By Mr Henry G Smith MBBS MRCS PhD, specialist registrar at The Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen
The number of hours in training that it takes for a surgical trainee to achieve both clinical and technical competence is a seemingly endless topic of debate. The significant global variation in a surgical trainee’s average hourly week begs the question as to why such variation exists and to what extent all training programmes are created equal (1). Given the increasing recognition of burnout amongst medical professionals, and its association with excessive workloads, it is reasonable to think a shorter working week may benefit the surgical trainee’s wellbeing (2). However, any potential benefits much be weighed against the risk of reducing training opportunities and clinical exposure. Having personal experience of both British, with its nominal 48-hour working week, and Danish general surgical training, where surgeons work a 37-hour week, it is clear that whilst these countries have very similar healthcare systems, they differ markedly in their approach to training. Whilst neither training programme is without its limitations, their differences highlight potential ways in which the efficiency of surgical training may be improved.
The most striking difference between the British and Danish programmes is the absence of the ‘firm’ structure in Denmark. Trainees belong to the department rather than to subspeciality specific teams. The same is true of acutely admitted patients, who whilst broadly divided into those with upper and lower gastrointestinal conditions are not ‘owned’ by the consultant who was on call at the time of admission. As a consequence, there are no ward rounds, post-take or otherwise. Instead, the acute and elective inpatients are divided more or less equally between consultants and trainees alike, with a typical ratio of 2-3 patients to be seen by a single doctor each day. The lack of a rigid structure dictated by a team-based ward round leads to much greater flexibility in all other aspects of the working day. These days are thematic, with trainees having 4 major functions: elective operations, endoscopy, outpatient clinics and on-calls. When a trainee is not assigned to one of these functions, they have zero hours to be used as they see fit.
The flexibility of the Danish system brings two major advantages. The first is that the structure leaves the trainee with the feeling that the majority of time spent at work is spent training. That feeling is emphasised by the organisation of the operating days in particular.
Whilst the trainee spends undoubtedly fewer days in an elective theatre than in the British system, these days are almost exclusively spent attending training lists. Attended by a single trainee and a consultant, comprising repeated exposure to the same operation and booked on the presumption that the trainee will be the primary surgeon, these lists maximise training opportunities. The same is more or less true in endoscopy, where the trainee has their own full day list, with a supervisor on hand if needed. The second advantage is that the planning of absence from work for annual leave, courses or conferences is far less complicated. The minimum number of trainees required at work is determined at a departmental level, avoiding the need to organise cross cover between firms. As such, denied requests to attend conferences are very much the exception rather than the rule and it is almost unheard of that a trainee would be unable to take all of their allocated leave during a rotation.
These structural differences are accompanied by an in-house culture that not only prioritises training but is also ferocious in its defence of working conditions. There is a greater expectation for trainees to be actively involved, at least in part, in the majority of operations, and independent operating is encouraged at a much earlier stage. Senior house officers are expected to be capable of independently performing common acute operations, such as appendicectomies, and whilst consultants are often present for laparotomies, their presence is not compulsory. ‘Service provision’ is rarely mentioned, perhaps a reflection of a healthcare system that is better resourced to match the demands of its population. With regard to the working environment, trainees hold a structured monthly meeting for both positive and negative feedback on issues ranging from training opportunities and supervision to the frequency of on-call duties and conditions of the on-call rooms. The vocal complaints in a recent meeting of the comfiness of the on-call beds are not only a far cry from trying to catch some rest on an old sofa in a British hospital mess but also give an insight into how seriously the Danes take their working conditions.
However, not all the differences are positive. The greater flexibility in the Danish system places greater demands on the discipline of its trainees. Although there are still dedicated rotations in trauma and tertiary centres, the lack of other subspecialty specific rotations means that the trainee must take more responsibility for ensuring that they meet the specific requirements of the training programme. Whilst focused trainees may turn this to their advantage, allowing them to focus on their preferred subspecialty at an earlier stage of training, those who are as of yet undecided may be at risk of drifting in a less structured system. In a similar vein, for a trainee raised in the British system, the absence of the firm structure is accompanied by a sense of a lack of belonging, at least at the beginning of a new placement, although this is somewhat lessened by the daily morning conferences, attended by the whole department. A further concern is the consequences a more flexible system has on the quality and continuity of care. It is not uncommon for acutely admitted patients to be seen by a different doctor each day, a situation commonly thought to increase the risk of delays in discharge or investigations. However, this does not appear to have an adverse effect on patient outcomes, with a 30-day mortality following high-risk laparotomies of approximately 20% in Denmark, mirroring the reports from the National Emergency Laparotomy Audit (NELA) in Britain (3-5). Finally, one must remember that achieving competence as a surgeon is not only about developing technical skills. As the old saying goes “good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate”. Although the Danes may have a more efficient approach to the technical aspects of training, it is undeniable that the clinical exposure of British trainees is far greater. The cumulative clinical experience of following both elective and acute patients from admission to discharge is difficult to replicate and whilst any differences in decision-making seem to have disappeared by the end of training, these skills appear to develop more rapidly in the British systems. Disruptions to the continuity of care present another barrier for clinical exposure in the Danish system, with the following up of the patients seen on-call or in the operating theatre left to the trainee’s own initiative.
The hourly week occupies much of the debate on surgical training and, in doing so, prioritises quantity over quality of training. With a focus on maximising the efficacy of training opportunities, the Danish surgical training system demonstrates how surgeons can be effectively trained on a shorter working week. Whilst this system has its own limitations, the organisation of a trainee’s operative commitments in particular provides an example for other systems to follow. Surgical training faces major challenges ahead, with a global pandemic that has not only limited training opportunities but also taken an inevitable toll on workforce morale (6). Furthermore, the backlog of operations cancelled since the beginning of the pandemic is likely to place a huge emphasis on efficiency in operating theatres, which may have further negative effects on training opportunities (7-8). However, the return of some degree of normality will also offer the opportunity to reconsider the structure of training and perhaps in doing so, the best aspects of these respective training systems could be combined, shifting the focus away from the number of hours spent at work to the amount of time spent training.
