Management of the Surgical Patient during the First and Second Wave of COVID-19 Pandemic: Experience of a Tertiary Care Centre

Objective: Due to the COVID 19 pandemic healthcare providers all over the world had brought some changes in the management of surgical patients. This study is aimed to estimate the impact of pandemic on surgical practices. Material(s) and Method(s): We conducted a retrospective review of the medical records of all patients admitted to the department of general surgery (both elective & emergency), SCB Medical College and Hospital, Odisha, India from April 1 to July 31, 2020, and 2021 and the records were those of patients who were admitted in the same period in 2019. Data collection includes the number of admissions, the reason for admission, the age & gender of the patients admitted patients and type of management. Result(s): There was a 57.5% reduction in total admission during first COVID in pandemic 2020 and 58.7% reduction during second wave of pandemic in 2021. The proportion of patient presenting to emergency department was more in 2020 and 2021 than 2019. Number of emergency admission decreased by 46.54% in 2020 and 46% in 2021. There was a 79.5% drop in the number of out-patients admission in 2020 and 84% in 2021. Furthermore a 79.8% reduction in elective surgical intervention noticed in 2020 and 80% in 2021. Conservative management was preferred over surgical management during the COVID era. Conclusion(s): COVID-19 has led to a drastic reduction in outpatient and elective surgical practices. Hence creating a major concern for all surgeons about the critical situation.Copyright © 2023, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

The lockdown effect on gynaecological cancer surgeries during the COVID-19 pandemic

The COVID-19 outbreak increased significantly the burden of hospital based services in an international setting. Facilities dealing with cancer cases had to cope with the burden of the disease and with the waiting lists that continuously grow as cancer patients tend to refer with increasing rates in referral centers. Surgical departments with oncological patients had to prioritize patients in order to help provide optimal care, without posing them at risk of a potential infection during their hospitalization. In the present article we report the experience of the Gynecologic oncology section of the First Department of Obstetrics and Gynecology of the National and Kapodistrian University of Athens during the first 12 months of the pandemic. © 2022 Authors. All rights reserved.

Minimally Invasive Procedures, Perioperative Telemedicine, and Decreased Hospital Stays Following Covid-19 Surgical Restrictions: Spinal Surgery.

The 2019 severe acute respiratory syndrome coronavirus 2 pandemic had devastating impacts on healthcare system operations. Disruption of this delicate system led to international healthcare challenges with new policy changes that affected all specialties, including the global spine surgery community. The pandemic disrupted normal spine surgery proceedings, restricting, and postponing elective procedures, which comprise a large proportion of spine surgeries. This disruption may have contributed to significant economic losses for providers and resulted in the prolonged impairment of patients who were forced to postpone their procedures. However, response to the pandemic precipitated new procedural guidelines and practices that prioritize health outcomes and satisfaction. These new changes and innovations are positioned to provide lasting economic and procedural impacts in favor of both providers and patients. Thus, the objective of our review is to explore how spinal surgical practices and post-op recovery changed following COVID-19 and highlight some lasting impacts the pandemic created for future patients.

Low-Intensity Pulsed Ultrasound Therapy in Patients With Post-traumatic Delayed Union and Non-union.

Background Fracture non-union can lead to significant patient morbidity with poor quality of life. Due to the cost, complexity, and potential risks of revision surgery, there has been an increased popularity in the use of low-intensity pulsed ultrasound therapy (LIPUS), which accelerates and promotes bone consolidation. There is an ongoing debate regarding the use and efficacy of LIPUS in delayed union and non-union. This study aims to assess the success rate of LIPUS therapy in patients treated for delayed and non-union fractures, explicitly focusing on the impact of patient co-morbidities and fracture characteristics. Method A retrospective observational study was performed of all consecutive patients who received LIPUS therapy in a single institution from January 2016 to September 2022. Of 127 identified patients, only 99 patients met our inclusion criteria. Data collection entailed reviewing the clinical notes to assess patients' sex, age, co-morbidities, initial treatment method, time to initiate LIPUS, whether a CT was performed to diagnose non-union, time to union and whether revision surgery was needed. Two independent senior orthopedic doctors reviewed the patients' radiographs, measured the interfragmentary bone gap of all fractures, and assessed whether the radiographic union was achieved. Results The mean age of the included patients was 52.5 (SD±16.9) years with a male-to-female ratio of 1:1.6. At initial presentation, 65 (out of 99) patients were treated surgically, whereas the rest were managed conservatively. 80.8% of patients developed atrophic non-union. All 99 included patients were fitted with LIPUS once delayed/ non-union was diagnosed; the average time to fitting was 5.1 (SD±3.9) months. Of these, 61.6% of patients were successfully treated with LIPUS with a clinical and radiological union at an average of 4.3 (SD±1.9) months. The rest of the patients needed further surgical intervention due to ongoing non-union. The interfragmentary bone gap was the only statistically significant factor influencing the success of LIPUS therapy (p=0.003). In contrast, no statistically significant association was identified between the outcome of LIPUS therapy and the patient's age, sex, diabetes, and smoking status. Conclusion This study demonstrated a 61.6% progression to union rate of patients treated with LIPUS therapy for delayed union and non-union. The interfragmentary bone gap was identified as the only statistically significant factor influencing the success of LIPUS therapy. In the current climate post-lockdown and with ongoing Covid 19 outbreaks impacting elective waiting lists negatively, there is increased value and demand for non-surgical treatment options. LIPUS therapy represents an important complementary non-surgical and low-risk treatment pathway for delayed union and non-union.

