key: cord-0691060-zw1959dn
authors: Gangbe, Ella; Cai, Emmy; Penta, Ruxandra; Mansour, Fady Williamson; Krishnamurthy, Srinivasan
title: Effects of Surgical Delay due to COVID-19 on Women Requiring Emergency Gynecological Surgery
date: 2021-06-18
journal: J Obstet Gynaecol Can
DOI: 10.1016/j.jogc.2021.05.016
sha: 7643c69e69ce80216abc2155533c6575ebbeb157
doc_id: 691060
cord_uid: zw1959dn

In response to the coronavirus-19 (COVID-19) pandemic, the McGill University Health Centre introduced protocols to protect health care workers during emergency surgeries. These included waiting for a COVID-19 test result or waiting 20 minutes after aerosol-inducing procedures before proceeding with surgery. The following brief communication describes the impact of surgical delay on the outcomes of 3 emergency gynaecologic procedures: dilatation and curettage, laparoscopic salpingectomy, and laparoscopic cystectomy and detorsion. Our results show that delays associated with COVID-19 protocols did not negatively impact patients undergoing these surgeries.

Key words: COVID-19, surgical delay, surgical outcomes, gynecological surgery, emergency surgery

On March 11th, 2020, the novel coronavirus 2019 (COVID-19) pandemic was declared. 1 At the McGill University Health Centre (MUHC), protocols were introduced to mitigate the propagation of the virus during emergency surgical interventions. 2 A minimum of 6-8 hours were required to obtain a nasopharyngeal COVID-19 test result, leading to a delay to proceed to surgery. Alternatively, patients needing immediate procedures did not have to wait for the swab result. Instead, the surgical team donned full personal protective equipment (PPE) and waited 20 minutes after intubation and extubation. Our objective is to understand whether the implementation of these safety protocols affected outcomes of women requiring emergency gynecological surgeries at the MUHC. To our knowledge, other Canadian hospitals have not published their adapted surgical protocols and the related outcomes.

A retrospective cohort study was conducted using data retrieved from chart review of patients who underwent emergency dilatation and curettage (D&C) for retained products of conception, laparoscopic salpingectomy for ectopic pregnancy and laparoscopic cystectomy and detorsion for ovarian torsion. This study, number 2021-6894, was approved by the MUHC research ethics board.

Procedures performed from October 2019 to August 2020 at the MUHC were included. As of February 28 2020, patients were screened for symptoms of COVID-19, sick contacts and recent travel. None in our cohort were considered at risk. Mandatory testing for COVID-19 of patients undergoing surgery was implemented on March 25th, 2020. The "pre-COVID" and "COVID" groups are formed by 64 emergency gynecological procedures done prior to and 46 done after mandatory testing, respectively.

A 20-minute delay was instituted after aerosolizing procedures for most cases without a COVID-test result. The records did not specify if the operating room staff were wearing full PPE.

Physicians booked cases as one of four possible categories. A category 1 case has the highest level of acuity and is to be performed immediately. Categories 2, 3 and 4 cases are to be performed within 4 hours, within 12 hours and above 12 hours, respectively.

Procedures from the last three categories are placed on a waiting list according to the time at which they were booked. We did not have access to information about the nongynecological emergency procedures booked during the study period.

One case with missing information and three outliers were excluded. Two of these outliers were booked for non-urgent D&C from out-patient clinics. The third outlier was a possible ovarian torsion with a time to operating room of 18 hours due to resolved pain.

The following data were recorded: age, American Society of Anesthesiologists (ASA) class, booking category, diagnosis, procedure, type of anesthesia, COVID-19 test result and the need to wait at least 20 minutes after aerosolizing procedure. Outcomes studied included time to and length of surgery, hemorrhage, blood transfusion, intensive care unit (ICU) admission and mortality.

Statistical significance was evaluated with χ 2 , t test and Mann-Whitney U test analyses using the SPSS software. Statistical significance was achieved when p-value was less than 0.05. Using the Shapiro-Wilk test, normal distribution was confirmed for the age variable. Time to operating room and procedure time variables were found to be nonnormally distributed.

