On February 28th, 2020 the first two cases of COVID–19 infection were detected in the Region of Madrid (Spain), with a subsequent rapid spread, reaching 44,783 positive cases on April 10th (figure 1) . This exponential increase in the number of newly infected overloaded the emergency departments and ICU of the hospitals in Madrid´s region. Human and material resources and daily activities were then reorganized to assist the high number of patients.
Due to the architectural design of our Hospital, the Women’s and Children’s Care Center are separated from the main Hospital building, where the vast majority of Covid–19 patients were admitted. Therefore, our department was able to continue some surgical activity, even at most saturated hospitalization moments.
The spectrum of SARS-Cov–2 symptomatic infection ranges from mild to critical. Fortunately, most infections are not severe [5–10]. Nevertheless, some authors suggest that surgery may accelerate and exacerbate the course of the infection, given that surgery may cause an immediate impairment of cell-mediated immunity, one of the major mechanisms that bring viral infections under control [11,12,16,17]. Lei et al. published the data of a retrospective cohort of 34 patients underwent elective surgeries, during the incubation period of COVID–19 in four different hospitals of Wuhan, China. 44,1% of the patients needed ICU and the mortality rate was 20,5% . This proportion of intensive care need is much higher than the reported (range 14–26 %) in hospitalized COVID–19 patients without surgery .
In our series, the incidence of patients with COVID–19 after surgery was 8.5%. In contrast with Lei et al. none of the patients presented postoperative complications or required hospital admission due to the SARS-Cov–2 infection. These differences may be explained by different factors. Firstly, is the time from surgery to the onset of symptoms. For Lei et al. the median time from surgery to the first symptom was 2.0 days whereas in our series it was 13.6 days. The incubation period for COVID–19 is thought to be within 14 days, being in most cases around 4–5 days after exposure [4,5]. However, only 44,4% of our patients became symptomatic in the first 14 days after surgery, and 33,3% in the first 5 days. Therefore, most of our patients underwent surgery out of the incubation period and probably they became infected after hospital discharge, minimizing thereby the inflammatory postoperative reaction. Most cases who developed symptoms underwent surgery during the phase 1 (no restrictions). Only two infected patients were operated during established screening periods. One patient who underwent an emergent surgery with a known positive PCR test and another one with a previous negative PCR test that developed symptoms two days after surgery with a final positive PCR test (considered as a false negative). None of the 26 patients operated in the second period (only epidemiologic questionnaire) were infected subsequently. Thus, our false negative rate for these screening measures was 0.8%.
Secondly, the type of surgeries included could be another factor. In the study of Lei et al., only three patients withstood gynecological surgery and all of them were radical. In contrast, according to the main scientific gynecological societies [13,14], after the declaration of the state of alarm, the surgical complexity was reduced in our department in order to reduce surgical adverse events and shorten postoperative hospital stay. This approach could have decreased the adverse outcomes in patients who underwent surgery during the incubation period, as well as have minimized the hospital exposure of uninfected patients. In this line, also individual protection measures for health professionals were increased and two different areas and independent workflows were established for suspected/confirmed COVID–19 patients. All the measures taken during these periods in our department were focused on achieving three objectives: to identify positive COVID–19 patients and place them in isolated areas, to prevent the risk of transmission of the virus to uninfected patients, increase the safety of healthcare personnel and try to minimize possible postoperative complications in COVID–19 positive patients.
Although the overall incidence of patients with COVID–19 after surgery was 8.5%, it was higher in the group of patients in whom no preoperative screening was done (11.3% vs. 4.2%; p = 0.1). In addition, five more elective surgeries were cancelled because of a positive SARS-Cov–2 infection screening, avoiding the possible morbidity/mortality derived from the infection and surgery in these patients.
This data supports the implementation of an early COVID- 19 infection screening to avoid surgical procedures in the incubation period. The diagnosis of COVID–19 is made by detection of SARS-CoV–2 RNA by RT-PCR, but in many cases, because of the limited availability of testing and concern for false-negative results, the diagnosis of COVID–19 is made presumptively based on a compatible clinical presentation in the setting of an exposure risk [19,20]. Therefore, excluding epidemiological criteria and COVID–19 symptoms before surgery is imperative and it can be sufficient in most cases if the RT-PCR is lacking.
Our study has several limitations. The sample size of the present study is small. Additionally, not all patients with COVID–19 symptoms had a confirmation test, due to the limited understanding of the epidemic situation and the shortage of SARS-CoV–2 kits at that time. Moreover, we have used an internal classification system of the surgical complexity that has not been standardized among centers, that preclude robust comparisons with other series. However, most centers used different combinations of surgical indicators to define the complexity, since it is believed that the more markers are used the better is the definition of the complexity. However, to the best of our knowledge, this is the first retrospective cohort study from a single center describing the incidence and clinical characteristics and outcomes of COVID–19 in patients with gynecological surgery. Accordingly, both knowledge of the data on the impact of surgery performed during the incubation period of COVID–19 infection and universal pre-operative screening of SARS-Cov–2 infection could reduce the morbidity and mortality of these patients.
In conclusion, we consider that establishing independent surgical workflows, correctly selecting the type of surgeries to be performed and the use of a pre-surgical screening to detect patients at risk will improve the surgical results in pandemic periods as the one we live in.