Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

Impact of the COVID-19 pandemic on surgical care in the Netherlands

BACKGROUND

The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.

METHODS

A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.

RESULTS

Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).

CONCLUSION

The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

BACKGROUND

The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs.

METHODS

First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score.

FINDINGS

In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1-84·9), which varied between HIC (88·5 [89·0-88·0]), MIC (81·8 [82·5-81·1]), and LIC (66·8 [64·9-68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0-4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1-5·5]; p<0·0001), MIC (2·8 [2·0-3·7]; p<0·0001), and LIC (3·8 [1·3-6·7%]; p<0·0001) settings.

INTERPRETATION

The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs.

FUNDING

National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic.

Outcomes of gynecologic cancer surgery during the COVID-19 pandemic: an international, multicenter, prospective CovidSurg-Gynecologic Oncology Cancer study

BACKGROUND

The CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear.

OBJECTIVE

This study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes.

STUDY DESIGN

This was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death.

RESULTS

We included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort.

CONCLUSION

One in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed.

Analysis of patient outcomes after urological surgery during the second and third waves of SARS-CoV-2 pandemic in a high incidence area

OBJECTIVE

To analyze surgical safety through postoperative COVID-19 incidence and mortality at the urology department of a tertiary hospital located in Madrid (Spain).

METHODS

Observational, prospective study including all patients undergoing urological surgery from 1st March 2020 to 28th February 2021. According to the hospital organization and local epidemiological situation we delimitate three epidemic waves. A set of screening and protective measures was applied from 4th May onwards. Demographic, baseline, surgical and perioperative variables, as well as postoperative outcomes, were collected. Telephone follow-up was performed at least 3 weeks after hospital discharge.

RESULTS

940 urological surgeries were performed, 12 of them had to be rescheduled due to active or recent SARS-CoV-2 infection identified by the screening protocol. Thirty-one patients developed COVID-19 (3.3% incidence) and 7 died (22.6% mortality). The average time to onset of symptoms was 62.6 days after discharge, being 25 cases attributable to community transmission. The remaining 6 cases, due to in-hospital transmission, had worse outcomes. Five of them were identified during the first wave, especially when no preoperative PCR was obtained. In contrast, during the second and third waves, fewer and milder cases were diagnosed, with just 1 in-hospital transmission among 857 urological patients.

CONCLUSIONS

After implementing complete protective measures, postoperative in-hospital COVID-19 cases almost disappeared, even during the second and third waves. Most of the cases were due to community transmission and thus driven by the general epidemiological situation. While hospitals follow recommendations to avoid COVID-19 infection, urological surgery remains safe and can be maintained.

Standard Versus Advanced Protective Measures in a COVID-Free Surgical Pathway

Introduction The importance of coronavirus disease (COVID)-free surgical pathways during the coronavirus disease 2019 (COVID-19) pandemic has been demonstrated. However, the extent of protective measures to be applied against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly before vaccines became available, remained unclear. Methods This retrospective study included all SARS-CoV-2-negative patients admitted to the COVID-free pathway of a regional abdominal surgery hub center in Northern Italy over 12 months, before the vaccination campaign. During the first seven months, basic protective measures against SARS-CoV-2 were adopted (surgical masks, swabs for symptomatic patients, and intra- or interhospital transfers), since patients were treated as effectively negative (standard management). During the last five months, advanced measures were implemented (enhanced personal protections and systematic control swabs), as patients were considered potentially positive (advanced management). The aim of this article was to compare SARS-CoV-2 incidence and surgical outcomes in these periods. Results A total of 283 and 194 patients were admitted under standard and advanced management, respectively; pre-admission data differed only in the rate of previous SARS-CoV-2 infection (2.5% versus 6.7%, p= 0.034). The SARS-CoV-2 incidence was 3.9% and 3.1% for standard and advanced periods, respectively (p = 0.835). Two internal outbreaks developed during the standard phase. The advanced protocol significantly increased the rate of patients re-tested for SARS-CoV-2 (83% versus 41.7%, p < 0.001) and allowed early detection of all infections, which remained sporadic. Surgical outcomes were similar. Conclusions Advanced management was instrumental in detecting positive patients early and preventing outbreaks, without affecting surgical results; accordingly, it stands as a reproducible model for future pandemic scenarios.

Handling of the Covid-19 Pandemic and Its Effects on Bariatric Surgical Practice: Analysis of GENEVA Study Database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic led to a worldwide suspension of bariatric and metabolic surgery (BMS) services. The current study analyses data on patterns of service delivery, recovery of practices, and protective measures taken during the COVID-19 pandemic by bariatric teams.

MATERIALS AND METHODS

The current study is a subset analysis of the GENEVA study which was an international cohort study between 01/05/2020 and 31/10/2020. Data were specifically analysed regarding the timing of BMS suspension, patterns of service recovery, and precautionary measures deployed.

RESULTS

A total of 527 surgeons from 439 hospitals in 64 countries submitted data regarding their practices and handling of the pandemic. Smaller hospitals (with less than 200 beds) were able to restart BMS programmes more rapidly (time to BMS restart 60.8 ± 38.9 days) than larger institutions (over 2000 beds) (81.3 ± 30.5 days) (p = 0.032). There was a significant difference in the time interval between cessation/reduction and restart of bariatric services between government-funded practices (97.1 ± 76.2 days), combination practices (84.4 ± 47.9 days), and private practices (58.5 ± 38.3 days) (p < 0.001). Precautionary measures adopted included patient segregation, utilisation of personal protective equipment, and preoperative testing. Following service recovery, 40% of the surgeons operated with a reduced capacity. Twenty-two percent gave priority to long waiters, 15.4% gave priority to uncontrolled diabetics, and 7.6% prioritised patients requiring organ transplantation.

CONCLUSION

This study provides global, real-world data regarding the recovery of BMS services following the COVID-19 pandemic.

Delayed presentation of a huge abdominopelvic mass during the COVID-19 pandemic

Background

Giant ovarian cysts are rare in developed countries due to advanced achievements in medical diagnostics. However, in the midst of the coronavirus disease 2019 (COVID-19) pandemic, patients with non-COVID-19-related illnesses tend to delay their health-seeking attention; thus, they had presented late.

Case presentation

A 25-year-old single lady complained of a 3-month worsening abdominal pain and distention. She was initially well but neglected the symptoms due to the COVID-19 situation, yet came to our attention after she developed obstructive symptoms. A computed tomography (CT) scan of the abdomen revealed a huge cystic lesion from the pelvic area, which later was found to be from the right ovary upon urgent laparotomy exploration. The histopathological examination was consistent with mucinous cystadenoma of the ovary.

Discussion

Acute non-COVID-19-related emergencies have decreased, as evidenced by reduced visits to the Emergency Department, and the number of abdominal CT scans. An emergency case like a huge abdominopelvic mass deserves an extensive radiologic examination as clinical assessment alone may not be adequate. Preoperative CT is superior to ultrasonography in getting the extent of the lesion, local infiltration, staging purpose, and surgical intervention. Pathology with a variety of spectrums such as mucinous neoplasm deserves to be investigated, evaluated, and resected even during the COVID-19 pandemic.

