The impact of COVID-19 on surgical procedures in Japan: analysis of data from the National Clinical Database

Surgical antimicrobial prophylaxis in Japanese hospitals: Real status and challenges

BACKGROUND

Information regarding the status of surgical antimicrobial prophylaxis (SAP) in Japanese hospitals is lacking. This study aimed to explore the status of SAP prescriptions for surgeries and adherence to Japanese SAP guidelines.

METHODS

From February to July 2020, a 1-day multicentre point prevalent survey was conducted at 27 hospitals in Aichi Prefecture, Japan. Patients prescribed SAP were included in this study. The appropriateness of the SAP was evaluated based on the guidelines for selection of antimicrobials and their duration. Surgery was defined as appropriate when all the items were appropriate.

RESULTS

A total of 728 patients (7.1 %; 728/10,199) received antimicrobials for SAP. Among them, 557 patients (76.5 %, 557/728) underwent the surgeries described in the guidelines. The overall appropriateness of all surgeries was 33.9 % (189/557). The appropriate selection of antimicrobial before/during and after surgery and their durations were 67.5 % (376/557), 67.5 % (376/557), and 43.3 % (241/557), respectively. The overall appropriateness ranged from 0 % (0/37, oral and maxillofacial surgery) to 58.7 % (88/150, orthopaedic surgery) and 27.7 % (36/130, community hospitals with 400-599 beds) to 47.2 % (17/36, specific hospitals). Cefazolin was the most prevalent antimicrobial prescribed before/during (55.5 %, 299/539), and after (45.1 %, 249/552) surgery. In total, 101 oral antimicrobials were prescribed postoperatively.

CONCLUSIONS

SAP adherence by specific surgical fields and hospitals was shown in this study. Intensive intervention and repeated surveillance are necessary to improve SAP prescriptions in Japanese hospitals.

Impact of the coronavirus disease 2019 pandemic on primary and metastatic lung cancer treatments in Japan: A nationwide study using an interrupted time series analysis

BACKGROUND

The coronavirus disease 2019 pandemic prompted healthcare providers to use different approaches from the current standards of care. We aimed to identify the changes in the number of treatments for primary non-small cell lung cancer (NSCLC) and metastatic lung cancer during the pandemic.

METHODS

We used nationwide insurance claims data from January 2015 to January 2021, and estimated changes in the number of treatments using an interrupted time series analysis.

RESULTS

The number of surgical resections for primary NSCLC significantly decreased in April 2020 (-888; 95% confidence interval [CI]: -1530 to -246) and July 2020 (-1314; 95% CI: -1935 to -694), while the number of stereotactic body radiotherapies (SBRTs) increased in April 2020 (95; 95% CI: 8-182) and July 2020 (111; 95% CI: 24-198). The total number of treatments for primary NSCLC remained unchanged; however, non-significant decreases were observed in 2020. The number of surgical resections for metastatic lung cancer significantly decreased in April 2020 (-201; 95% CI: -337 to -65), but it eventually increased in July 2020 (170; 95% CI: 32-308). Additionally, the number of SBRTs significantly increased in April 2020 (37; 95% CI: 3-71) and October 2020 (57; 95% CI: 23-91). The total number of treatments for metastatic lung cancer was maintained, with an initial decrease in April 2020 followed by a subsequent increase in July and October 2020.

CONCLUSION

In Japan, surgical triage for primary and metastatic lung cancer are likely to have been implemented during the pandemic. Despite these proactive measures, patients with primary NSCLC may have been untreated, likely owing to their undiagnosed disease, potentially leading to a deterioration in prognosis. By contrast, patients diagnosed with cancer prior to the pandemic are presumed to have received standard management throughout the course of the pandemic.

Effects of the COVID-19 pandemic on short-term postoperative outcomes for colorectal perforation: A nationwide study in Japan based on the National Clinical Database

Aim

Possible negative effects of the COVID-19 pandemic on short-term postoperative outcomes for colorectal perforation in Japan were examined in this study.

Methods

The National Clinical Database (NCD) is a large-scale database including more than 95% of surgical cases in Japan. We analyzed 13 107 cases of colorectal perforation from 2019 to 2021. National data were analyzed, and subgroup analyses were conducted for subjects in prefectures with high infection levels (HILs) and metropolitan areas (Tokyo Met. and Osaka Pref.). Postoperative 30-day mortality, surgical mortality, and postoperative complications (Clavien-Dindo grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1.

Results

In the NCD, postoperative 30-day mortality occurred in 1371 subjects (10.5%), surgical mortality in 1805 (13.8%), and postoperative complications in 3950 (30.1%). Significantly higher SMRs were found for 30-day mortality in November 2020 (14.6%, 1.39 [95% CI: 1.04-1.83]) and February 2021 (14.6%, 1.48 [95% CI: 1.10-1.96]), and for postoperative complications in June 2020 (37.3%, 1.28 [95% CI: 1.08-1.52]) and November 2020 (36.4%, 1.21 [95% CI: 1.01-1.44]). The SMRs for surgical mortality were not significantly high in any month. In prefectures with HILs and large metropolitan areas, there were few months with significantly higher SMRs.

Conclusions

The COVID-19 pandemic had limited negative effects on postoperative outcomes in patients with colorectal perforation. These findings suggest that the emergency system for colorectal perforation in Japan was generally maintained during the pandemic.

