Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Vaccination Status is Not Associated With Adverse Postoperative Outcomes Following Total Joint Arthroplasty in Patients With a Preoperative COVID-19 Diagnosis

Background

Previous studies have shown that COVID-19 diagnosis increases rates of perioperative infection, readmission, and other complications following surgery. However, the effect of the COVID vaccine in such patients is unknown. We hypothesized that of the patients with COVID diagnosis, vaccinated patients with COVID-19 diagnosis would have lower rates of adverse complications compared to unvaccinated patients undergoing total joint arthroplasty (TJA).

Methods

Using a national database registry, patients aged less than 85 years undergoing elective primary total knee or total hip arthroplasty with at least 90 days of follow-up were included during the first year of COVID-19 pandemic from April 2020-April 2021. Patients were included in the COVID-19 cohort if they had a diagnosis on the day of surgery or within 30 days prior to surgery. Patients with a history of malignancy, joint injection, femoral neck fractures, tibial fractures, and those undergoing revision arthroplasty were excluded from the study. All comparisons were performed using multivariate logistic regression with significance set at P < .05. Odds ratio and 95% confidence interval were reported for all comparisons.

Results

There were a total of 1280 patients with COVID-19 diagnosis matched with 3831 patients without COVID-19 diagnosis. Patients with a COVID-19 diagnosis were at an increased risk of pneumonia, acute kidney injury, urinary tract infection, and readmission following TJA compared to patients without COVID-19 diagnosis. However, there were no differences in any complications assessed between vaccinated patients and unvaccinated patients with COVID-19 diagnosis following TJA.

Conclusions

This study confirms that patients with a COVID-19 diagnosis in the 30 days prior to TJA, whether vaccinated or not, have increased risks of medical complications and hospital utilization. However, this study demonstrates that vaccination status does not appear to be associated with the incidence of adverse postoperative events in patients with a COVID-19 diagnosis prior to TJA.

Comparison of Sugammadex Versus Neostigmine for Postoperative Outcomes in Coronavirus Disease 2019 Patients Undergoing Thoracic Surgery: A Cohort Study

OBJECTIVE

This study was designed to evaluate whether the use of sugammadex was associated with a lower incidence of pulmonary complications than neostigmine in patients with coronavirus disease 2019 (COVID-19) undergoing thoracic surgery.

DESIGN

This was a matched cohort study using data from the TriNetX database.

SETTING

Operating room.

PARTICIPANTS

Adult patients with COVID-19 within 6 weeks before thoracic surgery.

INTERVENTION

The use of sugammadex or neostigmine to reverse muscular blockade.

MEASUREMENTS AND MAIN RESULTS

Outcomes included the incidence of composite pulmonary complications (CPCs) (primary outcome), pneumonia, respiratory failure, need for intensive care, mortality, sepsis, and acute kidney injury at 30-day follow-up. The potential benefits of sugammadex were also assessed at 90-day follow-up. Predictors of pulmonary complications were identified in those receiving sugammadex. After matching, 985 patients were included in each group. At 30 days, the incidence of CPCs (5.69% v 9.75%; odds ratio [OR]: 0.56, p = 0.0009), pneumonia (1.83% v 4.37%; OR: 0.41, p = 0.0016), and respiratory failure (1.42% v 3.25%; OR: 0.43, p = 0.0087) were significantly lower with sugammadex than neostigmine. No differences were found in other 30-day outcomes. Diabetes and chronic obstructive pulmonary disease were identified as risk factors for pneumonia and respiratory failure. At 90 days, no significant differences were observed, although mortality tended to be lower with sugammadex.

CONCLUSION

In patients with COVID-19 undergoing thoracic surgery, sugammadex was associated with a reduction in 30-day postoperative pulmonary complications compared with neostigmine. However, this finding requires validation in larger, randomized trials.

The impact of COVID-19 on inflammatory bowel disease surgery: a systematic review

INTRODUCTION

The COVID-19 pandemic caused a significant disruption to the delivery of surgical services. Guidance prioritising life-saving and cancer surgery was issued. Inflammatory bowel disease (IBD) often requires considered, timely surgery, which may have not been feasible under the conditions imposed by the pandemic. This systematic review aims to quantify the impact of COVID-19 on IBD surgery and assess the safety of performing such surgery.

METHODS

A systematic review of MEDLINE, Embase and Web of Science was performed. Studies that included a prepandemic and a pandemic cohort for comparison and reported on numbers of IBD surgeries or postoperative outcomes following IBD surgery were included. Heterogeneity of included studies precluded any meta-analyses.

FINDINGS

In total, 1,220 titles were screened and 13 were included in the final review. All were cohort studies other than one case-control study. A total of 1,673,282 and 1,445,971 patients were included in the prepandemic and pandemic cohorts, respectively. Rates of elective surgery during the pandemic varied from a 66% reduction to a 9.66% increase and emergency surgery varied from no difference to an 18% reduction. Urgent surgery in IBD inpatients appears to be unaffected. Postoperative outcomes were not shown to be negatively impacted by resource limitations.

CONCLUSIONS

The COVID-19 pandemic affected IBD surgical services considerably; however, those who did undergo surgery during this period do not appear to have been at an increased risk of adverse outcomes. Further work is required to describe the long-term impacts of these cancellations on IBD services and patient morbidity.

Perioperative Coronavirus Disease 2019 Infection and Its Impact on Postoperative Outcomes: Pulmonary Complications and Mortality Based on Korean National Health Insurance Data

Background/Objectives: The coronavirus disease 2019 (COVID-19) pandemic significantly disrupted global healthcare. This study explores the effects of perioperative COVID-19 infection on postoperative outcomes, aiming to refine risk assessment and enhance personalized perioperative care using a comprehensive dataset from the Korean National Health Insurance Service. This analysis extends previous research by providing a large-scale validation of risk factors associated with COVID-19 in a perioperative setting. Methods: In this retrospective cohort study, we analyzed data from 2,903,858 patients who underwent surgery under general anesthesia between January 2020 and December 2021. Patients were categorized into COVID-19 (+) and COVID-19 (-) groups within 30 d before or after surgery. Logistic regression models were used to identify independent risk factors for mortality and pulmonary complications. Results: After propensity score matching, the final cohort comprised 19,235 patients (COVID-19 (+): 3847; COVID-19 (-): 15,388). The COVID-19 (+) group had significantly higher overall mortality than the COVID-19 (-) group. No significant difference was observed between the groups concerning 30 d mortality. Pulmonary complications, including pneumonia and acute respiratory distress syndrome, were significantly more frequent in the COVID-19 (+) group. The independent predictors of 30 d mortality included advanced age, emergency surgery, and the American Society of Anesthesiologists physical status classification. Conclusions: Our study confirms that perioperative COVID-19 infection significantly elevates overall mortality and pulmonary complications, emphasizing the necessity of tailored perioperative management. Incorporating individual risk factors into care protocols not only reduces risks for surgical patients but also enhances treatment approaches. These findings advocate for the implementation of personalized medicine principles in surgical settings to improve patient outcomes during and after the COVID-19 pandemic. This research uses a comprehensive national medical claims dataset to set new standards for studying pandemic health impacts and improving clinical strategies.

Optimizing timing for elective surgery in cancer patients following COVID-19 infection; a post-pandemic analysis

INTRODUCTION

The COVID-19 pandemic introduced challenges including delaying elective surgery. For cancer patients, reducing delays is preferred to prevent unfavorable outcomes. there is a lack of consensus regarding the optimal timing of elective surgery following a SARS-CoV-2. This study aimed to find the optimal time to elective surgery to minimize 30-day postoperative morbidity and mortality.

METHODS

This is a retrospective chart review of all adult patients who underwent elective surgery with a confirmed preoperative COVID-19 diagnosis between September 2020 and April 2023. Patients' elective surgeries delays were examined to determine the optimal time to surgery in terms of postoperative complications. Analysis was controlled for age, ASA score, comorbidities, and smoking status.

RESULTS

358 records examined, 94.7% had delayed surgery and 5.3% had cancelled surgery. The optimal time to surgery was ≥ 17 days to minimize postoperative pulmonary complications [OR: 0.299, p = 0.048], other postoperative complications [OR: 0.459, p = 0.01], and a decrease in length of hospital stay. In multivariate analysis, the only significant predictors for postoperative complications were time to surgery; surgery ≥ 17 days after diagnosis had better postoperative outcomes [p < 0.001], and COVID-19 symptoms status [p = 0.019].

CONCLUSION

The best time to surgery in this cohort is at least 17 days (or a range of 2-3 weeks) for optimal results. Further research is needed to investigate the effect of such delays on oncological outcomes in this cohort.

The Severity of Appendicitis During the COVID-19 Pandemic: A Single Institution Experience

IntroductionThe COVID-19 pandemic led to nationwide stay at home orders, leading to delays in medical care. We sought to identify if the severity of appendicitis changed during the pandemic due to these delays and if there were differences in appendicitis severity in patients with simultaneous COVID-19 infection. We hypothesized that pandemic-related restrictions led to more severe cases of appendicitis.MethodsWe performed a retrospective study (4/2018-4/2022) of all patients ≥ 5y with appendicitis. Patients with a malignant appendiceal specimen were excluded. Clinical outcomes and characteristics were compared in those with appendicitis prior to the COVID-19 (PC) era to those in the COVID-19 (C) era, as well as between COVID-19 positive (C+) and negative (C-) individuals. Univariate analyses were conducted. A P-value <0.05 was considered to be statistically significant.ResultsA total of 1665 patients met inclusion criteria, 806 (48.4%) in PC era, and 859 (51.6%) in C era. Age and gender did not differ from PC era to C era, nor did they differ from the C- group to the C+ group. The C era had significantly higher 30-day readmissions than the PC era (C 6.29% (n = 54) v. PC 2.73% (n = 22), P = 0.001). The C era also had more greater than 30-day readmissions than the PC era (C 3.26% (n = 28) v. PC 1.74% (n = 14), P = 0.048). There was no significant difference in the reason for 30-day or greater than 30-day readmissions for the PC vs C eras. Of the C era, 833 (97.0%) were C- and 26 (3.0%) were C+. Rates of nonoperative management at index admission were not different between groups. The white blood cell (WBC) count was significantly lower in C+, 11.9 (8.55-13.35 IQR), vs C- group, 12.85 (9.9-15.3 IQR), P = 0.0336. There was no significant difference in the severity of appendicitis nor readmission status in C+ vs C- groups during the C era.ConclusionOur data indicates that the PC era had more severe cases of appendicitis as shown by higher rates of perforated and gangrenous appendicitis on pathology reports compared to the C era. Interestingly, readmissions were more prevalent in the C era as opposed to the PC era, which coincided with an increase in complications requiring readmission following laparoscopic appendectomies. In evaluating appendicitis patients according to COVID-19 status, we saw no significant differences in the severity of appendicitis in C- and C+ individuals.

