Keywords
SARS N-CoV 19 - interventional radiology - elective surgery
SARS-CoV-2 (COVID-19) is a pandemic due to a novel RNA coronavirus that originated
in Wuhan, China, and has spread to most countries in the world. It is a highly contagious
aerosol-borne viral illness with a high-infectivity rate, endangering health care
workers (HCWs) in health care settings. At the time of writing, there are 7 million
cases worldwide with 403,000 reported deaths associated with it. India has over 250,000
cases which are concentrated in the major metropolitan cities that also happen to
be the major health care hubs.[1] This has had a major impact on routine health care delivery, particularly in the
setting of surgical procedures. Although the advice is continually changing and dependent
on regional circumstances and guidelines, most surgical associations,[2]
[3]
[4] Center for Medicare and Medicaid service[5] in the US as well as the Government of India,[6] have recommended that all nonessential planned surgeries and procedures be limited
until further notice. The best modeled estimate was that 28,404,603 operations would
be cancelled or postponed during the peak 12 weeks of disruption due to COVID-19,
including 580,000 in India. The overall 12-week cancellation rate would be 72.3%.
Globally, 81.7% of benign surgery and 37.7% of cancer surgeries are likely to be postponed.[7] All elective procedures are canceled in England for at least 3 months,[8] and it would take considerable time (11 months, even if throughput is increased
by 20%) and resources (2 billion GBP) to make up for lost time.[8]
The reasoning behind these guidelines are manifold and quite compelling.
-
Possibility of viral contamination to staff during surgery, either open, laparoscopic,
or robotic, should be considered and full protection should be worn regardless of
the COVID status of the patient. Laparoscopy and electrocautery has been shown to
cause aerosolization of bloodborne viruses such as hepatitis B, papilloma virus, and
HIV.[9]
[10]
[11] Although aerosolization during surgery has not been reported during the current
pandemic, such transmission of SARS-CoV-2 cannot be neglected, as it is capable of
being viable in aerosols for 3 hours.[12] Use of bipolar devices and ultrasonic dissectors should therefore be minimized.
Similarly, endoscopists may be at greater risk of viral exposure from endoscopy and
airway procedures.[4]
-
Although improving, there are continuing resource constraints both in terms of personal
protective equipment (PPE), ventilators, intensive care availability as well as appropriately
trained staff. In the setting of the pandemic, the primary responsibility of health
care providers remain the care of critically ill patients afflicted with COVID-19
infection, with less available resources for less urgent surgeries.
-
Intubation and extubation are high aerosol-generating procedures and should ideally
take place in a negative pressure room. Therefore, it appears that local/regional
anesthesia should be preferred to invasive airway management, whenever possible, for
elective procedures. Operating rooms should be appropriately filtered and ventilated,
and such facilities may not be easily available up and down the country.[13]
-
Any risk factor or comorbidity (e.g., age > 60 years, obesity, high blood pressure,
cardiovascular disease, and diabetes) should be disqualifying conditions in the early
phase of elective surgery resumption, as these features impart a higher mortality
in patients with COVID-19.[14] The patient is also at a higher risk from surgery and anesthesia if they are positive
for COVID-19. A review of four reports of patients diagnosed with COVID-19 during
the perioperative period suggested a 14/51 (27.5%) postoperative mortality rate, severe,
mostly pulmonic, complications, and exposure and transmission to HCW.[15] This additional risk should be informed during the consenting procedure, as patients
may be asymptomatic at the time of surgery and the screening RT-PCR test may be negative
in the early part of the illness. In line with this, recently, the COVID Surg Collaborative[16] reported 30-day results of an international cohort study assessing postoperative
outcomes in 1,128 adults with COVID-19 who were undergoing a broad range of surgeries
(53.6% men and 46.4% women; 19.0% aged < 50 years, 31.3% aged 50–69 years, and 49.5%
aged ≥70 years). SARS-CoV-2 infection was diagnosed postoperatively in more than two-thirds
of the patients (71.5%). The overall postoperative mortality at 30 days was 23.8%
(268 of 1,128 patients). Pulmonary complications occurred in 577 (51.2%) patients
and 30-day mortality in these patients was 38.0% (219 of 577), accounting for 82.6%
(219 of 265) of all deaths.
