Introduction
Emergency surgical operation (ESO) can be defined as surgery needed to deal with an acute threat to life, tissue, limb, or organ caused by an acute disease process, trauma, complication of an interventional or surgical procedure, or acute exacerbation of a chronic disease process (1). Patients undergoing ESOs risk higher mortality and morbidity than elective operations due to the limited preoperative anesthesia preparation time (2-4). In developing countries, perioperative cardiac arrest rates range from 2.99 to 40.4 per 10,000 (5,6). The rate of perioperative cardiac arrest is higher in ESO patients, ranging from 6.48 to 62.1 per 10,000 (7,8). Two studies reported that 50-60% of all cardiac arrest episodes in surgical patients occurred in patients undergoing emergency surgery (9,10).
Declared a pandemic by the World Health Organization (WHO) in March 2020, the COVID-19 and its indirect effects had negative consequences on health systems and the habits of patients (11-13). The number of examinations in Turkey’s 2nd and 3rd-level state hospitals, which exceeded 321 million in 2019, decreased to approximately 205 million in 2020 (14). Decreased emergency department (ED) visits, including critically ill patients, have been reported during the pandemic period (11). There have also been delays in accepting and treating surgical emergencies (12,13). During the pandemic period, a significant decrease was observed in blood transfusions along with a decrease in the hospital admissions and a decrease in the number of surgical operations (15). This study examines the effects of the COVID-19 pandemic on the number of ESOs performed in state hospitals and their distribution by clinics throughout Turkey. It also provides a perspective for similar outbreaks we may encounter in the coming years.
Materials and Methods
In this retrospective, descriptive, observational study, ESOs performed in 2nd and 3rd-level state hospitals in Turkey in 2019 and 2021 were discussed. The number of ESOs performed by general surgery, orthopedics and traumatology, thoracic surgery, neurosurgery, cardiovascular surgery, plastic surgery, urology, ophthalmology, gynecology and obstetrics, and otolaryngology departments in Turkey in 2021 and the distribution according to surgical departments was recorded in the study form. ESOs performed in 2019 were taken as the control group. The same ESOs were recorded for the control group. The changes between the two groups were calculated. The primary outcome of this study was ESOs performed throughout Turkey in 2021 (pandemic period). The secondary outcome was to compare the 2021 data with the 2019 (pre-pandemic period) data.
Statistical Analysis
In this descriptive study, data were presented as number and percentages. The number and rates of surgical treatments included in the study and the changes over the years are summarized in Table 1. The distribution of ESOs according to departments is presented in Table 2. The changes in the number of ESOs performed in the departments in 2021 compared to 2019 are presented in Figure 1.
Results
A total of 1,822,075 [947,144 cases (52.0%) in 2019 vs. 874,931 cases (48.0%) in 2021] were included in the analysis. There was a 7.6% decrease in the total number of ESO in 2021 compared to 2019.
The most common ESO performed in 2019 and 2021 was a cesarean section, followed by surgical treatment of upper/lower extremity fractures and dislocations, and cholecystectomy, respectively. The highest increase in 2021 compared to 2019 was the repair of uterine perforation (442 cases in 2019 vs. 699 cases in 2021, a difference of 58.14%), repair of urethral injury (73 cases in 2019 vs. 100 cases in 2021, a difference of 36.99%), and repair of the ruptured aorta and/or aneurysm of its branches (539 cases in 2019 vs. 631 cases in 2021, a difference was 17.07%). The greatest decrease in 2021 compared to 2019 was the surgical treatment of spinal fracture-dislocations (6730 cases in 2019 vs. 3312 cases in 2021, a difference of -50.8%), surgical stabilization of rib fracture/sternum fracture, (991 cases in 2019 vs. 577 cases in 2021 cases, a difference of 41.78%), and repair of esophageal perforation (70 cases in 2019 vs. 40 cases in 2021, a difference of 37.14%). ESO numbers and change rates in 2021 and 2019 are summarized in Table 1.
In 2019, the most ESO was performed in the obstetrics and gynecology department with 292,941 cases (30.93%) followed by the general surgery departments with 290,795 cases (30.70%) and orthopedics and traumatology departments with 216,585 cases (22.87%). In 2021, the most ESO was performed in the obstetrics and gynecology departments with 285,238 cases (32.60%), followed by general surgery departments with 241,683 cases (27.62%) and orthopedics and traumatology departments with 227,079 cases (25.42%). The distribution of the ESOs according to the departments is summarized in Table 2.
An increase in the number of ESOs in 2021 compared to 2019 was observed only in the urology department (7.1%) and orthopedics and traumatology department (2.7%). Surgical departments with the greatest decreases were neurosurgery (-28.1%), Otolaryngology-Head and Neck Surgery (-27.7%), and thoracic surgery (-20.9%) (Figure 1).
Discussion
In this national retrospective study, ESOs performed in state hospitals in 2021 (pandemic period) were analyzed and the results were compared with 2019 (pre-pandemic) data. This study found a 7.6% decrease in the number of ESOs performed in state hospitals in 2021 compared to 2019. The most frequently performed ESOs in both periods were cesarean section and surgical treatment of upper/lower extremity fractures and dislocations. The ESOs with the highest increase in 2021 compared to 2019 were perforated uterus repair and repair of urethral injury. The most decreased ESOs were surgical treatment of spine fracture-dislocations and surgical stabilization of rib fracture/sternum fracture.
