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Pre-operative testing for SARS-CoV-2 infection

Research in plain English

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.

Background

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

Context

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.

Aim

To understand the value of preoperative SARS-CoV-2 testing to prevent serious breathing problems after surgery.

Impact

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.

Strategy

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.

Results

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.

Conclusion

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.

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.

Visual Abstract: Clean Cut programme

A success story in global surgery

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.

A View of the COVID-19 Impact on Surgery: A Social Media Analysis

Sergio M Navarro, MD MBA, Kelsey A Stewart, MD, Hashim Shaikh, BS^, Matthew C, Bobel, MD, Evan J Keil, BS, Jennifer Rickard, MD MPH, Todd M Tuttle, MD MS

^ Department of Surgery, University of California San Francisco, San Francisco, CA, USA

* Department of Surgery, University of Minnesota, Minneapolis, MN, USA Please contact: Sergio M Navarro, MD MBA 420 Delaware St SE, Minneapolis, MN 55455 mnavarro@alum.mit.edu

INTRODUCTION

The Coronavirus disease 2019 (COVID-19) has rapidly evolved and impacted all aspects of health policy and healthcare delivery – including surgery. Recommendations to postpone and provide additional guidelines regarding ‘elective surgery’ has left surgeons, patients, and hospitals with questions on the definition of ‘elective,’ the proper type and use of personal protective equipment (PPE) in surgery, the ethics of delaying medically indicated procedures, and the health and psychological impacts on patients and families. Analysis of social media information enables examination of the impact of COVID-19 and associated policy changes in a unique way and gathering of real-time data more rapidly than traditional methods. [1–4]

METHODS

From March 1 to March 31, 2020, we conducted a cross-sectional analysis of associated posts on Twitter to collect data related to COVID-19 and surgery.  The public domain was queried by filtering for five hashtags: #covidsurg, #covid19surgery, #COVID-19, #Coronavirus and #surgery. A binary scoring system was used for media format, perspective of the author, tone, user and post content, based on 2-person review. Data underwent descriptive and statistical analysis. All specific author information was de-identified. Non-English and non-surgery related tweets were excluded from analysis. 

RESULTS

890 posts met the inclusion criteria. Posts an average of 629 Likes, 95 Retweets, and 1.78 hashtags per post. Author categories included physicians (39.7%), news organizations (18.4%), institution/professional organization (13.6%), and patients (11.9%). The majority of posts occurred from Twitter users based in the US (51.3%), followed by the UK (25.3%), and Canada (4.4%). Content included the cancellation of surgery (24.9%), surgical guidelines (20.2%), commentary/other (18.2%), COVID-19 education (16.2%), and PPE availability (7.4%).

1Surgeons, physicians, and health care professionals, 2 Patients and patients’ families, 3 News, media, and academic organizations. Other Countries with 1 post included Brazil, Egypt, Germany, Ghana, Japan, Republic of Korea, Malta, New Zealand, Nigeria, Pakistan, Palestine, Russia, Sweden, Switzerland, Ukraine, Venezuela, and Zimbabwe respectively

Physicians were more likely than patients or patient’s families to post content related to PPE shortages, COVID19 education, research dissemination, as well as commentaries. Patients and patient families emphasized postoperative recovery and postoperative complication. Businesses, media outlets, and institutions posted most frequently about surgery cancellations and surgical guidelines. Authors from low and middle-income countries (LMICs) accounted for 4.4% (33/755) of posts where location of the post was available.

DISCUSSION

This initial exploration of the impact of COVID19 on surgery worldwide using social media found different perspectives from physicians, patients, families, media outlets, and institutions on various topics including cancellation of surgery, types of ‘non-essential’ surgery, concerns about PPE, and dissemination of surgical guidelines and educational information.

Non-Essential Surgery Cancellations

The cancellation of ‘non-essential’ surgery was the primary focus of content among all groups (25%, 222/890) and 40% (76/191) of posts by patients and families. Physician posts on cancellation comprised only 14.8% of their overall content. Their discussion on cancellation revolved around complex decision making in the designation of ‘non-essential’ surgeries and the inevitable consequences. One healthcare professional in Italy posted about the likely morbidity following lack of access to care and a surgeon in Canada discussed the difficult but important decision to delay surgery to improve healthcare capacity and protect patients from COVID19 exposure. A Urologist in Brazil described a difficult treatment decision for a patient with poor quality of life in need of a ‘non-essential’ surgery, emphasizing just how difficult it is to define ‘essential.’