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1. Rebecca C Grossman MA MBBS AKC DHMSA MRCS, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
2. Graham Mackenzie MD FRCPE, Penicuik Medical Practice, Imrie Place, Penicuik, UK
3. Julio Mayol MD PhD, Professor of Surgery, Chief Medical Officer, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain.
Competing interests: The authors declare no competing interests.
Funding: No funding was provided for this study.
Previous presentations: The findings of this study were presented as a poster at the Society for Surgery of the Alimentary Tract 60th Annual Meeting on the 21st May 2019.
It has long been the tradition to publish the Proceedings of surgical conferences 1. Over the last 15 years, the way surgeons interact has transformed extensively due to the advent of social media, with much of the conversation moving online 2-3. The covid-19 pandemic acted to accelerate this transition 4. The microblogging platform Twitter provides a vast library of information and allows real-time communication and dissemination of information, grouped along themes via a “hashtag” (metadata tag) 5-8. Twitter use is increasing among surgeons, researchers, healthcare professionals, and patients.
Organised conversations on Twitter, so-called “tweetchats”, are a forum through which experts, trainees, and patients from around the globe can communicate and discuss topics of shared interest via a hashtag and moderated by a host 5,7,9. Tweetchats allow real-time back and forth conversation, similar to face-to-face interactions10. These conversations are a treasure-trove of ideas that can provide great insight into the most cutting-edge trends in surgical practice 7,11-13.
On 28th July 2018, a social media initiative was created by Julio Mayol via his Twitter handle (@juliomayol), to focus on specific surgical interests, connected via the hashtag #SoMe4Surgery (Social Media For Surgery) 14. The aim was to bolster a more inclusive, multidisciplinary surgical community. Since the inception of #SoMe4Surgery, a number of tweetchats were planned and undertaken using the hashtag. In November 2018, a tweetchat was held with the subject of surgical technology. This theme was chosen as surgical technology is rapidly evolving in many directions, under multiple influences 15, and the authors felt it was a key time to take stock in where we are and where we are going. The aim of this study was to identify the main themes of the chat on surgical technology and to estimate the potential reach of the tweets.
No ethical approval was required for this retrospective study as it did not interfere with any patient or human data beyond measuring internet activity among Twitter users using publicly available tweets.
Sampling and data extraction
A retrospective analysis was performed of the tweetchat that was led by two surgeons with 941 (@rebgross) and 24,539 (@juliomayol) followers on November 23rd 2018, with ten predefined questions. The #SoMe4Surgery ecosystem was the primary target of the conversation. Ten tweets containing questions for the audience were posted in a 60-minute period (9:00 pm – 10:00 pm Madrid time).
Data analytics and visualization were carried out using two different online tools. Twitonomy is available at http://www.twitonomy.com, and provides advanced network analytics of tweets, hashtags and tweetchats, under subscription. Twitonomy analytics were performed by author JM on November 29th 2018, of tweets posted between November 22nd 2018 at 8:15 pm and November 29th 2018 at 8:17 pm using the two hashtags, “#some4surgery” and “#surgicaltechnology”. Potential reach was defined as the total aggregate number of followers of the people who mentioned both keywords in their tweets. Potential reach may be overestimated as Twitonomy may make assumptions to estimate impressions and/or audience, and geolcations are sometimes misclassified; therefore NodeXL analytics were also examined by author GM. NodeXL is a spreadsheet template that allows the creation of visual network graphs (Social Media Research Foundation; California, USA; https://www.smrfoundation.org/nodexl/). Using NodeXL, the extracts for 23rd November 2018 were extracted and mapped as described elsewhere 16.
The tweets from the tweetchat were manually reviewed on Twitter by author RG by searching for the terms [#SoMe4Surgery since:2018-11-23 until:2018-11-30] on 18th June 2019 to identify the themes of the chat for content analysis. Replies to the questions posted by the moderators were also reviewed to avoid missing tweets that did not include the hashtag. The handles (usernames) and profiles of the users were manually reviewed.
Twitonomy analytics revealed that, between 22nd November 2018 at 8:15 pm and 29th November 2018 at 8:17 pm, there were 348 tweets and retweets including the two hashtags posted by 60 users (40 men, 13 women, 7 unknown) from 50 geolocations in 5 continents. From the biographical information available in their Twitter profiles, specialties included general surgery (5), HPB/transplant (4), plastics/cosmetic (2), vascular (4), ophthalmology (1), hernia (1), colorectal (5), cardiovascular (1), endocrine/bariatric (1), spinal (1), global (1), trainees (1), associations (1), and non-medical (5). Conflicts of interest of individuals participating in the tweetchat included working for private health tech companies (4), criminal defence lawyer (1), and running the tweetchat (2).
From Twitonomy, the potential reach was 1,883,455 accounts. A tweetmap of the users of both #SoMe4Surgery and #SurgicalTechnology hashtags can be found in Fig. 1.
NodeXL data revealed, over the 1-day, 2-hour, 48-minute period from Thursday, 22nd November 2018 at 19:15 UTC to Friday, 23rd November 2018 at 22:04 UTC, there was a network of 39 Twitter users whose recent tweets contained both #SoMe4Surgery and #surgicaltechnology hashtags (Fig. 2), or who were replied to or mentioned in those tweets. There were 39 vertices, 71 unique edges, 303 edges with duplicates, 374 total edges, and 22 self-loops. Reciprocated vertex pair ratio was 0.19, and reciprocated edge ratio was 0.32. In a connected component, there were 39 maximum vertices and 374 maximum edges.
