Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study (2021)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative (includes *Blair J, *Lakhiani A, *Parry-Smith W, *Sahu B)

Citation:
The Lancet Oncology; 5th October 2021 [epub ahead of print]

Abstract:
Background: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.
Methods; This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.
Findings; Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.
Interpretation: Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.

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Intra-operative use of biological products: Are we aware of their derivatives? (2021)

Type of publication:
Journal article

Author(s):
Bhamra, Navdeep; Jolly, Karan; Darr, Adnan; *Bowyer, Duncan J; Ahmed, Shahzada K

Citation:
International Journal of Clinical Practice; Oct 2021; vol. 75 (no. 10); p. 1-6

Abstract:
INTRODUCTION Global medical advances within healthcare have subsequently led to the widespread introduction of biological products such as grafts, haemostats, and sealants. Although these products have been used for many decades, this subject is frequently not discussed during the consent process and remains an area of contention. METHODS A nationwide confidential online survey was distributed to UK-based junior registrars (ST3-5), senior registrars (ST6-8), post-CCT fellows, specialist associates/staff grade doctors and consultants working in general/vascular surgery, neurosurgery, otolaryngology, oral and maxillofacial surgery and plastic surgery. RESULTS Data were collected from a total of 308 survey respondents. Biological derivatives were correctly identified in surgical products by only 25% of survey respondents, only 19% stated that they regularly consent for use of these products. Our results demonstrate that most participants in this study do not routinely consent (81%) to the intra-operative use of biological materials. An overwhelming 74% of participants agreed that further education on the intra-operative use of biological materials would be valuable. DISCUSSION This study highlights deficiencies in knowledge that results in potential compromise of the consenting process for surgical procedures. A solution to this would be for clinicians to increase their awareness via educational platforms and to incorporate an additional statement on the consent form which addresses the potential intraoperative use of biological products and what their derivatives may be. CONCLUSION Modernising the current consent process to reflect the development and use of surgical biological products will help to ensure improved patient satisfaction, fewer future legal implications as well as a better surgeon-patient relationship.

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Perioperative outcomes afterlaparoscopic cholecystectomy in the elderly patients: Asystematic review and meta-analysis (2020)

Type of publication:
Conference abstract

Author(s):
Kew T.; Lin A.; Ekeozar C.; Bundred J.; Evans R.; Griffiths E.; Kamarajah S.; *Karri S.; Singh P.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 5-6

Abstract:
Aim: The need to perform elective and emergency cholecystectomy in an ever ageing population increases yet these risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population.
Method(s): A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted and a meta-analysis was performed in accordance with the recommendations of the Cochrane Library and PRISMA guidelines.
Result(s): This review identified 99 studies incorporating 333,041 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.33, CI95%: 2.00-2.71, p<0.001), major complication (OR 2.32, CI95%: 1.52-3.54, p<0.001), risk of conversion to open cholecystectomy (OR 2.32, CI95%: 1.95-2.76, p<0.001), risk of bile leaks (OR 2.05, CI95%: 1.18-3.55, p<0.001), risk of postoperative mortality (OR 5.99, CI95%: 3.77-9.52, p<0.001) and was significantly associated with increased length of stay (MD 2.12 days, CI95%: 1.01-3.24, p<0.001).
Conclusion(s): Post-operative outcomes such as overall and major complications are significantly higher in all age cut-offs. There is six-fold increase in perioperative mortality which increases by nine-fold in patients >80 years old. This study confirms preconceived suspicions of risk in elderly patients undergoing cholecystectomy and will aid treatment planning and informed consent.

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Boat propeller transection of hemithorax-successful multidisciplinary surgical reconstruction (2020)

Type of publication:
Conference abstract

Author(s):
*Cheruvu S.; Oo K.T.M.; Erel E.; Satur C.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 37

Abstract:
A 69 year old man fell into canal and was drawn into the propeller of his canal boat that resulted in transection of the right thoracic cavity and the right upper arm. Emergency helicopter transfer was made to our major trauma centre for multidisciplinary surgical care. Injuries included a full thickness antero-posterior transection from the sternum to beyond the tip of the scapula, and an open right midshaft humeral fracture with wound extending obliquely into the axilla. The entire thoracic cavity was contaminated by canal water. There was severe haemodynamic and cardiorespiratory compromise requiring level 3 intensive care. Following emergency resuscitative management, multidisciplinary surgical care was provided by the cardiothoracic, plastic and orthopaedic surgery teams utilising innovative operative techniques. Multistage operative management of chest wall required initial damage control surgery with debridement and negative pressure therapy. After 4 days of intensive care physiological stabilisation, reconstruction of the thoracic defect was undertaken with specialist thoracic titanium implants and the chest wall was reconstructed. This was a major thoracic trauma case treated successfully using revolutionary surgical techniques at the Royal Stoke Hospital. The subsequent impact on practice for thoracic polytrauma has led to improved survival rates by 75%.