Subspecialty Surgery Cancellations

A portion of the surgical cancellation content highlighted the ethical and political consequences of possible delays in specific types of surgeries; namely cancer surgery, orthopedic surgery, surgical abortion, and transgender surgeries.[5–8] Twitter served as a platform to discuss these ethical considerations for both surgeons and their affected patients. In one tweet, attention was drawn to a 17-year-old in need of surgery and chemotherapy; however, after spiking a fever he was subject to a two-week delay in care due to awaiting COVID-19 testing results.

Changes to practice

Another individual highlighted his mother’s breast cancer journey, sharing that instead of a partial mastectomy and reconstruction, an entire mastectomy without reconstruction would be performed – all due to changing guidelines regarding procedure safety. In terms of historically politicized surgeries, several state governments made decisions to limit access to abortion and gender affirming surgeries creating dissention within patients and physicians which was highlighted in over 10% of total tweet content where specific subspecialties were mentioned. [9]

Surgical Guidelines, Education, and Changes in Clinical Management

Throughout the analyzed tweets, several changes were recommended in the routine management of surgical conditions during the COVID-19 epidemic to conserve resources, limit exposure to the virus, and limit the use of PPE. These posts were primarily (46% in total) disseminated by academic institutions, other professional organizations, and media outlets. For example, the ACS and others have recommended limiting the use of laparoscopy which has the potential to aerosolize viral particles. Physicians worldwide have recommended alternate surgical techniques to reduce the risk of exposure to COVID19 including an Otolaryngologist in France who recommended the use of hammer and chisel in place of drilling. However, these changes are not without dissention, highlighted by a bariatric surgeon in the UK who struggled to follow a new guideline that he felt would worsen outcomes for patients.

Safety and Personal Protective Equipment

Surgeons, physicians, and other health professionals focused on commentaries and discussions about safety and PPE more than the other groups- giving insight that they see safety of patients and healthcare workers as the more important information surrounding the COVID-19 pandemic. One post from a trauma surgeon described lessons learned from performing emergency surgery on patients with COVID-19 and the need for clear guidelines and safety measures. The Columbia Chair of Surgery provided updates daily outlining the future need of PPE and justification for supplying a single mask per provider per day even at an early point in the COVID-19 outbreak.

Regional Differences

Concerns surrounding the COVID-19 pandemic vary in different regions and countries given their specific burden of disease and capacity to mount a public health response to the disease.[10–13]. High-income countries (HICs) made up an overwhelming majority of the posts and thus a complete picture of the global burden of disease and changes to surgery across the globe may not be able to be formed. It is known that LMIC authors are often underrepresented in the global social media sphere in regard to global surgery which we further affirm here.[14] Inclusion of LMICs in both the discussion and dissemination of global guidelines in regard to the COVID-19 pandemic ought to be a priority by the global surgical community. Some of the emphasized concerns from LMICs include internet outages that impact accessing surgical guidelines, hospital exposure of patients to the virus, as well as the dissemination of guidelines from other countries.

Geographical variation in COVID-19 Surgery twitter activity.

CONCLUSION

In this cross-sectional analysis, surgeons, physicians, and organizations expressed concerns about the impact of COVID-19 on surgical guidelines, the delay and cancellation of surgery, and the availability of PPE while disseminating COVID-19 education and information. We found minimal variation in the levels of mention regarding the impact of COVID-19 on surgical cancellations or delays, but the community of surgeons and physicians made more mention of PPE availability to conduct surgeries. These findings provide an indicative sampling of the key surgical perceptions of COVID-19 on these important populations.

REFERENCES

1.        Sorice SC, Li AY, Gilstrap J, Canales FL, Furnas HJ. Social Media and the Plastic Surgery Patient. Plast Reconstr Surg. 2017;140: 1047–1056. doi:10.1097/PRS.0000000000003769

2.        Navarro SM, Haeberle HS, Cornaghie MM, Hameed HA, Ramkumar PN. The Impact of Social Media in Medicine: An Examination of Orthopaedic Surgery. Social Media: Practices, Uses, and Global Impact. 2017.

