Surgery and COVID-19

Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: the COVIDSurg mortality score

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the best predictors and used these to create the COVIDsurg Mortality Score (https://covidsurgrisk.app). Our data demonstrates that it is safe to restart a wide range of surgical services for selected patients.

The impact of the COVID-19 pandemic on vascular surgery: Health care systems, economic, and clinical implications

The novel severe acute respiratory syndrome coronavirus-2 (coronavirus disease 2019 [COVID-19]) pandemic is responsible for more than 500,000 deaths in the United States and nearly 3 million worldwide, profoundly altering the landscape of health care delivery. Aggressive public health measures were instituted and hospital efforts became directed at COVID-19–related concerns. Consequently, routine surgical practice was virtually halted, resulting in billions of dollars in hospital losses as pandemic costs escalated. Navigating an uncertain new landscape of scarce resource allocation, exposure risk, role redeployment, and significant practice pattern changes has been challenging. Furthermore, the overall effect on the financial viability of the health care system and vascular surgical practices is yet to be elucidated. This review explores the economic and clinical implications of COVID-19 on the practice of vascular surgery in addition to the health care system as a whole.

The Incidence of COVID-19 Patients in Oral and Maxillofacial Surgery

Purpose

The SARS-CoV-2 global pandemic has resulted in widespread changes to healthcare practices across the United States. The purpose of this study is to examine the incidence of COVID-19 patients in the oral-maxillofacial surgery setting in order to help guide perioperative protocols during the pandemic.

Methods

In this retrospective cohort study, predictor variables (presence of preoperative symptoms on presentation, patient age, patient gender, patient race, hospital location, and presence of statewide stay-at-home orders) were examined with outcome variables (SARS-CoV-2 test results) over 10 months between March 2020 and December 2020 for patients undergoing surgical procedures in the operating room by the following Oral-Maxillofacial Surgery Departments:

- Louisiana State University Health Sciences Center (Baton Rouge, LA)

- University of Illinois at Chicago (Chicago, IL)

- University of Texas Health Science Center at Houston (Houston, TX)

Data analysis included Fisher exact tests to compare categorical variables across COVID test groups and Wilcoxon rank sum tests to compare continuous covariates. Two-sample tests of proportions were used to compare observed COVID-19 positivity rates to other study results.

Results

Out of 684 patients in 3 institutions, 17 patients (2.5%, 95% CI = 1.5 to 4.0%) tested positive for COVID-19 over a 10 month interval (March 1, 2020- December 31, 2020). The majority of patients that tested positive were asymptomatic in the preoperative setting (P-value = .09). They were significantly more likely to be African-American (P-value = .015) and less likely to have a stay-at-home order present at the time of surgery (P-value = .033). Age, gender, and hospital location did not play a statistically significant role.

Conclusion

Our results demonstrate a 2.5% incidence of COVID-19 infection in the total population of patients undergoing scheduled oral-maxillofacial surgeries in 3 major healthcare systems across the United States. This data may help inform perioperative protocols and infection control measures during the COVID-19 pandemic.

Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic

BACKGROUND

Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection.

METHODS

Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic.

RESULTS

Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls.

CONCLUSION

Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls.

Surgical stabilization of rib fractures in symptomatic COVID-19: A case report

Severe chest wall injury following trauma is a significant contributing factor to respiratory failure and need for mechanical ventilation in multiply injured patients. Surgical stabilization of rib fractures (SSRF) is increasingly considered to be advantageous in this population. Surgical stabilization has been shown to improve multiple outcomes including ventilator avoidance, liberation from mechanical ventilation, and diminished pulmonary complications in the trauma population, particularly when performed early. During the coronavirus disease 2019 (COVID-19) pandemic, ventilators have become a scarce resource, and conservative strategies have become a critical component of intensive care. We present a report of the perioperative outcome of SSRF in a geriatric polytrauma patient who initially presented after a mechanical fall and co-existing symptomatic COVID-19.

