|Year : 2021 | Volume
| Issue : 4 | Page : 213-215
Pandemic and pediatric surgery: A wholistic impact assessment
Ravi Prakash Kanojia
Department of Pediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||16-May-2021|
|Date of Acceptance||22-May-2021|
|Date of Web Publication||12-Jul-2021|
Dr. Ravi Prakash Kanojia
Block 3A Room No. 3103, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kanojia RP. Pandemic and pediatric surgery: A wholistic impact assessment. J Indian Assoc Pediatr Surg 2021;26:213-5
The relentless march of COVID-19, popularly known as Corona Virus, is now continuing into its 2nd year. The catastrophic pandemic has spared none. More than 160 million people have been affected worldwide with India surpassing the tally of many countries combined (23 million, as per COVID-19 India.org). The worldwide mortality from this pandemic has surpassed World war II (3.3 million). We are at the defining moments in the history of humankind and the life events might be referred as pre- and post-COVID-19. With the huge abysmal numbers, the healthcare system has been overwhelmed in every aspect. Hospital administrations have diverted resources and funding towards pandemic management. This has led to a severe collateral or ripple effect on other patients who are long awaiting surgical treatment. We are yet to study the impact of these adversities on our pediatric surgical patients. A large group of patients have borne the brunt of the pandemic indirectly. The following discussion lays down various dimensions of the impact due to this pandemic and how it has affected the world of pediatric surgery including its patients, and surgeons.
- Delays of elective surgery – lockdown and closures of elective surgeries were implemented from the very beginning of the pandemic. Hospitals especially the tertiary care centers like PGIMER and AIIMS had to curtail/stop the elective procedures. Gradually, these centers were converted to COVID centers with only emergency/semi-emergency and surgical oncology cases being operated as per the guidelines of the institutes. This has resulted in the delay of treatment for those who were not infected but had other surgical problems. Even conditions like pelvi-ureteric junction obstruction, Hirschsprung's disease, choledochal cysts and many other pediatric surgical conditions were not included in the category of semi-emergencies and were not allowed to be operated and so were day-care procedures like herniotomy, orchiopexy etc. Due to this, a large section of patients waiting to get treatment were turned away due to administrative embargo, which was the need of the hour. The problem lies in the fact that even these patients can wait only up to a certain extent and extra-ordinary delay in treatment can complicate their otherwise stable conditions. In our institutional practice, we have seen simple pelvi-ureteric junction obstructions presenting with pyonephrosis, urosepsis, and renal damage over the period of one and a half year. The incidence of obstructed/incarcerated hernias markedly increased due to delay in the surgery for more than a year for an otherwise simple inguinal hernia. Do not forget the miseries of patients and their parents managing the severe excoriating stomas while awaiting closures or definitive surgery. There are no statistics to cover and estimate the mortality and morbidity due to these delays
COVID-19 infection per say does not have any impact on the surgical conditions in pediatric surgery and most of our cases are the ones who have traveled for routine/emergency treatment of their condition and picked up infection from the community or the hospital. This is a small group of patients we have dealt with and at PGIMER of all the Pediatric COVID-19-positive patients including medical and surgical (340 patients March 2020 to April 2021) only 8% were surgical patients. This fraction may be small but is taken very seriously from a clinical and administrative point of view. This is the baseline data for the first and 2nd wave of pandemic and perhaps will be used to compare if there is a 3rd wave.