Conclusion

A giant abdominopelvic cystic mass can present emergency havoc during the COVID-19 pandemic. Urgent surgical intervention is mandatory by using full protection and exercising extreme precaution, regardless of the preoperative screening to avoid unnecessary viral transmissions.

•

Acute abdomen cases have reduced in numbers during COVID-19 pandemic which can cause delay in diagnosis and management.

•

Preoperative CT scan can determine the extent of the lesion, local infiltration, staging, and surgical intervention.

•

During pandemic, urgent surgical intervention is mandatory by using full protection regardless of the preoperative screening to avoid unnecessary viral transmissions.

Rate of COVID-19 infection and 30 day mortality between blue and green (dedicated COVID-19 safe) pathways: Results from phase 1 and 2 of the UK foot and ankle COVID-19 national (UK-FAlCoN) audit

OBJECTIVES

The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second UK national lockdowns.

SETTING

This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13th January 2020 and 30th November 2020.

PARTICIPANTS

All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection).

RESULTS

10,846 patients were included, 6644 from phase 1 and 4202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6470) and 0.21% on a green pathway (9/4280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p = .109), lockdown (p = .923) or post-lockdown (p = .577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p < .001) and lockdown periods (Odd's Ratio 0.077, p < .001). There was no significant difference in COVID-19 related mortality between pathways.

CONCLUSIONS

There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

Outcomes of patients undergoing elective liver and pancreas cancer surgery during the SARS-CoV-2 pandemic: an international, multicentre, prospective cohort study

BACKGROUND

The effect of SARS-CoV-2 infection upon HPB cancer surgery perioperative outcomes is unclear. Establishing risk is key to individualising treatment pathways. We aimed to identify the mortality rate and complications risk for HPB cancer elective surgery during the pandemic.

METHODS

International, prospective, multicentre study of consecutive adult patients undergoing elective HPB cancer operations during the initial SARS-CoV-2 pandemic. Primary outcome was 30-day perioperative mortality. Secondary outcomes included major and surgery-specific 30-day complications. Multilevel cox proportional hazards and logistic regression models estimated association of SARS-CoV-2 and postoperative outcomes.

RESULTS

Among 2038 patients (259 hospitals, 49 countries; liver n = 1080; pancreas n = 958) some 6.2%, n = 127, contracted perioperative SARS-CoV-2. Perioperative mortality (9.4%, 12/127 vs 2.6%, 49/1911) and major complications (29.1%, 37/127 vs 13.2%, 253/1911) were higher with SARS-CoV-2 infection, persisting when age, sex and comorbidity were accounted for (HR survival 4.15, 95% CI 1.64 to 10.49; OR major complications 3.41, 95% CI 1.72 to 6.75). SARS-CoV-2 was associated with late postoperative bleeding (11.0% vs 4.2%) and grade B/C postoperative pancreatic fistula (17.9% vs 8.6%).

CONCLUSION

SARS-CoV-2 infection was associated with significantly higher perioperative morbidity and mortality. Patients without SARS-CoV-2 had acceptable morbidity and mortality rates, highlighting the need to protect patients to enable safe ongoing surgery.

Safe Surgery During the COVID-19 Pandemic

PURPOSE OF REVIEW

Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future.

RECENT FINDINGS

Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

Patients awaiting surgery for neurosurgical diseases during the first wave of the COVID-19 pandemic in Spain: a multicentre cohort study

OBJECTIVES

The large number of infected patients requiring mechanical ventilation has led to the postponement of scheduled neurosurgical procedures during the first wave of the COVID-19 pandemic. The aims of this study were to investigate the factors that influence the decision to postpone scheduled neurosurgical procedures and to evaluate the effect of the restriction in scheduled surgery adopted to deal with the first outbreak of the COVID-19 pandemic in Spain on the outcome of patients awaiting surgery.

DESIGN

This was an observational retrospective study.

SETTINGS

A tertiary-level multicentre study of neurosurgery activity between 1 March and 30 June 2020.

PARTICIPANTS

A total of 680 patients awaiting any scheduled neurosurgical procedure were enrolled. 470 patients (69.1%) were awaiting surgery because of spine degenerative disease, 86 patients (12.6%) due to functional disorders, 58 patients (8.5%) due to brain or spine tumours, 25 patients (3.7%) due to cerebrospinal fluid (CSF) disorders and 17 patients (2.5%) due to cerebrovascular disease.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality due to any reason and any deterioration of the specific neurosurgical condition. Second, we analysed the rate of confirmed SARS-CoV-2 infection.

RESULTS

More than one-quarter of patients experienced clinical or radiological deterioration. The rate of worsening was higher among patients with functional (39.5%) or CSF disorders (40%). Two patients died (0.4%) during the waiting period, both because of a concurrent disease. We performed a multivariate logistic regression analysis to determine independent covariates associated with maintaining the surgical indication. We found that community SARS-CoV-2 incidence (OR=1.011, p<0.001), degenerative spine (OR=0.296, p=0.027) and expedited indications (OR=6.095, p<0.001) were independent factors for being operated on during the pandemic.

CONCLUSIONS

Patients awaiting neurosurgery experienced significant collateral damage even when they were considered for scheduled procedures.

Bioethics in an oncological surgery unit during the COVID-19 pandemic: the Verona experience

The spread of COVID-19 has overwhelmed medical facilities across the globe, with patients filling beds in both regular wards and in intensive care units. The repurposing of hospital facilities has resulted in a dramatic decrease in the capacity of hospitals-in terms of available beds, surgical facilities, and medical and nursing staff- to care for oncology patients. The Italian National Board of Bioethics provided precise and homogeneous guidelines for the allocation of the scarce resources available. In our experience, strictly following these general guidelines and not considering the clinical vocation of each single health care center did not allow us to resume usual activities but generated further confusion in resource allocation. To face the scarcity of available resources and guarantee our patients fair access to the health care system we created a surgical triage with four fundamental steps. We took into consideration " well defined and widely accepted clinical prognostic factors " as stated by the Italian Society of Anesthesia and Resuscitation. We were able to draw up a list of patients giving priority to those who theoretically should have a greater chance of overcoming their critical situation. The age criterion has also been used in the overall evaluation of different cure options in each case, but it has never been considered on its own or outside the other clinical parameters. Although not considered acceptable by many we had to forcefully adopt the criterion of comparison between patients to give priority to those most in need of immediate care.