3.        Ni hIci T, Archer M, Harrington C, Luc JGY, Antonoff MB. Trainee Thoracic Surgery Social Media Network: Early Experience With TweetChat-Based Journal Clubs. Annals of Thoracic Surgery. 2020. doi:10.1016/j.athoracsur.2019.05.083

4.        Henderson ML, Adler JT, Van Pilsum Rasmussen SE, Thomas AG, Herron PD, Waldram MM, et al. How Should Social Media Be Used in Transplantation? A Survey of the American Society of Transplant Surgeons. Transplantation. 2019. doi:10.1097/TP.0000000000002243

5.        Couloigner V, Schmerber S, Nicollas R, Coste A, Barry B, Makeieff M, et al. COVID-19 and ENT Surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2020. doi:10.1016/j.anorl.2020.04.012

6.        Iyengar KP, Jain VK, Vaish A, Vaishya R, Maini L, Lal H. Post COVID-19: Planning strategies to resume orthopaedic surgery –challenges and considerations. Journal of Clinical Orthopaedics and Trauma. 2020. doi:10.1016/j.jcot.2020.04.028

7.        Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. American Journal of Obstetrics and Gynecology. 2020. doi:10.1016/j.ajog.2020.02.017

8.        Nepogodiev D, Bhangu A. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020. doi:10.1002/bjs.11746

9.        Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic – Ensuring Access to an Essential Health Service. N Engl J Med. 2020. doi:10.1056/NEJMp2008006

10.      Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395: 1225–1228. doi:10.1016/S0140-6736(20)30627-9

11.      Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. doi:10.1016/S0140-6736(20)30566-3

12.      Fauci AS, Lane HC, Redfield RR. Covid-19 – Navigating the uncharted. New England Journal of Medicine. 2020. doi:10.1056/NEJMe2002387

13.      Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet. 2020. doi:10.1016/S0140-6736(20)30567-5

14.      Navarro SM, Mazingi D, Keil E, Dube A, Dedeker C, Stewart KA, et al. Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study. World J Surg. 2020. doi:10.1007/s00268-020-05553-8

Management of Crohn’s Disease. The shiny medical sports car or the worn out surgical banger?

Professor Steven R Brown, Sheffield Teaching Hospitals.

Based on the BJS Lecture at ACPGBI 2020

A success story

There is more and more convincing evidence that the number of patients undergoing surgery for Crohn’s disease is decreasing substantially (1,2). Of course this as a huge success story and testament to tremendous advances in medical therapy occurring particularly over the last 20-30 years, isn’t it? Not necessarily. Some would suggest the newer medications have made little to no difference in reducing the need for surgery (3,4). Other factors may be more pertinent. To give gastroenterologists credit, earlier recognition of disease and potential complications and better disease monitoring are likely to have played a role. On the other hand it may be nothing to do with medical care and there is a simple epidemiological explanation; for instance there are less smokers now than there was 30 years ago (5).

Or is it?

There is another more concerning explanation. The plethora of medical options for patients with Crohn’s disease continues to expand. As a simple surgeon it is difficult to keep up with the various biosimilars, protein kinase, IL , CAM and JAK3 inhibitors that are available or being developed. It is like a candy shop of choice for the physician and a huge temptation for the patient to at least try one or more of these cutting edge medical therapies. Give medical treatment ‘just one more go’ is an obvious impulsion. But the medical literature is consistent in suggesting over 70% of patients with Crohn’s Disease eventually come to surgery (6). This can only mean that an increasing proportion of those undergoing surgery have experienced protracted medical therapy and are likely to have more complex disease. Although difficult to confirm this is certainly the perception of many in the surgical community (7-9).

Naturally all clinicians strive for the ultimate goal of never requiring surgery for Crohn’s Disease, but we are not there yet. Indeed some argue that the trend for less surgery should be reversed and surgery offered for more patients much earlier in their treatment pathway.

