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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 64-68

Our experience of thoracic surgery during COVID19 pandemic


NH Rabindranath Tagore International Institute of Cardiac Sciences, K P C Medical College, Kolkata, India

Date of Submission19-Jun-2020
Date of Acceptance02-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Prof. Amitabha Chakrabarti
Consultant Thoracic Surgeon, RTIICS, Kolkata 700099
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_38_20

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  Abstract 


COVID19 pandemic has badly affected thoracic surgical services. In this difficult time Thoracic surgeons all over the world are boldly managing thoracic malignancies and life-threatening problems of benign thoracic diseases. Infection control, safety of patients & healthcare personnel remains the cornerstone. In this article we present our experience of Thoracic surgery during this pandemic. Our results & experience are similar to the guidelines & survey reports published by thoracic surgeons till date.

Keywords: COVID19, thoracic surgery, thoracic triage


How to cite this article:
Chakrabarti A, Bandyopadhyay M. Our experience of thoracic surgery during COVID19 pandemic. J Assoc Chest Physicians 2020;8:64-8

How to cite this URL:
Chakrabarti A, Bandyopadhyay M. Our experience of thoracic surgery during COVID19 pandemic. J Assoc Chest Physicians [serial online] 2020 [cited 2020 Sep 30];8:64-8. Available from: http://www.jacpjournal.org/text.asp?2020/8/2/64/294588




  Introduction Top


COVID 19 pandemic has affected all aspects of our healthcare. The unprecedented situation to manage the COVID-19 pandemic has disrupted the world’s ability to care for patients with benign thoracic disease and thoracic malignancies. The clinical data on surgical practice during covid19 pandemic are limited and more so for the thoracic surgery. Some articles, guidelines are coming out which may help us to plan and reshape our thoracic practices across the world. In this article we would like to present our experience of Thoracic surgical practice during this period of COVID19 pandemic.


  Materials and methods Top


This is a retrospective observational study of thoracic surgical practice conducted in private medical institution in Kolkata during COVID19 pandemic between15th March,2020 to 15th May,2020 under one Thoracic team. This hospital is treating COVID 19 patients (Inpatient load≤10/day) but not exclusively a COVID 19 hospital.


  Admission and operative policy Top


  1. Non-Urgent outpatients’ appointments were cancelled or deferred. Later on, video outpatients’ consultation was started. Cancer patients’ appointments were prioritized according to aggressiveness which may alter the survival of patients.
  2. To divide conventional pulmonary surgery into two categories- elective surgery and limited period surgery. Elective surgery has been defined as operations that can be observed over three months and therefore surgery is not recommended during the epidemic period (for example in case of Benign pulmonary nodules). Limited period surgery is defined as operations that should be performed within one month (for example patients with a clear diagnosis of lung cancer).
  3. For COVID 19 positive patients −Policy was to plan elective surgery later. If emergency surgery for COVID 19 positive patient was needed then it has to be weighed against risks and benefits of surgery. Also planned to offer alternative treatment, if any.
  4. Modifications in diagnostic and staging tests along with the overall management policy for the safety of patient was adequately explained. The increased expenditure due to RT-PCR COVID19 screening tests and use of Personal protective equipment (PPE) were explained to patient & his relatives.
  5. All management options of patients were finalized after discussion with multi-disciplinary team over a digital platform.


All admitted patients were kept in Isolation ward till report of RT-PCR for COVID19 turned out to be negative.

