Boerhaave syndrome: Provision of emergency services during the COVID era

Background: The provision of emergency surgery was significantly impacted during the COVID-19 pandemic. This was due to limited intensive care beds and the risk of catching COVID-19 in the post-operative period. The aim of this study was to determine whether outcomes for patients with Boerhaave syndrome were negatively affected by service constraints during the COVID-19 pandemic. Method(s): Single centre case control study of patients with Boerhaave syndrome before and during the COVID pandemic. Univariate and multivariate analyses was employed to determine whether patient outcomes following Boerhaave syndrome were influenced by the COVID pandemic (defined here as 2020-2022) compared to a pre-pandemic period (2013-2019). Result(s): During the COVID pandemic, 7 patients presented with Boerhaave syndrome, although none of these patients tested positively for COVID-19. Patient characteristics and outcome data of these patients were compared to a group of 14 patients with Boerhaave syndrome during a pre-pandemic period. The median age of patients presenting with Boerhaave syndrome was statistically significantly lower during the pandemic compared to those presenting before the pandemic (28 years versus 60 years, p=0.04). There was no significant difference in the treatment approach between the two groups, with non-operative and operative measures being employed in both groups equally (p=0.66), suggesting that the pandemic did not influence treatment decision. There was no difference in the use of endoscopic stenting between the groups (p=0.25). 30-day mortality was equal between patients admitted during the pandemic and those admitted before the pandemic (p=0.13). Conclusion(s): This study demonstrated that the median age of patients presenting with Boerhaave syndrome during the pandemic was significantly lower than it was historically. This may have reflected shifts in behaviour and lifestyle during the pandemic. Never-the-less, the impact on services during the pandemic did not appear to influence treatment choice, and 30-day mortality remained the same for both patient groups. This may have reflected provision of COVID-secure pathways and locations.

Ten year experience of treating Boerhaave syndrome: A single centre analysis

Background: Boerhaave syndrome is a rare condition characterised by spontaneous barogenic, transmural rupture of the oesophagus. We aimed to examine a ten-year experience of Boerhaave syndrome at our centre. Method(s): Cohort analysis of Boerhaave syndrome over a ten year period (2012-2022). Univariate analysis was employed to determine risk factors associated with inferior patient survival. Result(s): During the study period, 40 patients presented with oesophageal perforation, of which 21 (52.5%) were spontaneous transmural rupture. Median age of patients with Boerhaave syndrome was 51 years, in predominantly male (15, 71.4%), non-smokers (13, 61.9%). The most common site of rupture was the lower oesophagus (12, 57.1%), although the exact site of rupture was unknown in 5 (23.8%) patients. 14 (66.7%) patients were treated conservatively with antibiotics. Three (14.3%) patients underwent endoscopic oesophageal stent insertion (either alone or in combination with surgical treatment). Five (23.0%) underwent thoracoscopic washout and drain insertion and 1 (4.8%) underwent open thoracotomy washout and drain insertion. Overall 10-year survival was 80.8%. There was no association between mortality and patient age, sex, smoking status, length of stay, location of perforation, coronavirus status or mode of nutrition on univariate analysis (p>0.05 throughout). Patient age was the greatest predictor of prolonged length of stay beyond 10 days (c-statistic 0.74). Modality of surgery also had no bearing on 1- and 10-year mortality (p=0.95). Conclusion(s): Boerhaave syndrome is an uncommon condition which may be treated with an array of approaches, including non-operative measures, endoscopic and surgical intervention, depending on individual patient characteristics. The availability of multimodal treatment at a specialist oesophagogastric centre may have contributed to favourable patient outcomes. Given the rarity of Boerhaave syndrome, identification of risk factors for poor patient outcomes is difficult to determine, due to statistical underpowering.

The Effect of COVID-19 on the Management of Upper Gastro-intestinal Cancers at a London NHS Trust

Background: The advent of the COVID-19 pandemic in 2020 led to staff redeployment and prioritization of urgent care services. Cancer services were impacted by staff and resource diversion. Cancer diagnoses fell by 33% due to reduction in surveillance, diagnosis, and screening. Upper gastro-intestinal cancers (UGI) include cancers of the esophagus, stomach, small intestine, pancreas, liver, and gall bladder. These cancers progress insidiously, present at late stages and are challenging to treat. Delayed diagnosis significantly reduces the scope of treatment options available and therefore impacts the prognosis of the patient. A Public Health England Report in 2021 showed a reduction in tumor resection surgeries in UGI cancers between March to May 2020 and December to February 2021. The backlog of surgical cancer management is ongoing as the pandemic evolves and NHS service provisions adapt. It is important to understand the effects of COVID-19 on diagnosis, staging and treatment of UGI cancers in order to improve service provision in the ensuing years. Method(s): This was a cross-sectional study conducted at Barking, Havering and Redbridge NHS Trust from January to June 2019, 2020 and 2021. Data for 316 study participants was sourced from the Somerset Cancer Database and supplemented with data from electronic patient care records. Six months of data was compared in 2019 (pre-pandemic), 2020 (mid-pandemic including the first lockdown) and 2021. The data was analysed as raw proportions and percentages. Result(s): The number of UGI cancers diagnosed was lowest in 2020 during the height of the pandemic compared to 2019 and 2021. The most common cancer in all three years was pancreatic. Pancreatic cancer was also the most common emergency cancer presentation. The highest proportion of stage IV cancers presented in 2021 (67%). The proportion of cases that resulted in palliative care management increased from 2019 to 2021 (67% and 70% respectively). 53% of all patients came from neighbourhoods that fell within 50% of the most deprived areas nationally. Conclusion(s): The COVID-19 pandemic has had variable impacts on the presentation and management of UGI cancers at the BHRUT NHS Trust. This study exhibits local trends and percentages following suit from Public Health England's National Cancer Registration and Analysis Service data for trend-based discussion. Further research within London NHS Trusts is encouraged to understand the full impact of COVID-19 on surgical cancer services in the NHS.