Nomogram for prediction of severe postoperative complications in elective hepato-pancreato-biliary surgery after COVID-19 breakthrough infection: A large multicenter study

BACKGROUND

Currently, there is a deficiency in a strong risk prediction framework for precisely evaluating the likelihood of severe postoperative complications in patients undergoing elective hepato-pancreato-biliary surgery subsequent to experiencing breakthrough infection of coronavirus disease 2019 (COVID-19). This study aimed to find factors predicting postoperative complications and construct an innovative nomogram to pinpoint patients who were susceptible to developing severe complications following breakthrough infection of COVID-19 after undergoing elective hepato-pancreato-biliary surgery.

METHODS

This multicenter retrospective cohort study included consecutive patients who underwent elective hepato-pancreato-biliary surgeries between January 3 and April 1, 2023 from four hospitals in China. All of these patients had experienced breakthrough infection of COVID-19 prior to their surgeries. Additionally, two groups of patients without preoperative COVID-19 infection were included as comparative controls. Surgical complications were meticulously documented and evaluated using the comprehensive complication index (CCI), which ranged from 0 (uneventful course) to 100 (death). A CCI value of 20.9 was identified as the threshold for defining severe complications.

RESULTS

Among 2636 patients who were included in this study, 873 were included in the reference group I, 941 in the reference group II, 389 in the internal cohort, and 433 in the external validation cohort. Multivariate logistic regression analysis revealed that completing a full course of COVID-19 vaccination > 6 months before surgery, undergoing surgery within 4 weeks of diagnosis of COVID-19 breakthrough infection, operation duration of 4 h or longer, cancer-related surgery, and major surgical procedures were significantly linked to a CCI > 20.9. A nomogram model was constructed utilizing CCI > 20.9 in the training cohort [area under the curve (AUC): 0.919, 95% confidence interval (CI): 0.881-0.957], the internal validation cohort (AUC: 0.910, 95% CI: 0.847-0.973), and the external validation cohort (AUC: 0.841, 95% CI: 0.799-0.883). The calibration curve for the probability of CCI > 20.9 demonstrated good agreement between the predictions made by the nomogram and the actual observations.

CONCLUSIONS

The developed model holds significant potential in aiding clinicians with clinical decision-making and risk stratification for patients who have experienced breakthrough infection of COVID-19 prior to undergoing elective hepato-pancreato-biliary surgery.

Postoperative Outcomes in Surgical Coronavirus Disease 2019 Patients: A Retrospective Cohort Study

PURPOSE

Patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-COV-2) who require surgical procedures are likely to experience higher postoperative mortality and morbidity. Our objective was to evaluate the perioperative course of patients infected with SARS-COV-2 undergoing surgical procedures. The purpose of this study was to describe the characteristics, outcomes, and the effect of the presence of symptoms.

DESIGN

Retrospective cohort.

METHODS

We analyzed the records of patients with SARS-CoV-2 infection who underwent surgical procedures from March 2020 to March 2021. Patients with ongoing infection at the time of surgery and those who had recently recovered were included. The primary outcome measure was 30-day in-hospital mortality after surgery. Secondary outcomes were intensive care unit (ICU) admission, length of stay in ICU, postoperative length of stay, and complications.

FINDINGS

Data from 102 patients were analyzed. Twenty-four patients (23.5%) died postoperatively in the hospital within 30 days. Forty-four patients required ICU admission (average stay 13 days). The median postoperative length of stay was 8 days (interquartile range, 3.75 to 19.25 days). Pulmonary, thromboembolic, and surgical complications were noted in 29 (28.4%), 14 (13.7%), and 18 (17.6%), respectively. Patients aged 41 to 60 years experienced higher rates of pulmonary and thromboembolic complications. Comparison of asymptomatic versus symptomatic patients revealed significantly higher 30-day in-hospital mortality (9 [15%] vs 15 [35.7%], P = .019), ICU admission (17 [28.3%] vs 27 [64.3%], P < .001), length of stay in ICU (3 [2 to 11.5] vs 18 [7 to 27], P = .001), postoperative length of stay (6 [3 to 10.75] vs 12 [5 to 25.25], P = .016) and pulmonary complication rates (11 [18.3%] vs 18 [42.9%], P = .008) in the symptomatic patients.

CONCLUSIONS

Symptomatic SARS-COV-2 patients undergoing surgical procedures experience significantly higher 30-day in-hospital mortality, ICU admission, longer ICU and hospital stay, and pulmonary complications.

Lung ultrasound on first postoperative day predicts out-of-hospital pulmonary complications following video-assisted thoracic surgery: A prospective cohort study

BACKGROUND

The integration of enhanced recovery after surgery (ERAS) protocols into the peri-operative management of video-assisted thoracic surgery (VATS) has facilitated rapid patient recovery, enabling discharge within 48 h. However, postoperative pulmonary complications (PPCs) postdischarge pose significant concerns for patient welfare. Despite the established utility of lung ultrasound (LUS) in diagnosing the causes of dyspnoea, the effectiveness of quantitative LUS in predicting PPCs after VATS remains uncertain.

OBJECTIVES

To determine whether quantitative LUS performed 24 h after surgery can identify patients with a higher risk of developing PPCs within 30 days after discharge from hospital.

DESIGN

Single-centre prospective cohort study.

SETTING

Academic tertiary care medical centre.

PATIENTS

Adults scheduled for elective VATS under general anaesthesia from November 2022 to January 2023.

MAIN OUTCOME MEASURES

This primary aim was to verify the association between lung ultrasound score (LUSS) on postoperative day 1 (POD1) and PPCs. The secondary aim was to identify other relevant peri-operative factors closely related to PPCs and establish a model capable of predicting the risk of PPCs in patients undergoing fast-track VATS.

RESULTS

Of the 200 recruited patients, 182 completed the LUS examination and 30-day follow-up. Of these, 66 (36.2%) developed various types of PPCs. These patients had a higher LUSS on POD 1 ( P  < 0.001), and more subpleural consolidation areas compared to those without PPCs ( P  < 0.001). Receiver-operating characteristics (ROC) analysis identified the optimal LUSS cut-off value at 6 points for predicting the occurrence of PPCs, with an area under the curve (AUC) of 0.838 (95% CI, 0.768 to 0.909). Patients with PPCs had higher rates of immune system diseases and ARISCAT score, longer hospital stay and procalcitonin levels, increased frequency of lobar resection, longer durations of surgical and mechanical ventilation, and greater incidence of unplanned hospital readmissions within 30 days postdischarge, compared with those without PPCs (all P  < 0.001). Multivariable logistic regression analysis indicated that the comorbidity of immune system disease, along with postoperative 24 h LUSS, were independent risk factor for PPCs within 30 days after VATS.

CONCLUSION

LUSS on POD 1 emerged as an independent risk factor for PPCs in fast-track VATS patients and reliably predicted the occurrence of PPCs within 30 days of hospital discharge.

TRIAL REGISTRATION

ClinicalTrials. gov No. ChiCTR2200065865.

Litigation Involving Delay of Spinal Care During the COVID-19 Pandemic: A Review of Reported Legal Cases in the United States

BACKGROUND

During the coronavirus disease 2019 (COVID-19) pandemic, access to medical care was delayed worldwide. In multiple instances, the pandemic has led to delay in care, suboptimal patient outcomes and litigation. This study was designed to assess the incidence and characteristics of litigation in the United States related to delays in spine care secondary to the COVID-19 pandemic.

METHODS

A retrospective review of the legal database LexisNexis following PRISMA guidelines was conducted. LexisNexis was queried for cases, verdicts, and settlements involving a delay of spinal care during the COVID-19 pandemic. Collected data included plaintiffs' demographics and spinal pathology, delay length and reason, legal cause of action, state/region of occurrence, and case outcome.

RESULTS

Thirty-two cases met the criteria for full review. The average reported delay in litigated cases was 5.64 ± 3.83 months, with 25% having not received the necessary spinal care at the time the claim was filed, most of which were in 2022. Most cases involved lumbosacral disease with pain as the predominant symptom (96.88%), followed by neurological deficits (25%). Most cases (62.50%) involved inmates and were based on a claim of cruel and unusual punishment in violation of the 8th Amendment of the U.S. Constitution.

CONCLUSIONS

This study provides granular detail about the characteristics of litigation related to delay of spinal care secondary to the COVID-19 pandemic in the United States. Most plaintiffs were inmates who had difficulty obtaining a specialist appointment, imaging, or treatment. In many cases the reason for litigation were unattended requests for simple and low-cost interventions.

Evaluating the impact of the COVID-19 pandemic on outcomes of conversion and revisional bariatric surgery: a Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) study

BACKGROUND

The COVID-19 pandemic significantly impacted healthcare delivery worldwide, including bariatric surgery. While revisional procedures remained essential for weight recurrence and complications, practice patterns evolved during different phases of the pandemic.

OBJECTIVES

To evaluate the effect of COVID-19 on revisional bariatric procedures by comparing trends across pandemic (2020), vaccination rollout (2021), and postpandemic (2022) periods.

SETTING

Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, United States.

METHODS

Retrospective analysis of 72,189 bariatric surgeries (of which 55,854 conversions and 16,335 revisions) from 2020 to 2022. Outcomes included surgical volume, indications, complications, and mortality.