-
Patients with cancer face a triple jeopardy. First, they are twice more prone to contract
the illness than the general population due to their frequent hospital visits, advanced
age, poor functional status, and their immunocompromised state due to malignancy and
anticancer therapy.17 Second, the case fatality in COVID-19 patients with cancer
is higher (5.6%) than the overall reported case fatality (2.3%), as seen in a study
of 72,314 patients from China.[18] Cancer was associated with higher risk of severe events (i.e., admission to the
intensive care unit, invasive ventilation, or death) seen in 7 of 18 patients (39%)
with cancer versus 124 of 1,572 patients (8%) without cancer; (p = 0.0003).[19] Synergy of cancer, surgery, and COVID-19 may all contribute to this high-mortality
rate. Third, while there is a higher perioperative mortality in patients with COVID-19,
delaying oncological surgery may also be associated with poorer outcomes and disease
progression. Patients’ conditions may deteriorate, worsening their quality of life,
as they wait for rescheduled surgery. In malignancy, delayed surgeries may lead to
several unnecessary deaths.[17] In this setting, nonoperative treatments, without invasive ventilation and lesser
pulmonary risks, may be more suitable to be chosen during this period. As an example,
contrary to nonpandemic times, a microwave ablation of a 3 cm metastasis may be a
more appropriate decision by a multidisciplinary team rather than a liver resection,
even in a surgically fit patient.
Most current surgical guidelines suggest that resumption of surgical services should
be done in a phased manner based on current and projected COVID-19 cases in the facility
and region, supply of PPE to the facilities, staffing availability, bed availability,
especially ICU beds, ventilator availability, health and age of the patient, and urgency
of the procedure.[2]
[3]
[4] The American College of Surgeons have proposed an elective surgery acuity scale
(ESAS) to enable decisions about recommencement of planned surgery by considering
six case scenarios based on: a) the clinical urgency, b) prevalence of COVID-19 in
the hospital, and c) health status of the patient.[20] There are suggestions to perform elective procedures in an ambulatory care setting
whenever possible in four of these six patient tiers. Although not specifically addressed
in this document, it is worth noting that most interventional procedures are performed
in an ambulatory setting and does fulfil this requirement. Fibroid embolization for
symptomatic uterine fibroids and prostatic artery embolization for benign prostatic
hypertrophy are good examples in this regard.
Interventional radiology (IR) therapies already offer treatment solutions with equivalent
results to more invasive surgery in several disease conditions and organ systems.
In certain conditions, these therapies are equally curative, while, in other conditions,
they offer temporizing solutions till more definitive surgery. Detailed comparative
analysis is beyond the scope of this article. In the background of an ongoing pandemic,
some of these therapies may become even more appropriate ([Table 1]) in the multidisciplinary setting with several advantages:
Table 1
Suggested list of clinical conditions where currently surgery or endoscopy is the
current gold standard and IR can offer an effective
solution
|
Disease condition
|
Surgical treatment
|
IR treatment
|
Remark
|
|
Abbreviations: CBD, common bile duct; DEB, drug-eluting bead; ERCP, endoscopic retrograde
cholangiopancreatography; EVAR, endovascular aortic repair; IR, interventional radiology;
PEG, percutaneous endoscopic gastrostomy; PTC, percutaneous transhepatic cholangiography;
RIG, radiologically inserted gastrostomy; SFA, superficial femoral artery; TACE, transarterial
chemoembolisation; TARE, transarterial radioembolization; TASC, Intersociety consensus
for the management of peripheral arterial disease; TURP, transurethral resection of
prostate.
|
|
Significant carotid artery stenosis
|
Carotid endarterectomy
|
Carotid stent
|
Definitive and curative
|
|
Benign thyroid nodule
|
Thyroid lobectomy
|
Thyroid ablation
|
Definitive and curative
|
|
Pleural empyema
|
Decortication
|
Staged percutaneous drainage and fibrinolytic therapy
|
Mostly definitive
|
|
Small lung tumor (primary or metastatic)
|
Lobectomy, segmentectomy or metastatectomy
|
Lung tumor ablation
|
Definitive, for small tumors only
|
|
Small hepatocellular carcinoma
|
Liver transplantation, Surgical resection
|
Ablation, TACE, TARE
|
Usually definitive. Can be used as temporizing therapy prior to surgery or transplant
|
|
Limited liver metastasis
|
Liver resection
|
Ablation, DEB-TACE, TARE
|
Usually definitive. Can be used as temporizing therapy prior to surgery or transplant
|
|
Small kidney tumor (T1)
|
Partial nephrectomy
|
Percutaneous renal ablation
|
Definitive and curative
|
|
All biliary obstruction including in distal CBD
|
ERCP stent insertion
|
PTC and stenting
|
Definitive and palliative
|
|
Acute unresolving cholecystitis
|
Cholecystectomy
|
Percutaneous cholecystostomy
|
Temporizing
|
|
Enteral feeding
|
PEG insertion
|
RIG insertion
|
Definitive and palliative
|
|
Urinary obstruction
|
Cystoscopic ureteric stent insertion
|
Nephrostomy, percutaneous ureteric stent
|
Usually temporizing
|
|
Aortic aneurysm
|
Open aortic repair
|
EVAR
|
Definitive and curative
|
|
Aortoiliac occlusion: TASC C, D
|
Aortofemoral grafts
|
Aortoiliac stents
|
Definitive but potentially inferior long-term result
|
|
Uterine fibroids and adenomyosis
|
Myomectomy
|
Uterine artery embolization
|
Definitive and curative
|
|
Benign prostatic hypertrophy
|
TURP/other transurethral procedures
|
Prostatic artery embolization
|
Definitive and curative
|
|
Grade 3 hemorrhoids
|
Banding, hemorrhoidectomy
|
Hemorrhoidal artery embolization
|
Definitive but scant evidence
|
|
Long SFA occlusions
|
Femoropopliteal graft
|
Angioplasty +/□ stent
|
Definitive but potentially inferior long-term result
|
|
Knee osteoarthritis: Grade 3
|
Total knee replacement
|
Local injections, genicular embolization
|
Scant evidence but at least temporizing
|
-
IR therapies usually do not require invasive ventilation, reducing risk to the anesthetist
as well as less risk of pulmonary complications in asymptomatic COVID-19 patients.