Surgical complications in COVID-19 patients in the setting of moderate to severe disease

The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on the work of physicians and surgeons. The connection between the patient and the surgeon cannot be replaced by telemedicine. For example, the surgical staff faces more serious difficulties compared to non-surgical specialists during the COVID-19 pandemic. The primary concerns include the safest solutions for protecting healthcare staff and patients and the ability to provide adequate surgical care. Additionally, the adverse effects of any surgery delays and the financial consequences complicate the picture. Therefore, patients' admission during the COVID-19 pandemic should be taken into consideration, as well as preoperative measures. The COVID-19 situation brings particular risk to patients during surgery, where preoperative morbidity and mortality rise in either asymptomatic or symptomatic COVID-19 patients. This review discusses the recent factors associated with surgical complications, mortality rates, outcomes, and experience in COVID-19 surgical patients.

Evidence, not eminence, for surgical management during COVID-19: a multifaceted systematic review and a model for rapid clinical change

BACKGROUND

Coronavirus (COVID-19) forced surgical evolution worldwide. The extent to which national evidence-based recommendations, produced by the current authors early in 2020, remain valid, is unclear. To inform global surgical management and a model for rapid clinical change, this study aimed to characterize surgical evolution following COVID-19 through a multifaceted systematic review.

METHODS

Rapid reviews were conducted targeting intraoperative safety, personal protective equipment and triage, alongside a conventional systematic review identifying evidence-based guidance for surgical management. Targeted searches of PubMed and Embase from 31 December 2019 were repeated weekly until 7 August 2020, and systematic searches repeated monthly until 30 June 2020. Literature was stratified using Evans' hierarchy of evidence. Narrative data were analysed for consistency with earlier recommendations. The systematic review rated quality using the AGREE II and AMSTAR tools, was registered with PROSPERO, CRD42020205845. Meta-analysis was not conducted.

RESULTS

From 174 targeted searches and six systematic searches, 1256 studies were identified for the rapid reviews and 21 for the conventional systematic review. Of studies within the rapid reviews, 903 (71.9 per cent) had lower-quality design, with 402 (32.0 per cent) being opinion-based. Quality of studies in the systematic review ranged from low to moderate. Consistency with recommendations made previously by the present authors was observed despite 1017 relevant subsequent publications.

CONCLUSION

The evidence-based recommendations produced early in 2020 remained valid despite many subsequent publications. Weaker studies predominated and few guidelines were evidence-based. Extracted clinical solutions were globally implementable. An evidence-based model for rapid clinical change is provided that may benefit surgical management during this pandemic and future times of urgency.

Publication bias is the consequence of a lack of diversity, equity, and inclusion

Publication bias has been shown to exist in research across medical and surgical specialties. Bias can occur at any stage of the publication process and can be related to race, ethnicity, age, religion, sex, gender, or sexual orientation. Although some improvements have been made toward addressing this issue, bias still spans the publication process from authors and peer reviewers, to editorial board members and editors, with poor inclusion of women and underrepresented minorities throughout. The result of bias remaining unchecked is the publication of research that leaves out certain groups, is not applicable to all people, and can result in harm to some populations. We have highlighted the current landscape of publication bias and strived to demonstrate the importance of addressing it. We have also provided solutions for reducing bias at multiple stages throughout the publication process. Increasing diversity, equity, and inclusion throughout all aspects of the publication process, requiring diversity, equity, and inclusion statements in reports, and providing specific education and guidelines will ensure the identification and eradication of publication bias. By following these measures, we hope that publication bias will be eliminated, which will reduce further harm to certain populations and promote better, more effective research pertinent to all people.

National and regional trends in MRI utilization in the face of the ongoing COVID-19 pandemic

BACKGROUND AND PURPOSE

Marked reductions in imaging exams have been documented during the COVID-19 pandemic. The study aimed to examine the effect of the two waves of COVID-19 on magnetic resonance imaging (MRI) utilization at the national and regional level.

MATERIALS AND METHODS

A retrospective-archive study was conducted in Israel, comparing March-December 2020 with March-December 2018 and 2019. Data on MRI utilization were obtained from the national MRI registry, while data on confirmed COVID-19 cases, by place of residence, were obtained from the Israeli Ministry of Health open COVID-19 database.