Over the 21-hour, 40-minute period from Friday, 23rd November 2018 at 00:18 UTC to Friday, 23rd November 2018 at 21:59 UTC, there was a network of 152 Twitter users whose recent tweets contained the #SoMe4Surgery hashtag (Fig. 3), or who were replied to or mentioned in those tweets. There were 152 vertices, 329 unique edges, 546 edges with duplicates, 875 total edges, and 44 self-loops. Reciprocated vertex pair ratio was 0.13, and reciprocated edge ratio was 0.22. In a connected component, there were 128 maximum vertices and 848 maximum edges.
From Twitonomy, the ten most influential users (8 men, 1 woman, 1 unknown) had a median number of followers of 16,648 (range 747-344,648). The ten most engaged users (4 men, 3 women, 3 unknown) posted a median number of 27 tweets (range 11-346). The top hashtags were #SoMe4Surgery, #surgicaltechnology, #surgicalpractice, #AI and #SSI.
Current technological improvements to surgical practice
In a poll asking which surgical technology has most significantly improved surgical practice (Question 4), preoperative imaging received the most votes (53% out of 288 votes), with intraoperative imaging receiving 10% of the votes (Fig. 4). @WarrenRozen stated that preoperative imaging is certainly of benefit, while intraoperative imaging has not yet demonstrated this effect despite having great potential. @MrRJEgan stated that preoperative imaging reported by specialists can improve quality and outcomes. @perbinder highlighted that this was particularly important in vascular surgery, where preoperative Duplex and CT angiography are widely used. @SJ_Chapman suggested that in colorectal surgery, medical imaging in general had revolutionised patient care before, during and after surgery, for example with the use of post-processing CT colonography, PET-CT, and MR. @EUrologyReg agreed, stating that the now widespread availability of CT scans has had a huge impact on surgical decision-making.
Energy delivery systems received 33% of the votes. @DrSantiagoOrtiz explained that technologies such as laser, phacoemulsification, and vitrectomy had revolutionised his field of ophthalmology. @MrRJEgan stated that the main benefit of energy devices lies in efficiency and reduced operating times.
Biomaterials received the fewest votes (4%) and were considered more likely to be of benefit in the future (@WarrenRozen), although @DrSantiagoOrtiz thought that they were becoming very relevant in ophthalmology with the use of intraocular lenses.
@A160186 reported that endoscopy and endoluminal surgery have also changed the face of surgery, and that interventional radiology has radically impacted the management of surgical conditions, pointing out that it is a non-surgical technology, and that saving the patient from having an operation should be considered an achievement in itself. @DrSantiagoOrtiz agreed that non-surgical technology will likely have the highest impact in surgical practice.
In a poll asking which surgical technology is most frequently used for intraoperative bleeding (Question 7), 82% of the 102 votes were for energy delivery devices, 10% for fibrin sealants, and 2% for thrombin gels (Fig. 5). @YorkLawLondon stated that intraoperative bleeding can be problematic in fibroid surgery, and that pharmacological therapy, such as preoperative hormone suppressants and intraoperative vasopressin, is frequently used to counter this.
In a poll asking about the use of surgical technology to reduce the rates of surgical site infection in surgical practice (Question 5), 40% voted “yes” (of 78 respondents), 22% voted “sometimes”, and 31% voted “no” (Fig. 6). @DrSantiagoOrtiz expressed surprise by the high proportion answering “no”, stating that the use of such technology is widespread in ophthalmology.
Future innovations in surgical technology to improve patient safety
A wide range of technological innovations were proposed to improve patient safety in future surgical practice. These included energy devices, advances in anaesthesia, pharmacology, information technology services and data management, radiology and nuclear medicine, and advances in medical allied medical specialities such as gastroenterology, clinical genetics, and medical oncology.
An area in which many Twitter users were interested was navigation-guided surgery, particularly with respect to finding the right planes and avoiding at-risk structures (@dr_samehhany81). @A160186 described a “surgical GPS or an intraoperative Siri/Alexa” to guide surgeons through tough terrain. @polom_karol took this further, adding a preoperative diagnostic tool overlay and the help of artificial intelligence to assist in surgical decision making.
“It would be great if during a lap cholecystectomy [you] could just go ‘Siri [please] tell me if this is the cystic duct’ (hoping she’d have the right answer).” (@A160186)
@Eric_Vibert and @jamestoml1 both highlighted the importance of the OR Black BoxTM in changing the relationship between surgery and human error, which has a significant impact on patient safety. @schnitzb suggested that direct loop feedbacking would lead to a reduction in human error.
The most commonly mentioned technological advance was laparoscopic and robotic surgery. @CelestinoGutirr argued that robotic surgery improves the technical precision of surgery; @alessiominuzzo countered that as it has been introduced as an “instrument” and its indications have altered, its use should be considered “off label surgery”, or should only be in the context of research. It was compared to laparoscopy, with @RNCsantander and @anhanssen suggesting that the outlook for robotics was similar to that of laparoscopy in its early days, and @DrSantiagoOrtiz stating that the evidence has shown laparoscopy to improve patient safety, while the jury is still out for robotics. Overall, the consensus was that, in the future, the evidence would reveal robotic surgery to be beneficial to patient safety.
In a poll asking how robotic surgery will evolve in the future (Question 2), 42% of respondents (134 votes) predicted that robots would be smaller (Fig. 7). Only 11% of respondents thought that robotic surgery would be phased out. @tuttlejebetsy argued that the “the case reimbursement is too low for sustainability and widespread adoption”, suggesting that robotic surgery only has a future as long as it can demonstrate a sustainable, cost-effective return on investment.
@RNCsantander questioned how we can improve the learning curve and training in robotic surgery to generalize its use. The high cost of the technology was felt to be a barrier to its accessibility (@A160186, @RNCsantander, @rcanterocid). @rebgross suggested the use of simulation training, and @A160186 suggested that robotics should be included in training or fellowship programs, arguing that one must have seen it to practise, and subsequently teach, the technique. @JoshuaTylerMD stated that skill monitoring and improved mentorship via online platforms were essential in improving training.
