Global surgical collaboration to support data driven decision making during the COVID-19 pandemic.

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.

SURG-WEEK

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. 

These data generated a significant media response, featuring in the global press including the Economist, New York Times and Daily Mail.

Rescheduling and prioritising operations presents a huge challenge to providers. COVIDSurg is supporting decision making in several ways:

  1. 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.
  2. 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

There are several research questions outstanding,.

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.

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