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COVID-19 COVID-19 has undoubtedly had an impact on health care over recent years and continues to do so. [...]it is no surprise that papers on COVID-19 feature in this month's journal. Out of hospital cardiac arrest (OHCA) There are a couple of papers in this month's journal focussing on OHCA. Patient involvement in research As healthcare professionals we are ultimately there to look after and treat our patients. [...]understanding their perspective on how we do what we do is crucially important.
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Corticosteroids have been a mainstay in the treatment protocols and guidelines of COVID-19. However, its use in high dosage or for extended duration renders patients immunocompromised after COVID-19 recovery, and thus, susceptible to secondary opportunistic infections. We report the two cases of septic hip arthritis due to Aspergillus species in corticosteroid immunosuppressed post-COVID-19 patients. One patient recovered successfully from the arthritis and subsequently underwent total hip arthroplasty with good outcome. The second patient presented late to us in a critical condition and had two comorbid conditions along with, due to which, in spite of all measures, could not be revived and succumbed to death. We highlight the issue of the rare cause of fungal hip arthritis in immunosuppressed post-COVID-19 patients and stress the necessity to remain vigilant and identify the causative organisms correctly, especially fungal pathogens in such susceptible populations in the present COVID-19 era.
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Background: With increased restrictions following the COVID-19 pandemic, use of virtual care has shown an appreciable rise in clinical practice. Use of self-administrated surveys in triaging patients with low back pain assists with prioritizing care. The objective of this study was to assess the diagnostic value of a self-administrated, self-reported history questionnaire (SSHQ) in diagnosing patients with lumbar spinal stenosis (LSS), using combined clinical and imaging results as the gold standard. The SSHQ has 4 questions that all need to be true for a positive diagnosis of LSS. Methods: Patients with low back pain with and without leg symptoms who had a telephone interview with an advanced practice physiotherapist as a part of a new virtual care initiative were included. A score of 4 points on Q1-Q4 was indicative of the presence of LSS. The relationship between the SSHQ and the Oswestry Disability Index (ODI), the STarT Back questionnaire and the 5-repetition sit-to-stand Test was explored. Results: Data for 57 patients, of whom 26 were female (46%), with a mean age of 57 (standard deviation 17) years were analyzed. The majority of the patients had a diagnosis of radiculopathy (19 [33%] claudication type and 19 [33%] disc related). Of the remaining patients, 9 (16 %) had a mechanical low back pain, 5 (9%) had neurogenic claudication with bilateral symptoms, 3 (5 ) had degenerative disc disease and 2 (4 %) had peripheral joint involvement with referred pain. The SSHQ score did not correlate with the ODI, STarT Back or performance measure scores. The SSHQ did not differentiate the claudication-type radiculopathy or neurogenic claudication from the disc-related radiculopathy or other diagnoses. Patients whose symptoms were reduced by bending forward as the typical sign of LSS had a significantly lower STarT Back score (p = 0.015), indicating less risk of physical or psychological disability. Conclusion: The SSHQ did not clearly identify patients with and without LSS, potentially because 3 out of 4 SSHQ questions refer to symptoms that overlap with other diagnostic categories. The STarT Back risk categories appear to be more informative in the diagnosis of LSS.
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James Price, Senior Lecturer and Honorary Consultant in Infection, Brighton and Sussex Medical School, University of Sussex, UK Broad infection prevention and control (IPC) measures are routinely employed to prevent surgical site infections (SSIs),1 including screening for (and subsequent suppression of) key pathogens and surgical antimicrobial prophylaxis. Prediction There is growing literature on the application of mathematical modelling to routinely collected healthcare data in order to accurately predict an individual's: (i) risk of carrying or acquiring key pathogens;(ii) future need for surgery;and (iii) likelihood of developing a healthcare associated infection. [...]with large proportions of the population yet to receive routine vaccinations, incorporation of assessment and vaccine delivery within secondary care pathways has the potential to support post-discharge outcomes and to optimise preparation of future hospital admissions and procedures.