Three-dimensional printing for surgical practice
In a poll, 51% of 164 individuals voted to say that three-dimensional (3D) printing might be useful for surgical practice (Question 6), while 35% said it will have a big impact, and 7% voted for “it’s a fad” (Fig. 8).
Participants of the tweetchat had found 3D printing to be useful in colorectal (@dr_samehhany81) 17, orthopaedic and maxillofacial (@rcanterocid), and vascular surgery (@TMCAvascular).
@GaneshPuttu and @JasamineCB both stated that 3D printing has been useful in complex cases or with complex anatomy, to assist in visualisation for pre-operative planning, as well as an education tool for trainees and patients, with @MMakgasa suggesting they be used in the consent process. @TMCAvascular called 3D printing fundamental for case planning, posting “before” and “after” images of a ruptured cannulation site pseudo-aneurysm treated with an atrial septal device via brachial approach with intravascular ultrasound and intracardiac echography with the aid of 3D printing.
@LumsdenHMDHVC stated that his centre had moved away from 3D printing for training purposes, for which they used virtual simulation, but that its use was better indicated in case planning and device printing. @jmills1955 thought that the ability of 3D printing to allow the creation of patient and anatomic-specific devices would lead to it having a significant impact. @VerranDeborah echoed its use for implants and extended this to the biofabrication of tissue, suggesting that it may pave the way for the printing of organs in 10-20 years.
Artificial intelligence and its impact on surgical practice
Overall, the consensus was that artificial intelligence (AI) had the potential to have a significant impact on surgical practice. @juliomayol suggested that AI will change the way decisions are made and outcomes are monitored. @dr_samehhany81 and @Dr_A_Sturiale countered that AI would aid and complement the work of humans, but will never replace them.
In particular, it was thought that AI would have the largest impact in medical specialties in which imaging plays a crucial role in diagnosis (@DrSantiagoOrtiz). It was also felt that AI may result in a lower workload and administrative burden, with more time left to devote to direct patient care (@schnitzb). @polom_karol had a dramatic view of AI, stating: “AI will change all”, and that it was “the biggest revolution since [the] early beginning of surgery.” @hgok went so far as to suggest that in only 10 years, appendicectomies and cholecystectomies would be performed by AI-controlled robotic platforms, but that in hernia surgery this would take more time to develop.
@A160186 felt that one of the biggest benefits of AI would be found in patient safety, by creating “safety checkpoints” in clinical decision making, leading to the standardisation of diagnostics and procedures. She added that it was not clear whether AI would ever be autonomous; @YorkLawLondon and @DSoybel suggested this would mean it would only be as good as the data entered, and, for example in diagnostics, a diagnosis could be missed. @DSoybel further posed the critical question of who would control the data and algorithms. @YorkLawLondon added that any outsourcing could lead to companies exploiting or restricting data access and profiting from it; @DSoybel answered: “If neither data nor algorithms are proprietary there would be chaos. If both are proprietary there would be monopoly and potential for gaming. If one is and the other is not, there will be competition.”
“I’m sure surgeons prefer artificial intelligence over lack of intelligence.” @A160186
The patient’s perspective
There were some very insightful answers given when patients were asked which surgical technology they most valued. They can be found here. The most common theme was that the surgeon was valued above the technology.
Ethical issues in the development of new surgical technology
The issue of data ownership again arose when discussing the ethical issues surrounding the development of new surgical technology (@polom_karol).
The evaluation of risks and benefits was frequently mentioned (@CelestinoGutirr, @RNCsantander). Other issues included the dangers of optimism bias (@rebgross), as not all innovations are successful or result in improved patient care, and publication bias (@SJ_Chapman), leading to research waste 18. @SJ_Chapman also stated that it is ethically essential to determine not only if biotechnology results in patient benefit, but also the mechanics of why it works and has benefit, and that this would require well-designed qualitative work and patient and public involvement to facilitate the future development of the technology. @DrJamesGlasbey raised the issues of learning curves, proctorship, and early outcomes reporting. @schnitzb added the problems of rushing a product into market based on inadequate data. Finally, @coezycoe suggested that value and cost would have an impact on patient access to new surgical technology.
“[We] need to avoid ‘try it, bin it’ attitudes when evaluating surgical [biotechnology].”@SJ_Chapman
The tweetchat reached a global audience across different surgical specialties, as well as attracting engagement from patients.
The form of surgical technology currently found to be the most useful among the tweetchat participants was preoperative imaging. Energy delivery systems were the most commonly used technology to assist with intraoperative bleeding. Most participants employed surgical technology to reduce the rates of surgical site infection. Exciting avenues for future innovation included navigation-guided surgery, increased use of the OR Black BoxTM, and developments in laparoscopic and robotic surgery. The use of 3D printing and AI were both considered to increase in the coming years, with potential advances in automation. There were numerous important ethical issues to consider when developing new surgical technology. Finally, the consensus among patients was that, while advances in surgical technology were welcome, they were not as important or valued as the surgeon who employs them.
Limitations of analytics
It should be noted that Twitter polls are unvalidated and subjected to selection bias, and one person may also control multiple accounts. Although some users provide information about their areas of expertise in their Twitter bios, this is unregulated, and they may not include conflicts of interest. There is therefore the risk of non-expert or uncited opinions being included in the synthesis. This caveat must be emphasised when sharing such data.
Some data may be confounded by “incidental retweeting”, whereby if a tweeter uses two hashtags together, it is not always possible to determine from which hashtag the retweet results. Third party social media tools tend to overestimate impressions and audience. Although Twitter Analytics may provide a more accurate measure of impressions, this is not possible to collect from a tweetchat in which multiple Twitter accounts are engaged. Finally, collecting such data is subject to the Hawthorne effect, where changes in behaviour may be affected by the act of observation 19.
To validate the findings, further research could incorporate validated methods of qualitative research, such as thematic analysis.
