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.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Prognostic value of BRAF and KRAS mutation status in stage II and III microsatellite instable colon cancers

Microsatellite instability (MSI) has been associated with favourable survival in early stage colorectal cancer (CRC) compared to microsatellite stable (MSS) CRC. The BRAF V600E mutation has been associated with worse survival in MSS CRC. This mutation occurs in 40% of MSI CRC and it is unclear whether it confers worse survival in this setting. The prognostic value of KRAS mutations in both MSS and MSI CRC remains unclear. We examined the effect of BRAF and KRAS mutations on survival in stage II and III MSI colon cancer patients. BRAF exon 15 and KRAS exon 2-3 mutation status was assessed in 143 stage II (n = 85) and III (n = 58) MSI colon cancers by high resolution melting analysis and sequencing. The relation between mutation status and cancer-specific (CSS) and overall survival (OS) was analyzed using Kaplan-Meier and Cox regression analysis. BRAF V600E mutations were observed in 51% (n = 73) and KRAS mutations in 16% of cases (n = 23). Patients with double wild-type cancers (dWT; i.e., BRAF and KRAS wild-type) had a highly favourable survival with 5-year CSS of 93% (95% CI 84-100%), while patients with cancers harbouring mutations in either BRAF or KRAS, had 5-year CSS of 76% (95% CI 67-85%). In the subgroup of stage II patients with dWT cancers no cancer-specific deaths were observed. On multivariate analysis, mutation in either BRAF or KRAS vs. dWT remained significantly prognostic. Mutations in BRAF as well as KRAS should be analyzed when considering these genes as prognostic markers in MSI colon cancers.

The cervical spine in mutilant rheumatoid arthritis

The purpose of this study was to detect the frequency of inflammatory cervical spine changes and characteristic features such as resorption in rheumatoid arthritis (RA) with arthritis mutilans (AM) hand deformity. The series included 23 patients with AM hand deformity who fulfilled the 1987 American Rheumatism Association criteria for RA. Cervical spine radiographs were evaluated for subluxations, atlantoaxial impaction (AAI), and apophyseal joint ankylosis. Assessment of the severity of inflammatory changes in the cervical spine was based on former radiographic criteria for operation. Twenty patients (87%) showed subluxations, AAI, or apophyseal joint ankylosis in the cervical spine. Anterior atlantoaxial subluxation (aAAS) was observed in nine (39%), AAI in 13 (57%), and apophyseal joint ankylosis in 12 (52%). Six (26%) had been operated on the cervical spine. Patients with AM hand deformity evinced frequent and severe inflammatory cervical spine changes often requiring operation. Resorptive change (AAI) in the upper cervical spine and ankylosis of apophyseal joints were the most characteristic abnormalities in these patients.

Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis

OBJECTIVE

Serum C reactive protein (CRP) concentration was evaluated in patients with rheumatoid arthritis (RA) undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) to ascertain the postoperative CRP response.

METHODS

Thirty seven consecutive patients with RA who had undergone THA or TKA were included in the study. The CRP concentration was measured in every patient once preoperatively and every other day for one week postoperatively.

RESULTS

The peak median CRP concentration (94 mg/l) was achieved on the first and second day postoperatively and was seven times higher than the median preoperative concentration (13 mg/l). CRP declined to the preoperative concentration in about one week. The rise of the CRP concentration was significant (p< 0.001). No infection was encountered in this series.

CONCLUSION

A rapid rise in the postoperative CRP concentration is normal in patients with RA treated by THA or TKA. The CRP concentration decreases to the preoperative value in about one week. Serial CRP measurements, including at least one preoperative measurement, are needed when the clinical significance of the postoperative CRP values is evaluated. When the postoperative CRP concentration remains raised for several days compared with the preoperative value, or even rises, it may indicate the presence of a complication in these patients.

When does subluxation of the first carpometacarpal joint cause swan-neck deformity of the thumb in rheumatoid arthritis: a 20-year follow-up study

The aim of our study was to assess the incidence of subluxation of the first carpometacarpal joint (CMC I) and to evaluate which degree of subluxation produces swan-neck deformity of the thumb in rheumatoid arthritis (RA) occurring over 20 years. The hands of 83 rheumatoid factor (RF)-positive RA patients with recent (< or = 6 months) arthritis were evaluated radiographically at onset and at 1, 3, 8 and 15 years; 68 patients were evaluated at 20 years from entry. Subluxation was assessed in millimetres and compared with the MCP-I angle measurement to evaluate the thumb deformity. A statistical end-point analysis was performed between two different grades of subluxation. Subluxation of 2-3 mm was non-specific and only one third of these thumbs showed swan-neck deformity. At the end-point, subluxation of > or = 4mm was present in 17% of the thumbs, 81% of which had the swan-neck deformity; only five thumbs did not show this deformity, but presented deformed and unstable MCP I and interphalangeal joints. The frequency of swan-neck deformity was highly significantly (p < 0.0001) increased in the thumbs with severe CMC I subluxation (> or = 4 mm) compared with lesser subluxation (< 4 mm). When subluxation of the CMC I exceeds 4 mm, the swan-neck deformity of the thumb is a common consequence. This deformity is often progressive, and the hand function of such patients should be followed up carefully, both clinically and radiographically.

Epidemiology and traumatology of injuries in elite soccer: a prospective study in Finland

A prospective study of male soccer injuries among 12 teams playing at the highest competition level was carried out in Finland in 1993. Overall, two out of three players were injured during the whole season. The injury incidence per 1000 playing hours among injured players and all players during games was higher than during practice, 14.2 vs. 11.3 and 2.3 vs. 1.8, respectively. The lower extremity was involved in 76% of the injuries. Thigh injuries were most frequent (22%), whereas overuse injuries were scarce (6%). Eighteen per cent of the injured players needed surgery and in most cases (58%) the reason for surgery was a knee injury. Sixteen per cent of all injured players were absent from soccer for more than 1 month after the injury. The mean absence time was 17 days for all and 84 days for operatively treated players.

Replacement of the ureter by small intestine: clinical application and results of the ileal ureter in 89 patients

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.

Carcinoma of the prostate: a study of 213 patients with stage C tumors treated by total perineal prostatectomy

The effects of age, histological grade and clinical extension of carcinoma of the prostate are analyzed in a series of 213 patients with stage C carcinomas treated by total perineal prostatectomy. Survival data and the incidence of local recurrence, distant metastases and deaths from cancer of the prostate are the parameters used for comparison with 132 stage B patients, 70 patients with seminal vesicle invasion and data from the literature. Long-term survivors in the young age group and some long-term survivors with high grade lesions are good arguments for the possible curability of early stage C carcinoma of the prostate by total prostatectomy. Correct surgical staging of these tumors by previous pelvic lymphadenectomy is mandatory.