No. of patients admitted under Thoracic Unit: 11

No. of patients admitted last year :31 (Same Period)

Emergency

  1. Trauma with Hemopneumothorax − 5
  2. Malignant Pleural effusion − 2


Elective

  1. Lung Cancer − 1
  2. Cancer Esophagus − 1
  3. Pulmonary Hydatid Cyst with Hemoptysis − 1
  4. Paravertebral SOL (? Neurogenic Tumour) − 1


Total Patients admission deferred − 5

  1. Stage 3 Empyema Thoracis − 2
  2. Bronchopleural Fistula − 2
  3. Non obstructed endobronchial tumour − 1


FOB deferred/Alternative Investigation suggested − 4

Total Patients failed to get admitted in spite of advice (Due to Lock Down) − 2; Ca Lung − 1 and Ca Esophagus-Post CROSS Protocol − 1 [Table 1] and [Table 2].
Table 1 Comparison between thoracic operations and admission in 2019 and 2020

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Table 2 Patients deferred and deprived of surgery during COVID 19 pandemic

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Diagnostic Work up-RT-PCR for COVID19 from Nasopharyngeal swab after admission and HRCT Thorax to screen for COVID 19 for all the inpatients.

Fibreoptic Bronchoscopy (FOB)-Avoided due to aerosol generating procedure (AGP). Alternative like PETCT & CT guided Trucut biopsy prioritized before staging EBUS. When done it is done with full Personal Protective Equipment (PPE).
  1. Spirometry − Done after RT-PCR was negative. When planned for elective surgery as Pre-op work up − 1 patient (Disinfection of whole circuit done after the procedure).
  2. DLCO − Done after RT-PCR was negative. When planned for elective surgery as Pre-op work up − 1 patient.


These tests could not be done initially as RT-PCR testing was not available in private hospitals.


  Operative protocol Top


A) If a COVID 19 positive patient or strongly suspected patient has to be operated it should be done in an exclusive operating room preferably with negative pressure (not available in our hospital).

B) For NonCOVID19 patient’s surgery to infectious and non-infectious patients risk assessed. Personal protective equipment (PPE) as per hospital infection prevention control practices. But during this pandemic FFP2 mask, glasses, gown and face shield are mostly used by surgeons-when opening airways (Sleeve lobectomy, Tracheal surgery). Personal protective equipment must be worn as per protocol (ICMR) and extra personnel was not allowed inside the operating room. For all our Intercostal chest drain which carried a chance of pleural fluid PPE was worn as per guideline.

C) Several Structural adjustments inside Operation Theatre was undertaken. Aerosol/droplet infection is recognized as a significant risk to anaesthesiologists, surgeons and other health care workers. Air Conditioner was switched off for 30 mins during and after endotracheal intubation. Similarly, it was again switched off for another 30 minutes during and after extubation ± reinsertion of tube (i.e. Switching over from Double lumen endotracheal tube to single lumen tube but Bronchial blocker was favoured to avoid the procedure of reintubation). Number of OT personnel inside the theatre was minimized.

D) To minimise the surgical smoke, suction device to be used and electrosurgical instrument to be maintained in a lowest effective power.

E) Operative technique of open excision and repair of bronchus was replaced by staplers.

Procedures done

  1. Intercostal Chest Drain − 6
  2. Intercostal Chest Drain with Talc Pleurodesis − 1
  3. Transhiatal Esophagogastrectomy (Post CROSS protocol therapy) − 1
  4. Open Bilobectomy of Right Lung Cancer (upper and middle lobe) with mediastinal lymphadenectomy − 1
  5. Open Excision of Hydatid Cyst of Left lower lobe of lung with repair of bronchus − 1
  6. Left thoracotomy with excision of left paravertebral mass − 1


Post-operative protocol

For COVID19 positive or highly suspected patients-Routine use of Digital suction drainage was planned but we did not have viral filter to be connected to the drainage tube as per recommendation. Disinfection of operation theatre according to guideline as advised by Indian Council for Medical Research.[1] Non COVID patients were transferred to Intensive care or High Dependency Units or wards according to condition of patient. Postoperative care was as usual. Patient discharged when chest drain removed and patient was ambulatory. No special chest drain maintenance was followed.


  Result and analysis Top


Outcome

Mortality-Nil.

Morbidity-Nothing significant.

Total No. of Patients attended the hospital for admission was 58% compared to last year data (18/31).