Postoperative outcomes in patients undergoing elective general surgery after recovery from Covid-19 at a tertiary care centre: A one-year case series

Background Planned elective surgery had to be postponed for a large number of patients who tested positive for Covid-19 in the preoperative period. We aimed to assess the postoperative outcomes of patients who were operated on for elective indications, following recovery from Covid-19 infection. Methods We did a retrospective study of patients who underwent elective general surgery between 1 April 2020 and 31 March 2021, following recovery from Covid-19. The 30-day postoperative morbidity and mortality were analysed. The data relevant for the study were retrieved from the hospital's electronic medical records. Results Of the 109 patients included, 54.1% were women and the median (range) age was 49 (16-76) years; 53.2% of operations were performed for benign indications and the rest were for malignancies. Eighty-five (78%) patients underwent surgery following recovery from an asymptomatic Covid-19 infection and 23 (21.1%) patients following recovery from mild Covid-19 infection; 73.3% of the operations were performed following a planned delay of 2- 5 weeks from the diagnosis of Covid-19. The 30-day major postoperative morbidity (Clavien-Dindo grade ≥3) was 6.4%, the postoperative pulmonary morbidity was 0.9%, and there was no 30-day mortality. Conclusions Elective general surgical procedures can be done safely in patients who have recovered from asymptomatic and mild Covid-19 infection, following a minimum wait period of 2 weeks.

Outcomes of Acute Gallstone Disease During the COVID-19 Pandemic: Lessons Learnt

Introduction

This study aims to compare the patient demographics and management of acute manifestations of gallstone disease during the COVID-19 pandemic with an equivalent period in 2019 and assess the differences in recurrence patterns throughout the first and second waves of the pandemic in the UK.

Methods

A retrospective cohort study of all adult patients aged >16 years presenting to the emergency department at a large District General Hospital with symptoms related to gallstones. Data were obtained from electronic patient records. The primary outcomes were incidence and management of gallstone disease, while secondary outcomes studied included length of stay, readmission rate, and recurrence. Data were tabulated and analyzed using Excel (Microsoft, 2016 version). Chi-square and t-test were used as appropriate. One way ANOVA test was used to compare data of three groups.

Results

Fifty-one patients presented during the period of first-wave and 105 patients during the second wave as compared to 71 patients in the study period in 2019. The median age of patients during the first wave of COVID was significantly higher than pre-COVID in the second wave. During both the waves of the pandemic, there was no significant difference in patients presenting with cholecystitis compared with 2019 (47 and 94 in the first and second wave, respectively, versus 60 in 2019; p-value 0.39). There was no significant increase in the use of cholecystostomy, and the use of radiological investigations was comparable. There was no significant difference in recurrence and readmissions. The majority of the patients still await surgery.

Conclusion

During the pandemic, older patients with higher co-morbidity presented with acute gallstone disease. Conservative management was effective in the management of these patients.

Lockdown surgery: the impact of coronavirus disease 2019 measures on cardiac cases

OBJECTIVES

The need to ration medical equipment and interventions during the coronavirus disease 2019 pandemic translated to an ever-lengthening wait list for surgical care. Retrospective analysis of lockdowns is of high importance to learn from the current situation for future pandemics. This monocentric study assessed the impact of lockdown periods on cardiac surgery cases and outcomes.

METHODS

The single-centre cross-sectional descriptive observational study was conducted to investigate the first lockdown period and the following post-lockdown period in comparison to the same periods during the previous 3 years at the Department of Cardiac Surgery at the Medical University of Innsbruck. Data were prospectively collected and retrospectively analysed from the department-specific quality management system. The primary objective was to compare the number of open-heart procedures between the prelockdown and the lockdown period. The secondary objectives were to analyse the characteristics and the outcomes of open-heart procedures.

RESULTS

There were no differences in patient demographics. A significant decrease of 29% in weekly surgical procedures was observed during the lockdown period. The surgical case-mix was unaffected: The numbers of aortic valve replacements, coronary artery bypass grafts, mitral valve repair or replacement procedures and others remained stable. The urgency of cases increased significantly, and the general health conditions of patients appeared to be worse. However, outcomes were unchanged.

CONCLUSIONS

By implementing a rational patient selection process, the quality of open-heart procedures was maintained even though patients who underwent surgery during lockdown were sicker and more symptomatic.

Safe provision of elective endocrine surgery operations amid the COVID-19 crisis

INTRODUCTION

The aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.

METHODS

A retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.

RESULTS

In the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.

CONCLUSIONS

The COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.

When to operate after SARS-CoV-2 infection? A review on the recent consensus recommendation of the DGC/BDC and the DGAI/BDA

Since the eruption of the worldwide SARS-CoV-2 pandemic in late 2019/early 2020, multiple elective surgical interventions were postponed. Through pandemic measures, elective operation capacities were reduced in favour of intensive care treatment for critically ill SARS-CoV-2 patients. Although intermittent low-incidence infection rates allowed an increase in elective surgery, surgeons have to include long-term pulmonary and extrapulmonary complications of SARS-CoV-2 infections (especially "Long Covid") in their perioperative management considerations and risk assessment procedures. This review summarizes recent consensus statements and recommendations regarding the timepoint for surgical intervention after SARS-CoV-2 infection released by respective German societies and professional representatives including DGC/BDC (Germany Society of Surgery/Professional Association of German Surgeons e.V.) and DGAI/BDA (Germany Society of Anesthesiology and Intensive Care Medicine/Professional Association of German Anesthesiologists e.V.) within the scope of the recent literature. The current literature reveals that patients with pre- and perioperative SARS-CoV-2 infection have a dramatically deteriorated postoperative outcome. Thereby, perioperative mortality is mainly caused by pulmonary and thromboembolic complications. Notably, perioperative mortality decreases to normal values over time depending on the duration of SARS-CoV-2 infection.

Surgical training during the COVID-19 pandemic at a designated 'cold' site: are we meeting the challenge?

INTRODUCTION

There has been a marked reduction in surgical operative training opportunities during the COVID-19 pandemic. This may be improved by the establishment of 'cold' sites for NHS elective surgery. We investigated the training opportunities at a newly designated elective surgery cold site in the West Midlands, UK.

METHODS

An observational retrospective study was undertaken to include all gastrointestinal and urological elective surgery at a single 'cold' site during the first peak of the COVID-19 pandemic. Patient demographics, details of surgery and data relating to surgical training such as primary surgeon and portfolio index procedure were collected. Factors affecting the likelihood of trainees being the primary surgeon were analysed using logistic regression models.

RESULTS

There were 880 patients, with a median (interquartile range) age of 62 (48-74). Some 658 (74.8%) procedures were defined as 'index procedures' for specialty training year 4 (ST4) level: 409/509 (80.4%) for urology, 155/235 (66%) for colorectal and 94/136 (69.1%) for upper gastrointestinal (GI). Only 253/880 (28.8%) procedures were performed by a trainee as the primary surgeon: 201/509 (39.4%) for urology, 21/235 (8.9%) for colorectal and 31/136 (22.8%) for upper GI. The likelihood of a trainee being the primary surgeon was reduced for major surgery (p<0.001) and for GI surgery when compared with urology (p<0.001).

