The role of surgeons during the COVID-19 pandemic - The experience of the Surgery Clinic of the Clinical Hospital Center Zemun

Introduction: In December 2019, the existence of a new type of disease, caused by SARS coronavirus 2 (SARS-CoV-2), was discovered in the city of Wuhan, the Republic of China. The disease itself is characterized by a large number of patients with moderate and severe clinical presentation, who require hospital treatment. The organization of the healthcare system of Serbia, during the aforementioned pandemic, has required the engagement of all doctors, regardless of their specialty, in the treatment of patients with COVID-19. Surgeons of all branches, from the Surgery Clinic of the Clinical Hospital Center Zemun, were directly engaged in the treatment of both primary manifestations of the virus and the numerous surgical complications arising in the wake of this disease, but also in the treatment of primary acute surgical diseases in COVID-19-positive patients.

Aim: The aim of this paper is to present the functioning of the Surgery Clinic of CHC Zemun, in the conditions of the COVID-19 pandemic, as well as to present the types and results of surgical procedures performed in patients with the COVID-19 infection.

Methods: This study was conceived as a retrospective study and was conducted in the period between February 2020 and April 2021, in patients who had undergone emergency surgery and in whom the COVID-19 infection had previously been verified. A total of 232 patients surgically treated at the level of the entire Surgery Clinic of the CHC Zemun participated in the study. Results: Chest drainage, due to the development of pneumothorax, accounted for a quarter of all surgical procedures performed, while, in 53.85% of cases, surgical treatment was undertaken due to acute abdomen of various etiology, and in 21.15% of cases, due to vascular diseases.

Conclusion: The COVID-19 pandemic is, in itself, a major challenge for the entire healthcare system. The role of the surgeon is significant, both in organization and in direct treatment, which is additionally complicated by the uniqueness of the entire situation and the severity of the disease itself. In addition to their involvement in the treatment of the COVID-19 infection itself, surgeons were, in a large number of cases, engaged in their primary activity in health care, i.e., in the treatment of surgical diseases and complications of COVID-19, performing demanding surgical procedures in very difficult and unique conditions.

INTRODUCTION

In December 2019, the existence of a new type of disease, caused by SARS coronavirus 2 (SARS-CoV-2), was discovered in the city of Wuhan, the Republic of China [1]. At the beginning of the global pandemic of the SARS-CoV-2 virus, we were entering uncharted territory, as little was known of the nature of the virus itself, its biological behavior, or the way that the COVID-19 disease should be treated. As of this moment, around 175,000,000 people have been diagnosed with COVID-19 worldwide, while 3.8 million have died. According to the data of the Institute for Public Health, until now, in Serbia, 716,000 people have been diagnosed with the disease, while 7,013 have died.

As the pandemic progressed, a high transmission potential of the virus was proven, as well as a rather high morbidity and mortality rate. The following most frequent symptoms of this disease were verified: dry cough, malaise, muscle pain, elevated body temperature, loss of the senses of smell and taste, etc. Diagnostics is, in most cases, based on radiographic and CT scan confirmation of unilateral as well as bilateral pneumonia. The disease itself is also characterized by a relatively large number of associated complications, especially in patients with preexisting comorbidities, which requires a multidisciplinary approach in the treatment of these patients and the involvement of doctors from a number of different medical specialties. The following are amongst the most severe complications: the development of cardiac rhythm disturbance, of acute renal insufficiency, sepsis, vascular ischemic disturbance at the level of different systems of organs, as well as the development of acute respiratory distress syndrome (ARDS) and the occurrence of sudden cardiac death [2],[3].

