Abbreviations
BMI:
Body Mass Index
COVID-19:
Coronavirus disease 2019
CT:
Computer tomography
IQR:
Interquartile range
LMU:
Ludwig-Maximilians-University
PCR:
Polymerase chain reaction
SARS-CoV-2:
Severe acute respiratory syndrome coronavirus 2
Introduction
COVID-19 is an infectious disease caused by the SARS-CoV-2 virus, first described
in December 2019 that became pandemic in the first quartile of 2020 [1 ]
[2 ]. The rapid pandemic spread of SARS-CoV-2 virus and the consecutive alarming COVID-19-related
morbidity and mortality enforced emergent changes in patient management across all
medical and surgical specialties and sub-specialties including thoracic surgery [1 ]
[2 ].
As previously reported by our [3 ] and other groups [4 ], postoperative COVID-19 represents a severe threat to the postoperative patient
health. Therefore, continued treatment of patients in need of thoracic surgery requires
an effective screening of patients for symptomatic and asymptomatic COVID-19 prior
to admission. Moreover, the diagnosis of postoperative COVID-19 as well as isolation
and treatment of affected patients remain an important, but complex task. The differentiation
of COVID-19 symptoms and those of a normal postoperative course of patients is challenging.
In order to maintain routine thoracic surgery patient care and protect thoracic surgery
patients from COVID-19, new strategies in perioperative patient management had to
be put in place in March 2020 with no practical experience or data of a similar pandemic
available. We describe the implemented measures to protect thoracic surgery patients
from postoperative COVID-19 during the 1st and 2nd wave of coronavirus-19 pandemic
in Germany and report similarities and differences between symptoms of early COVID-19
and symptoms of patients recovering from thoracic surgery.
Material and methods
All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (Ethics Committee of the Ludwig-Maximilians-University
of Munich, LMU, Germany, project number 20-618) and with the Helsinki Declaration
of 1975, as revised in 2008. This mono-institutional retrospective study was performed
at the thoracic surgery, oncological and pneumology departments of the Asklepios Lung
Clinic Munich-Gauting, Germany. Informed medical consent was obtained on admission
from all patients undergoing thoracic surgery.
Measures to minimize SARS-CoV-2 infections in patients of the thoracic surgery department
were analyzed based on internal documentation and validated in our patient cohort.
Patient demographic data were retrospectively collected from hospital discharge letters
as well as from radiological, histopathological and lung function testing reports.
Data of COVID-19 incidence in the district area Munich-Gauting (city of Munich, district
of Munich and district of Gauting-Starnberg) and the incidence of whole Germany were
obtained from the national platform for geographic data (NPGEO) Corona Hub of the
Robert Koch Institute, Germany.
Surgical procedures were performed via video-assisted thoracoscopy or anterolateral
thoracotomy under general anesthesia. These procedures included wedge resections,
major anatomical resections (segmentectomy, lobectomy, pneumonectomy), pleurectomy,
pleurodesis and open tumor biopsies. Minor procedures such as sole chest tube or port
catheter placement, cervical lymph node dissection, tracheotomy, vacuum-assisted therapy
or bronchoscopy procedures were not included in the study cohort. All patients with
benign and malignant disease consecutively admitted for non-elective, semi-elective
and elective thoracic surgical procedures between March 1st and May 15th, 2020 were
retrospectively included in the study.
With the beginning of the pandemic on March 1st to March 22nd 2020, we experienced
three cases of postoperative COVID-19 in detail described in Stoleriu et al., Annals
of Thoracic Surgery (2020) [3 ]. Under the impression of severe disease courses in patients with postoperative COVID-19,
we implemented strict prevention measures starting on March 23rd in parallel to the
governmental declaration of emergency status in Bavaria, Germany on March 21st. Therefore,
the analyzed time frame was subdivided into two time periods: the “Surveillance Phase”
from March 1st to March 22nd 2020 and the later “Restriction Phase” from March 23rd
to the suspension of the emergency status in Bavaria on May 15th 2020 ([Fig. 1 a ]).