Changes in the place of death before and during the COVID-19 pandemic in Japan

BACKGROUND

In the global aging, the coronavirus disease 2019 (COVID-19) pandemic may have affected the place of death (PoD) in Japan, where hospital deaths have dominated for decades. We analyzed the PoD trends before and during the COVID-19 pandemic in Japan.

METHODS

This nationwide observational study used vital statistics based on death certificates from Japan between 1951 and 2021. The proportion of PoD; deaths at home, hospitals, and nursing homes; and annual percentage change (APC) were estimated using joinpoint regression analysis. Analyses were stratified by age groups and causes of death.

RESULTS

After 2019, home deaths exhibited upward trends, while hospital death turned into downward trends. By age, no significant trend change was seen in the 0-19 age group, while hospital deaths decreased in the 20-64 age group in 2019. The trend change in home death in the ≥65 age group significantly increased since 2019 with an APC of 12.3% (95% confidence interval [CI]: 9.0 to 15.7), while their hospital death trends decreased by -4.0% (95% CI: -4.9 to -3.1) in 2019-2021. By cause of death, home death due to cancer and the old age increased since 2019 with an APC of 29.3% (95% CI: 25.4 to 33.2) and 8.8% (95% CI: 5.5 to 12.2), respectively.

CONCLUSION

PoD has shifted from hospital to home during the COVID-19 pandemic in Japan. The majority of whom were older population with cancer or old age.

Impact of COVID-19 pandemic on short-term outcomes after low anterior resection in patients with rectal cancer: Analysis of data from the Japanese National Clinical Database

Aim

The Coronavirus Disease 2019 (COVID-19) pandemic affected the allocation of various medical resources to several areas, including intensive care units (ICUs). However, currently, its impact on the short-term postoperative outcomes of gastrointestinal cancer surgeries remains unclear. We aimed to evaluate the impact of the pandemic on the incidence of complications occurring after low anterior resection in patients with rectal cancer in Japan.

Methods

Data from the Japanese National Clinical Database between 2018 and 2021 were retrospectively examined. The primary outcome of the study was the postoperative morbidity and mortality rates before and after COVID-19 pandemic. Moreover, the postoperative ICU admission rate was assessed. Morbidity and mortality rates were also assessed using a standardized morbidity/mortality ratio (SMR, the ratio of the actual number of incidences to the expected number of incidences calculated by the risk calculator).

Results

This study included 74 181 patients, including 43 663 (58.9%) from COVID-19 epidemic areas. The mean actual incidences of anastomotic leakage (AL) and pneumonia during the study period were 9.2% and 0.9%, respectively. The SMRs of these complications did not increase during the pandemic but those of AL declined gradually. The mean 30-day mortality and operative mortality rates were 0.3% and 0.5%, respectively. Moreover, SMRs did not change significantly in the pandemic or regional epidemic status. The ICU admission rate temporarily decreased, especially in the epidemic areas.

Conclusion

Although the pandemic temporarily decreased the ICU admission rate, its impact on short-term outcomes following low anterior resection in patients with rectal cancer was insignificant in Japan.

Impact of the coronavirus disease 2019 pandemic on gastric and colorectal cancer surgeries: a multicenter epidemiologic study from the Kinki region of Japan

The coronavirus disease 2019 pandemic affected cancer surgeries and advanced cancer diagnoses; however, the trends in patient characteristics in medical institutions during this time, and the surgical approaches used are unclear. We investigated the impact of the pandemic on gastric and colorectal cancer surgeries in the Kinki region of Japan. We grouped 1688 gastric and 3493 colorectal cancer surgeries into three periods: "pre-pandemic" (April 2019-March 2020), "pandemic 1" (April 2020-March 2021), and "pandemic 2" (April 2021-September 2021), to investigate changes in the number of surgeries, patient characteristics, surgical approaches, and cancer progression after surgery. Gastric and colorectal cancer surgeries decreased from the pre-pandemic levels, by 20% and 4%, respectively, in pandemic 1, and by 31% and 19%, respectively, in pandemic 2. This decrease had not recovered to pre-pandemic levels by September, 2021. Patient characteristics, surgical approaches, and cancer progression of gastric and colorectal surgeries did not change remarkably as a result of the coronavirus disease 2019 pandemic.

Impact of the coronavirus disease 2019 pandemic on 20 representative surgical procedures in Japan based on the National Clinical Database: annual surveillance of 2021 by the Japan Surgical Society

PURPOSE

The volume of surgical services has significantly reduced globally due to the coronavirus disease 2019 (COVID-19) pandemic. This study evaluated the level of recovery in terms of the number of operations performed in Japan in 2021, based on nationwide periodic surveillance.

METHODS

Information on the weekly and annual volumes of 20 representative procedures in 6 surgical subspecialties in 2021 was extracted from the National Clinical Database. Statistical data for 2018 and 2019 (pre-pandemic era) were compared with those for 2020. Data on waves of infection, peak period, and high-prevalence areas (13 of 47 prefectures) were analyzed individually.

RESULTS

The volumes of the 10 procedures, including gastrectomy, hepatectomy, valve replacement and valve plasty, coronary artery bypass grafting, infrarenal abdominal aorta replacement, ventricular septal defect closure, lung lobectomy, inguinal hernia repair (age < 16 years old), and appendectomy (age < 16 years old), did not reach 95% of that in the pre-pandemic era. The most striking decline in the surgical volume of these 10 procedures was observed during the peak period of wave 5 in high-prevalence areas.

