Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials

BACKGROUND

There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes.

METHODS

MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival.

RESULTS

We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay.

DISCUSSION

Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings.

TRIAL REGISTRATION NUMBER

CRD42021232067.

Validation of NEWS2, SIRS, and qSOFA in Postoperative Cardiac Patients: A Retrospective Cohort Study

INTRODUCTION

The 'quick Sepsis Related Organ Failure Assessment' (qSOFA), 'Systemic Inflammatory Response Syndrome' (SIRS), and 'National Early Warning Score' 2 (NEWS2) scores are yet to be comparatively validated in ward-based cardiac surgical patients despite widespread routine use in clinical practice. We sought to assess the predictive validity of NEWS, SIRS, and qSOFA in identifying postoperative, ward-level cardiac surgical patients at risk of poor short-term mortality.

METHODS

All adult patients who underwent cardiac surgery at a single tertiary center between November 2014 and October 2017 were identified. Data for bedside observations, hematological results, and microbiology requests were obtained from electronic health records. Survival data were acquired from a national registry. The primary outcome was the discriminatory ability, measured by the area under the receiver operating characteristic (AUROC), of each score for in-hospital mortality.

RESULTS

One thousand five hundred forty three (male n = 1101, 71%) patients were included. Overall in-hospital mortality was 2.4%. There was no significant difference in discriminatory ability of NEWS (AUROC 0.5060), SIRS (AUROC 0.4874), and qSOFA (AUROC 0.5139) for in-hospital mortality (P = 0.881). Sensitivity for this outcome was ubiquitously low (13.51-40.54%).

CONCLUSIONS

Current illness-severity scores show a low discriminatory ability for in-hospital mortality in ward-based cardiac surgical patients. Caution should be used in the application of these prognostic screening tools for early detection of poor outcomes in this population.

Impact of the SARS-CoV-2 pandemic on lung cancer survival in England: an analysis of the rapid cancer registration dataset

Early changes in lung cancer care can affect survival. Given the decrease in diagnosis during lockdowns, we calculated their impact on survival using National Lung Cancer Audit data. Percentage survival and HRs for death were compared between 2019 and lockdown periods of 2020. Decreased survival was observed from the first national lockdown onwards and within 90 days of diagnosis. HRs were highest for people diagnosed at the end of 2020 at 1.26 (95% CI 1.20 to 1.32) for death within 90 days and 1.51 (95% CI 1.42 to 1.60) for death between 91 and 270 days. Further work is needed on measures to mitigate this impact.

The Impact of COVID-19 on Lung Cancer Incidence in England: Analysis of the National Lung Cancer Audit 2019 and 2020 Rapid Cancer Registration Datasets

BACKGROUND

The COVID-19 pandemic has caused significant disruption to health-care services and delivery worldwide. The impact of the pandemic and associated national lockdowns on lung cancer incidence in England have yet to be assessed.

RESEARCH QUESTION

What was the impact of the first year of the COVID-19 pandemic on the incidence and presentation of lung cancer in England?

STUDY DESIGN AND METHODS

In this retrospective observational study, incidence rates for lung cancer were calculated from The National Lung Cancer Audit Rapid Cancer Registration Datasets for 2019 and 2020, using midyear population estimates from the Office of National Statistics as the denominators. Rates were compared using Poisson regression according to time points related to national lockdowns in 2020.

RESULTS

Sixty-four thousand four hundred fifty-seven patients received a diagnosis of lung cancer across 2019 (n = 33,088) and 2020 (n = 31,369). During the first national lockdown, a 26% reduction in lung cancer incidence was observed compared with the equivalent calendar period of 2019 (adjusted incidence rate ratio [IRR], 0.74; 95% CI, 0.71-0.78). This included a 23% reduction in non-small cell lung cancer (adjusted IRR, 0.77; 95% CI, 0.74-0.81) and a 45% reduction in small cell lung cancer (adjusted IRR, 0.55; 95% CI, 0.46-0.65) incidence. Thereafter, incidence rates almost recovered to baseline, without overcompensation (adjusted IRR, 0.96; 95% CI, 0.94-0.98).

INTERPRETATION

The incidence rates of lung cancer in England fell significantly by 26% during the first national lockdown in 2020 and did not compensate later in the year.

Impact of enhanced personal protective equipment on surgeon workload and intraoperative patient outcomes

This work shows the need for targeted improvement to mitigate communication challenges associated with use of enhanced personal protective equipment. The data provide reassurance to surgeons and patients that there is no negative impact on surgeon workload or patient outcomes from use of enhanced personal protective equipment in the operating theatre.

617 Does Wearing Enhanced Personal Protective Equipment (PPE) In Theatre Increase Surgeon Workload and Patient Morbidity?