Fig. 1 Timeline with regional and national incidence of COVID-19 in Munich-Gauting and Germany,
post-operative COVID-19 cases and precautionary measures for postoperative COVID-19
prevention. a Timeline of COVID-19 incidence in whole Germany and in the district area Munich-Gauting
with time periods of governmental “lockdown” measures in Bavaria and Germany indicated
in green and blue bars. Blue vertical lines indicate dates of surgery of patients
with postoperative COVID-19 as in Stoleriu et al. (2020). b Timeline dividing the time interval of interest into a “Surveillance Phase” and a
“Restriction Phase” with time periods of preventive measures put in place in the thoracic
surgery department of the Asklepios Lung Clinic Munich-Gauting to prevent postoperative
COVID-19 during the pandemic.
During the “Surveillance Phase” perioperative patient management and care were performed
according to standard operating procedures. The “Restriction Phase” was characterized
by implementation of strict preventive measures in the thoracic surgery department
to reduce SARS-CoV-2 infections, in parallel with the enactment of governmental regulations,
the so-called “lockdown”.
In detail, COVID-19 preventive measures in perioperative patient management were implemented
in chronological order, as illustrated in [Fig. 1 ]: Starting 23rd of March 2020, a standardized pre-admission questionnaire by phone
interviews was routinely performed 1–2 days before hospitalization in order to prevent
the admission of potentially infected patients and secondary virus transmission. A
mouth-nose cover protection became mandatory for all healthcare workers and patients
in the hospital. Moreover, SARS-CoV-2 polymerase chain reaction (PCR) from oro-/nasopharyngeal
swab was performed in all patients on admission day. Patients were preemptively isolated
until a negative PCR test was obtained. Single bedroom accommodation together with
a no visitors policy on the normal wards and intensive care unit were introduced.
Later, an oro-/nasopharyngeal swab for SARS-CoV-2 PCR was performed in a drive-through
setting replacing the testing on admission. In this approach, an out-patient qPCR
SARS-CoV-2 screening from oro-/nasopharyngeal swab was performed on the days before
admission in a drive-through setting outside the hospital. Following drive-through
testing, patients were advised to isolate at home until admission on the next day.
Additionally, the incidence of the symptomatic postoperative COVID-19 cases and the
clinical characteristics of the affected patients were compared with non-surgical,
oncological patients undergoing chemotherapy at the oncological department of the
same hospital during the analyzed time interval. The continued surgical patient care
during 1st pandemic wave was compared to the same time period (calendar weeks 10–20)
of the last 5 years before pandemic. The time between admission and surgery (defined
as “time to surgery”), length of hospital stay, as well as the surgical volume were
comparatively evaluated before and during 1st and 2nd pandemic waves.
In response to three postoperative COVID-19 cases identified in patients undergoing
thoracic surgical procedures during the “Surveillance Phase”, all patients in the
“Surveillance Phase” and “Restriction Phase” of the 1st pandemic wave were postoperatively
followed-up. Patients were interviewed twice by phone, during the whole early (1st–4th
week) and late (5th–8th week) post-discharge phases, in order to depict potential
postoperative COVID-19 cases and to determine the incidence of postoperative COVID-19
in our thoracic surgical department. As qPCR tests were nation-wide not available
for asymptomatic patients during this time period, this follow-up aimed to identify
symptomatic COVID-19 cases only.
In order to identify COVID-19 specific symptoms that only rarely occur during the
postoperative course of thoracic surgery patients, we retrospectively compared early
symptoms of COVID-19 patients with symptoms of patients recovering from thoracic surgery.