Reduction in Admission & operative procedure:66% reduction compared to previous year admission & procedure (11/31).

Elective Benign Thoracic operations were deferred or delayed.

Benign Thoracic Disease operated for Hydatid Cyst of Lung due to Hemoptysis not amenable to medical management − 1

Pandemic Lockdown led to deferring management due to conveyance and other infrastructural problem − 2 patients (11%)

Pandemic Lockdown led to policy of deferring management in benign diseases − 5 patients (27.7%).

All of them were managed medically and none of them had to be admitted in hospital during this period.

In spite of known false negative report of RT-PCR for COVID19 no OT personnel or medical staff were turned out to be RT-PCR positive for COVID19.

Subjective & Objective problems faced by the surgical team and OT personnel inside OT during this COVID19 pandemic:
  1. Operative Time- Increased
  2. Mobility after wearing PPE-Decreased in all staff
  3. Sweating & Soakage of Scrub Suit-Present in all staff
  4. Hearing problem with PPE-Most of the staff (60%)
  5. Fogging of Googles & or Hood with difficulty in vision-All staff (Particularly during Intubation)
  6. Feeling of suffocation with PPE-Most of the staff (75%)
  7. Feeling of Vasovagal symptoms by one surgeon after 2 hours of OT
  8. Perception of surgeons to carry out long hour OT as before with PPE
  9. singlehandedly- Doubtful (May have to share with another surgeon).



  Discussion Top


Our experience shows admission in Thoracic unit during this pandemic had 42% reduction than the same period of last year. There was 66% reduction in operative procedure compared to previous year .This significant reduction in patient care & inability to turn up by few malignant patients (who were advised surgery) is in line with the observation that the increasing demands of managing the COVID-19 pandemic has disrupted the world’s ability to care for patients resulting in radical alterations to thoracic services.[2],[3],[4] Our hospital has deferred & rescheduled outpatient consultation of non-urgent benign thoracic patients. The same policy was advised by most of the guidelines.[2],[4],[6] Earlier we did not have clinical data about COVID19 positive surgical patients but we followed the advice gathered

from previous SARS experience[5] and prioritized the management of malignant thoracic diseases. We advised surgery for five malignant thoracic patients out of them three turned up. The reason for prioritization was based on the logic that if left unoperated during this period of COVID19 pandemic (presumed to continue for at least 3-4 months) these thoracic malignancy patients will have reduction in median survival.[2] Our hospital was not an exclusive COVID19 hospital and the COVID19 patient load was less. Therefore, we could utilize our resource for the treatment of benign thoracic and trauma patients. The surgery for patient with Hydatid Cyst could not be delayed due to persistent hemoptysis not amenable to medical management. The patient with paravertebral mass was operated because of excruciating pain with tingling sensation of lower limb and inconclusive trucut biopsy report. The indications for operation in our hospitals corroborates phase I status as recommended by Thoracic surgeons’ network in their Triage policy.[2] Our multidisciplinary digital meeting decision during this difficult period has been similar to the international experience.[2],[7] We did Fibreoptic bronchoscopy in two patients after examining the patient for COVID19 negativity and after excluding other alternatives.

Our policy for bronchoscopic investigation is similar to the recommendations from BTS.[4] Intercostal chest drain insertion & chest trauma management was in line with the guideline suggested.[10],[11] For non COVID19 thoracic surgeries the screening tests for RT-PCR and operative protocol for safety of patients and OT personnel were in pursuance of the recommendations from ICMR and some previous publications.[1],[7],[8] The open technique of bronchus closure by interrupted suture to reduce the cost of stapler practiced at earlier was avoided .There were several structural adjustment made inside the operation theatre as mentioned before. They were in conformity with the guidelines of several associations.[12],[13] The idea was to reduce aerosol exposure as much as possible. The smoke management arising out of electrocautery was done by using suction device and keeping the cautery at minimum setting.[8],[9] Personal protective equipments were used according to the guidelines.[10],[14] We have noted several subjective & objective difficulties related to Personal Protective Equipment (PPE). They were very problematic to continue a long hour operation. This has also been advised by Japanese thoracic surgeons.[3] The increased expenditure due to COVID19 screening tests and use of Personal protective equipment (PPE) was an added burden to the increased health care expenditure of a country like India. Modifications in diagnostic & staging tests along with the overall management policy for the safety of patient during this pandemic was adequately explained to patient. This has also been overemphasized by the BTS guideline.[4] Initially during the pandemic, we were clueless to manage these thoracic patients but over weeks equipped with more experience and information we could deliver a reasonable quality of care to our patients.