WHO reported that as of October 19, 2022, there had been more than 623 million confirmed cases of COVID-19, including 6,550,033 deaths, since the pandemic’s start (16). COVID-19 has deeply affected the entire healthcare system (11,17,18). The question that inevitably arises is how the COVID-19 pandemic has affected our ability to maintain the highest quality of care for all of our patients, not just COVID-19 patients. In this process, elective surgical operations have come to a standstill in many hospitals, and a change is needed in the treatment protocols of ESOs (18,19). Additionally, a general decrease in surgical emergency procedures has been observed during the COVID-19 pandemic (12,20). Cano-Valderrama et al. (12) reported that there was a 65.4% decrease in emergency surgical activity during the pandemic period, and the number of patients who underwent emergency surgery in each hospital decreased from 2.6 during the control period to 0.9 during the pandemic period. Alimoglu et al. (21) reported that emergency surgical case consultations, hospitalizations, and ESOs decreased significantly during the pandemic period compared with 2018 and 2019. Rausei et al. (22) reported a 45% decrease in emergency surgery admissions and a 41% decrease in ESOs in March 2020 compared with March 2019. Kamine et al. (23) reported a decrease in the number of hospitalizations in trauma patients during the pandemic period, but no change in the number of emergency surgeries. The inclusion of all types of emergency surgery patients in our study may have caused this difference. İlhan et al. (24,25), in their study in a tertiary hospital with a trauma center, reported that there was a decrease in the number of patients visited with trauma during the pandemic period, but there was no change in the emergency surgical needs of the patients. The lack of a decrease in the number of ESOs may be because the hospital where the study was conducted was an important trauma center in the region and the selected patient group. All secondary and tertiary state hospitals were included in our study. One of the leading reasons for the decrease in the number of ESOs in this study may be the hospitals where the data were obtained. Our study excluded data from private and university hospitals. Along with the pandemic, many state hospitals have been declared as pandemic hospitals. Therefore, patients requiring ESO may have preferred universities or private hospitals more than in previous years. Additionally, during the pandemic period, the ministry of health encouraged emergency health services to move more patients to private health institutions. The abovementioned situations may have contributed to the decrease in the number of ESOs performed in state hospitals compared to the pre-pandemic period. Moreover, the COVID-19 pandemic has affected the habits of patients and the healthcare system (26-28). A significant decrease in ED visits for acute life-threatening conditions has been reported during the COVID-19 pandemic (17,29). There has also been an increase in the rates of refusal of treatment despite medical advice in patients visiting the ED during the pandemic (26). Patients may have delayed or avoided medical care because of the risk of catching COVID-19, stay-at-home advice, or other reasons.
In our study, most of the ESO was performed in obstetrics and general surgery departments in both years. In both periods, the most frequently performed ESO was a cesarean section. Cesarean section was the most frequently performed major operating room procedure in the United States of America (USA) (30). In the USA, cholecystectomy with a rate of 129.4 per 100,000 people, and appendectomy with a rate of 93.3 are the most commonly performed operating room procedures, except for non-mother and newborn hospitalizations (31). Although their numbers decreased during the pandemic period in this study, cholecystectomy and appendectomy were among the most frequently performed ESOs in both periods.
A significant proportion of the patients in this study were trauma patients. The number of trauma surgeries decreased during the pandemic period compared with the previous period. However, the surgical treatment of upper/lower extremity fractures and dislocations increased by 2.9% in 2021 compared to 2019. İlhan et al. (24) reported that the frequency of multiple trauma decreased during the pandemic period compared to the previous period, but the frequency of upper and lower extremity injuries increased. Similarly, in the study by Esteban et al. (32), the incidence of upper and lower extremity injuries increased during the pandemic period. With the pandemic restrictions, people had to spend more time at home. This situation may be demonstrated as the reason for the decrease in high-energy trauma such as traffic accidents and the increased incidence of lower-energy extremity injuries such as home accidents.
Considering these findings, healthcare systems should guide to help patients choose the most appropriate hospital to receive care and ensure that patients with severe illnesses and injuries continue to visit EDs without fear of contamination or inefficiency. A careful balance must be struck between patient needs and resource availability during the pandemic. To respond effectively to the COVID-19 pandemic, hospitals should prepare detailed pandemic preparedness plans for emergency surgical services. Otherwise, secondary damage from health problems unrelated to outbreaks can have enormous social and economic consequences for the entire health system.
Study Limitations
This was a retrospective study that could lead to selection bias. The data only belong to state hospitals; data from private hospitals are excluded. However, in our study, emergency elective differentiation could not be made in some surgical procedures such as cholecystectomy and splenectomy. Finally, we could not distinguish in which department some surgical interventions were performed. Spinal trauma surgery was included in the neurosurgery department, and Fournier’s gangrene was included in the urology department. Finally, we could not differentiate between pediatric surgery because we did not know the ages of the patients.
Conclusion
It is important to underline the points learned from the past in the 3rd year of the COVID-19 pandemic. This article provides an overview of Turkey’s statistics on ESOs during the pandemic. The number of ESOs performed in 2nd and 3rd-level state hospitals in Turkey decreased compared to the previous year during the COVID-19 pandemic. This decrease in ESO numbers is likely attributable to the strict stay-at-home policy, many patients staying away from healthcare facilities for fear of contracting Severe acute respiratory syndrome-Coronavirus-2 in the hospital, or opting for private healthcare facilities they consider more reliable.
Ethics
Ethics Committee Approval: The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. The study was approved by the Ethical Committee of Ankara City Hospital (date: 27/05/2022, no: E2-22-1883).
Informed Consent: Retrospective study.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: A.B., A.T., Design: A.B., H.A., Data Collection or Processing: A.B., A.T., Analysis or Interpretation: A.B., A.T., Literature Search: A.B., H.A., Writing: A.B., H.A.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.