Impact of the COVID-19 Pandemic on Elective and Emergency Surgeries, and Postoperative Mortality in a Brazilian Metropolitan Area: A Time-Series Cohort Study.

Purpose: The COVID-19 pandemic posed a worldwide challenge, leading to radical changes in surgical services. The primary objective of the study was to assess the impact of COVID-19 on elective and emergency surgeries in a Brazilian metropolitan area. The secondary objective was to compare the postoperative hospital mortality before and during the pandemic. Patients and Methods: Time-series cohort study including data of all patients admitted for elective or emergency surgery at the hospitals in the Public Health System of Federal District, Brazil, between March 2018 and February 2022, using data extracted from the Hospital Information System of Brazilian Ministry of Health (SIH/DATASUS) on September 30, 2022. A causal impact analysis was used to evaluate the impact of COVID-19 on elective and emergency surgeries and hospital mortality. Results: There were 174,473 surgeries during the study period. There was a reduction in overall (absolute effect per week: -227.5; 95% CI: -307.0 to -149.0), elective (absolute effect per week: -170.9; 95% CI: -232.8 to -112.0), and emergency (absolute effect per week: -57.7; 95% CI: -87.5 to -27.7) surgeries during the COVID-19 period. Comparing the surgeries performed before and after the COVID-19 onset, there was an increase in emergency surgeries (53.0% vs 68.8%, P < 0.001) and no significant hospital length of stay (P = 0.112). The effect of the COVID-19 pandemic on postoperative hospital mortality was not statistically significant (absolute effect per week: 2.1, 95% CI: -0.01 to 4.2). Conclusion: Our study showed a reduction in elective and emergency surgeries during the COVID-19 pandemic, possibly due to disruptions in surgical services. These findings highlight that it is crucial to implement effective strategies to prevent the accumulation of surgical waiting lists in times of crisis and improve outcomes for surgical patients.

Evolución de la cirugía urgente en un servicio de cirugía general durante la pandemia de COVID-19 y comparación con una cohorte histórica.

BACKGROUND: Acute care surgery decreased during the first wave of the COVID-19 pandemic. OBJECTIVE: To study the evolution of acute care surgery and its relationship with the pandemic severity. METHOD: Retrospective cohort study which compared patients who underwent acute care surgery during the pandemic to a control group. RESULTS: A total of 660 patients were included (253 in the control group, 67 in the first-wave, 193 in the valley, and 147 in the second wave). The median daily number of acute care surgery procedures was 2 during the control period. This activity decreased during the first wave (1/day), increased during the valley (2/day), and didn't change in the second wave (2/day). Serious complications were more common during the first wave (22.4%). A negative linear correlation was found between the daily number of acute care surgery procedures, number of patients being admitted to the hospital each day and daily number of patients dying because of COVID-19. CONCLUSIONS: Acute care surgery was reduced during the first wave of the COVID-19 pandemic, increased during the valley, and returned to the pre-pandemic level during the second wave. Thus, acute care surgery was related to pandemic severity, with fewer surgeries being performed when the pandemic was more severe.

ANTECEDENTES: La cirugía urgente disminuyó durante la primera ola de la pandemia de COVID-19. OBJETIVO: Estudiar la evolución de la cirugía urgente y su relación con la gravedad de la pandemia. MÉTODO: Estudio de cohortes retrospectivo que compara los pacientes intervenidos de forma urgente durante la pandemia con un grupo control. RESULTADOS: Se incluyeron 660 pacientes (253 en el grupo control, 67 en primera ola de la pandemia, 193 en el periodo valle y 147 en la segunda ola). La mediana del número de cirugías urgentes fue de 2 (intervalo intercuartílico: 1-3) durante el periodo control, disminuyó durante la primera ola (1/día), aumentó durante el valle (2/día) y no se modificó en la segunda ola (2/día). Las complicaciones mayores fueron más comunes durante la primera ola (22.4%). Se encontró una correlación lineal negativa entre el número de procedimientos quirúrgicos urgentes diarios y el número de ingresos hospitalarios y fallecimientos diarios por COVID-19. CONCLUSIONES: La cirugía urgente se redujo durante la primera ola, aumentó durante el periodo valle y volvió a niveles prepandémicos durante la segunda ola. Además, la cirugía urgente se relaciona con la gravedad de la pandemia, ya que se realizaron menos cirugías urgentes durante el periodo de mayor gravedad de la pandemia.

Successful management of the open abdomen with hydrocolloid dressing in a resource-constrained setting.