CONCLUSIONS

Surgical training was facilitated at an elective surgery 'cold' site during the COVID-19 pandemic, but at lower levels than anticipated. Type of surgery influenced trainee participation. Surgical training should be incorporated into 'cold' site elective surgical services if trainees are to be prepared for the future.

Effect of COVID-19 on the delivery of care for thoracic surgical patients

Objective

In this study we aimed to determine the effect of the COVID-19 pandemic on the delivery of care for thoracic surgical patients at an urban medical center.

Methods

A retrospective analysis of all thoracic surgical cases from May 1, 2019, to December 31, 2020, was conducted. Demographic characteristics, preoperative surgical indications, procedures, final pathologic diagnoses, and perioperative outcomes were recorded. A census of operative cases, relevant ancillary services, and outpatient thoracic clinics were obtained from our institutional database.

Results

Six hundred nineteen cases were included in this study (329 pre-COVID-19 and 290 COVID-19, representing an 11.8% reduction). There were no differences in type of thoracic procedures or perioperative outcomes among the 2 cohorts. Prolonged reduction of thoracic surgical cases (50% of baseline) during the first half of the COVID-19 period was followed by a resurgence of surgical volumes to 110% of baseline in the second half. A similar incidence of cases were performed for oncologic indications during the first half whereas more benign cases were performed in the second half, coinciding with the launch of our robotic foregut surgery program. After undergoing surgery during the pandemic, none of our patients reported COVID-19 symptoms within 14 days of discharge.

Conclusions

During the initial surge of COVID-19, while there was temporary closure of operative services, our health care system continued to provide safe care for thoracic surgery patients, particularly those with oncologic indications. Since phased reopening, we have experienced a rebound of surgical volume and case mix, ultimately mitigating the initial negative effect of the pandemic on delivery of thoracic surgical care.

Epidemiological Pattern of Traumatic Brain Injury in the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

BACKGROUND

Although the incidence of traumatic brain injury (TBI) has decreased since the beginning of the coronavirus disease 2019 (COVID-19) pandemic and severe acute respiratory syndrome coronavirus 2 is still evolving, the number of TBI cases has still greatly increased in multiple countries. In the present systematic review and meta-analysis, we evaluated the epidemiological characteristics of patients with TBI before and during the COVID-19 pandemic.

METHODS

We conducted a systematic literature search of original studies, short reports, and research letters from databases on studies that contained data about the severity, mortality, presence of neurological deficits, radiological diagnosis, cause of injury, and type of management of TBI during a specified period within the pandemic compared with before the pandemic.

RESULTS

A total of 18,490 subjects from 13 studies were included in the present study. The results of the meta-analysis showed a higher TBI mortality rate during the COVID-19 pandemic in the low-to-middle income countries (odds ratio, 1.65; 95% confidence interval, 1.12-2.41; P < 0.05; I2 = 40.8%; P = 0.18). The proportion of subdural hemorrhage was decreased, and the proportion of subarachnoid hemorrhage was increased in low- to middle-income and high-income countries, respectively. The proportion of assaults as the cause of TBI had increased during the pandemic (odds ratio, 1.40; 95% confidence interval, 1.06-1.86; P = 0.02; I2 = 20.8%; P = 0.28). We did not find any significant differences in the incidence of surgical intervention for TBI during the pandemic.

CONCLUSIONS

Our results have indicated that during the COVID-19 pandemic, the TBI mortality rate had increased in low- to middle-income countries. The rate of assault as the cause of TBI had also increased during the pandemic.

A survey among physicians in surgery and anesthesiology departments after the first surge of SARS-CoV-2 infections in Germany : Preparing for further challenges ahead

BACKGROUND

The SARS-CoV‑2 pandemic has extensively challenged healthcare systems all over the world. Many elective operations were postponed or cancelled, changing priorities and workflows in surgery departments.

AIMS

The primary aim of this cross-sectional study was to assess the workload and psychosocial burden of surgeons and anesthesiologists, working in German hospitals during the first wave of SARS-CoV‑2 infections in 2020.

METHODS

Quantitative online survey on the workplace situation including psychosocial and work-related stress factors among resident and board-certified surgeons and anesthesiologists. Physicians in German hospitals across all levels of healthcare were contacted via departments, professional associations and social media posts.

RESULTS

Among 154 total study participants, 54% of respondents stated a lack of personal protective equipment in their own wards and 56% reported increased staff shortages since the onset of the pandemic. While routine practice was reported as fully resumed in 71% of surgery departments at the time of the survey, work-related dissatisfaction among responding surgeons and anesthesiologists increased from 24% before the pandemic to 36% after the first wave of infections. As a countermeasure, 94% of participants deemed the establishment of action plans to increase pandemic preparedness and strengthening German public health systems a useful measure to respond to current challenges.

CONCLUSION

The aftermath of the first wave of SARS-CoV‑2 infections in Germany has left the surgical staff strained, despite temporarily decreased workloads. Overall, a critical review of the altered conditions is indispensable to identify and promote effective solutions and prudent action plans required to address imminent challenges.

Timing of elective surgery and risk assessment after SARS-CoV-2 infection: an update: A multidisciplinary consensus statement on behalf of the Association of Anaesthetists, Centre for Perioperative Care, Federation of Surgical Specialty Associations, Royal College of Anaesthetists, Royal College of Surgeons of England

The impact of vaccination and new SARS-CoV-2 variants on peri-operative outcomes is unclear. We aimed to update previously published consensus recommendations on timing of elective surgery after SARS-CoV-2 infection to assist policymakers, administrative staff, clinicians and patients. The guidance remains that patients should avoid elective surgery within 7 weeks of infection, unless the benefits of doing so exceed the risk of waiting. We recommend individualised multidisciplinary risk assessment for patients requiring elective surgery within 7 weeks of SARS-CoV-2 infection. This should include baseline mortality risk calculation and assessment of risk modifiers (patient factors; SARS-CoV-2 infection; surgical factors). Asymptomatic SARS-CoV-2 infection with previous variants increased peri-operative mortality risk three-fold throughout the 6 weeks after infection, and assumptions that asymptomatic or mildly symptomatic omicron SARS-CoV-2 infection does not add risk are currently unfounded. Patients with persistent symptoms and those with moderate-to-severe COVID-19 may require a longer delay than 7 weeks. Elective surgery should not take place within 10 days of diagnosis of SARS-CoV-2 infection, predominantly because the patient may be infectious, which is a risk to surgical pathways, staff and other patients. We now emphasise that timing of surgery should include the assessment of baseline and increased risk, optimising vaccination and functional status, and shared decision-making. While these recommendations focus on the omicron variant and current evidence, the principles may also be of relevance to future variants. As further data emerge, these recommendations may be revised.

