Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases

Introduction and aims: At the Upper Gastrointestinal Tract Clinic of the Hospital General de Mexico, achalasia treatment has been standarized through strictly graduated cardiomyotomy. This procedure guarantees a complete myotomy for the satisfactory resolution of dysphagia, a characteristic symptom of achalasia. To ensure the inclusion of the entire lower esophageal sphincter, an 8 cm Penrose drain is placed at the surgical site 6 cm above the gastroesophageal junction and 2 cm in a caudal direction, for accurate laparoscopic measuring. The aim of our study was to evaluate the results of this technique. Materials and methods: A descriptive, retrospective, longitudinal, and observational study was conducted on a cohort of patients diagnosed with achalasia at the Upper Gastrointestinal Tract Clinic of the Hospital General de México “Dr. Eduardo Liceaga”. Results: The study included 48 patients, 40 of whom had no prior surgical treatment and 8 that presented with recurrence. Forty-seven patients (97.9%) underwent a laparoscopic procedure and conversion to open surgery was required in 2 of them (4.25% conversion rate). Postoperative progression was satisfactory in all cases, with mean oral diet commencement at 52 h and mean hospital stay of 5.7 days. No recurrence was registered during the mean follow-up period of 35.75 months and there were no deaths. Conclusions: Laparoscopic graduated (strictly measured) cardiomyotomy with anterior fundoplication is a reproducible, efficacious, and safe option for the surgical treatment of achalasia. Resumen: Introducción y objetivos: En la Clínica de Tracto Digestivo Superior del Hospital General de México, el tratamiento de la acalasia se ha estandarizado mediante la realización de una cardiomiotomía estrictamente graduada que permite garantizar una miotomía completa para resolver de forma satisfactoria la disfagia característica de esta enfermedad. Un penrose de 8 cm, se coloca sobre el lecho quirúrgico, para garantizar la inclusión de todo el EEI, 6 cm por arriba de la UGE y 2 cm en sentido caudal, para asegurar la medición laparoscópica. El objetivo del estudio fue evaluar los resultados obtenidos con esta técnica. Material y métodos: Estudio descriptivo, retrospectivo, longitudinal, observacional, en una cohorte de pacientes con diagnóstico de acalasia, en la Clínica de Tracto Digestivo Superior, del Hospital General de México «Dr. Eduardo Liceaga». Resultados: Se incluyeron 48 pacientes; 40 sin tratamiento quirúrgico previo y 8 con recurrencia. En 47 casos el abordaje fue laparoscópico (97.9%); se requirió conversión a procedimiento abierto en 2 casos (tasa conversión 4.25%). La evolución postoperatoria fue satisfactoria en todos los casos, con inicio de la vía oral a las 52 h en promedio y una estancia intrahospitalaria promedio de 5.7 días. Durante el seguimiento de 35.75 meses en promedio no se han registrado recurrencias. No se presentó mortalidad. Conclusiones: La cardiomiotomía graduada (estrictamente medida) con funduplicatura anterior mediante abordaje laparoscópico es una opción reproducible, eficaz y segura para el tratamiento quirúrgico de la acalasia. Keywords: Achalasia, Cardiomyotomy, Laparoscopy, Anterior fundoplication, Palabras clave: Acalasia, Cardiomiotomía, Laparoscopía, Funduplicatura anterio

Cardiomiotomía graduada con funduplicatura anterior laparoscópica en acalasia, experiencia de 48 casos

Resumen: Introducción y objetivos: En la Clínica de Tracto Digestivo Superior del Hospital General de México, el tratamiento de la acalasia se ha estandarizado mediante la realización de una cardiomiotomía estrictamente graduada que permite garantizar una miotomía completa para resolver de forma satisfactoria la disfagia característica de esta enfermedad. Un penrose de 8 cm, se coloca sobre el lecho quirúrgico, para garantizar la inclusión de todo el EEI, 6 cm por arriba de la UGE y 2 cm en sentido caudal, para asegurar la medición laparoscópica. El objetivo del estudio fue evaluar los resultados obtenidos con esta técnica. Material y métodos: Estudio descriptivo, retrospectivo, longitudinal, observacional, en una cohorte de pacientes con diagnóstico de acalasia, en la Clínica de Tracto Digestivo Superior, del Hospital General de México «Dr. Eduardo Liceaga». Resultados: Se incluyeron 48 pacientes; 40 sin tratamiento quirúrgico previo y 8 con recurrencia. En 47 casos el abordaje fue laparoscópico (97.9%); se requirió conversión a procedimiento abierto en 2 casos (tasa conversión 4.25%). La evolución postoperatoria fue satisfactoria en todos los casos, con inicio de la vía oral a las 52 h en promedio y una estancia intrahospitalaria promedio de 5.7 días. Durante el seguimiento de 35.75 meses en promedio no se han registrado recurrencias. No se presentó mortalidad. Conclusiones: La cardiomiotomía graduada (estrictamente medida) con funduplicatura anterior mediante abordaje laparoscópico es una opción reproducible, eficaz y segura para el tratamiento quirúrgico de la acalasia. Abstract: Introduction and aims: At the Upper Gastrointestinal Tract Clinic of the Hospital General de Mexico, achalasia treatment has been standarized through strictly graduated cardiomyotomy. This procedure guarantees a complete myotomy for the satisfactory resolution of dysphagia, a characteristic symptom of achalasia. To ensure the inclusion of the entire lower esophageal sphincter, an 8 cm Penrose drain is placed at the surgical site 6 cm above the gastroesophageal junction and 2 cm in a caudal direction, for accurate laparoscopic measuring. The aim of our study was to evaluate the results of this technique. Materials and methods: A descriptive, retrospective, longitudinal, and observational study was conducted on a cohort of patients diagnosed with achalasia at the Upper Gastrointestinal Tract Clinic of the Hospital General de México “Dr. Eduardo Liceaga”. Results: The study included 48 patients, 40 of whom had no prior surgical treatment and 8 that presented with recurrence. Forty-seven patients (97.9%) underwent a laparoscopic procedure and conversion to open surgery was required in 2 of them (4.25% conversion rate). Postoperative progression was satisfactory in all cases, with mean oral diet commencement at 52 h and mean hospital stay of 5.7 days. No recurrence was registered during the mean follow-up period of 35.75 months and there were no deaths. Conclusions: Laparoscopic graduated (strictly measured) cardiomyotomy with anterior fundoplication is a reproducible, efficacious, and safe option for the surgical treatment of achalasia. Palabras clave: Acalasia, Cardiomiotomía, Laparoscopía, Funduplicatura anterior, Keywords: Achalasia, Cardiomyotomy, Laparoscopy, Anterior fundoplicatio