RESULTS

Of 609,240 bariatric procedures, 72,189 (11.8%) were revisional or conversion procedures, with conversions representing 9.2% (55,854) and revisions 2.7% (16,335). The combined proportion remained stable (12.1%, 12.1%, 11.5%, P < .001), but urgent revision rates were higher during the pandemic (3.1% versus 2.2% versus 1.8%, P < .001). Pandemic-era cases focused on severe complications (fistula, perforation, stricture), shifting postpandemic toward weight recurrence and reflux. Sleeve-to-bypass conversions increased from 41.2% to 53.6%. Serious complications were highest in 2020-2021 (6.6%, 6.4%) compared to 2022 (5.8%, P < .001), while mortality remained unchanged (.15%).

CONCLUSIONS

The study demonstrates distinct trends throughout pandemic periods, reflecting Centers for Disease Control and Prevention guidance on surgical urgency . While complication rates were slightly higher during the pandemic, procedures remained safe with stable mortality. Postpandemic shifts toward elective indications and increasing conversion procedures suggest adaptation to accumulated surgical needs.

Postoperative cardiopulmonary complications in children with preoperative Omicron SARS-CoV-2 variants infection: a single-center retrospective cohort study

OBJECTIVE

The purpose of this study was to investigate: (1) the incidence of cardiopulmonary complications within 30 days after surgery in pediatric patients with preoperative Omicron variants infection, (2) the mortality, and (3) their possible risk factors.

METHODS

This retrospective study included a consecutive patient cohort who underwent elective non-cardiac surgery for any indication in the Pediatric Department of our hospital between November 2022 and February 2023. Cardiopulmonary complications and mortality within 30 days after surgery were compared between patients with pre-operative SARS-CoV-2 infection (Omicron variants infected group) and those without infection (the uninfected group) within 90-day before the surgery. The study evaluated the demographic data and related clinical factors of complications by analyzing their clinical records.

RESULTS

Our study included 502 patients, of which 194 (38.65%) had a pre-operative Omicron variants diagnosis. The mean duration between definite Omicron variants infection and surgery was 31.28 ± 10.19 days. In our study, the incidence of pulmonary complications was 1.59% (8/502 patients), no cardiac complication or mortality was found in the 30-day postoperative follow-up. The Omicron variants infected group had a significantly higher incidence of complications (7/194, 3.61%) compared to the uninfected group (1/308, 0.32%) (p = 0.006). After adjusted for other factors, it was found that the Omicron variants infection within 4 weeks before surgery (OR = 17.84, 95% CI: 1.25-255.35, p = 0.034), higher BMI (OR = 1.26, 95% CI: 1.02-1.55, p = 0.034), ASA physical status grade III-V (OR = 17.35, 95% CI: 1.19-253.80, p = 0.037), and abnormal preoperative chest radiograph (OR = 60.07, 95% CI: 1.92-1878.21, p = 0.020) were independent risk factors for postoperative pulmonary complications in patients within 30 days after the surgery.

CONCLUSIONS

Omicron infection may heighten the risk of pulmonary complications in children undergoing elective non-cardiac surgery. It is advisable to schedule elective surgery at least 4 weeks after infection of Omicron variants.

The side effects of the pandemic on all-cause postoperative mortality in a COVID reference Hospital in Brazil: a before and after cohort study with 15156 patients

BACKGROUND

Before the pandemic, healthcare systems in Low-Middle Income Countries (LMIC) experienced a limited capacity to treat postoperative complications. It is uncertain whether the interference of the Coronavirus (COVID-19) pandemic on surgical systems has increased postoperative mortality.

METHODS

This before and after cohort study aimed to assess the pandemic's impact on in-hospital postoperative mortality in a university COVID-19 reference hospital in southern Brazil. Data from patients who underwent surgery before (January 2018 to December 2019) the pandemic were compared to data from patients who underwent surgery during the pandemic (February to December 2020). The primary outcome was in-hospital mortality. We developed Poisson regression models to examine the mortality risk of being operated on during the COVID-19 pandemic.

RESULTS

We assessed 15156 surgical patients, 12207 of whom underwent surgery before the pandemic and 2949 during the first year of the pandemic. Mortality rates were 2.5% (309/12207) in the pre-pandemic versus 7.2% (212/2949) in the pandemic. Of these, 25.8% (32/124) of patients with COVID-19 and 6.4% (80/2816) of patients without COVID-19 died. The proportion of urgent surgeries and ASA-PS III was higher in the pandemic group. After adjusting for mortality-related variables, the Relative Risk (RR) associated with undergoing surgery during the pandemic was 1.51 (95% CI 1.27 to 1.79). We excluded COVID-19-positive to perform a sensitivity analysis that confirmed the increased risk of undergoing surgery during the pandemic RR = 1.50 (95% CI 1.27 to 1.78).

CONCLUSION

The substantial number of additional deaths, even amongst those without COVID-19 infection, suggests the pandemic disrupted the surgical service in an LMIC context. Fragile surgical systems may suffer more significant adverse impacts from external stressors such as a pandemic, and urging measures are needed to increase their performance and resilience.

Association between serum creatinine-to-albumin ratio and 28-day mortality in intensive care unit patients following cardiac surgery: analysis of mimic-iv data

BACKGROUND

Creatinine-to-albumin ratio (CAR) has been recognized as a predictive indicator in the postoperative setting. However, its relationship with outcomes in patients receiving cardiac surgery remains elusive. This study aimed to discuss the link between CAR and 28-day mortality in patients admitted to intensive care unit (ICU) following cardiac surgery, hoping to provide some insights for targeted interventions for improvement of patient outcomes.

METHODS

MIMIC-IV database was searched to obtain data of patients admitted to ICU following cardiac surgery. Retrieved patients were split into three groups based on CAR levels. The 28-day ICU mortality in each group was evaluated and compared using Kaplan-Meier analysis. Subgroup analysis, multivariate Cox regression and restricted cubic spline (RCS) analysis were used to further examine the relationship between CAR and outcomes. Receiver operating characteristic (ROC) curves were used to assess the predictive ability of CAR. Mediation analysis was conducted to investigate the potential mechanism by which CAR affects 28-day ICU mortality.

RESULTS

A total of 5,670 patients were included and divided into three groups. Patients with high CAR values (CAR ≥ 0.31) had a significantly increased rate of 28-day ICU mortality (11.4%), as compared to those with low CAR levels (CAR < 0.23, 1.83%). In addition, patients with high CAR values (CAR ≥ 0.31) had a lowest survival rate than the other two groups (p < 0.0001). ROC curve analysis showed that CAR exhibited a moderate predictive power (AUC = 0.748). Moreover, CAR was identified as a strong risk factor for 28-day ICU mortality, and a significant dose-response association was presented. Further subgroup analysis revealed pronounced mortality risks in females and patients without chronic conditions such as chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). Mediation analysis indicated that CAR affected 28-day ICU mortality through biomarkers like chloride (39.8%), glucose (11.8%), potassium (24.4%), and sodium (28.3%).

CONCLUSION

CAR served as a risk factor for 28-day ICU mortality in patients receiving cardiac surgery, and it showed a complex dose-response and subgroup-specific association with 28-day ICU mortality. Additionally, CAR affected 28-day ICU mortality through multiple key biomarkers, providing some insights for targeted interventions.

Development of a Preoperative Screening Tool to Reduce Morbidity and Mortality of COVID-19-positive Hepatobiliary Patients

PURPOSE

This study aimed to create a preoperative risk assessment form for COVID-19-positive hepatobiliary patients to guide further prevention of complications after surgery and reduce morbidity and mortality.

DESIGN

Based on the literature, focus groups, and case studies, a multidisciplinary panel of 15 experts conducted three rounds of a Delphi study that resulted in the development of a preoperative risk assessment form to be used by healthcare professionals in the treatment of COVID-19-positive hepatobiliary patients.

METHODS

A preoperative risk assessment form for health professionals to use among COVID-19-positive hepatobiliary patients was developed based on literature, focus groups, and case studies. A 3-round Delphi study was conducted to validate and revise the risk assessment form using a multidisciplinary panel of 15 experts involved in hepatobiliary surgery.

FINDINGS

The experts demonstrated high cooperation and familiarity with the research topic, with positive coefficients ranging from 93.33% to 100% and authority coefficients ranging from 0.83 to 0.86. The coordination coefficients were 0.33, 0.26, and 0.22, respectively, indicating good coordination among expert opinions. The final risk assessment form included 9 primary (first-level) indicators, 38 secondary (second-level) indicators, and 122 tertiary (third-level) indicators.

CONCLUSIONS

The preoperative risk assessment form for hepatobiliary surgery patients infected with COVID-19 is scientifically rigorous, reliable, and valid. This screening tool may be used by health providers to identify high-risk patients, prevent postoperative complications, and reduce morbidity and mortality.

Multicentre analysis of severe perioperative adverse events in children undergoing surgery who were infected with SARS-CoV-2: a propensity score-adjusted analysis

BACKGROUND

The incidence of severe adverse events in children with SARS-CoV-2 undergoing anaesthesia has not been well established. We examined the relationship between SARS-CoV-2 infection and severe perioperative adverse events in children.

METHODS

This multicentre (21 North American institutions), retrospective cohort study included children <18 years old, with American Society of Anesthesiologists physical status (ASA PS) of 1-4 and non-severe SARS-CoV-2, who underwent general anaesthesia between April 1, 2020, and March 31, 2021. The primary outcome was the incidence of severe perioperative adverse events (admission to the intensive care unit for escalation of respiratory support, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death) within 7 days of the anaesthetic, assessed using multivariable analysis with inverse probability of treatment weighting by the propensity score. A propensity score mixed-effects model included variables selected a priori. Inverse probability of treatment weighting was used to retain all data while balancing exposure groups on measured confounders.

RESULTS

We matched 1138 patients with SARS-CoV-2 positive testing within 10 days of the anaesthetic to 3396 non-infected controls. The cohort included 56.6% (2568/4534) male patients, 69.9% (2839/4060) White patients, and 63.5% (2879/4533) ASA PS 1-2 patients. General surgery cases comprised 38.4% (1739/4534) of the cohort, followed by orthopaedic surgery at 12.6% (573/4534) and ear, nose, and throat surgery at 8.2% (371/4534). In the overall sample of 4534 patients, 52 had a severe adverse event (0.01%). Children with SARS-CoV-2 had a higher risk of at least one severe adverse event (25/1138 [2.20%] vs 27/3396 [0.80%] in those non-infected; adjusted odds ratio 2.34; 95% confidence interval 1.25-4.39). None of the children with SARS-CoV-2 had a cardiac arrest, required extracorporeal life support, or died.