- Impact on training– besides the healthcare impact in terms of morbidity and mortality there are many other indirect influences which are going to affect pediatric surgical care in the long term. Nothing has been said for the void in the training of our postgraduates resulting from the closures and embargos talked about in the first section. The lockdown with varying intensities and closures is now spanning a duration of 1½ years. This has resulted in a drastic reduction of surgical exposure of the final year/near completion trainees who get a major opportunities of in hand surgical experience during their last year. First- and second-year trainees have not been clinically exposed enough to pre- and postsurgical management of many elective cases. The closures have created a training lacuna for which they will have to compensate whenever the opportunity is available to them. With every 6 months being engulfed in the ongoing pandemic conditions more and more students will suffer for their field-level training and operating room exposure. Fortunately, the theory part of the training was taken care via online classrooms, case presentations, and webinars. Webinars are now omni-present with all conferences and presentations going on virtual platforms. This has given some light to the trainees during the dark gloomy times of pandemic
- Guidelines for patients and health care workers (HCWs) – Indian Association of Pediatric Surgeons had formulated guidelines for COVID-19 management in pediatric surgery at the peak of the first wave. Similar steps were taken by several other surgical associations who came up with empirical suggestions on handling affected and unaffected patients during the pandemic. The emphasis was on testing, deferring of nonessential surgeries, and prevention of exposure of HCWs. Pediatric Surgery staff in departments across India are limited in numbers compared to other big departments and fear is of partial or complete disruption of pediatric surgery services even if a small number of pediatric surgeons get infected. Last year till the time these guidelines were released vaccines were still under development and vaccination options were not available for HCW. All these guidelines now need to be updated with fresh light on the management of COVID with emphasis on vaccinating pediatric patients, the staff and their near contacts. We also need to redefine elective and semi-elective conditions, especially to prevent complications in children. To my understanding essentially all elective procedures waiting for a period of >3 months should be re-categorized as semi emergency
- The 3rd wave – By the time you read this the 2nd wave may be ebbing. All of us have been forced to stay in lockdown to curb the spread of infection. The vaccination drive is in full swing and as per the COWIN portal, 180 million have been vaccinated There is a target of covering 70% + population in the age group of 18 and above under the ambit of vaccination. This also means that a large section of the under 18 population is left out of the vaccination drive and this is the section we designate as the Pediatric population. So, if you are wondering why the 3rd wave is being projected to affect the kids is because of this reason. So far, the available vaccines given in India (COVAXIN and COVISHIELD) are not recommended for use in the pediatric population. Recently as per United States-Food and Drug Administration (US-FDA), Pfizer-BioNTech is the only vaccine which has been approved by US-FDA for pediatric use between 12 and 18 years. This still leaves out many under 12 vulnerable patients. This does bring some hope for the 12+ patients. Preparation of 3rd wave from pediatric perspective is now already recognized by the government agencies and thankfully there is talk of preparation on this aspect. The emphasis for this preparation should be on the premise of prevention and infrastructure setup for the sick pediatric patients preventing any kind of misery arising out of lack of ventilators or oxygen supplies
- Gear up for a permanent pandemic code – with the trend seen since March 2020 its for sure that this pandemic is going to stay for some years. We will be fortunate if we see a day where the COVID protocols are called off. The current healthcare system will have to follow the code of protocols for a long time. This is going to change the way we practice surgery in the post COVID era. Day-care services definition has changed and whenever and wherever they are being done, require admission just for testing purposes, for example, a double-J stent removal which was a walk-in procedure in the operating room now requires an admission for testing. This leads not only to a significant burden on the health care system but also results in loss of several man-hours of work for the family. The flexibility of the day-care procedures is thus lost.
With these concerns in mind, I must also congratulate the Pediatric surgery teams involved nationwide and at various hierarchal levels. We know that many pediatric surgical trainees have been providing services at ground level wearing PPE. Several others have provided their expertise at the administrative level. Overall the entire community of pediatric surgeons has done a commendable job at various levels at handling this colossal catastrophe and the Indian Association of Pediatric surgeons appreciates their dedication and service to the nation. The job is far from over and we as a group need to stay on guard to let this pass with minimum possible damage.
| References|| |
Committee on Infectious Diseases. COVID?19 vaccines in children and adolescents. Pediatrics 2021. e2021052336. [doi:10.1542/peds. 2021?052336]. Epub ahead of print.