All data are presented as median with interquartile range (1st–3rd quartile). Comparative
analysis of patients’ demographics and symptoms between the postoperative surgical
cohort (n = 53) and non-surgical COVID-19 patient group (n = 60) was performed by
using the Mann-Whitney-U-test for continuous data or the chi-squared test for categorial
data, respectively. Statistical differences were considered significant with a type
I error rate of p < 0.05. If appropriate, p-values were corrected for multiple-testing
using the Bonferroni method. For the three comparisons between the thoracic surgical
patient follow-ups and the COVID-19 patient cohort, a Bonferroni factor of 3 was applied,
accordingly. Here, only p-values below 0.05/3 = 0.0167 were considered significant
([Table 1 ]). Statistical analysis was done on Prism version 8.0 (GraphPad, San Diego, CA) and
the scikit package version 1.1.0 in Python version 3.6.6.
Table 1
Demographics of patients admitted for thoracic surgery. Demographics are shown for
the patient groups in “Surveillance Phase” (March 1st 2020–March 22nd 2020) and “Restriction
Phase” (March 23rd 2020–May 15th 2020) of the 1st pandemic wave included in the study.
“Surveillance Phase”
n = 35
“Restriction Phase”
n = 54
Age (median [IQR]) years
63 [56–71]
68 [58.8–75.5]
Sex
49 %
35 %
51 %
65 %
BMI (median [IQR]) kg/m2
25 [23 ]
[24 ]
[25 ]
[26 ]
[27 ]
25 [24–27.5]
Adiposity[* ]
14.3 %
11.1 %
Smoker status
14 %
32 %
74 %
42 %
11 %
26 %
Pack years (median [IQR])
25 [6–40]
25 [0–40]
Respiratory comorbidities
40 %
28 %
6 %
2 %
9 %
6 %
14 %
13 %
Cardiac comorbidities
37 %
28 %
Chronic kidney disease
11 %
15 %
Diabetes mellitus
17 %
15 %
Surgical procedure
37 %
43 %
34 %
26 %
34 %
19 %
11 %
20 %
Surgical approach
60 %
44 %
40 %
50 %
0 %
6 %
Pathology
Benign disease
31 %
28 %
14 %
6 %
0 %
4 %
6 %
6 %
6 %
6 %
5 %
6 %
Malignant disease
69 %
72 %
34 %
35 %
0 %
4 %
9 %
2 %
23 %
22 %
3 %
0 %
0 %
9 %
Patients with
0
2 %
5 %
2 %
0
4 %
0
2 %
In-hospital stay
9 [7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
11.5 [10.0–13.8]
* Adiposity was defined by a BMI > 30 kg/m2 according to the WHO [27].
Results
During the 1st wave of the pandemic, the highest incidence of COVID-19 in Germany
and the district area Munich-Gauting ([Fig. 1 a ]) was recorded between March 1st and May 15th, 2020. During this time period, 122
surgical procedures were performed in our department. Thirty minor procedures were
primarily excluded from the study. Ninety-two procedures were performed on 89 patients
and were included in the study. One patient was not admitted for surgery after pre-admission
interview due to COVID-19 symptoms and thus not included in the study. The patient
was hospitalized for COVID-19 treatment. The surgery was postponed with the patient
readmitted for thoracic surgery with two consecutive negative SARS-CoV-2 PCR tests
after four weeks. Surgical procedures were postponed in other 4 patients with benign
disease in agreement with the patients’ decision. Of note, surgery was offered to
additional 7 patients with (suspected) malignant disease and one patient with benign
disease, who denied surgery for personal reasons.
Patient demographics are summarized in [Table 1 ]. Seventy-one to seventy-eight percent of patients reported active nicotine abuse,
adiposity, diabetes, respiratory, cardiac or renal comorbidities, seen as risk factors
for a severe COVID-19 course of disease. Thirty-five patients underwent surgery in
the 22 day long “Surveillance Phase” (in median 11.0 procedures per week), whereas
54 patients underwent surgery during the 54 day long “Restriction Phase” (in median
6.5 procedures per week). Of all 92 surgical procedures performed during both phases,
36 major surgical anatomical resections (34 lobectomies, one segmentectomy and one
pneumonectomy) were performed. The remaining surgical procedures included metastasectomies,
diagnostic and therapeutic resections of lesions and nodules highly suspicious for
malignancy, as well as urgent non-malignant conditions including symptomatic empyemas,
pleural effusions, pneumothoraces or hemothoraces.