CONCLUSIONS

In the largest cohort to date of paediatric patients undergoing general anaesthesia, SARS-CoV-2 infection was associated with severe perioperative adverse events, but no children in the infected cohort died.

Colorectal Cancer Surgery at a Regional Cold Site Centre During the SARS-CoV-2 Pandemic: A Comparison With Prepandemic Practices

INTRODUCTION

Stockholm, Sweden had among the highest excess mortality rates during the first wave of the SARS-CoV-2 pandemic. In March 2020, an entire hospital implemented an infection-free cold site infrastructure and scaled up imperative mainly colorectal cancer surgery, for the Stockholm health care region. The study evaluated the efficacy of the concept.

METHODS

Strict preadmission screening and prophylactic interventions were implemented. The outcomes of the cold site cohort (30th March-21st June 2020) were compared to a prepandemic control. Population-based data on colorectal cancer patients were collected from the Swedish Colorectal Cancer Registry.

RESULTS

There were 107 patients in the cold site cohort and 109 in the control cohort. None developed COVID-19 within 30 days postoperatively. The proportions of pelvic and laparoscopic surgery were similar. The cold site cohort had more potentially avoidable stomas (32/94 (34%) vs 19/91 (21%), p = 0.0442). In the region, the proportion of colorectal cancer resections at the cold site increased from prepandemic 12.9% (58 of 448) to 43.3% (94 of 217) (p < 0.001).

CONCLUSION

A SARS-CoV-2-cold site can be kept infection-free by screening, allowing increased volumes of colorectal cancer surgery with outcomes comparable to prepandemic practice. The cold site model should be more widely adopted in future similar scenarios.

SUMMARY

This study reports on the implementation of an entire cold site hospital for imperative colorectal surgery, in particular colorectal cancer, during the SARS-CoV-2 pandemic. By comparing outcomes to prepandemic practices, we demonstrated that the cold site hospital was effective in preventing infection and safely increasing surgical volume many-fold.

The effect of SARS-CoV-2 Omicron BA. 5.2 infection on perioperative physiological indicators in orthopedic patients

OBJECTIVE

The aim of this study was to investigate the effect of SARS-CoV-2 Omicron BA. 5.2 (hereafter referred to as Omicron BA. 5.2) infection on perioperative physiological indices and to provide clinical considerations for the precautions needed for patients who tested negative for SARS-CoV-2 infection perioperatively.

METHODS

Patients who underwent time-limited surgery (surgery that must be performed within a certain time) at the Department of Orthopedics of our hospital from September 1, 2022, to March 31, 2023, were divided into an observation group (those with Omicron BA 5.2 and a negative nucleic acid test after December 7, 2022, n = 100) and a control group (those negative for SARS-CoV-2 infection before December 7, 2022, n = 100). Changes in the following factors were compared within and between the two groups: heart rate, mean arterial pressure, oxygenation index at the time of entry into the operating room, incision of the skin and exit from the operating room and the neutrophil‒lymphocyte ratio (NLR), platelet‒lymphocyte ratio (PLR), systemic immune inflammation index (SII), D-dimer level, and fibrinogen degradation product (FDP) level. Changes in interleukin-6 and calcitonin levels were assessed the day after surgery, and multivariate regression analysis of the meaningful results was conducted.

RESULTS

Heart rate, mean arterial pressure, oxygenation index, NLR, PLR, SII, interleukin-6 and calcitonin were similar between the two groups (P > 0.05). The observation group had higher postoperative D-dimer and FDP levels (P < 0.05). Multivariate regression analysis revealed that Omicron BA 5.2 infection, older age and a history of cerebral infarction were associated with increased D-dimer and FDP levels, and their odds ratios (ORs) and confidence intervals are 3.339 [95% CI, 1.372-8.419], P = 0.008; OR, 1.080 [95% CI, 1.023-1.139]; P = 0.005; OR, 10.644 [95% CI, 1.352-83.320], P = 0.025, respectively.

CONCLUSION

Omicron BA. 5.2 Infection affects the perioperative coagulation function of orthopedic patients, thereby inducing a hypercoagulable state characterized by significant elevations in D-dimer and FDP levels and increasing the risk of venous thrombosis. This infection had no obvious effect on other physiological indices. Early surgery is feasible, but thrombotic events need to be considered.

Effects of COVID-19 on short-term outcomes of hip arthroplasty: a multicenter, retrospective, propensity score matched study

PURPOSE

The Coronavirus Disease 2019 (COVID-19) pandemic delayed elective procedures such as total joint arthroplasty. As surgical volumes return to prepandemic levels, understanding the implications of COVID-19 becomes imperative. This study explored the effects of COVID-19 on the short-term outcomes of hip arthroplasty.

METHODS

This multicenter, retrospective, case-control study included patients who had undergone hip arthroplasty between 2020 and 2022. Propensity score matching (PSM) was performed to compare demographic characteristics, primary outcomes, and secondary outcomes between patients with a history of COVID-19 (COVID-19 cohort) and those without it (control cohort). The primary outcomes were surgical site infection, periprosthetic joint infection (PJI), dislocation, prosthesis loosening, deep vein thrombosis, and pulmonary embolism. The secondary outcomes were intraoperative blood loss, nerve injury, renal injury, urinary tract infection (UTI), pneumonia, and acute coronary syndrome.

RESULTS

The COVID-19 and control cohorts comprised 153 and 4925 patients, respectively. After PSM, significant between-cohort differences were observed in the incidence of pneumonia (p < 0.001) and UTI (p = 0.0424). The odds ratio for PJI was 1.62, which is not significant (p = 0.3238) but the culture-negativity rate is higher in the COVID-19 cohort (25%).

CONCLUSION

Our findings suggest that COVID-19 only elevated risks of postoperative pneumonia and UTI after hip arthroplasty. This disease significantly increases the risk of postoperative pneumonia but not of 90-day mortality or any major perioperative complication. On the other hand, PJI still remains a concern because its treatment is challenging owing to its culture-negativity, often necessitating the Girdlestone procedure.

Perioperative outcomes in patients with symptomatic versus asymptomatic previous COVID-19 infection undergoing neurosurgical treatment (post-COVID-19 study)

Background and Aims

The long-term effects of coronavirus disease 2019 (COVID-19) infection (long-COVID) are being increasingly recognized. The long-COVID effects are more likely in individuals who were symptomatic than asymptomatic during their previous COVID-19 infection. The data on perioperative outcomes of patients undergoing elective neurosurgery long after their recovery from COVID-19 infection is lacking. The primary objective of this study was to compare the perioperative outcomes after elective neurosurgery between patients who were symptomatic and those who were asymptomatic during their previous COVID-19 infection. The secondary objectives were to compare the earlier COVID-19 characteristics and the perioperative pulmonary profile during current surgery between these groups.

Material and Methods

This prospective observational study was performed in adult patients undergoing elective neurosurgery with history of previous COVID-19 infection. Data was collected regarding previous COVID-19 infection (symptoms, hospitalization, treatment, complications, etc.) and current perioperative characteristics (pulmonary profile, perioperative complications, hospital stay, mortality, etc.).

Results

A total of 50 patients were recruited during the study period, of which 35 (73%) patients were symptomatic during previous COVID-19 infection (two patients were excluded). The mean duration between current surgery and previous COVID-19 infection was 7 months. Patients symptomatic during earlier COVID-19 infection were females, older, and had a lower oxygen level during current surgery. There was no difference between symptomatic and asymptomatic groups in adverse perioperative outcomes such as desaturation, pulmonary or extrapulmonary complications, or non-extubation.

Conclusion

The perioperative outcomes of patients undergoing elective neurosurgery with previous mild to moderate symptomatic COVID-19 infection may not be different from those of patients with asymptomatic COVID-19 infection.

Outcomes of Patients Undergoing Elective Cancer Surgery After SARS-CoV-2 Infection: An Observational Cohort Study

BACKGROUND

We evaluated the impact of preoperative SARS-CoV-2 infections on postoperative outcomes among patients undergoing elective cancer surgery.

METHODS

This ambidirectional (retrospective and prospective) study was conducted among patients undergoing elective cancer surgery between December 2022 and March 2023. Patients with different time intervals between SARS-CoV-2 infection and surgery (0-6 weeks and ≥7 weeks) were compared with those without SARS-CoV-2 infection. The primary outcome was 30-day postoperative pulmonary complications (PPCs). Secondary outcomes included 30-day postoperative mortality, major adverse cardiovascular events (MACE), and other postoperative adverse outcomes.

RESULTS

Of the 830 patients analyzed, 239 (28.8%) had SARS-CoV-2 infection 0-6 weeks before cancer surgery, and they had a higher incidence of PPCs (4.6% in no SARS-CoV-2 infection, 12.1% in 0-6 weeks, and 5.1% in ≥7 weeks, p = 0.001). The logistic regression model revealed that, compared with patients without SARS-CoV-2 infection, surgery performed 0-6 weeks after SARSCoV-2 infection was associated with a higher risk of PPCs (adjusted odds ratio [aOR] 2.83; 95% confidence interval [CI] 1.34-5.98), and surgery performed ≥7 weeks after SARSCoV-2 infection was associated with a similar risk of PPCs (aOR 1.19; 95% CI 0.54-2.64). However, preoperative SARS-CoV-2 infection was not associated with a risk of 30-day postoperative mortality, MACE, or other adverse postoperative outcomes.

CONCLUSIONS

In patients with preoperative Omicron variant infection, nonemergency cancer surgery can be scheduled ≥7 weeks after the infection to decrease the risk of PPCs, but it can be advanced if the risk of delay exceeds the risk of proceeding with the surgery.