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative.

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.

Bowel Ischemia in COVID-19 Infection: One-Year Surgical Experience.

BACKGROUND: COVID-19 is a deadly multisystemic disease, and bowel ischemia, the most consequential gastrointestinal manifestation, remains poorly described. Our goal is to describe our institution's surgical experience with management of bowel ischemia due to COVID-19 infection over a one-year period. METHODS: All patients admitted to our institution between March 2020 and March 2021 for treatment of COVID-19 infection and who underwent exploratory laparotomy with intra-operative confirmation of bowel ischemia were included. Data from the medical records were analyzed. RESULTS: Twenty patients were included. Eighty percent had a new or increasing vasopressor requirement, 70% had abdominal distension, and 50% had increased gastric residuals. Intra-operatively, ischemia affected the large bowel in 80% of cases, the small bowel in 60%, and both in 40%. Sixty five percent had an initial damage control laparotomy. Most of the resected bowel specimens had a characteristic appearance at the time of surgery, with a yellow discoloration, small areas of antimesenteric necrosis, and very sharp borders. Histologically, the bowel specimens frequently have fibrin thrombi in the small submucosal and mucosal blood vessels in areas of mucosal necrosis. Overall mortality in this cohort was 33%. Forty percent of patients had a thromboembolic complication overall with 88% of these developing a thromboembolic phenomenon despite being on prophylactic pre-operative anticoagulation. CONCLUSION: Bowel ischemia is a potentially lethal complication of COVID-19 infection with typical gross and histologic characteristics. Suspicious clinical features that should trigger surgical evaluation include a new or increasing vasopressor requirement, abdominal distension, and intolerance of gastric feeds.

Management of Acquired Factor VIII Inhibitors With NovoSeven and Obizur.

Acquired hemophilia A (AHA) is a rare hemorrhagic disorder caused by the production of autoantibodies against coagulation factor VIII (FVIII). AHA is associated with significant morbidity and mortality primarily as a result of bleeding. Although many disorders are associated with the development of these inhibitors, up to 50% of cases remain idiopathic. The approach to therapy involves an initial strategy often to control acute bleeding episodes followed by definitive treatment to eradicate the inhibitor with immunosuppressive agents. We present the case of a 63-year-old Caucasian male hospitalized for severe Covid-19 who developed bleeding due to an acquired FVIII inhibitor that had never been treated definitively. Our case presentation focuses on in-hospital management of this patient's acute bleeding episodes with by-passing agents and recombinant porcine factor VIII.

Management of proximal femur fractures in the elderly: current concepts and treatment options.

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Surgical Management of Gallstone Ileus in Low-Settings Hospital during COVID-19 Outbreak: A Case Report.

Introduction Gallstone ileus is a very infrequent complication of cholelithiasis in which single or multiple stones pass through an abnormal fistula to the lumen of the intestine leading to a true mechanical obstruction. We are reporting a case of a female who developed intestinal obstruction due to gallstones during the coronavirus disease 2019 (COVID-19) outbreak and was managed urgently surgically in a low-settings hospital. Case Presentation An 85-year-old white female with 40 years history of gallstone disease, hypertension, and type-2 diabetes presented to the accidents and emergency unit with upper central crampy abdominal pain for 5 days associated with green color vomiting and absolute constipation. On examination, she was barely stable, dehydrated, had a distended abdomen, and guarding in the epigastric region. Her electrolytes were disturbed and had elevated serum creatinine and blood urea. Imaging studies confirmed gallstone ileus. Management was surgical despite the lack of facilities and equipment including COVID-19 personal protective equipment. Conclusion Despite being an infrequent complication, gallstone ileus might present at the most unexpected time and in the least equipped hospital where the surgeon's suspicion, risk stratification, and improvisation by utilizing what is available are the keys for successful management and saving lives.

