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Blood, Guts & Surgery in the COVID-19 Era: A Report from the Trenches



Blood, Guts & Surgery in the COVID-19 Era: A Report from the Trenches

Haytham Kaafarani, MD, MPH, FACS


Associate Professor of Surgery, Harvard Medical School
Director General, The Center for Outcomes & Patient Safety in Surgery (COMPASS)
Massachusetts General Hospital, Boston, MA, USA
 

 

Blood & Guts             
While COVID-19 was initially regarded as a respiratory disease, an increasing body of evidence is demonstrating its multi-system manifestations. Many of its complications in the critically ill patients required surgical attention. In our own experience at Massachusetts General Hospital (MGH), that was published in the Annals of Surgery, we showed the gastrointestinal (GI) system to be particularly involved in the disease process with 74% of patients with severe COVID-19 developing at least one GI complication during their hospital stay (1). These complications ranged between transaminitis, severe ileus, and inability to tolerate tube feeds to life-threatening GI bleeds, pancreatitis, cholecystitis, colonic pseudo-obstruction and bowel ischemia necessitating emergent surgery. A significant number of patients had bowel ischemia, nine of which required surgery. All patients taken to the operating room were found to have the same distinct pattern of bowel ischemia: patchy tannish discoloration of the serosa on the antimesenteric border with a clear demarcation between well perfused and ischemic bowel. Pathology of the resected bowel demonstrated abundance of fibrin thrombi in the small vessels beneath the areas of necrosis suggestive of thrombosis at the microvascular level. Evidence for increased risk of thrombotic events in COVID-19 is accumulating especially in patients with elevated D-dimer levels more than six times the from the normal levels. However, the benefit for full anticoagulation has not been established to be higher than the risk of bleeding in these patients, as GI bleeding and retroperitoneal bleeding have been reported as well, even without anticoagulation. View that lactate levels were normal in almost all patients, we developed a protocol and disseminated it across all the ICUs raising awareness about this devastating complication and encouraging early surgical consultation in critically ill COVID-19 patients with new leukocytosis or increased vasopressor requirements.
 
Surgery in the COVID-19 Era
An international collaboration called COVIDSURG was established in the early days of the pandemic including researchers from the University of Birmingham in the UK as well as our own research team at MGH in Boston, USA. Data has since been collected on more than 25 thousand patients who are COVID-19 positive from more than 80 countries and 6,000 hospitals across the world. An early report of the first 1,128 patients was published in The Lancetand is sending a clear cautionary message. The rate of mortality of patients with perioperative COVID-19 is as high as 23.8% and the rate of postoperative pulmonary complications is as high as 51%. The independent predictors of 30-day mortality were male sex, age more than 70 years, ASA grades 3–5 risk assessment, malignant disease, as well as emergency and/or major surgery. Based on these preliminary data, we recommend that thresholds for surgery during the COVID-19 pandemic be higher than during normal practice, and that serious consideration be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery.
 
Cancelled Surgery     
Our COVIDSURG collaborative also used Bayesian modeling techniques and estimated that more than 28 million surgical procedures were cancelled during the 12 weeks of the COVID-19 pandemic. In that project, published in the British Journal of Surgery, we estimated that it would take, even with 20% increased surgical capacity post-COVID-19, 45 weeks to clear the surgical backlog.