The importance of informed consent in the return of elective surgeries during the COVID-19 pandemic
A importância do consentimento informado no retorno das cirurgias eletivas durante a pandemia de COVID-19

Dear editor,

The new coronavirus outbreak (COVID-19) was declared an international public health emergency on January 30, 2020, and a pandemic on March 11, 2020, by the World Health Organization (WHO). As of October 16, 2020, a total of 39,580,502 cases of COVID-19 were confirmed by WHO, of which 1,108,215 patients died. The morbidity of patients with COVID-19 is higher than that of influenza A, severe acute respiratory syndrome-coronavirus (SARS-CoV), and middle east respiratory syndrome (MERS)¹.

Currently, there is no specific treatment or effective vaccine approved and available, so sanitary measures, which include social distance, quarantine, and control of risk factors for COVID-19, are the most effective for controlling the disease².

Given this scenario, several international societies of medical specialties have recommended the postponement of elective surgeries³. However, with the gradual decrease in the number of COVID-19 cases and the emptying of hospital beds, the possibility of returning to elective surgeries appears. Desta forma, os cirurgiões plásticos devem estar atentos a algumas situações dentro de nossa área de atuação para que haja um retorno seguro das cirurgias eletivas.

Thus, plastic surgeons must be aware of some situations within our operation area to have a safe return from elective surgeries. Both COVID-19 and obesity are pandemic, and any degree of obesity (BMI≥30kg/m²) is associated with a worse prognosis in patients with COVID-19. Obesity increases the severity and duration of COVID-19⁴.

The association between obesity and COVID-19 can be assessed in several aspects. First, obesity causes dysfunctions in the respiratory system, such as decreased chest wall elasticity, lung compliance, and expiratory reserve volume. Second, obesity is associated with other diseases, such as diabetes, high blood pressure, and cardiovascular diseases, identified as risk factors for COVID-19. These comorbidities can exacerbate COVID-19 and increase the likelihood of hospitalization in intensive care units and mortality. Third, there is a state of hypercoagulability and hyperinflammation in obesity. Whether obesity exacerbates COVID-19 due to the increase in inflammatory factors is unclear and requires further research⁵.

In addition to the concern about comorbidities in patients who are candidates for plastic surgery procedures, such as obesity, we must not forget that there is an increased risk of infection transmission during the patient’s admission to an elective procedure. The disease’s signs and symptoms can make it difficult to follow up with these patients in the postoperative period, even with isolation measures. Patients may have an infection acquired in the community of asymptomatic patients in the family during the postoperative period. The medical team itself can be appointed as responsible and responsible for the transmission.

Besides, patients residing in other cities, far from the place where the operation was performed, make medical monitoring by the responsible surgeon difficult and delay a patient’s possible hospitalization for better management and assessment of the COVID-19 condition. Also, there may be an overlap of clinical manifestations typical of the postoperative period and the symptoms of COVID-19, such as dyspnea, fever, relative lymphopenia, and pulmonary changes in the chest computed tomography.

In a cohort study carried out in Italy among patients with and without COVID-19 who underwent different surgical procedures, the risk of thrombotic, pulmonary, and surgical complications was 13.3; 35.6 and 9.5 times higher in patients with COVID-19 compared to patients without COVID-19, respectively⁶. Studies indicate that patients who acquire COVID-19 infection during the postoperative period are more prone to severe conditions and higher mortality rates⁷.

The patient must be selected for elective surgical procedures in plastic surgery, following careful scientific criteria with strict observance of health protocols and preventive measures established by the federal, state, and municipal government. Above all, always listening and deciding with the patient the time to perform the desired surgical procedures.

The observations noted above must be part of the consent form given to the patient to sign. However, the consent form is not just a sheet of paper, but a knowledge process based on permission and clarification to the patient. The surgeon must clarify to the patient the need for regular follow-up and management of complications in different situations. The relationship between surgical trauma and the possibility of worsening SARS-CoV-2 infection should be objectively clarified. Nothing replaces the explicit setting of realistic expectations during the consultation so that there is future satisfaction with the operation and a collaborative patient in the postoperative period.

REFERENCES

1. World Health Organization (WHO). Timeline: WHO's COVID-19 response [Internet]. Geneva: WHO; 2020; [citado 2020 Out 5]. Disponível em: https://www.who.int/news-room/detail/16-10-2020-covid

2. Kawr SP, Gupta V. COVID-19 vaccine: a comprehensive status report. Virus Res. 2020;288:198114.

3. Yang W, Wang C, Shikora S, Know L. Recommendations for metabolic and bariatric surgery during the COVID-19 pandemic from IFSO. Obes Surg. 2020 Jun;30(6):2071-3.

4. Sanchis-Gomar F, Lavie CJ, Mehra MR, Henry BM, Lippi G. Obesity and outcomes in COVID-19: when an epidemic and pandemic collide. Mayo Clin Proc. 2020 Jul;95(7):1445-53.

5. Chiappetta S, Sharma AM, Bottino V, Stier C. COVID-19 and the role of chronic inflammation in patients with obesity. Int J Obes. 2020 Mai;44:1790-2.

6. Doglietto F, Vezzoli M, Gueza F, Lussardi GL, Domenicucci M, Vecchiarelli L, et al. Factors associated with surgical mortality and complications among patients with and without coronavirus disease 2019 (COVID-19) in Italy. JAMA Surg. 2020 Jun;155(8):1-14.

7. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020 Jul;396(10243):27-38.

1. Asa Norte Regional Hospital, Plastic Surgery Service, Brasília, DF, Brazil.
2 . University of the Brasília, Department of Morphology, Brasília, DF, Brazil.

Corresponding author: Jefferson Lessa Soares Macedo, Quadra SQS 213, Bloco H, Apto 303, Asa Sul, Brasília, DF, Brazil. CEP: 70292-080. E-mail: jlsmacedo@yahoo.com.br

Article received: October 18, 2020.
Article accepted: November 10, 2020.

Conflicts of interest: none