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.