The duration of the disease, as well as its pandemic character, required that surgeons should, in addition to their engagement in the treatment of the COVID-19 infection itself and its most common manifestation, i.e., pneumonia, also be actively involved in the treatment of numerous emergency surgical diseases developing during the course of the COVID-19 disease. The publishing of studies presenting the results of surgical work during COVID-19 infection has started. Such is a retrospective study by Lei et al., from China [4], which included 34 patients surgically treated during the incubation period of COVID-19 infection, in four different hospitals, in the period between January 1 and February 5, 2020. This study involved patients who were surgically treated due to the pathology of different systems of organs, e.g., rectal and esophageal cancer resection, kidney transplantation, hip replacement surgery, etc. In all of the patients, COVID-19 pneumonia was diagnosed soon after the surgery, during postoperative recovery. In as many as 44.1% of the patients, intensive care treatment was necessary due to illness progression, while 20% of the patients died upon being admitted to the intensive care unit [4]. In Iran, as well, a retrospective study on four patients surgically treated during COVID19 infection was presented, with a proven lethal outcome, due to the progression of the illness, in 2 of these patients [5]. Also of note is one of the latest large multicentric prospective studies carried out in the context of large-scale global cooperation between doctors around the world, i.e., the GlobalSurg Collaborative. This study included 140,231 surgically treated patients from as many as 116 countries, and its aim was to determine the appropriate timing for surgical treatment after COVID- infection. The study has shown that the risk of postoperative mortality and morbidity significantly increases in patients surgically treated within 6 weeks from being diagnosed with the COVID-19 infection [6].

When all the above stated is taken into consideration, as well as the fact that the risk of pulmonary complications and of lethal outcome has been proven to be higher in patients with postoperative COVID-19 infection [7],[8], it is clear that the task of the surgeon is thereby made significantly more difficult and is connected to making much more difficult decisions than is customary in the normal course of work.

STUDY AIM

The aim of this study is to present the functioning of the Surgery Clinic, within the COVID-19 Hospital of CHC Zemun, in the conditions of the COVID-19 pandemic, as well as to present the results of surgical procedures performed in patients with COVID-19 infection.

METHODS

This paper is designed as a retrospective study, carried out between February 2020 and April 2021, in patients who had undergone emergency surgical procedures due to complications arising within the progression of the COVID-19 disease.

A total of 232 patients, surgically treated at the level of the entire Surgery Clinic of the CHC Zemun, were included in the study, while the doctors from the Department of General Surgery were involved in the treatment of 156 (67.24%) cases. The criteria for patient inclusion in the study were as follows: patients with confirmed COVID-19 infection (PCR or Ag test), both sexes, age 18 years and above; with written consent for surgical treatment and upon granted approval for the study by the ethics committee of CHC Zemun.

All patients were preoperatively prepared, in the sense that, for all of them, complete basic and additional diagnostics was carried out. Within additional diagnostics, certain diagnostic procedures were undertaken, i.e., CT imaging of targeted topographic regions, doppler imaging of major blood vessels in the extremities, and X-ray and ultrasound imaging of the abdomen. All patients were preoperatively examined by an internist and anesthesiologist, in order to be optimally stabilized for surgical treatment.

Descriptive statistical methods: absolute and relative numbers (n, %), as well as measures of central tendency (arithmetic mean, median value), were applied in the study. The research protocol was as follows: data necessary for the study were taken from surgery protocols, patient histories, patient temperature charts, anesthesia charts of surgical treatment, and pathology reports.

RESULTS

Of the total number of in-patients treated at the CHC Zemun during its operation within the COVID-19 system, in 232 cases surgical treatment was carried out within 48 hours of admission, i.e., the development of clinical presentation. A certain number of these patients were already in-patients at CHC Zemun, while the rest of them were admitted to hospital, either upon examination at the triage examination room or were referred from other hospitals from or outside the COVID-19 system. The SARS-CoV-2 infection was confirmed in all patients, with a positive PCR test result in 80.13% of the cases, and/or a positive Ag test result in 61.54% of the cases. Bilateral pneumonia was confirmed in 109 patients (69.87%), while the rest of the patients had symptoms of mild intensity with an absence of radiographic verification. The age of the patients ranged from 21 to 84 years, with the median value being 73.5 years. A total of 60.25% of the patients were male (Table 1).

Table 1. Data on patients operated on at the COVID Hospital of the CHS Zemun within the Department of General Surgery

The predominant procedure was chest drainage due to the development of pneumothorax, accounting for one quarter of all surgical procedures, while surgical treatment was carried out in 53.85% of the cases due to clinical presentation of acute abdomen of different etiology, and in 21.15% of the cases due to the existence or development of vascular complications. A total of 25 amputations of lower extremities was performed. Patients with diagnosed retroperitoneal hematoma – there were 30 such patients - were not involved in the study, and they were treated with conservative therapy. In almost all cases, retroperitoneal hematoma developed as the result of aggressive anticoagulation therapy, administered due to a high level of thromboembolic complications connected to this disease. A total of 38 (16.38%) patients required treatment by an ENT specialist, most frequently for performing tracheostomy, due to prolonged intubation, but also due to the occurrence of epistaxis. Orthopedic treatment involved osteosynthesis procedures, neurosurgical treatment was performed in cases of intracranial bleeding, while urological treatment was carried out for persistent hematuria (Table 2).