CONCLUSION

This near-complete enumeration survey identified the polarization of 20 representative procedures in terms of resumption of surgical service after the pandemic.

The impact of COVID-19 for postoperative outcomes using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer

Background

The coronavirus disease 2019 (COVID-19) pandemic had resulted in either failure to provide required medical resources or delayed treatment for gastric cancer patients. This study aimed to investigate the impact of COVID-19 on the incidence of postoperative complications using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer.

Methods

We collected the data of patients who underwent distal gastrectomy from January 2018 to December 2021 from the National Clinical Database (NCD), a web-based surgical registration system in Japan. The number of surgical cases, the use of intensive care units, and the incidence of morbidity per month were analyzed. We also calculated the standardized mortality ratio (SMR), defined as the ratio of the number of observed patients to the expected number of patients calculated using the risk calculator established in the NCD, for several morbidities, including pneumonia, sepsis, 30-day mortality, and surgical mortality.

Results

A decrease of 568 gastrectomies was observed from April 2020 to May 2020. Although the absolute number of patients admitted to intensive care units had declined since 2020, the proportion of patients admitted to the ICU did not change before and after the pandemic. Mortality and critical morbidity (such as pneumonia and sepsis) rates were not worse during the pandemic compared to pre-pandemic periods per the SMR.

Conclusions

Surgical management was conducted adequately through the organized efforts of the entire surgery department in our country even in a pandemic during which medical resources and staff may have been limited.

Analysis of the short-term outcomes after esophagectomy for esophageal cancer during the COVID-19 pandemic using data from a nationwide Japanese database

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had adversely impacted cancer screening, diagnosis, and treatment. We investigated the change in medical resource, such as the intensive care unit use, and short-term outcomes after esophagectomy during the pandemic.

METHODS

Data of patients who underwent esophagectomy for esophageal cancer registered in the National Clinical Database (NCD) in Japan from January 2018 to December 2021 were analyzed. The time series change in the number of surgical cases; usage of intensive care unit; incidence of morbidity and mortality; standardized mortality and morbidity ratio (SMR) for 30-days mortality; surgical mortality; and morbidities for pneumonia, sepsis, unplanned intubation, and anastomotic leakage were evaluated.

RESULTS

The annual number of patients undergoing esophagectomy remained similar from 2018 to 2021. The negative impact of the pandemic on medical resources was strongly identified in the patients from an epidemic area where there is a higher cumulative number of infections per population as compared to all prefectures. The proportions of patients admitted to the intensive care unit were 91.4%, 93.0%, 91.6%, and 90.5% in 2018, 2019, 2020, and 2021, respectively. Moreover, 93.3%, 94.0%, 92.0%, and 90.9% patients who underwent surgery in an epidemic area were admitted to the intensive care unit in 2018, 2019, 2020, and 2021, respectively. However, the morbidity and mortality rates during the pandemic did not worsen according to the SMR values.

CONCLUSIONS

Esophagectomy was performed during the pandemic despite limited medical resources by a systematic endeavor of the entire surgical department in Japan, without increasing the incidence rate of worse outcome.

What has changed? The impact of the COVID-19 pandemic on the management of acute biliary pancreatitis

BACKGROUND

The COVID-19 pandemic thoroughly changed the daily practices of medicine. We retrospectively evaluated the impact of the COVID-19 pandemic on our management strategies for patients with acute biliary pancreatitis (ABP).

METHODS

A total of 91 patients with ABP who were treated at Trakya University Faculty of Medicine between March 15, 2019 and March 15, 2021 were retrospectively recruited. Patients were classified as pre-COVID and COVID-era patients. The comorbidity markers, data from laboratory tests, inflammatory markers, and radiological examinations were evaluated. Length of stay, need for an intensive care unit, morbidity, mortality, recurrent ABP, and definitive treatment rates were evaluated, and the data of the two periods were compared.

RESULTS

Two groups of patients, 57 in the pre-COVID period and 34 in the COVID period, were included in the study. We found that ABP admissions decreased significantly during periods of increased national COVID-19 diagnoses. Type 2 diabetes mellitus was significantly higher in the COVID period patients (P=0.044), and COVID patients had significantly higher total (P=0.004), direct bili-rubin (P=0.007), and lipases (P<0.001). The cholecystectomy rate after an attack decreased from 26% in the pre-COVID period to 15.6% during COVID.

CONCLUSION

COVID strikingly reduced the admissions of ABP patients in the early stages of the disease to hospitals, leading to inevitable admissions in advanced severity. Moreover, a significant increase was detected in the recurrence rates of ABP. This can be explained by the reduction in cholecystectomy performed.

Maintaining early diagnosis of pancreatic adenocarcinoma in Japan: Local resilience against COVID-19

BACKGROUND AND AIMS

This study evaluated the impact of the coronavirus disease 2019 (COVID-19) pandemic on pancreatic adenocarcinoma (PA) practice in our region and discussed the effects of our institution's regional collaborative system, the "Early Stage Pancreatic Cancer Diagnosis Project," which was originally unrelated to this study's purpose.

METHODS

We retrospectively investigated 150 patients with PA at Yokohama Rosai Hospital by defining three time periods: before (C0), during the first year (C1), and during the second year (C2) of the COVID-19 pandemic.

