Tag Archives: Global surgery

Healthcare workers wearing PPE and surgical gown, Creative Commons image

Guest post: COVID Secure Surgery

Authors:
Aneel Bhangu (@aneelbhangu), University Hospital Birmingham, UK, a.a.bhangu@bham.ac.uk

Dhruv Ghosh, CMC Ludhiana, India 

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.

References:

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

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.

BJSOpen April 2020 issue published.

BJSOpen is a fully-online and open access journal & is proud to publish high-quality surgical research. This month, papers span surgical oncology, methdology, benign disease, and global surgery. The full table of contents is here.

We would also like to draw your attention to the EHS/AHS guidelines on primary hernias in rare locations or special circumstances.

images from this months BJS open
Some of the key images from this months papers

Methodology

Anyone submitting papers to a journal will be familiar with the role of checklists. These are intended to improve the quality of reporting of publications. This review has assessed how well benefits and harms of treatments are reported in surgical trials. It shows that the surgical community needs to do better; outcomes were poorly described, or presented in a manner where it was not possible to interpret effect sizes with any degree of precision.

Randomised trials

Whilst breast cancer surgery aims to conserve breast tissue, mastectomy is still an important tool for the breast surgeon. One of the problems seen here is with bleeding from this typically vascular area. This Norwegian trial randomised 208 patients to either topical tranexamic acid or topical saline to wound edges for haemostasis. There was reduced drain output in the TXA group. There was also a non-significant (but interesting) reduction in the rate of haematomas. 

The pilonidal sinus is a sadly unloved condition. This is despite being a constant presence for the colorectal surgeon. This RCT compared alginate vs DACC (hydrophobic-type) dressings in wound healing after excision of pilonidal sinus. There was no difference in wound healing at 75 days on the per-protocol analysis. The trial needed 222 patients to complete to reach power calculations and managed to retain 200 patients. There might be other things to learn about trial management. This population is quite young and may pose problems with recruiting to trials

Surgical oncology

Other surgical oncology papers this month include a review of outcomes of immediate and delayed autologous breast reconstruction in post-mastectomy radiotherapy. This is a well conducted review and highlights the issues with the literature. On a related note, this patient survey on immediate breast reconstruction is interesting. It looks at some of the important socioeconomic factors that drive patient decision making around this treatment.

For the HPB surgeons, a cohort study shows the outcomes of resection for HCC with tumour thrombus extending into the IVC. In practice, this is a small group with advanced disease and this is shown by a 20 year case series. And not forgetting the oesophagogastric surgeons, we have a retrospective cohort study comparing laparoscopic proximal gastrectomy with double‐flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer. This study was intended to assess the impact on nutrition between these two approaches. No difference in these outcomes were seen.

Advanced cancer

This is a growing field, and this growth is reflected in the many submissions we receive on this topic.Two of the big questions are on the prediction of development of peritoneal disease, and the role of chemotherapy dosing in HIPEC.

A large cohort study from the Danish Colorectal Database has tried to answer the first of these questions. Rates of metastatic peritoneal disease were low, but factors such as advanced tumour or node stage were associated with early presentations, whereas R1 resection was associated with recurrence at 3 years.

The second question was addressed by the PRODIGE 7 trial, which suggested cytoreductive surgery was key in treatment of peritoneal disease. This is reflected in a cohort study of ‘real world’ experience from the Netherlands. This has compared intraperitoneal chemotherapy outcomes based on agents used and adjusted for body surface area. It doesn’t seem to disagree with PRODIGE 7… 

On a related note, the introduction of new technology demands robust assessment. For surgeons this typically follows the IDEAL framework. This review has looked at reports on the development of Pressurized intraperitoneal aerosol chemotherapy (PIPAC), which is based on laparoscopy to deliver intraperitoneal chemotherapy for peritoneal metastases. We now know that we are following the rules with this technology. However, progress is slow and we need bigger definitive studies to understand efficacy.

Global surgery

There are two papers on global surgery this month. One highlights the challenges related to deployment of electrosurgical and laparoscopic kit in LMICS. This shows that equipment is available, but surgeons still had problems using or maintaining it. The second paper shows that traumatic brain injury is common in Uganda, with a male preponderance. The mortality rate in this group is 33%. The authors suggest this may be influenced by limited access to CT and ICP monitoring.

Summary

These are just some of the papers published in this issue of BJSOpen. We welcome direct submissions to the journal. If you think your work would fit in here, please have a look at the instructions for authors page.