Outcomes and CT scan three-dimensional volumetric analysis of emergent paraesophageal hernia repairs: predicting patients who will require emergent repair.

INTRODUCTION: Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair. METHODS: A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software. RESULTS: Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm3, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm2, p < 0.001). In multivariate analysis, HSV increase of 100cm3 (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence. CONCLUSIONS: Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.

Moving forward with elective vascular work: a reflection on the impact of COVID-19 on a regional vascular hub.

INTRODUCTION: Following the initial COVID-19 surge in the UK, there was a national incentive for elective vascular surgery to be restricted to 'clean' sites to reduce perioperative cross-infection and subsequent mortality. We assessed the risk of dying from perioperatively acquired COVID-19 during the peak of the London outbreak. METHODS: Forty-three consecutive patients who had vascular (n=48) procedures in March and April 2020 at a regional hub serving five London hospitals were analysed. The patients were screened for COVID-19 in the 30-day postoperative period and the main outcome measure was mortality from COVID-19. A comparison was then made with patients who underwent minimally invasive procedures in our integrated interventional radiology department. Median follow-up was 41 days (interquartile range 8-58) overall. RESULTS: Three patients (7%) in the vascular group (median age 61 years, all diabetic, two male) died from COVID-19, all of whom tested positive postoperatively. Two others became positive but recovered. In comparison, two patients (2%) in the interventional radiology group died from COVID-19; however, one was positive prior to their procedure. CONCLUSION: Only urgent vascular cases should be performed during a COVID-19 surge. However, with growing waiting lists for elective surgery following the pandemic's second wave, further restrictions may not be a viable long-term solution. When prevalence of the disease is lower and if resources allow, resumption of care at 'hot' sites should be considered, if safety measures can be implemented. The advantages of minimally invasive surgery may also reduce risk.

Safe Surgery During the COVID-19 Pandemic.

PURPOSE OF REVIEW: Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future. RECENT FINDINGS: Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

Tracheotomy in the SARS-CoV-2 pandemic.

The severe acute respiratory syndrome (SARS)-CoV-2 pandemic continues to produce a large number of patients with chronic respiratory failure and ventilator dependence. As such, surgeons will be called upon to perform tracheotomy for a subset of these chronically intubated patients. As seen during the SARS and the SARS-CoV-2 outbreaks, aerosol-generating procedures (AGP) have been associated with higher rates of infection of medical personnel and potential acceleration of viral dissemination throughout the medical center. Therefore, a thoughtful approach to tracheotomy (and other AGPs) is imperative and maintaining traditional management norms may be unsuitable or even potentially harmful. We sought to review the existing evidence informing best practices and then develop straightforward guidelines for tracheotomy during the SARS-CoV-2 pandemic. This communication is the product of those efforts and is based on national and international experience with the current SARS-CoV-2 pandemic and the SARS epidemic of 2002/2003.

Nosocomial SARS-CoV-2 transmission in postoperative infection and mortality: analysis of 14 798 procedures.

This study used a national administrative database to estimate perioperative SARS-CoV-2 infection risk, and associated mortality, relative to nosocomial transmission rates. The impact of nosocomial transmission was greatest after major emergency surgery, whereas laparoscopic surgery may be protective owing to reduced duration of hospital stay. Procedure-specific risk estimates are provided to facilitate surgical decision-making and informed consent. Estimated risks.

Surgical oncology operative experience at a high-volume safety-net hospital during the COVID-19 pandemic.

BACKGROUND: The coronavirus (COVID-19) pandemic led to disruptions in operative and hospital capabilities as the country triaged resources and canceled elective procedures. This study details the operative experience of a safety-net hospital for cancer-related operations during a 3-month period at the height of the pandemic. METHODS: Patients operated on for or diagnosed with malignancies of the abdomen, breast, skin, or soft-tissue (September 3, 2020-September 6, 2020) were identified from operative/clinic schedules. Sociodemographics, tumor and treatment characteristics, and COVID-19 information was identified through retrospective chart review of a prospectively maintained database. Descriptive statistics were calculated. RESULTS: Fifty patients evaluated within this window underwent oncologic surgery. Median age was 61 (interquartile range: 53-68), 56% were female, 86% were White, and 66% were Hispanic. The majority (28%) were for colon cancer. Only two patients tested positive for COVID-19 preoperatively or within 30 days of their operation. There were no mortalities during the 1-year study period. CONCLUSION: During the COVID-19 pandemic, many hospitals and operative centers limited interventions to preserve resources, but oncologic procedures continued at many large-volume academic cancer centers. This study underscores the importance of continuing to offer surgery during the pandemic for surgical oncology cases at safety-net hospitals to minimize delays in time-sensitive oncologic treatment.

