Elective Surgical Activity Research Articles

Tackling a Post-COVID-19 Cholecystectomy Waiting List: Are We Meeting the Challenge?

Background and Objectives: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity. Our hospital trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Materials and Methods: A prospective observational study was undertaken, investigating patients who received a cholecystectomy at a large United Kingdom hospital trust between February 2021 and February 2022. There were multiple phased strategies to tackle a 533-patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. The correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Results: A total of 657 patients underwent a cholecystectomy. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. A total of 30 (4.6%) patients were listed due to gallstone pancreatitis, 380 (57.8%) for symptomatic cholelithiasis, and 228 (34.7%) for calculous cholecystitis. Median waiting times were reduced from 428 days (IQR 373-508) to 49 days (IQR 34-96), R2 = 0.654, p < 0.001. For pancreatitis specifically, waiting times had decreased from a median of 218 days (IQR 139-239) to 28 (IQR 24-40), R2 = 0.613, p < 0.001. Conclusions: This study demonstrates the methodology utilised to safely and effectively tackle the cholecystectomy waiting list locally. The approach utilised here has potential to be adapted to other units or similar operation types in order to reduce elective waiting times.

503 Post-Pandemic Elective Surgical Activity: A Focus on Day-Case Laparoscopic Cholecystectomies Across England

Abstract Aim To investigate the association between post-pandemic activity levels and day-case rates for laparoscopic cholecystectomies in England. Method We examined data from HES (Hospital Episode Statistics) on adult elective laparoscopic cholecystectomies for the period January 2019 to September 2022 (inclusive). Activity levels in the first six months of 2022 were compared to activity levels for the whole of 2019 (the baseline). Day-case activity was identified where the length of stay record in HES was zero days. Data were summarised at an Integrated Care Board (ICB) level for analysis. Results Data were available for 168,811 patients across the 42 ICBs in England. By April–September 2022, activity levels had returned to 89% of pre-pandemic levels for the whole of England. The South West Region stood out as having recovered activity levels to the greatest extent, with activity at 102% of pre-pandemic levels by April–September 2022. The South West also had the highest post-pandemic day-case rate at 75% of all patients seen as day-cases during April–September 2022; this compares to an England average of 66%. All other regions had day case rates between 62 and 68%. At an ICB level, there was a significant correlation between day-case rates and post-pandemic activity levels (r = 0.327, p &amp;lt; 0.035). Conclusions Recovery of elective laparoscopic cholecystectomy activity has been better in South West England than in other regions. Day case rates may be important if ICBs in other regions are to increase activity levels.

OGBN P19 Tackling a post-COVID-19 cholecystectomy waiting list, are we meeting the challenge?

Abstract Background The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity, with over six million people on waiting lists and only 64% of patients meeting the 18-week elective standard. Our Hospital Trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Methods A prospective observational study was undertaken investigating patients who received a cholecystectomy at large UK hospital Trust, between February 2021 and February 2022. There were multiple phased strategies to tackle a 533 patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. An additional 364 patients were added and 145 removed, for multiple reasons, from the list during the study period. Correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Results 657 patients underwent a procedure, of which 628 (95.6%) were completed electively. The median age was 49 years, 602 (91.6%) patients had an ASA of 1–2, and 494 (75.2%) were female. Thirty (4.6%) patients were listed post gallstone pancreatitis, 380 (57.8%) for cholelithiasis, and 228 (34.7%) for cholecystitis. The median length of stay was zero days (IQR 0–1), with 30-day complication (C-D ≥3, 1.8%), readmission (3.0%) and mortality (0.0%) rates noted. The current waiting list includes 95 patients, with median waiting times reduced from 428 days (IQR 373–508) to 49 (IQR 34–96), R2=0.654, p&amp;lt;0.001. For pancreatitis specifically, waiting times have dropped from a median of 218 days (IQR 139–239) to 28 (IQR 24–40), R2=0.613, p&amp;lt;0.001. Conclusions We have safely and effectively tackled the cholecystectomy waiting list locally utilising a number of phased strategies. Significant progress is being made towards once again meeting the gold-standard target for gallstone pancreatitis patients. The approach utilised here has potential to be adapted to other units, or other operation types in order to reduce elective waiting times.We have safely and effectively tackled the cholecystectomy waiting list locally utilising a number of phased strategies. Significant progress is being made towards once again meeting the gold-standard target for gallstone pancreatitis patients. The approach utilised here has potential to be adapted to other units, or other operation types in order to reduce elective waiting times.

Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals.

