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.

Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Extranodal extension of axillary metastasis of invasive breast carcinoma as a possible predictor for the total number of positive lymph nodes

INTRODUCTION

By the implementation of the sentinel node procedure in the treatment of breast carcinoma routine axillary lymph node, dissection can be abandoned in patients with a tumour-negative sentinel node. When the sentinel node is positive there are two options; an axillary dissection or radiotherapy of the axilla. In the latter case one is not informed about the total number of positive lymph nodes which can be of importance for the choice of adjuvant chemotherapy. In this paper we analyse whether it is possible to use histological parameters of a lymph-node metastasis to predict the number of tumour-cell-containing nodes.

METHODS

Four hundred and ninety-eight patients treated for invasive breast cancer at our department from 1991 to 1996 were investigated to see whether extranodal extension of axillary metastases had a significant predictive value for the number of positive lymph nodes. Extranodal extension was scored as: no extranodal extension (NEE) and extranodal extension (EE); the latter was subdivided in minimal extranodal extension (MEE) or extensive extranodal extension (EEE).

RESULTS

Of 498 patients, 230 patients had axillary involvement. NEE was seen in 83 (36.1%) patients and 147 (63.9%) had EE. Subdivision of this latter group revealed 77 patients with MEE (52%), 65 patients with EEE (45%) and five patients not further specified (3%). The number of positive nodes for the EE-group (6.9+/-0.5) was significant higher compared with the NEE-group (2.1+/-0.2) (P<0.001). The number of positive nodes was also significantly higher for the EEE-group compared to the MEE-group, 10.6+/-0.8 vs 4.0+/-0.4 (P<0.001). The predictive value for > or =4 positive axillary lymph nodes was 84.6% for EEE, 58.5% for EE and only 14.5% for NEE. These differences were significant (P<0.001).

CONCLUSIONS

The presence of extranodal extension in axillary lymph-node metastases can be a good predictor for the expected number of positive nodes. This histological parameter could be of value to determine the kind of adjuvant chemotherapy after a positive sentinel-node biopsy with only radiotherapy of the axilla and no further axillary lymph-node dissection.

Isosorbide dinitrate in the treatment of anal fissure: a randomised, prospective, double blind, placebo-controlled trial

OBJECTIVE

To assess the efficacy of isosorbide dinitrate in healing anal fissures.

DESIGN

Randomised, prospective, double blind, placebo controlled trial.

SETTING

Teaching hospital, The Netherlands.

SUBJECTS

37 consecutive subjects with anal fissure diagnosed in the surgical outpatient department.

INTERVENTIONS

After randomisation, 20 patients were given isosorbide dinitrate, and 17 patients placebo.

MAIN OUTCOME MEASURES

Healing of anal fissure, recurrence, and tolerance.

RESULTS

Both groups were treated for a median (range) of 5 weeks (range 1-10). After this period, 17 in the isosorbide group had healed compared with 6 controls (p < 0.003). The fissure recurred in 2 patients who had had an initial good response to isosorbide, and in 2 in the control group. Side effects (particularly headache) were more common after isosorbide dinitrate, but not significantly so (9/20 compared with 3/17).

CONCLUSIONS

Isosorbide dinitrate is an effective treatment for anal fissure, and is significantly better than placebo.

Arterial reconstruction for subclavian obstructive disease: a comparison of extrathoracic procedures

OBJECTIVES

Comparison of the immediate and long-term results of three different extrathoracic arterial reconstruction procedures for subclavian obstructive disease.

DESIGN

Retrospective analysis of 51 extrathoracic subclavian artery reconstructions in 49 patients performed in a single centre over an 18-year period (mean follow-up 64 months, range 3-192).

METHODS

Carotid-subclavian bypass (CSB, n = 21), subclavian-carotid transposition (SCT, n = 21) and subclavian-subclavian or axillo-axillary cross-over bypass (COB, n = 9) was performed. Upper extremity ischaemic complaints were present in 45/49 patients (92%) and vertebrobasilar insufficiency in 25/49 patients (51%). Symptom relief, improvement of haemodynamic parameters and graft patency were compared.

RESULTS

Operation time was significantly shorter (p < 0.001, t-test) in SCT (80 +/- 5 min) compared to CSB (112 +/- 7 min) and COB (116 +/- 6 min). Symptom relief and improvement of haemodynamic parameters were similar for all groups. There were no differences in morbidity rate and there was no mortality. The cumulative patency of SCT was significantly better with 100% at 2, 5 and 10 years postoperatively compared to CSB (75.6%, 62.6% and 52.2%, respectively) (p < 0.005, log-rank test) and COB (76.5%, 63.7% and 63.7%, respectively) (p < 0.02, log-rank test). There was a tendency for a better patency in prosthetic grafts as compared to autologous vein grafts in CSB (NS, log-rank test).

CONCLUSIONS

Satisfactory immediate and long-term results were obtained with all of the above techniques. When technically feasible, SCT is the procedure of choice for extrathoracic arterial reconstruction in subclavian obstructive disease.