Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

Abstract

Introduction

The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.

Methods

A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.

Results

In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.

Conclusions

The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

Introduction

The COVID-19 pandemic has significantly affected health systems on a global basis since the beginning of the outbreak.^1–7 The increasing number of patients needing to be hospitalised for COVID-19 treatment has reduced the number of available beds for elective operations.^8,9 Furthermore, the need for intensive care unit (ICU) or high dependency unit (HDU) beds to treat COVID-19 patients has increased proportionally, putting severe restraints in the use of such beds for any other patient.^10–15 In the UK, at the time of writing, we are considered to be in the second phase of the pandemic, with the first phase having ended around October 2020.¹⁶

The hospital bed occupancy trend in our hospital from April to October 2020 was similar to what was observed overall in England with a significant reduction in hospital load during the summer. The provision of clinical care during the COVID-19 crisis has varied significantly between hospitals and regionally owing to a combination of factors such as availability of local resources/workforce, impact of COVID-19 in the area and regional collaborations.⁹

During the first phase of the pandemic, our hospital adopted a proactive approach in trying to maintain as much of the urgent/cancer surgery volume as possible across all specialties. Significant efforts were made to introduce and implement systems and pathways that allowed for the provision of safe surgical operations. In accordance with the trust’s and national guidelines, we prioritised our patients according to their urgency and operated on those who were deemed to be clinically urgent or needed an operation for a potential malignancy.^17,18 Given the unprecedented nature of the pandemic, there were valid concerns around whether surgical operations should be offered at all during this time.^8,19,20

Much like any other surgical pathology, endocrine disorders require prompt diagnosis and treatment. Owing to the added functional component of endocrine disorders, there is an additional risk to patients should their treatment be delayed.^21,22 Thyroid pathologies requiring urgent treatment include thyroid malignancies, patients with airway compromise and/or swallowing difficulties and patients with difficult to control thyrotoxicosis.²³ Primary hyperparathyroidism can cause life-threatening hypercalcaemia and cardiac events, and can lead to hospital admission for control of hypercalcaemia.^24,25 Adrenal malignancies, phaeochromocytomas and paragangliomas require urgent surgery because of the lack of alternative treatments such as adjuvant non-surgical therapies.^26–29 Functional adrenal tumours such as Conn’s and Cushing’s tumours may have severe consequences for the patient’s quality of life, and medical management is occasionally inadequate to control the symptoms.²⁷

During the COVID-19 period, our hospital trust tried to provide as many of the urgent/cancer operations as possible in accordance with the guidance published by the British Association of Endocrine and Thyroid Surgeons (BAETS).^30–33 Our department of endocrine and general surgery is a regional referral centre that provides services to over 2.5 million residents of Nottingham and the surrounding communities. The aim of this study was to present the clinical outcomes and productivity of the department during the first phase of the pandemic, and to compare it with the pre-COVID-19 era in order to draw conclusions regarding the safety and quality of care offered to patients.

Methods

This study was approved by the review board at our institution (20-661C). The patient population was identified by a search of prospectively collected data in the endocrine surgery database. The patients were grouped according to the time period in which they were treated in our department; the first group represents those treated between 1 April and 31 October 2019 (the pre-COVID-19 period) and the second group represents those treated between 1 April and 31 October 2020 (the COVID-19 period).

Clinical information was obtained from the patient database and (when necessary) supplemented with data obtained directly from institutional medical records. Extracted data included demographic information (sex, age), presenting symptoms, type of operation, nursing notes, histopathological results, perioperative complications and follow-up details (outcome of surgery etc).

A number of operations were performed as a combined operation with another surgical specialty (eg adrenalectomy and bowel resection). These combined cases were excluded from analysis of length of stay.

For the COVID-19 cohort, clinically urgent and cancer cases were prioritised whereas elective cases were postponed. Only a small number of elective cases were performed towards the end of the period (September–October 2020).

Fine needle aspiration thyroid cytology was classified according to the British Thyroid Association/Royal College of Pathologists (Thy 1–Thy5) classification system.^34,35

Surgical technique

All operations were undertaken by an experienced surgeon using the same operative techniques and the same postoperative protocols during both study periods. The operations throughout COVID-19 were performed according to the trust’s guidelines at the time of the operation. The protocol used included a period of self-isolation preoperatively (up to 14 days), a negative COVID-19 swab 2–3 days before the operation and elective admission to a designated COVID-19 secure ward. Other measures put in place to reduce the risk of hospital-acquired COVID-19 infection included not allowing any visitors on the wards, changing clothes before entering the ward and timely discharge.

