Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Abordaje robótico frente a abordaje laparoscópico con visión 3D en el tratamiento quirúrgico del cáncer de recto

Introducción El cáncer de recto es una de las patologías malignas más frecuentes en nuestro medio y su tratamiento se basa en la cirugía. El abordaje laparoscópico del cáncer de recto ha demostrado unos resultados oncológicos equivalentes a los del abordaje clásico por vía abierta, con menores complicaciones postoperatorias y estancia hospitalaria. De manera paralela, el abordaje robótico permite realizar una cirugía oncológica de calidad, aportando ciertas ventajas: visión tridimensional y mayor rango de movimiento y estabilidad del instrumental y la cámara. Esto se traduce en menores tasas de conversión, aunque con un mayor coste. Los actuales sistemas de laparoscopia con visión tridimensional mejoran la percepción durante el procedimiento quirúrgico. Hay estudios que refieren una conversión y resultados postoperatorios y oncológicos similares entre los abordajes laparoscópico 3D y robótico en el cáncer de colon, aunque con un tiempo operatorio más largo y mayor coste con este último. Según esto, la laparoscopia con visión 3D podría aportar resultados equivalentes a los de la cirugía robótica también en el cáncer de recto, aunque hasta ahora no se han encontrado estudios publicados que comparen ambos abordajes en esta patología. Material y metodología Se llevó a cabo un estudio de intervención no aleatorizado, con diseño cuasiexperimental, en pacientes intervenidos de cáncer de recto con intención curativa en el Hospital Universitario Virgen del Rocío. Se incluyeron un total de 124 pacientes entre marzo de 2016 y noviembre de 2019, divididos en dos grupos de 62 pacientes: uno de abordaje robótico (ROB) y otro de abordaje laparoscópico con visión 3D (L3D). Todas las intervenciones quirúrgicas fueron realizadas por tres cirujanos con amplia experiencia en la cirugía del cáncer de recto mediante ambos abordajes. La variable principal del estudio fue la conversión a cirugía abierta. Se recogieron además variables demográficas y características del tumor, así como variables relativas al procedimiento quirúrgico, la evolución postoperatoria, las características anatomopatológicas del tumor y el seguimiento postoperatorio. Resultados El grupo ROB y el grupo L3D fueron comparables en cuanto características demográficas, clínicas y relativas al tumor. La tasa de conversión fue similar entre los dos abordajes (12,9% vs. 11,3%; p=0,783). El tiempo operatorio fue superior en el abordaje robótico (237 vs. 167 minutos; p<0001). No hubo diferencias entre los grupos en cuanto a complicaciones intraoperatorias, complicaciones postoperatorias, estancia hospitalaria, afectación de los márgenes radial y distal, calidad de la escisión mesorrectal ni supervivencia global y libre de enfermedad a 4 años. La conversión a cirugía abierta presentó mayor incidencia de complicaciones postoperatorias, mayor tasa de afectación del margen radial y peor supervivencia global y libre de enfermedad a 4 años que en los procedimientos completados por vía mínimamente invasiva. Conclusiones El abordaje laparoscópico 3D en el tratamiento quirúrgico del cáncer de recto presenta una tasa de conversión, una evolución postoperatoria y unos resultados oncológicos similares a los del abordaje robótico, con un tiempo operatorio inferior. La conversión a vía abierta en la cirugía mínimamente invasiva del cáncer de recto se asocia a peores resultados de evolución postoperatoria, recidiva neoplásica y supervivencia

Cross-cultural adaptation, analysis of psychometric properties and validation of the Spanish version of a perioperative satisfaction questionnaire (EVAN-G).

Patient satisfaction is a reliable and measurable indicator of the quality provided by a healthcare service. There are several questionnaires for measuring it, but only a few have shown good psychometric properties, an outstanding one being the EVAN-G (Evaluation du Vécu de l'Anesthésie Générale) questionnaire, which measures patient satisfaction regarding perioperative care and is validated in French. The aim of this study is the validation of a Spanish version of the EVAN-G questionnaire. A translation/back-translation of the questionnaire into Spanish was carried out and the final version obtained was administered to three hundred patients. Its psychometric properties were measured and compared with those of the original EVAN-G questionnaire to verify that they had been maintained after the previous translation process. The questionnaire's content, construct and external validity were measured. To calculate reliability, Cronbach-α coefficient and test-retest method were used. The Global Satisfaction Index was calculated and satisfaction level in our sample was analyzed. Content, construct and external validity were proven with similar results that in the original EVAN-G. The translated version of the questionnaire showed good reliability: Cronbach-α coefficient was 0.92 and intraclass correlation coefficient measured by test-retest method was 0.9. The acceptability was high. The average Global Satisfaction Index in our sample was 73±12. The translation into Spanish and cross-cultural adaptation of the EVAN-G questionnaire has proven its validity, reliability, and acceptability to measure patient satisfaction in interventions performed under general anesthesia

Early implementation of protective measures defines surgical outcomes in the COVID-19 pandemic

Quick implementation of specific protocols and protective measures in a tertiary hospital in Spain allowed for the early diagnosis and optimal management of patients with SARS-CoV-2 infection and proper protection of staff and inpatients. From the COVID-19 outbreak in this country until the time of writing, 14 patients in our hospital underwent surgery with COVID-19, or COVID-19 developed postoperatively. Their postoperative outcomes did not differ from those in our routine clinical practice, with a 0% respiratory failure rate and a 7.14% mortality rate, in contrast with other published series. COVID-19 did not develop in any of the healthcare workers present in the operating room during these procedures or in those who cared for these patients on the ward

What defines an incisional hernia as 'complex': results from a Delphi consensus endorsed by the European Hernia Society (EHS)

The authors acknowledge the contribution of patient representatives Elena Albanese (Patient representative, President of 'Diastasi Donna ODV', Italy), Jackie Bullock (Patient representative, Hernia patient support group EHS, UK), and David J. Cummings (Pat; (EHS, UK