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Assessing the adequacy of radiographs for hip fractures (2020)

Type of publication:
Conference abstract

Author(s):
*Mulrain J.; *Omar N.; *Burston B.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 138

Abstract:
Aim: Radiographs for the assessment of femoral neck fractures are frequently inadequate for the visualisation of the proximal femur. A low centred radiograph of both hips offers enough information but is rarely achieved.We sought to determine the proportion of hip fractures where initial radiographs adequately visualised the femur to encompass the proposed surgical management.We also sought to find the proportion of patients who required repeat radiographs and whether this was affected by time of presentation. Method(s): A retrospective review of the radiographs of hip fractures presenting to our institution, over a three-month period was undertaken. The timings, number and adequacy of radiographs was assessed. Result(s): Radiographs of 89 patients were reviewed. Most radiographs were taken between 8am and 5pm. Radiographs of 58 patients were centred on the pelvis rather than the hips. Patients presenting overnight were more likely to have adequate radiographs. Despite a duplicate x-ray rate of 48%, most patients (55%) had inadequate visualisation of the proximal femur. The average excess radiation exposure by duplicate radiographs was 2.31mSv per patient. Conclusion(s): The majority of patients had inadequate visualisation of the fractured proximal femur on their radiographs.Many had excessive radiographs performed. This was not improved by increased staffing levels during daylight hours.

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Acute appendicitis-can we shorten the length of hospital stay? (2020)

Type of publication:
Conference abstract

Author(s):
British Journal of Surgery; Jun 2020; vol. 107 ; p. 197

Citation:
*Jones G.; *Bura K.; *Rink J.

Abstract:
Introduction: Appendicectomy is the most commonly performed emergency general surgical operation in the UK. Hospital episode data revealed that our unit had longer than average length of stay (LOS). We designed a study to examine our length of stay and management of acute appendicitis. Method(s): We performed a retrospective study of consecutive patients undergoing appendicectomy from January to March 2019. Cases were identified from theatre logbooks. Data collection included demographics, pre and post-operative LOS, CT imaging and histology. The data was then examined to see what factors were associated with length of stay and where improvements might be realised. Result(s): 71 patients were identified. Mean LOS was 81 hours, mean time to theatre from admission was 22 hours withmean post-operative LOS at 58 hours. There was a difference between females vs males LOS 95 vs 67 hours. CT scan was obtained in 26 patients and the mean time to theatre in these patients was longer at 27 hours compared to 20 hours in the non- CT group. Patients who took longer to get to theatre had increased LOS. Conclusion(s): Rapid access to CT could shorten time to theatre. Getting patients to theatre quicker might shorten post-operative length of stay.

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‘Daycase parathyroidectomy: Time to change the norm?’ (2020)

Type of publication:
Conference abstract

Author(s):
Chang J.; Neophytou C.; Howard E.; Houghton A.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 37

Abstract:
Introduction: The most recent BAETs audit report of 2017 shows a surprisingly low rate of same-day discharge following parathyroidectomy (10%). In our unit we have developed a simple and safe protocol which allows same day discharge for almost all patients (95%). The 2017 BAETS report has 11,463 patients recorded for primary hyperparathyroidism. Following this simple protocol could save over 9,500 inpatient bed days.
Method(s): Demographics, histology, biochemistry and length of stay were identified for all patients undergoing parathyroidectomy for primary hyperparathyroidism between 01/01/2010 and 31/12/2019. Following surgery all patients were discharged on Calcichew D3 one tablet tds, with arrangements for serum calcium analysis and outpatient appointment at 7 and 10 days Results: We performed 264 parathyroid procedures during the study period. The cohort had a median age of 63 (range 15 – 90). Day-case procedures were carried out in 95% (n=249). 10 patients stayed 24 hours, 4 for 48 hours and 1 patient for 4 days (urgent parathyroidectomy following acute medical admission with symptomatic hypercalcaemia). 1 patient was admitted overnight for observation of bleeding wound (no return to theatre). The remainder were admitted for a mixture of social and anaesthetic reasons. 6 patients (2%) had 30 day morbidity: 2with symptoms of relative hypocalcaemia (not admitted), 1 patient with hypocalcaemia requiring intravenous calcium, 1 seroma, 1 patient presented with an exacerbation of COPD and 1 haematoma.
Conclusion(s): We have shown that same-day discharge after parathyroid surgery is safe and ought to become the norm in other units.

