Impact of the COVID-19 pandemic on surgical care in the Netherlands

BACKGROUND

The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.

METHODS

A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.

RESULTS

Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).

CONCLUSION

The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

Preoperative imaging for colorectal liver metastases: a nationwide population-based study

Background

In patients with colorectal liver metastases (CRLM) preoperative imaging may include contrast‐enhanced (ce) MRI and [¹⁸F]fluorodeoxyglucose (¹⁸F‐FDG) PET–CT. This study assessed trends and variation between hospitals and oncological networks in the use of preoperative imaging in the Netherlands.

Methods

Data for all patients who underwent liver resection for CRLM in the Netherlands between 2014 and 2018 were retrieved from a nationwide auditing database. Multivariable logistic regression analysis was used to assess use of ceMRI, ¹⁸F‐FDG PET–CT and combined ceMRI and ¹⁸F‐FDG PET–CT, and trends in preoperative imaging and hospital and oncological network variation.

Results

A total of 4510 patients were included, of whom 1562 had ceMRI, 872 had ¹⁸F‐FDG PET–CT, and 1293 had combined ceMRI and ¹⁸F‐FDG PET–CT. Use of ceMRI increased over time (from 9·6 to 26·2 per cent; P < 0·001), use of ¹⁸F‐FDG PET–CT decreased (from 28·6 to 6·0 per cent; P < 0·001), and use of both ceMRI and ¹⁸F‐FDG PET–CT 16·9 per cent) remained stable. Unadjusted variation in the use of ceMRI, ¹⁸F‐FDG PET–CT, and combined ceMRI and ¹⁸F‐FDG PET–CT ranged from 5·6 to 100 per cent between hospitals. After case‐mix correction, hospital and oncological network variation was found for all imaging modalities.

Discussion

Significant variation exists concerning the use of preoperative imaging for CRLM between hospitals and oncological networks in the Netherlands. The use of MRI is increasing, whereas that of ¹⁸F‐FDG PET–CT is decreasing.

Volume-outcome relationship of liver surgery: a nationwide analysis

Background

Evidence for an association between hospital volume and outcomes for liver surgery is abundant. The current Dutch guideline requires a minimum volume of 20 annual procedures per centre. The aim of this study was to investigate the association between hospital volume and postoperative outcomes using data from the nationwide Dutch Hepato Biliary Audit.

Methods

This was a nationwide study in the Netherlands. All liver resections reported in the Dutch Hepato Biliary Audit between 2014 and 2017 were included. Annual centre volume was calculated and classified in categories of 20 procedures per year. Main outcomes were major morbidity (Clavien–Dindo grade IIIA or higher) and 30‐day or in‐hospital mortality.

Results

A total of 5590 liver resections were done across 34 centres with a median annual centre volume of 35 (i.q.r. 20–69) procedures. Overall major morbidity and mortality rates were 11·2 and 2·0 per cent respectively. The mortality rate was 1·9 per cent after resection for colorectal liver metastases (CRLMs), 1·2 per cent for non‐CRLMs, 0·4 per cent for benign tumours, 4·9 per cent for hepatocellular carcinoma and 10·3 per cent for biliary tumours. Higher‐volume centres performed more major liver resections, and more resections for hepatocellular carcinoma and biliary cancer. There was no association between hospital volume and either major morbidity or mortality in multivariable analysis, after adjustment for known risk factors for adverse events.

Conclusion

Hospital volume and postoperative outcomes were not associated.

Feasibility study of transanal total mesorectal excision

BACKGROUND

Laparoscopic resection of colorectal cancers is a safe alternative to open surgery. The conversion rate to open surgery remains fairly constant but is associated with increased morbidity. A new approach to the surgical excision of rectal cancer is transanal total mesorectal excision (TME), in which the rectum is mobilized peranally using endoscopic instruments. This feasibility study describes initial results with transanal TME.

METHODS

Between June and August 2012, five consecutive unselected patients with rectal carcinoma underwent surgical excision of rectal tumours by means of transanal TME.

RESULTS

Transanal endoscopic dissection of the complete rectum was possible in all patients. Histopathological examination confirmed clear surgical margins and an intact mesorectal fascia in all patients. One patient developed a presacral abscess. Median duration of operation was 175 (range 160-194) min.

CONCLUSION

Transanal TME using the down-to-up principle is feasible. Whether the oncological and clinical results are comparable with those of standard laparoscopic or open TME has yet to be proven.

Single-incision versus conventional laparoscopic cholecystectomy: a case control study

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique which can be used for treatment of gallbladder disease. To evaluate our initial experience, patients treated with SILS cholecystectomy were compared with a comparable group of patients treated with a conventional four trocart technique (LC).

METHODS

Between May 2009 and April 2010, 60 SILS cholecystectomies were performed. These patients were matched by Body Mass Index (BMI) with 60 cases of conventional LC.

RESULTS

The operative time was significantly longer in the SILS group 55 min (range, 25-126 min) compared to 49 min (range, 28-75 min) for the LC group. Excluding the first 15 SILS cases the operative time became comparable to the conventional technique, with a mean operative time of 51 min (range, 25-90 min). No patients were converted to open cholecystectomy. In the SILS group 3 patients developed a wound infection, in the conventional LC group 2.

CONCLUSION

SILS cholecystectomy seems to be a safe and feasible procedure when performed by an experienced laparoscopic surgeon. Complication rates are comparable to conventional LC. With a learning curve of around 10 to 15 procedures, operative times approach those of conventional LC.

Transanal single-port surgery for the resection of large polyps

INTRODUCTION

Transanal endoscopic microsurgery (TEM) is widely used for the excision of both benign and malignant rectal tumours. It is relatively expensive and can be a challenging technique. A recent development in laparoscopic surgery is the single-port technique (single-incision laparoscopic surgery, SILS). The SILS port is a flexible multichannel port for transumbilical laparoscopic surgery. Even though not developed for transanal use the port could be ideal because of its shape and texture.

METHODS

12 patients underwent transanal resection using an SILS port and normal laparoscopic instruments.

RESULTS

10 out of 12 patients were treated successfully with the SILS port. Two polyps were resected using an open transanal technique because the distance between the SILS port and the polyp was too small. The average operative time was 55 min (range 40-80 min). All patients could be discharged on the first postoperative day. There were no major complications.

CONCLUSION

Our current data show that transanal surgery using a single port is a relatively easy procedure with operative times comparable to TEM. More surgeons will therefore be able to perform transanal endoscopic surgery.