RESULTS

Among the three periods (C0, C1, and C2), there were significantly less patients with stage I PA (14.0%, 0%, and 7.4%, p = 0.032) in C1, and significantly more patients with stage III PA (10.0%, 28.3%, and 9.3%, p = 0.014) in C1. The pandemic significantly prolonged the median durations from disease onset to patients' first visits (28, 49, and 14 days, p = 0.012). In contrast, there was no significant difference in the median durations from referral to first visit to our institution (4, 4, and 6 days, p = 0.391).

CONCLUSIONS

The pandemic advanced the stage of PA in our region. Although the pancreatic referral network remained functional during the pandemic, there were delays from disease onset to patients' first visit to healthcare providers, including clinics. While the pandemic caused temporary damage to PA practice, the routine regional collaboration provided by our institution's project allowed for early resilience. A notable limitation is that the impact of the pandemic on PA prognosis was not evaluated.

Impact of the COVID-19 pandemic on mortality trends in Japan: a reversal in 2021? A descriptive analysis of national mortality data, 1995-2021

OBJECTIVE

The COVID-19 pandemic led to an increase in mortality in most countries in 2020, deviating from prior decreasing trends. In Japan, however, mortality was suggested to decrease in 2020. This study investigated long-term mortality trends and cause-specific contributions, focusing on the period of the COVID-19 pandemic in Japan.

DESIGN

We analysed Japanese age-standardised mortality rates (ASMRs) from 1995 to 2021 using vital statistics.

MAIN OUTCOME MEASURES

The cause-specific annual ASMR changes were calculated in comparison with the previous year over the abovementioned period.

RESULTS

There was a general downward trend in overall ASMR for both sexes until 2020 followed by a small increase in 2021. In men, the all-cause ASMR (per 100 000 persons) decreased from 1352.3 to 1328.8 in 2020 (-1.74% from 2019), and increased to 1356.3 in 2021 in men (+2.07% from 2020). In women, the all-cause ASMR decreased from 746.0 to 722.1 in 2020 (-3.20% from 2019), and increased to 737.9 (+2.19% from 2020) in 2021. ASMRs from malignant neoplasms, pneumonia, accidents and suicide (men only) continued to decrease during the COVID-19 pandemic while the trend of cardiovascular mortality increased in 2021. Analysis of ASMR changes revealed that COVID-19, senility, cardiovascular disease and 'other causes not classified as major causes' contributed to the all-cause mortality increase in 2021.

CONCLUSIONS

In Japan, the decreasing trend in overall mortality continued in 2020 despite the COVID-19 pandemic. However, approximately 2% mortality increase was observed in 2021, which was attributable to COVID-19, senility, cardiovascular disease and 'other causes'. The year 2021 was a turning point of mortality trends in Japan, although continued monitoring is warranted.

The clinical impact of COVID-19 on endoscopic surgery in Japan: Analysis of data from the National Clinical Database

Aim

This study aimed to evaluate the impact of the coronavirus disease (COVID-19) pandemic on elective endoscopic surgeries in Japan using the National Clinical Database.

Methods

We retrospectively analyzed the clinicopathological factors and surgical outcomes of laparoscopic cholecystectomy (LC), laparoscopic distal gastrectomy (LDG), and laparoscopic low anterior resection (LLAR) and compared the monthly numbers of each procedure performed in 2020 with those in 2018 and 2019. The degree of infection in prefectures was classified into low and high groups.

Results

In 2020, the number of LCs (except for acute cholecystitis) was 76 079 (93.0% of that in 2019), the number of LDGs was 14 271 (85.9% of that in 2019), and the number of LLARs was 19 570 (88.1% of that in 2019). Although the number of robot-assisted LDG and LLAR cases increased in 2020, the growth rate was mild compared with that in 2019. There was little difference in the number of cases in the degree of infection in the prefectures. The numbers of LC, LDG, and LLAR cases decreased from May to June and recovered gradually. In late 2020, the proportion of T4 and N2 cases of gastric cancer and the number of T4 cases of rectal cancer increased compared with those in 2019. There was little difference between the proportions of postoperative complications and mortality in the three procedures between 2019 and 2020.

Conclusion

The number of endoscopic surgeries decreased in 2020 as a result of the COVID-19 pandemic. However, the procedures were performed safely in Japan.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study

BACKGROUND

Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours.

METHODS

In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186.

FINDINGS

Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039).

INTERPRETATION

Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation.

FUNDING

None.

Changes in colorectal cancer treatment during the COVID-19 pandemic in Japan: Interrupted time-series analysis using the National Database of Japan

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic forced us to accept changes in our usual diagnostic procedures and treatments for colorectal cancer. This study aimed to determine the impact of the pandemic on colorectal cancer treatment in Japan.

METHODS

The number of colorectal surgeries, stoma constructions, stent placements or long tube insertions, and neoadjuvant chemoradiotherapies were determined each month using sampling datasets from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. The observation periods before and during the pandemic were January 2015 to January 2020 and April 2020 to January 2021, respectively. An interrupted time-series analysis was used to estimate the changes in the number of procedures during the pandemic.