Social media may be used to disseminate information within a vast surgical ecosystem, engaging surgeons with a strong social media presence. The use of a standardised hashtag in a tweetchat allows information to reach a high volume of global Twitter users in the surgical community in a short space of time. Tweetchats between a diverse group of surgeons, allied health professionals, and the general public, can be a goldmine for determining the direction of future surgical innovations.
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Maria Picciochi (@MariaPicciochi), Hospital Prof Doutor Fernando Fonseca, Portugal
Dmitri Nepogodiev (@dnepo), University Hospital Birmingham, UK
Virtually all elective surgical services around the world suffered some form of shutdown due to the COVID-19 pandemic1. Now, patients and surgeons are desperately looking to re-start services. Efforts to re-start after the first waves faced multifactorial challenges, including patient safety and ensuring enough staff along the whole patient pathway to support operating theatre availablity.2,3
The impact of the reduction in surgical capacity is likely to be staggering. Initial estimates of 28 million cancelled operations likely escalated to 50 million towards Autumn 2020, and may now be in excess of 100 million. That is only one part of the story, since the many undiagnosed patients with surgical conditions sitting in the community over the last 12 months may never make it to a surgeon or waiting list. Without adequate surgical capacity, there will be a major global decline in population health due to the burden of a full range of inadequately treated non-communicable diseases.
There is no single factor or solution that will enable surgery to re-start at scale, quickly. There is no single set of solutions that will work across every region. Since every single hospital around the world functions differently, context specific and whole system solutions are needed.
Vaccination will hopefully provide solutions to the current pandemic, although the global rollout is occurring at different paces globally, meaning surgical recoveries will differ. Cultural challenges across countries are adding to this variation. Unlike acute major incidents which disable elective surgical but are quickly over (e.g. major trauma or bombings), this pandemic has exposed specific, longer-term weaknesses of current systems. Post-pandemic planning will now happen across all spectrums of society. Surgeons need to lead efforts to create resilient elective surgical services that are pandemic resistant for the future, advocating for hospital and political awareness.
The COVIDSurg collaborative has taken a data driven approach to supporting safe surgery, and for 2021-2022 will provide further data to support re-starts globally. Data is needed across the whole system and patient pathway, that includes referrals, preoperative selection, perioperative testing and safety, postoperative risk reduction, and structural organisation of hospitals4–6.
Figure 1 – Centres enrolled in COVIDSurg studies
Learning from other non-medical disciplines, surgeons have little barometer of how secure their elective surgical services are compared to everyone else’s. COVIDSurg will deliver a validated Elective Surgery Resilience Index in the first half of 2021, allowing surgeons to test their systems and identify areas for immediate strengthening.
Re-starting surgery safely will be a complex interplay of these multiple factors. Not all resources will be available across all regions, and in some resource limited settings, surgery is at risk of being seen as a burden. To further support the re-start, an easily accessible, digital, online toolkit is needed that will provide key take-home messages and downloadable pathways for surgical teams to take and adapt. This will include the ability to self-certify individual department and hospital level of COVID Secure Surgery. This will provide the building blocks to provide ring-fenced, pandemic secure surgery by 2030.
Conflicts of interest: We have no conflicts of interest to declare.
Funding: No funding was received for this blog article.
1. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: An international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
3. COVIDSurg Collaborative. COVID-19-related absence among surgeons: development of an international surgical workforce prediction model. BJS Open. doi:10.1093/BJSOPEN/ZRAA021
4. COVIDSurg Collaborative. Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic. Color Dis. December 2020:codi.15431. doi:10.1111/codi.15431
5. COVIDSurg Collaborative. Elective cancer surgery in COVID-19–Free surgical pathways during the SARS-cov-2 pandemic: An international, multicenter, comparative cohort study. J Clin Oncol. 2021;39(1):66-78. doi:10.1200/JCO.20.01933
6. COVIDSurg Collaborative. Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic. Br J Surg. 2021;108(1):88-96. doi:10.1093/bjs/znaa051
Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS)
Recently published as open access in BJS, the 5-year results of the merged Finnish SLEEVEPASS and Swiss SM-BOSS randomised controlled trials comparing laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass shows that Roux-en-Y led to greater weight loss and better control of hypertension than sleeve gastrectomy, with no difference in outcomes for type 2 diabetes, obstructive sleep apnoea, or quality of life. More details can be found in the paper.
By Deep Chakrabarti, MD, Senior Resident, Department of Radiotherapy, King George’s Medical University, Lucknow, India
I reach the radiotherapy outpatient department on a Monday morning geared up and ready for the week ahead. With thoughts of a busy day and a busy week lying ahead of me, little do I appreciate then that my experiences over the week will continually repeat in cycles, much like the entire human existence and offer me reflections on life. The pandemic has made many of us re-evaluate ourselves and our relationships, many of which have been strained.
I believe that oncology endpoints can be assumed to mimic human relationships. A 70-year-old frail gentleman has a metastatic oral cavity cancer and is planned for palliative therapy with oral methotrexate. While his overall survival will most likely be a few months, we offer him oral metronomic chemotherapy and supportive care aiming for a decent quality of life. Most chemotherapeutic agents offer a similar overall survival of around six to nine months in the context of advanced or metastatic head and neck cancers. Similarly, in life, some relationships come with an expiry date, no matter what.
A 50-year-old gentleman presents with a recurrence of his locally advanced rectal cancer nine months after completing adjuvant treatment. Our surgical colleagues have seen him, and his disease has been deemed unresectable. He has been started on chemotherapy with oxaliplatin and capecitabine and has tolerated the first two cycles. I know well it is a matter of time that the drugs will delay progression. Progression-free survival (PFS) is a popular endpoint in oncology research that loosely means the time it takes for a disease to get worse.1 Interpersonal relationships are often subject to intense emotional and mental stress, that require continual repairing. However, situations arise when it may not be possible to start on a clean slate entirely, and one is left with no choice but to accept whatever has happened and move on. In other words, one has to take the inevitable that the relationship cannot be “cured”, but further worsening can be avoided. For some tumours like advanced ovarian or colorectal cancers, PFS may even be a loose surrogate for overall survival and may often be nearly equal to overall survival. Likewise, some relationships may not worsen again after one episode when both parties make conscious efforts to put things behind them and move on.