Table 2. Type of surgery and number of procedures, by department, performed at the COVID Hospital of CHC Zemun

In postoperative recovery, the occurrence of complications was registered in 15 (9.61%) patients. Surgical wound dehiscence was the most common one, occurring in 3.85% of the cases, primarily due to associated and pronounced coughing, followed by recurring bleeding in the treatment of patients with retroperitoneal hematoma and bleeding ulcers, resulting from the administration of high dose anticoagulant therapy (3.20%). Wound infection and anastomosis dehiscence was registered in less than 2% of the cases. All cases of surgical wound and anastomosis dehiscence were treated with reoperation. In all thrombectomy patients, rethrombosis occurred within 48 hours. Overall mortality was 13.46% and occurred predominately in older patients or those with associated comorbidities, primarily reflecting the severity of the clinical presentation of the COVID-19 infection, but also the burden of additional complication or an acute surgical condition (Table 1).

DISCUSSION

Generally speaking, and as to be expected for this disease, the greatest problem and the most severe complications occurred at the level of the respiratory tract. In patients on mechanical ventilation, the complication in the form of pneumothorax occurred to a great extent. Papers have been published showing that, largely, barotrauma, caused by prolonged ventilation, leads to pneumothorax, with or without accompanying pneumomediastinum, in as many as 15% of cases [8]. In our study, 39 patients were treated with chest drainage due to pneumothorax, which is as many as 25% of patients treated by general surgeons. Our study did not involve a smaller number of patients treated conservatively for partial pneumothorax.

Regarding thromboembolic events at the level of the extremities, in addition to the standard factors affecting thromboembolic events, special pathophysiological mechanisms in the course of the COVID-19 infection also contribute to increased risk of the occurrence of these events. Thus, a greater tendency towards the development of both venous and arterial thromboses has been demonstrated. At the present time, it is believed that the SARS-CoV-2 virus itself leads to increased risk, as it causes excessive inflammatory response, disturbance at the level of blood flow itself, as well as direct thrombocyte activation and the disruption of endothelial integrity [9]. Thus, in our study, thrombectomy was performed in 8 patients; in 7 cases it was in the lower extremities, and in one patient in one of the upper extremities. Rethrombosis occurred in all patients within 48 hours, despite the administration of appropriate conservative therapy. In 25 patients, lower extremity amputation was performed, due to prolonged ischemia of the extremity and contraindicated attempt of thrombectomy or salvaging the extremity.

An overview of the complications within the digestive tract in critically ill COVID-19 patients, in a study from the Massachusetts General Hospital [10] showed that as many as 75% of patients (a total of 141 patients were involved in the study) developed at least one gastrointestinal complication. In as many as 56% of the patients intestinal motility problems and ileus development were diagnosed, while in 4 patients intestinal ischemia was identified [10].

In our study, we have presented our experience in resolving and treating emergency surgical diseases in COVID-19 patients. Patients with developed clinical presentation of acute abdomen occurring in acute appendicitis, and ileus, as the result of mechanical obstruction within the presentation of colorectal cancer, were surgically treated.

As far as complications of the surgical procedures themselves are concerned, a study by Romanian authors compared patients surgically treated during the COVID-19 infection, between April and July 2020, and patients who had undergone surgical procedures in the same months of 2019. Interesting results were obtained – surgical wound infection occurred in 2% of patients surgically treated during the COVID-19 pandemic, as opposed to 13.95% of surgical wound infections in patients treated in the same months of 2019 [11]. In our study, 2% of patients treated by general surgeons developed the clinical presentation of surgical wound infection, however, all of the surgically treated patients also had confirmed COVID-19 infection.

CONCLUSION

In itself, the COVID-19 infection is a great challenge for the entire healthcare system. The role of the surgeon is very important, not only in organization, but also in direct treatment, which is additionally made more difficult by the singularity of the overall situation and the severity of the disease itself. In addition to their involvement in the treatment of the COVID-19 infection itself, surgeons were, in a large number of cases, engaged in their primary activity in health care, i.e., in the treatment of surgical diseases and complications of COVID-19, performing demanding surgical procedures in very difficult and unique conditions.