As the Delta variant spikes across the country and fills up hospital beds, elective surgeries are once again taking a back seat to more urgent and life-threatening medical needs.
Since early 2020, hospitals and clinicians have been forced to allocate resources to fight the pandemic, and millions of elective procedures have been postponed, delayed, or canceled. Although the move to shift personnel, equipment, and resources is necessary, stakeholders in the medical community have expressed widespread concern about the repercussions of delaying elective surgeries.
“[R]esearch to date suggests that delays can have functional, psychologic, and economic ramifications for patients,” wrote the authors of a study published in Annals of Surgery. "Moreover, postponing care could lead to delays in diagnosis and treatment as disease burden continues to accumulate.”
Furthermore, patients are often confused by the term “elective surgery,” which does not mean optional or frivolous. “It simply means that the surgery can be scheduled in advance, according to Johns Hopkins Medicine. “It may be a surgery you choose to have for a better quality of life, but not for a life-threatening condition. But in some cases it may be for a serious condition such as cancer.” In fact, many elective procedures are considered vital, from biopsies to orthopedic and spine surgeries, to certain heart procedures, hernia repair, and more.
According to the American College of Surgeons (ACS), “While some cases can be postponed indefinitely, the vast majority of the cases performed are associated with progressive disease (such as cancer, vascular disease and organ failure) that will continue to progress at variable, disease-specific rates. As these conditions persist, and in many cases, advance in the absence of surgical intervention, it is important to recognize that the decision to cancel or perform a surgical procedure must be made in the context of numerous considerations, both medical and logistical.”
Below, we examine five critical elective procedures that should not be postponed. This list is based, in part, on a report published by the ACS, which provides a framework for providers caring for cancer patients during the pandemic. Importantly, the necessity of these surgeries depends on what stage of the pandemic we are in, as outlined in the guidance. We look at an important heart procedure as well.
In its report, ACS Guidelines for Triage and Management of Elective Cancer Surgery Cases During the Acute and Recovery Phases of Coronavirus Disease 2019 (COVID-19) Pandemic, the ACS highlighted various breast surgeries that should be done as soon as possible, depending on the stage (acute or recovery) of the pandemic, as defined in the guidelines. This guidance is derived from the COVID-19 Pandemic Breast Cancer Consortium, which includes National Accreditation Program for Breast Cancers, Commission on Cancer, American Society of Breast Surgeons, National Comprehensive Cancer Network, and American College of Radiology.
The following cases should not be delayed:
Breast abscesses in septic patients
Expanding hematomas in hemodynamically unstable patients
Ischemic autologous tissue flap (eg, full-thickness ischemic mastectomy flap with exposed prosthesis)
Stage T2 or N1 ER+HER2- tumors (eg, biopsies, malignant/local recurrence)
Cancer prophylactic surgeries
Breast cancer patients needing additional axillary surgery
Various presentations of melanoma require immediate surgery, according to the ACS. This guidance is based on data from the Society of Surgical Oncology and the National Comprehensive Cancer Network.
Here’s a list, depending on the phase of the pandemic recovery:
Anorectal carcinoma (which is always considered high risk)
Palliative resection for symptomatic metastatic lesions (eg, bleeding, bowel obstruction)
Patients who have completed neoadjuvant treatment and need curative surgery
Untreated patients with possibly curative disease who will need a short stay
Historically, the removal of pancreatic, ampullary, and duodenal neoplasms has entailed a high risk of adverse events, prolonged hospitalization, and readmission, according to the aforementioned ACS report. Such adverse events are due to the technical complexity of these operations and tumor-related factors including cachexia and malnutrition, as well as age and comorbidities.
“It should also be noted that although surgery is necessary for cure of localized pancreatic cancer, most patients who undergo pancreatectomy for this disease are not cured. Factors such as serum CA 19-9 level and tumor anatomy should be critically evaluated for each patient to determine the role of surgery. And, every case should be discussed in a multidisciplinary forum to establish the most appropriate care plan,” wrote the authors of the ACS document.
The following cases need to be performed as soon as possible, depending on the phase of the pandemic:
Previously treated, potentially curable pancreatic cancer
Previously untreated, potentially curable pancreatic cancer
Potentially curable pancreatic cancer along with biliary and/or gastric obstruction in those at risk for swift decompensation
Pancreatic cystic lesions or duodenal neoplasms harboring high-grade dysplasia
Fortunately, radical prostatectomy (RP) is a safe procedure often performed under general anesthesia. It usually necessitates only a 23-hour hospital stay after surgery. Postoperative complications are uncommon.
The following interventions should not be postponed, depending on the phase of the recovery:
RP for intermediate- or high-risk prostate cancer, especially for patients more than 6 months post-diagnosis
RP for those needing biopsy stratified by risk group based on PSA > 10, clinical stage >=T2b, or adverse MRI findings
Prostate biopsy for those being considered for active surveillance but exhibiting an increased likelihood of harboring high-risk disease (high PSA, high clinical stage, adverse MRI)
Prostate biopsy for those overdue by more than 6-12 months
Severe aortic stenosis
Determining whether a patient with symptomatic severe aortic stenosis needs immediate aortic valve replacement (AVR) during the pandemic is tricky. In a cohort study published in JAMA, researchers investigated outcomes in such patients who received either deferral or expedited AVR secondary to prespecified criteria.
“The algorithm used in this study to allocate the treatment strategy was similar to the triage recommendation from the American College of Cardiology and Society for Cardiovascular Angiography & Interventions consensus statement issued after initiation of patient recruitment for the study,” wrote the authors.
“Deferral of AVR in patients with symptomatic severe aortic stenosis was associated with an increased risk of hospitalization for valve-related symptoms or worsening heart failure. Patients with symptomatic severe aortic stenosis in combination with relevant multivalvular disease may particularly benefit from expedited AVR,” they added.
Click here to read more about the pandemic’s effect on elective surgeries on MDLinx.