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Background: In response to COVID-19, Quebec repurposed surgical care infrastructure and delayed many elective cancer surgeries. However, postponing cancer surgery is known to cause anxiety and distress. Methods: A qualitative study was conducted to understand patients experiences receiving surgical cancer treatment during the COVID-19 pandemic. Patients who underwent general surgery for cancer at the McGill University Health Centre between March 2020 and January 2021 were invited to one-to-one interviews. Patients were purposefully selected for maximum variation using quota sampling (i.e., targeting delay status, pandemic phase, cancer site, and clinical/ demographic characteristics) until interviews produced no new information (i.e., thematic saturation). Interviews were conducted using a semistructured guide, audio-recorded, transcribed verbatim, and analyzed independently by 2 researchers. Data were managed using MAXQDA2020 and analyzed according to inductive thematic analysis. Results: Interviews were conducted with 20 patients (mean age 64 yr;10 males;cancer sites: 8 breast, 4 skin, 4 hepato-pancreato-biliary, 2 colorectal, and 2 gastroesophageal). Surgery was delayed for 14 patients: 8 by the hospital, 4 by the patient, and 2 owing to a positive COVID-19 test. Thematic analysis revealed that patients considered their susceptibility to infection, hospital safety measures, and burden on health care resources when determining willingness to undergo surgery. Patients weighed these risks against the urgency of their health condition and recommendations of their provider. Changes to the hospital environment (e.g., COVID-19 preventative measures) and deviations from expected treatment (e.g., alternative treatments, remote consultations, rescheduled care) caused diverse psychological responses, ranging from increased satisfaction to severe distress. Patients employed coping strategies (e.g., reframing care interruptions, communicating with clinicians, information seeking) to mitigate distress. Conclusion: Changes in care during the pandemic elicited diverse psychological responses from patients undergoing cancer surgery. Patient coping was facilitated by open, consistent communication with clinicians, emphasizing the importance of patient-centred discussions regarding surgical delays within and beyond the pandemic.
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Background: During the COVID-19 pandemic, access to planned surgical care was restricted. It remains unknown whether this had any impact on outcomes for surgical oncology patients. We hypothesized that the pandemic resulted in diagnostic and therapeutic delays, leading to stage migration among patients with malignancies treated with a Whipple procedure. Methods: We performed a retrospective review of adult patients with a gastrointestinal malignancy who underwent surgical exploration for a planned pancreaticoduodenectomy (PD) at St. Joseph's Health Centre between Mar. 11, 2019, and Mar. 11, 2021. Primary outcomes included pathological findings and rates of nontherapeutic laparotomies between the 2 years. Secondary outcomes included wait-times for an operation and perioperative outcomes. Results: Comparing the 2 cohorts, the COVID-19 group (n = 53) had median wait-times of 27.75-42.25 days, which was statistically longer than the pre-COVID-19 cohort (n = 87) of 14.5-37 days (p < 0.001). With respect to baseline characteristics, types of pathologies, rate of unresectable disease and perioperative outcomes, the 2 cohorts had similar results. For patients with pancreatic ductal adenocarcinoma, 31% in the COVID-19 cohort were found to have metastatic disease compared with 14% in the pre-COVID-19 cohort, although not statistically significant (p < 0.16). The absolute volume of Whipple procedures was 39% less in the year of the pandemic, and the COVID-19 cohort experienced statistically significant longer wait times for imaging and surgery, confirming therapeutic and diagnostic delays during the pandemic. Despite this, there were no significant differences in primary and secondary outcomes between the cohorts. There was a trend toward a higher rate of metastatic disease in the COVID-19 cohort;however, the small sample sizes limited statistical power. Conclusion: While the short-term outcomes of those planned for PD were statistically similar between the 2 cohorts, longer term outcomes may differ due to changes in treatment practices during the pandemic.
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In its 2015 NG12 guidance, NICE recommended the use of guaiac-based faecal occult blood test (gFOBT) and not FIT in primary care to triage patients with low-risk symptoms for cancer, due to paucity of evidence on FIT diagnostic accuracy at the time.1 But as evidence on FIT efficacy in symptomatic patients continued to emerge, gFOBT was replaced with FIT in NICE 2017 DG30 guidance.2 However, this recommendation was not extended to patients with high-risk symptoms for cancer or rectal bleeding.2 Since then, several pioneering centres in the UK, including centres in Nottingham, Oxfordshire and Tayside in Scotland, introduced FIT in patients with high and low risk symptoms using record linkage as part of service development projects, and reported promising results.3–5 At the same time, three large research studies were conducted in England, investigating the diagnostic accuracy of FIT in high and low risk symptomatic patients and reporting similar results.6–8 Two recent meta-analyses evaluated this and other evidence of the diagnostic accuracy of FIT.9,10 The key message from these studies remains remarkably consistent: The diagnostic accuracy of this test is, counter-intuitively, barely improved by the addition of other clinical characteristics into a risk-score.3,11Despite these encouraging results, there has been reluctance on the part of some groups in the UK, including NHS England, to recommend the use of FIT in the high-risk symptomatic patients because of concerns about missing cancer. Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study.