BackgroundRed blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions.MethodsWe retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models.ResultsDuring the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered.ConclusionInappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.

TU6.1 Tackling the training deficit due to COVID-19 disruptions

Abstract Aim Surgical training has been severely affected by stop, start and stop of elective surgical activity during the COVID pandemic. The aim of this study was to analyze the effectiveness of strategies put in place to tackle them. Methodology We looked at the four UK Statutory Education Bodies (SEBs) published guidance and trainee led resources to see what measures were put in place to mitigate the severe disruptions in surgical training due to COVID-19 pandemic. Results Across the world, training programmes have been affected and craft specialities have fared the worst. Lesser operative experience and redeployment to non-surgical critical areas being the top 2 causes. A Post Graduate Medical Education (PGME) Recovery Programme was established in April 2021 to reset, recover and reform PGME with one to one trainee recovery discussions. Simulations and virtual CME sessions are being put in place to help mitigate the deficiencies in the current training programmes. These measure may be suitable for Medical specialities, but Surgical specialities need hands on training on human cadavers in lieu to catch up and prevent extension of period of training. Conclusion The COVID 19 pandemic has not only affected the physical and mental well-being of trainees but has also restricted training opportunities, professional development and severely dented trainee confidence. The plans put in place are not good enough for surgical trainees who need hands on experience. Increased didactic teaching around cadaveric training programs is the quickest way of overcoming this deficit.

Efficacy and safety of emergency ureteroscopy as first-line treatment for patients with renal obstruction due to ureteral stones in the COVID-19 pandemic

Introduction and objective: Acute renal colic due to ureteral calculi is a common urological emergency that can be managed conservatively, by providing renal drainage and medical management of the pain syndrome followed by planned treatment, or by emergency surgery. With the onset of the COVID-19 pandemic leading to the temporary suspension of elective surgical activity, emergency ureteroscopy has become a valuable modality for the treatment of acute renal obstruction. The objective of this study is to evaluate the efficacy and safety of emergency ureteroscopy as first-line treatment for patients with acute renal obstruction due to ureteral stones during the COVID-19 pandemic. Material and methods: A prospectively collected database of 120 patients with acute renal obstruction due to ureteral stone who underwent emergency ureteroscopy within 24 hours from hospitalization between March 2020 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates and complication rates was analyzed. Results: Patients’ mean age was 51.4±15.2 years. Male-to-female ratio was 73.3%/26.7%. Mean preoperative serum creatinine values were 120.1±64.1 umol/l. 33 patients (2.5%) had a solitary functioning kidney. Stone location was proximal ureter in 3 patients (27.5%), mid-ureter – in 12 (10%), distal ureter – in 73 (60.8%), distal and proximal ureter – in 2 cases (1.6%). Mean stone size was 8.1±3.3 mm. Stone-free rate after a single procedure was 95% and mean operative time – 25.1±11.5 min. Postoperative drainage was stent JJ in 34 (28.3%) and ureteral catheter for 12h – in 22 (18.3%) patients. 21 patients (17.5%) had a narrow ureter, necessitating the use of smaller caliber ureteroscope (6 Fr). In 2 patients (1.7%) the ureter could not be accessed and a stent JJ was inserted. Intraoperative complications were present in 5 cases – 1 ureteral perforation (0.8%) and 4 cases of upward stone migration (3.3%). Postoperative complications were fever in 2 patients (1.7%) and postoperative renal colic pain - in 7 (5.8%). Conclusions: The results of this prospective study suggest that emergency ureteroscopy is a safe and effective first-line treatment for acute renal obstruction due to ureteral stones. It offers a one-stage management, without the potential complications of obstruction and loss of renal function due to delayed treatment during the COVID-19 pandemic. Key words: Ureterorenoscopy, Ureteral obstruction, Ureteral stone, Covid-19

Perioperative and oncologic outcomes of interval colectomy performed by acute care surgeons after stenting as a bridge to surgery for left-sided malignant colonic obstruction are non-inferior to the outcomes of colorectal surgeons in the elective setting: single center experience.