Involvement of the Liver in COVID-19: A Systematic Review

COVID-19, a respiratory viral infection, has affected 388 million individuals worldwide as of the February 4, 2022. In this review, we have outlined the important liver manifestations of COVID-19 and discussed the possible underlying pathophysiological mechanisms and their diagnosis and management. Factors that may contribute to hepatic involvement in COVID-19 include direct viral cytopathic effects, exaggerated immune responses/systemic inflammatory response syndrome, hypoxia-induced changes, vascular changes due to coagulopathy, endothelitis, cardiac congestion from right heart failure, and drug-induced liver injury. The majority of COVID-19-associated liver symptoms are mild and self-limiting. Thus management is generally supportive. Liver function tests and abdominal imaging are the primary investigations done in relation to liver involvement in COVID-19 patients. However, imaging findings are nonspecific. Severe acute respiratory syndrome coronavirus 2 RNA has been found in liver biopsies. However, there is limited place for liver biopsy in the clinical context, as it does not influence management. Although, the management is supportive in the majority of patients without previous liver disease, special emphasis is needed in those with nonalcoholic fatty liver disease, cirrhosis, hepatocellular carcinoma, hepatitis B and C infections, and alcoholic liver disease, and in liver transplant recipients.

Feasibility and usability of a regional hub model for colorectal cancer services during the COVID-19 pandemic

The outbreak of the COVID-19 pandemic produced unprecedented challenges, at a global level, in the provision of cancer care. With the ongoing need in the delivery of life-saving cancer treatment, the surgical management of patients with colorectal cancer required prompt significant transformation. The aim of this retrospective study is to report the outcome of a bespoke regional Cancer Hub model in the delivery of elective and essential colorectal cancer surgery, at the height of the first wave of the COVID-19 pandemic. 168 patients underwent colorectal cancer surgery from April 1st to June 30th of 2020. Approximately 75% of patients operated upon underwent colonic resection, of which 47% were left-sided, 34% right-sided and 12% beyond total mesorectal excision surgeries. Around 79% of all resectional surgeries were performed via laparotomy, and the remainder 21%, robotically or laparoscopically. Thirty-day complication rate, for Clavien-Dindo IIIA and above, was 4.2%, and 30-day mortality rate was 0.6%. Re-admission rate, within 30 days post-discharge, was 1.8%, however, no patient developed COVID-19 specific complications post-operatively and up to 28 days post-discharge. The established Cancer Hub offered elective surgical care for patients with colorectal cancer in a centralised, timely and efficient manner, with acceptable post-operative outcomes and no increased risk of contracting COVID-19 during their inpatient stay. We offer a practical model of care that can be used when elective surgery "hubs" for streamlined delivery of elective care needs to be established in an expeditious fashion, either due to the COVID-19 pandemic or any other future pandemics.

The Impact of COVID-19 on Surgical Training: the Past, the Present and the Future

The COVID-19 pandemic and infection control measures had an unavoidable impact on surgical services. During the first wave of the pandemic, elective surgery, endoscopy, and 'face-to-face' clinics were discontinued after recommendations from professional bodies. In addition, training courses, examinations, conferences, and training rotations were postponed or cancelled. Inadvertently, infection control and prevention measures, both within and outside hospitals, have caused a significant negative impact on training. At the same time, they have given space to new technologies, like telemedicine and platforms for webinars, to blossom. While the recovery phase is well underway in some parts of the world, most surgical services are not operating at full capacity. Unfortunately, some countries are still battling a second or third wave of the pandemic with severely negative consequences on surgical services. Several studies have looked into the impact of COVID-19 on surgical training. Here, an objective overview of studies from different parts of the world is presented. Also, evidence-based solutions are suggested for future surgical training interventions.

The impact of coronavirus 2019 on trauma

PURPOSE OF REVIEW

The relationship between trauma and the ongoing global coronavirus 2019 (COVID-19) pandemic is still largely unclear. This comprehensive review of recent studies examining overall trauma volumes, mechanisms of injury, and outcomes after trauma during the COVID-19 pandemic was performed to better understand the impact of the pandemic on trauma patients.

RECENT FINDINGS

In the early stages of the pandemic, the overall volumes of patients seen in many major trauma centers had decreased; however, these rates largely returned to historical baselines after the cessation of stay-at-home orders. An increasing proportion of trauma patients were injured by penetrating mechanisms during the pandemic. Being a victim of interpersonal violence was an independent risk factor for COVID-19 infection. In two studies utilizing propensity score-matched analysis among trauma patients, COVID-19 infection was associated with a five- to sixfold increase in mortality risk as compared to uninfected patients.

SUMMARY

Consequences of the COVID-19 pandemic include increased financial stressors, job loss, mental illness, and illegal drug use, all of which are known risk factors for trauma. This is particularly true among vulnerable patient populations such as racial minority groups and low socioeconomic status patients. To lessen the impact of COVID-19 on trauma patients, increased awareness of the problem and heightened emphasis on injury prevention must be made.

Establishing a COVID-secure site for elective surgery during the COVID pandemic: An observational study

INTRODUCTION

Maintaining timely and safe delivery of major elective surgery during the COVID-19 pandemic is essential to manage cancer and time-critical surgical conditions. Our NHS Trust established a COVID-secure elective site with a level 2 Post Anaesthetic Care Unit (PACU) facility. Patients requiring level 3 Intensive Care Unit admission were transferred to a non-COVID-secure site. We investigated the relationship between perioperative anaesthetic care and outcomes.

MATERIALS AND METHODS

All consecutive patients undergoing major surgery at the COVID-secure site between June and November 2020 were included. Patient demographics, operative interventions and 30-day outcomes were recorded. Multivariate logistic regression was used to determine the odds ratio of outcomes according to PACU length of stay and the use of spinal or epidural anaesthesia, with age, sex, malignancy status and American Society of Anesthesiologists grade as independent co-variables.

RESULTS

There were 280 patients. PACU length of stay >23h was associated with increased 30-day complications. Epidural anaesthesia was associated with PACU length of stay >23h, increased total length of stay, increase hospital transfer and 30-day complications. Two patients acquired nosocomial COVID-19 following hospital transfer.

DISCUSSION

Establishing a separate COVID-secure site has facilitated delivery of major elective surgery during the COVID-19 pandemic. Choice of perioperative anaesthesia and utilisation of PACU appear likely to affect the risk of adverse outcomes.

Minimally invasive esophagectomy for cancer in COVID hospitals and oncological hubs: are the outcomes different?

Introduction

The outbreak of coronavirus disease 2019 (COVID-19) has caused significant delays in oncological care worldwide due to restriction of elective surgery and intensive care unit capacity. It has been hypothesized that COVID-free oncological hubs can provide safer elective cancer surgery compared to COVID hospitals. The primary aim of the present study was to analyze the outcomes of minimally invasive esophagectomy for cancer performed in both hospital settings by the same surgical staff.

Methods

All esophagectomies for cancer performed during the pandemic by a single team were reviewed and data were compared with control patients operated during the preceding year. Screening for severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) was performed prior to surgery, and special precautions were taken to mitigate hospital-related transmission of COVID-19 among patients and healthcare workers.