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Background: Loop ileostomy closure is associated with low complication rates, consisting mostly of postoperative ileus, but is still leading to significant length of hospitalization. Hence, decreased length of stay could be achieved by decreasing ileus rates. The purpose of this study was to assess the safety and feasibility of ileostomy closure performed in a 23-hour hospitalization setting using a standardized enhanced recovery pathway. Methods: This randomized controlled trial included healthy adults undergoing elective ileostomy closure. All patients were enrolled in a standardized enhanced recovery pathway specific to ileostomy closure, including daily irrigation of the efferent limb with an enteral nutritional formula for 7 days preoperatively. Once surgery was completed, patients were randomized to either conventional hospitalization (CH) or to 23-hour stay (23HS). Primary outcome was total length of stay in days, and secondary outcomes were 30-day rates of readmission, postoperative ileus, surgical site infection, postoperative morbidity and mortality. Owing to COVID-19 limiting access to surgical beds, the study was terminated early. Results: A total of 47 patients were randomized;23 in the CH arm and 24 in the 23HS arm. Patients in the 23HS arm had a shorter median length of stay (1 d v. 2 d, p = 0.015) and similar readmission rates (4% v. 13%, p = 0.348), postoperative ileus (0% in both arms), surgical site infection (0% v. 4%, p = 0.489), postoperative morbidity rates (17% v. 22%, p = 0.724) and mortality rate (0% in both arms). Conclusion: This study suggests that loop ileostomy closure as a 23-hour stay procedure in a standardized enhanced recovery pathway is feasible and safe.
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Background: The aim of this study was to quantify trainees' operative volume and assess the effect of the first wave of COVID-19 on general surgery residents' training at a Canadian academic centre. An observational study was performed, focusing on objective operative volumes, hands-on experience, and subjective perceived impact of the pandemic by trainees. Methods: All residents enrolled in our program were included. Quantitative data were collected from anonymized residents' case logs and annual departmental statistics. Qualitative data on residents' perception of the impact of the pandemic was provided by a resident-led focus group. The period of interest, the first wave of the COVID-19 pandemic (January-June 2020), was compared with a reference period (January-June 2019). Case logs of all 21 residents were reviewed. Results: During the first wave of the COVID-19 pandemic, residents logged a total of 475 cases, compared with 914 cases before the pandemic. This represents a decrease of 48% in operative volume;junior residents saw a decrease of 50% and senior residents saw a decrease of 46%. Postgraduate year (PGY)-1 residents were most affected, with a reduction of 58% in operative volume. PGY-4 was the group least affected with a reduction of 37%. When looking at key procedures, junior residents performed 71% fewer laparoscopic appendectomies and 49% fewer laparoscopic cholecystectomies during the pandemic. Senior residents saw a reduction of 55% in lower anterior resections and a reduction of 58% in right hemicolectomies compared with reference period. The resident focus group discussion revealed that 92% of residents think the pandemic had significant drawbacks on their surgical skills and they unanimously reported an overall negative perceived effect on their training. Conclusion: The data provided by this study demonstrate how much the pandemic compromised hands-on exposure of all residents. The reduction in operative volume affected all years of training, especially junior years. This raises concern about the short- and long-term effects on trainees' technical skills. The insights brought by this study will help create personalized mitigating measures and guide future curricula to be more resilient in the face of a next sanitary crisis.