To analyze if perioperative and oncologic outcomes with stenting as a bridge to surgery (SEMS-BS) and interval colectomyperformed by acute care surgeons for left-sided occlusive colonic neoplasms (LSCON) are non-inferior to those obtained by colorectal surgeons for non-occlusive tumors of the same location in the full-elective context. From January 2011 to January 2021, patients with LSCON at University Regional Hospital in Málaga (Spain) were directed to a SEMS-BS strategy with an interval colectomy performed by acute care surgeons and included in the study group (SEMS-BS). The control group was formed with patients from the Colorectal Division elective surgical activity dataset, matching by ASA, stage, location and year of surgery on a ratio 1:2. Stages IV or palliative stenting were excluded. Software SPSS 23.0 was used to analyze perioperative and oncologic (defined by overall -OS- and disease free -DFS-survival) outcomes. SEMS-BS and control group included 56 and 98 patients, respectively. In SEMS-BS group, rates of technical/clinical failure and perforation were 5.35% (3/56), 3.57% (2/56) and 3.57% (2/56). Surgery was performed with a median interval time of 11days (9-16). No differences between groups were observed in perioperative outcomes (laparoscopic approach, primary anastomosis rate, morbidity or mortality). As well, no statistically significant differences were observed in OS and DFS between groups, both compared globally (OS:p < 0.94; DFS:p < 0.67, respectively) or by stages I-II (OS:p < 0.78; DFS:p < 0.17) and III (OS:p < 0.86; DFS:p < 0.70). Perioperative and oncologic outcomes of a strategy with SEMS-BS for LSCON are non-inferior to those obtained in the elective setting for non-occlusive neoplasms in the same location. Technical and oncologic safety of interval colectomy performed on a semi-scheduled situation by acute care surgeons is absolutely warranted.

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study).

BackgroundThis study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic.MethodsCHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality.ResultsThis study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121).ConclusionCHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic.

How the First Year of COVID-19 Affected Elective Pediatric Urology Patients: A Longitudinal Study Based on Waiting Lists and Surveys From 10 European Centers.

IntroductionCOVID-19 impacted healthcare systems worldwide, and elective surgical activity was brought to a minimum. Although children were not primarily affected by the disease, pediatric urology was halted by clinical closedown and staff allocation. We aimed to document how these prioritizations affected waiting lists, and to investigate how European centers dealt with the challenge of these logistical and financial prioritizations.Materials and MethodsThis was a 1-year prospective study, starting March 2020. Participants were surveyed at 3-month intervals about waiting lists for several common procedures as well as OR capacity and funding. Further, centers retrospectively reported on surgical and outpatient activity rates during 2019–2021. Waiting list tendencies were evaluated in relation to study baseline.ResultsA marked decrease in surgical and outpatient activity was seen in the spring of 2020. Some included pediatric urology centers were able to increase their budget (15%) and staff working hours (20%) during part of the study period. Still, at the end of the study, the centers had increased the total number of patients on waiting lists with 11%, whereas the average days on waiting lists had accumulated with 73%, yielding a total of 6,102 accumulated waiting days in the study population. Centers with decreased resources had markedly negative effects on waiting lists.ConclusionsCorrelations between COVID-19 derived burdening of healthcare systems and the availability of pediatric urology greatly depends on the prioritizations made at individual centers. Ongoing monitoring of these correlations is warranted to safely avoid unnecessary negative impact on the pediatric population.

EP.WE.82Positive impact of COVID-19 pandemic on future of Surgery in the NHS

AimTo assess how surgical units innovated and adapted to meet the Lockdown challenges and highlight best practice developmentMethodsLook at the Royal Surgical Colleges and national surgical society Guidelines during the pandemic and recovery phase of the Lockdowns. To assess how to local trust level modifications made in the first lockdown were reinforced during the second lockdown.ResultsDuring the first lockdown all elective surgical activity was suspended from 14th March. Day case urgent elective work restarted after 6 weeks, during this period only life and limb saving emergencies were performed on CEPOD theatres. Full PPE, aerosol generating precautions and thorough cleaning between cases ensured that no healthcare worker developed COVID-19 from occupational exposure in Theatres. Remote access from home has been a boon. The outpatients rapidly moved to online appointments. No routine follow up scans were done. Endovascular interventions increased. The telephonic clinics have reduced footfall, allowed routine follow-ups to be permanently put on telephonic clinics and patients too seem to be satisfied that they do not have to waste a day for a 10 minute appointment to come and be told that we will see you again in 12months time. Non-essential surgery has stopped,ConclusionPandemic has been a time for surgeons to reflect on their practice. Instead of going back to old ways-outpatient clinics, day surgery units and main theatres have seen rapid adaptation of newer ideas. Pandemic has fast forwarded innovation in the NHS.