Results

Compared to the prepandemic period, the esophagectomy volume decreased by 64%. Comorbidities, time from onset of symptoms to first visit, waiting time between diagnosis and surgery, operative approach and technique, and the pathological staging were similar. None of the patients tested positive for COVID-19 during in-hospital stay, and esophagectomy was associated with similar outcomes compared to control patients.

Conclusion

Outcomes of minimally invasive esophagectomy for cancer performed in a COVID hospital after implementation of a COVID-free surgical pathway did not differ from those obtained in an oncological hub by the same surgical team.

Can patients with asymptomatic SARS-CoV-2 infection safely undergo elective surgery?

Current or recent infection with SARS-CoV-2 increases the risk of perioperative morbidity and mortality. Consensus guidelines recommend delaying elective major surgery after acute SARS-CoV-2 infection for 7 or 8 weeks. However, because of the growing backlog of untreated surgical disease and the potential risks of delaying surgery, surgical services may be under pressure to reduce this period. Here, we discuss the risks and benefits of delaying surgery for patients with current or recent SARS-CoV-2 infection in the context of the evolving COVID-19 pandemic, the limited evidence supporting delays to surgery, and the need for more research in this area.

The comparison of Post-Operative Complications pre Covid era versus during Covid-Era based on Clavien-Dindo-classification: A Systematic Review and Meta-Analysis.. [DOI: 10.1101/2022.02.25.22271519]

Introduction

Coronavirus Disease 2019 (COVID -19) pandemic challenged the healthcare system drastically, and it was concomitant with a remarkable decline in surgeries and modified routine care of patients worldwide. This systematic review and meta-analysis aimed to compare the surgical complications before COVID -19 (Pre-COVID) and after COVID -19 (post-COVID) appearance using the Clavien-Dindo classification (CDC).

Methods

between January 1, 2019, to November 3, 2021, we performed a comprehensive search in PubMed/Medline and Scopus for studies reporting the postoperative complications based on/transformable to CDC.

Result

From 909 screened articles, 34 studies were included for systematic review. Among included articles, 11 were eligible for meta-analysis. Nineteen thousand one hundred thirty-seven patients (pre-COVID: 3522, post-COVID: 15615) were included, mostly undergoing elective surgeries (86.32%). According to CDC classification, there were no significant change between pre-COVID and post-COVID for grade 1 (Odds ratio (OR) and 95% confidence interval (95-CI): 0.99, 0.60-1.63, p=0.96), grade 2 (OR and 95-CI: 0.65, 0.42-1.01, p = 0.055), grade 3 (OR and 95-CI: 0.86, 0.48-1.57, p=0.64), grade 4 (OR and 95-CI: 0.85, 0.46-1.57, p =0.60). However, the postoperative mortality was lower before the COVID -19 outbreak (OR and 95-CI: 0.51, 0.27-0.95, p= 0.035). The included studies for systematic review and meta-analysis had a low risk of bias and unsignificant publication bias.

Conclusion

Although delivering routine surgery was challenging, the postoperative complications during the pandemic remained identical to the pre-pandemic era. The stricter patient selection tending to choose more critical states and more advanced clinical stages of the operated patients may explain some extent of higher mortality during the pandemic. Adopting preventive strategies helped deliver surgeries during the outbreak of COVID -19 while limiting the capacity of operations and admissions.

Has the COVID-19 Pandemic Affected Breast Cancer Stage and Surgical Volume?

Background

This study investigates the effects of COVID-19 on the breast cancer stage and the volume of breast cancer surgery in a specialized breast institute.

Methods

Data of 332 patients who were diagnosed and treated for breast cancer between December 2019 and November 2020 were evaluated retrospectively according to periods of pandemic.

Results

A significant decrease in the number of operations, especially upfront surgeries rather than surgeries after neoadjuvant chemotherapy, was detected in the early period of the COVID-19 pandemic. It was found that patients with complaints were mostly admitted during this period (p = 0.024). No statistical significance was found for age, sex, side of the tumor, type of tumor, surgery to breast, and axilla. Following the early period of the pandemic, it was observed that patients with mostly luminal, early-stage, and less axillary nodal involvement (p < 0.05) were admitted, and as a result, it was founded that upfront surgeries increased, although no change in TNM staging was observed. However, it did affect the decision of initial treatment. Thus, the number of upfront surgeries was significantly higher than the NCT group (p = 0.027) following the early period.

Conclusion

Surgical volume is significantly affected in the early period of the COVID-19 pandemic. To overcome overload due to delayed surgeries related to pandemics, some hospitals should be spared for oncological treatments. Following the early period, mostly luminal type, early-stage patients were admitted, probably because of increased self-awareness and short wave duration, but the breast cancer stage was not affected.

Oncological Surgery During the COVID-19 Pandemic: Effectiveness of Preoperative Screening and Factors Associated with Postoperative SARS-CoV-2 Infection

Background

Routine preoperative screening of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with reverse transcriptase-polymerase chain reaction (RT-PCR) may reduce in-hospital SARS-CoV-2 transmission.

Methods

This was a prospective, observational, cohort study. The endpoints were the incidence of asymptomatic patients with positive preoperative RT-PCR results and the incidence and factors associated with postoperative SARS-CoV-2 infection in patients with cancer referred for elective surgery. Patients with elective surgery between May and October 2020 were included. RT-PCR of nasopharyngeal swabs was performed preoperatively for all patients. Postoperative SARS-CoV-2 infection was assessed within 30 postoperative days.

Results

A total of 1636 preoperative screening RT-PCR tests were performed. Of these, 102 (6.2%) cases were positive, and 1,298 surgical procedures were analyzed. The postoperative SARS-CoV-2 infection rate was 0.9%. The length of stay (odds ratio [OR] 1.08; 95% confidence interval [CI] 1.04–1.11; p < 0.001), surgical time (OR 1.004; 95% CI 1.001–1.008; p = 0.023), intensive care unit admission (OR 7.7; 95% CI 2.03–29.28; p = 0.003), and hospital readmissions (OR 9.56; 95% CI 2.50–36.56; p = 0.001) were associated with postoperative coronavirus disease (COVID-19). Using unadjusted and adjusted logistic regression, length of stay (OR 1.08; 95% CI 1.04–1.11; p < 0.001), and readmission (OR 9.02; 95% CI 2.30–35.48; p = 0.002) were independent factors of postoperative COVID-19.

Conclusions

Screening patients preoperatively may reduce in-hospital SARS-CoV-2 transmission. Length of stay and readmission were independently correlated with postoperative COVID-19.