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Background: Minimally invasive lumbar interbody fusion (MI-LIF) procedures are an effective treatment for patients with degenerative lumbar disease (DLD). However, consensus does not exist among surgeons for selecting 1 approach over another. The objectives were to collect patientreported, surgical and fusion outcome data at 1 year after surgery for patients receiving either anterior lumbar interbody fusion (ALIF), direct lateral interbody fusion (DLIF), oblique lumbar interbody fusion (OLIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) or midline lumbar interbody fusion (MIDLF) for DLD. Methods: A total of 340 patients with DLD were consecutively enrolled in a prospective, global, multicentre cohort study (MASTERS-D2;NCT02617563). Patients were treated according to the surgeon's choice with 1 of 6 MI-LIF procedures. Outcome data for disability (Oswestry Disability Index), back and leg pain (Visual Analogue Scale), quality of life (EQ-5D) were collected at baseline, 4 weeks, 3 months and 12 months. Demographic, surgical and safety data were also recorded. Fusion status was assessed by using computed tomography or x-rays at 1 year (plus or minus 6 mo) after surgery. Paired sample t tests were used to test for improvement from baseline. Results: One year after surgery, patients attained clinically significant improvements on all patient-reported outcome measures regardless of approach used. Patients who were selected to receive an ALIF comprised the highest proportion of smokers, were the youngest and had the longest operating time, but low fluoroscopy exposure. Anterolateral (ALIF, DLIF, OLIF) compared with posterior (MIDLF, PLIF, TLIF) approaches had the least amount of blood loss, despite similar or longer surgical times. Within 1 year of follow-up, 7 device-related and 7 surgery-related serious adverse events (SAEs) had been recorded. Assessment of fusion was hindered by the effects of COVID-19. In total, 196 out of 340 (57.6%) patients were assessed. The aggregate fusion rate for anterolateral approaches was 88.1% and for posterior approaches 85.1% at 12 months of follow-up. Conclusion: All 6 approaches for MI-LIF surgery demonstrate favourable patient-reported and surgical outcomes for patients with DLD. Continuing data collection up to 5 years after surgery will yield information on long-term effectiveness, safety, health economics and revision surgery and on the long-term impact of surgeons' choice of approach.
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Background: The COVID-19 pandemic has affected health care workers in unprecedented ways. Surgical residents at baseline have higher prevalence of burnout and depression, and now face unique challenges related to the pandemic. This study sought to evaluate the psychological impact of COVID-19 on surgical residents. Methods: An online survey was distributed to surgical residents between June 2020 and January 2021. It covered multiple domains: demographics, socioeconomic factors, clinical experience, educational experience, and psychological outcomes. The Mayo Clinic Resident Well-Being Index (RWBI) was used as a validated measure of resident mental health. Analysis was done with logistic regression. Results: A total of 31 residents responded to the survey, corresponding to a 36.0% response rate. Respondents were from general surgery (n = 21), orthopedic surgery (n = 5), otolaryngology (n = 2), urology (n = 2) and vascular surgery (n = 1) training programs. Seventeen (54.8%) respondents were female, 24 (77.4%) were senior residents and 21 (67.7%) were in a relationship. Residents were concerned about infecting family members (71.0%) and about personal protective equipment (PPE) supply (54.8%). Most residents (64.5%) were satisfied or very satisfied with their operative experience, but only 41.9% were happy with educational activities. Despite measures that were put in place to support the wellness of residents, 57.1% reported feeling burnt out and 46.4% depressed. Residents who were concerned about PPE supply were found to have 6.67 (95% confidence interval [CI] 1.24-35.71, p = 0.027) times the odds of depression than those who were not. The median RWBI was 2.5, slightly higher than the United States National Resident Survey median of 2. There were 10.7% of residents who had an at-risk score of 5 or more, compared with the US National 20.25%. Conclusion: The pandemic had a considerable impact on the psychological well-being of surgical residents. Continued investigation into mental health risk and protective factors is needed to improve future response of residency programs to unexpected stressors.