A total of 37 cases were in the pre-COVID group and 31 cases in the COVID group.

Both groups were similar in age, ASA class, type of anesthesia received and booking category for all three surgeries (Table 1) . No patient tested positive for COVID-19. There were no admissions to the ICU and no death.

For patients who underwent a D&C, there was no statistical difference for most of the outcomes studied between the two groups ( Table 2 ). The median procedure time was however lower for the pre-COVID group compared to the COVID group (7 minutes versus 15 minutes p 0.02). Only one patient in the COVID group suffered blood loss over 500mL and required a blood transfusion. Twelve out of seventeen patients had to wait for a COVID result prior to getting surgery. In the remaining 5 patients, intubation was not required, avoiding the minimal 20-minute delay before the start of the procedure.

In patients who underwent a laparoscopic salpingectomy, it also took significantly less time to complete the surgery in the pre-COVID group (57 minutes versus 106 minutes, p 0.04). Time to start the surgery and number of cases with hemorrhage or blood transfusion were otherwise similar ( Table 2 ). Out of the 10 patients in the COVID group, two waited to get a COVID test result prior to surgery. These were the only two patients who did not have the diagnosis of a ruptured ectopic pregnancy. Neither of them had blood loss over 500mL or required blood transfusion. Of the patients who did not wait for a COVID test result prior to surgery, all but two had at least a 20-minute delay after intubation and extubation.

The delay prior to surgery and time to completion of laparoscopic cystectomies and detorsions in the pre-COVID and COVID groups were similar. None of these patients had any of the adverse outcomes studied ( Table 2 ). Two of the four patients needed to wait for their COVID status prior to surgery. For the remaining two patients, the protocol requiring a 20-minute delay after intubation and extubation was respected.

Our study demonstrates that surgical delays awaiting for COVID results in urgent gynecological surgeries do not significantly worsen patient outcomes. The lack of statistically significant difference of the time to intervention and booking category between both groups is the most likely reason. Another explanation is that our study might have been too underpowered given the small size of our cohort. Rates of ICU admissions for retained products of conception, ectopic pregnancies and ovarian torsions are very low. Although significant blood loss and need for blood transfusion might be more commonly associated with ruptured ectopic pregnancies, the incidence of these outcomes is generally low for retained products of conception and ovarian torsions. It is well known that small study populations will fail to reject a null hypothesis. Despite this limitation, the procedure times for D&C and laparoscopic salpingectomies were shorter in the pre-COVID group.

Many have suggested general methods to reduce the transmission of COVID-19 during emergency surgeries that are similar to those of our institution. These include the use of a screening questionnaire, testing for the virus prior to surgery and donning of pull PPE in case of immediate need for surgery. A rapid chest x-ray or chest computed tomography has also been suggested. 3, 4 However, a national guideline has yet to be established and Canadian institutions have not shared their specific COVID-19 surgical protocols.

The most important limitation of our study is the small sample size. The lack of statistically significant differences in the outcomes between the two groups could be due to the study being underpowered. Also, our study population could have been too small to detect rare adverse outcomes.

Due to the nature of emergency surgeries, limited hospital resources and lack of access to some data, it is difficult to ascertain whether surgical delays were caused by unknown COVID statuses or by other reasons, such as surgeries with higher priorities.

Additionally, the data was obtained within a single tertiary care institution. Thus, the findings cannot be generalized to all institutions.

Our study demonstrates that there is no significant increase in morbidity in patients who required emergency gynecological surgeries, but waited for a COVID test to result. Our findings encourage healthcare professionals to wait for a COVID status in these women. For patients who require immediate life-saving surgical interventions and have an unknown COVID status, appropriate precautions should be undertaken by the medical team. Studies with a larger patient population would be required to confirm our results and allow the generalization of our conclusions. 

World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 -11

Precautions for Operating Room Team Members During the COVID-19 Pandemic

Practical recommendations for gynecologic surgery during the COVID-19 pandemic

International Society for Gynecologic Endoscopy (ISGE) guidelines and recommendations on gynecological endoscopy during the evolutionary phases of the SARS-CoV-2 pandemic