Associate Member of the Romanian Academy
The COVID-19 pandemic broke out in December 2019 in the city of Wuhan, China, and spread with astonishing speed across the rest of the world. Europe was quickly affected, from the first months of 2020. No-one will ever be able to forget the reports coming out of northern Italy, the desperation of the afflicted and of medical staff alike, the horror scenes in which doctors were forced to decide who lives and who dies, the panic that had taken hold of, practically, the entire population. One could clearly see how the large number of cases surpassed by far the capacity of the Italian health system, one of the best and most efficient in the world.
It was, however, noted that in such circumstances – and especially if the scale of the epidemic surpasses a certain threshold – no healthcare system in the world can truly be fully prepared. There are undoubtedly a number of beds that can quickly be made available if needed, spare medication and extra staff ready to counteract calamity; yet not calamity on such a scale.
With a certain amount of time at our disposal (Romania registered its first case of COVID-19 towards the end of February), the Romanian healthcare system attempted to face this enromous challenge. And, at least initially, it succeeded – especially since, for unknown reasons, the pandemic was somewhat kinder with our country during the „first wave”, a blessing not to be repeated with the „second wave” that appeared at the start of fall 2020 on the back of a much too early and much to quick summer relaxation, nor with the “third wave”, beginning in the winter of 2020 and extending to spring 2021, without completely disappearing until now (when we are already expecting a “fourth wave”).
Throughout this period, the healthcare system was subjected to extraordinary pressure, with which it barely coped and which affected every single service (primary care, city hospitals, county hospitals and university clinics, the emergency services etc.).
Moreover, all types of pathology and medical activities were also affected, to a greater or lesser extent.
In this context, surgery could naturally not be the exception.
Some surgery wards were entirely shuttered in hospitals designated as COVID centres. The most typical example in this regard was the Colentina Hospital; though many other hospitals, such as the Ilfov County Hospital, the Witting Hospital etc. (from among public medical facilities) or the Monza-Metropolitan hospital (from among private ventures) found themselves in the exact same situation.
In all other hospitals, the primary characteristic of surgical activity was a sharp reduction in the number of procedures undertaken, which in some hospitals dropped by 75-80% compared to previous years.
This was due to the fact that a certain number of beds was allotted to COVID relief, especially with regard to intensive care units; moreover, special circuits were created which, more often than not, significantly reduced the available space for patient care.
Several operational programmes designed to prevent and control infection rates were instituted in all medical facilities. More specifically:
- Triage units were established;
- Triage questionnaires became mandatory procedures;
- Informational materials on the SARS-CoV-2 infection were published and made available;
- With epidemiologists’ input, dedicated circuits for patients suspected or confirmed with COVID-19 were created;
- Medical staff received thorough training on the correct procedures for donning and removing protective equipment, as well as on adequate safety measures during medical procedures;
One of the greatest priorities for hospitals was the establishment and accreditation of laboratories to identify, confirm and monitor SARS-CoV-2 infection rates.
At the same time, maximum priority was awarded emergencies, which often reflected negatively on the treatment of patients suffering from chronic afflictions (one might add, however, that many of these patients themselves refused to attend hospital for fear of becoming infected, thereby neglecting their ailments, with all pursuant consequences that follow).
For surgical emergencies, patients were admitted to hospital and underwent surgery (where necessary) in specially designated wards.
The activity of surgical teams within these wards (surgeons, anaesthaeticians, intermediate and auxiliary staff) was carried out in exceptional conditions: special protective equipment, masks and FFP3 visors. If we add to this the recommendation to not use air conditioning units within operation rooms, we can start to realize how difficult the work of these teams truly was.
It is perhaps not surprising that simple and less radical procedures were often chosen instead of more radical treatments of patients’ ailments, which would have required a lengthier treatment duration in order to be effective.
Surgical interventions were carried out in special wards, destined for patients either confirmed or suspected to carry COVID-19. In non-COVID hospitals that were nevertheless forced to accept COVID surgical emergencies, special circuits were established in order to separate these patients from the remainder of the patient body still uninfected with SARS-CoV-2.
Moreover, all medical personnel received training both in terms of respecting established priority circuits as outlined above, as well as on proper protection and hygiene rules. Patients undergoing emergency surgery that were later confirmed as having had COVI-19 were transferred to Phase I (a category primarily comprised of infectious disease hospitals) or Phase II hospitals (COVID-19 hospitals, designated by the Ministry of Health and the Healthcare Steering Committees) as soon as they no longer presented a surgical emergency.
As an example of the typical activity of a surgical ward during the COVID-19 pandemic, we can review the Surgery Clinic at the “St Spiridon” Hospital in Iași (Chief Medical Officer: Professor Cristian Lupașcu). Over a period of 60 days, from the beginning of the pandemic 38 patients received emergency surgery; eight of them had already been diagnosed with COVID-19 upon admittance, while the others, whose initial tests for SARS-CoV-2 infection returned negative, were rediagnosed with COVID-19 through further tests carried out on day 5-7 from surgery.