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Background: Appendectomy has been the standard of care for treatment of appendicitis for decades. Nonoperative management (NOM) of appendicitis is an alternative treatment strategy and had a resurgence of interest owing to the COVID-19 pandemic and the need for alternate care delivery models. One of the concerns for treatment of appendicitis with NOM is the recurrence rate. Despite this, there are few data examining the predictors of recurrence to tailor patient selection for NOM of appendicitis. The objective of this study was to identify predictors for recurrent appendicitis in patients with appendicitis previously treated nonoperatively. Methods: We conducted a prospective cohort study of all adult patients with appendicitis treated at a tertiary care hospital between May 1, 2019, and Apr. 30, 2021. Patients with appendicitis who were treated nonoperatively were identified. Patient demographics, radiographic information, management, and clinical outcomes were recorded. Results: The primary outcome was recurrent appendicitis within 6 months after discharge from the index admission. Given the competing risk of interval appendectomy, a univariate and multivariate time-toevent competing-risk analysis was performed with Cox regression. Of the 74 patients, 35 (47.3%) were women (median age 48 [interquartile range (IQR) 33-64] yr) with appendicitis treated successfully nonoperatively, 21 patients (29.2%) had recurrent appendicitis and 20 (27.8%) underwent an interval appendectomy. Median time to recurrence was 17 days (IQR 7-66). Presence of an appendicolith on imaging was associated with a higher cause-specific hazard of recurrent appendicitis. Age, sex and history of diabetes were not found to be associated with recurrence of appendicitis. The adjusted cause-specific hazard ratio of recurrent appendicitis for presence of appendicolith was 2.67 (95% confidence interval 1.09-6.56, p = 0.032). Conclusion: Our study found that presence of appendicolith was associated with a 2.67 increase in cause-specific hazard of developing recurrent appendicitis within 6 months. This information can help tailor patient selection for nonoperative management.
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Purpose. To analyze changes in work of the Khabarovsk branch of the Fyodorov Eye Microsurgery Federal State Institution (Khabarovsk branch) caused by combination of elective and emergency ophthalmic care in the context of a pandemic of the novel coronavirus disease (COVID-19). Material and methods. The article presents the organizational restructuring of activities medical units of the Khabarovsk branch, due to need for additional performance of functions emergency ophthalmological service in connection with closure of the regional ophthalmological center of the City Clinical Hospital no. 10, which previously performed this function. Complex of organizational anti-epidemic measures taken to prevent the spread of COVID-19 in pandemic is presented, their feasibility is analyzed, the results of the clinic's activities in new conditions of the COVID-19 pandemic are reflected. Results. The COVID-19 epidemic required a significant organizational restructuring of the Khabarovsk branch. In addition to large volumes of elective surgery, emergency ophthalmosurgical care was added, performed in a round-the-clock hospital. All this was superimposed on the organizational restructuring of patient flows, created to minimize their interpersonal contacts. Conclusion. The Khabarovsk branch fully coped with the tasks set, stable work was organized in the new pandemic conditions, effectively combining planned and emergency algorithms of ophthalmic surgical care. The measures taken made it possible to provide emergency ophthalmic care in full throughout the entire period of the epidemic, to resume the provision of planned ophthalmic care in full, without compromising the safety of patients' stay in the clinic.
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Background: We sought to determine how real-time video feedback compares to delayed written feedback on junior resident performance of laparoscopic skills using at-home laparoscopic training boxes. Methods: Junior surgical residents from Memorial University were randomized into 3 groups: a control group (group A), a delayed feedback group (group B), and a live feedback group (group C). Data collection was 5 months in duration. Participants practised prescribed laparoscopic skills biweekly. Intervention groups (B and C) received either delayed or live feedback on weekly practice from an expert. Pre- and post-testing were completed. Results: Twelve residents were recruited;1 was lost to follow-up. After the data collection period, the average number of pegs transferred correctly increased by 2.8 ± 1.7 for group A, 3.0 ± 2.6 for group B, and 2.0 ± 1.4 for group C. There was significant group variance (F2,8 = 5.928, p = 0.026). Post hoc testing resulted in group B outperforming groups A and C. For the intracorporeal knot tying task and number of throws completed, groups B and C both improved;no significant difference was noted between groups. Qualitative data showed an increase in confidence for all groups in completing the tasks and a preference for live compared with delayed feedback. Conclusion: Access to box trainers allowed residents to practise at home, leading to improved skill and confidence. Participants receiving delayed feedback showed a significant improvement in peg transfer. Further studies with larger sample sizes should be conducted on how feedback can affect resident outcomes in laparoscopic surgery skills.