RESULTS

The number of endoscopic surgeries for colon cancer significantly decreased in April and July 2020 and for rectal cancer in April 2020. Additionally, the number of laparoscopic and open surgeries for colon cancer significantly decreased in July 2020 and October 2020, respectively. The number of stoma constructions and stent placements or long tube insertions did not increase during the observation period. Neoadjuvant chemoradiotherapy for rectal cancer significantly increased in April 2020 but levels returned shortly thereafter. These results suggest that the recommendations to overcome the pandemic proposed by expert committees, including the replacement of laparoscopic surgery with open surgery, stoma construction to avoid anastomotic leak, and replacement of surgery on the ileus with stent placement, were not widely implemented in Japan. However, as an exception, neoadjuvant chemoradiotherapy for rectal cancer was performed as an alternative treatment to delay surgery in small quantities.

CONCLUSION

A declining number of surgeries raises concerns about cancer stage progression; however, we found no evidence to suggest cancer progression from the trajectory of the number of stoma constructions and stent placements. In Japan, even during the pandemic, conventional treatments were performed.

Impact of coronavirus disease 2019 pandemic on breast cancer surgery using the National Database of Japan

Various countries have reported a decrease in breast cancer surgeries during the coronavirus disease 2019 (COVID-19) pandemic; however, inconsistent results have been reported in Japan. This study revealed changes in the number of surgeries during the pandemic using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) from January 2015 to January 2021, where insurance claims data from Japan as a whole are comprehensively accumulated. The number of breast-conserving surgeries (BCS) without axillary lymph node dissection (ALND) significantly decreased in July (- 846; 95% confidence interval (CI) - 1190 to - 502) and October 2020 (- 540; 95% CI - 861 to - 218). No decrease was observed for other types of surgery, BCS with ALND, and mastectomy with or without ALND. In the age-specific subgroup analysis, significant and transient reduction in BCS without ALND was observed in all age groups (0-49, 50-69, and ≥ 70 years). The number of BCS without ALND significantly decreased for a relatively short period in the early pandemic stages, suggesting reduced surgery for patients with a relatively low stage of cancer. Some patients with breast cancer might have been left untreated during the pandemic, and an unfavorable prognosis would be a concern.

Axillary Treatment Management in Breast Cancer during COVID-19 Pandemic (Association between ACOSOG Z0011 Criteria and OSNA Test)

The outbreak of the SARS-COVID-2 pandemic (COVID-19) had a significant effect on the organisation of healthcare systems. Surgical units saw a significant reduction in the volume of surgical procedures performed, with lengthening waiting lists as a consequence. We assessed the surgical activity in relation to breast cancer that took place at the University Hospital of Cagliari, Italy, from February 2018 to March 2022. Two phases were identified based on the epidemiological circumstances: Phase 1-February 2018 to February 2020; Phase 2-March 2020 to March 2022. The surgery performed in the two phases was then compared. All the patients in our sample underwent a breast surgical procedure involving a lymph node biopsy using OSNA associated with the ACOSOG Z0011 criteria. In the study period overall at our facility, there were 4214 procedures, 417 of which involved breast surgery. In Phase 2, 91 procedures were performed using the OSNA method and ACOSOG Z0011 criteria, enabling the intraoperative staging of axillary nodes. Axillary treatment in breast cancer using this approach resulted in a significant reduction in the number of reoperations for the radicalisation of metastatic sentinel lymph nodes.

Delayed Presentation and Referral Time from General Practitioners Contribute to Increased Complicated Appendicitis during the Initial COVID-19 Pandemic Period in Japan

Objectives

This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the situation of acute appendicitis (AA) with respect to patients' and general practitioners' behaviors in a general community hospital in Japan.

Methods

The surgical outcomes and periods from symptom onset to medical presentation besides practitioners' referral time for consecutive AA patients were compared between the control (January 2016 to March 2020) and COVID-19 periods (April 2020 to April 2021).

Results

Eighty-three patients who underwent emergency surgery for AA were reviewed. Complicated appendicitis significantly increased in the COVID-19 period (63.6% vs. 31.2%, P = 0.023). In the COVID-19 period, the time from symptom onset to the medical presentation (2.2 vs. 0.9 days, P < 0.001) was significantly longer than in the control period. Among the patients who first presented to a general practitioner, the referral time from the practitioner to our hospital was significantly longer in the COVID-19 period (1.6 vs. 0.7 days, P = 0.017). Furthermore, among patients with a fever of higher than 38°C at medical presentation, the time from symptom onset to medical presentation was significantly longer in the COVID-19 period (3.0 vs. 0.7 days, P = 0.015). There was no difference in severe postoperative complications.

Conclusions

Hesitation to seek surgical treatment for AA was seen in both the patients and practitioners in the COVID-19 period. The delay in surgical treatment presumably led to the increase in severe AA. In a pandemic era, timely care for emergent conditions is a crucial challenge.

Effects of the COVID ‐19 pandemic on gastroenterological surgeries in 2020: A study using the National Clinical Database of Japan

Aim

This study aimed to investigate the effect of the coronavirus disease pandemic on the number of surgeries for gastroenterological cancer cases in Japan.

Methods

The data recorded in the National Clinical Database of Japan between 2018 and 2020 were utilized for this study. Five specific surgeries for primary cancers and surgery for acute diffuse peritonitis were considered the primary endpoints. We divided the study period into the prepandemic and postpandemic (after April 2020) periods and examined the number of surgeries in relation to clinical factors.