The afflictions which required these patients to undetgo emergency treatments were as follows:
- Acute lithiazic colecystitis;
- Perforated ulcers;
- Gastric neoplasm;
- Colon neoplasm;
- Pancreatic neoplasm;
- Chronic arteritis in the lower limb;
- Acute appendicitis;
- Intestinal occlusion;
- Acute ischemia at the level of upper or lower limbs;
- Severe burns.
Six patients received conservative treatment (without surgery), 7 underwent minor surgery (under local anaesthetic), and 25 underwent major surgery (which required general anaesthaesis with oro-tracheal intubation).
6 deaths were confirmed (15.7% of the total), a significantly higher percentage than the usual mortality rates for surgical emergencies prior to the outbreak of the pandemic. The primary cause of death was pulmonary complications, directly imputable to infection with the SARS-CoV-2 virus or otherwise amplified by it.
The most vulnerable category were patients over 70, patients with associated ailments and those requiring major surgical interventions.
With regard to the evolution of patients suffering from chronic ailments, the vast majority of evaluations clearly show they had the most to suffer throughout.
The most affected type of procedure, from the very beginning, were minor interventions, owing to the closure of ambulatories and specialized practices.
Waiting lists were drafted for patients requiring major surgery, dictated by the reduced number of admissions and operations carried out during this period. Although no express indications were ever given by the authorities regarding restricting patient intake or the number of operations, in reality this situation arose due to the need of permanently having beds available on-hand, in the event that the numbers of COVID-19 positive patients suddenly and dramatically spiked.
While some of the ailments of patients thusly delayed could afford to wait (hernias, eventrations, uncomplicated bilial lithiasis etc.), others could ill afford to. Among the latter, malign tumours (variously localized) were the clearest example of afflictions for which any delay to the surgery had significant negative consequences on the disease’s evolution. Many such patients also attended hospital in later stages of the ailment, when the chances of a successful curative operation had already diminished substantially. Even worse, some patients never attended hospital at all.
In turn, surgeons were placed in a somewhat similar position to their colleagues working in ICUs (who, given the insufficient number of ventilators, were at one point forced to decide whom they would intubate and whom they would not – or, in other words, to decide who lives, and who dies!), being forced to decide whom they would operate and whom they would not, which is tantamount to almost the same conundrum: “who lives, and who dies”. An impossible dilemma for Hippocratean disciples who, at the conclusions of their studies, even swore a solemn oath!
A group of experts, comprised primarily of the chief medical officers of the surgery wards of larger hospitals throughout the country, drafted a synthetic report on the surgical activity at the national level in Romania during the pandemic. The group found, above all, a broad reduction in procedures undertaken across the specialty nationwide, owed to the entire set of measures taken by hospital management during the pandemic in accordance with instructions and recommendations received from the Directorate for Emergency Situations, the Ministry of Health and the Healthcare Steering Committees, namely:
- The recommendation to limit the number of elective surgieries;
- The emergency transfer of some surgical professionals to other medical specializations;
- The incidence of COVID-19 infections among members of the surgical teams themselves, or otherwise their mandatory quarantine. Unfortunately, surgeons also had to pay tribute to this terrible pandemic, over whose course a series of highly reputable surgeons fell victim to SARS-CoV-2 infection, such as Professors Octavian Unc from the Constanța County Hospital, Dan Mogoș of the CFR Craiova Hospital, Firmilian Calotă from the Craiova County Hospital, or Dr. Iosif Koszeghi of the Piatra Neamț County Hospital. They were not the only ones, as losses just as painful were recorded among intermediate and auxiliary staff as well.
- The establishment of discrete intrahospital circuits and the reservation of operating rooms for surgical interventions on patients suspected or confirmed as carrying COVID-19;
- The redesign of pre- and post-surgery care networks;
- Longer times needed to decontaminate operation rooms and hospital surgery wards;
Minimally invasive surgery (in effect, laparoscopic and robotic surgery) was particularly badly affected, for several reasons:
- A large part of minimally invasive surgeries were classed as elective procedures and consequently, as per official guidelines, they could afford a delay;
- The exuflation necessary for minimally invaside procedures was deemed to carry the risk of contaminating medical personnel through the generation of aerosols. This handicap was overcome through the airtight seal of the peritoneal cavity during the intervention, and through the use of a closed evacuation system, featuring adequate filtration.
The most serious issue, however, was the limitation of the number of oncologic surgeries. Firstly, it is important to note that programmes designed to detect early stage cancer were, for the most part, closed down – appalling, considering that this is the same stage in which the results of surgical intervention are optimal, and that forms of cancer which are operated at early stages can much more easily be later healed.