Buying a car

I like to think that the choice of surgery or medical therapy is analogous to buying a car. When making such a decision there are various factors that should be considered. These include safety, comfort, reliability, cost and perhaps most important of all what your partner thinks. The car may seem perfect in terms of all of these factors but he/she does not like the salesman, the brand or the colour.  

So when it comes to the choice of the medical or surgical ‘car’ option, safety is in some respects paramount. There is a justifiable fear of surgery and a dread by many for the need for a stoma. However, optimisation of the patient, use of minimally invasive techniques, minimal resection and enhanced recovery mean that many of these fears are unfounded in the majority of patients (10). Indeed there are not insignificant risks associated with the alternative long-term immunosuppression.

Car comfort translates to quality of life. We know from the LIRIC study that quality of life is pretty much equivalent when it comes to medical or surgical options (11). No obvious winner here. However, when it comes to reliability or the chance of needing surgery there is an outright winner. As mentioned earlier the universally consistent literature suggests a greater that 70% chance of Crohn’s patients eventually needing surgery despite enhanced medical therapy (6). The ‘shiny medical sports car’ is very likely to break down. Compare with the ‘banger’ that is the surgical car. This just keeps going.

Additionally, long-term studies suggest at least 50% of patients will be symptom free 10 years after resection and two thirds will avoid further surgery (6). If this were the data for a new drug it would undoubtedly become a best seller. Furthermore it may be possible to customize the surgical ‘banger’ to make it even more reliable and attractive to the discerning customer. The Kono-S anastomosis and more radical mesenteric resection have both been touted as techniques that may reduce recurrence even further (12,13).

What does the data say?

Two recent publications back up these observations. A recent meta-analysis comparing early surgery with medical therapy decreases the risk of overall relapse (OR 0.53) , surgical relapse (OR 0.47) and the need for biological maintenance therapy (OR 0.24) whilst showing no difference in morbidity (14). Perhaps more significantly, long term analysis of the LIRIC data suggests nearly half of those treated with biological end up having surgery within 5 years and the rest remain on medication, switch or escalate treatment. Compare that with the surgical group were although about a quarter of the group required medical therapy for symptomatic recurrence, no one has required further surgery (15) Add to that cost, another clear winner for the surgical ‘banger’. Data again from LIRIC suggests it is €9000 cheaper than the medical option and almost 100% likely to be cost effective (16).

Therefore, it seems that the surgical car is cheaper, more reliable and, despite the looks, is as comfortable and safe as the shiny new medical sports car. However, the unpredictable factor is of course what your partner (patient) thinks. A study by Scott and Hughes (17) suggested about 80% of patients who underwent iloecaecal resection for Crohn’s disease said they ‘wished they had had surgery sooner’. Whilst a pre-biological era study and full of potential bias, many surgeons would be familiar with this phrase from the happy patient sitting in front of them, having undergone successful resection.

How do we proceed?

So there is a quandary here. Every doctor, regardless of specialty, wishes to reduce the need for surgery in Crohn’s but I would argue the evidence points to this being a less favorable option in many. The solution in my view lies in the underlying principle of good care for IBD, a multidisciplinary approach. Patients with Crohn’s Disease who require escalation of treatment should be fully informed of the risks and benefits of both medical and surgical options and make their own mind up. The only way this can be done fully and in an unbiased fashion is by meeting the surgeon earlier, preferably together with the physician in a joint clinic.