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Delivery of health care is coming to an inflection point in regard to supply and demand, with joint replacement demand in Canada increasing from 2014 to 2019 by 20.1% for hip replacement and 22.5% for knee replacement.1 Increasing demand, combined with delays related to the COVID-19 pandemic, has created a large backlog of surgical procedures, especially in countries with universal health care like Canada and the United Kingdom, where efficient delivery of health care is even more critical.2-4 Prolonged surgical wait-lists are further compounded by systemic inefficiencies: in North America, health care functions at a productivity level of about 43%;in the surgical care setting, inefficient use of time and space accounts for 30% of costs.5 To address this, various initiatives to increase throughput, such as high-efficiency operating rooms (ORs) and parallel processing with anesthesia block rooms, have been suggested.6 At our institution, to address wait times and increasing demands, 4-joint rooms were instituted in 2004, but successful completion of 4 joint replacement procedures within the assigned OR time (i.e., 4 joints between 0730 and 1530) has been inconsistent.7 This lack of efficiency, with overtime and lack of improvement, can lead to staff disengagement, fatigue and a sense of impossibility of the task at hand.8 To foster self-improvement and staff engagement to work as a team, various models of team efficiency have been developed using the Lean method, Six Sigma and process mapping, which can be quite effective but very resource intensive.9,10 An alternative approach that has shown excellent results in improving the quality of individual surgeon practices is positive deviance (PD) seminars,11,12 which use individual performance feedback to identify team members who outperform their peers. Positive deviance has been effectively used in health care, public health, education and the private sector.13 Positive deviance seminars focus on individual strengths and resources already present, instead of negatives that require improvement. Measures The time interval data were recorded by the circulating nurse using the Surgical Information Systems. The time intervals used to determine OR efficiency were a modified version of those defined by the Association of Anesthesia Clinical Directors:14 anesthesia preparation time;patient in room to anesthesia ready, surgical preparation time;anesthesia ready to procedure start, procedure duration;(procedure start time to procedure finish), anesthesia finish time;procedure finish to patient out of room, and turnover time;start of room cleanup to patient in room.
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IntroductionThe aim of this study was to assess faecal immunochemical test (FIT) negativity in terms of its effect on cancer risk in the local symptomatic two-week wait (2WW) population. FIT was introduced to the colorectal 2WW pathway at the start of the pandemic. This study analyses the FIT-negative (<10µg Hb/g) cohort and calculates the relative risk and odds ratio associated with a negative FIT test.MethodsFIT tests were sent to symptomatic 2WW patients without rectal bleeding, iron-deficient anaemia or palpable mass. Where FIT was <10µg Hb/g investigations were moved to a radiology protocol.ResultsThe test return rate was 91% with a FIT-negative (<10µg Hb/g) rate of 82%. The FIT-negative group in the symptomatic referral pathway in Cornwall have a low (1.4%) risk of colon cancer but a significant risk (6.6%) when all cancer types are considered. The impact of a negative quantitative FIT changes the odds ratio of a patient having a luminal cancer by 0.26. The odds ratio for ‘all cancer' risk was affected by 0.83.ConclusionA negative FIT test within the local NG12 symptomatic patient group signifies a low risk of colon cancer and identifies patients who can be initially investigated with cross-sectional imaging. However, when all cancer types are considered, cancer prevalence in this group remains above 6%. In relative risk terms a negative FIT represents a small change in overall risk and this patient group still qualify for investigation through 2WW pathways.
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Background: There are well-established guidelines surrounding target wait times for patients diagnosed with cancer. Wait 1 is the time from referral to a patient's first surgical oncology appointment. Wait 2 is the time from the decision to operate to the actual operation. During the first wave of COVID-19 in March 2020, elective operations decreased and the majority of in-person appointments were cancelled or changed to telephone appointments. Oncologic operations were allowed to continue;however, routine screening temporarily stopped. Previous data have shown that during the first wave of the pandemic, the percentage of patients meeting the target time for Wait 2 significantly decreased. This translates to longer wait times for oncologic operations overall. The objective of this study was to determine the effect that the COVID-19 pandemic has had on postoperative and oncologic outcomes in patients who underwent surgery for colorectal or hepatobiliary malignancy during the first wave of the pandemic. Methods: Outcomes from all patients who underwent oncologic colorectal or hepatobiliary surgery from Mar. 15, to June 30, 2020, were compared with the same time period in 2019. Results: In patients who underwent either colorectal or hepatobiliary surgery, there was no significant difference in readmission rates, postoperative emergency department visits, or length of stay between 2019 and 2020. In patients who underwent hepatobiliary (HPB) surgery there was no significant difference in tumour stage (p = 0.122), margin status (p = 0.157), postoperative complications (p = 0.328) or 30-day mortality (p = 0.977) from 2019 to 2020. There was a significantly higher 1-year mortality in 2020 (29.2%) than 2019 (4%) (p = 0.017). Conclusion: Our study shows that the effect of the COVID-19 pandemic was not associated with increased immediate complications or higher stage of malignancy at the time of operation;however, it was associated with a significantly higher mortality at 1 year for patients who underwent HPB oncologic surgery.