Surgical safety in the COVID-19 era: present and future considerations

The impacts of coronavirus disease 2019 (COVID-19) have been globally paradigm shifting in all aspects. Surgeons have experienced unprecedented changes regarding operation schedules, preparations before surgery, and the precautions needed both during and after surgery. Many medical centers simultaneously reported a decrease in their numbers of surgeries, whether they were elective or emergent, or for cancerous or benign resections. However, accumulated surgical outcomes from the last 2 years of experience presented postoperative morbidity and mortality data that were comparable to the pre-pandemic era, whether in elective or urgent settings. Although COVID-19 showed a significant association with postoperative morbidity and mortality, the majority of noninfected patients could be treated successfully with stringent mitigation protocols. Initially recommended to be avoided at the start of the pandemic, minimally invasive surgery seems to be safe and feasible according to reported surgical outcomes. Numerous sets of guidelines have now been produced from medical societies and adhering to the basic precautions has been found to be practicable. It is crucial that health care systems and surgical staff remain vigilant and attentive to the ever-changing situation in this pandemic in order to provide optimal medical support to their patients.

Thyroid surgery during the COVID-19 pandemic: results from a systematic review

PURPOSE

During the COVID-19 pandemic, elective thyroid surgery is experiencing delays. The problem is that the COVID-19 pandemic is ongoing. The research purposes were to systematically collect the literature data on the characteristics of those thyroid operations performed and to assess the safety/risks associated with thyroid surgery during the COVID-19 pandemic.

METHODS

We used all the procedures consistent with the PRISMA guidelines. A comprehensive literature in MEDLINE (PubMed) and Scopus was made using ''Thyroid'' and "coronavirus" as search terms.

RESULTS

Of a total of 293 articles identified, 9 studies met the inclusion criteria. The total number of patients undergoing thyroid surgery was 2217. The indication for surgery was malignancy in 1347 cases (60.8%). Screening protocols varied depending on hospital protocol and maximum levels of personal protection equipment were adopted. The hospital length of stay was 2-3 days. Total thyroidectomy was chosen for 1557 patients (1557/1868, 83.4%), of which 596 procedures (596/1558, 38.3%) were combined with lymph node dissections. Cross-infections were registered in 14 cases (14/721, 1.9%), of which three (3/721, 0.4%) with severe pulmonary complications of COVID-19. 377 patients (377/1868, 20.2%) had complications after surgery, of which 285 (285/377, 75.6%) hypoparathyroidism and 71 (71/377, 18.8%) recurrent laryngeal nerve injury.

CONCLUSION

The risk of SARS-CoV-2 transmission after thyroid surgery is relatively low. Our study could promote the restart of planned thyroid surgery due to COVID-19. Future studies are warranted to obtain more solid data about the risk of complications after thyroid surgery during the COVID-19 era.

British Gynaecological Cancer Society recommendations for women with gynecological cancer who received non-standard care during the COVID-19 pandemic

During the COVID-19 pandemic, pressures on clinical services required adaptation to how care was prioritised and delivered for women with gynecological cancer. This document discusses potential 'salvage' measures when treatment has deviated from the usual standard of care. The British Gynaecological Cancer Society convened a multidisciplinary working group to develop recommendations for the onward management and follow-up of women with gynecological cancer who have been impacted by a change in treatment during the pandemic. These recommendations are presented for each tumor type and for healthcare systems, and the impact on gynecological services are discussed. It will be important that patient concerns about the impact of COVID-19 on their cancer pathway are acknowledged and addressed for their ongoing care.

Assigning green hospitals during the COVID-19 pandemic assure continuous and safe resumption of surgical services

Background

Coronavirus 19 pandemic impacted the health system with more pressure on the critical areas, leading to direct manpower working in the Operating Room to help treat this new problem by postponing elective surgical cases and affecting some urgent ones. However, elective surgical services start to recover by establishing one or more hospitals that deal with COVID-19 free patients (green hospital) in each area with a dedicated one to treat COVID19 cases. Our research shows if this model's application assures safe and continued recovery of surgical services to reach the level before the pandemic. This study aimed to explore if assigning a green hospital to assure safe and continuous resumption of surgical services during a pandemic.

Methods

This study used a multicenter, national, quasi-experimental, post-test-only control group design. All hospitals assigned at least one hospital as a green hospital (COVID-19 free hospital) in the northern areas of Saudi Arabia were included in the study. We also included Riyadh's large tertiary care hospital as a control none green hospital. We reported the number of surgical backlog in each city, the number of surgical cases performed, the percentage of OR utilization in each city and the percentage of COVID-19 cases to the number of ICU bed cases in each city.

Results

This study included green hospitals in five cities in the northern area of Saudi Arabia. Besides, we included one none large green hospital in Riyadh city as a control group. The median of weekly procedures in green hospitals was 101 (99, 109.5) in Alqurayat, 233 (194, 237) in Tabuk, 180 (162, 199) in Haill, 108 (90, 120) in Al Jawf and 257 (155, 313) in Northern Borders. The median of weekly procedures in the control hospital was 245 (215, 259). Green hospitals contributed to reducing the surgical backlog by a median percentage of 74% (38, 108) in Alqurayat, 25% (21, 26) in Tabuk, 8% (7, 9) in Haill, 81% (54, 91) in Al Jawf and 78% (72, 88) in Northern Borders. While in the control hospital was 8% (8, 9).

Conclusion

Implementing elective surgeries in green hospitals contributes to a continuous resumption of surgical services during the COVID-19 pandemic.

•

The pandemic of COVID-19 impacted the healthcare system, delaying elective surgical cases, certain urgent procedures, and increasing the surgical backlog.

•

Surgical patients are vulnerable to being exposed to SARS-CoV-2 transmission in hospitals.

•

Assigning a COVID-19-free-hospital (green hospital) may assure safe and continued recovery of surgical services.

Characteristics and patterns of care of endometrial cancer before and during COVID-19 pandemic

Objective

Coronavirus disease 2019 (COVID-19) outbreak has correlated with the disruption of screening activities and diagnostic assessments. Endometrial cancer (EC) is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms. Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of EC patients.

Methods

This is a retrospective study involving 54 centers in Italy. We evaluated patterns of presentation and treatment of EC patients before (period 1: March 1, 2019 to February 29, 2020) and during (period 2: April 1, 2020 to March 31, 2021) the COVID-19 outbreak.

Results

Medical records of 5,164 EC patients have been retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. Surgery was the mainstay of treatment in both periods (p=0.356). Nodal assessment was omitted in 689 (27.3%) and 484 (21.2%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.7% in period 1 vs. 52.8% in period 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during COVID-19 pandemic (p<0.001).

Conclusion

Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic.

The prevalence of patients with early-stage endometrial cancer (EC) has been lower during coronavirus disease 2019 (COVID-19) pandemic than before its onset. Further evidence is needed to assess the impact of COVID-19 pandemic on survival outcomes of EC patients.

Impact of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients: a nationwide study in Spain

OBJECTIVE

To assess the effect of the first wave of the SARS-CoV-2 pandemic on the outcome of neurosurgical patients in Spain.

SETTINGS

The initial flood of COVID-19 patients overwhelmed an unprepared healthcare system. Different measures were taken to deal with this overburden. The effect of these measures on neurosurgical patients, as well as the effect of COVID-19 itself, has not been thoroughly studied.