RESULTS

The number and rate of MRI examinations decreased during the first COVID-19 wave, with the steepest drop in April 2020: 47.5% relative decrease compared to April 2019, and 42.2% compared to 2018. This was followed by a compensatory increase between the waves and a return to almost pre-pandemic levels of use, with just a modest decrease, during the second, more intense COVID wave, compared with the previous year. Existing differences between regions increased during the pandemic. The rate ratio of MRI exams between Tel-Aviv and the Northern periphery increased from 2.89 in April 2019 to 3.94 in April 2020. Jerusalem metropolitan region, with the largest burden of COVID disease, demonstrated only a modest decrease (1%) in MRI utilization during the first 10 months of the pandemic.

CONCLUSIONS

At the national level, time trends in reduced MRI utilization followed the first wave of COVID-19, and were accompanied by increased regional disparities. These changes were not explained by differences in the burden of COVID-19 disease but might be explained by unequal distribution of MRI scanners among regions. Reduced utilization was not evident during the second wave, nor at the beginning of the third wave, despite higher COVID-19 case load, demonstrating adaptation to the new normal. Patterns of MRI utilization might help policy-makers and healthcare managers predict the behavior of imaging as well as other sectors, such as elective surgical procedures, during an ongoing pandemic. This forecast might help to manage the lasting effects of the pandemic, including extended waiting times, in the months and years following its remission. In preparation for future national emergencies, timely and detailed data on MRI utilization can serve as a "sensor" for a wide array of diagnostic and interventional medical activities, providing policy-makers with an updated snapshot to guide their response at the regional and national levels.

Continuity of Cancer Care: The Surgical Experience of Two Large Cancer Hubs in London and Milan

The SARS-CoV-2 (COVID-19) pandemic is having a large effect on the management of cancer patients. This study reports on the approach and outcomes of cancer patients receiving radical surgery with curative intent between March and September 2020 (in comparison to 2019) in the European Institute of Oncology, IRCCS (IEO) in Milan and the South East London Cancer Alliance (SELCA). Both institutions implemented a COVID-19 minimal pathway where patients were required to self-isolate prior to admission and were swabbed for COVID-19 within 72 h of surgery. Positive patients had surgery deferred until a negative swab. At IEO, radical surgeries declined by 6% as compared to the same period in 2019 (n = 1477 vs. 1560, respectively). Readmissions were required for 3% (n = 41), and <1% (n = 9) developed COVID-19, of which only one had severe disease and died. At SELCA, radical surgeries declined by 34% (n = 1553 vs. 2336). Readmissions were required for 11% (n = 36), <1% (n = 7) developed COVID-19, and none died from it. Whilst a decline in number of surgeries was observed in both centres, the implemented COVID-19 minimal pathways have shown to be safe for cancer patients requiring radical treatment, with limited complications and almost no COVID-19 infections.

The perception of patient safety in an alternate site of care for elective surgery during the first wave of the novel coronavirus pandemic in the United Kingdom: a survey of 158 patients

BACKGROUND

We undertook a prospective qualitative survey to ascertain the perceptions and experience of National Health Service patients in the United Kingdom who underwent planned or elective procedures and surgery at alternate 'clean' hospital sites during the coronavirus disease 2019 (COVID-19) pandemic. These alternate 'clean' hospital sites were independent hospitals running active staff and patient testing programmes for COVID-19 and which did not admit or treat patients suffering with COVID-19.

METHODS

A prospective survey was undertaken to include patients at least 30 days after a planned surgery or procedure conducted at a 'clean' alternate hospital site during the COVID-19 pandemic. The study was conducted using structured interviews undertaken by trained assessors. A 20% sample group of patients were randomly selected to participate in this study. Qualitative data related to confidence, safety and perceptions of safety were collected.

RESULTS

Ninety-five patients (60%) reported that they had prior worries or concerns about undergoing an elective procedure during the COVID-19 pandemic. A total of 47 patients (30%) had delayed their surgery at least once because of these concerns. A total of 150 patients (95%) felt that the precautions in place to protect their safety in the setting of an alternate 'clean' hospital site were well thought out and proportionate. Patients reported high levels of confidence in the measures undertaken. Separation of patient pathways using the independent sector and patient testing were identified by patients as having the greatest impact on their perception of safety.

CONCLUSIONS

Patient confidence will be key to ensuring uptake of planned and elective procedures and surgery during the COVID-19 pandemic. Perceptions of safety will be key to this confidence and efforts to demonstrably enhance safety are well received by patients. In particular, patients felt that a dedicated programme of patient testing and separation of patient pathways provided the greatest levels of confidence in the safety of their treatment.