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Background: Enabling technologies such as robotic assistance for lumbar fusions are being combined with minimally invasive surgical (MIS) techniques to optimize patient outcomes. During the COVID-19 pandemic, substantial restrictions in performing inpatient spine surgeries were encountered. Thus, an opportunity to consider outpatient lumbar fusions was presented. This report summarizes a single surgeon's experience of outpatient lumbar fusions using robotic-assisted MIS techniques. Methods: A retrospective review of prospectively collected cases from a single-surgeon, multi-institution database was performed for all robotic-assisted lumbar fusions. Data including patient demographics, diagnosis, procedure type, operating room time, robot time, blood loss and complications were analyzed. Results: A total of 98 robotic-assisted lumbar fusions were performed. Of these, 22 (22%) cases were performed on an outpatient basis, at the hospital. Two of the patients were male and 10 were female. Average age was 60 years (range 32-80 yr) and average body mass index was 27.3 (range 20-34). Nineteen of the cases were considered primary surgery, and 3 were revisions. The most common indications for lumbar fusion were spondylolisthesis, spinal stenosis and spondylolysis. Techniques for fusion included: transforaminal lumbar interbody fusion (18), posterior lumbar interbody fusion (3) and oblique lateral interbody fusion (1). All instrumentation was placed using a percutaneous, roboticassisted technique, using either the Mazor X or the Mazor X Stealth Edition.Twenty cases were 1 level, 1 case was 2 level and 1 case was 3 level. Average surgery time was 146.9 minutes (range 90-224 min), and robot time was 28.3 minutes (range 17-50 min). Average time was similar between the private, community hospital (surgery time 151.7 min, robot time 29.3 min) and the academic medical centre (surgery time 142.1 min, robot time 27.3 min). There were no procedurerelated complications or any complications that required admitted to hospital a patient with a planned outpatient stay. Two patients developed urinary retention requiring in/out catheterization before discharge. One male patient returned to the emergency department for urinary retention requiring catheterization and 1 female patient returned for leg edema. Conclusion: Outpatient lumbar fusions can be safely and successfully performed using MIS and robotic-assisted techniques, especially when hospital bed availability is limited.
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IntroductionThe aim of this study was to determine the impact of the COVID-19 pandemic on the provision of clinical services (perioperative clinical outcomes and productivity) of the department of endocrine and general surgery at a teaching hospital in the UK.MethodsA retrospective chart review was conducted of all patients who were operated in our department during two periods: 1 April to 31 October 2019 (pre-COVID-19 period) and 1 April to 31 October 2020 (COVID-19 period). The perioperative clinical outcomes and productivity of our department for the two time periods were compared.ResultsIn the pre-COVID-19 period, 130 operations were carried out, whereas in the COVID-19 group, this reduced to 89. The baseline characteristics between the two groups did not significantly differ. Parathyroid operations decreased significantly by 68% between the two study periods. Overall, during the COVID-19 phase, the department maintained 68% of its operating workload compared with the respective 2019 time period. The clinical outcomes for the patients who had a thyroid/parathyroid/adrenal operation were not statistically different for the two study periods. There were no COVID-19 related perioperative complications for any of the operated patients and no patient tested positive for COVID-19 while an inpatient. For the COVID-19 group, the department maintained 67% of its outpatient appointments for endocrine surgery and 26% for general surgery pathologies.ConclusionsThe COVID-19 pandemic significantly reduced the clinical activity of our department. However, it is possible to continue providing clinical services for urgent/cancer cases with the appropriate safety measures in place.