The effect of the COVID-19 pandemic on orthopedic surgeries in a tertiary referral center.

OBJECTIVES: The aim of this study is to investigate the effect of the novel coronavirus-2019 (COVID-19) pandemic on the operational trends in the orthopedic surgery department of a tertiary referral center. PATIENTS AND METHODS: A total of 305 orthopedic surgical procedures in 245 patients (136 males, 109 females; mean age: 34±26.6 years; range, 0 to 91 years) between March 16th and June 27th, 2020 were retrospectively analyzed. The same period of the year before including 860 procedures in 783 patients (364 males, 419 females; mean age: 33.6±25.8 years; range, 0 to 95 years) was also reviewed as a pre-pandemic control group. Patient demographics, surgical indications, COVID-19 polymerase chain reaction (PCR) test status, method of anesthesia, surgical subspecialties (trauma, sports, etc.), trauma mechanisms, and surgical priorities were evaluated. The pandemic and the pre-pandemic periods were compared. RESULTS: The rate of elective surgeries decreased compared to the previous year, and priority C type surgeries had the highest frequency (42.5%). Orthopedic trauma was the leading subspecialty with 91 (29.8%) cases and had a higher share, compared to the pre-pandemic period (17.0%). Hip fractures (18.7%) were the most common cause of trauma surgery, and simple falls (42.3%) composed the largest group of trauma mechanisms, which was similar to the pre-pandemic period (hip fractures, 13.6%; simple falls, 42.5%). The distribution of surgical urgency levels and subspecialties differed significantly between the pre-pandemic and pandemic periods (p<0.001). Post-hoc analysis of subspecialty distribution revealed a significant decrease in arthroplasty (p=0.002) and hand surgery (p<0.001), and a significant increase in trauma (p<0.001) and the "other" category (p<0.001). CONCLUSION: Our experience in a tertiary referral center illustrated a shift toward performing emergent and urgent surgeries, when the severity of the outbreak increased. Prioritizing surgical urgencies during the outbreak changed the orthopedic surgery practice with an emphasis on trauma and oncology surgeries. Hip fractures were the most common cause of trauma surgery, and simple falls composed the largest group of trauma mechanisms.

Reintroduction of elective cardiac interventions in the era of COVID-19: the Barts experience.

BACKGROUND: The response to COVID-19 has required cancellation of all but the most urgent procedures; there is therefore a need for the reintroduction of a safe elective pathway. METHODS: This was a study of a pilot pathway performed at Barts Heart Centre for the admission of patients requiring elective coronary and structural procedures during the COVID-19 pandemic (April-June 2020). All patients on coronary and structural waiting lists were screened for procedural indications, urgency and adverse features for COVID-19 prognosis and discussed at dedicated multidisciplinary teams. Dedicated admission pathways involving preadmission isolation, additional consent, COVID-19 PCR testing and dedicated clean areas were used. RESULTS: 143 patients (101 coronary and 42 structural) underwent procedures (coronary angiography, percutaneous coronary intervention, transcatheter aortic valve intervention and MitralClip) during the study period. The average age was 68.2; 74% were male; and over 93% had one or more moderate COVID-19 risk factors. All patients were COVID-19 PCR negative on admission with (8.1%) COVID-19 antibody positive (swab negative). All procedures were performed successfully with low rates of procedural complications (9.8%). At 2-week follow-up, no patients had symptoms or confirmed COVID-19 infection with significant improvements in quality if life and symptoms. CONCLUSION: We demonstrated that patients undergoing coronary and structural procedures can be safely admitted during the COVID-19 pandemic, with no patients contracting COVID-19 during their admission. Reassuringly, patients reflective of typical practice, that is, those at moderate or higher risk, were treated successfully. This pilot provides important information applicable to other settings, specialties and areas to reintroduce services safely.

Impact of the COVID-19 pandemic on emergency and elective hip surgeries in Norway.

