During the first pandemic declaration in March 2020, rescheduling elective surgeries began by allowing only limited semi-emergency lists, emergency and obstetric cases in this institution to proceed as a COVID-19 hybrid medical centre. The operating theatre (OT) was reduced to less than 30% to channel workforce, resources and hospital beds to manage the increasing number of COVID-19 patients in this region. After 8 weeks, the OT capacity was gradually increased to its routine with reinforced protocols for patient and healthcare safety.
This study demonstrated that 23.5% of elective surgeries were postponed cases from March 2020. These postponed elective cases were minor and non-cancer-related surgeries as recommended by international guidelines to triage procedures in the OT lists. Following that, the American College of Surgeons published guiding principles to lead institutions in making decisions based on surgical prioritization during the pandemic phase while, at the same time, conserved manpower and resources (American College of Surgeons, 2020a). Retrospectively, we experienced Acute Phase 1 during the first OT closure and relied on identifying and performing surgeries that were needed within 3 months or otherwise survivorship would have been compromised. All emergency and semi-urgent cases such as cancer-related surgeries were given priorities as recommended (Federation of Surgical Specialty Associations, 2021; European Society for Medical Oncology, 2020; American College of Surgeons, 2020b).
The highest number of rescheduled cases was notably from surgical specialties such as ophthalmology and urology since the profile of their patients was usually older, which was also the main inclusion criteria in this study. Furthermore, lens and cataract removal had always been shown to be the most common procedure for adults aged above 65 years old (Deiner et al., 2014). And because this procedure is clearly defined as minor, most of them would have been postponed. Similarly, urology tends to have older patients and minor procedures such as transurethral resection of prostate or removal of urinary obstruction, another common surgery for geriatric patients. Hence, the same clinical decision was made for patients under this team during the OT semi-closure.
Although countries around the world were compelled to postpone or cancel their surgical lists during the same period, reports related to the medical impact or patients’ outcome remained scarce and variable. Surgical departments in two German university hospitals concluded that no disproportionate impact on patient outcomes occurred in their institutions while averting nosocomial transmission of COVID-19 with well-organized and early suspension of elective surgery (Metelmann & Busemann, 2020). Their elective surgery was completely suspended from March to April 2020 with an average time of postponement differing from 47 to 124 days. However, it would not be appropriate to make a fair comparison of their analysis to the current study results since both were relatively small centres of less than a hundred beds, had low COVID-19 infection rates and maintained reliable capacities for ventilation of ill patients and intensive care unit (ICU) beds throughout the epidemic (Deiner et al., 2014). In Italy, at the peak of the epidemic curve when 91.3% of the ICU beds were used for COVID-19 patients, elective surgery reduced by 75.0% while urgent or emergency surgery then decreased by 30.0% (Di Marzo et al., 2020). The study reported short-term impact of surgeries performed, looking into significantly higher median operative time, stay in OT and rate of patients with Clavien-Dindo grade 3b postoperative complications requiring a second procedure within 7 days but not the effect on rescheduled cases after that cancellation period (Dindo et al., 2004).
Based on the interview findings, we found that anxiety and depression were not uncommon especially in the elderly above 85 years old and females which were similar to previous studies (Mirani et al., 2019; Löbner et al., 2012). Both forms of psychological distress also resulted in significant loss of appetite. Despite the lack of statistical significance, the HADS scores for both anxiety and depression were higher in the group with postponement from their original dates. Although prevalent, peri-operative anxiety and depression are often under-reported and overlooked in vulnerable individuals displaying subtle geriatric-specific syndromes (Kim et al., 2015; Byers et al., 2010). Furthermore, when anxiety was present, the risk for depression would follow with a significant rise and vice versa as shown in our study.
In the past, these psychological disorders were mostly due to inadequate adjustment to unfamiliar hospital environment, insufficient privacy, exposure to strange instruments, financial concerns and disease stress (Mirani et al., 2019). But for the months preceding this study, a new concern for older surgical patients developed and profoundly impacted their well-being (Arjomandi Rad & Vardanyan, 2020). Strict lockdowns, social isolation and lack of support in addition to fear of contracting the COVID-19 infection from both community and within hospitals while seeking treatment compounded to the existing reasons for deteriorating mental health (Arjomandi Rad & Vardanyan, 2020). Postponement of their surgeries caused further harm ‘downstream’ in the consequence of waiting for a new date and managing the disease at home (Brown et al., 2021). Even so, with a lengthy waitlist despite resuming elective surgeries, patients continue to experience clinical depression that could lead to disruption of their daily activities (The Lancet R, 2021). Moreover, anxiety and depression peri-operatively are psychological factors associated with surgical recovery, length of hospitalization, readmission rates and mortality of the older patient (Abraham et al., 2020; Ghoneim & O'Hara, 2016; Singleton & Poutawera, 2017). Even though it is important to be cognizant of peri-operative psychological distress, this study however, did not demonstrate the impact of postponement on HADS scores in a statistically significant manner.