References

  1. Kalman TD, Everhov ÅH, Nordenvall C, et al. Decrease in primary but not in secondary abdominal surgery for Crohn’s disease: nationwide cohort study, 1990-2014 [published online ahead of print, 2020 May 26]. Br J Surg. 2020;10.1002/bjs.11659.
  2. Beelen EMJ, van der Woude CJ, Pierik MJ, et al. Decreasing Trends in Intestinal Resection and Re-Resection in Crohn’s Disease: A Nationwide Cohort Study [published online ahead of print, 2019 Jun 10]. Ann Surg. 2019;10.1097/SLA.0000000000003395.
  3. Lakatos PL, Golovics PA, David Get al. Has there been a change inthe natural history of Crohn’s disease? Surgical rates and medicalmanagement in a population based inception cohort from Western Hungary between 1977–2009. Am J Gastro2012;107: 579–88.
  4. Jeuring SF, van den Heuvel TR, Liu LY, et al. Improvements in the Long-Term Outcome of Crohn’s Disease Over the Past Two Decades and the Relation to Changes in Medical Management: Results from the Population-Based IBDSL Cohort. Am J Gastroenterol. 2017;112(2):325-336.
  5. Cosnes J. Smoking and diet: impact on disease course? Dig Dis. 2016;34:72–77
  6. Latella G, Caprilli R, Travis S. In favour of early surgery in Crohn’s disease: a hypothesis to be tested. J Crohns Colitis. 2011;5:1-4.
  7. Buskens CJ, Bemelman WA. The surgeon and inflammatory bowel disease. Br J Surg. 2019;106:1118-1119
  8. Macfie J. Commentary: Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:208.
  9. Mege D, Garrett K, Milsom J, Sonoda T, Michelassi F. Changing trends in surgery for abdominal Crohn’s disease. Colorectal Dis. 2019;21:200-207.
  10. 2015 European Society of Coloproctology (ESCP) collaborating group. Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate. World J Gastrointest Surg. 2019;11:261-270.
  11. Ponsioen CY, de Groof EJ, Eshuis EJ, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: a randomised controlled, open-label, multicentre trial Lancet Gastroenterol Hepatol. 2017;2:785-792.
  12. Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn’s disease: a systematic review [published online ahead of print, 2020 May 17]. Colorectal Dis. 2020;10.1111/codi.15136.
  13. Coffey CJ, Kiernan MG, Sahebally SM, et al. Inclusion of the Mesentery in Ileocolic Resection for Crohn’s Disease is Associated With Reduced Surgical Recurrence. J Crohns Colitis. 2018;12:1139-1150.
  14. Ryan ÉJ, Orsi G, Boland MR, et al. Meta-analysis of early bowel resection versus initial medical therapy in patient’s with ileocolonic Crohn’s disease. Int J Colorectal Dis. 2020;35:501-512.
  15. Stevens TW, Haasnoot ML, D’Haens GR, et al. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastro hepatol. 2020 Available on line 30 June.
  16. de Groof EJ, Stevens TW, Eshuis EJ, et al. Cost-effectiveness of laparoscopic ileocaecal resection versus infliximab treatment of terminal ileitis in Crohn’s disease: the LIR!C Trial. Gut. 2019;68(10):1774-1780.
  17. Scott NA, Hughes LE. Timing of ileocolonic resection for symptomatic Crohn’s disease–the patient’s view. Gut. 1994;35:656-657.

Visual abstract blog

As Monty Python would say…

Time for an upbeat blog!

The BJS ‘how to write a paper’ session is a fixture at many UK surgical meetings. This covers lots of the ‘nuts and bolts’ of writing a paper. We delivered a short version of this course at the Association of Surgeons in Training Meeting in Birmingham.

One of the fun and developing parts of publishing is the promotion of material on social media. Visual abstracts have emerged as a concise way of sharing the key points of a manuscript online. Therefore it shouldn’t come as a surprise that we cover making visual abstracts in this course.

We discuss things like picking out key points and the use of icons and images. We then give the participants a choice of two abstracts and invite them to submit a visual abstract to our competition. This year we chose this paper on peripheral vascular disease and this paper on oesophageal cancer as subjects for the exercise.

We were pleased to receive a number of visual abstracts, which were of a really high standard. Most participants opted for the peripheral artery disease abstract. The team were really impressed by the abstracts that were submitted to us. Dr Jia Ying Lim (blue background) was the winner, and Dr Rucira Ooi (red background) was awarded the runner up prize. You can see these below.

Please keep an eye out for the course at future meetings. If you would like us to deliver this course at your meetings, please get in touch!

Covid19

Guest post: The effects of COVID-19 on surgeons and patients

When the first cases of the disease that would have been later named COVID-19 (Coronavirus Disease 2019) caused by SARS-CoV2 were described in Wuhan approximately three months ago, it would have been difficult to predict the impact and the burden that the subsequent outbreak would have had globally. The first case was tracked back to November 2019, indeed the spread COVID-19 proved to be incredibly rapid, and is currently causing several challenges to most health systems.

