Elective Operation Scheduling during the COVID-19 Pandemic

We were greatly interested to read the article by Prachand and colleagues¹ on the scoring system that empowers surgery departments to prioritize medically necessary operations that should not be delayed because of risk associated with COVID-19. COVID-19 is reducing the ability to perform surgical procedures worldwide, giving rise to a multitude of ethical and medical dilemmas. A critical issue is balancing the benefit of surgery against the unknown risk of developing COVID-19 and its associated complications. All elective/nonurgent procedures have been cancelled or postponed to a later date all over the globe. In such a scenario, this scoring system seems to be a promising tool for assessing and scheduling elective operations.

There are a few concerns regarding the Medically Necessary, Time Sensitive (MeNTS) instrument, which has been proposed to stratify cases for operation. Surgical team size under the “Procedure” factor starts with a scoring of 1 for 1 member. Most operations would require at least a team of 2 surgeons to operate. Also, the experience of the surgeons has not been taken into consideration. In a recently published paper by Shrikhande and colleagues,² 494 elective cancer operations were performed, and postoperatively, 6 patients tested positive for COVID-19. These procedures were performed by surgical teams with an average age of 40 years led by senior consultants with an average age of 48 years. All had higher grade operations, but none required escalated or intensive care treatment related to COVID infection. Risk of COVID transmission increases with prolonged operation and we feel, to mitigate this, surgical teams should have experienced surgeons guided by senior consultants.

The Royal College of Surgeons published guidelines on good practice for surgical teams during COVID-19 on March 31.³ However, advice is lacking on operation selection when more than 1 procedure is available. One must also ask, how does this affect long-term outcomes? Does the short-term benefit outweigh the long-term risk? Does medical/conservative management have better long-term outcomes in comparison to operation?

The scoring system does not take into consideration the diagnostic burden and the number of contacts the patient has to encounter when getting prepped for elective operation. Gastrointestinal malignancies, for example, would require CT scans, colonoscopies, X-rays, etc, and this would result in multiple consultations with other departments, which can result in further spread of COVID-19 because of asymptomatic patients.

The audit, which was done for a period of 6 days, totalling 41 patients, was very miniscule. The subset factors under the “Patient” heading include variables such as loss of blood and operating time, which are subjective and highly variable, depending on the operating surgeon. Also, we believe the impact on 2-week and 6-week delays on disease progression and surgical difficulty has a huge spectrum of variation for benign and malignant diseases.

Densely populated developing countries have a huge disease burden. There are about 1 million new cancer cases in India, of which around 0.2 million will require operation. In the absence of surgery, most patients will experience disease progression with resultant mortality. Given that death due to COVID-19 in India is 99 per million of population, with case fatality rate of about 3%,⁴ the cancer mortality in absence of definitive surgery will far exceed the mortality due to infection with COVID-19.

Shrikhande and associates² at the TATA Memorial Cancer Institute in Mumbai have done 494 elective cancer operations during the COVID pandemic, of which 423 (85.6%) were higher grade complex procedures (IV–VI). Six patients tested positive for COVID-19 postoperatively. However, all patients recovered, and there were no deaths. The results were achieved based on individual case selection, adopting best surgical practices and having the best operating teams.

Though the MeNTS instrument looks promising, it needs further validation and should comply with the AGREE guidelines reporting checklist.⁵ Also, clinical judgment, ethical decision-making, and individual case selection can supersede patient selection.