The Impact of the COVID-19 Pandemic on Surgical Activities: A Single-Center Experience and Literature Review

Aim The aim of this article is to investigate the effect of the coronavirus disease 2019 (COVID-19) pandemic on our surgical department, which is situated in Athens, Greece, as well as to review published literature on the COVID-19 pandemic's impact on surgical activities in our department. Material and methods We retrospectively reviewed the surgical procedures that were performed in the surgical department of a tertiary University hospital in Athens, Greece, before and during the pandemic. Furthermore, we performed a literature review evaluating articles on surgical activity and COVID-19 published from the beginning of the pandemic up until the January of 2022 on the PubMed database. Results In total, 894 patients were included in the study. Of those, 264 (29.5%) underwent surgery during the control period and 630 (70.5%) in the pandemic period. Overall, we performed 20.5% fewer surgeries in the post-sanitary period. In particular, elective surgeries decreased on average by 23.9%, emergency procedures decreased by 8.9%, and oncology surgeries increased by an average of 6.4% after the year 2020. Concerning the review of literature, 51 studies were selected for this review. According to them, the main effect of the pandemic on the surgical sector was reflected in the reduction of total surgeries, mainly due to the postponement of elective surgical procedures, which showed a median reduction of 54% compared to the pre-COVID-19 period. A smaller decrease was observed in the number of emergency and oncological surgeries. Conclusions Reduced surgical activity during the pandemic, due to the health measures imposed, requires courageous corrective interventions to avoid its adverse effects, such as disease progression, increased treatment costs, reduced quality of life, and ultimately the survival of the patients.


Introduction
Following a series of cases of pneumonia of unknown etiology in Hubei province, China, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was isolated as the cause of coronavirus disease 2019 (COVID-19) [1]. The virus spread rapidly worldwide and led the World Health Organization to declare the novel coronavirus (COVID-19) outbreak a global pandemic on 11 March 2020 [2].
COVID-19 has proven to be a complex entity, having a high rate of transmissibility, numerous mutations, and causing multisystem disorder [3]. The often-exponential spread of the pandemic has highlighted the greatest challenge: the increased need for health services in health systems with finite resources. This mismatch of resources and needs has led to not only radical changes in the supply of health services but also in socio-economic relationships in general.
The impact of the pandemic on the surgical sector is multifaceted and concerns the surgical staff and practice, the risk of transmission between patients and medical personnel, and lastly, medical education. In response to these challenges, the following guidelines were issued for the safe practice of surgical practice [4,5]: preparation of a surgical case management plan in case of deterioration of the

Results
In total, 894 patients were included in the study. Of those, 264 (29.5%) underwent surgery during the control period and 630 (70.5%) in the pandemic period. No significant differences in mean age (62.1 years in the COVID-19 cohort vs 63.4 years in the control group, p=0.146) or gender distribution (58% males within the COVID-19 cohort vs 52.1% among the control cohort, p= 0.107) were noted ( Table 1).  Overall, we performed 20.5% fewer surgeries in the post-sanitary period. In particular, elective surgeries showed a decrease of 23.9%, while emergency procedures were less affected, with an average decrease of 8.9%. Oncology surgeries did not show a decrease but instead, increased by an average of 6.4% after the year 2020. From the statistical study of the above sample, there is no statistically significant change between the control and the pandemic cohort, except for the category of elective surgical operations (p= 0.044) ( Table 2).  The literature review search produced 11063 unique PubMed results. Articles matching our selection criteria were 51 and were used for data collection   (Figure 1). researchers drew data from national databases. With regard to the surgical specialty, general surgery was the most represented specialty, with 13 of the articles studying the whole surgical sector (  We observed a decrease in the total surgical activity after the pandemic outbreak compared to the pre-COVID-19 period in 23 of the 24 studies, The reduction was significant in all surgical specialties and the median decrease was 50.7% (Table 4).

Author
Specialization-Sector Change in the total volume of operations  Furthermore, we reported a decrease in elective surgical procedures in all the articles studying this topic. The median decrease was 54% and exceeded 90% in certain cases (   Concerning oncological surgery, we noticed a statistically significant decrease in surgical activity in three out of nine articles, reaching up to a reduction of 56% in a general surgery clinic in Parma, Italy [21] (Table  7).