Results

Overall, 228 860 surgeries were analyzed. Among the five primary cancer surgeries, the number of distal gastrectomies for gastric cancer decreased the most (to 81.0% of the monthly number in the prepandemic period), followed by that of low anterior resections for rectal cancer (91.4%). In contrast, the number of pancreaticoduodenectomies for pancreatic cancer increased by 7.1%, while that of surgeries for peritonitis remained stable. This trend was observed nationwide. We also noted a marked reduction in the number of distal gastrectomy (to 72.5%), low anterior resection (84.0%), and esophagectomy (88.8%) procedures for T1 tumors. The noncurative resection rate and mortalities were low despite the increased proportion of T4 tumors and older patients.

Conclusion

A marked reduction in surgeries for gastric and rectal cancers with early T factors may reflect prioritization of surgeries and reduction in cancer screenings. Although the quality of the surgery was maintained in terms of reduced mortalities and morbidities, the long-term effects of this pandemic should be monitored.

Association between COVID-19 incidence and postponement or cancellation of elective surgeries in Japan until September 2020: a cross-sectional, web-based survey

OBJECTIVES

This study aimed to examine whether and how the COVID-19 pandemic has affected the postponement or cancellation of elective surgeries in Japan.

DESIGN AND SETTING

A cross-sectional, web-based, self-administered survey was conducted nationwide from August 25 to September 30 2020. We used data from the Japan 'COVID-19 and Society' Internet Survey collected by a large internet research agency, Rakuten Insight, which had approximately 2.2 million qualified panellists in 2019.

PARTICIPANTS

From a volunteer sample of 28 000 participants, we extracted data from 3678 participants with planned elective surgeries on any postponement or cancellation of elective surgeries.

OUTCOME MEASURES

The main outcome measure was any postponement or cancelltion of elective surgeries. In addition, for all respondents, we extracted data on sociodemographic, health-related characteristics, psychological characteristics and prefectural-level residential areas. We used weighted logistic regression approaches to fulfil the study objectives, minimising potential bias relating to web-based surveys.

RESULTS

Of the 3678 participants, 431 (11.72%) reported experiencing postponement or cancellation of their elective surgeries. Notably, the participants living in prefectures where the declaration of the state of emergency was made on 7 April 2020 were significantly more likely to experience postponement or cancellation of elective surgeries than those residing in prefectures with the state of emergency beginning on 16 April 2020 (174 (26.02%) vs 153 (12.15%)).

CONCLUSIONS

The proportion of patients whose elective surgery had been postponed was limited during Japan's first wave of the COVID-19 pandemic, although the declaration of a state of emergency increased the likelihood of postponement. It is imperative to increase awareness of the secondary health effects related to policy intervention in pandemics and other health crises and to use appropriate countermeasures such as standard infectious control measures and triage of surgical patients.

The Impact of the COVID-19 Pandemic on Surgical Activities: A Single-Center Experience and Literature Review

Aim The aim of this article is to investigate the effect of the coronavirus disease 2019 (COVID-19) pandemic on our surgical department, which is situated in Athens, Greece, as well as to review published literature on the COVID-19 pandemic's impact on surgical activities in our department.  Material and methods We retrospectively reviewed the surgical procedures that were performed in the surgical department of a tertiary University hospital in Athens, Greece, before and during the pandemic. Furthermore, we performed a literature review evaluating articles on surgical activity and COVID-19 published from the beginning of the pandemic up until the January of 2022 on the PubMed database.  Results In total, 894 patients were included in the study. Of those, 264 (29.5%) underwent surgery during the control period and 630 (70.5%) in the pandemic period. Overall, we performed 20.5% fewer surgeries in the post-sanitary period. In particular, elective surgeries decreased on average by 23.9%, emergency procedures decreased by 8.9%, and oncology surgeries increased by an average of 6.4% after the year 2020. Concerning the review of literature, 51 studies were selected for this review. According to them, the main effect of the pandemic on the surgical sector was reflected in the reduction of total surgeries, mainly due to the postponement of elective surgical procedures, which showed a median reduction of 54% compared to the pre-COVID-19 period. A smaller decrease was observed in the number of emergency and oncological surgeries. Conclusions Reduced surgical activity during the pandemic, due to the health measures imposed, requires courageous corrective interventions to avoid its adverse effects, such as disease progression, increased treatment costs, reduced quality of life, and ultimately the survival of the patients.

Diagnosis and treatment of digestive cancers during COVID-19 in Japan: A Cancer Registry-based Study on the Impact of COVID-19 on Cancer Care in Osaka (CanReCO)

Background

The coronavirus disease 2019 (COVID-19) affected cancer care in Japan, but the detailed impact on cancer diagnosis and treatment is not well-understood. We aimed to assess the impact of COVID-19 on digestive cancer care in Osaka Prefecture, which has a population of 8.8 million.

Methods

We conducted a multi-center cohort study, using hospital-based cancer registry (HBCR) data linked to administrative data from 66 designated cancer care hospitals in Osaka. Records of patients diagnosed with cancer of the stomach, colorectum, esophagus, liver, gallbladder or pancreas were extracted from the HBCR data. Baseline characteristics, such as the number of diagnoses, routes to diagnosis and clinical stage, were compared between patients diagnosed in 2019 and those in 2020. We also compared treatment patterns such as the number of treatments (operations, endoscopic surgeries, chemotherapies, radiotherapies), pathological stage and time to treatment for each digestive cancer.