The number of major surgical procedures during the 1st in comparison to the 2nd pandemic
wave as well as prepandemic years (2014–2019) is summarized in Supplementary Table 1S .
The median time to surgery was 2 (1–3) days in the “Surveillance Phase“ and 3 (2–4.8)
days in the “Restriction Phase“ of the 1st pandemic wave as well as 1 (1–3) days during
the 2nd wave. Similarly, the median time to surgery during the same time interval
in 2019 was 1 (1–3) days. Moreover, demographical data did not show any significant
differences between the “Surveillance Phase“ and “Restriction Phase“, reflecting a
homogenous patient collective in the analyzed periods ([Table 1 ]).
Three out of 35 patients, who underwent thoracic surgery in the “Surveillance Phase”,
were re-hospitalized and diagnosed with COVID-19 pneumonia ([Fig. 1 a ], [Fig. 2 a ]). Clinical course of these patients was described in detail in Stoleriu et al. (2020)
[3 ].
Fig. 2 Incidence of postoperative COVID-19 with and without pre-admission COVID-19 screening.
a Flow chart of 35 patients during the “Surveillance Phase” without pre-admission COVID-19
screening: Three patients with postoperative COVID-19 were identified. b Flow chart of 56 patients during the “Restriction Phase” with pre-admission COVID-19
screening. Two patients tested positive for SARS-CoV-2 from oro-/nasopharyngeal swab
and surgery was postponed. In 54 patients who had been tested negative on admission,
no postoperative COVID-19 cases were observed.
From 56 patients admitted for surgery in the “Restriction Phase”, two patients tested
positive for SARS-CoV-2 preoperatively on admission and were discharged to home quarantine.
Both patients were readmitted for the surgery after three and four weeks respectively
with two consecutive negative SARS-CoV-2 PCRs from oro-/nasopharyngeal swab. No cases
of post-operative COVID-19 were observed during the “Restriction Phase” ([Fig. 2 b ]).
Eighty-eight out of 89 surgical patients were followed-up to diagnose symptomatic
postoperative COVID-19 after discharge ([Fig. 3 ]). In three patients operated during the “Surveillance Phase” COVID-19 was ruled
out by PCR or computer tomography (CT) upon clinical suspicion ([Fig. 3 a ]). Three out of 53 patients in the “Restriction Phase” reported symptoms suspicious
for COVID-19 on first follow-up interview and two patients on second follow-up interview.
In these patients, COVID-19 was ruled out by two consecutive PCR tests from oro-/nasopharyngeal
swab or CT ([Fig. 3 b ]).
Fig. 3 Detailed study flow chart showing patients admitted for thoracic surgery during the
“Surveillance Phase” and “Restriction Phase”. a In the “Surveillance Phase”, 35 patients underwent thoracic surgery without COVID-19
screening on admission. Three patients were hospitalized for COVID-19 postoperatively.
All other patients were followed-up by phone interview, raising suspicion for COVID-19
in other three patients who finally were tested negative by SARS-CoV-2 PCR from oro-/nasopharyngeal
swab or CT. b In the “Restriction Phase”, 54 patients underwent thoracic surgery upon negative
COVID-19 screening. 53 patients were followed-up in two consecutive phone interviews
for COVID-19 typical symptomatology. On 5 occasions clinical suspicion of postoperative
COVID-19 based on the patient interviews was made. These patients were followed up
by SARS-CoV-2 PCR from oro-/nasopharyngeal swab or CT.
