COVID-19 Update from Dr. Smith: 4/9/20

Each day during the COVID-19 crisis, Dr. Craig Smith, Chair of the Department of Surgery, sends an update to faculty and staff about pandemic response and priorities. Stay up to date with us.

Dear Colleagues,

A Department of Surgery shares some dimensions of this pandemic with much of the broader population. Our primary revenue-generating activities (operations) have been reduced to ~10% of normal. Anxiety associated with that state of affairs is buffered by our ability to contribute to the fight against this awful virus in the front lines, a blessing for which we are all grateful. Nonetheless, we must look ahead towards safe resumption of elective surgery, the timing of which depends on many factors. When will we have sufficient ICU and recovery floor capacity? When can we reactivate the ORs converted to ICUs? Most important, when will the risk to patients return to baseline? That is a critical question about which very little is known. It’s intuitively logical to assume that iatrogenic coronavirus infection is best avoided during recovery from an operation. What about operative risk in patients who are already infected?

Data from Wuhan just published by one of The Lancet’s online journals attempts to answer that question (EClinicalMedicine 000 (2020) 100331). 34 patients underwent elective operations before showing symptoms but were subsequently shown to have COVID-19 infection, with timing that strongly suggests the infections were present preop. The postoperative mortality (20.5%) was many-fold higher than would have been predicted for the procedures done, or for isolated COVID-19 infection in the general population. However, we must be careful not to over-react to a small retrospective series in which health-care-system differences may be important. For example, it is not clear why these patients were admitted 2.5 days preop. Nonetheless, the data is suggestive and cautionary, if only for operations performed during the latent phase of infection prior to appearance of symptoms. The latent-phase window can be narrowed by PCR testing for virus but is impossible to eliminate. Wider applicability of these results is speculative. Seen as an example of the interaction between outcomes of coronavirus infection and stress, surgical stress in this case, it is not surprising that stress, like comorbidities, would be detrimental.

Our specialty hospitals may help answer this question. Some cancer hospitals, like MD Anderson, cut back quickly on non-urgent surgery, and immediately shared their PPE supplies with neighboring hospitals. Hospital for Special Surgery did the same, and magnanimously opened beds to NYP. Unfortunately, herd behavior like that won’t help us understand the data from Wuhan. Here at home, Memorial Sloan Kettering has soldiered on alone, offering up their patients as a control group. We can look forward to publication of their experience with gradations of “elective” cancer surgery performed during this pandemic. At the center of the epicenter.

Until then, we should cautiously rejoice in our flattening curve, while steeling ourselves for weeks of care for patients we already have, and for the decreasing numbers of patients still to come. Irresistibly, in the past two days many news outlets have shared celebration over successful mating by two giant pandas in Hong Kong, ending 13 years of celibate cohabitation. It’s assumed the joyous occasion was facilitated by the privacy of their shuttered zoo. May we hope their ring fence protects them from us.

Craig R. Smith, MD
Chair, Department of Surgery
Surgeon-in-Chief, NYP/CUIMC

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