Impact of previous COVID-19 infection on postoperative complications and functional recovery: a 1-year follow-up ambispective cohort study

BACKGROUND

It's necessary to reassess the patients' short-term and long-term postoperative outcomes in the post-COVID-19 era. This study aims to provide more comprehensive evidence regarding the timing of surgery after COVID-19 infection among the vaccinated population upon Omicron variant, considering the duration after acute COVID-19 infection, the severity of COVID-19, patients' comorbidities, and the full course quality of postoperative recovery.

MATERIALS AND METHODS

This is a single-center cohort study. Patients diagnosed with preoperative COVID-19 infection were consecutively included before surgery. Patients' demographics, surgical characteristics, and COVID-19-related factors were documented. Exposure was the time interval from COVID-19 infection to surgery. The primary outcome was postoperative complications within 30 days. The secondary outcomes included postoperative mortality within 30 days, functional disability at 6 and 12 months after surgery.

RESULTS

A total of 4953 patients were included, and postoperative complications occurred in 353 patients (7.1%) within 30 days after surgery. Time interval from COVID-19 infection to surgery was associated with postoperative complications within 30 days after surgery [adjusted odds ratio (aOR) per day: 0.99; 95% CI, 0.99-1.00; P <0.01], as well as postoperative 6- and 12-month functional disability [(aOR): 1.00; 95% CI, 0.99-1.00; P <0.01; and (aOR) 0.99; 95% CI, 0.98-1.00; P =0.01, respectively). Delaying surgery beyond a time interval of 2 weeks was associated with reduced postoperative 30-day complications [(aOR): 0.63; 95% CI, 0.43-0.91; P =0.01] and mortality [(aOR): 0.07; 95% CI, 0.01-0.38; P <0.01]. Meanwhile, delaying surgery beyond a time interval of 7 weeks was associated with reduced functional disability at both 6-month [(aOR): 0.67; 95% CI, 0.58-0.79; P <0.01] and 12-month postoperatively [(aOR): 0.71; 95% CI, 0.53-0.95; P =0.02].

CONCLUSION

A 2 weeks delay after COVID-19 infection is necessary for decreasing short-term postoperative risks, and a longer waiting period could be beneficial for long-term functional recovery.

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

Comparison of WALANT and general anaesthesia for trapeziectomy and abductor pollicis longus hammock ligamentoplasty

Background

Trapeziectomy and abductor pollicis longus hammock ligamentoplasty may be performed in the surgical management of trapeziometacarpal joint osteoarthritis (TMC OA). Several anaesthesia techniques are available for TMC joint surgery, including wide-awake local anaesthesia no tourniquet (WALANT), regional anaesthesia, and general anaesthesia (GA). The aim of this study was to compare the clinical outcomes of trapeziectomy and abductor pollicis longus hammock ligamentoplasty performed under WALANT versus GA.

Methods

This retrospective study included 22 patients who underwent surgery for TMC OA between 2017 and 2019. Patients' pre- and post-operative pain intensity, grip and pinch strength, and functional scores were compared. Pain intensity was assessed 1 h after surgery, while overall outcome measures were evaluated one year post-operatively.

Results

The results showed that patients who underwent WALANT had significantly lower pain intensity 1 h postoperatively compared to those who received GA. Both groups experienced a reduction in pain, improvement in grip strength, and functional scores after at one year, with no significant differences between them. No significant differences were found between the GA and WALANT groups in terms of postoperative VAS scores, grip strength, and functional scores.

Conclusions

We recommend WALANT for trapeziectomy and APL hammock ligamentoplasty due to its effectiveness in reducing early post-operative pain and achieving functional outcomes comparable to those of GA.

Age and clinical spectrum of COVID-19 are associated with safety of transarterial chemoembolization in hepatocellular carcinoma: a retrospective cohort study

Background

Hepatocellular carcinoma (HCC) patients with coronavirus disease 2019 (COVID-19) undergoing open surgery show increased adverse events (AEs) and mortality, while the safety of transarterial chemoembolization (TACE) in coinfected patients remains understudied, limiting available evidence. This study aims to investigate the safety of TACE in HCC patients coinfected with COVID-19, and to explore the potential risk factors affecting the occurrence of serious AEs (SAEs), thus providing evidence for clinical treatment strategies in such patients.

Methods

This retrospective study involved HCC patients who underwent TACE with or without COVID-19 infection at our institution from November 2022 to February 2023. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was used for the diagnosis of COVID-19. Patients were divided into an infected group (diagnosed with COVID-19 within 2 weeks before or after the procedure) and an uninfected group (tested negative for COVID-19). SAEs were ascertained according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 5.0. Logistic regression analysis of multiple clinical factors in preoperative baseline characteristics was performed to identify risk factors that might predict the occurrence of SAEs.

Results

A total of 118 patients (73 in the infected group, 45 in the uninfected group) were included, of whom 83.9% were male (86.3% in the infected group vs. 80.0% in the uninfected group) and the median age was 55.9±12.4 years (56.8±12.3 vs. 54.5±12.7 years). The clinical spectrum of COVID-19 in the infected group were 80.8% mild, 13.7% moderate, 1.4% severe and 4.1% critical. Sixteen of the 118 patients experienced SAEs (19.2% vs. 4.4%, P=0.046). The predominant SAEs were respiratory system diseases (9.6% vs. 0.0%) and liver damage (2.7% vs. 2.2%). In the univariate analysis, infection status [odds ratio (OR): 5.102, P=0.04, 95% confidence interval (CI): 1.102-23.627], gender (OR: 2.857, P=0.09, 95% CI: 0.862-9.468), age (OR: 1.061, P=0.03, 95% CI: 1.007-1.118) and clinical spectrum of COVID-19 (OR: 4.259, P<0.001, 1.943-9.336) were considered as the potential risk factors of grade ≥3 AEs. In multivariate analysis, younger age (OR: 1.064, P=0.044, 95% CI: 1.002-1.131) and a milder clinical spectrum of COVID-19 (OR: 5.736, P=0.004, 95% CI: 1.772-18.568) were independent factors associated with a lower occurrence of SAEs.

Conclusions

TACE in HCC patients co-infected with COVID-19 was considered relatively safe. Age and clinical spectrum of COVID-19 were associated with SAEs in HCC patients treated with TACE.

Timing of surgery for spinal deformity patients during the COVID‑19 pandemic: experience from a prospective cohort at Peking Union Medical College Hospital

BACKGROUND

The purpose of this study was to explore the optimal timing and associated risks of spinal deformity surgery during the COVID‑19 pandemic.

METHODS

All consecutive surgical cases for spinal deformity between November 2022 and April 2023 were included. The population was divided into several categories according to the time from diagnosis of SARS-CoV-2 infection to the day of surgery: without infection (pre-COVID-19), infection at 0 to 4 weeks (peri-COVID-19), infection at 4 to 8 weeks (early post-COVID-19), and infection over 8 weeks (late post-COVID-19). The primary outcome and secondary outcomes were 90-day complication rate and total hospital stay. Postoperative complications and total hospital stay were analyzed using logistic regression and linear regression models, and we simultaneously showed the results from the crude model, minimally adjusted model and fully adjusted model. In addition, we performed various sensitivity analyses.

RESULTS

A total of 60 consecutive patients were enrolled. The overall complication rate at 90 days postoperatively was 41.6% (25 of 60 patients), and the total hospital stay for all patients was (10.1 ± 3.5) days. In the fully adjusted model, compared with pre-COVID-19 patients, peri-COVID-19 patients had a 5.1-fold increased risk of postoperative complications (OR = 6.1, 95% CI 1.1-31.9, P = 0.030), early post-COVID-19 patients and late post-COVID-19 patients were at essentially equal risk. In terms of total hospital stay, compared with patients not infected with SARS-CoV-2, peri-COVID-19 patients had a 3.1-day longer hospital stay (ꞵ = 3.1, 95%CI 0.3-5.8, P = 0.032), early post-COVID-19 patients also had a 3.1-day longer hospital stay (ꞵ = 3.1, 95%CI 0.3-6.0, P = 0.032), and late post-COVID-19 patients had the similar hospital stay (ꞵ = -0.4, 95%CI -2.9-2.1, P = 0.741). Sensitivity analysis showed that the conclusions were robust.

CONCLUSIONS

With careful preoperative screening of patients for COVID-19, spinal deformity surgery can proceed safely during the epidemic. We recommend that spinal deformity surgery be delayed in patients with COVID-19 until 8 weeks after SARS-CoV-2 infection.

Impact of COVID-19 on the time to counseling and treatment of prostate cancer

PURPOSE

This study investigates how the COVID-19 pandemic (CP) impacted the timeline between initial diagnosis (ID) of prostate carcinoma and subsequent therapy consultation (TC) or radical prostatectomy (RP) due to the implementation of a "minimal contact concept," which postponed clinical examinations until the day of admission.

METHODS

We analyzed patient data from a tertiary care center from 2018 to September 2021. The focus was on comparing the time intervals from ID to TC and from ID to RP before and during the CP.

RESULTS

Of 12,255 patients, 6,073 (61.6%) were treated before and 3,791 (38.4%) during the CP. The median time from ID to TC reduced from 37 days (IQR: 21 - 58d) pre-CP to 32 days (IQR: 20 - 50d) during CP (p < 0.001). Similarly, the time from ID to RP decreased from 98 days (IQR: 70 - 141d) to 75 days (IQR: 55 - 108d; p < 0.001) during the CP. There was a significant decrease in low-risk tumor cases at ID (18.9% vs. 21.4%; p = 0.003) and post-RP (4% vs. 6.7%; p < 0.001) during the CP.

CONCLUSION

Our findings suggest that the COVID-19 pandemic facilitated more timely treatment of prostate cancer, suggesting potential benefits for both low-risk and aggressive tumor management through expedited clinical procedures.

Pulmonary complications and mortality among COVID-19 patients undergoing a surgery: a multicentre cohort study

OBJECTIVES

Our primary objective was to assess the association between symptoms at the time of surgery and postoperative pulmonary complications and mortality in patients with COVID-19. Our secondary objective was to compare postoperative outcomes between patients who had recovered from COVID-19 and asymptomatic patients and explore the effect of the time elapsed between infection and surgery in the former. Our hypotheses were that symptomatic patients had a higher risk of pulmonary complications, whereas patients who had recovered from the infection would exhibit outcomes similar to those of asymptomatic patients.