PARTICIPANTS

This was a multicentre, nationwide, observational retrospective study of patients who underwent any neurosurgical operation from March to July 2020.

INTERVENTIONS

An exploratory factorial analysis was performed to select the most relevant variables of the sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

Univariate and multivariate analyses were performed to identify independent predictors of mortality and postoperative SARS-CoV-2 infection.

RESULTS

Sixteen hospitals registered 1677 operated patients. The overall mortality was 6.4%, and 2.9% (44 patients) suffered a perioperative SARS-CoV-2 infection. Of those infections, 24 were diagnosed postoperatively. Age (OR 1.05), perioperative SARS-CoV-2 infection (OR 4.7), community COVID-19 incidence (cases/10⁵ people/week) (OR 1.006), postoperative neurological worsening (OR 5.9), postoperative need for airway support (OR 5.38), ASA grade ≥3 (OR 2.5) and preoperative GCS 3-8 (OR 2.82) were independently associated with mortality. For SARS-CoV-2 postoperative infection, screening swab test <72 hours preoperatively (OR 0.76), community COVID-19 incidence (cases/10⁵ people/week) (OR 1.011), preoperative cognitive impairment (OR 2.784), postoperative sepsis (OR 3.807) and an absence of postoperative complications (OR 0.188) were independently associated.

CONCLUSIONS

Perioperative SARS-CoV-2 infection in neurosurgical patients was associated with an increase in mortality by almost fivefold. Community COVID-19 incidence (cases/10⁵ people/week) was a statistically independent predictor of mortality.

TRIAL REGISTRATION NUMBER

CEIM 20/217.

Gastrointestinal manifestations in COVID-19

Coronavirus disease 2019 (COVID-19), a respiratory viral infection, has affected more than 78 million individuals worldwide as of the end of December 2020. Previous studies reported that severe acute respiratory syndrome coronavirus 1 and Middle East respiratory syndrome-related coronavirus infections may affect the gastrointestinal (GI) system. In this review we outline the important GI manifestations of COVID-19 and discuss the possible underlying pathophysiological mechanisms and their diagnosis and management. GI manifestations are reported in 11.4-61.1% of individuals with COVID-19, with variable onset and severity. The majority of COVID-19-associated GI symptoms are mild and self-limiting and include anorexia, diarrhoea, nausea, vomiting and abdominal pain/discomfort. A minority of patients present with an acute abdomen with aetiologies such as acute pancreatitis, acute appendicitis, intestinal obstruction, bowel ischaemia, haemoperitoneum or abdominal compartment syndrome. Severe acute respiratory syndrome coronavirus 2 RNA has been found in biopsies from all parts of the alimentary canal. Involvement of the GI tract may be due to direct viral injury and/or an inflammatory immune response and may lead to malabsorption, an imbalance in intestinal secretions and gut mucosal integrity and activation of the enteric nervous system. Supportive and symptomatic care is the mainstay of therapy. However, a minority may require surgical or endoscopic treatment for acute abdomen and GI bleeding.

Impact of COVID-19 Pandemic on Cancer Surgical Services-AIIMS, New Delhi Experience

COVID pandemic has impacted cancer care delivery and cancer surgical services globally. There is an urgent need to study the extent of the impact of COVID on cancer surgery and individual institutional response and strategies adopted to counter the adverse impact. A review of administrative and clinical policy changes adopted at the tertiary cancer center to combat COVID pandemic and resume cancer surgical services were performed. A retrospective comparative analysis of cancer out-patient census during COVID pandemic affected year and the preceding normal year along with cancer surgery data audit for the same periods was performed to assess the impact of the pandemic on cancer surgery. In addition, COVID infection rates among cancer surgery patients and healthcare workers were evaluated. There was approximately a 50% reduction in cancer outpatient registrations during COVID pandemic affected year. A trend of increasing footfalls was noted with decreasing COVID intensity and opening of lockdowns. There was a 33% reduction in major elective surgery and a 41% reduction in emergency surgery performed during the COVID period. As far as cancer surgeries are concerned, there was a 12-50% reduction in volumes involving different subsites. Overall COVID positivity rates among cancer surgery patients was low (8.17%), and approximately 30% of healthcare workers involved in cancer surgery were tested positive for COVID during the study period. Results of the current study indicate a significant impact of COVID pandemic on cancer surgical services. There was a significant impact on outpatient visits and cancer surgery volumes. However, a multidisciplinary-coordinated team approach, effective administrative and policy implementation, adoption of revised surgical safety and anesthesia protocols, COVID screening, and testing protocols facilitated resumption of cancer surgical services without adverse impact on surgical outcomes.

Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic

BACKGROUND

This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

METHODS

This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January-October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection.

RESULTS

This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001).

CONCLUSION

Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

Outcomes after perioperative SARS-CoV-2 infection in patients with proximal femoral fractures: an international cohort study

OBJECTIVES

Studies have demonstrated high rates of mortality in people with proximal femoral fracture and SARS-CoV-2, but there is limited published data on the factors that influence mortality for clinicians to make informed treatment decisions. This study aims to report the 30-day mortality associated with perioperative infection of patients undergoing surgery for proximal femoral fractures and to examine the factors that influence mortality in a multivariate analysis.

SETTING

Prospective, international, multicentre, observational cohort study.

PARTICIPANTS

Patients undergoing any operation for a proximal femoral fracture from 1 February to 30 April 2020 and with perioperative SARS-CoV-2 infection (either 7 days prior or 30-day postoperative).

PRIMARY OUTCOME

30-day mortality. Multivariate modelling was performed to identify factors associated with 30-day mortality.

RESULTS

This study reports included 1063 patients from 174 hospitals in 19 countries. Overall 30-day mortality was 29.4% (313/1063). In an adjusted model, 30-day mortality was associated with male gender (OR 2.29, 95% CI 1.68 to 3.13, p<0.001), age >80 years (OR 1.60, 95% CI 1.1 to 2.31, p=0.013), preoperative diagnosis of dementia (OR 1.57, 95% CI 1.15 to 2.16, p=0.005), kidney disease (OR 1.73, 95% CI 1.18 to 2.55, p=0.005) and congestive heart failure (OR 1.62, 95% CI 1.06 to 2.48, p=0.025). Mortality at 30 days was lower in patients with a preoperative diagnosis of SARS-CoV-2 (OR 0.6, 95% CI 0.6 (0.42 to 0.85), p=0.004). There was no difference in mortality in patients with an increase to delay in surgery (p=0.220) or type of anaesthetic given (p=0.787).

CONCLUSIONS

Patients undergoing surgery for a proximal femoral fracture with a perioperative infection of SARS-CoV-2 have a high rate of mortality. This study would support the need for providing these patients with individualised medical and anaesthetic care, including medical optimisation before theatre. Careful preoperative counselling is needed for those with a proximal femoral fracture and SARS-CoV-2, especially those in the highest risk groups.

TRIAL REGISTRATION NUMBER

NCT04323644.