Introduction

Delivery of surgical services during the Covid-19 pandemic has required the use of enhanced PPE in the operating theatre. We sought to evaluate the impact of this change on surgeon workload and intraoperative patient outcomes.

Method

Surgeons performing as primary operator completed an online procedure-specific questionnaire on workload ratings for each operative case, using an extension of the validated Surgeon Task Load Index (SURG-TLX) tool (reported on a 20-point scale), together with operative details. Local approval was obtained at individual sites. Data was analysed in Stata SE v16.

Results

118 responses (17 surgeons, 7 specialties) were collected from June to September 2020. 77.1% used enhanced PPE. There was no association between enhanced PPE use and overall workload (p = 0.151) as measured with SURG-TLX, although surgeons wearing enhanced PPE commonly reported finding individual procedures harder than expected (37% vs 0%, p < 0.001). Communication was rated worse when using enhanced PPE use (MD -4.38, 95%CI -6.74 to 02.03; p < 0.001). There was no association between enhanced PPE use and intraoperative complications (p = 0.745).

Conclusions

The use of enhanced PPE is not associated with complications or increased surgeon workload assessed by SURG-TLX. It is, however, associated with difficulty in communicating, and subjectively experiencing more procedural challenge than anticipated.

443 Minimally Invasive Versus Open Bronchial Sleeve Lobectomy for Non-Small Cell Lung Cancer: A Systematic Review and Meta-analysis

Introduction

Minimally invasive surgery (MIS) for bronchial sleeve lobectomy (SL) remains unproven in safety and efficacy. We sought to evaluate current literature on outcomes following MIS or open surgery (OS) for SL in non-small cell lung cancer (NSCLC).

Method

The MEDLINE, Embase and Cochrane Library databases were searched in August 2020. Studies of SL comparing MIS to OS were included. The primary outcome was disease-free survival. Data was analysed in Stata SE v16.

Results

506 patients (87.9% male) from 5 studies were included, with 325 (64.2%) OS, 164 (32.4%) VATS, and 17 (3.4%) RATS cases. Risk of bias was low to moderate in included papers.

There was no difference in disease-free survival (OR -0.20, 95% CI -0.63 - 0.23, p = 0.37), overall survival (OR -0.03, 95% CI -0.63 - 0.58, p = 0.93), 30-day survival (OR -0.60, 95% CI -1.73 - 0.54, p = 0.30), resection margin involvement (OR 0.16, 95% CI -1.07 - 1.39, p = 0.80), or intraoperative bleeding (MD -16.94 ml, 95% CI -63.05 - 39.16, p = 0.47).

MIS was associated with longer operative times (MD 53.90 min, 95% CI 36.57 - 71.23, p &lt; 0.01) but shorter postoperative stay (MD -1.24 days, 95% CI -3.99 - 1.51, p = 0.41).

Conclusions

MIS for SL was associated with longer surgical time, shorter postoperative stay, and equivalent oncologic outcomes compared to OS.

Uniportal video-assisted versus open pneumonectomy: a propensity score-matched comparative analysis with short-term outcomes

OBJECTIVES

Uniportal (U-VATS) pneumonectomy in lung cancer patients remains disputed in terms of oncological outcomes, and has not been compared to open approaches previously. We evaluated U-VATS versus open pneumonectomy at a high-volume centre.

METHODS

Patients undergoing pneumonectomy for lung cancer between 2014 and 2018 were retrospectively reviewed and divided into two groups based on surgical approach. Propensity-score matching was performed (1:1), and intention-to-treat analysis applied. Overall survival, operative time, intraoperative blood loss, hospital-stay and readmission, pain, time to adjuvant therapy, morbidity and mortality were tested. Statistical analysis was performed using SAS version 9.4 (SAS Institute Inc. NC) RESULTS: 341 patients underwent pneumonectomy; 23 patients with small-cell lung cancer were excluded, thus 318 patients were submitted to surgery by either U-VATS (n = 54) or open (n = 264). After matching, 52 patients were selected from each group. Five patients (9.2%) in the uniportal group required conversion. There was no significant difference in intraoperative outcomes, complication rates, readmission rates or mortality. The U-VATS group experienced significantly shorter hospital stay (mean ± SD; 6.7 ± 2.7 vs 9.1 ± 2.3 days, p < 0.001) and reported less pain postoperatively (p < 0.0001). Adjuvant chemotherapy was initiated sooner after U-VATS (38.1 ± 8.4 vs 50.8 ± 11.5 days, p < 0.0001). Overall survival appeared to be superior in U-VATS when pathology stage was aligned (p = 0.001).

CONCLUSIONS

Uniportal VATS is a safe and effective alternative approach to open surgery for pneumonectomy in lung cancer. Complications and oncologic outcomes were comparatively similar. U-VATS showed lower postoperative pain, shorter hospital stay and superior overall survival. The study is a preliminary analysis.