A joint statement from the American and European Societies of Regional Anesthesia
and Pain therapy states that regional anesthesia should be used in preference to general
anesthesia in patients to reduce aerosol generation and reduce opioid-related respiratory
compromise.[21]
-
There is no risk of surgical smoke and aerosol-related HCW infection.
-
The shorter hospital stay related to IR therapies reduces the risk of acquiring an
infection for both the patient and the HCW.
-
The IR operator (e.g., at the wrist or groin) may well be further away from the patient’s
nose and mouth and be at less risk than in conventional surgeries. This is, however,
a supposition, as there is no available data on rate of infections amongst physicians
based on specialty. A carotid stent as opposed to an endarterectomy is a good example
in this regard. Coiling of intracranial aneurysms has not been included in this list
as it most often requires a general anesthesia. But, even here, the location of the
operator is further away from the airway when compared with a craniotomy.
-
In certain scenarios (e.g., in fibroid embolization versus myomectomy, liver resection
versus ablation), the relevant IR procedure may be shorter in duration, thereby reducing
the risk of transmission.
-
Most IR procedures can be performed by a single operator, as opposed to the larger
surgical team required for equivalent surgical therapies.
-
Some procedures may be performed at the bedside, reducing the risk of transmission
from a COVID-19 positive patient, for example, abscess drainage.
-
These advantages are particularly relevant in patients with cancer facing the triple
jeopardy mentioned earlier, that is, IR offering an effective treatment to cure or
prevent disease progression, without exposing the patient or the HCW to excessive
risks. Emerging consensus statements are already beginning to reflect this thought,
for example, treatment of Barcelona Clinic Liver Cancer A primary liver cancer with
locoregional therapies.[22]
Although there is, as yet, no evidence of increased IR workload during the pandemic,[23] there are interesting snippets in the current guidelines. An urology review suggests
use of ureteric stents or nephrostomy tubes under local anesthesia to be considered
first in urinary tract obstruction or infection.[24] The American College of Surgeons suggest[25] nonoperative treatment of common urgent surgical conditions such as appendicitis,
cholecystitis, and diverticulitis, including antibiotics or nonsurgical intervention
as the mainstay of therapy. Therefore, drainages and cholecystostomy may need to be
performed increasingly to avoid anesthetic risks. We feel that this argument should
be extended further to include even elective therapies such as in fibroids, prostate,
thyroid, hemorrhoids, or knee osteoarthritis.
On the other hand, the availability of IR resources as well as the cost of IR procedures
in certain health care settings could be a limiting factor. The conditions mentioned
in [Table 1 ]may not at all be suitable for IR procedures and a case-by-case consideration by
the multidisciplinary team should be performed. Nonurgent conditions would need to
be deferred, but may still be very helpful over the next year as health care facilities
face the burden of canceled elective cases. Finally, although less risky, the possibility
of infection of a scarce resource such as IR personnel need to be considered and all
relevant precautions need to be taken.
Wider dissemination of IR procedures has suffered from lack of public, patient and
physician awareness. The current pandemic could be an occasion for IR to step up to
fill a void to offer safer therapies and help our multidisciplinary colleagues at
the time of a crisis. Procedures will, of course, need to be performed with adequate
precautions and safety considerations, as outlined in local guidelines and recommendation
by IR societies.[26]
[27] With severe travel restrictions, local IR services may be called upon to deliver
these therapies. These new referral pathways and increased patient confidence can
result in improved service delivery that may outlast the pandemic. IR teams across
the globe are already showing their adaptability and versatility in the setting of
heavy COVID-19 caseload health care settings,[28] sharing intensive care responsibility, performing bedside procedures, inserting
lines, etc. Now, more than ever, the patients and the multidisciplinary teams should
be given the choice of the benefits offered by IR therapies, and interventional radiologists
should embrace this situation by offering their skills and services to the wider community
both during as well as during the emergence from the pandemic.