At the same time, difficulties in accessing hospitals during the pandemic, as well as patients’ fear of hospital, caused a series of patients whom surgical intervention carried out in optimal time would have awarded high odds of survival to only admit themselves to hospital when the disease had either suffered complications (in intestinal occlusion, or peritonitis), or had advanced so far that surgical intervention was no longer of use for them.
At the national level, the review group found a reduction of surgical activity by more than half (52.05%) compared to surgeries during the preceding year. As such, between March and August 2020, the 45 hospitals included in the study admitted 24.821 patients for surgical procedures, of which 24.388 underwent surgery.
Of the 24.388 interventions carried out in 45 surgery wards in Romania between March and August 2020, 5.268 patients were operated in dedicated full protective gear to combat contamination with the SARS-CoV-2 virus. Infection was later only confirmed in 236 of these patients, but the safety measures were imposed by the multiple ambiguities surrounding the establishment of a case definition for infection with the novel coronavirus.
The general death rate among patients undergoing surgery between March and August 2020 was 5.82% - 56.36% greater than that recorded over the similar period of the previous year. In patients that tested positive for COVID-19, the death rate was 20.33%, compared with only 3.37% for COVID-19 negative patients. The majority of deaths occurred as a consequence of pulmonary complications.
A rise in the number of post-surgery haemorrhagic complications was also ascertained, owed to anticoagulant treatment of discovered SARS-CoV-2 infections.
The COVID-19 hospitals that were active during this period saw the number of “surgical” admissions significantly lowered. As such, an analysis of the activity of three such centres between March and August 2020 found a total of 639 patients admitted, who underwent 35 surgical interventions (only 5.46% of total patients, a significantly low percentage).
It is important to note that the reduction in surgical activity during the pandemic also had a major impact on the practical training of surgical students, whose workload was severely affected even though their theoretical training continued, to a certain extent, online. However, one of the great advancements made over this period is the fact that the online conference and meeting spaces naturalized over the course of the pandemic will, most certainly, be maintained well after its eventual remission, as it greatly optimizes both professors’ and students’ schedules. What is, however, irreplaceable is practical, hands-on training; and, in this regard, the training of prospective surgeons has suffered greatly.
One item worthy of special mention was the issue of organ transplants during the pandemic, in the circumstances of the abovementioned nationwide restrictions. Of note, transplants had always been carried out according to the motto of “no organ left behind”, which had a remarkable effect even in the dire conditions of the pandemic, in the sense that this slogan was adhered to to the letter. Moreover, all necessary prevention measures were, likewise, taken: the testing of donors, of receivers and the transportation teams, assurance of optimal transport conditions, etc.
In these circumstances, at the Fundeni Clinical Institute – the flagship unit for organ transplants in Romania – between January 1 – May 20, 2020 28 liver transplant and 23 kidney transplant operations were carried out. This figure is lower than in previous years, but the explanation is somewhat paradoxical: we have seen a drop in the number of donors due to restricted activity in the hospitals wherefrom, under normal circumstances, donors cerebrally dead donors would have come. Nevertheless, the transport teams were readily available every time a donor was announced, carrying out both the collections and the transplant operations themselves.
Post-surgery results broadly followed the same patterns as before the pandemic. In order to periodically monitor transplanted patients (who, as is well know, go on to take immunosuppressive medication for the rest of their lives), remote medicine (teleconferences, telephone calls, e-mail) was routinely employed, especially during the “peak” of the pandemic. The lessons learned during this time have proven useful, and many of these novel methods and means will continue to be used even after the global health crisis abates, in order to avoid the overcrowding of hospitals and the formation of lengthy queues, due to the large number of patients that require monitoring at present.
In conclusion, during the pandemic the medical and surgical teams made heroic efforts to continue their surgical activity, in particularly difficult conditions and, at times, having to pay significant tribute to this deadly affliction. Surgical emergencies received the highest priority in treatment, but mortality rates were greater than usual as well, especially in patients infected with COVID-19.
The national transplant programme continued in conditions very close to normal values, adhering to the motto of transplantologists that “no organ is left behind”. The total volume of surgical interventions shrank significantly, however, and the corollary effects of this development were particularly evident in patients suffering from neoplasic ailments.
The lessons learned during the pandemic will, most certainly, prove useful in the unfortunate scenario where a fourth COVID wave will be confirmed – a wave which, as is well-known, many are already anticipating, with the rapid spread of the Indian variant of SARS-CoV-2.
All we can say, at this point, is that surgical activity will continue at levels that are estimated to be purportedly higher than those recorded during the first three COVID waves. However, we still nurture the hope that, perhaps, this impending fourth wave will be kinder to Romania – or, even, that it might not come at all.