BACKGROUND

Managing COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce.

DESIGN

To address this gap, we conducted a multicentre observational cohort study.

SETTING

Across seven hospitals in the province of Québec, the Canadian province was most affected during the initial waves of the pandemic.

PARTICIPANTS

We included adult surgical patients with either active COVID-19 at the time of surgery or those who had recovered from the disease, from March 22, 2020 to April 30, 2021.

OUTCOMES

We evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. The primary outcome was a composite of any postoperative pulmonary complication (atelectasis, pneumonia, acute respiratory distress syndrome and pneumothorax). Our secondary outcome was hospital mortality, assessed from the date of surgery up to hospital discharge.

RESULTS

We included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) at the time of surgery and 206 who had recovered from COVID-19 prior to surgery in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (OR 3.19, 95% CI 1.12 to 9.68, p=0.03) and hospital mortality (HR 3.67, 95% CI 1.19 to 11.32, p=0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had recovered from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients.

INTERPRETATION

Symptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimise surgical care in this patient population.

STUDY REGISTRATION

ClinicalTrials.gov Identifier: NCT04458337 registration date: 7 July 2020.

Building resilient surgical systems that can withstand external shocks

When surgical systems fail, there is the major collateral impact on patients, society and economies. While short-term impact on patient outcomes during periods of high system stress is easy to measure, the long-term repercussions of global crises are harder to quantify and require modelling studies with inherent uncertainty. When external stressors such as high-threat infectious disease, forced migration or climate-change-related events occur, there is a resulting surge in healthcare demand. This, directly and indirectly, affects perioperative pathways, increasing pressure on emergency, critical and operative care areas. While different stressors have different effects on healthcare systems, they share the common feature of exposing the weakest areas, at which point care pathways breakdown. Surgery has been identified as a highly vulnerable area for early failure. Despite efforts by the WHO to improve preparedness in the wake of the SARS-CoV-2 pandemic, measurement of healthcare investment and surgical preparedness metrics suggests that surgical care is not yet being prioritised by policy-makers. Investment in the 'response' phase of health system recovery without investment in the 'readiness' phase will not mitigate long-term health effects for patients as new stressors arise. This analysis aims to explore how surgical preparedness can be measured, identify emerging threats and explore their potential impact on surgical services. Finally, it aims to highlight the role of high-quality research in developing resilient surgical systems.

Health systems strengthening through surgical and perioperative care pathways: a changing paradigm

Global health has traditionally focused on the primary health development with disease-specific focus such as HIV, malaria and non-communicable diseases (NCDs). As such, surgery has traditionally been neglected in global health as investment in them is often expensive, relative to these other priorities. Therefore, efforts to improve surgical care have remained on the periphery of initiatives in health system strengthening. However, today, many would argue that global health should focus on universal health coverage with primary health and surgery and perioperative care integrated as a part of this. In this article, we discuss the past developments and future-looking solutions on how surgery can contribute to the delivery of effective and equitable healthcare across the world. These include bidirectional integration of surgical and chronic disease pathways and better understanding financing initiatives. Specifically, we focus on access to safe elective and emergency surgery for NCDs and an integrated approach towards the rising multimorbidity from chronic disease in the population. Underpinning these, data-driven solutions from high-quality research from clinical trials and cohort studies through established surgical research networks are needed. Although challenges will remain around financing, we propose that development of surgical services will strengthen and improve performance of whole health systems and contribute to improvement in population health across the world.

Acute Appendicitis Management in Patients Aged Above 40 Years During the COVID-19 Pandemic: A Retrospective Study With Four Years of Follow-Up

Background The COVID-19 pandemic led many units to increase their utilization of nonoperative management (NOM) of acute appendicitis, with the literature showing its non-inferiority when compared to operative management (OM). Therefore, we compared NOM to OM against standard guidelines in order to ascertain the effectiveness of NOM. Primary outcomes were rates of admission, complications, hospital length of stay (LOS), and the incidence of colonic malignancy following NOM upon subsequent bowel evaluation using colonoscopy and/or computed tomography (CT) scan. Methods This was a retrospective observational study done on patients who were admitted with acute appendicitis from January 2020 to January 2022 at Wirral University Teaching Hospital, UK. Data was electronically collected from medical records. Inclusion criteria were patients aged 40 years and above, admitted with a diagnosis of acute appendicitis using a CT scan, and who underwent either OM or NOM. Exclusion criteria were patients below 40 years old or not diagnosed with acute appendicitis. Results This study included 211 cases of acute appendicitis (female to male: 110:101), with a median age of 60. One hundred and twenty-five (60%) patients were managed operatively, while 86 cases (40%) were managed by NOM. All of the cases were diagnosed using a CT scan. The mean LOS for operative and non-operative cases were 4.77 and 4.89 days, respectively. When readmission days were added over the following three years, adjusted LOS was 5.35 days for operative cases, in comparison to 10.86 days for NOM. Forty-five percent of NOM cases had at least one episode of readmission, with 37% of them being in the first year. We found six cases of malignancy in the NOM cohort, none of which were detected on colonoscopy following discharge. Conclusion NOM is associated with increased LOS and increased readmission rates, and 44% of cases eventually required appendicectomy.

Hematological picture of pediatric Sudanese patients with visceral leishmaniasis and prediction of leishmania donovani parasite load

BACKGROUND

Visceral leishmaniasis (VL) is a systemic protozoan infection caused by Leishmania donovani (L. donovani) and transmitted by sand flies, causing macrophage invasion in the liver, spleen, and bone marrow. Diagnosis of VL is currently based on clinical signs, symptoms, and specific in-vitro markers and bone marrow investigations. However, VL's specific hematological and bone marrow manifestation in Sudanese pediatric patients is not well studied.

AIM

To examine the blood and bone marrow characteristics in pediatric patients from Sudan who have VL.

METHODS

This is a retrospective hospital-based study with a sample of 107 consecutive Sudanese pediatric patients. The data focused on hematological and bone marrow results. We included only the completed records of the pediatric patients with VL in the Tropical Disease Teaching Hospital in Khartoum, Sudan from the period of 2016 to 2020.

RESULTS

The majority of pediatric patients included in this study are below 5-years-old (n = 59, 55.2%). Moreover, anemia, thrombocytopenia, and leukopenia were among the prevalent characteristics in the population under study. To further analyze the data, we developed a machine learning model using boosted forest algorithms to predict L. donovani parasites load, with a mean accuracy of 0.88 for the training dataset and an accuracy of 0.46, 0.50, and 0.74 for mild, moderate, and severe L. donovani parasite load in the validation dataset.

CONCLUSION

This study shows that the most common bone marrow change among Sudanese VL children was increased chronic inflammatory cells (n = 88, 82.2%) with present macrophage hemophagocytes (n = 103, 96.3%). While anemia and thrombocytopenia were the most common hematological changes. These results will hopefully lead to an early diagnosis and hence better management for Sudanese pediatric patients with suspected VL.

Optimal surgical timing for lung cancer following SARS-CoV-2 infection: a prospective multicenter cohort study

BACKGROUND

With the ongoing prevalence of the emerging variant and global vaccination efforts, the optimal surgical timing for patients with resectable lung cancer in the Omicron-dominant period requires further investigation.

METHODS

This prospective multicenter study involved patients who underwent radical surgery for lung cancer between January 29, 2023 and March 31, 2023. Patients were categorized into four groups based on the interval between SARS-CoV-2 infection and surgery. The main outcomes evaluated were 30-day mortality and 30-day morbidity.

RESULTS

A total of 2081 patients were enrolled in the study, of which 1837 patients (88.3%) had a confirmed SARS-CoV-2 diagnosis before surgery. Notably, no instances of 30-day mortality were observed in any patient. Patients without prior infection had a 30-day morbidity rate of 15.2%, with postoperative pneumonia occurring in 7.0% of cases. In contrast, patients diagnosed with SARS-CoV-2 before surgery had significantly higher rates of 30-day morbidity and postoperative pneumonia when surgery was performed within 4-5 weeks (adjusted odds ratio (aOR) (95% CI):2.18 (1.29-3.71) and 2.39 (1.21-4.79), respectively) or within 6-7 weeks (aOR (95% CI):2.07 (1.36-3.20) and 2.10 (1.20-3.85), respectively). Conversely, surgeries performed ≥ 8 weeks after SARS-CoV-2 diagnosis exhibited similar risks of 30-day morbidity and pneumonia compared to those in the no prior infection group (aOR (95% CI):1.13 (0.77-1.70) and 1.12 (0.67-1.99), respectively).

CONCLUSIONS

Thoracic surgery for lung cancer conducted 4-7 weeks after SARS-CoV-2 infection is still associated with an increased risk of 30-day morbidity in the Omicron-dominant period. Therefore, surgeons should carefully assess the individual risks and benefits to formulate an optimal surgical strategy for patients with lung cancer with a history of SARS-CoV-2 infection.

Preoperative COVID-19 and Postoperative Mortality in Cancer Surgery: A South Korean Nationwide Study

BACKGROUND

We evaluated the impact of preoperative COVID-19 on early postoperative mortality in patients undergoing time-sensitive cancer surgery.

METHODS

This retrospective, nationwide cohort study included adult patients who underwent various cancer (thyroid, breast, stomach, colorectal, hepatobiliary, genitourinary, lung, and multiple cancer) surgeries under general anesthesia in South Korea in 2022. Patients were grouped according to the duration from the date of COVID-19 confirmation to the date of surgery (0-2 weeks, 3-4 weeks, 5-6 weeks, and ≥7 weeks). Patients without preoperative COVID-19 also were included. Multivariable logistic regression analysis with Firth correction was performed to investigate the association between preoperative COVID-19 and 30-day and 90-day postoperative mortality. The covariates encompassed sociodemographic factors, the type of surgery, and vaccination status in addition to the aforementioned groups.