Potential symptoms for COVID-19, such as cough, dyspnea, and low energy levels, also
occur during the normal postoperative recovery of thoracic surgery patients. Therefore,
the identification of specific symptoms for COVID-19 in this patient cohort might
be useful to identify suspected COVID-19 cases and trigger PCR-based COVID-19 testing.
We observed a substantial overlap between symptoms of recovering patients after thoracic
surgery and potential COVID-19 symptoms, described in literature. Comparing symptoms
of patients with confirmed COVID-19 and patients recovering from thoracic surgery,
we found that fever, dry cough, dyspnea and diarrhea were significantly more prevalent
in patients with COVID-19. Other symptoms such as low energy levels and expectoration
appeared similarly frequent in post thoracic surgery patients and in patients suffering
from acute COVID-19. Detailed differences in the symptomatology of patients normally
recovering from thoracic surgery and COVID-19 patients are summarized in [Table 2 ].
Table 2
Comparison between symptoms of thoracic surgery patients on postoperative follow-up
and acute COVID-19 symptoms. Symptoms reported by patients during recovery from thoracic
surgery without COVID-19 approximately 4 weeks (follow-up I) and 8 weeks (follow-up
II) postoperatively were compared to those of hospitalized non-surgical COVID-19 patients.
For comparisons chi-squared tests were used if not indicated otherwise.
Thoracic surgery on follow-up I
Thoracic surgery on follow-up II
COVID-19
follow-up I vs. follow-up II
follow-up I vs. COVID-19
follow-up II vs. COVID-19
Gender (% female)
36 %
45 %
–
p = 0.32
Age (median [IQR])
67 [58–74]
62.5 [51–74]
–
p = 0.18[# ]
Fever
2 %
0 %
70 %
p = 0.32
p < 0.001[* ]
p < 0.001[* ]
Dyspnea
15 %
15 %
48 %
p = 0.99
p < 0.001[* ]
p < 0.001[* ]
Cough
8 %
11 %
77 %
p = 0.51
p < 0.001[* ]
p < 0.001[* ]
Diarrhea
13 %
8 %
25 %
p = 0.34
p = 0.11
p = 0.013[* ]
Expectoration
13 %
6 %
18 %
p = 0.18
p = 0.46
p = 0.041
Anosmia
8 %
4 %
3 %
p = 0.70
p = 0.32
p = 0.90
Headache
9 %
11 %
13 %
p = 0.75
p = 0.51
p = 0.75
Low energy levels
47 %
35 %
41 %
p = 0.40
p = 0.82
p = 0.40
Body ache
17 %
16 %
25 %
p = 0.99
p = 0.94
p = 0.94
Throat ache
2 %
4 %
2 %
p = 0.56
p = 0.93
p = 0.49
Nausea
11 %
8 %
10 %
p = 0.51
p = 0.82
p = 0.65
Disorientation
5 %
8 %
8 %
p = 0.70
p = 0.58
p = 0.88
# For comparison of median age, Mann-Whitney-U-test was used.
* After adjustment for multiple-testing with a Bonferroni factor of 3 as an approximation,
only p-values below p < 0.05/3 = 0.0167 were considered significant.
During the same time interval, 398 admissions of oncological patients were recorded
in our hospital. In total, 222 patients experiencing malignant lung diseases were
primarily admitted for oncological diagnostics (staging examinations, n = 50, 22.5 %),
conservative, non-surgical treatment (chemotherapy, n = 132, 59.5 %) or best supportive
care (n = 40, 18 %). A pre-admission COVID-19 screening via phone calls was implemented
on the oncological department at the same time as in the thoracic surgery department.