Thyroid/parathyroid operations

All patients who had an operation during 2019 underwent preoperative fibreoptic nasoendoscopy (FNE) to assess vocal cord function. During 2020, preoperative FNEs for these patients were performed on an ad hoc basis, only if there was suspicion of recurrent laryngeal nerve (RLN) involvement or voice changes, or if it was a redo operation. We only undertake postoperative FNE if there is intraoperative loss of signal in the intraoperative nerve monitoring (IONM), a recognised nerve injury or postoperative voice change. All thyroid/parathyroid operations were carried out with IONM and all parathyroid operations were performed with intraoperative parathyroid hormone (PTH) measurement.

The postoperative protocol for these patients included two postoperative blood tests for PTH, and bone profile at 8pm on the evening of the operation and at 6am the next morning. All patients who had a total thyroidectomy or completion thyroidectomy were prescribed prophylactic calcium supplementation while being inpatient until receiving the results of the morning blood tests. If the PTH was normal at that point, the regular calcium supplementation was discontinued and the patient was discharged with oral calcium for pro re nata use only.

Temporary hypoparathyroidism is considered to be the occurrence of a PTH value of <20pg/ml on the blood test of postoperative day 1. Permanent hypoparathyroidism is considered to be present in any patient requiring calcium supplementation at six months after surgery with/without PTH values of <20pg/ml.

Adrenalectomy operations

All laparoscopic adrenalectomies were performed via the anterior transperitoneal approach.

The hospital bed occupancy by COVID-19 patients was calculated from data published by NHS England.³⁶

Consent for surgery

The risk of contracting COVID-19 while an inpatient and COVID-19-related complications were discussed prior to surgery, and this was documented in the preoperative consent form.

Outpatient department appointments

All the outpatient appointments were performed face to face throughout both study periods while maintaining social distancing and wearing appropriate PPE.

Postoperative telephone follow-up

In June 2019, our department set up a telephone follow-up virtual clinic for postoperative patients. June to July 2019 was used as a trial period to validate the efficiency of the new clinic and fine-tune/troubleshoot any issues that were identified. From August 2019 onwards, the setup of the virtual clinic has remained the same.

Setup of postoperative appointments

All patients operated for a thyroid/parathyroid/adrenal pathology receive a telephone follow-up appointment postoperatively. The timing of the telephone follow-up is seven days after the operation for parathyroidectomy patients and three weeks after the operation for patients who had a total thyroidectomy, hemithyroidectomy or adrenalectomy. Any postoperative patient with a histopathological diagnosis of cancer or a postoperative complication was seen face to face as an outpatient.

Surgical follow-up

All patients had an initial postoperative follow-up appointment and if there were no complications, they were discharged back to their general practitioner. The thyroidectomy/parathyroidectomy patients had a repeat blood test for PTH/bone profile at six months after surgery with their general practitioner.

Statistical analysis

Demographic and clinical characteristics were summarised. Data were reported as the mean and standard deviation. Differences between the two study groups were compared with chi-squared and Fisher’s exact tests. Associations of continuous variables between groups were assessed using the non-parametric Mann–Whitney U test. SPSS^® Statistics version 20.0 (IBM, New York, US) was employed to perform linear regression analysis and to establish correlation coefficients. A p-value of <0.05 was considered statistically significant.

Results

During the pre-COVID-19 period, a total of 130 operations were performed compared with 89 operations for the COVID-19 cohort (Figure 1). Among all of the patients who were offered an operation during the pandemic, there was only one (a 75-year-old man) who decided to postpone his operation solely on the basis of COVID-19 concerns. (The patient had primary hyperparathyroidism and was offered a parathyroidectomy.) The baseline characteristics of the patients who were operated on during the pandemic were similar to those for the 2019 time period. (There was a trend towards a higher percentage of male patients with adrenal pathologies during the pandemic; p=0.080.)

Figure 1 .

Comparison of type of operations and the monthly breakdown for the pre-COVID-19 (1 April to 31 October 2019) and COVID-19 (1 April to 31 October 2020) time periods

The decrease in operating activity during April, May and August 2019 can be attributed to on-call commitments for general surgery (suspension of elective activities during that period) and annual leave. Parathyroid operations were significantly decreased in the COVID-19 cohort (68% decrease). Overall, for the COVID-19 group, the department maintained 68% of its operating workload compared with the respective time period in 2019.

The comparison of the demographics and clinical outcomes between the two study periods is presented in Table 1. There were no significant changes in basic demographics (age, sex) for the two groups. The clinical outcomes for patients who had a thyroid/parathyroid/adrenal operation in the two time periods were similar. There was a trend towards identifying more thyroid malignancies on the final histopathology report during COVID-19 (p=0.051).