PURPOSE: To evaluate and detail the management of a difficult, long-term, open abdomen in a resource constraint setting with the use of Hydrocolloid dressing. METHOD: An observational retrospective study was conducted at a single level-1 trauma center. Over a 5-year period, all the open abdomen patients were evaluated and the cohorts who were treated with Hydrocolloid dressings were described in detail from their admission to their discharge. RESULTS: During this period, there were 147 open abdomens. 7.5% (11) patients required long-term open abdomen management, in which Hydrocolloid dressing was utilized. Of this group, there were no entero/colonic-atmospheric fistulas, and there was either de-novo complete skin coverage, successful skin graft placement, or definitive abdominal wall repair in all the patients. De-novo complete skin coverage took an average of 7.4 months. All the patients were discharged home after an average of 107 days hospitalized. CONCLUSION: Despite not being an optimal management of an open abdomen, there are always a small group of these patients who lose abdominal domain, are critically ill or injured, and have prolonged hospitalization with an open abdomen. In this cohort, and especially in resource constraint settings, Hydrocolloid dressing is a cost-efficient, simple, and effective method to treat the 'long-term' open abdomens.

Cost evaluation of temporary abdominal closure methods in abdominal sepsis patients successfully treated with an open abdomen. Should we take temporary abdominal closure methods at face value? Health economic evaluation.

BACKGROUND: Many commercial and artisanal devices are utilized for temporary abdominal closure in patients being managed with an open abdomen for abdominal sepsis. The costs of materials required to treat patients with an open abdomen varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected. STUDY DESIGN: A single-center retrospective review of 46 patients diagnosed with abdominal sepsis and successfully treated with an open abdomen and one of the three temporary abdominal closure methods during the year 2018 in a tertiary hospital was evaluated using a gross-cost pricing model developed by the authors. The three temporary abdominal closure methods were a locally manufactured Bogota Bag, and commercial abdominal negative pressure therapy dressing and negative pressure therapy with 0.9% saline solution instillation. The per-unit-costs were hospital day and intensive care day, number of surgical procedures per patient, cost negative pressure therapy kits. RESULTS: Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other temporary abdominal closure methods. The reduction of hospital length of stay, as well as fewer number of surgeries were the main contributing factors in diminishing costs. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was nearly 50% lower than using the other two temporary abdominal closure methods. CONCLUSIONS: The costs relating to managing abdominal sepsis in the septic open abdomen vary greatly according to the temporary abdominal closure utilized. If the hospital length of stay, intensive care unit length of stay and number of surgeries required are the main parameters used in determining costs, the use of negative pressure therapy with 0.9% saline solution instillation reduces costs by nearly 50% in comparison to conventional negative pressure wound therapy and Bogota Bag. In this instance, the more expensive method at first glance, obtained a considerable cost reduction when compared to therapies that utilize less expensive materials.

Expanding the field of acute care surgery: a systematic review of the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in cases of morbidly adherent placenta.

PURPOSE: Prophylactic placement of endovascular balloon occlusion catheters has grown to be part of the surgical plans to control intraoperative hemorrhage in cases of abnormal placentation. We performed a systematic literature review to investigate the safety and effectiveness of the use of REBOA during cesarean delivery in pregnant woman with morbidly adherent placenta. METHODS: A systematic review was performed. Relevant case reports and nonrandomized studies were identified by the literature search in MEDLINE. We included studies involving pregnant woman with diagnosis of abnormal placentation who underwent cesarean delivery with REBOA placed for hemorrhage control. MINORS' criteria were used to evaluate the risk of bias of included studies. A formal meta-analysis was not performed. RESULTS: Eight studies were included in cumulative results. These studies included a total of 392 patients. Overall, REBOA was deployed in 336 patients. Six studies reported the use of REBOA as an adjunct for prophylactic hemorrhage control in pregnant woman with diagnosis of morbidly adherent placenta undergoing elective cesarean delivery. In two studies, REBOA was deployed in patients already in established hemorrhagic shock at the moment of cesarean delivery. REBOA was deployed primarily by interventional radiologists; however, one study reported a surgeon as the REBOA provider. The results from our qualitative synthesis indicate that the use of REBOA during cesarean delivery resulted in less blood loss with a low rate complications occurrence. CONCLUSION: REBOA is a feasible, safe, and effective means of prophylactic and remedial hemorrhage control in pregnant women with abnormal placentation undergoing cesarean delivery.