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.

ACUTE ABDOMEN IN AN ELDERLY PATIENT WITH SUSPICION OF SARS-COV-2 INFECTION – DIAGNOSTIC AND TREATMENT CHALLENGES DURING THE PANDEMIC OF 2020 FOR EMERGENCY SURGEON

După apariţia pandemiei SARS-CoV-2 la începutul anului 2020, chirurgia a cunoscut schimbări în paradigmele de diagnostic şi management, cu un nou accent pe menţinerea unui mediu sigur pentru pacient şi chirurg, asigurând totodată îngrijire medicală adecvată. În ciuda faptului că testarea rRT-PCR este metoda preferată pentru diagnosticare, multiple studii au arătat că tomografia toracică a prezentat specificitate superioară. Prezentăm cazul unei paciente în vârstă de 84 de ani care a fost internată pentru febră şi durere abdominală, cu afecţiuni cronice multiple, precum şi spitalizare recentă într-o altă unitate cu focar de COVID-19 identificat la scurt timp după externarea acesteia. În ciuda rezultatului negativ pentru SARS-CoV-2, datorită semnelor radiologice sugestive, pacienta a fost tratată ca suspectă pe parcursul spitalizării. La 48 de ore de la internare s-a intervenit chirurgical şi s-a descoperit diverticulită gangrenoasă Meckel. Evoluţia a fost favorabilă şi pacienta a fost externată în ziua 5 postoperatorie, dar a a fost testată pozitiv SARS-CoV-2 la şase zile după externare (test de screening). La 30 de zile postoperator starea generală se menţinea bună şi nu a avut nevoie de spitalizare în terapie intensivă pentru COVID-19. Acest lucru subliniază două probleme apărute în pandemie în 2020: examenul CT toracic trebuie efectuat întotdeauna preoperator, chiar şi la pacienţii ale căror teste rRT-PCR sunt negative şi că pacienţii geriatrici pot fi diagnosticaţi greşit din cauza manifestărilor clinice anormale şi acest lucru poate fi trecut cu vederea în timp ce medicii sunt preocupaţi de diagnosticarea COVID-19.Alternate abstract:After the emergence of the SARS-CoV-2 pandemic in early 2020, surgery has seen shifts in diagnostic and management paradigms, with a new focus on maintaining a safe environment for both patient and surgeon, all the while ensuring the proper medical care. Despite rRT-PCR testing being the preferred method of diagnosing the infection, multiple studies have shown that chest CT has exhibited superior specificity. We present the case of an 84-year old patient who presented with fever, abdominal pain and multiple chronic ailments, as well as recent hospitalization in another unit that had multiple COVID-19 patients diagnosed shortly after her discharge. She tested negative for SARS-CoV-2 but had suggestive radiological signs, hence she was treated as a suspect. Forty-eight hours after admission her state worsened and emergency surgery was performed, which revealed gangrenous Meckel's diverticulum. The postoperative course was uneventful and the patient was discharged on postoperative day 5, but she tested positive for SARS-CoV-2 six days after discharge (screening testing). She remained in good health 30 days postoperatively and did not need intensive care measures for COVID-19. This underlines two issues brought forth by the pandemic in 2020: that chest CT should always be performed preoperatively, even in patients whose rRT-PCR tests are negative, and that geriatric patients can easily be misdiagnosed due to abnormal clinical manifestations and this can be overlooked while doctors are busy looking for COVID-19.