  Conclusion Top


The impact of Covid19 pandemic has placed thoracic surgeons across the world in difficult situation. Even in this difficult time Thoracic surgeons are boldly trying to find out an optimal solution to this challenge. Triaging of patients, deeper understanding of cancer biology and COVID 19 Pathophysiology, safety of patient and health care personnel while fighting the COVID 19 pandemic remains the cornerstone. Our limited experience in managing thoracic patients during this pandemic has provided us a valuable insight to manage thoracic patients. Further research, robust clinical data, and publications will enlighten us to plan our future thoracic surgical practices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Government of India. https://mohfw.gov.in/  Back to cited text no. 1
    
2.
Thoracic Surgery Outcomes Research Network, Inc. COVID-19 guidance for triage of operations for thoracic malignancies: a consensus statement from thoracic surgery outcomes research network. The Journal of Thoracic and Cardiovascular Surgery 2020, doi: https:// doi.org/10.1016/j.jtcvs.2020.03.061  Back to cited text no. 2
    
3.
Jheon S, Aneez DB, Ahmed XX et al. General thoracic surgery services across Asia during the2020 COVID-19 pandemic. Asian Cardiovascular & Thoracic Annals 0:1-7  Back to cited text no. 3
    
4.
Evison M, Grundy S et al. Lung cancer and mesothelioma service guidance during the COVID-19 pandemic Version 2: the restoration and recovery COVID-19 endemic phase. Available from www.britthoracic.org.uk  Back to cited text no. 4
    
5.
Li X, Liu M et al. Preliminary recommendations for lung surgery during COVID-19 epidemic period. Thoracic Cancer 2020;1-3  Back to cited text no. 5
    
6.
Liu Z, Zhang Y et al. Recommendations for surgery during the novel coronavirus (COVID-19) epidemic. Indian J Surg 2020;11:1-5  Back to cited text no. 6
    
7.
8.
Johnson GK, Robinson WS. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments. J Med Virol 1991;33:47-50.  Back to cited text no. 8
    
9.
Gloster HM, Roenigk RK. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol 1995;32:436-41.  Back to cited text no. 9
    
10.
Hallifax R, Wrightson JM et al. Pleural services during the COVID-19 Pandemic − Revised. Available from www.brit-thoracic.org.uk  Back to cited text no. 10
    
11.
Pieracci FM, Burlew CC et al. Tube thoracostomy during the COVID-19 pandemic: guidance and recommendations from the AAST Acute Care Surgery and Critical Care Committees. Trauma Surg Acute Care Open 2020;5:e000498.  Back to cited text no. 11
    
12.
Senturk M et al. Thoracic anesthesia of patients with suspected or confirmed2019 novel coronavirus infection: preliminary recommendations for airway management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee. Journal of Cardiothoracic & Vascular Anaesthesia DOI: https://doi.org/10.1053/j.jvca.2020.03.059.15  Back to cited text no. 12
    
13.
Naveen Malhotra et al. COVID Operation Theatre- Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National). Indian Journal of Anaesthesia 2020 ;64:355-62  Back to cited text no. 13
    
14.
Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief] Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment. Available from https://mohfw.gov.in/  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Materials and me...
Admission and op...
Operative protocol
Result and analysis
Discussion
Conclusion
References
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