Advantages of, and Adaptations to, Enhanced Recovery Protocols for Perioperative Care during the COVID-19 Pandemic

Optimizing Surgical Care Amidst COVID-19: A Scoping Review of Practices and Policies

BACKGROUND

The coronavirus disease (COVID-19) pandemic significantly disrupted surgical care worldwide, affecting different specialties in various ways. Lockdowns, surges in COVID-19 cases, and changes in hospital policies notably impacted patient attendance, management practices, and access to surgical services. This scoping review examines the adverse impacts of the COVID-19 pandemic on surgical services and the policies adopted to address these care barriers.

METHODS

We conducted a comprehensive literature review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) guidelines. Our search, spanning 31 December 2019, to 29 January 2023, focused on understanding the multifaceted impacts of COVID-19 on surgical services, particularly across different specialties.

RESULTS

An analysis of 75 articles indicated that the pandemic challenged surgeons worldwide to maintain a balance between delivering emergency and elective surgical care, and implementing safety measures against viral transmission. There was a marked decline in the surgical volume, leading to extended waitlists and decreased operating theater usage. Strategies such as prioritizing medically necessary and time-sensitive surgeries and integrating telemedicine have emerged as pivotal for ensuring the continuity of urgent care. Despite the reduced rates, essential surgeries such as appendectomies and cancer-related operations continued, yet faced hurdles, including reduced staffing, limited operating theater capacity, and complications in patient transfers.

CONCLUSIONS

This review emphasizes the steep reduction in surgical service utilization at the beginning of the pandemic and emergence of new compounded barriers. Policies that designated surgeries as essential, and focused on equitable and timely access, were effective. Incorporating these findings into post-pandemic assessments and future planning is crucial to sustain adequate surgical care during similar health emergencies.

Consent in surgery

This article will focus on obtaining informed consent from the perspective of a surgical advanced clinical practitioner (SACP). There are many considerations regarding obtaining informed consent and it is recognised that the duty of this role will vary within each NHS trust. This article will reflect on whether SACPs should obtain consent for surgical procedures.

How Efficient Are Isolation Protocols? Outcome of Isolation Protocol in Surgery during COVID-19 Pandemic: A Single Institute Experience

Background. The timing of screening for SARS-CoV-2 preoperatively by RT-PCR/CBNAAT, isolation protocols in preoperative wards, operation theatres, and postoperative wards are not well established. Methods. Evaluating the effectiveness of maintaining three pathways of two COVID-19 negative pathways (1) immediate testing pathway (2) isolation, or quarantine for five days and testing prior to surgery pathway, and (3) the tested COVID-19-positive pathway, was the aim of the study. The primary objective was to assess the utility and outcome of the two COVID-19 negative pathways adopted before surgery in terms of infectivity (seroconversion; COVID-19 positivity rate before surgery and symptomatic COVID-19 disease after surgery). The secondary objective was to derive a practical protocol for isolation or quarantine for emergency and elective surgery. Enrolled patients were grouped based on the need for surgery; Group-1 emergency basis, Group-2 urgent basis, and Group-3 COVID-19 positive and the three channels were kept separate with separate dedicated healthcare staff for each channel. Results. There were 199 (4.56%) COVID-19-positive patients, of whom 80 (40%) were operated. COVID-19 positivity rate was low in Group 2 (3% vs. Group 1, 11%). There was no seroconversion from negative to positive in our patients during the peri-operative period. Conclusion. COVID-19 positivity rate in Group-2 was significantly less. None of the COVID-19-negative patients turned symptomatic and the probability of seroconversion from COVID-19-negative was less during the peri-operative period. The isolation protocol of non-COVID-19 positive patients with the separate channel is effective.

Safety and feasibility of same-day discharge following minimally invasive hysterectomy in the morbidly obese patient population

OBJECTIVES

To determine whether morbid obesity should serve as an independent factor in the decision for same day discharge following minimally invasive hysterectomy.

METHODS

Retrospective review was performed of patients with BMI ≥ 40 who underwent minimally invasive hysterectomy within a single comprehensive cancer center between January 2018 - August 2020. Demographics, perioperative factors, post-operative monitoring, complications, and readmissions were compared between patients who underwent same day discharge and overnight observation using Fisher's exact tests and Wilcoxon rank-sum tests.

RESULTS

374 patients with BMI ≥ 40 were included. Eighty-three (22.2%) patients underwent same day discharge, and 291 (77.8%) patients underwent overnight observation. Factors associated with increased likelihood of same day discharge included younger age (median age 53 vs 58; p = 0.001), lower BMI (median BMI 45 vs 47; p = 0.005), and fewer medical co-morbidities (Charlson Co-Morbidity Index 2 vs 3; p < 0.001). On multivariate regression analysis, frailty (OR 2.16 [1.14-4.11], p = 0.019) and surgical completion time after 12 PM (OR 3.67 [2.16-6.24], p < 0.001) were associated with increased risk of overnight observation. Few patients admitted for routine overnight observation required medical intervention (n = 14, 4.8%); most of these patients were frail (64.3%). The overall hospital readmission rate within 30 days of discharge was 3.2% (n = 12), with no patients discharged on the day of surgery being readmitted.

CONCLUSIONS

Morbid obesity alone should not serve as a contraindication to same day discharge following minimally invasive hysterectomy. Admission for observation was associated with low rates of clinically meaningful intervention, and patients who underwent same day discharge were not at increased risk of adverse outcome.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy

Simple Summary

The SARS-CoV-2 (COVID-19) pandemic has significantly modified the medical services provided for patients that receive care either for COVID-19 or for those that need care for benign diseases, including obesity, or for malignant ones, such as gynecological cancer. We sought to investigate the association among three major worldwide health issues (COVID-19, obesity, and malignancy) and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. We strongly believe that the application of ERAS protocols could play a key role during these unprecedented COVID-19 times.

Abstract

The outbreak of the SARS-CoV-2 (COVID-19) pandemic has transformed the provision of medical services for both patients that receive care for COVID-19 and for those that need care either for benign diseases, including obesity, or for malignancies, such as gynecological cancer. In this perspective article, we focus on the association among three major worldwide health issues and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. A thorough search of the literature on the respective topics was performed. Patients with malignancy and obesity presented with increased vulnerability to COVID-19 infection. However, the management of their disease should not be withheld. Protective measures should be established to reduce exposure of patients with oncological diseases to SARS-CoV-2 while simultaneously enabling their access to vaccination. Since ERAS protocols have proved to be efficient in many surgical fields, including gynecologic oncology, general surgery, and orthopedics, we strongly believe that ERAS protocols may play a significant role in this effort. The end of the COVID-19 pandemic cannot be accurately predicted. Nevertheless, we have to ensure the appropriate and efficient management of certain groups of patients.