Table 1 .

Comparison of demographics and clinical outcomes for patients who had a thyroid/parathyroid/adrenal operation during the pre-COVID-19 (1 April to 31 October 2019) and COVID-19 (1 April to 31 October 2020) time periods

	Thyroid			Parathyroid			Adrenal
	Pre-COVID-19 (n=47)	COVID-19 (n=48)	p-value	Pre-COVID-19 (n=56)	COVID-19 (n=18)	p-value	Pre-COVID-19 (n=9)	COVID-19 (n=15)	p-value
Mean age in years	48 (SD: 16)	50 (SD: 16)	0.558	60 (SD: 15)	61 (SD: 17)	0.658	64 (SD: 14)	57 (SD: 18)	0.293
Male-to-female ratio	17%/83%	21%/79%	0.794	25%/75%	44%/56%	0.143	11%/89%	53%/47%	0.080
Mean hospital stay in days*	1.1 (SD: 0.3)	1.4 (SD: 1.9)	0.417	1.1 (SD: 0.3)	1.1 (SD: 0.6)	0.736	3.8 (SD: 3.8)	2.3 (SD: 2.7)	0.346
Malignancy on histology	11 (23%)	21 (44%)	0.051	0 (0%)	0 (0%)	–	0 (0%)	5 (33%)	0.118
Readmission	0 (0%)	1 (2%)	–	1 (2%)	0 (0%)	–	0 (0%)	0 (0%)	–
Recurrent laryngeal nerve injury	0 (0%)	1 (2%)	–	1 (2%)	0 (0%)	–	–	–	–
Neck haematoma	0 (0%)	1 (2%)	–	0 (0%)	0 (0%)	–	–	–	–
Temporary hypoparathyroidism	10/26 (39%)	8/23 (35%)	1.000	–	–	–	–	–	–
Permanent hypoparathyroidism	2/26 (8%)	1/23 (4%)	1.000	–	–	–	–	–	–
Intensive care unit utilisation	1/47 (2%)	1/48 (2%)	–	0 (0%)	0 (0%)	–	5/9 (55%)	7/15 (47%)	–

SD = standard deviation

*Cases combined with other specialties excluded

All thyroidectomy patients with a postoperative follow-up duration of less than six months had a normal PTH and serum calcium at their postoperative surgical follow-up appointment. All parathyroidectomy patients with a follow-up of less than six months had a >50% drop in PTH, a histopathological confirmation of removing a parathyroid adenoma and postoperative PTH/serum calcium values consistent with cure from primary hyperparathyroidism.

The ICU utilisation for the two cohorts is shown in Table 1. There were two thyroidectomy patients in total who needed a one-day stay on the ICU postoperatively. (Both were unplanned owing to cardiovascular instability and a wound haematoma.) The adrenalectomy operations that needed an ICU stay postoperatively were all planned, in both study periods. These were because of the diagnosis (phaeochromocytoma/paraganglioma) or due to the extent of the operation (laparotomy/multivisceral organ resection).

There were no COVID-19 perioperative complications for any of the operated patients. No patient tested positive for COVID-19 while an inpatient.

Twelve operations from the COVID-19 cohort were performed in the independent sector (as part of the NHS/independent sector partnership scheme during the pandemic). All other operations were performed at Nottingham City Hospital.

The comparison of diagnosis/indication for operation for the two groups is presented in Table 2. The perioperative complications are presented in detail in Table 3.

Table 2 .

Comparison of diagnosis/indication for operation during the pre-COVID-19 (1 April to 31 October 2019) and COVID-19 (1 April to 31 October 2020) time periods

	Pre-COVID-19	COVID-19
Thyroid
Thy1 on FNAC	1 (2%)	1 (2%)
Thy3a on FNAC	0 (0%)	4 (8%)
Thy3f on FNAC	4 (6%)	7 (15%)
Thy4 on FNAC	2 (4%)	4 (8%)
Thy5 on FNAC	3 (6%)	3 (6%)
Thyrotoxicosis	17 (36%)	10 (21%)
Multinodular goitre	11 (23%)	5 (10%)
Completion thyroidectomy	4 (9%)	11 (23%)
Retrosternal goitre	2 (4%)	2 (4%)
Thyroid cyst	1 (2%)	1 (2%)
Other diagnosis	2 (4%)	0 (0%)
Total	47	48
Adrenal
Conn’s tumour	3 (33%)	1 (7%)
Cushing’s tumour	1 (11%)	2 (13%)
Phaeochromocytoma	2 (22%)	4 (27%)
Paraganglioma	2 (22%)	0 (0%)
Adrenal/retroperitoneal mass	1 (1%)	8 (53%)
Total	9	15
Parathyroid
Primary hyperparathyroidism	56	18

FNAC = fine needle aspiration cytology

Table 3 .

