National and institutional policies, including ethical guidelines applicable in the presence of scarcity, dominate decision-making and should be followed. Colorectal cancer/high-grade dysplasia, intractable stenosis failing medical/endoscopic management, penetrating luminal disease resistant to medical treatment and poorly controlled abdominal/perianal abscesses belong to the top priority list. It is noteworthy that the performance of elective surgery in disease-free patients during viral incubation has been associated with high mortality (up to 20%) and high ICU requirement (up to 44%). Owing to the paucity of symptoms in the majority of COVID-positive people, each patient may be considered infectious. Generalised testing of patients scheduled for any surgery is strongly advised, as is the separation of hospital facilities into dedicated COVID-positive and COVID-negative areas. A number of screening tests, such as PCR swab tests and large-scale antigen testing, and also chest CT/chest X-ray, allow for same-day assessment and surgery.
As no test has an absolute negative predictive value, the careful use of personal protective equipment (PPE) is one mainstay of sustainable provision of care. Face masks offer some protection, with complete filtration of viral aerosol only assured when wearing a tight FFP3 mask. An N95/FFP2 mask is required when caring for suspected COVID patients. Fastidious hand hygiene and avoidance of contact with potentially contaminated surfaces are integral to personal protection, and proper donning and doffing of PPE is essential.
When contemplating surgery, contamination with body fluids is a concern. To date, infectious virus has been found in airway, blood and faeces. Whether ascites, bile and urine contain viable virus is not known. Aerosol formation is potentiated by tissue dissection with energy devices, while concentration of abdominal aerosol is inherent to laparoscopy. Scientific societies have issued conflicting statements on the use of laparoscopy in the COVID era. Low energy setting and pneumoperitoneum pressure, avoidance of two-way insufflators and gentle desufflation are advised. Efficient filtration of pneumoperitoneum is ensured by closed gas circulation filtered to retain viral particles as small as 0.06–0.14 microns. The vast majority of laparoscopic equipment fails this requirement, which has triggered the publication of many unproven home-made filtration devices and practice recommendations, as well as precautionary advice that open surgery is preferable in order to minimise the contamination risk for theatre staff. While in Lombardy COVID was recognised as a nosocomial infection, no contamination of theatre staff has been reported so far. The need for avoidance of laparoscopy is thus debatable, bearing in mind that open surgery will translate to additional morbidity and resource utilisation. In this context, institutional policy should ensure a negative pressure operating room as well as proper PPE in the crowded theatre, including at least N95/FFP2 masks and/or proven gas filtration devices, in particular if laparoscopy is further offered as the standard of care for the benefit of patients.
IBD patients are at a higher risk of complicated COVID, and this risk may rise in accordance with the complexity of the medical care and the contemplated surgery. There is no indication that IBD patients tolerate vaccination poorly, other than the surgical delay required for a full vaccination schedule. A COVID vaccination is therefore advisable prior to an elective procedure. The rising availability of COVID vaccines worldwide makes this recommendation realistic.
In Switzerland, a small country with a population of eight million, more than 20,000 surgical procedures have already been postponed since November 2020 and the beginning of the second COVID wave; these cancellations include many IBD-related procedures. Catching up with these postponed procedures and dealing with the societal, medical and surgical consequences of delayed IBD care will require a significant effort and will maintain high pressure on healthcare systems worldwide for longer than we have spent in the pandemic so far. Dynamic and innovative strategies to optimise resource allocation, adapted to the local, regional and national environment, are required to ensure the best possible delivery of care for COVID and non-COVID patients. In our experience, evolving interprofessional roles (e.g. physician assistant in the OR and on the ward), flexible surgical lists (evening and weekend lists), finely tuned interdisciplinary care (timing), digitalisation and the simplification of processes help in adapting and optimising the provision of care.