Re-defining Elective Surgery During the COVID Pandemic

Written by Benjamin G. Herbosa, MD, FPCS, FPAPRAS

Because of the COVID-19 pandemic, numerous surgeons and institutions have been forced to place on hold almost all procedures in the area of elective surgery during this period of uncertainty. This view is upheld by a majority of task force members of various governments worldwide. During the lockdowns in designated areas, the rules banned all unnecessary procedures in major hospitals. The move prevents indefinitely any and all electives during the pandemic. A main thrust is to move for closures of institutions or facilities (surgicenters or ambulatory care centers) that cater to elective cases which will then allow doctors for redeployment to the community hospitals and assist in the care for the patients stricken with COVID.

Major medical centers have been overburdened by the loads of patients who contracted the deadly virus. The indefinite postponement or outright cancellation of non-essential procedures decreed until hospital staffing are eased and the ICU and critical care units are decongested is of no argument. Reassignment of the operating suites often used for elective procedures at this time occurs to accommodate the increasing number of COVID cases. Other areas have been temporarily converted into makeshift wards. I totally agree that a patient may be compromised and even be exposed to the virus while having a procedure in a COVID designated facility. Aside from a patient undergoing a non-essential aesthetic procedure displacing a critically-ill COVID patient, the surgeon may likewise risk acquiring the infection. Numerous reasons have been enumerated and all of the concerns to delay and postpone “elective” surgeries given are founded. Most resources are channeled to the fight of the pandemic and are also directed to protect our frontliners.

COVID patients have understandably been given priority during this period. But what about the patients who still require surgical attention but are not infected with the virus? How do we address the needs and concerns of these subset of patients who are uninfected? Thousands of individuals who are unfortunately “kept at bay” and awaiting medical and surgical interventions are now seemingly left out in the cold. These are a multitude of sidelined medical and surgical patients also in need of medical attention.

Controversial as it sounds, there is an overall bad imprint left on the possibility of doing elective surgeries during these times. And why? Because the majority of elective surgeries in Plastic and Reconstructive Surgery are aesthetic in nature. Secondly, the overemphasis on COVID concerns has become so overwhelming. Timing should also probably be taken into consideration as well as the availability of extra surgical staff and nonCOVID facilities.

The truth is that there may always be a negative connotation of cosmetic or aesthetic procedures, with or without COVID. This is mere proof that they are unnecessary and non essential. Possibly correct to an extent but wrong in another premise. There are many procedures that may be cosmetic but necessary like Breast Reconstructions after Cancer Extirpations, Release of Burn Contractures as a result of Deforming Conditions secondary to scalding, Cleft lip and palate or Craniofacial Repairs to name a few on the issues of Reconstruction and maybe aesthetic as well. On the matters 34 of Breast Augmentations and/or Reductions, when the mental health benefits are considered, can these be enough reason enough or justifyable as medical necessities? To quote a recent article of Forbes magazine (May 2020):

“Rhinoplasties and facelifts often involve mental health and wellness; potentially making the lines between optional and medically necessary even grayer”.

Thus the word “elective” as a category used for certain surgeries, I personally feel, is an absolute misnomer.

Naturally, there is no quick fix and obvious answer to this public and professional disagreement as facts and data evolve each day regarding the behavior of the virus. There are just too many unknowns today. But when the COVID case numbers begin to dwindle and as the government efforts become successful in curbing and controlling the spread, I surely can welcome the reintroduction of these procedures in the OR’s list of scheduled operations. The Department of Surgery of the University of Chicago studied this issue and instigated how to help those patients and their surgeons stratify an approach to this dilemma. The concern of triaging hundreds of these patients will now be subjected to the MeNTS (Medically Necessary, Time-Sensitive) scoring system to assess the acuity and safety of patients for surgery having a high benefit and a low risk status at the same time reducing harm to the health care providers and to the patients as well.

The Journal of the American College of Surgeons, March 2020, with Dr. Jeffrey Matthews, chair of the Dept of Surgery at the University of Chicago, offers this quick and reproducible guideline for Elective Surgeries at this time.

I. Procedure:

• How long is the surgery?
• Will the patient need an ICU bed after surgery?
• How much blood will be lost during surgery?
• How many surgeons and nurses are needed in the operating room?
• Will the patient need a ventilator during or after the surgery?
• Is the surgery in the abdomen (lower risk) or in the airway/lungs (higher risk)?

II. Disease:

• Is non-operative treatment available?
• Would the outcome of the illness be impacted with a 2-week delay?
• What about a 6-week delay?

III. Patient Issues:

• How old is the patient? (under 20 years is lowest risk; over 65 years is highest risk)
• Do they have breathing issues like lung disease or sleep apnea?
• Do they have heart disease?
• Are they diabetic?
• Do they have a weakened immune system?
• Do they have signs of an acute respiratory illness?
• Do they have known COVID-19 exposure in the past 2 weeks?

With this protocol, an Elective Surgery Acuity Scale (ESAS) is established. For my purposes, this gives me a small chance to redefine, restart and resume my work. Though deep in my heart I know that some semblance of my immediate past life may still be salvageable, the forthcoming months might just prove me wrong and that lifestyle may no longer be part of the New Normal.