Three patients undergoing in-hospital chemotherapy (neoadjuvant n = 2, adjuvant n = 1)
experienced COVID-19 post-discharge. These patients were systematically followed-up
to identify COVID-19 cases, as part of the TERAVOLT study [5 ]. Taken together, the incidence of symptomatic COVID-19 patients in the analyzed
period was 2.3 % upon chemotherapy and 2.5 % upon thoracic surgery. A comparative
analysis of patient demographics is illustrated in Supplementary Table 2S .
Conclusion
This study underlines the usefulness of the primary and secondary COVID-19 prevention
measures for an uninterrupted patient management and care in the thoracic surgery
department of the Asklepios Lung Clinic Munich-Gauting. We report real world data
on classical symptomatology of recovering thoracic surgery patients with implications
for the screening of postoperative COVID-19. Primary and secondary prevention measures
described in this study might serve as blueprint for prevention of postoperative COVID-19,
thus ensuring continued surgical treatment of patients with thoracic diseases during
the pandemic.
Discussion
The COVID-19 pandemic represents a threat to human health, especially in risk groups
such as patients recovering from surgery [6 ]. Here, we report real world clinical data of thoracic surgery patients during the
first COVID-19 wave in Germany from March to May 2020 with focus on the successfully
implemented COVID-19 preventive measures that allowed continued care of patients undergoing
thoracic surgery.
Previous studies demonstrated the high incidence of complications in patients with
postoperative COVID-19. In particular, thoracic surgery patients are prone to severe
courses of COVID-19 with postoperative pulmonary complications being associated with
a high mortality rate ranging between 27.3–66.7 % [4 ]
[7 ]
[8 ]. This might be mediated by associated risk factors such as nicotine abuse, cardio-respiratory
comorbidities and advanced age in patients suffering from thoracic malignancies, as
well as acute lung tissue injury caused by surgery [9 ]. In accordance with previous studies, the most frequent comorbidities identified
in our patients were the pulmonary and cardiac diseases, followed by renal and metabolic
comorbidities, suggesting that the admitted surgical patients are often per se high
risk patients for severe COVID-19 course – even before surgery. Given the high mortality
rate of thoracic surgery patients perioperatively infected with SARS-CoV-2, it is
of outmost importance to minimize the spread of the infection in this vulnerable subgroup
of patients and to early detect putative symptoms of postoperative COVID-19 [3 ]
[4 ]
[8 ].
Recommendations of the American Association for Thoracic Surgery and the Thoracic
Surgery Outcomes Research Network designed during the first pandemic wave underlined
the need for continued surgical care of patients [10 ]
[11 ], taking the global emergency status of the COVID-19 pandemic and the availability
of hospital resources limited by the COVID-19 patient treatment into account. In addition,
recommendations of the European Society of Medical Oncology (ESMO) proposed a stage-based
lung cancer treatment, with three levels of priority based on clinical, radiological
and histological considerations [12 ]. Subsequently, many surgical departments had to postpone important diagnostic and
therapeutic procedures during this challenging time period. As a result, surgical
operation volume dramatically decreased in many surgical specialties including vascular,
cardiac surgery and general surgery to 28.3 %, 54 % and 57 % of baseline, respectively
[13 ]
[14 ]
[15 ]. A predictive model designed by the COVIDSurg Collaborative, estimated a large amount
of surgical operations (ca. 28 mil. for 81.7 % benign and 37.7 % malignant lesions)
to be cancelled or postponed worldwide during the first 12 weeks of the pandemic peak
in 2020 [16 ]. Multiple studies showed the medical impact of postponed mandatory diagnostic and
surgical procedures [17 ]
[18 ].