On the 11th March the World Health Organization (WHO) declared COVID-19 pandemic. Between the last week of February and the first week of March, the number of cases outside China increased 13-fold and the numbers of affected countries tripled. By the time the present piece is being typed, 164 837 cases were recorded globally, with 6470 deaths, 146 countries involved. 

Among European countries, Italy has been hit first and more deeply, the reasons for this still being analysed, and no agreed explanation available. Since the first cases were described on the 30th January 2020, two Chinese tourists, the outbreak showed a logarithmic growth, and by today (16/03/2020), the overall number of individuals who tested positive was 24 747 (20 603 still positive) with 1809 deaths. This would mean a mortality rate overall as high as 7.3%, and 43.6% of those who had an outcome. Of those currently infected, approximately 8% is in serious/critical conditions. Lombardy, considered the economic heart of Italy, where an ideal health system is in place, registered the highest number of COVID-19, exceeding 13 200 patients, more than half than all Italian cases. The outbreak is rapidly spreading to the entire peninsula, islands not being spared: almost 1000 cases between South and Islands (3.73%). Even if these figures might not seem worrisome, they actually are, as facilities and infrastructures might not be prepared to afford a similar outbreak as that observed in Northern Italy, and the system could collapse. Restrictive measures had to be taken, and the Italian Government ordered an unpreceded lockdown effective as the 12th March 2020, and its effect and meaning are well testified by the empty Italian cities. Florence’s Uffizi Gallery is closed; St. Peter’s Square in Rome is empty.  

These images are self-explanatory.  Similar measures are being taken in other European countries, even if the strategies to face COVID-19 were not consistent. Spain followed a similar pathway observed in Italy, with 7753 cases and 288 death as of today, mainly in Madrid, and adopted the same measures. 

The impact of COVID-19 on our society is already immense, and some have suggested that the post-pandemic era is likely to blow away the world as we used to know it. 

COVID-19 and Cancer

Liang et al. analysed the cases of COVID-19 in China, and found that patients with cancers were at higher risk of developing the symptoms from SARS-CoV2 infection. Out of 1590 COVID-19 cases analysed, an history of cancer was found in 1% of them, versus 0.29% observed in the general population. One out of four had received chemotherapy or surgery within 30 days from infection, whereas another 25% were on follow-up after treatment. This might suggest that cancer patients might be at increased risk, even after curative treatment of the disease, for reasons that are not completely understood. Liang et al. also suggested that severe events were more common in cancer patients with COVID-19, as more patients in this population required invasive treatment measures or died compared with patients without cancer (even [39%] of 18 patients vs 124 [8%] of 1572 patients; Fisher’s exact p=0·0003); the risk was even higher if chemotherapy or surgery were performed in the last month, administered. These findings raise concerns on the ideal care to provide to such patients and whether or not should chemotherapy be continued during the outbreak, or at least stopped or reduced in selected patients at higher risk of infection. Of note, the actual impact of COVID-19 on the outcome of cancer patients in this specific cohort remains to be clearly proven, as the age of this cohort was higher than that of non-cancer patients with COVID-19. Moreover, they were more frequently smokers, and more frequently had polypnea. These considerations advocate for prudence at the time of interpreting the findings of studies which are currently being published on the topic, due to the limited knowledge available and to the relatively low (yet) number of cases described in these publications, which might be underpowered to show clinically relevant findings.

Similar concerns are applicable to patients who are chronically immunodepressed and to those with chronic conditions that might expose them to an increased risk of contracting COVID-19, and with potentially detrimental outcomes.

COVID-19 and usual hospital routine

The effects on COVID-19 on patients with chronic diseases or cancers are more extensive than the risk of contracting the virus for carriers of these conditions. The health system is almost collapsing in several countries, with few available beds in intensive care units. Elective surgery has been stopped in many hospitals, giving priority to cancer patients and to emergency. The personnel is being shortened to the minimum necessary to deliver the basic services, and, while intensive care units and medical wards are saturated, the current appearance of surgical wards is appalling.