RESULTS

Of the 99,555 patients analyzed, 30,933 (31.1%) were preoperatively diagnosed with COVID-19. Thirty-day mortality was increased in those who underwent surgery within 0-2 weeks after diagnosis of COVID-19 (adjusted odds ratio [OR], 1.47; 95% confidence interval [CI], 1.02-2.12; P = 0.038); beyond 2 weeks, there was no significant increase in mortality. A similar pattern was observed for 90-day mortality. Full vaccination against COVID-19 was associated with reduced 30-day (OR 0.38; 95% CI 0.29-0.50; P < 0.001) and 90-day (OR 0.39; 95% CI 0.33-0.46; P < 0.001) mortality.

CONCLUSIONS

Cancer surgery within 2 weeks of COVID-19 diagnosis was associated with increased early postoperative mortality. These findings support current guidelines that recommend postponing elective surgery for at least 2 weeks after the diagnosis of COVID-19.

Impact of COVID-19 pandemic-induced surgical restrictions on operational performance: a case study at the University Hospital of Ulm

INTRODUCTION

The operating room (OR) is a high-cost and high-revenue area in a hospital comprising extremely complex process steps to treat patients. The perioperative process quality can be optimized through an efficiency-oriented central OR management based on performance indices. However, during the COVID-19 pandemic with the corresponding OR restrictions, there was a significant nation- and worldwide decline in the performance, which may have a lasting impact. Therefore, we proposed the hypothesis that COVID-19 pandemic-related OR restrictions could reduce operative performance in the long term.

METHODS

A retrospective, descriptive analysis of perioperative processing times was conducted exemplarily at the University Hospital Ulm using a pre-post design, examining the corresponding second quarters of 2019 to 2022. In total, n = 18,489 operations with n = 314,313 individual time intervals were analyzed. The statistical analyses included the Kruskal-Wallis test adjusted for multiple testing, and the significance level was set at p < 0.01.

RESULTS

The results revealed not only a significant decrease in the case volume by 31% (2020) and 23% (2021) during the COVID-19 crisis years, but also significant time delays in various process steps; e.g. the median patient's OR occupancy time (column time) rose from 65 min (2019) to 87 min (2020) and remained elevated (72 min in 2021 and 74 min in 2022, respectively). Even in 2022, beyond the pandemic, the net anaesthesia time was permanently enhanced by 9 min per case. Furthermore, both, the incision-to-closure time and surgeon attachment time were each significantly prolonged by 7 additional minutes, and the time from the end of anaesthesia to the release of the next patient was extended by 4 min. Selected standardized index operations showed only a trend towards these changes, even with a decrease in the incision-to-closure time over time.

CONCLUSION

Overall, long-term changes were found in essential perioperative process times even after retraction of the COVID-19 restrictions, indicating some processual "slow down" after the Covid-19-induced "shut down". Further analyses are needed to determine the appropriate targeted control measures to improve processing times and increase the process quality.

Current insights on social media as a tool for the dissemination of research and education in surgery: a narrative review

The purpose of our narrative review is to summarize the utilization of social media (SoMe) platforms for research communication within the field of surgery. We searched the PubMed database for articles in the last decade that discuss the utilization of SoMe in surgery and then categorized the diverse purposes of SoMe. SoMe proved to be a powerful tool for disseminating articles. Employing strategic methods like visual abstracts enhances article citation rates, the impact factor, h-index, and Altmetric score (an emerging alternative metric that comprehensively and instantly quantifies the social impact of scientific papers). SoMe also proved valuable for surgical education, with online videos shared widely for surgical training. However, it is essential to acknowledge the associated risk of inconsistency in quality. Moreover, SoMe facilitates discussion on specific topics through hashtags or closed groups and is instrumental in recruiting surgeons, with over half of general surgery residency programs in the US efficiently leveraging these platforms to attract the attention of potential candidates. Thus, there is a wealth of evidence supporting the effective use of SoMe for surgeons. In the contemporary era where SoMe is widely utilized, surgeons should be well-versed in this evidence.

The trends and outcomes of inflammatory bowel disease surgery during the COVID-19 pandemic: A retrospective propensity score-matched analysis from a multi-institutional research network

Background and Aims

The coronavirus disease 2019 (COVID-19) pandemic has affected the management of inflammatory bowel disease (IBD) patients. Elective operations and surveillance endoscopies were postponed for IBD patients to preserve healthcare resources and to prevent the spread of COVID-19. This study aimed to describe the trends and outcomes of IBD surgery during the pandemic.

Methods

This was a retrospective propensity score-matched analysis using data extracted from TriNetX, a multi-institutional research database. IBD patients admitted for surgery were identified between March 2019 to February 2020 (prepandemic) and March 2020 to February 2023 (pandemic). The monthly volume of IBD surgical procedures was compared during the pandemic to the prepandemic period. After matching, the risk of adverse outcomes following IBD surgery was compared between the 3 years of the pandemic compared to the prepandemic cohort.

Results

There was a reduction in both elective and emergency IBD operations during the pandemic. These trends were not significant. After matching, the risks of returning to theaters and hospital readmission were comparable across the 3 years of the pandemic. In the first and second years of the pandemic, elective patients were at a greater risk of mortality (risk ratio [RR], 2; 95% confidence interval [CI], 1.160-3.448 and RR, 1.778; 95% CI, 1.003-3.150, respectively) and the emergency cohort had a higher risk of critical care admission (RR, 1.759; 95% CI, 1.126-2.747 and RR, 1.742; 95% CI, 1.131-2.682, respectively).

Conclusion

Our study highlights the impact of the COVID-19 pandemic on the management of IBD patients undergoing surgery. These results provide insights into the management of IBD surgery during times of crisis and can help guide decision-making and resource allocation for IBD patients requiring surgical intervention.

Timing of oral and maxillofacial surgery in infected COVID-19 subjects: A retrospective cohort study

This study aims to investigate the association of time to oral and maxillofacial surgery after Covid-19 infection with the risk of postoperative complications in a population from China. In the current study, a total of 1342 consecutive patients underwent general anesthesia (GA) in the maxillofacial district of the Chinese Oral and Maxillofacial COVID Collaborative, which consists of 27 teaching hospitals. Pulmonary, cardiovascular and thrombotic complications were monitored for 1 month after GA surgery (GAS) and their incidence was reported for the first 30 days. Post-operative complications were observed in 4 of 1076 cases (0.37%) who had suffered from mild Omicron infection and in none of the controls. Results from the Quasi-Poisson multivariate regression models showed that Omicron infection was not associated with increased post-operative complications compared to controls. Among the infected patients, delays of >4 but not >6 weeks were associated with lower OR of complications (0.08, 95% CI 0.01-0.78 and 0.06, 95% CI 0.01-1.80, respectively). Findings of this study suggest that delaying surgery for a period of 4-6 weeks following infection can provide a protective effect.

Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery - a prospective cohort study

Background

Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia.

Methods

A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions.

Findings

3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively.

Interpretation

The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care.

Funding

This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

Assessing the safety of ureteral stent placement for obstructive urolithiasis in patients during the COVID-19 pandemic

Background

Patients with an active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [coronavirus disease 2019 (COVID-19)] infection are at a higher risk of post-operative mortality. In this retrospective case-control study, we analyzed the post-operative safety of patients undergoing cystoscopy with ureteral stent placement for obstructing ureteral calculi who tested positive for COVID-19.

Methods

We retrospectively identified patients who underwent cystoscopy and ureteral stent placement between June 5, 2020 and December 31, 2022 as an add-on case. Patients were stratified by whether they had a positive COVID-19 test on admission. Baseline characteristics were compared using Students t-test for continuous variables and Pearson chi-square test for categorical variables. Univariate and multivariate logistic regression analysis was performed to identify predictors of postoperative 30-day mortality.

Results

A total of 1,408 patients underwent add-on cystoscopy with ureteral stent placement for an obstructing calculus, of which 55 (3.9%) patients had a positive COVID-19 test. When stratified by COVID-19 status, both groups were similar with regards to age, sex, race, co-morbidities, indications, procedure duration, and type of anesthesia administered. Of the 137 patients that were admitted to the intensive care unit (ICU), 9 patients were COVID-19 positive (16.4% vs. 9.5%, P=0.09). On multivariate logistic regression, patients with COVID-19 had a higher odds of 30-day mortality [odds ratio (OR) =7.06; 95% confidence interval (CI): 2.03-24.47; P=0.002] when controlling for age, co-morbidities, vaccination status, anesthesia type, and indication for the stent.

Conclusions

Patients that underwent cystoscopy and ureteral stent placement for an obstructing ureteral stone with a concurrent COVID-19 diagnosis had an increased risk of perioperative 30-day mortality.

Outcomes Following Vascular and Endovascular Procedures Performed During the First COVID-19 Pandemic Wave

OBJECTIVE

The first COVID-19 pandemic wave was a period of reduced surgical activity and redistribution of resources to only those with late stage or critical presentations. This Vascular and Endovascular Research Network COVID-19 Vascular Service (COVER) study aimed to describe the six-month outcomes of patients who underwent open surgery and or endovascular interventions for major vascular conditions during this period.

METHODS

In this international, multicentre, prospective, observational study, centres recruited consecutive patients undergoing vascular procedures over a 12-week period. The study opened in March 2020 and closed to recruitment in August 2020. Patient demographics, procedure details, and post-operative outcomes were collected on a secure online database. The reported outcomes at 30 days and six months were post-operative complications, re-interventions, and all cause in-hospital mortality rate. Multivariable logistic regression was used to assess factors associated with six-month mortality rate.

RESULTS

Data were collected on 3 150 vascular procedures, including 1 380 lower limb revascularisations, 609 amputations, 403 aortic, 289 carotid, and 469 other vascular interventions. The median age was 68 years (interquartile range 59, 76), 73.5% were men, and 1.7% had confirmed COVID-19 disease. The cumulative all cause in-hospital, 30-day, and six-month mortality rates were 9.1%, 10.4%, and 12.8%, respectively. The six-month mortality rate was 32.1% (95% CI 24.2-40.8%) in patients with confirmed COVID-19 compared with 12.0% (95% CI 10.8-13.2%) in those without. After adjustment, confirmed COVID-19 was associated with a three times higher odds of six-month death (adjusted OR 3.25, 95% CI 2.18-4.83). Increasing ASA grade (3-5 vs. 1-2), frailty scores 4-9, diabetes mellitus, and urgent and or immediate procedures were also independently associated with increased odds of death by six months, while statin use had a protective effect.