Background and purpose - Many countries implemented strict lockdown policies to control the COVID-19 pandemic during March 2020. The impacts of lockdown policies on joint surgeries are unknown. Therefore, we assessed the effects of COVID-19 pandemic lockdown restrictions on the number of emergency and elective hip joint surgeries, and explored whether these procedures are more/less affected by lockdown restrictions than other hospital care.Patients and methods - In 1,344,355 persons aged ≥ 35 years in the Norwegian emergency preparedness (BEREDT C19) register, we studied the daily number of persons having (1) emergency surgeries due to hip fractures, and (2) electively planned surgeries due to hip osteoarthritis before and after COVID-19 lockdown restrictions were implemented nationally on March 13, 2020, for different age and sex groups. Incidence rate ratios (IRR) reflect the after-lockdown number of surgeries divided by the before-lockdown number of surgeries.Results - After-lockdown elective hip surgeries comprised one-third the number of before-lockdown (IRR ∼0.3), which is a greater drop than that seen in all-cause elective hospital care (IRR ∼0.6). Men aged 35-69 had half the number of emergency hip fracture surgeries (IRR ∼0.6), whereas women aged ≥ 70 had the same number of emergency hip fracture surgeries after lockdown (IRR ∼1). Only women aged 35-69 and men aged ≥ 70 had emergency hip fracture surgery rates after lockdown comparable to what may be expected based on analyses of all-cause acute care (IRR ∼0.80)Interpretation - It is important to note for future pandemics management that lockdown restrictions may impact more on scheduled joint surgery than other scheduled hospital care. Lockdown may also impact the number of emergency joint surgeries for men aged ≥ 35 but not those for women aged ≥ 70.

Time to adapt in the pandemic era: a prospective randomized non -inferiority study comparing time to intubate with and without the barrier box.

BACKGROUND: The challenges posed by the spread of COVID-19 disease through aerosols have compelled anesthesiologists to modify their airway management practices. Devices such as barrier boxes are being considered as potential adjuncts to full PPE's to limit the aerosol spread. Usage of the barrier box raises concerns of delay in time to intubate (TTI). We designed our study to determine if using a barrier box with glidescope delays TTI within acceptable parameters to make relevant clinical conclusions. METHODS: Seventy-eight patients were enrolled in this prospective non-inferiority controlled trial and were randomly allocated to either group C (without the barrier box) or the study group BB (using barrier box). The primary measured endpoint is time to intubate (TTI), which is defined as time taken from loss of twitches confirmed with a peripheral nerve stimulator to confirmation of end-tidal CO 2. 15 s was used as non-inferiority margin for the purpose of the study. We used an unpaired two-sample single-sided t-test to test our non- inferiority hypothesis (H 0: Mean TTI diff ≥15 s, H A: Mean TTI diff < 15 s). Secondary endpoints include the number of attempts at intubation, lowest oxygen saturation during induction, and the need for bag-mask ventilation. RESULTS: Mean TTI in group C was 42 s (CI 19.2 to 64.8) vs. 52.1 s (CI 26.1 to 78) in group BB. The difference in mean TTI was 10.1 s (CI -∞ to 14.9). We rejected the null hypothesis and concluded with 95% confidence that the difference of the mean TTI between the groups is less than < 15 s (95% CI -∞ to 14.9,p = 0.0461). Our induction times were comparable (67.7 vs. 65.9 s).100% of our patients were intubated on the first attempt in both groups. None of our patients needed rescue breaths. CONCLUSIONS: We conclude that in patients with normal airway exam, scheduled for elective surgeries, our barrier box did not cause any clinically significant delay in TTI when airway manipulation is performed by well-trained providers. The study was retrospectively registered at clinicaltrials.gov (NCT04411056) on May 27, 2020.

Colorectal Cancer Surgery During the COVID-19 Pandemic: A Single Center Experience.

BACKGROUND/AIM: A notable re-allocation of healthcare resources and specific clinical and organizational measures have been required to prevent COVID-19 infection among hospitalized patients and healthcare workers. PATIENTS AND METHODS: From March 9th to May 9th 2020 we performed colorectal cancer elective surgery on 25 patients: a pre-hospital screening was carried out in order to avoid hospitalization of patients suspected of COVID-19 infection. RESULTS: All patients (median age=76 years; range=37-88 years) were considered suitable for admission after telephone triage; the median interval between primary diagnosis and hospital admission was 23.1 days (range=1-55 days). The median hospitalization was 7.8 days (range=4-18 days). One COVID-19-associated death was reported. CONCLUSION: Our experience demonstrates that safe colorectal cancer elective surgery can be performed during the pandemic COVID-19. Further consensus and guidelines to prevent diffusion of pandemic diseases among hospitalized patients and healthcare workers still need to be implemented.