Covid 19 is a global pandemic disease that have forced major changes in human healthcare systems all around the world. In Italy, the exponential increase in severe cases led to a rise in hospitalizations with a progressive overcrowding in ICUs. As a consequence, we witnessed a switch from permanent emergency room’s respirator stations to beds equipped with mechanical ventilation. This reorganization resulted in a greater demand for dedicated ICU personnel and a rapid decrease in planned surgeries.
During the lockdown period, EDs experienced a large influx of patients with respiratory failure due to COVID 19 related pneumonia and a rapid increase in cases requiring immediate treatment in parallel with the growing outbreak. A restructuration of all medical services was provided and in particular for patients in need of surgical care. Elective non-oncological surgery was temporarily allocated to a stand-by position mainly to relocate staff members, particularly anesthesiologists, to help with emergency cases and to switch the operative theatres into emergency rooms for the sickest COVID-19 patients. Non-operative management (NOM) of surgical patients had to be considered whenever possible. Only emergency cases and selected oncological procedures continued taking place.
In our region the public healthcare system closed five peripheral EDs to concentrate emergency surgical activity in our hub hospital only. Dedicated COVID 19 protocols was established. All surgical patients we screened for Covid-19 before admission to EDs. To prevent contamination of holding areas no patients were moved between different hospital areas until their destination had been confirmed ready and a dedicated COVID-19 operating theatre was designated.
To our knowledge this is one of the first studies analyzing the impact of COVID 19 disease and lockdown on emergency surgical procedures in a single hub hospital by comparing two cohorts of patients enrolled in the same time periods before and during the pandemic (2019 versus 2020). A unique feature of our study is the comparison of outcomes in the same clinical units having the same senior surgical staff before and during the pandemic. Our findings demonstrate the consequences of reduced ED resources for ordinary non-COVID-19 patients in need of emergency surgery during the pandemic.
We observed a decrease in overall emergency surgical activities of 20.4% (p = 0.03) during the pandemic which is comparable to other international findings (12, 13). Nevertheless, bowel obstruction, acute appendicitis, extra-uterine pregnancy and pelvic inflammatory disease (PID) increased. Other authors have also found a change in clinical presentation of emergency cases during the COVID-19 pandemic with a reduction in less severe conditions like urinary tract pathology and an increase in some surgical conditions such as bowel obstruction, acute appendicitis, extra-uterine pregnancy and PID (14). These observations most likely have a multifactorial explanation. The Italian Government said that the most important action to save lives was for people to stay at home as much as possible. This restriction might explain the reduction of patients with hospital access due to “non-essential” surgical consults and trauma. Many people may have avoided visiting hospitals in fear of contracting COVID 19. General practitioners probably managed symptoms of abdominal pain, pelvic pain and urinary burning in patients` homes in a larger extent than before the pandemic. Lifestyle changes during lockdown may explain the lower incidence of some diseases like acute cholecystitis. The lower rate of cholecystectomy during the pandemic might be due to NOM using percutaneous cholecystostomy in more cases. Another aspect could be that surgeons adopted a more conservative behavior driven by fear of becoming patients themselves (15). Estimates show that 85% of healthcare workers get exposed to the virus and the International Council of Nurses estimated an infection rate of 9% in Italy during period March-April 2020 (16). Finally, as many elective procedures were postponed, fewer patients required emergency surgical revision due to complications. Interestingly, patients undergoing surgery were similar before and during the pandemic regarding gender, age, frailty and comorbidity, as assessed by NEWS and CCI (17). The Italian World Bank Staff estimates that Italy has the second largest proportion of older adults in the world (18). Therefore, Italian EDs are used to manage older subjects who are more susceptible to and more strongly affected by COVID-19 with at greater risk of developing emergency surgical conditions and related complications. In this study patients` median age was only slightly lower during the pandemic but we didn’t observe any statistically significant differences regarding the age.
A declared delayed access to ED of 48–92 hours from the onset of clinical signs was observed in 15.5% of patients during the pandemic. Several factors could explain this finding such as changes in outpatient pathways (19) and patients’ fear of going to hospitals and becoming infected with COVID-19 (20). Many surgical patients were initially treated without surgery. Acute appendicitis, acute cholecystitis, uncomplicated diverticulitis and urinary tract infections were given antibiotics only. Hence, many subjects were not referred to hospital until after NOM failure and in a worse clinical condition. Cano-Valderrama et al (21) observed a decrease of 65.4% in emergency surgical activity in a Spanish hospital caused by delayed access. They also found an increased proportion of emergency surgery cases without alternative treatments, such as intestinal obstruction and incarcerated hernia. Consequently, patients requiring surgical care presented with more advanced disease due to delayed admission. This explains the poorer patient outcomes in the declared delayed access cohort in our Group 2. On logistic regression analysis, a delayed access predicted an increase in postoperative morbidity, blood transfusion and 30-days mortality rate.
An open surgical approach was used more often during the pandemic. This was conditioned by the clinical status of patients but we did not find any significant difference in terms of mortality or morbidity as compared with 2019-data. However, patients in the open surgery group had an increased blood transfusion crude rate, which was probably due to a higher numbers of patients presenting with active bleeding, obstruction, perforation or need of a rapid damage control. Institutions like Centers for Disease Control and Prevention in US and the American College of Surgeons (22) recommend using negative-pressure operative rooms for patients who are positive or suspected of having COVID‐19 infection. Authors of research papers (23) support this recommendation. The rationale is that pneumoperitoneum leakage may cause aerosol exposure for the operating team during standard laparoscopy (24). Active replication of the SARS‐CoV‐2 virus occurs in the respiratory and gastrointestinal tracts (25) and De Simone et al (26) suggested that laparoscopy on COVID-19 patients should better be avoided, especially in an emergency setting. The United Kingdom Royal College of Surgeons suggested considering mini-invasive surgery in highly selected individual cases only where clinical benefits to patients substantially exceed the risk of potential viral transmission (27). Zheng et al. advised caution with laparoscopy, limiting the intra‐abdominal pressure, reducing the electrocautery settings and minimizing the Trendelenburg position (28). A switch of surgical approach from minimally-invasive to open was observed especially for procedures in general surgery or in case of emergency bowel disease in order to avoid intestinal virus spreading. However, up to date there is low evidence for an increased risk of contamination of health care providers during laparoscopy, nor of operating room pressure, surgical smoke, tissue extraction or CO2deflation (29). Therefore, abandoning laparoscopic surgery in favor of open surgery for fear of COVID-19 infection among staff is actually not justified. While median LOS was not statistically different in the two groups, detailed analysis showed an increase in median LOS during the pandemic. Delayed access and increased morbidity justified a longer length of stay.
Morbidity rate increased during the pandemic, especially Dindo Clavien score > 3. Subjects with older age, frailty, sepsis, delayed hospital access, comorbities and those who were admitted during lockdown were at higher risk of complications. According to Mc Lean et al (14) patients in need of emergency surgery should attend promptly and receive the surgical care that they require immediately. The risk of perioperative complications associated with COVID 19 disease is significant and can affect morbidity and mortality (30). The COVID Surg Collaborative group performed an international multicenter cohort study on patients undergoing surgery. In adjusted analyses of the COVID 19 positive test group, 30-day mortality and morbidity (Dindo Clavien > 3) were associated with age > 70 years, ASA score > 3 and emergency surgery versus elective surgery (OR 1.67 [1.06–2.63], p = 0·026) (31). The low number of COVID-19 patients in our series does not allow any conclusions in this respect.