Coronaviruses have been known since the middle of the last century to cause mild respiratory infections. Already in the 21st century, there were 2 severe epidemics in 2002 (SARS-CoV coronavirus) and 2012 (MERS-CoV coronavirus). All coronaviruses have a natural reservoir which are bats, but they need an intermediate host which is usually a mammal that transmits the disease to humans. In December 2019, the Epidemic began in the Chinese city of Wuhan (SARS-CoV-2 virus) under circumstances not yet clarified. And due to a hyper-connected world, the pandemic has today reached colossal dimensions.
Today, Monday, April 6, 2020, the total number of infected is over one million and the death toll is approaching 70,000. The overall mortality rate is 5% (Europe and Spain 10%). Fortunately, in 80% of cases the disease is mild-moderate. In critically ill patients, however, mortality is 50% and increases with age.
Transmission appears to be by person-to-person droplets that are deposited on surfaces and may remain for 2 to 3 days. Fecal-oral and blood-borne transmission also appear to be possible although there is less evidence for this.
Coronavirus viral load is highest in the first week of infection, and after 7-10 days viral pneumonia may appear which, in some cases, can trigger a massive inflammatory response leading to respiratory distress and, in a smaller percentage, death. In addition, between 1 and 2 weeks after healing, there may be viral elimination and therefore risk of contagion to third parties.
The data show that there is a large percentage of infected and asymptomatic patients capable of transmitting the disease and producing symptoms in other individuals, hence the confinement measures proposed by governments.
We also know that surgical intervention is a critical moment both for the infection of the surgical team and for the postoperative results of the operated patient. The reason is the aerosolization of the virus that occurs during surgery and anesthesia if the patient is infected. The consequences are more serious the higher the viral load. There are currently around 20,000 healthcare workers in Spain who are probably infected during their work, including surgeons.
Surgeries have adapted to the new situation.
However, in addition to the COVID-19 disease, other pathologies affecting human beings continue to exist in parallel and we must continue to attend to them during the pandemic even though circumstances have changed radically. With respect to surgical pathology, health systems in collapse or at risk of collapse have adapted to this new situation to continue offering continuity of care while trying to protect patients and professionals.
For this reason, in recent weeks a series of measures have been developed for the management of surgical pathology that are extraordinarily framed in a crisis situation. But they are based on previous studies and the experience of countries that are ahead in the management of the pandemic.
Thus, in Spain today, as in other countries, the tendency is to operate on as few cases as possible during the pandemic. This means that all non-emergent pathology has been delayed. By non-emergent pathology we mean pathology that is not imminently life-threatening and/or for which there is a proven alternative to surgery. Thus, tumors that are not immediately life-threatening, inflammation of the gall bladder, mild inflammation of the appendix, etc., have not been operated on.
Care for surgical pathology that cannot be delayed, i.e. urgent life-threatening surgical diseases for which there are no other alternatives, is being developed under two main axioms: the identification of the patient as COVID positive or negative and the protection of the surgical team. Thus, in the case of a patient suggestive of COVID (symptoms, history, chest CT, laboratory…) but not confirmed by PCR (reference test), the patient is considered positive and protective measures must be taken accordingly.
As far as the way of operating is concerned, the technique itself has not been modified. We are more aware of the need to be practical, as fast as possible and resolute within our abilities and logistical resources. In this sense, there has been much debate on the use of minimally invasive surgery or laparoscopy in the context of the pandemic. We do not know if there is a higher risk of contagion through this route, although it is presumable due to the use of gases. We have sealing and smoke extraction systems that have not been tested for this purpose and therefore we do not know whether our protection mechanisms are completely effective. In any case, its proven benefits before the pandemic and the ratio of assuming possible added risks must be individualized for each patient and hospital setting. But logically its practice, in those cases in which assuming the supposed risks entails a clear benefit, should be recommended with the maximum caution available. This is a scenario with great potential for contagion in an environment with many infected patients.
Telemedicine, an effective solution in times of pandemic
With regard to the follow-up care of surgical patients, there has been an acceleration in what is known as Telemedicine, a trend that has been growing over the last few years. The application of telematics to medicine is what is known as Telemedicine and consists of offering assistance to our patients in a virtual manner without any travel or physical contact and with immediacy. Crucial facts in our society, increased in an oversized way during the pandemic.
Surgical societies have been observing a change of trend in the appearance of urgent surgical pathology. During the first weeks of the pandemic, there was a decrease in the number of urgent consultations for surgical diseases that were previously common. Subsequently we have observed the arrival of somewhat more evolved cases than usual but not in as striking a number as we had anticipated due to the lack of consultation during confinement. What will happen during the next few weeks in this regard is an unknown at this time. What is clear is that this pandemic will make us learn new things about surgical pathology not related to COVID-19 that will change the management of many diseases in our specialty, General and Digestive System Surgery.
Finally, it is worth considering that once the state of alarm is over, surgical services will gradually resume elective surgery in delayed cases considered non-urgent during the pandemic. This may lead us to witness the arrival of more advanced tumor pathology and therefore with a worse prognosis, as has been documented in historical war conflicts. In addition, this will involve a large volume of patients requiring more operating room hours and undoubtedly the support of private health institutions and a greater effort, if possible, of health personnel in order not to delay waiting lists in a titanic way.
The way of learning is also changing due to the measures resulting from the pandemic. Our courses, forums and scientific discussions are being conducted virtually in a productive way. It is likely that after the pandemic, our methods of continuing education, clinical research and teaching will also change forever.