Management of melanoma patients during COVID-19 pandemic in an Italian skin unit.

Due to the COVID-19 crisis, many scheduled medical and surgical activities have been suspended. This interruption to the healthcare system can negatively affect the diagnosis and management of melanoma. Neglecting melanoma throughout the outbreak may be associated with increased rates of mortality, morbidity, and healthcare expenses. We performed a retrospective review of all dermatological and surgical activity performed in our Melanoma Skin Unit between 23 February 2020 and 21 May 2020 and compared these data with those from the same period in 2019. During the lockdown period, we observed a decrease in dermatologic follow-up (DFU) (-30.2%) and in surgical follow-up (SFU) (-37%), and no modification of melanoma diagnosis (-3%). Finally, surgical excisions (SE) (+ 31.7%) increased, but sentinel lymph node biopsy (SLNB) (-29%) and lymph node dissections(LND) (-64%) decreased compared to the same period in 2019. Our experience supports the continuation of surgical and diagnostic procedures in patients with melanoma during the COVID-19 pandemic. Surgical and follow-up procedures for the diagnosis and treatment of melanoma should not be postponed considering that the pandemic is lasting for an extended period.

[A surgically relevant summary of the addendum to the S3 guidelines of the DGVS on Crohn's disease and ulcerative colitis : Treatment of chronic inflammatory bowel diseases in the COVID-19 pandemic]. / Eine chirurgisch relevante Zusammenfassung des Addendums zu den DGVS-S3-Leitlinien Morbus Crohn und Colitis ulcerosa : Therapie chronisch entzündlicher Darmerkrankungen in der COVID-19-Pandemie.

In order to improve the care of patients with chronic inflammatory bowel diseases during the coronavirus disease 2019 (COVID-19) pandemic, the currently valid guidelines of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) on Crohn's disease and ulcerative colitis were extended within a virtual conference to include current and practically relevant recommendations. The addendum addresses in particular the risk of COVID-19 infections in patients with chronic inflammatory bowel diseases, the diagnostics under the conditions of the pandemic, the consequences for the pharmacotherapy and operative treatment of the underlying disease. It also addresses general measures for protection against infections and for adjunctive treatment of patients with chronic inflammatory bowel diseases.

Recommendations for perinatal and neonatal surgical management during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has spread rapidly around the world and is a significant threat to global health. Patients in the Neonatal Surgery Department have rapidly progressing diseases and immature immunity, which makes them vulnerable to pulmonary infection and a relatively higher mortality. This means that these patients require multidisciplinary treatment including early diagnosis, timely transport, emergency surgery and intensive critical care. The COVID-19 pandemic poses a threat to carrying out these treatments. To provide support for the health protection requirements of the medical services in the Neonatal Surgery Department, we developed recommendations focusing on patient transport, surgery selection and protection requirements with the aim of improving treatment strategies for patients and preventing infection in medical staff during the current COVID-19 pandemic.

Anesthetic and surgical management of tracheostomy in a patient with COVID-19.

OBJECTIVE: The ongoing pandemic coronavirus disease-2019 (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare. Since COVID-19 spreads through contact and droplet infection routes, careful attention to infection control and surgical management is important to prevent cross-contamination of patients and medical staff. Tracheostomy is an effective method to treat severe respiratory dysfunction with prolonged respiratory management and should be performed as a high-risk procedure METHOD: The anesthetic and surgical considerations in this case involved difficult goals of the patient safety and the management of infection among health care workers. Our surgical procedure was developed based on the previous experiences of severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). RESULTS: We described the management procedures for tracheostomy in a patient with COVID-19, including the anesthesia preparation, surgical procedures, required medical supplies (a N95 mask or powered air purifying respirator, goggles, face shield, cap, double gloves, and a water-resistant disposable gown), and appropriate consultation with an infection prevention team. CONCLUSION: Appropriate contact, airborne precautions, and sufficient use of muscle relaxants are essential for performing tracheostomy in a patient with COVID-19.