Perioperative complications during the pre-COVID-19 (1 April to 31 October 2019) and COVID-19 (1 April to 31 October 2020) time periods

Diagnosis	Age	Sex	Operation	Hospital stay	Complication	Histology	Clavien–Dindo classification
Pre-COVID-19
Paraganglioma	70 years	F	Laparotomy/para-aortic PG excision	11 days	Chest sepsis	Extra-adrenal PG, PASS 3 (8.5cm)	2
PET+ thyroid nodule	71 years	M	Hemithyroidectomy	1 day	Temporary hoarseness (resolved)	Benign	2
pHPT	55 years	F	MIP – right inferior	1 day	Temporary hoarseness (resolved)	Parathyroid adenoma	1
pHPT	56 years	M	BNE – left superior PTX	1 day	Wound infection	Parathyroid adenoma	1
pHPT	47 years	M	Redo – right superior PTX and right hemithyroidectomy	1 day	RLN inadvertent injury/permanent RLN palsy	Parathyroid adenoma	1
pHPT	67 years	M	BNE – right inferior PTX	1 day	Readmission for hypocalcaemia	Parathyroid adenoma	2
COVID-19
Retroperitoneal mass	77 years	F	Laparotomy/right-sided retroperitoneal mass excision	10 days	Planned relook for bleeding	Primary leiomyosarcoma, grade 2 (13cm)	3b
Phaeochromocytoma	51 years	M	Left laparoscopic adrenalectomy	10 days	Postoperative ileus	Phaeochromocytoma, PASS 8 (6cm)	1
Thyrotoxicosis	57 years	F	Total thyroidectomy	1 day	Temporary hoarseness (resolved)	Benign	1
Toxic multinodular goitre	51 years	F	Hemithyroidectomy	2 days	RLN inadvertent injury/permanent RLN palsy	Benign	1
Thyrotoxicosis	70 years	F	Total thyroidectomy	2 days	Neck haematoma washout + readmission for hypocalcaemia	Classical papillary thyroid carcinoma (T1a)	3b
pHPT	84 years	M	BNE – left inferior PTX	1 day	Failure to cure	Parathyroid adenoma	1

BNE = bilateral neck exploration; MIP = minimally invasive parathyroidectomy; PASS = pheochromocytoma of the adrenal gland scaled score; PET+ = positron emission tomography positive; PG = paraganglioma; pHPT = primary hyperparathyroidism; PTX = parathyroidectomy; RLN = recurrent laryngeal nerve.

For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies (Figure 2). When comparing the periods of August to October 2019 and August to October 2020, there was a decrease of 55% in telephone follow-up appointments (Figure 2).

Figure 2 .

Comparison of outpatient department (OPD) appointments for endocrine and general surgery as well as postoperative telephone follow-up appointments for the pre-COVID-19 (1 April to 31 October 2019) and COVID-19 (1 April to 31 October 2020) time periods

The COVID-19 hospital bed occupancy trends nationally and in our hospital can be seen in Figure 3.

Figure 3 .

Comparison of number of hospital beds occupied by patients with a COVID-19 positive swab for the whole of England and Nottingham University Hospitals NHS Trust (NUH) for the time period from April to October 2020

Discussion

Given the long time required for the COVID-19 pandemic to regress or stop being an obstacle to the provision of surgical treatment, it has become obvious that a response plan is needed that will allow for a number of surgical operations to continue while waiting for the COVID-19 pandemic to settle.^23,37–44 Our hospital followed the national guidelines and recommendations from NHS England and the government regarding managing the effects of COVID-19.^17,18 The allocation of theatre lists between surgical subspecialties was undertaken by the cancer prioritisation group.

Our study has demonstrated that it is possible to provide endocrine surgical services in a safe and COVID-19 secure environment. None of our patients contracted or were diagnosed with COVID-19 perioperatively. The exact systems put in place in our hospital that allowed for the continuation of the provision of surgical services were centred around preoperative COVID-19 screening with a reverse transcription polymerase chain reaction test.^18,45,46 Together with the preoperative self-isolation, this testing allowed us to safeguard the negative COVID-19 status of our patients before their hospital admission.

