The precautions required for the safe return of elective surgery - a letter to the editor in response to "Impact of the coronavirus (COVID-19) pandemic on surgical practice - Part 2 (surgical prioritisation)ˮ.

Dear Editor,

We were greatly interested to read the article by Al-Jabir et al. on the significant impact of COVID-19 on surgical practice across the world [1]. They highlighted sudden changes in guidelines for practice of several surgical subspecialties including colorectal, oncological, vascular and cardiothoracic surgery. They also described the continued necessity for emergency trauma procedures and urgent orthopaedic procedures despite the ongoing 2019 novel coronavirus (SARS-CoV-2) pandemic. Whilst emergency procedures have continued, elective procedures have been hugely disrupted [2]. We discuss how elective surgery can be safely reintroduced so that patients can have long-awaited procedures that have been postponed due to the coronavirus pandemic.

As of May 2020, almost 30 million elective procedures have been cancelled due to SARS-CoV-2. Many cancellations have been for benign conditions; however, over 80% of cancer operations have been postponed, as well as a quarter of elective Caesarean sections [3]. This is frustrating for patients as they are left untreated, and also for surgeons who have had to swap the operating room for medical wards in order to help treat COVID-19 patients.

As lockdown measures ease across the world, hospitals need to prepare for the safe reintroduction of elective surgeries. A key factor is widespread provision of adequate personal protective equipment (PPE), including N95 masks, glasses, face shields, gloves and disposable aprons. Since the early stages of the coronavirus outbreak, insufficient PPE has led to the preventable deaths of many healthcare professionals, with surgeons at particularly high risk due to the invasive nature of surgical procedures [4].

The other key element is testing. Two tests are currently being used in clinical practice. One of these is the polymerase chain reaction (PCR) test for the SARS-CoV-2 antigen; a positive test indicates current infection. Despite most patients displaying symptoms within 2 weeks of infection, incubation periods are highly variable. Thus, a negative antigen test may be a false negative in the early stages of infection. It would be wise for patients and surgeons to have the antigen test as close as possible to procedures, whilst ensuring minimal contact with others in the time between a negative test and operations. Patients will likely need to be isolated from others during their hospital stay, and ought to be tested again before discharge [5].

The other test in current use is serology for SARS-CoV-2 antibodies; a positive result indicates previous infection. However, this may be more useful if it is shown that presence of SARS-CoV-2 antibodies provides genuine immunity to re-infection. It is still unknown whether presence of antibodies means that one cannot transmit the virus.

In summary, it is beneficial to both the general public and the medical profession for elective procedures to return. For this to proceed safely, frequent testing of both patients and surgeons before procedures must become a part of routine practice. Additionally, baseline standards of PPE must be maintained. These measures will serve to reduce the needless mortality of patients, surgeons and their respective families alike.

Data statement

The data in this article is accessible to the public and is not sensitive in nature.

Ethical approval

No ethical approval was required for this letter.

Sources of funding

No sources of funding were received.

Author contribution

SO Cheng and A Liu co-authored this article.

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Name of the registry: N/A.

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Guarantor

SO Cheng and A Liu accept full responsibility for this work.

Provenance and peer review

Not commissioned, internally reviewed.

Declaration of competing interest

There are no conflicts of interest to disclose.