Results

In total, 62,609 eligible records were identified. The number of diagnoses decreased in 2020, ranging from -1.9% for pancreatic cancer to -12.7% for stomach cancer. Screen-detected cases decreased in stomach and colorectal cancer. The percentage of clinical stage III slightly increased across different cancers, although it was only significant for colorectal cancer. Among 52,741 records analyzed for treatment patterns, the relative decrease in radiotherapy was larger than for other treatments. The median time from diagnosis to operation was shortened by 2–5 days, which coincided with the decrease in operations.

Conclusion

The impact of COVID-19 on cancer care in 2020 was relatively mild compared with other countries but was apparent in Osaka. Further investigation is needed to determine the most affected populations.

Impact of COVID-19 on the endoscopy department since the early phase of the pandemic in 2020: A questionnaire study among patients with canceled examinations at a single Japanese institution

INTRODUCTION

In early 2020, the Japanese government declared a nationwide state of emergency for the COVID-19 pandemic. We investigated the impact of the emergency declaration on endoscopy adherence and conducted a follow-up study of patients with canceled examinations at a tertiary endoscopy facility in Japan in 2020.

METHODS

We compared the number of endoscopies performed, and cancelations at the endoscopy unit between 2019 and 2020 and used the Bayesian structural time series (BSTS) model to estimate the decrease in the number of endoscopies in 2020. We administered a questionnaire to those who had not undergone a scheduled endoscopy.

RESULTS

Of 14 146 and 13 338 scheduled examinations, 1233 (8.7%) and 1403 (10.5%) were canceled in 2019 and 2020, respectively. During both years, age < 50 years, age > 80 years, upper endoscopy, and experience of endoscopy in the past 5 years were significantly associated with cancelations. In 2020, cancelations in the 14th-26th week of the year, including the period of state of emergency, increased significantly, and more women canceled. Of the 409 questionnaire-respondents, 174 (42.5%) indicated that COVID-19 had influenced their cancelation, and 315 (77.0%) had not undergone similar endoscopic examinations since then. The BSTS model predicted a decrease of 957 (95% CI -1213 to -708, P = .003) examinations.

CONCLUSION

In 2020, despite low numbers of COVID-19 cases in the study site, the number of endoscopies decreased, and cancelation increased. Further research is needed on the future impact of a decrease in the number of endoscopies during a COVID-19 pandemic.

Impact of the COVID-19 pandemic on colorectal cancer surgery in Japan: Clinical Study Group of Osaka University-A multicenter retrospective study

Aim

Due to the overwhelming spread of SARS-CoV-2 and its disruption of the healthcare system, delays and reduced numbers were reported for colorectal cancer screening, colonoscopies, and surgery during the COVID-19 pandemic. This multicenter retrospective study investigated the still poorly understood impact of the COVID-19 pandemic on colorectal cancer treatment in Japan.

Methods

This study was organized by the Clinical Study Group of Osaka University, which comprised 32 major institutions in Osaka. We retrospectively analyzed the number of surgeries and colonoscopies performed and the characteristics of patients who underwent surgery for colorectal cancer between March 2019 and February 2021. We compared data collected before and during the COVID-19 pandemic. We also assessed the methods used for detecting colorectal cancer, including fecal occult blood test, abdominal symptoms, and anemia.

Results

The COVID-19 pandemic caused reductions in the annual numbers of surgeries (3569 vs 3198) and colonoscopies (67 622 vs 58 183) performed in the 2020 fiscal year, compared to the 2019 fiscal year. During the COVID-19 pandemic, a significantly lower proportion of patients were treated for clinical stages ≤I (24.2% vs 26.9%; P = .011), compared to the proportion treated before the pandemic. Fecal occult blood tests for detecting colorectal cancer were used significantly less frequently during the COVID-19 pandemic (26.2% vs 29.6%; P = .002). These trends were more significant in larger institutions.

Conclusion

The COVID-19 pandemic reduced the number of colonoscopies and surgeries performed for colorectal cancer and hindered the detection of asymptomatic early-stage cancers, and its impact varied by hospital size.

The impact of COVID-19 on thoracic surgical procedures in Japan: analysis of data from the National Clinical Database

Objective

The COVID-19 pandemic has far-reaching collateral health impacts on the ongoing delivery of surgical care worldwide. The current study was designed to analyze the impact of the COVID-19 pandemic on the number of surgeries of general thoracic surgery in Japan.

Methods

Changes in the number of surgeries for total and three representative tumors were analyzed using the National Clinical Database data with reference to the pandemic infection rate and lung cancer screening.

Results

In 2020, the number of surgeries in total and for primary lung cancer and mediastinal lung tumor decreased by 4.9, 5.1, and 5.0 %, respectively. Considering the five-year trend towards a 5 % annual increase, there was a potential 10 % decrease in the number of primary lung cancer surgeries. The number of primary lung cancer surgeries bottomed in July 2020 but recovered towards the end of the year. In contrast, the number of metastatic lung tumor surgeries in 2020 increased by 3.2 %, following a similar trend observed over the previous five years. The number of lung cancer screening examinees decreased markedly with the lowest number in May. Our findings indicate that surgical triage had a limited impact on the decrease in primary lung cancer surgeries during the pandemic; rather, the decrease in lung cancer screening, which was a few months preceding, is most likely responsible.

Conclusions

The decrease in primary lung cancer was mainly caused by the decrease in lung cancer screening, indicating that continuing screening is vital even during a pandemic.

