INTRODUCTION

The ongoing outbreak of coronavirus disease 2019 (COVID-2019) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been declared a pandemic by the World Health Organization.[¹] This pandemic has brought unique challenges for the conduct of surgical procedure and anesthesia in hospitals worldwide. Considering the sudden increase in the demands of viral diagnostic tests, personal protective equipment (PPE), N95 masks, isolated beds, ventilators, and intensive care units, even the most developed countries in the world have appeared vulnerable to this pandemic. In an already resource-challenged country like India with such a huge population, management of hospitals is almost impossible if proper triage is not done between elective and emergency cases. Although children have been found to be less affected by the virus, they are not immune to it.[²³⁴]

Pediatric surgery department caters to a set of patients ranging from different congenital neonatal anomalies to pediatric emergencies such as trauma and foreign body bronchus. Each of these has its own challenges and therefore cannot be deferred. Due to a significant proportion of such cases, re-organization of surgical care in the light of COVID-19 pandemic is a must for efficient management. We present the surgical data and analyze the impact of this pandemic on the management of pediatric surgical cases at four tertiary care centers in Northern India.

MATERIALS AND METHODS

A retrospective study was conducted in the department of pediatric surgery at four different tertiary care centers in North India after approval from ethics committee (Approval No. 1443/IEC/2020/IGIMS). Data of all pediatric patients who underwent surgery for different indications during the first three phases of lockdown (from March 23, 2020 to May 17, 2020) and from January 2020 to the start of lockdown period was collected after consent and analyzed retrospectively. This data included the demographic details, detailed history, diagnosis; investigation results, COVID-19 status, surgical details, waiting time before definitive management postoperative stay, any complications, and cost of management.

Standard protocol for managing surgical patients at these institutions

Being a global pandemic with no definite drug therapy or vaccine against it, COVID-19 has brought an unprecedented crisis due to its highly contagious nature. Social distancing remains the only means to check its spread at present; this has made it necessary for the law makers to enforce a lockdown in various countries. In India, it was implemented on March 23, 2020, for a period of 2 weeks and thereafter extended without a break for successive phases of 2 weeks duration. During this period, as a protocol outpatients' clinic functioned under limitation to cater to the needs of only serious and emergency cases; all the elective cases were postponed and only emergency cases were operated. Different hospitals were designated for COVID-positive and COVID-negative patients; a strict rule of treating COVID-positive patients in COVID hospitals and non-COVID patients in non-COVID hospitals was followed once reverse transcriptase – polymerase chain reaction (RT-PCR) results became obvious. In doing so, individual hospitals developed their own standard operating protocol (SOP) which involved triaging of patients for their symptoms, admitting all emergency patients in isolated area, subjecting all admitted patients to RT-PCR for COVID-19, transferring patients who turn negative for these tests to the primary ward designated for the individual department whose care is essential for the definitive management of the patient and referring the COVID-positive patients to designated COVID hospitals for further treatment. The SOP also had provision for facilities of complete protection of all the health-care professionals by the provision of PPE including masks (level 2 or 3 filtering face piece depending on the aerosol-generating risk level), eye protecting goggles, double nonsterile gloves, gowns, suites, caps, and shoe-covers. Each department was allotted a specified time daily for telemedicine facility to advise nonemergent cases and follow-up cases. This further reduced the number of patients in the outpatients' clinic. Any health-care professional or supporting staff, on accidental exposure to some COVID positive patient was quarantined for a period of 2 weeks as a part of the institutional SOP and on turning positive for corona virus, received treatment at an isolation center in designated COVID positive hospital.

RESULTS

1. Table 1 shows the number of surgeries done during this period at different institutions. When comparing data from 55 days prior to imposition of lockdown to that in the first 55 days of the lockdown, there was a sharp decline in the total number of cases at these four institutions from 596 to 100. A wide range of age could be seen (from 1 day to 17 years) with a mean of 21.53 months. Majority were neonates, mostly due to a variety of malformations. Male children outnumbered females by a ratio of 4:1.
2. Table 2 enlists the different indications for which surgery was done during the lockdown period and compares it to the number of surgeries done in the corresponding category just before lockdown. Almost all categories showed a decrease during the lockdown period. Congenital deformities in neonates were the most common indication for surgery during this period; most common among these were Anorectal malformation, Bowel atresia, oesophageal atresia, infantile hypertrophic pyloric stenosis; trauma cases had lessened at all institutions; only one case of polytrauma with pelvic and femoral fracture with urethral injury came to the hospital during lockdown; tumors were operated on a semi-emergency basis.
Nonperformance of elective cases such as pelvi-ureteric junction obstruction, hypospadias, epispadias–exstrophy bladder, asymptomatic renal and gallbladder stones, all types of stoma closure (bowel stoma, vesicostomy, ureterostomy), and asymptomatic cystic lesions (thyroglossal, mesenteric, choledochal, branchial) were the major cases which were deferred. Delaying stoma closure increased morbidity and cost of management. Other conditions did not cause any specific problem for the patient in our study.
Two cases of acute appendicitis underwent laparoscopic appendicectomy while one patient with foreign body bronchus had bronchoscopic removal of the foreign body.

