Senior Consultant GI-HPB cancer/Bariatric surgeon, Kauvery Hospital, Trichy, India
I was having a brief conversation with one of my colleagues from a different surgical specialty about the difficulties faced in providing perioperative care to surgical patients during this COVID-19 pandemic. He said he had recently deal with a 65-year-old patient who had major elective surgery and developed severe COVID-19 infection few weeks later and struggled hard to recover back to normal. This patient did not have his vaccination for COVID preoperatively, even though there was a national call for all senior citizens to get vaccinated. He didn’t have the vaccine because he was very much concerned about the side effects. Could this have been prevented by preoperative COVID vaccination after adequate counselling and consenting?
COVIDSurg and GlobalSurg Collaborative of UK published an article recently in British Journal of Surgery, highlighting the fact that patients going for elective surgery should get prioritized for SARS-CoV-2 vaccination ahead of the general population. This study looked at the impact of COVID vaccination in adult patients undergoing any type of elective inpatient surgery. The primary outcome measure was number of patients needed to be vaccinated (NNV) in order to prevent one postoperative COVID-19 related death over one year assuming that surgical patients would receive the vaccine before operation. The secondary outcome measures were prevention of one postoperative COVID-19 related death over 30 days after vaccination, and additional COVID-19 related deaths prevented by prioritizing preoperative vaccination for surgical patients versus age matched controls in the population.
NNV estimates were stratified by age group (18–49 years, 50–69 years, 70 years or more) and also by indication for surgery (cancer versus non-cancer). The parameters used for analysis were postoperative COVID rates & COVID attributable mortality; Community COVID infection rates and case fatality rate and COVID vaccine effectiveness in preventing deaths. All these parameters were used for main analysis, and best and worst-case scenarios.
The results showed that NNV to prevent one COVID-19 related death over one year were lowest in aged > 70 years: NNV 351 in patients needing cancer surgery, 733 in non cancer surgery and 1840 in general population. Overall, the results showed that preoperative COVID vaccination seemed to reduce postoperative COVID related 30-day and 1 year mortality when compared to general population. This calculated benefit is more seen in the elderly, cancer surgery and major surgery subgroups. Sensitivity analyses showed that vaccination of surgical patients had greater advantage in countries with low community COVID-19 infection rates.
In India, currently we are facing a high COVID-19 incidence and vaccine supplies may not be enough because of huge demand. All elderly has been invited openly to get vaccinated early but only a certain proportion had the vaccine. With the above data published, it seems reasonable to prioritize and vaccinate all elderly patients going for major elective surgery, cancer surgery in particular.
Even after a significant uptake of vaccination by the population, it may be prudent to check with every patient about their vaccination status before major elective surgery. We feel that it is our responsibility to counsel these patients and alleviate their fear and get them vaccinated preoperatively.
However, these recommendations may become inappropriate at any point of time as the COVID-19 pandemic patterns keep changing rapidly across the globe.
COVIDSurg Collaborative, GlobalSurg Collaborative. SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international perspective cohort study. Br J Surg. 2021;1–8