Nevertheless, recommendations to acknowledge the psychological symptoms early is still recommended as the first step, followed by simple screening tools to confirm and discuss coping strategies with patients and family (Arjomandi Rad & Vardanyan, 2020). Another solution suggested by experts is to prioritize novel approaches in telemedicine (Hildrew, 2020). This will avoid person-to-person contact and yet preserve the continuum of care for some form of psychological support intervention in a prehabilitation bundle for their health management by general or specialized practitioners (Arjomandi Rad & Vardanyan, 2020; Xiao et al., 2017; Tsimopoulou et al., 2015).
A particular subgroup of patients during this period of COVID-19 who had imposed critical challenges to medical teams were cancer patients (Aminian et al., 2020). The surgical management in cancer patients may be more complicated, especially in those who were clinically frail and ill from the capacitating disease itself or other co-morbidities. Thereby, exposing these patients to peri-operative risks will necessitate intensive postoperative care, longer hospitalizations and concurrently raise their susceptibility to both common infections and COVID-19 transmission (Di Saverio et al., 2020; Sharma et al., 2020). From the results, most postponed cases were non-cancer related. Only a few were cancer-related surgeries from breast, colorectal, plastic and urology specialties that were likely to be long surgeries, requiring the already exhausted critical care support and resources such as blood supply.
In some cancers, surgical deferment can be considered, particularly if alternative treatments are available. For example, in breast cancer, adopting neoadjuvant chemotherapy and hormonal therapy has been proposed (Sheng et al., 2020). On the other hand, the timing may have a significant impact on prognosis and subsequent quality of life in cancer patients (Samson et al., 2015; Grotenhuis et al., 2010; van Harten et al., 2015). The decision to proceed or postpone can be challenging and should be done with care from a multi-disciplinary approach by considering all the aspects of each case including the type and stage of cancer, the age, the physical status, the psychological issues and other treatments (Soltany et al., 2020). There was definitely fear among cancer cases that had to be postponed for the spread of their disease and evidence that the disease has progressed unfavourably. Nevertheless, the knowledge regarding cancer surgery and oncology management is rapidly evolving. It is on the onus of the primary teams, as a whole, to decide and adopt the principle of a global approach for specific cancers versus a case-by-case approach as recommended by the Society of Surgical Oncology amidst the restricted hospital access and resources in the present state (Bartlett et al., 2020).
This study has several limitations. First of all, data of the exact number of postponed surgeries were not collected, and the cases captured here may represent only a fraction of the rescheduled cases. Patients who had decided to undergo their procedures in other institutions or those who had succumbed to death while on the waiting list were not captured in this study. Among oncological cases, some were also referred to nearby centres for surgery to mitigate the long wait or risks of cancellation which might have caused a certain degree of selection bias. Secondly, the low number of postponed cases included in this sample especially for cancer-related diagnosis limits conclusions and generalizability of the findings. Patient sampling was also limited to the period of 3 months when elective surgery restarted, done in a single centre and did not include emergency cases. Hence, postponed patients who ended up requiring urgent procedures because of complications in their primary diagnosis could have been missed. Finally, we did not explore specific fears in patients towards COVID-19 as a cause of their anxiety and depression.
However, this study focused mainly on the clinical and psychological impact of older patients who underwent elective procedures when OT was resumed following the lockdown. Across the globe, many institutions would have likely experienced the same dilemma when millions of operations were cancelled or postponed to enhance capacity to manage the peak of COVID-19 cases in 2019-2020 (COVIDSurg Collaborative, 2020). In the aftermath of managing the pandemic, a massive backlog of surgical cases became a repercussion to many older patients, increasing their anxiety, depression and fear. As a result, their elective surgeries became ‘too long to wait’ for (The Lancet R, 2021). As the healthcare system moved towards handling wave after wave of the pandemic, drastic measures for surgical prioritization and redirection of medical attention continued to dilute and prevent the escalation of the much-needed care in non-COVID-19 patients.