Notwithstanding the effort put in treating as many cancer patients as possible, the timeliness of cures is inevitably delayed, and the outcomes of treatment might well be affected in the long-term.  At the same time, screening is not being offered consistently.  A delayed diagnosis is associated with worse outcome in cancer surgery. Sanjeevi et al. showed that potentially curable pancreatic cancers had 0% unresectability rate at surgery when the interval between imaging and resection was shorter than 23 days, highlighting the importance of acting within a window of opportunity to achieve optimal survival results. An analysis of a US National Cancer database with over 60 thousands patients with curable colon cancer, found that overall survival was longer in patients operated on within 16 days from diagnosis compared with those operated on after 37 days or more (5-year survival 75.4 vs 71.9%, 10-year survival 56.6 vs 49.7%, both p<0.001). Moreover, the long-term effects and associated indirect costs of cancer surgery include the assessment of lost work-hours due to sick leave after surgery. Postoperative recovery after colorectal cancer surgery might be slower than thought, and advanced disease further impair return to work, suggesting that delaying diagnosis and surgery impacts the economy further.

Many chronic conditions are likely to be affected by delayed treatment. Patients waiting for transplantation are another facet to consider. Discussions are ongoing globally in order to face these difficult situations, and how to deal with the current status of things still remains to be clarified.

Patients, family, and COVID-19 

During crisis, priorities are being reorganized, meaning that priority is given to patients with more worrisome conditions or those more likely to benefit from a treatment. However, this generates a stressful environment and brings about nonnegligible consequences to individuals’ wellbeing. Surgical patients with conditions that are not being regarded as priority may feel let down by the doctors and the health system, and they need appropriate support to face this new condition, and their families to be cared for, and this will be much more relevant once the current acme of the outbreak has settled. Many societies and patients’ associations have made available for patients’ guidance and suggestions to help them during these difficult times. 

Moreover, family visits to patients who are currently being hospitalized are being strictly controlled, so that the postoperative recovery or the in-hospital stay in general are made even more challenging by an overwhelming sense of loneliness.     

Facing COVID-19: ongoing initiatives, collaboration

Emergencies can bring to light the worst aspects of humanity, but they can also strengthen the spirit of collaboration against a common issue. Even if many have been forced in isolation or quarantined, even if travel is forbidden from and to several countries, social media proved again to be a powerful means to disseminate knowledge, to facilitate discussions, and to establish collaborative initiatives on a global scale.

The response to the fears of doctors and patients on how to deal with COVID-19 and how to act during the outbreak has been immediate, and several scientific societies have provided documents and platforms to be used as guidance. The Spanish Association of Surgeons (Asociación Española de Cirujanos, AEC) released on the 15th March a Position Statement that can be freely accessed on the measures to be taken for patients needing surgery during the pandemic, and a similar initiative has been announced by the Spanish Association of Coloproctology (Asociación Española de Coloproctología, AECP), with specific focus on patients needing surgery for colorectal conditions. These documents are being developed with an innovative format, meaning that they are solidly grounded on available evidence but they are dynamic, open to updating that can occur within hours. 

This is relevant at a time when no agreed policy has been decided to face the COVID-19 pandemic. As of today, not all nations have decided to adopt the same stringent measures acting in Italy and Spain, and likely to be extended to France and other countries. For example, UK has announced a different strategy, relying on the development of an immunity against COVID-19, with no need for restrictive measures. Indeed, this was not agreed by the entire scientific community, and hundreds of UK scientists signed an open letter pressing the Government to enforce social distancing. It is difficult to identify which strategy is the more appropriate, but a common effort towards an agreed strategy is desirable in the following months.

A joint GI Society Message on COVID-19 was released on the 16th March by the American Gastroenterology Association, the American Association for Liver Disease, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy. The document deals with recommendations to provide care, including endoscopy, to patients with gastrointestinal conditions during the pandemic.

The European Crohn’s and Colitis Organisation (ECCO) launched a questionnaire aiming to identify the fears and difficulties that IBD doctors are facing while practising during the COVID-19 pandemic, in order to take actions and provide support. An international, online, secure database has been started to report information on IBD patients diagnosed with COVID-19.

An initiative that rapidly captured the attention of the surgical community globally was the launch of an international prospective registry of patients operated on for whichever condition while positive for COVID-19. The initiative was launched by Aneel Bhangu on the 14th March on Twitter and is open for registration. A draft protocol is available to access and registration can be performed at this link.

