Mr Henry Tilney, Consultant General Surgeon MBBS MD FRCS (Gen Surg), discusses in two videos the challenges of managing cancer surgery during the COVID-19 pandemic.
My name is Henry Tillney, I’m a general and colorectal surgeon at Frimley Park Hospital in the UK, I’m going to talk a little bit about how we are trying to manage our cancer services, and specifically cancer surgery during the COVID crisis.
The fact of the matter is clearly that COVID-19 has become an all-consuming problem which is overtaking lots of our hospitals all over the world, and there’s a very real risk to many of our minds that patients who form the bulk of the rest of our work load, and indeed still the bulk of the workload for healthcare systems around the country could run the risk of being left out in the cold, and to an extent ignored while all of the focus of many people’s efforts is on managing the COVID crisis.
We were afraid this if cancer patients particularly don’t receive surgery in a timely manner then it might disadvantage them in that in the long term. But in addition to that there’s a whole range of other medical specialties in whom patients could come to harm; that includes cardiovascular services, vascular surgery, obstetrics, mental health. A whole ranges of problems which if not dealt with adequately during the COVID crisis could cause a second peak of mortality which could be an order of magnitude higher than that which is experienced in the COVID pandemic itself.
To that end we’ve helped to devise some strategies for providing clean, urgent surgical centres to manage patients during the COVID crisis, and the key on this I think is to is to provide a zone within a hospital, or a separate hospital which is as we can make it free from COVID.
But I think that we all have to accept that there is no such thing as a completely COVID free environment, all we can do is to minimize the risk to our patients, and we know that developing code in the COVID perioperative period or indeed harbouring asymptomatic COVID before an operation could be very harmful for the individual patient.
In some instances into our hospitals are given over to to ‘cold operating’ and in other situations it seems quite reasonable to create a ‘clean zone’, for want of a better term, within an existing acute hospital. But there has to be very strict separation of services and to an extent some duplication of services between areas so that patients are protected as far as possible.
Our view is the patient should be screened before admission, certainly with swabs after a period of self isolation and probably with a CT scan of the chest to try to pick up asymptomatic COVID disease.
Surgeons and other staff including anaesthetist and nursing staff should be isolated from the hot area for a number of days prior to entering the cold area, and staff swabbing and testing is also sensible.
We also have to accept that we need to provide equity between specialties and equity within specialties; there are some people who over the course of months are unlikely to progress and come to any harm from having their surgery deferred, and there are radiological guides that we can use to help to select those patients in whom a period of waiting, especially if they have medical comorbidities, might be more appropriate than being exposed to the increased risk of surgery during this period.
There’s another group who would come to harm if not operated on in the short term, and for them providing urgent surgery during this period is essential.
So I think the priority in prioritizing patients within specialties is essential so that we can operate on that group who do need surgery, and we can accept that there may be slightly increased risk to them from receiving an operation in the current period. But also we can prioritize the high-risk patients within a group.
We can also help to identify different specialties, where there may be a cohort of patients who have higher priority than for instance my specialty, which was be dealing with colorectal cancer. So there may be renal tumours that need to be done more quickly, and we need to provide the limited resource to that group of patients rather than simply spending all the effort on that on our own specialties.
I think that one of the keys in this area is to have a clinical prioritization group which can help to deliver services between different groups and maintain some equity in access to the elective operating sites, so that the right patients get operated on at the right time, with the appropriate support.
It’s only in this way that we can allow the precious resource that is operating space and operating theatres to be used to its maximum efficiency, and to ensure that we treat the greatest number of people that we can in this period in the safest possible way.
We can make sure that patients from different areas can have equality of access to these services and we can minimize the harm. At the same time as this we can probably identify a group of patients for whom waiting for several months for their surgery is the safest thing for them to do, and they can shield at home. And if we can apply some of the radiological guides that we’ve looked at then those patients can be reassured that the safest thing for them is to sit tight at home and wait for something approaching more normal service within our healthcare systems to return. Then they can have their surgery on a safer basis at that time.