Trends in Trauma Admissions During the COVID-19 Pandemic in Los Angeles County, California

IMPORTANCE

Describing the changes in trauma volume and injury patterns during the course of the coronavirus disease 2019 (COVID-19) pandemic could help to inform policy development and hospital resource planning.

OBJECTIVE

To examine trends in trauma admissions throughout Los Angeles County (LAC) during the pandemic.

DESIGN, SETTING, AND PARTICIPANTS

In this cohort study, all trauma admissions to the 15 verified level 1 and level 2 trauma centers in LAC from January 1 to June 7, 2020 were reviewed. All trauma admissions from the same period in 2019 were used as historical control. For overall admissions, the study period was divided into 3 intervals based on daily admission trend analysis (January 1 through February 28, March 1 through April 9, April 10 through June 7). For the blunt trauma subgroup analysis, the study period was divided into 3 similar intervals (January 1 through February 27, February 28 through April 5, April 6 through June 7).

EXPOSURES

COVID-19 pandemic.

MAIN OUTCOMES AND MEASURES

Trends in trauma admission volume and injury patterns.

RESULTS

A total of 6777 patients in 2020 and 6937 in 2019 met inclusion criteria. Of those admitted in 2020, the median (interquartile range) age was 42 (28-61) years and 5100 (75.3%) were men. Mechanisms of injury were significantly different between the 2 years, with a higher incidence of penetrating trauma and fewer blunt injuries in 2020 compared with 2019 (penetrating: 1065 [15.7%] vs 1065 [15.4%]; blunt: 5309 [78.3%] vs 5528 [79.7%]). Overall admissions by interval in 2020 were 2681, 1684, and 2412, whereas in 2019 they were 2462, 1862, and 2613, respectively. There was a significant increase in overall admissions per week during the first interval (incidence rate ratio [IRR], 1.02; 95% CI, 1.002-1.04; P = .03) followed by a decrease in the second interval (IRR, 0.92; 95% CI, 0.90-0.94; P < .001) and, finally, an increase in the third interval (IRR, 1.05; CI, 1.03-1.07; P < .001). On subgroup analysis, blunt admissions followed a similar pattern to overall admissions, while penetrating admissions increased throughout the study period.

CONCLUSIONS AND RELEVANCE

In this study, trauma centers throughout LAC experienced a significant change in injury patterns and admission trends during the COVID-19 pandemic. A transient decrease in volume was followed by a quick return to baseline levels. Trauma centers should prioritize maintaining access, capacity, and functionality during pandemics and other national emergencies.

COVID-19 risk in elective surgery during a second wave: a prospective cohort study

Background

The COVID‐19 pandemic has greatly affected access to elective surgery, largely because of concerns for patients and healthcare workers. A return to normal surgery workflow depends on the prevalence and transmission of coronavirus in elective surgical patients. The aim of this study was to determine the prevalence of active SARS‐coronavirus‐2 infection during a second wave among patients admitted to hospital for elective surgery in Victoria.

Methods

Prospective cohort study across eight hospitals in Victoria during July–August 2020 was conducted enrolling adults and children admitted to hospital for elective surgery or interventional procedure requiring general anaesthesia. Study outcomes included a positive polymerase chain reaction (PCR) test for SARS‐CoV‐2 in the preoperative period (primary outcome), and for those with a negative test preoperatively, the incidence of a positive PCR test for SARS‐CoV‐2 in the post‐operative period.

Results

We enrolled 4965 elective adult and paediatric surgical patients from 15 July to 31 August 2020. Four patients screened negative on questionnaire but had a positive PCR test for coronavirus, resulting in a Bayesian estimated prevalence of 0.12% (95% probability interval 0–0.26%). There were no reports of healthcare worker infections linked to elective surgery during and up to 2 weeks after the study period.

Conclusion

The prevalence of SARS‐CoV‐2 in asymptomatic elective surgical patients during a second wave was approximately 1 in 833. Given the very low likelihood of coronavirus transmission, and with existing current hospital capacity, recommencement of elective surgery should be considered. A coronavirus screening checklist should be mandated for surgical patients.