3. Table 3 shows the COVID-specific measures taken by these institutions to manage patients during lockdown. All these measures had one common theme – to limit the number of patients at registration, outpatient's department and indoor admission without denying care to the needy who presents with any emergent symptom.
Both the laparoscopic procedures during this period were performed at Institution 1 and so laparoscopy-specific measures are mentioned only with Institution 1.

4. There was an increase in the number of patients who left against medical advice (LAMA) during this period (seven in total), while awaiting results of PCR for COVID-19. At institution 1, five patients went LAMA after admission but before the test results came. The attendants of all these patients feared of getting infected with the corona virus during their hospital stay.
5. In all, there were three deaths in the patients operated during lockdown but none of them were due to corona virus. Among these, two patients had jejuno-ileal atresia (one with anastomotic leak and other with accidental aspiration while feeding). The third mortality was in a case of gastric pull-up for wide gap oesophageal atresia that had been operated prior to lockdown; he had a pulled feeding jejunostomy tube that resulted in a high output entero-cutaneous fistula.
6. Four patients tested positive during this period at Institution 1 and it being a declared “non-COVID” hospital they were sent to a COVID – hospital for proper advice. Among them, a 2-year-old intussusception patient died later due to her sick state; while a child having pelvi-ureteric junction obstruction was operated when he turned negative for COVID-19. Two other positive patients (Empyema thoracis and right-sided Wilms' tumor) were operated at another hospital designated to operate and take care of COVID positive patients.
7. Four nursing staff and one treating physician were found to be corona–positive. They were kept in quarantine and returned to work after testing negative after a couple of weeks.
8. Following the protocol of testing for COVID-19 before surgery delayed surgery by an average of 20 h; use of RT-PCR, protective kits and all other protective measures added additional cost of around Rs. 11,500 (Indian rupees) in every patient.

DISCUSSION

The novel corona virus pandemic has necessitated a change in the approach to health-care delivery making “triage,” an important step in prioritizing the management of patients. This has affected the surgical disciplines also.[⁵] Recently, the European Association of Urology Guidelines Office suggested key points for prioritization of surgical care.[⁶] This includes the impact of delay on the outcome of surgical procedure, feasibility of alternative procedures, the risks to the patient's life or organ dysfunction if surgery is delayed, presence of co-morbidities and increased risks of complications and the risks of progression of symptoms or disease progression if the procedure is not performed.[⁶] Therefore, a balance between the patient's needs, available resources and the risks of deferring surgery must be taken into consideration when decision regarding an individual patient is to be taken.

Different countries and institutions have come up with their own recommendations regarding elective and emergency surgeries. The approach to deal with the pandemic varies even between two departments in the same institution, while also obeying the institutional protocol. The American College of Surgeons have divided the operative procedures into different tiers depending upon the urgency of surgery; they recommend postponement of all surgeries up to tier 2b.[⁷] This, however, does not apply to majority of high risk cancer surgeries and surgical patients who are very sick to survive without an operative procedure (Tiers 3a and 3b).[⁷]

National Health Survey, England, recommends to undertake elective pediatric surgeries only if patients are low risk for anesthesia (American Society of Anesthesiologists Grade 1), with the exception of cancer cases.[⁸]

As per the guidelines of the Indian Council of Medical Research (ICMR), all high-risk cases who need surgery should undergo PCR test for COVID-19 before surgery (all symptomatic contacts of laboratory-confirmed cases or asymptomatic-direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact).[⁹] Thereafter, if the patient's PCR test is negative, he undergoes surgery with precautions as per surgical protocol; if positive, he is kept in isolation meant for COVID-19 positive patients and operated with tertiary protection measures for anesthesia and surgery. In the postoperative period, patient is again managed in isolation ward. All the four institutions in this study were guided by the protocols issued for the conduct of pediatric surgery which is in line with that advocated by the American College of Surgeons, ICMR and the institutional SOP.[⁵]

Surgical procedure being a teamwork, the conduct of a single surgery exposes the entire health-care team involved in hospital registration, outpatient consultation, admission, inpatient care, investigation and radiological workup, anesthetic procedure, definitive surgery, postoperative care and sanitation and disinfection measures to the risks of this virus. Hence, strict measures must be taken at every level to lessen the exposure; online registration, restricting the counts of patients turning up for outdoor consultation to only those having emergent symptoms, initial isolation followed by PCR test for corona virus followed by all other investigations and resorting to primary, secondary and tertiary protection measures as per the risk group of the patient.[¹⁰] All these steps were taken at the institutions included in the study [Table 3].

Most of the hospitals, including the four hospitals included in this study, have limited their outpatients' clinics as a part of their COVID containment strategy.[⁸] Only emergency and life-threatening cases were operated. For other patients, telemedicine sessions were used. Use of Telemedicine or Tele-health services has seen a surge during this Pandemic.[¹¹¹²] Such facilities ensure delivering health-related advice to those in need without unnecessary crowding in the hospital premises. These services were available to patients treated at all four institutions and on average 3.5 pediatric patients used to avail these services daily. However, only medical advice can be given through this medium; patients can only be advised to come to the treating center, should any need for surgical intervention arise. Also, public awareness is lacking regarding such facilities which is reflected by the limited number of patients availing them.