Until March 22nd, three cases of postoperative COVID-19 were identified and triggered
the implementation of strict measures to prevent further cases of COVID-19 in thoracic
surgical patients. For primary prevention of postoperative COVID-19, the influx of
SARS-CoV-2 positive patients into the thoracic surgical departments should be prevented,
e. g. by COVID-19 screening measures for admitted patients. In addition, cross-transmission
between patients, healthcare workers and visitors should be minimized, e. g. by universal
use of nose-mouth covers, no visitors policy and a drive-through approach. During
the 1st wave, testing of patients without symptoms was initially not available in
test centers. Drive-through testing at our hospital side was initially the only option
to test surgical outpatients before admission and aimed to reduce additional hospital
rooms for the preoperative COVID-19 screening as well as to overcome a prolonged in-hospital
stay. We assume that pre-admission drive-through screening followed by strict home
isolation is a feasible approach and equally effective to the in-hospital testing
on admission. In addition, pre-admission testing might reduce in-hospital stay time
– an important economic factor. Accordingly, the median time to surgery after implementation
of the drive-through testing was reduced from 4 to 3 days. With all abovementioned
preventive measures took in place, the time to surgery during the 2nd wave was similar
in comparison to the last five years.
Furthermore, secondary prevention by early detection of postoperative COVID-19 in
surgical patients is of crucial importance to treat these COVID-19 cases early and
identify failure of primary prevention measures. This postoperative screening effort
was designed to retrospectively identify the potential transmission events on wards
and in the operating room [19 ]. After implementation of the described preventive measures, no perioperative symptomatic
COVID-19 cases were identified.
Due to the high prevalence of COVID-19 in the hospital district area, not only patients
but also healthcare workers of our department were affected. In the “Restriction Phase”,
positive SARS-CoV-2 tests in four symptomatic healthcare workers were reported 8,
14 and 19 days after the surgical procedure of the last COVID-19 patient reported
on our department. With permanent surgical mask wearing and no temporal association
to the described cases, cross-transmission in the hospital seemed unlikely to us,
however, cannot be excluded.
The preventive measures (e. g. single bed accommodation) increased the use of hospital
human resources and materials for the admitted thoracic surgery patients and led to
lower bed capacity on wards. Accordingly, the surgical routine between March 1st and
May 15th, 2020 was not interrupted, but the surgery volume decreased by 23 % compared
to the same time frame of the previous six years (2014–2019, data not shown) in our
hospital. This might be explained by the implementation of the single bed policy leading
to a 50 % reduction of ward capacity in the “Restriction Phase”. In addition, the
socio-medical context of the pandemic led also to strict home isolation of multimorbid
patients. Consecutively, patient contacts in private medical practices were cancelled
or postponed, leading to underdiagnosis of thoracic diseases, such as lung cancer
[20 ].
The abovementioned preventive measures were also applied during the 2nd wave. With
no symptomatic postoperative COVID-19 cases reflecting an efficient perioperative
prevention, our department reintroduced the standard two-bed rooms policy. These measures
led to an increased ward admission capacity and operation volume, with no re-appearance
of post-operative COVID-19 cases. Therefore, we believe, that all measures but single-patient
room accommodation are helpful to protect patients with no reduction in volume of
surgery required.
In order to identify postoperative COVID-19 after discharge, the patients were followed
up using standard telephone interviews and symptom-triggered testing of patients.
The lack of symptomatic postoperative COVID-19 during the “Restriction Phase” could
point at a successful application of the prevention measures. Because of the lack
of qPCR tests during the early phase of the pandemic, a qPCR testing from oro-/nasopharyngeal
swab was not available for the asymptomatic patients in this study. Thus, the number
of asymptomatic post-operative COVID-19 cases remains elusive, being a limitation
of the study. However, according to the recently published S2k Guideline-Recommendations
for inpatient therapy of patients with COVID-19 (February 2021), only 6 % of the patients
with mild symptoms including cough and fever require hospitalization [21 ]. Based on this consideration, the aforementioned symptoms depicted in the context
of the postoperative follow-up by phone calls should trigger SARS-CoV-2 screening.
