The positive impact of GIRFT (getting it right first time) on arthroplasty services in times of COVID-19 (2022)

Type of publication:
Journal article

Author(s):
*Khan MM; *Khawar H; *Perkins R; Pardiwala A

Citation:
Annals of medicine and surgery, 2022 May; Vol. 77, pp. 103655

Abstract:
Background: This observational study evaluates the trends in arthroplasty services across National Health Services (NHS) following the COVID-19 pandemic about GIRFT (Getting it Right First Time) guidelines concerning National joint registry data (NJR data). Introduction: Since the advent of the COVID-19 crisis sustainability of elective arthroplasty services have become a burning question in NHS. Capacity crisis, unknown COVID-19 infection status, lack of ring-fenced beds, winter crisis, and unprecedented trauma have aggravated the situation further leading to severe impairment in quality of life and service provision. GIRFT guidelines have suggested a few solutions to this crisis and one of them is dividing the hospitals into Hot (trauma) and cold (elective) sites. Objectives: To review NJR data for pre and post COVID era along with the service structure of the hospital and test the hypothesis that whether redistribution of services into hot and cold sites is a possible solution for sustainable arthroplasty service across NHS. Methodology: A search was made into the NJR data from 2019, 2020, and 2021. The First 7 months were taken from each year I.e. From Ist January to 31st of July. A review of entries for arthroplasty was considered for all hospitals across England and Wales. Hospitals in Scotland, Ireland, and Isles of Man and major trauma centers were excluded. Any hospital that was recording at least 15 arthroplasty cases for 4 out of 7 months in 2021 was considered for review. A brief evaluation of their service structure was made, and hospitals were divided into Elective Centres (EC), Urgent Care Centres (UCC), and District General Hospitals (DGH) with in-house emergency services based on the information provided on their official website. In NJR data "completed operations by submission date" column was considered as a reference for data collection. A total of 1807, 1800, and 1810 were identified for 2019, 2020, and 2021 respectively. However, after applying inclusion criteria total number of entries was reduced to 120 hospitals. Data analysis and selection of hospitals were reviewed twice by two authors (MMK and AP) at different times to avoid any bias and reduce the chances of human error that can affect the outcome. A sub-analysis of data for the last 3 months (May, June, and July) was also performed for the respective years to get a better picture of arthroplasty trends and reduce the flaws of data interpretation. Ethical Approval and Data Consideration: A formal approval was taken from the NJR team in the UK before the data processing was initiated. The data source being used was available for public review on the NJR website. The team was happy for us to process and evaluate the data as per needs of our study. However, they requested a disclaimer and appreciation note for the members of the NJR team and hospital personnel across the UK that have made the provision of data and subsequent analysis leading to this study feasible. Results: 18 EC were included. The mean number of cases recorded per center was 427, 68, 348 for 2019, 2020, and 2021 respectively.20 UCC were identified. The mean number of cases performed were 213, 24, and 195 in 2019, 2020, and 2021 respectively. Similarly, 60 DGH with emergency services were included and the average number of cases recorded were 194, 27, and 166 for 2019, 2020, and 2021 respectively. Compared to 2019 out of 148 DGH in 2019 only 60 can provide a sustainable arthroplasty service signifying a drop of 40% in 2021 in the number of DGH which are contributing to elective services. Conclusions: The overall productivity of theatres in terms of arthroplasty services has decreased since the reinitialization of services in 2021. There is a need of hour to divide the services into hot and cold sites in terms of A/E and elective centers to provide safe and uninterrupted provision of arthroplasty services and address long waiting times for patients. Provisional of ring-fenced beds and arthroplasty wards is more technically feasible in centers that are not providing in-house emergency admission pathways or are specialist, dedicated elective centers

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Vesicourachal diverticulum (2022)

Type of publication:Journal article

Author(s):*Mohamed G; *Ghani Z; *Lynn N; *Masilamani M; *Rowlands J

Citation:Annals of the Royal College of Surgeons of England, 2022 Apr 21 [epub ahead of print]

Abstract:We report a rare complication involving a healthy 45-year-old male patient who underwent an emergency laparoscopic appendicectomy for acute perforated gangrenous appendicitis. The patient was catheterised pre- procedure and the ports were inserted under vision. Upon completion of the procedure, a 15 Fr Robinson drain was left in the pelvis and was fed through the suprapubic port hole. Postoperatively the patient developed worsening, generalised abdominal pain and high output from the drain. The patient was re-catheterised but the computed tomography (CT) cystogram did not show any injury to the bladder. The drain fluid creatinine was noted to be raised (>4,000), indicating that urine was leaking into the drain. Conventional cystogram confirmed a contrast leak from the dome around the drain. Flexible cystoscopy confirmed that the drain had transversed the vesicourachal diverticula. The drain was pulled back and converted to a suprapubic catheter with the patient subsequently being discharged. Vesicourachal diverticula is a rare and often asymptomatic anomaly. When undertaking laparoscopic surgery, precautions should be taken to prevent port site injury such as catheterising the patient to ensure the bladder is empty and inserting the ports under direct vision. It is safer to visualise muscle rather than peritoneum during port insertion. In this case, the bladder diverticula was noticed extraperitoneally. Though the indirect CT cystogram reported no injury, this was unreliable as the bladder was not distended which led to the subtle injury being missed. Traditional cystogram should be considered in cases with a negative CT cystogram and a strong suspicion of bladder injury.

Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study (2022)

Type of publication:
Journal article

Author(s):
Claydon O; Down B; *Kumar S

Citation:
Cureus, 2022 Mar 10; Vol. 14 (3), pp. e23034

Abstract:
Background and objective In many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications. Methods We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery. Results A total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed. Conclusion Time from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.

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The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study (2022)

Type of publication:Journal article

Author(s):Abouelazayem, Mohamed; Viswanath, Yirupaiahgari K S; Bangash, Ali Haider; Herrera Kok, Johnn Henry; Cheruvu, Chandra; Parmar, Chetan; Atici, Semra Demirli; Yang, Wah; Galanis, Michail; Di Maggio, Francesco; Isik, Arda; *Bandyopadhyay, Samik Kumar

Citation:Surgery; Mar 2022 [epub ahead of print]

Abstract:BACKGROUND Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health.
METHODS We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level ofharm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score.
RESULTS A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%)were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively. CONCLUSION Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

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Learning curves in minimally invasive pancreatic surgery: a systematic review (2022)

Type of publication:Systematic Review

Author(s):Fung, Gayle; Sha, Menazir; Kunduzi, Basir; Froghi, Farid; *Rehman, Saad; Froghi, Saied

Citation:Langenbeck's archives of surgery; Mar 2022 [epub ahead of print]

Abstract:BACKGROUND The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery.
METHODS A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included.
RESULTS In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10-30) and 23.5 cases (7-40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4-60) and 36.5 cases (20-80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon's experience and patient's demographic.
CONCLUSIONS There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.

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Acute cholecystectomy in elderly - age is not a limit (2021)

Type of publication:
Conference abstract

Author(s):
*Gupta A.; *Rashid M.U.; *Rupasinghe N.; *Adjepong S.; *Rink J.; *Kirby G.; *Jain R.; *Riera M.; *Parampalli U.; *Pattar J.

Citation:
British Journal of Surgery. Conference: UGI Congress 2021. Belfast United Kingdom. 108 (SUPPL 9) pp. ix34

Abstract:
Background: Acute or hot cholecystectomy (AC) has been established as a safe and efficacious modality of managing acute biliary pathology. However, it has been performed with caution in the elderly (defined by the world health organisation as patients over the age of 65). The NICE guidance in this area does not preclude this practise on elderly patients. Our acute cholecystectomy service treats patients of all ages according to performance status and fitness for surgery rather than age we audited our results in this age group. Method(s): All patients over the age of 65 who underwent acute cholecystectomy in the dedicated emergency cholecystectomy lists were audited from the period starting 31st December 2019 to 31st June 2021. Patient demographics, co-morbidies and surgical factors were recorded. The primary outcomes measure was in hospital stay and readmission, secondary outcome were complications and perioperative mortality. Result(s): 41 elderly patients underwent AC during the audit period, (male 18: female 23). Majority of patients had acute cholecystitis 30(73%). The median inpatient stay following surgery was 2 days(range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Only 3(7%) patients had a subtotal cholecystectomy. There was only 3 complications from surgery which were all between a clavien-dindo score of 2 and 3. There were 3 readmission in the immediate post-operative period. There was one 30-day mortality which was from necrotising pancreatitis as a result of ERCP and not from the operation. Conclusion(s): Acute cholecystectomy in this age group appears to be safe and effective way to treat acute biliary pathology and compares similarly to the outcomes in the younger

Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study (2021)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative; GlobalSurg Collaborative (COVIDSurg Collaborative includes *Yen Nee Jenny Bo, *Mohammad Iqbal, *Aarti Lakhiani, *Guleed Mohamed, *William Parry-Smith, *Banchhita Sahu of Shrewsbury and Telford Hospital NHS Trust)

Citation:
Anaesthesia, June 2021, Volume 76, Issue 6, Pages 748-758

Abstract:
Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

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SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study (2021)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative, GlobalSurg Collaborative (COVIDSurg Collaborative includes *Yen Nee Jenny Bo, *Mohammad Iqbal, *Aarti Lakhiani, *Guleed Mohamed, *William Parry-Smith, *Banchhita Sahu of Shrewsbury and Telford Hospital NHS Trust)

Citation:
British Journal of Surgery. 2021 Sep 27;108(9):1056-1063

Abstract:
Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling.
Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty.
Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year.
Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population.

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Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study (2022)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative; GlobalSurg Collaborative (COVIDSurg Collaborative includes *Yen Nee Jenny Bo, *Mohammad Iqbal, *Aarti Lakhiani, *Guleed Mohamed, *William Parry-Smith, *Banchhita Sahu of Shrewsbury and Telford Hospital NHS Trust)

Citation:
Anaesthesia. November 2021 Nov, Volume 76, Issue 11, Pages 1454-1464.

Abstract:
We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care.

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SARS-CoV-2 infection and venous thromboembolism after surgery (2022)

Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative; GlobalSurg Collaborative. (COVIDSurg Collaborative involves *Yen Nee Jenny Bo, *Mohammad Iqbal, *Aarti Lakhiani, *Guleed Mohamed, *William Parry-Smith, and *Banchhita Sahu of Shrewsbury and Telford Hospitals NHS Trust)

Citation:
Anaesthesia, Jan 2022, Volume77, Issue1, Pages 28-39

Abstract:
SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1–6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1–2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2–3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9–3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3–6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

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