Salvador Morales: "The voice of the scientific society must be above political decisions"

The pandemic of covid-19 has considerably affected surgical activity of our country. Especially in the first wave, most of the operations that were not of extreme urgency went to the background to face the fight that the coronavirus supposed for the health system.

The risk of complications for the patient, the danger of contagion for the health personnel and the strong healthcare pressure, were the causes that many surgeries were postponed in several hospitals in Spain.

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Now, in the middle of the second wave, we chat with the president of the Spanish Association of Surgeons, Salvador Morales Conde, to know how the covid-19 is currently affected in operating rooms, the differences with the first wave and the innovations that are expected in its field.

During the last months, Morales has led the working group ‘Surgery-AEC-COVID’, which has prepared a series of position papers and recommendations for action in relation to surgery and the coronavirus.

QUESTION. How did the first wave of the coronavirus affect the operating rooms?

REPLY. The big problem we had in the first wave was that we did not know how to get the patient safely to the operating room, because there was no scientific evidence. We knew that there was a percentage of asymptomatic patients who, if operated on, would have a higher rate of postoperative complications. In addition, there could be a transmission of the coronavirus to healthcare personnel and other patients.

Also, when we started to have an idea that it was good to do a PCR on all patients, there were also no resources at that time. There was not enough infrastructure to diagnose patients who were entering the emergency room with covid and who had to be operated on.

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There was also some panic on the part of the staff, as there were no resources to protect ourselves adequately, we did not even know how to do it.

Q. And how is this second wave being lived? What has been learned from the previous one?

A. The second wave in the impact of surgeries has been different. We have scientific knowledge, such as that transmitted by scientific societies, that it is good to do PCR between 48 and 72 hours before the operation to diagnose asymptomatic patients, which allows the patient to enter the operating room safely.

We also have resources to protect ourselves and we know how to act in the hospital. In addition, ‘covid free’ circuits already exist in health centers.

Q. Has this suspension of surgeries led to an increase in mortality or severity of patients?

A. As such we cannot say that. What has concerned us as surgeons is the stop that may occur in the diagnostic circuit.

Primary care is very important to take care of covid patients, but it is also tremendously important to start the diagnostic circuit of patients. For example, when primary care was stopped, endoscopies, except for urgent ones, were stopped, so certain tumors could not be diagnosed.

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It is true that there could be delays in certain diagnoses. At the peak of the first wave, following decisions of scientific committees, some patients were given extra chemotherapy cycles to postpone surgery and operate with greater safety conditions.

But it is true that the multidisciplinary committees have worked to take patients to the operating room in the best safety conditions, with special attention to oncological pathology.

Q. Has the suspension of surgeries had a different impact on public health than on private?

A. It is actually a bed management issue. If there are beds, it is operated, that is what I can transmit. Here the fact of being public or private does not rule, but the existence of resources.

There are places like Valladolid where an agreement was reached to keep private hospitals free of covid and that public surgeons will operate in private ones.

I consider public-private cooperation important, I have always considered it essential and there need not be confrontations.

P. Is Spain failing something in health policies compared to other countries?

R. I am not going to analyze if it fails or does not fail. But I think there are opinion leaders at the international level who are the scientific community and their voice should be above many political decisions. And this is key, because some positions may be politicized, but in scientific societies there is no internal interest.

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Scientific societies are based on evidence and I believe that we should work hand in hand with them to attack health problems like the ones we are experiencing.

Q. From what you are saying … do you consider that scientific societies are not sufficiently served in our country?

R. We are currently working with the Ministry of Health, but it was difficult for us to reach them. Now we are starting to work with the Ministry in some aspects, but I think we should cooperate more closely.

For example, the Federation of Spanish Medical Scientific Associations (Facme) has created working groups to issue statements on ways of working and managing this second wave of the pandemic, the key to operation should be more focused on scientific societies.

Q. What role does Spain have in international scientific societies?

R. Very much. For example, from the Spanish Association of Surgeons, on March 14, we created the group 'Cirugía-AEC-COVID', in which we meet 17 surgeons from different parts of Spain to collect scientific evidence from China and other places that it affected before the first wave, like Italy.

The objective was to obtain information and start issuing training documents for Spanish surgeons. These writings began to have a great impact worldwide and were translated into many languages ​​such as Polish, Italian or English. They started calling us from all over the world to participate in training sessions.

Q. How can we convey that social responsibility is key to getting out of this situation we are experiencing?

A. Social responsibility is the key to the success of this pandemic. There are three key points. One is the health professional working in hospitals, another the science that moves to investigate and extract data to pass what we are going through, and another very important is social responsibility.

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Q. This week the XXXIII National Congress of Surgery is being held, what are the latest advances in technology for the sector?

R. There are three fundamental pivots of the surgery of the future. The first is the standardization of procedures. When standardized surgical procedures are made reproducible, they can be taught and this is key from a training point of view.

Another important point is the impact that robotics is having on surgery. Until now we have only talked about the Da Vinci, but now new robots are emerging that are going to revolutionize interventions. The latest is image-guided surgery, which consists of making 3D reconstructions with a CT to have an image and superimpose it intraoperatively to know where the structures are and where the operation is going to be done. In addition, we also have substances that are injected intravenously that go to certain organs to be able to identify them.

If we add to these aspects the issue of artificial intelligence or ‘big data’, which will provide information during the procedure, the coming revolution in surgery is made.

Q. All these innovations you are talking about, are they the present, the immediate future …?

R. There is precisely a round table at the congress called 'From illusion to real implementation', where we will deal with robotics, image-guided surgery and we are going to give real data that many operating rooms are working and can be Apply.

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The good thing about all this is that it is not an illusion, it is already a reality. What is still missing is a supportive umbrella, that is, to standardize. Robotics is there and imaging surgery is developing in an impressive way, what to apply to all this and how to fit it with artificial intelligence and 'big data'.

Q. Do you think that all public systems would be willing to invest in such innovative technology?

R. There are already robots in many hospitals, but the new ones we will see when they are implemented. Do not forget one thing, the impact of innovation is not the whims of surgeons, but important contributions to safety. It means that there is a patient who is not going to have any problems and who is actually going to have a tremendously positive financial impact.

But for example, I have been working with image-guided surgery for 6 years and I have it both privately and publicly. We have lowered the intestinal junction failure rate from 7% to 1% thanks to technology. This means that 6 out of 100 patients no longer need reoperation, use of the ICU and prolonged stays in hospital. With which it is clear that with the cost that you save on these 6 patients, you can buy many intraoperative navigation systems, because you have saved a lot of money. And remember that the important thing is not the economic impact but the human, there are 6 people who have stopped suffering.