On Tuesday, I see a 40-year-old lady with visceral dissemination of hormone receptor-positive breast cancer receiving systemic chemotherapy. While she and her family have been counselled about their predicament, they may still have some time with their loved one to fulfil their wishes. Like the overall tenure of each human relationship, overall survival parameters vary grossly from one cancer to another. For example, a metastatic gall bladder cancer is likely to be fatal in a matter of mere months, even with the best available chemotherapy. On the contrary, a man with metastatic prostate cancer can be expected to survive a few years with the current standards of care.
Overall survival is the gold standard when it comes to measuring the worth of any cancer-directed intervention.2However, in patients or in relationships where one knows that the writing is on the wall, quality of life, or quality of the time left in the relationship is a premium. Quality of life is a crucial metric that seeks to quantify the actual well-being of an individual.3 While one may explore multiple therapeutic options to prolong life, one has to make a conscious decision as to how the prolongation will impact on its quality. Merely prolonging life while impairing its quality is detrimental. Similarly, when one knows that a relationship is irreparable, it is best to consider its quality than to keep trying to prolong it endlessly.
On Wednesday, I get an urgent consultation request for a lady with non-small cell lung cancer admitted in the neurosurgical ward who has presented with acute onset lower limb weakness with bladder and bowel involvement and has been diagnosed to have metastatic spinal cord compression. She is 70 years old with a WHO performance score of 2. The surgeons have already determined she is not a candidate for decompression. She is taken for urgent palliation with a single fraction of radiotherapy, with adequate steroid cover. Similar to the previous example, while her fate is probably already decided, but the urgent intervention offers to improve her quality of life, even if minimally.
On Friday, I get a call for radiotherapy planning for a patient who has cervical cancer with brain metastases and had received primary chemoradiotherapy three years ago. She is 74 years old, with a WHO performance score of 3 and requires continuous oxygen support. A decision is taken not to treat her with radiotherapy to the brain but offer her supportive care. Her three-year disease-free interval reminds me that a repaired relationship may suffer a relapse at any time. And sometimes a relapse can be so devastating that it does not offer much in terms of salvage.
On Saturdays, I see my radiotherapy patients on their weekly follow-up. We have a preponderance of head and neck cancer patients who will often present with grade II or III acute skin and mucosal toxicities as they move into the last weeks of therapy. Acute radiation reactions are defined as those occurring within 90 days of treatment and usually heal entirely with adequate care. However, late reactions or those occurring beyond 90 days persist and never completely heal. Some acute reactions may persist as late reactions, the so-called “consequential late reactions” (for example, chronic xerostomia is a consequential late reaction to acute xerostomia). For human relations, an acute bad episode may be amenable to rationalization and understanding, that may completely disappear like the resolution of acute radiation mucositis. But they may even persist, and then never go away completely. Therefore, the role of supportive care cannot be overemphasized, both in cancer care and in human relations.
The previous year has been a revelation for all of us. While it has subjected us to intense mental, emotional, and physical stress4, we have gained a thorough idea of what is vital in our lives. It is imperative that human relationships are valued on par with professional commitments, and the ongoing global crisis should teach us to prioritize personal contentment over professional gains. A morbidity audit from the CDC in August 2020 depicted that nearly one in four healthcare professionals had considered suicide in the immediately preceding one month for their troubles.5 While this is an alarmingly high number, it depicts the frailties ingrained in each of us and reiterates that before clinicians, we are humans. Even when our human forms are damaged and broken, sometimes beyond repair, empathy and patience for ourselves and our fellow beings might hold the key in this perennial struggle. May the progression-free survival of our relationships always closely mimic their overall survival.6 After all, as said by Rabindranath Tagore, “faith is the bird that feels the light and sings when the dawn is still dark.”
Conflicts of interest: There are no conflicts of interest to declare.
Funding: There is no funding to declare.
1 Korn RL, Crowley JJ. Overview: Progression-Free Survival as an Endpoint in Clinical Trials with Solid Tumors. Clin Cancer Res 2013; 19: 2607–12.
2 Driscoll JJ, Rixe O. Overall Survival: Still the Gold Standard. Cancer J 2009; 15: 401–5.
3 Selby P. The value of quality of life scores in clinical cancer research. Eur J Cancer 1993; 29A: 1656–7.
4. Vallée M, Kutchukian S , Pradère B et al. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France. Br J Surg. 2020 Oct;107(11):e486-e488. doi: 10.1002/bjs.11947.
5 Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020; 69: 1049–57.
6 Lebwohl D, Kay A, Berg W, Baladi JF, Zheng J. Progression-Free Survival. Cancer J 2009; 15: 386–94.
Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
on behalf of S-COVID Collaborative Group
The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,1which seems to be occurring again in countries that are being hit by the second wave.2
1/ I may be repeating myself, but I want to fight this sense of security that I see outside of the epicenters, as if nothing was going to happen “here”. The media in Europe are reassuring, politicians are reassuring, while there’s little to be reassured of. #COVID19#coronavirus
The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.
Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.3 Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job.
China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.4 The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.5
Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.6 Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.7 Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.8, 9
In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.10, 11
Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.
Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.12, 13 A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.14
A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.
Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;15 a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.16During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.17
A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group
Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,18 and additional supply strategies have been established,19 the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.20, 21
Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,22 the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.23
It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.24 However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.25 It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,26 and to help HCW who are struggling, left alone.
13. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.
15. Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).
16. Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).
17. An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).
18. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.
19. Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.
23. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).
25. Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.
26. Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.