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IMPACT. Operating Department Human Factors Training for the whole team (2020)

Type of publication:
Conference abstract

Author(s):
Allman T.; Schunke N.; Fenton C.; Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 14

Abstract:
Aims: We identified a gap in effective staff training and developed a novel truly multidisciplinary training day to capture the whole team and expose them to simulation in their usual environment amongst usual peers. Our aim was to maximise the impact factor of multidisciplinary operating department human factors training and utilise high fidelity simulation to expose unknown unknowns and improve theatre safety.
Method(s): Novel human factors training run onsite. On a rotational basis designated theatre lists are blocked for the mandatory training to ensure all members of the theatre teams can attend ranging from porters to consultants and team leaders. Line managers enforce attendance and feedback is collated. Anaesthesia retained oversight and organisation. 3 main sessions run in parallel by teams of multidisciplinary facilitators.

  1. WHO Steps to Safer Surgery: Trust ‘STOP THE LINE’ video and discussion.
  2. Raising concerns: discussion lead by consultant surgeon.
  3. Theatre simulation & debrief: High fidelity in the operating theatre.

Result(s): The training received exemplary feedback and review from all staff across specialties.Multiple gaps in knowledge, particularly the location of rarely used emergency equipment and drugs was exposed and this allowed for on the spot, high yield training. Candidate feedback revealed the impact of our training was maximised by the facilitation led by consultant surgeons. Conclusion(s): Human factors training is notoriously variable and limited. We’ve collaborated surgical, anaesthetic and theatre teams to deliver high impact and resourceful training by addressing the human factors that mould our own learning.

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Laparoscopic ligation of inferior mesenteric artery (IMA) for the management of type II endoleak post endovascular aneurysm repair (EVAR) (2020)

Type of publication:
Conference abstract

Author(s):
*Mashar R.; *Gangwar A.; *McCloud J.; *Shawish E.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 96-97

Abstract:
Aim: Type II endoleaks following EVAR are caused by patent aortic collaterals causing retrograde blood flow, with the IMA being involved in 45-85% of all cases. Transarterial embolization has been described as a management option, but with a high failure rate. We present laparoscopic ligation as an alternative therapeutic strategy, with both technical success and a favourable outcome.
Method(s): An 80-old hypertensive male was diagnosed with a type II endoleak post-EVAR. Shrinkage of the sac was seen initially from 58mm to 52mm on surveillance-computed tomography (CT) of the aorta at 6 months with apersistent type II endoleak involving the IMA and lumbar arteries. Surveillance at 18 months demonstrated a persistent endoleak with enlargement of the sac to 65 mm. After a failed attempt with arterial embolization, he underwent laparoscopic ligation of the IMA Results: The procedure time was 22 minutes and his length of stay was 2 days, with no signs or symptoms of bowel ischaemia. A CT at 2 weeks demonstrated sac shrinkage to 58 mm. Conclusion(s): There have been reports of persistent endoleaks being associated with adverse outcomes, with their primary management remaining controversial. IMA ligation has been associated with sac shrinkage in 65% of patients, an important prognostic factor, and there have been no reported complications thus far. Therefore, it should be strongly considered as an option for management of type II endoleaks in centres with both vascular and general surgical expertise being available

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The benefits of multidisciplinary human factors training in theatre (2020)

Type of publication:
Conference abstract

Author(s):
*Jones R.; *Branfield L.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 75

Abstract:
Aims: The awareness of Human Factors (HF) and their role in patient safety is vital in the theatre environment.
The aim of this audit was therefore to assess the awareness of human factors within our theatre team during a Human Factors Training Course at a District General Hospital.
Method(s): The Human Factors Training Course started with a questionnaire assessing roles, experience, and awareness of HF. It also looked at staff morale. The course involved a presentation and 2 simulation scenarios in theatre. After completion, there was a post course questionnaire looking at awareness of human factors, effects on staff morale and impact on patient care.
Result(s): Of the respondents, experience varied from 1 to 10+ years. The pre-course awareness of HF averaged 6.1 out of 10. The opinions on morale averaged at 6.7 out of 10, and the effect of HF training on morale averaged 8.4 out of 10. All respondents believed that the course could improve patient care. Post course awareness of HF increased and staff morale also increased as a consequence of the course.
Conclusion(s): From the results we can see that the awareness of human factors within the cohort prior to training was relatively low. Post course, we can see an increase in terms of awareness of human factors. As well as providing a training opportunity, this course had a positive effect on staff morale, and vitally, it was thought that the course would have positive impact on patient care.

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