Impact of the COVID-19 pandemic on the diagnosis of cancer in Japan: analysis of hospital-based cancer registries

BACKGROUND

There is significant concern that cancer care is adversely impacted due to the coronavirus disease pandemic. Using the national database, we document the impact of the pandemic on cancer diagnosis in Japan.

METHODS

Data from 735 hospital-based cancer registries, covering >70% of newly diagnosed cases, were analysed. We compared trends during 2016-2019 and those in 2020 by the type of cancer, diagnostic process, stage and 13 prefectures as requiring special precautions to prevent the spread of infection.

RESULTS

Overall, the number of patients who began treatment decreased by 1.9% in 2020 as compared with the average number during 2016-2019. A sharp decline of 13.8% was observed for stomach cases. The decline in cases (22.0% decrease for all cancers) was more pronounced in May. Cancer screening and resulting detection decreased significantly in 2020 (8.1-24.3%). Case registrations of stage I and II gastric cancer, stage II intrahepatic cholangiocarcinoma, stage II oesophageal cancer, stage 0 and I laryngeal cancer and stage II gallbladder cancer decreased by >10% compared with those in 2018 and 2019. The trends in cancer cases by area of residence indicated a decline in 13 prefectures in May 2020 compared with other areas.

CONCLUSIONS

The number of cancer diagnoses decreased during the year 2020 under coronavirus pandemic, especially right after the Japanese government declared the first state of emergency in April. We need to carefully observe the consequences of these decrease in diagnosis, or perhaps the delay in care, on patient survival or population mortality.

Changes in Health Care Access during the COVID-19 Pandemic: Estimates of National Japanese Data, June 2020-October 2021

The COVID-19 pandemic has disrupted health care access around the world, both for inpatients and outpatients. We applied a quasi-Poisson regression to national, monthly data on the number of outpatients, number of inpatients, length of average hospital stay, and the number of new hospitalizations from March 2015 to October 2021 to assess how these outcomes changed between June 2020 to October 2021. The number of outpatient visits were lower-than-predicted during the early phases of the pandemic but normalized by the fall of 2021. The number of inpatients and new hospitalizations were lower-than-predicted throughout the pandemic, and deficits in reporting continued to be observed in late 2021. The length of hospital stays was within the predicted range for all beds, but when stratified by bed type, was higher than predicted for psychiatric beds, lower-than-predicted for tuberculosis beds, and showed variable changes in long-term care insurance beds. Health care access in Japan was impacted by the COVID-19 pandemic.

Decreased numbers of gastric, colorectal, lung, and breast cancer surgeries performed in 17 cancer-designated hospitals in Gunma Prefecture of Japan during the COVID-19 pandemic

Purpose

This study aims to clarify the influence of the COVID-19 pandemic on cancer surgery in Gunma Prefecture.

Methods

A total of 9839 cases (1406 gastric cancer, 3569 colorectal cancer, 1614 lung cancer, and 3250 breast cancer) from 17 hospitals in Gunma Prefecture were investigated. We compared the number of surgical cases, proportion of cases found by screening, and cStage at the time of the first visit by month in 2020 and 2021 with those in 2019.

Results

The rate of decline in cancer surgery was 8.9% in 2020 compared with 2019 (p = 0.0052). Compared with the same month of 2019, in some months of 2020 and 2021, significant decreases were observed in the number of surgeries for gastric and colorectal cancer, the percentage of surgical cases detected by screening in all four cancers, and the proportion of cancers with a relatively early cStage in gastric and breast cancer.

Conclusions

The number of surgical cases of the four cancer types detected by cancer screening decreased in Gunma Prefecture owing to the influence of the COVID-19 pandemic. Furthermore, for some cancer types, the number of operations performed in patients with early-stage cancer is also decreased.

Prognostic impact of LY6K and CDCA1 expression for patients with esophageal squamous cell carcinoma

AIM

In the present study, we investigated the relationship between the expressions of two cancer testis antigens (CTA), LY6K (lymphocyte antigen 6 complex locus K) and CDCA1 (cell division cycle associated 1), in esophageal squamous cell carcinoma (ESCC) tumors and the long-term outcomes of patients with ESCC to clarify the clinical significance of LY6K and CDCA1 expression in ESCC tumors.

METHODS

A total of 175 patients with thoracic ESCC who had undergone a thoracic esophagectomy with three-field lymphadenectomy without neoadjuvant therapy were retrospectively reviewed in this study. LY6K and CDCA1 expressions were evaluated in tumor tissues using immunohistochemical (IH) staining.

RESULTS

Median patient age was 63 years; 159 patients (90.9%) were men. Ninety-four patients (55.3%) were LY6K-positive, and 85 patients (48.6%) were CDCA1-positive. The LY6K-positive group had a significantly worse overall survival (OS) than the LY6K-negative group (P = 0.012), and the CDCA1-positive group had a significantly worse OS than the CDCA1-negative group (P = 0.010). A multivariate analysis suggested that pathological N stage, venous invasion, LK6Y-positive and CDCA1-positive were independent prognostic factors. The patients were classified into four groups according to the staining pattern combinations of the two CTA. The LY6K-positive and CDCA1-positive group was found to have a significantly poorer outcome than the other groups.

CONCLUSION

ESCC patients with a combination of LY6K and CDCA1 expression in their tumor tissues had a worse prognosis than all the other ESCC patients and it was an independent factor associated with prognosis for patients with ESCC.