These initiatives will hopefully help to clarify the actual impact of COVID-19 on surgical patients, and help to define the ideal pathways and perioperative management of these patients.

Impact on psychical well-being of healthcare professionals: who cares for the carers? 

Last but not least, healthcare professionals are being exposed on the frontline. They are working in extremely difficult conditions, far different from what most of them were trained to work. The intensely stressful conditions in which doctors, surgeons and all healthcare professionals are called to work, is exposing them and their families to unpredictable consequences. 

Not being able to treat everyone, the need to do extra shifts, wearing protective equipment during the entire shifts as well as the lack of protective devices, the fear of getting infected, all contribute to a potential burnout. 

Doctors are choosing to isolate themselves from their relatives, in order to protect them, even if asymptomatic. The fear of being tested positive, apart from the fact that being affected already implies, brings about the necessity of being quarantined, and further reduces the number of available team members. This is further aggravated by the required quarantine for those colleagues who were in contact with the index healthcare professional tested positive.

Indeed, many institutions and entities are providing help to doctors struggling with the current crisis. The Physician Council of Barcelona (Colegio de Medicos de Barcelona, COMB), for example, established a telephone-based service to support doctors who are experiencing psychological stress and difficulties while in isolation, and a similar service was offered to struggling doctors at local hospitals (e.g. Hospital Vall d’Hebron in Barcelona). Similar initiatives are needed, and must not be limited to the emergency only, but should last long after this has been controlled.

Things are changing rapidly with COVID-19. A financial crisis is likely to occur, that will require to be faced jointly when the emergency has been resolved. It is however needed to maintain our focus on what we are doing every day with every single patient, and those of us who are isolated need not to forget that this is part of caring for the others. Doctors, surgeons, nurses, all the healthcare professionals need to feel backed by the institutions and by the people. In Italy and Spain, people under lockdown have started clapping their hands as a tribute to healthcare professionals. During such difficult times, similar spontaneous acts are fuel for our practice and help us to cope with the burden and the negativity that COVID-19 has spread, while scanning the horizon in search of the end of the current crisis.

Gianluca Pellino (@GianlucaPellino) and Antonino Spinelli (@AntoninoSpin) are surgeons from Italy.

Surgical research in Plain English

Randomized controlled trial of plain English and visual abstracts for disseminating surgical research via social media

BJS started with the aim of of being a medium through which surgeons “can make our voice intelligibly heard”, according to Sir Rickman Godlee, President of the Royal College of Surgeons of England in 1913.

The aim of a recently published paper in BJS was to increase the engagement (defined compositely as the total number of replies, retweets, or likes on Twitter) of clinicians and patients in the communication of surgical research – part of the core values of BJS.

Ibrahim et al. showed in the Annals of Surgery that visual abstracts increased engagement on Twitter in their case-control study, but plain English summaries have not previously been studied in the context of surgical research. Plain English summaries are becoming a real priority for funders (e.g. NIHR), as well as for clinical practice (BMJ, AoMRC). Patients are involved in the development of research, and need to have access to it.

This was a three-arm, randomized controlled trial with crossover of two intervention arms. Manuscripts that were eligible for inclusion were randomly allocated to three arms and disseminated via Twitter. The arms were standard tweets, plain English abstracts & visual abstracts.

Visual abstracts are a simplified graphical summary of a study’s scientific abstract. Plain English abstracts were developed according to NIHR INVOLVE ‘make it clear’ guidance and edited to satisfy a minimum readability index.

The primary outcome was online engagement by the public within 14 days of dissemination. The secondary outcome was online engagement by healthcare professionals.

The results can be seen in the visual abstract, with more details available in the paper. Overall: visual abstracts attracted a greater number of total engagements than plain English abstracts, and engagement by members of the public was low across all abstract types.

Note that this study only looked for the potential benefits from the point of view of the journal – not data from the perspective of patients, although a Twitter poll suggested that there was an appetite for informing the public about the findings of research studies.

More work needs to be done in collaboration with the public to understand how and in what format they prefer to engage with surgical research. We need to avoid soundbites of results, and instead provide a balanced & educated interpretation, to help to counter the avalanche of false information to which the public is exposed.