Exploring psychological consequences for BRCA+ women in the post-Covid era
by Grace Brough1, Douglas Macmillan2, Kristjan Asgeirsson2, and Emma Wilson1 1Division of Epidemiology and Public Health, University of Nottingham 2Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
Whilst the global female population has a 12.5% overall lifetime risk of developing breast cancer and a 1.3% risk of ovarian cancer (Howlader et al), the risk for those with a pathogenic BRCA1 or BRCA2 mutation is 60-70% and 10-20% respectively (van Egdom et al). BRCA1 mutation carriers have a particularly high incidence of triple-negative breast cancer (TNBC) (Greenup et al) for which treatment options are more limited and always include chemotherapy (Bianchini et al; Collignon et al).
In the NHS, asymptomatic women with at least a 10% estimated chance of having a BRCA mutation are offered testing (NICE). Knowing you are at high risk of breast cancer and the increased likelihood of TNBC is a well-documented cause of anxiety (Wenzel et al) and many women describe having a BRCA gene mutation as living with a ‘ticking time bomb’. Bilateral mastectomy with or without reconstruction is the only proven method of drastically decreasing risk and can improve quality of life (McCarthy et al) and decrease anxiety (Rebbeck et al) for correctly selected cases, despite its potential negative outcomes (Gahm et al).
The strongest predictor for choosing to undergo risk reducing mastectomy is having a first or second degree relative die from breast cancer (Singh et al), a factor associated with fear, anxiety and vulnerability to this disease. Most women choosing it have clear and long-considered reasoning and have been prepared for it through well-established pathways guided by genetic counsellors, specialised surgeons and nurses. It is however, classified as elective surgery. As such, waiting lists for risk reducing mastectomies are impacted by other healthcare challenges and needs.
Being on NHS waiting lists causes anxiety across all specialities (Carr et al). With an estimated 10 million people on NHS waiting lists in the post-COVID era, levels of health-related anxiety within the population are anticipated to significantly increase. For BRCA mutation carriers, the prevailing fear is that they will develop breast cancer whilst on the waiting list. This reality is related to the length of time on the waiting list and represents potential conversion of a risk reducing scenario to one of chemotherapy and cancer surgery, often with other treatments, and all the life changing and life threatening implications of cancer diagnosis.
In pre-COVID times, there was a 18 week target time from referral to treatment for risk reducing mastectomy (UK GOV). Due to COVID, the majority of elective surgery has been put on hold and Breast Units now anticipate at least a 2-year waiting list for non-cancer surgery, such as risk reducing mastectomies, delayed reconstructions, and revisional surgery. Prioritisation is a difficult necessity.
In addition, breast screening services ceased or were significantly curtailed as a result of COVID related restrictions, and this adds to an already complex situation for BRCA mutation carriers. Not only may they now get breast cancer whilst on the waiting list, but they are denied the reassurance afforded by negative screening, or potentially a diagnosis may be delayed (Maringe et al).
Combining pre-existing anxieties of being a BRCA mutation carrier, new waiting list anxieties, and wider COVID general health anxieties, the post-COVID era has the potential to see significant levels of psychological burden in this population, which could negatively impact mental health and quality of life. Providing additional psychological support is likely to be the short-term solution, though this is also resource limited. In reality the collateral impact of pandemic related consequences for healthcare in this particular group may not be realised for some time.
Scientific research can be challenging to follow, especially for those who are not experts in the field. There is lots of interest in COVID-19 from the public. The authors of the paper published in the BJS have provided a plain English summary to help people understand the work.
As we continue in and between subsequent pandemic waves, and patients are booked for surgery, the CovidSurg cancer study data can help to identify where services can best spend resources to protect patients. This paper, published in the BJS evaluates the associations between SARS-CoV-2 testing before operations and serious breathing problems afterward.
SARS-CoV-2 swab testing before planned surgery reduces serious breathing complications
At least 28 million operations were delayed during the first COVID-19 pandemic wave. As we resume operating, we need the ability to identify patients with pre-symptomatic infection and postpone surgery to keep those patients safe. We also need to use resources wisely by testing in situations where it will likely provide a benefit.
To understand the value of preoperative SARS-CoV-2 testing to prevent serious breathing problems after surgery.
To maximise the benefits for patients and guide the use of resources, this study looks at where and when swab testing can change patient outcomes.
Surgical team members in 432 hospitals in 53 countries collected anonymised data for all patients having planned cancer surgery during the pandemic up to 19 April 2020. We included all patients with data about preoperative testing. Patients suspected of having the infection pre-operatively were excluded. Researchers recorded if a patient died or had serious breathing problems up to 30 days after their operation.
2303/8784 patients (23%) were tested for SARS-CoV-2 before their operation. 1458 had a swab test, 521 a CT scan of their chest and 324 had both tests. 6746 major operations and 1087 minor operations were performed in high SARS-CoV-2 risk areas and a minority of operations took place in low risk areas.
Overall, 4% of patients experienced serious breathing problems following surgery. The rate was higher in patients with no test or CT scan-only testing. At least one negative swab before operation reduced the risk of serious breathing problems after surgery. Having repeated swabs did not add extra benefit.
The data showed that swab testing reduced breathing problems in high risk COVID areas but not in low risk areas. It also showed that a swab before major surgery reduced breathing problems but not before minor surgery.
How many patients must be swabbed to prevent one patient having serious breathing problems?
To prevent one patient having serious breathing problems after major surgery, in a high risk area, 18 patients had to be swabbed; 48 had to be swabbed before minor surgery in a high risk area. This increased to 73 patients swabbed before major or 387 before minor surgery in low risk areas, to prevent one patient having breathing problems.
Some evidence also suggested there was a lower death rate among patients who were swabbed before their surgery.
The study group was able to recommend that ‘A single preoperative swab should be performed for patients with no clinical suspicion of COVID-19 before major surgery in both high and low risk areas and before minor surgery in high risk population areas’.