Discussion
In our surgical department, we observed an average decrease of 20.5% in the total number of surgical procedures performed after the COVID-19 outbreak, mainly due to the postponement of elective surgeries. Emergency cases were less affected and in regard to oncological procedures, we noted an average increase of 6.4%. This data aligns with the current literature suggesting that the surgical sector worldwide prioritized emergency and oncological over elective non-life-threatening cases.
COVID-19 is manifested mainly as an acute respiratory disease, which can be complicated by Acute Respiratory Distress Syndrome (ARDS) and multi-organ failure. Its global spread has put severe pressure on Health Systems worldwide, resulting, among other things, in the transfer of resources from the surgical sector to the medical units directly involved in the fight against the pandemic. The release of personnel and equipment from surgical units is not without negative effects, the results of which will be revealed over a horizon of years or even decades.
Following the recommendation to postpone non-life-threatening surgeries issued by WHO and major surgical colleges [57][58][59][60], a reduction of surgical operations for benign or non-life-threatening diseases was expected. It is worth noting that delaying the treatment of such conditions is not free of consequences, as it can lead to a worsening of the state of health, an increasing disability and a decrease in the working capacity of patients. These effects entail significant social costs, especially in low-middle-income countries, where costs related to the surgical condition can lead to impoverishment [61].
Similar to elective surgical procedures, the observed decrease in emergency surgical operations needs to be investigated. On the one hand, the change may be due to a real decrease in emergencies due to the recommendation to stay at home and avoid social activity. These measures have resulted in a shrinking number of sports [62], road accidents [63] injuries and the spread of communicable diseases [64] other than COVID-19.
At the same time, the issued guidelines to avoid unnecessary attendance at hospitals have led patients to seek late medical help possibly awaiting later stages of the disease before attending the emergency department [6,9,13,26,31,52,55]. Their aggravated condition was associated with increased complication rates [18,31,43] and mortality rate [14,17,24]. Taking into account the inherent inability of the patients to evaluate the severity of their condition, it is crucial to inform the population about the nature of emergency surgical conditions as well as to prepare for an outbreak of surgical cases during the periods of remission of the pandemic.
The management of oncological cases is a major priority of health systems, as a delay in their treatment has serious consequences for patients and society in general. Therefore, health authorities must ensure the proper and incessant function of screening, diagnosis and treatment of oncology patients. According to the research of Yun et al. [65] a postponement in the treatment of malignancy of more than one month is related to a worse prognosis for rectal and breast cancer in high-volume centers. In addition to increased mortality, delays also result in increased costs of care in the form of surgery and/or chemotherapy. More resources will be required if a patient presents with an emergency such as perforation, acute bleeding or gastrointestinal obstruction.
Another major issue, which is being overlooked with unknown long-term consequences is the training of medical staff. The reduction of surgical operations has a negative effect on the development of specialized surgeons, whose training requires a high number of surgeries, in order to acquire the necessary skills and techniques. Indicatively, Inzunza et al. [66] report a decrease of 61.7% in the total number of surgical procedures of the third-year surgical residents, possibly requiring an extension of the training programme of the affected trainees by at least one year.
Eventually with the expected recession of the pandemic, the health systems will face the accumulated volume of elective surgical cases which have been postponed since the beginning of 2020. Performing these operations will require funding from the surgical sector for an extended period of time. Indicatively, to carry out the postponed surgeries for a period of 12 weeks, with an increase of the basic activity by 20%, will require an average of 45 weeks (range 43-48 weeks) [61]. It is thus clear that a return to normal surgical practice and the clearance of the backlog of surgical work within a reasonable period of time requires major changes that go beyond the return of surgical personnel and equipment and extend to the reform of health systems expenditures.
The current study has some limitations. Firstly, it involved a single center in a tertiary referral hospital in Athens, Greece, so it does not reflect the pandemic impact across the country. Secondly, the literature review excluded data from non-English papers; Asian countries, which were particularly affected during the first wave of the pandemic, were represented in a limited number of surveys. In addition, it only included articles published in the PubMed database, thus missing data from other databases. Furthermore, the majority of studies included data for a specific time period, usually outbreaks, rather than for the entire pandemic, Finally, it is noted that the pandemic is still ongoing and despite the accumulated experience of the last two years, its course and impact on the health systems worldwide is still difficult to predict.

Conclusions
The impact of the COVID-19 pandemic worldwide is apparent in all areas of surgical activity. It is reflected mainly in the reduction of elective surgical procedures and to a lesser extent in emergency and oncological cases, a trend that we also noticed in our surgical department. Reduced surgical activity has various adverse effects including disease progression, increased treatment costs, reduced quality of life, and ultimately the survival of the patients.
In this setting, it is vital for all nations around the globe to take into account the malfunctions that occurred in the surgical sector during the pandemic to recognize the weaknesses of the health systems and draw up a plan based on the lessons learned to deal with a possible future epidemic disease.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.