CONCLUSION

During the first wave of the pandemic, the six-month mortality rate after vascular and endovascular procedures was higher compared with historic pre-pandemic studies and associated with COVID-19 disease.

Increased 90-Day Morbidity and Mortality Among Patients With Hip Fracture During the COVID-19 Pandemic

BACKGROUND

When coronavirus disease 2019 (COVID-19) first spread to the United States, our institution was at the outbreak's epicenter. Despite limited understanding of COVID-19's long-term effects, we continued performing surgical fixation of geriatric hip fractures under strict guidelines. This study examined the outcomes of these patients during the pandemic compared with those of patients treated pre-pandemic.

MATERIALS AND METHODS

We conducted a retrospective cohort study of patients with hip fractures between December 2019 and June 2020, the peak of the pandemic in our region. Outcomes of patients treated with surgical fixation (2020 cohort) were compared with those of a historical control group (2019 cohort). The primary outcome was 90-day mortality, with secondary outcomes including pneumonia, thromboembolic events, emergency department visits, readmission, and cardiac events.

RESULTS

The 2020 cohort (n=64) and 2019 cohort (n=78) had similar baseline characteristics. The 2020 cohort had a 4.27 times higher risk (95% CI, 1.30-13.98) of developing pneumonia compared with the pre-pandemic cohort but had no other differences in 90-day complications. Patients with COVID-19 in the 2020 cohort had a 5.09 times higher risk (95% CI, 1.35-19.20) of developing pneumonia and a 5.38 times higher risk (95% CI, 1.13-25.64) of postoperative mortality. There was no increased risk for thromboembolism between the 2020 and 2019 cohorts, even among COVID-19 cases, as all patients received anticoagulation with heparin.

CONCLUSION

Our study demonstrates that hip fracture surgery remained safe during the peak of the US COVID-19 pandemic, with an expected increase in pneumonia and mortality risk for patients with hip fracture with COVID-19. [Orthopedics. 202x;4x(x):xx-xx.].

Assessment of Complications and Length of Hospital Stay Associated With Surgical Emergencies in Patients With Concurrent COVID-19 Infection

The delivery of surgical services was profoundly affected by the COVID-19 pandemic, resulting in the postponement of elective surgeries and a shift in focus to essential emergency procedures. Our study aimed to assess the impact of concurrent COVID-19 infection on complications, hospital stay, and recovery following emergency surgery. A retrospective matched cohort study was conducted between July 2020 and February 2022 at a tertiary care hospital in India. Data from 48 patients with COVID-19 infection in the immediate preoperative period was compared with 48 matched controls not infected with the virus. The data collected included patient demographics, surgical procedures, duration of hospital stay, and postoperative complications. Patients with concurrent COVID-19 infection had notably longer mean hospital stays (13.44 days) than the controls (6.63 days) (P = 0.002). An elevated proportion of COVID-19-positive patients experienced discharge delays (36 out of 48, 75%), compared to just six of the 48 non-COVID-19 patients (12.5%) (P ≤ 0.001). Postoperative findings in the COVID-positive cohort revealed elevated rates of pulmonary complications (5/48, 10.4%), higher rates of postoperative ICU admissions (8/48, 16.7%), and persistently elevated D-dimer levels extending beyond postoperative day seven (18/48, 37.5%). This suggests that emergency surgery in patients with COVID-19 is linked to significantly lengthier hospital stays, increased discharge delays, and a greater prevalence of adverse events in the postoperative period when compared to controls. These findings underscore the need for enhanced perioperative strategies and preparedness for potential future pandemics.

Effects of the COVID-19 pandemic on short-term postoperative outcomes of emergency surgery for gastroduodenal perforation: A nationwide study in Japan based on the National Clinical Database

Aim

To examine the potential negative effects of the COVID-19 pandemic on short-term postoperative outcomes of emergency surgery for gastroduodenal perforation in Japan.

Methods

A total of 7973 cases of gastroduodenal perforation from 2019 to 2021 were retrieved from the National Clinical Database (NCD), which includes >95% of surgical cases in Japan. Data were analyzed nationally and in subgroups for subjects in areas with high infection levels (HILs). Postoperative 30-d mortality, surgical mortality, and complications (Clavien-Dindo (CD) grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1.

Results

Nationally, data from 2019 vs 2020 and 2021 showed 30-d mortality of 175 (6.7%) vs 398 (7.4%), surgical mortality of 250 (9.5%) vs 537 (10.1%), and complications (CD ≥3) of 558 (21.2%) vs 1163 (21.8%). Among these data, the only significantly high SMR was found for complications in July 2020 (1.36 [95% CI: 1.001-1.80]). In areas with HILs, data from 2019 vs 2020 and 2021 indicated 30-d mortality of 91 (6.3%) vs 215 (7.3%), surgical mortality of 135 (9.4%) vs 294 (10.0%), and complications (CD ≥3) of 304 (21.1%) vs (23.1%). In these data, no month had a significantly high SMR.

Conclusion

The COVID-19 pandemic had few negative effects on outcomes after surgery for gastroduodenal perforation. These findings suggest that the emergency system for gastroduodenal perforation in Japan was generally maintained during the pandemic.

From Alpha to Omicron and Beyond: Associations Between SARS-CoV-2 Variants and Surgical Outcomes

INTRODUCTION

The COVID-19 pandemic has significantly influenced surgical practices, with SARS-CoV-2 variants presenting unique pathologic profiles and potential impacts on perioperative outcomes. This study explores associations between Alpha, Delta, and Omicron variants of SARS-CoV-2 and surgical outcomes.

METHODS

We conducted a retrospective analysis using the National COVID Cohort Collaborative database, which included patients who underwent selected major inpatient surgeries within eight weeks post-SARS-CoV-2 infection from January 2020 to April 2023. The viral variant was determined by the predominant strain at the time of the patient's infection. Multivariable logistic regression models explored the association between viral variants, COVID-19 severity, and 30-d major morbidity or mortality.

RESULTS

The study included 10,617 surgical patients with preoperative COVID-19, infected by the Alpha (4456), Delta (1539), and Omicron (4622) variants. Patients infected with Omicron had the highest vaccination rates, most mild disease, and lowest 30-d morbidity and mortality rates. Multivariable logistic regression demonstrated that Omicron was linked to a reduced likelihood of adverse outcomes compared to Alpha, while Delta showed odds comparable to Alpha. Inclusion of COVID-19 severity in the model rendered the odds of major morbidity or mortality equal across all three variants.

CONCLUSIONS

Our study examines the associations between the clinical and pathological characteristics of SARS-CoV-2 variants and surgical outcomes. As novel SARS-CoV-2 variants emerge, this research supports COVID-19-related surgical policy that assesses the severity of disease to estimate surgical outcomes.

90-Day Complication and Readmission Rates for Geriatric Patients With Hip Fracture at Different Time Points From COVID-19 Positivity: A Database Study

INTRODUCTION

Geriatric patients with hip fracture are at risk of having COVID-19 while needing fracture treatment. Understanding the associated risks of variable timing of COVID-19 before surgery may help direct care algorithms.

METHODS

Geriatric patients with documented hip fracture surgery were identified within the PearlDiver M157 database. Patients with a preoperative COVID-19 diagnosis were classified based on time from diagnosis to surgery: ≤ 1 week, > 1 to ≤ 4 weeks, > 4 to ≤ 7 weeks, > 7 to ≤ 10 weeks, and > 10 to ≤ 13 weeks. The association of COVID-19 diagnoses with 90-day complications was evaluated.

RESULTS

Overall, 263,771 patients with hip fracture were identified, of which COVID-19 within 13 weeks of surgery was documented for 976. On multivariable analysis, patients with COVID-19 infection within ≤ 1 week preoperatively demonstrated increased rates of minor adverse events (odds ratio (OR) = 1.50), all adverse events (OR = 1.59), sepsis (OR = 1.70), and pneumonia (OR = 2.35) (P ≤ 0.0007 for each). For time points greater than 1 week, there were no differences in complication rates.

DISCUSSION

Patients with COVID-19 within 1 week of hip fracture surgery demonstrated greater odds of 90-day complications. Reassuringly, patients with COVID-19 diagnoses more than 1 week preoperatively were not associated with increased odds of any assessed complication.

Impact of SARS-CoV-2 infection on short-term postoperative outcomes after gastroenterological cancer surgery using data from a nationwide database in Japan

Background

Due to the coronavirus disease 2019 (COVID-19) pandemic, cancer screening, diagnosis, and treatment have changed. This study aimed to investigate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection prior to gastroenterological cancer surgeries on postoperative complications using data from a nationwide database in Japan.

Methods

Data on patients who underwent surgery for cancer including esophageal, gastric, colon, rectal, liver, and pancreatic cancer between July 1, 2019, and September 300, 2022, from real-world sources in Japan were analyzed. The association between preoperative SARS-CoV-2 infection and short-term postoperative outcomes was evaluated. A similar analysis stratified according to the interval from SARS-CoV-2 infection to surgery (<4 vs. >4 weeks) was conducted.

Results

In total, 60 604 patients were analyzed, and 227 (0.4%) patients were diagnosed with SARS-CoV-2 infection preoperatively. The median interval from SARS-CoV-2 infection to surgery was 25 days. Patients diagnosed with SARS-CoV-2 infection preoperatively had a significantly higher incidence of pneumonia (odds ratio: 2.05; 95% confidence interval: 1.05-3.74; p = 0.036) than those not diagnosed with SARS-CoV-2 infection based on the exact logistic regression analysis adjusted for the characteristics of the patients. A similar finding was observed in patients who had SARS-CoV-2 infection <4 weeks before surgery.

Conclusions

Patients with a history of SARS-CoV-2 infection had a significantly higher incidence of pneumonia. This finding can be particularly valuable for countries that have implemented strict regulations in response to the COVID-19 pandemic and have lower SARS-CoV-2 infection-related mortality rates.