Comparing complaints of surgical patients in postoperative recovery with those of
hospitalized COVID-19 patients, several symptoms reported by thoracic surgery patients,
such as expectoration, low energy levels and anosmia, were similarly frequently reported
by COVID-19 patients. In contrast, symptoms significantly more often seen in COVID-19
patients were fever, dyspnea, cough, and diarrhea. In patients with these postoperative
or post-discharge symptoms, COVID-19 should be considered as differential diagnosis
and a COVID-19 test should be routinely performed.
Fever and cough were found to be the most prevalent symptoms for a COVID-19 pneumonia
[6 ]
[22 ]
[23 ]. Symptoms found in COVID-19 patients were in accordance with the preliminary description
of the COVID-19 symptomatology including fever (83 %), dyspnea (31 %), cough (82 %)
and diarrhea (2 %) as initially reported by Chen et al. (2019) [6 ]. Of note, anosmia was reported in five patients post-thoracic surgery after adjuvant
therapy and only in two non-surgical COVID-19 patients, suggesting that this symptom
might be considered less helpful in differentiating normal postoperative recovery
from postoperative COVID-19. The high prevalence of headache, low energy levels, nausea
and disorientation in the thoracic surgery patients postoperatively might also be
linked to analgesic treatment or adjuvant chemotherapy. Therefore, these symptoms
could be less reliable in screening for postoperative COVID-19. Given the symptom
heterogeneity and the course of post thoracic surgery recovery, we assume that it
is more challenging to detect a COVID-19 pneumonia in post thoracic surgery patients
than in the healthy individuals based on symptomatology.
Based on the successful prevention implemented during the 1st wave and routinely applied
in the 2nd wave, we assume that the pre-admission patient interview, the outpatient
drive-through PCR screening and the pre-admission home quarantine, might be of long-term
benefit and thus, warranty an uninterrupted surgical patient care. Second, our department
introduced a weekly screening of healthcare workers prior to vaccination, as well
as an immediate screening of patients upon clinical suspicion. Specifically, symptoms
including fever, dry cough, dyspnea, or diarrhea should trigger an emergent screening
on the wards.
Taken together, the challenges reported on our thoracic surgery department included:
The lack of first-hand screening experience in the advent of the pandemic that implied
a stepwise implementation of primary and secondary preventive measures.
The abrupt reduction of intensive care resources for the surgical patient care that
determined a postoperative monitoring on normal wards.
The rapid spread of the infection and possible cross-contamination between patients
and healthcare workers that emerged a single room patient hospitalization, no visitor
policy, as well as mandatory regular screening for patients and healthcare workers
or upon clinical suspicion.
The elusive identification of the asymptomatic postoperative COVID-19 patients in
outpatient setting, that determined a second follow up call and a SARS-CoV-2 screening
upon clinical suspicion.
Based on these considerations, the lessons learned during the first pandemic wave
in our thoracic surgical unit were:
Continued thoracic surgical patient care was possible in a high-prevalence COVID-19
region by implementing strict primary and secondary preventive measures.
Symptoms of recovering thoracic surgery patients and COVID-19 patients overlap, complicating
COVID-19 diagnosis postoperatively.
Postoperative dyspnea, fever, cough, or diarrhea in thoracic surgery patients should
trigger COVID-19 testing.
Author contributions: R. H., C. K., M. G. S. and K. S. conceptualized the study. M. G. S., M. G., K. S.,
F. O, J. H., I. K., F. M. S. and N. R. collected and analyzed clinical data and documentation.
M. H. N., E. S. P, J. B., U. G., J. K., and N. S. aided in interpreting results. M. G. S.
and M. G. drafted and wrote the manuscript. R. H., C. K. and K. S. revised the manuscript.
All authors discussed the results and commented on the manuscript.
Paper’s main novel aspects
Continued thoracic surgical patient care with non-elective as well as elective surgeries
is possible in a high-prevalence COVID-19 region.
Symptoms of recovering thoracic surgery patients and COVID-19 patients overlap.
Postoperative dyspnea, fever, cough or diarrhea should trigger postoperative COVID-19
screening in patients.
