Immediate and Long-Term Impacts of COVID-19 on Surgical Services and Patient

Background: In December 2019 COVID 19 originated in Wuhan, Hubei province, of China, but as of 23july 2021 >192 million cases and >4 million deaths have been reported globally. These dramatic figures have a profound, potentially long-lasting and extensive effect on the delivery of surgical services worldwide. Objective: Aimed to support surgical teams and health service by identifying key domains that should be covered in pandemic preparedness plans. Methods: The data and information is collected from various international journals and electronic media published throughout the world. Results: As regions with the highest volume of operations per capita are being hit, a large number of operations are being postponed. Patients are being deprived of surgeries, with uncertain loss of function and risk of adverse prognosis as a collateral damage by the pandemic. No major entity has enlisted the difficulties faced by general public as conditions for general surgeries are not on par with the ones required. Surgical services need a backup plan for maintaining surgical care in an ongoing or post pandemic time phase. Conclusion: A pandemic is a rapidly changing scenario, requiring reorganization and teamwork flexibility of the healthcare delivery. In future research required to study the impact of COVID-19 infection on postoperative outcomes, identifying risk stratification strategies, and determining whether prophylaxis using anti-COVID drugs and how to reduces rates of hospital-acquired COVID-19 infection.


Introduction
Corona virus comprises of a large family coronaviridae sub family coronavirinae of viruses that infect a large range of hosts including human beings as well animals (camels, cattle, cats, and bats).
There are four different strains of corona virus [1].  The virus is released along with the respiratory secretions when an infected person coughs, sneezes or talks. These droplets carrying the infection can spread infection to others if they make direct contact with the mucous membranes. Infection can also spread by touching an infected surface and followed by eyes, nose or mouth. Patients are thought to be most contagious when they show clinical symptoms of active disease. Some spread might be possible before symptoms appear, but this is not thought to be a common occurrence [4][5][6]. Asymptomatic carriers (also referred to as super spreaders) have been shown to spread the COVID-19. These are cases that have no symptoms and radiological manifestations but can transmit the virus to others [7]. Globally, as of 23 rd july 2021, 17

Pathophysiology of COVID-19
The Coronaviruses are a large family of single-stranded RNA viruses (+ssRNA) that can be isolated in different animal speciesSARS-CoV-2 belongs to the betaCoVs. It has a round or elliptic and often pleomorphic form, and a diameter measuring approximately 60-140 nm (Figure 2). According to recent research, this spike mutation, which probably occurred around late November 2019, triggered transmission to humans. The disease progression can be divided into below mentioned three distinct phases [9][10][11] ( Table 1)

Clinical Features
a) Incubation period-approximately 4 to 14 days following exposure [12,13] b) Common clinical features at the onset of illness were [13,14]. The most important finding in early stages is a single or multiple limited ground-glass opacity which is most commonly located under the pleura or near the blood vessel of the bronchus especially in the lower lobes. Severe period is very rare, manifested by diffuse unilateral or bilateral consolidation of lungs and a mixed presence of ground glass opacities [15]. Consolidation with surrounding halo seen in pediatric patients and was suggested as a typical sign in pediatric patients [16] (Figures 3 & 4).

Impact of COVID 19 Pandemic on Delivery of Surgical Care
The pandemic of COVID-19 caused by the coronavirus SARS-CoV-2 is disrupting global health, social welfare and the economy in a proportion unparalleled in modern history [17]. In addition to the effects of the COVID 19 pandemic itself on public health, a collateral effect from panuniversal disruption and cancellation of operative interventions has emerged. The current pandemic has unprecedented implications for surgical services and patients with surgical conditions [18]. Surgical capacity may experience extreme challenges in pandemic zones [19,20].  Number of surgeries being put on a pause and how this burden will be addressed in the fallout of the pandemic. Rough estimates suggest that approximately 330 million operations are done worldwide annually [22]. The vast majority in high-income countries now following a strong policy of deferring of all nonemergency surgeries (North America and European countries).
With a global average of about six million a per week, the total numbers of patients who will be affected over the coming months are growing rapidly .In the current pandemic, patients may prefer to have elective surgery deferred due to fear of contracting the disease during the hospital stay .However, this fear also leads to patients not seeking timely care for conditions that would otherwise have been correctable or curable by presenting at an earlier stage; loss of function, reduced life expectancy and chronic debility may be the result of delayed presentation and hence an untimely diagnosis.
This burden will only increase with the duration and severity of the pandemic. When the destructive effects of natural or man-made forces overwhelm the ability of a given area or community to meet the demand for healthcare [23].
Trauma admissions still occur during a pandemic, although there are unconfirmed reports of a reduction in acute and trauma admissions due to social distancing and overall reduced activity in society. Although trauma admissions may drop, so may the recruitment of the regular bunch of blood donors, potentially leading to a shortage of blood products in many systems. In addition, coagulation may be affected in patients who are COVID-19-positive, potentially adding to issues with bleeding injuries [24].
Patients who were admitted for an acute abdomen or any pathology requiring acute surgery may be co-infected with COVID-19, and hence represent a risk for infecting the healthcare personnel and other patients, even when asymptomatic or experiencing severe symptoms suggestive of COVID-19. One of the main concerns is the ability asymptomatic patients may have to infect during the incubation period [25].
Pandemic effects on organ transplantation is related to its impact on the donor pool and the risk of transmission of infection, risk to healthy living donors and overall access to scarce resources [26,27]. The scenario of exposing a healthy donor to a major surgical procedure in concordance with the risk of being infected with COVID-19 must be considered and calls for caution, even if cases of successful recovery exist [28]. As the overall strain of the pandemic intensifies, this might dynamically change organ allocation and prioritization of policies [26,27].

Material and Methods
The information and statistical data is collected from various international journals published worldwide and electronic media.

Results
Abbreviations: PPE: Personal protective equipment; WHO: World Health Organization been, or would be, seen for planned surgery ( Figure 6).

The effects of COVID-19 on surgical outcomes (and vice versa)
are not known. Pathological changes in blood coagulation [30], inflammatory response [31], and co-morbidities added to single or multiple organ failures, [32] may be considered as mechanisms for added risk for surgery. Blood and blood products reserves could be affected to a great extent as blood donations decrease due to decrease in frequent (regular) blood donors, potentially leading to as shortage of blood and blood products in some systems. In addition, coagulation system may be deranged in patients who to tackle shortage and include surgical services as an essential part to maintain appropriate surgical care.

Discussion
As elective surgery has been cancelled on a scale never before seen in modern history, the collateral damage to health and wellbeing, maintenance of function, and risk of shortened lifespan is present for patients in countries of all income designation, poor and marginalized will be affected most severely. In a situation where resources are scarce, one should not treat or prioritize on a first-come, first-served principle [34]. With a long-lasting lockdown and social distancing in effect, there will be millions of operations cancelled, postponed or simply not done at all over the times to come. Surgery is already recognized as a scarce resource in much of the world [35][36]. with a global challenge to provide safe surgery and anesthesia as a recognized area of priority [37,38].
A strong advocacy agenda is needed that includes investigation,