ABSTRACT
Background: Lymph node yield following oesophagogastric (OG) cancer resection remains a valuable prognosticator of overall patient survival. It is also a quality indicator of histopathological assessment and a surrogate marker of surgical technique. The Royal College of Pathologists' state a minimum lymph node yield of 15 per specimen should obtained in 100% of cases where a radical OG resection has been undertaken. It is well known that the COVID-19 pandemic placed immense strain on NHS services. This study aimed to evaluate its effect on lymph node yield reporting following major OG resection in a large volume tertiary unit. Method(s): Retrospective National OG Cancer Audit (NOGCA) metrics were collected. Histological data including total lymph node yield and positive node status were extracted from patient records. Patient data was categorised into two study periods;pre-pandemic (March 2018-Feb 2020) and pandemic (March 2020- Feb 2022) following the first UK national lockdown. Comparative analysis between the two study periods was performed and for lymph node yield >15 per specimen a X2 statistic calculated. Result(s): In the pre COVID period a total of 280 (excluding GIST) resections were performed, 75% (210) oesophagectomies v. 25% (70) gastrectomies. The median age was 69 (range 25-90, males= 189 v. females =91). In the post pandemic period a total of 188 resections were performed, 72% (135) oesophagectomies v. 28% (53) gastrectomies. The median age was 69 (38-87, males = 142 v. female= 46). Lymph node yield was available for 275 resections in pre-pandemic study period, with a median nodal yield of 20 (5-61). In the pandemic study period lymph node yield data was available for 180 patients, median 19.5 (0-69). The minimum nodal yield (>15) was obtained in 80.7% of resection specimens pre-pandemic v. 68.9% in the pandemic study period (p= 0.00382). Conclusion(s): Our study demonstrates a higher rate of inadequate nodes examined in the post pandemic study period. Despite staffing pressures, efforts should be made to improve number of nodes examined to provide robust prognostic data.
ABSTRACT
Background: With many resources redirected to care for the those affected by the COVID-19 pandemic, the NHS faced unprecedented pressure to maintain oesophagogastric (OG) cancer resectional services. Our institution along with many tertiary units across the country were faced with limited access to essential critical care beds. The implementation of emergency contracts between the NHS and the independent sector (IS) allowed our unit to maintain a high volume resectional service by utilising the resources of a local private hospital with HDU/ ITU provision. We began operating within the IS shortly after the first UK lockdown in March 2020, and continued through till February 2022. During this period, we continued operating at our tertiary unit (TU) albeit at a reduced capacity. This study aimed to evaluate the surgical outcomes of patients undergoing major OG resectional surgery between the two sites. Method(s): This retrospective study included all patients who underwent major OG resectional surgery (including GIST) from March 2020-February 2022. Operation type and site were identified using OPCS-4 clinical codes and combined with National OG Cancer Audit (NOGCA) data to compare basic patient demographics, length of stay, complication rates, COVID infection rates and 90-day mortality. Descriptive and statistical analysis between the two operating sites was performed. Result(s): A total of 204 major OG resections were undertaken, 44% (89) at our TU;57 oesophagectomies and 32 gastrectomies, with 56% (115) at a local IS hospital;86 oesophagectomies and 29 gastrectomies. Additionally, 13 (6.4%) open and close procedures were performed across both sites. Median patient age was similar, 69 (45-86) years at our TU v. 68 (38-85) years at the IS site. A higher proportion of ASA 3 patients (46%) were operated on at our TU. No difference in median length of stay was observed;TU= 8 (1-93) days v. IS =9 (3-69) days, this included all patients who were repatriated to the TU. Higher complication rates seemed to occur in patients operated at the IS site v. the TU though these did not reach statistical significance;18 (15.7%) patients suffered an anastomotic leak v. 9 (10.1%) respectively (p= 0.246). 21 (18.3%) v. 13 (14.6%) patients suffered a major respiratory (p=0.487) and 4 (3.5%) v. 1 (1.1%) a major cardiac (p=0.281) complication. There were no cases of COVID infection within 30 days of primary procedure at the IS site, with 2 cases within the TU cohort. Our 90-day mortality rates were similar (IS= 4.54% v. TU=5.32%), p=0.661. Conclusion(s): Our study demonstrates that resection of patients with OG cancer is feasible in an independent sector hospital if supported by critical care. It allowed a high-volume tertiary unit to continue offering potentially curative surgery to patients whose treatment options would have otherwise been limited to oncological therapy only. Long term survival data compared to non-resecting trusts is required to determine whether this approach was superior. When considering future pandemic planning, we have demonstrated the value of this model in maintaining major OG resectional services.
ABSTRACT
Thyroiditis is an inflammatory process that can be triggered by infection, autoimmune diseases, medications, post-partum, and in very rare instances, vaccine adjuvants. In this case report, we focus on the latter cause of thyroiditis as we discuss a 35-year-old male who developed palpitations, heat intolerance, and night sweats after receiving the first dose of the COVID-19 Pfizer-BioNTech vaccine. Our patient presented with clinical symptoms of hyperthyroidism ten days after receiving the vaccine and he did not have a painful thyroid. Initial laboratory studies showed a suppressed TSH, elevated free triiodothyronine (FT3) and free thyroxine (FT4), elevated erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) and negative thyroid autoantibodies. Ultrasound showed a heterogenous thyroid with decreased vascularity and Radioactive Iodine Uptake and Scan had less than 5% uptake. Within two months, laboratory tests progressed into the thyroiditis pattern of transient hyperthyroidism followed by hypothyroidism. Based on imaging and laboratory results in conjunction with the clinical progression of our patient, we hypothesize that he developed vaccine-induced thyroiditis. Given the novelty of the COVID-19 vaccine, this hypothesis has yet to be validated by more reports of similar reactions in other patients. Before arriving to this diagnosis, we carefully evaluated for and excluded more common causes of painless thyroiditis including Hashimoto's, Graves' disease, and medication-induced thyroiditis. Interestingly, in recent months there have been reports of two females who developed Graves' disease three days after receiving the Pfizer vaccine (3) and one female who developed Subacute Thyroiditis five days after the same vaccine (16). A possible explanation for this autoimmune reaction is molecular mimicry due to the vaccine's spike glycoprotein having genetic similarities with a human heptapeptide (15). Additionally, this innovative vaccine contains a nanoparticle with polyethylene glycol lipid conjugates that has been reported to cause anaphylaxis and to induce autoimmune responses in susceptible patients (10-14). Although the numbers of CoVID-19 infections, and thus morbidity and mortality from this pandemic, have significantly decreased with vaccination, like with any other vaccine, adverse reactions will occur (17). We believe that as more patients get vaccinated, the data regarding vaccine-induced thyroid disease will increase.