During admission, a number of policies further minimised the COVID-19 risk by reducing patient contact with other individuals and surfaces found in common areas (such as banning visitors to the wards).^1,47,48 Beneficial towards this goal were also the short overall hospital stay of our patients (for the majority of cases, this was an overnight stay only), the low overall risk of anaesthetic complications and the infrequent use of ICU/HDU resources for endocrine surgery patients. It may be helpful in future for each surgical specialty to devise a risk assessment algorithm relating to COVID-19 risk for patients based on the particularities of that specialty (surgical complications, length of stay, expected ICU stay etc).

As expected, the indication for which patients had an operation did change during the pandemic and we prioritised our theatre slots for patients with a potential malignancy (thyroid and adrenal). As primary hyperparathyroidism has an extremely low rate of malignancy, it is unsurprising that mainly parathyroidectomy operations were significantly decreased during the COVID-19 period.⁴⁹ Given this significant reduction in parathyroidectomy rates during the pandemic, perhaps these operations should receive priority status once normal surgical activities resume.

Our data suggest that the beginning of the COVID-19 pandemic (April–May 2020) was the time that had the largest impact on our hospital’s activities, namely significant reduction in outpatient appointments and number of operations. That can be easily explained by the fact that this was a period of great uncertainty and fear, which kept the patients away from hospitals. Furthermore, the majority of hospitals shut down most of their activities while they were developing systems to cope with the pandemic. This adaptation to the new reality combined with a decrease in the total number of COVID-19 cases during the summer led to an increase in our productivity in the months following May 2020.

It is well known that in experienced hands, complications in endocrine surgery (as a whole) are small in number although they can be significant.^50,51 Our data demonstrate that our clinical outcomes were well within the national standards as described in the fifth national BAETS audit report,⁵² both before and during the pandemic. The vast majority of cases with temporary hypoparathyroidism had resolved by the time of the first postoperative follow-up appointment and only a minority of patients required lifelong calcium supplementation. Our temporary hypoparathyroidism rates reflect our status as a referral centre for thyroid pathologies (large goitres, retrosternal thyroid glands, cancer operations, lymph node dissections).

This study confirms that most of the thyroid operations undertaken in the COVID-19 period were performed for suspected malignancy in accordance with the mandate from the BAETS.³⁰ The remaining (non-cancer) cases were either clinically urgent cases or a small number of elective operations (the latter being performed towards the August to October months).

The use of virtual clinics in our practice for postoperative follow-up proved to be very successful, with a significant number of patients being discharged after a virtual clinic follow-up appointment. This was something that we had planned even before the pandemic but proved even more beneficial in 2020, minimising the return of patients to the hospital. Increased use of virtual clinics was among the recommendations of The Royal College of Surgeons of England and other societies.^43,53,54

Furthermore, the willingness of our patients to undergo an operation during the pandemic was notable and was much higher compared with the findings of an Ipsos MORI survey commissioned by the Health Foundation, which showed that overall public confidence in using the NHS in May 2020 was only 52%.⁵⁵ Perhaps this discrepancy can be explained by the combination of adequate patient communication coupled with appropriate hospital measures or by the fact that patients requiring an operation are much more motivated than those needing non-surgical treatment.

Study strengths and limitations

The strengths of this study include the use of consistent clinical protocols between the two time periods, which allowed us to obtain a homogeneous cohort of clinical results, enabling direct comparisons to be made. Our study will hopefully encourage other centres to publish their own results, which will then allow for systematic reviews and meta-analysis to be performed on the published literature.

In addition to its strengths, this study has several limitations, including the fact that it was conducted almost entirely on a single site (and with a single operating surgeon) and the relatively small numbers, which did not allow for statistical comparisons between groups for some variables (certain complications). Moreover, for patients in the COVID-19 group, there was not always a surgical follow-up for up to six months. However, given the positive histopathological findings and postoperative blood tests, it is unlikely that any of these patients will present later with a surgical complication (failure to cure, permanent hypoparathyroidism, nerve injury).

We also accept that by not performing routine postoperative FNEs in all of the thyroid/parathyroid patients, a small number of silent palsies may have been missed.⁵⁶ Nevertheless, the combination of a normal signal from the vagus nerve on IONM at the end of the operation and a normal postoperative quality of voice means that the rate of missed silent vocal cord palsies would be extremely low. Although our results may not be directly translatable to other surgical specialties where there is a higher risk of complications (leaks, graft failure, prolonged ICU stay etc), we believe that despite the limitations of this study, it is possible to reach certain useful conclusions.

Conclusions

This study has shown that the COVID-19 pandemic has significantly affected the provision of surgical care for certain pathologies (parathyroidectomies and elective general surgery). Despite this, with an appropriate plan in place, it is possible to continue offering elective endocrine operations for clinically urgent/cancer cases, even during the COVID-19 era, with a high degree of safety and with similar outcomes to those of before COVID-19.