Our data demonstrates a significant fall in the number of patients operated at each of the four institutions during the lockdown period. This not only is due to nonperformance of elective cases, but also due to reduction in emergency cases (possibly due to restrictions imposed on transport facilities).

Different subgroups of surgical patients who received surgical care are evident on analyzing the multi-institutional data.

Trauma patients constitute a subgroup that needs treatment despite their COVID-status.[¹³] Fortunately, with the imposed lockdown and restriction to unnecessary movement and transportation, the overall number of these patients declined considerably. In our study, trauma patients were very few in number and they were managed following appropriate guidelines.[¹⁴¹⁵]

Neonatal surgical deformities formed the bulk of the operated patients. Anorectal malformation, esophageal atresia, Jejuno-ileal atresia, Duodenal atresia, Malrotation with midgut volvulus, Necrotizing enterocolitis, Hirschsprung's disease, Idiopathic Hypertrophic pyloric stenosis, Congenital diaphragmatic hernia, Congenital lung cysts, Biliary atresia and posterior urethral valves were some common conditions for which surgery was performed. This spectrum mimics the range of cases found during non-COVID times. So, with regard to neonatal surgery no limitation was observed for any specific condition. None of these conditions can be considered non life-threatening or not capable of causing any organ damage. Children with bowel atresia had a prolonged hospital stay, often exceeding 2 weeks, thereby making them at risk for exposure.

Cancer surgeries, on most occasions, cannot be deferred fearing tumor growth, its spread (metastases) and risk to life. These points must be carefully balanced against the risks of viral transmission to these patients (due to their immune-compromised state).[¹⁶] All tumor surgeries were done on semi-emergency basis and their hospital stay was kept as short as possible by allowing early feeds and mobility, lessening their overall exposure.[¹⁷] Wherever applicable, they were also sent for chemotherapy and radiotherapy after discussion in online Institutional tumor board to provide comprehensive cancer care.

The number of emergencies in grown up children were fewer and their number had declined compared to the non-COVID period. Some of these included foreign body bronchus, Acute Appendicitis, Empyema Thoracis, Intestinal obstruction, perforation peritonitis and tumors. We followed the guidelines whereby a diversion stoma is preferred over an anastomosis if a choice has to be made between the two. This lessens the chances of a second surgery, should an anastomotic leak occur.[¹⁸] SARS-CoV-2 has been found in many fecal specimens and this implies precaution during bowel surgeries.[¹⁹²⁰²¹]

The advantages and disadvantages of laparoscopic surgery during COVID period have often been compared.[²²²³] Less trauma, faster recovery and discharge, contained surgical field limiting exposure to fumes and fluids, wider spacing between persons involved in surgery and anesthesia are some direct advantages of laparoscopic procedure;[²⁴] however, energy devices, surgical plume and smoke have been regarded as potential risk factors for viral transmission.[²⁰²²] These risks are not well substantiated by available data. Using filters and safe smoke evacuator for the released carbon dioxide during surgery, creating a closed circuit for insufflation preventing any release of free gas during the procedure, limiting the use of energy devices to minimum and lessening the insufflation pressure to decrease the risks of aerosolization of the virus are a few described measures.[²²²⁵] In case, smoke evacuators are not available, direct application of suction device to the laparoscopic trocars facilitates safe disposal of the smoke.[²²] Also, any surgical specimen should always be removed when the abdomen in desufflated.[²²] We had only two laparoscopic procedures during this period and both these patients were discharged the next day. We used lower insufflations pressures, applied suction to the trocar to achieve safe evacuation of gas and smoke and retrieved the surgical specimen after desufflation.

Number of males who had surgery during this period was four times the number of females who were operated. If not due to social discrimination for the female child, this implies that males are more affected with anomalies and emergencies, which necessitate hospital admission in a crisis situation like lockdown.

A disturbing trend was the increase in the number of patients who LAMA, while awaiting the results of PCR for corona before surgery. In all, there were seven such patients; they left due to fear of getting infected.

There were no COVID – related deaths in the department of pediatric surgery in any of these four institutions. Three children who died during this period were all due to non-COVID related causes. At institution one, four nursing staff and one doctor were positive for corona virus and were safely quarantined to re-return to work on testing negative for COVID-19.

Following the protocol (intervening only after testing) led to unnecessary delay in instituting definite care to needy patients.

This global pandemic has changed the dynamics of the hospitals and the number, nature and expenses of the cases which are now subjected to surgery. All the four hospitals involved in the study have high volume pediatric surgery units which have been limited by the lockdown and the SOP in their functioning and patient care.

CONCLUSION

COVID-19 has severely impacted the functioning of hospitals and health-care delivery by decreasing the number and types of patients getting treatment; following the recent protocol often delays treatment and adds to the cost of management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.