Swab testing before surgery is likely to benefit patients by identifying pre-symptomatic or asymptomatic COVID-19 infection prior to admission. A positive swab result triggers operation delay, protects patients from severe breathing problems after surgery and helps protect other patients from in-hospital infection. Swabs together with other strategies, should be used to protect patients from COVID-19 during hospital care.
Maria Picciochi, Harvinder Mann, Sam Lawday, James Glasbey
On behalf of the COVIDSurg Collaborative
What are the GlobalSurg & COVIDSurg Collaboratives?
GlobalSurg was born in 2013 as a group of frontline surgeons around the world with the aim of improving outcomes for their patients by joining together to collect high-quality data. The CovidSurg collaborative represents the COVID-19 response of the NIHR Global Health Research Unit at the University of Birmingham. The CovidSurg group is made up of an international collaborating group of surgeons, anaesthetists and researchers. They capture and share real world data for international multi-centre research studies. These groups overlap and are an expanding network aiming to improve global surgical care through collaborative research.
Since March the CovidSurg collaborative has run three prospective cohort studies and launched one randomised control trial:
(1) CovidSurg, an international cohort study assessing the outcomes of surgery in patients diagnosed with COVID-19
(2) CovidSurg-Cancer, an cohort study to assess the impact of COVID-19 on cancer surgery
(3) SURG-Week, which took place in October 2020. This set out to determine the optimal timing for surgery following a SARS-CoV-2 infection
(4) PROTECT-Surg, an international platform adaptive randomised trial to evaluate the effectiveness of chemoprophylaxis for SARS-CoV-2 infection in surgical patients.
The CovidSurg Collaborative is proud to announce it has captured outcomes for over 150, 000 patients from 2000 hospitals in 130 countries for these studies to date.
The SURG-Week study is set to be the largest international prospective collaborative study ever conducted, with over 15000 collaborators participating. It is an incredibly exciting time for collaborative research in surgery, encouraging colleagues internationally to take part in research and helping improve surgical outcomes in such unprecedented times.
COVID-19 in surgical patients
Our first study, published in the Lancet, demonstrated severe impact of COVID-19 in patients undergoing surgery. This found that patients with a positive perioperative SARS-CoV-2 test had a 30-day mortality rate was as high as 23.8%. Pulmonary complications occurred in 51.2% of patients and accounted for 81.7% of all deaths.
Certain patient groups were at higher risk. Male sex, older age, ASA grade 3-5, cancer indiciation, emergency, and major surgery, were all associated with postoperative death. These findings have allowed surgeons to optimise selection for surgery. They have already been implemented into several guidelines, and featured in over 400 news articles around the world.
Learning from this data, the COVIDSurg steering group rapidly synthesize evidence to provide a pragmatic global surgical guideline to provide care for surgical patients during the early phases of the pandemic.
The growing problem of cancellation elective surgery
The COVID-19 pandemic has disrupted surgical services worldwide. A modelling study from the COVIDSurg Collaborative published in BJS aimed to estimate the impact on surgical activity around the world. This estimated that 28.4 million elective surgeries would be cancelled or postponed around the world in the first 12 weeks of the pandemic; to clear this backlog, surgical providers would have to provide 120% operative capacity for over one year. With a second wave and lockdown of countries around the world, this is likely to be a gross underestimate. Many patients face progression of time-dependent conditions, or significant delays of quality of life surgery.
Rescheduling and prioritising operations presents a huge challenge to providers. COVIDSurg is supporting decision making in several ways:
COVIDSurg-Cancer will examine the impact of delay on cancer surgery. It will also look at the impact of neoadjuvant therapy on early oncological outcomes to inform prioritisation once surgery restarts.
COVIDSurg and COVIDSurg-Cancer data are being used to create risk stratification scoring systems. These will use principles of machine learning to allow high-fidelity risk estimation and support patient consent.
How to protect patients and safely upscale surgery during COVID-19 waves
COVIDSurg-Cancer provides an opportunity to identify best practises to optimise protective measures for patients during the second SARS-CoV-2 wave and beyond. Our first analysis, published in the Journal of Clinical Oncology demonstrated the use of COVID-19 free surgical pathways to protect patients from perioperative SARS-CoV-2 infection and subsequent complications. COVID-19 free zones throughout the hospital could be created in dedicated hospitals for elective surgery only, and major acute hospitals treating COVID-19 free patients; however, less than a third of patients received their care in totally COVID-19 free zones.
We have also been able to identify best practices for preoperative testing of patients for SARS-CoV-2. In our screening paper, released in BJS on 11th November 2020, obtaining a single negative preoperative nasopharyngeal swab testing was demonstrated to reduce subsequent postoperative pulmonary complications; this was likely due to a reduction in presymptomatic carriage of SARS-CoV-2 into the perioperative setting. Swab testing was most beneficial before major surgery and in high SARS-CoV-2 risk areas. The use of CT imaging for preoperative testing or serial swab testing was, however, had no proven benefit.
Unanswered research questions
SURG-Week unites the COVIDSurg and GlobalSurg Collaborative networks for the first time. It will address the evidence gap about the optimal of surgery for patients previously infected with SARS-CoV-2. Early pilot data from 122 patients published in BJS demonstrated a signal that a minimal interval of at least 4 weeks protected patients from severe complications of SARS-CoV-2.
It will also determine key global surgical indicators for future benchmarking and modelling studies. All hospitals and all surgical specialties can take part and will collect data from all patients operated regardless of their SARS-CoV-2 status during a 7-day period in October. The follow-up will occur at 30 days and will include mortality, pulmonary complications and surgical complications. With 15000 collaborators from over 2000 registered to date, it is set to be the largest prospective study ever to be undertaken. You can read more about this ongoing study on our website: www.globalsurg.org/surgweek.
Recently published as open access in BJS, this prospective quality improvement study showed a reduction in surgical site infections using an adaptive, multimodal surgical infection prevention programme for low-resource settings. Further information can be found at the Lifebox website.