Discussion
Main Findings
Our study demonstrates the dramatic reduction in endometriosis surgery
by nearly 50% overall, . This is significantly higher than the 38.6%
reduction in elective procedures nationwide, indicating that
endometriosis surgery has been particularly badly affected. the number
of endometriosis operations per centre decreased by a median 51%, while
the number of centres remained approximately the same. Only 9 centres
had increased operation numbers, which may have been newer centres in
the process of growing their workload as usually occurs when centres
acquire additional staff. Despite these changes, the proportions of
patients undergoing the different types of surgery on the bowel
(shaving, disc resection and segmental resection) remains unaffected.
Reduction in endometriosis operations at a regional level were
correlated with regional COVID-19 death rates.
Strengths and Limitations
This study is the first to provide a comprehensive assessment of the
effect of the COVID-19 pandemic on surgery for severe endometriosis in
the UK. A nation-wide, standardised approach was taken in data
collection, however only BSGE-registered operations were taken into
account, and there may have been other operations performed which were
not registered with the BSGE. There was also a lack of data from
Northern Ireland, restricting analysis to Great Britain.
Interpretation
The magnitude of the reduction in operations for this common, chronic,
unremitting gynaecological condition is of major concern, and highlights
the challenges for the restoration of endometriosis services. There is a
pressing need in the pandemic recovery period for substantial investment
to provide the necessary resources for adequate surgical service
provision. Despite national prioritisation guidance stating that surgery
for severe endometriosis with uncontrolled pain should be performed
within 3 months, it is likely that patients will experience
significantly longer wating times than this, as they did prior to the
pandemic. Indeed, NHS England statistics from March 2021 show only
65.3% of patients receive treatment within 18 weeks of referral for
gynaecological disease, and this figure may be considerably worse for
endometriosis treatment.
Most endometriosis surgery is performed laparoscopically, and part of
the decline in operations may have been due to concerns early in the
pandemic about laparoscopy as an aerosol-generating procedure. The
increased use of pre-operative testing of patients and measures to
improve the COVID-safety of laparoscopy have allowed the careful
re-starting of endometriosis surgery at some centres through 2020 and
2021, mitigating some of the disruption. However, a survey by the Royal
College of Obstetricians and Gynaecologists in December 2020 found that
only 20% of respondents felt that elective gynaecology activity at
their units had returned to pre-2020 levels, indicating that the effect
of the pandemic is likely to have extended well into 2021.
The reduction in operations for severe endometriosis is unsurprising
given the lack of operating theatre capacity and redeployment of staff.
However, reduced patient access to GP services may be equally important,
as well as other obstacles to obtaining a referral for endometriosis
treatment, such as the need to self-isolate and reductions in
endometriosis clinic capacity. In support of this, a report into
elective care in England found that while there was a large decrease in
the number of referred patients receiving definitive care in 2020
compared to 2019, there was an even larger decrease in the number of new
referrals made, so that the total number of patients waiting for surgery
actually decreased. As more patients are able to access GPs and obtain
referrals to specialist endometriosis services, it is likely that most
hospitals will experience a surge in referrals. Increased demand from
primary care will add to those patients already awaiting surgery whose
operations have been delayed, and existing services are unlikely to have
capacity to meet the increasing demand. Furthermore, the ensuing delays
in surgical treatment will cause additional costs to the NHS through
emergency and pain management services, as well as other costs from lost
time at work and education.
Considering the almost universal decline in centre activity, the BSGE
has made a decision not to use operation numbers from 2020 as part of
the accreditation process. This will allow many centres to remain on the
BSGE centres list, and thereby ensure that the infrastructure is in
place for an increase in operation numbers in the pandemic recovery
period. Nevertheless, the effect on waiting times for endometriosis
surgery will be dramatic, and the full extent of the impact on the wait
for surgery is not yet known.
The sharp reduction in surgical case-load for highly complex surgery
will undoubtedly have caused ripple-effects on proficiency, training and
hands-on experience for both experienced and trainee-level endometriosis
surgeons. “Buddy” operating, where experienced surgeons operate
together, has been suggested by some to help reattain pre-pandemic
levels of proficiency and confidence. This is a difficult debate as it
represents a further cost pressure to organisations to fund what is
regarded by some as a necessity. Meanwhile, new endometriosis surgeons
will have felt the impact on their training acutely, with significant
delays to the acquisition of new skills. Additional resources may
therefore be required for advanced laparoscopic surgery training in
order to maintain any benefit in additional surgical capacity for the
longer term.
This study finds that reduction in endometriosis operations at a
regional level are correlated with regional COVID-19 death rates. There
are several reasons why this may be the case. Firstly, the repurposing
of operating theatres for the care of COVID patients left few operating
theatres available, particularly for elective surgery, and this effect
may have been greater in regions with higher numbers of critically
unwell COVID patients. Staffing required for endometriosis surgery is
likely to have been worse affected by redeployment in regions worse
affected by the pandemic, particularly affecting the availability of
anaesthetists. Staff absence due to illness with COVID or a household
member with COVID may have played a significant role. In fact, a survey
by the Royal College of Physicians in April 2020 showed 21% of staff
away from work primarily due to these two reasons. Also, regions with
worse COVID outbreaks may have seen fewer patients accessing GP services
and endometriosis clinics due to a combination of reduced primary care
services and patient avoidance of healthcare
facilities15. Evidence that regions worse affected by
the pandemic suffered greater reductions in endometriosis operations may
be helpful in planning the allocation of resources so that operating
capacity is increased where it is most needed. Indeed, greater sharing
of patient pathways and working beyond single hospital boundaries may be
required to smooth out some of the inequities in waiting times and
access to care. However, this is only one of several factors to
consider, and pre-pandemic waiting times will need to be taken into
account alongside other concerns.