755 Elective Surgery in the COVID-19 Pandemic: Outcomes of 100 Consecutive Cases

IntroductionThe COVID-19 pandemic halted elective surgical activity. Basildon University Hospital established an elective Green Zone for COVID-19 swab negative patients who isolated for 14 days. This study reviewed the outcomes of the first 100 patients.MethodA single-centre study was performed. Demographic and perioperative electronic data were supplemented with telephone follow-up for the first 100 Green Zone patients and analysed in Microsoft Excel.ResultsOne hundred Green Zone patients underwent surgery between 21/05/2020 and 16/06/2020. The median age was 55 (14-88) years. 52% were female. Their operations were performed by General Surgery (39%), Gynaecology (17%), Vascular Surgery (14%), Oral Surgery (12%), ENT (9%), Urology (8%), and Pain Management (1%).Preoperatively, 100% had a negative SARS-CoV-2 swab and one had CT evidence of mild resolving COVID-19. Two patients had postoperative SARS-CoV-2 swabs, both negative. Median length of stay was 0 (0-7) days. 84% responded to telephone follow-up at a median 25 (13-54) postoperative days, 69% of whom were asymptomatic There were no 30-day major complications (>Clavien-Dindo IIIa) or 90-day mortality.ConclusionsElective surgery can be safe during the COVID-19 pandemic, with appropriate measures in place. This has significant implications in the context of an ever-expanding NHS waiting list during a pandemic of uncertain duration.

How to Resume Elective Orthopaedic Surgical Procedures during the COVID-19 Pandemic?

This document was prepared by the College of Orthopedics of the Portuguese Medical Association with the aim of developing the guidelines on the resumption of elective surgical activity in Orthopedics during the COVID-19 pandemic. It sets the criteria that allow the prioritization of surgeries according to the severity of the clinical situation, based on existing and published classifications. Moreover, it provides an organizational model for patient preparation and describes the patient pathways in the preoperative, intraoperative and postoperative periods. It also describes safety rules for elective surgery and a model for monitoring patients after discharge according to scientific evidence.

Changes in the activity levels and financing sources of Israel\u2019s private for-profit hospitals in the wake of reforms to the public-private divide

BackgroundThe Israeli National Health Insurance Law provides permanent residents with a basket of healthcare services through non-profit public health insurance plans, independently of the individual’s ability to pay. Since 2015, several reforms and programs have been initiated that were aimed at reinforcing public healthcare and redressing negative aspects of the health system, and specifically the constant rise in private health expenditure. These include the “From Reimbursement-to-Networks Arrangement”, the “Cooling-off Period” program and the program to shorten waiting times. The objectives of this study were to identify, describe, and analyze changes in private hospitals in 1) the volume of publicly and privately funded elective surgical procedures; and 2) private health expenditure on surgical procedures.MethodsData on the volume and funding of surgical procedures during 2013–2018 were obtained from Assuta Medical Center, Hertzelia Medical Center, the Israeli Ministry of Health and the Central Bureau of Statistics. The changes in the volume and financing sources of surgical activities in private hospitals, in the wake of the reforms were analyzed using aggregate descriptive statistics.ResultsBetween 2013 and 2018 the volume of surgical activities in private for-profit hospitals increased by 7%. Between 2013 and 2017, the distribution of financing sources of surgical procedures in private hospitals remained stable, with most surgical procedures (75–77%) financed by the voluntary health insurance programs of the health plans (HP-VHI). In 2018, following the regulatory reforms, a significant change in the distribution of financing sources was observed: there was a sharp decline in the volume of HP-VHI-funded surgical procedures to 26%.Concurrently, the share of publicly-funded surgical procedures performed in private hospitals increased to 56% in 2018.,. During the study period, private spending on elective surgical procedures in private hospitals declined by 53% while public funding for them increased by 51%.Conclusions and policy implicationsIn the wake of the reforms, there was a substantial shift from private to public financing of elective surgical activity in private hospitals.Private for-profit hospitals have become important providers of publicly-funded procedures. It is likely that the reforms affected the public-private mix in the financing of elective surgical procedures in those hospitals, but due to the absence of a control group, causality cannot be proven. It is also unclear whether waiting times were shortened. Health reforms must be accompanied by a clear and comprehensive set of indicators for measuring their success.

Changes in surgicaL behaviOrs dUring the CoviD-19 pandemic. The SICE CLOUD19 Study

BackgroundThe spread of the SARS-CoV2 virus, which causes COVID-19 disease, profoundly impacted the surgical community. Recommendations have been published to manage patients needing surgery during the COVID-19 pandemic. This survey, under the aegis of the Italian Society of Endoscopic Surgery, aims to analyze how Italian surgeons have changed their practice during the pandemic.MethodsThe authors designed an online survey that was circulated for completion to the Italian departments of general surgery registered in the Italian Ministry of Health database in December 2020. Questions were divided into three sections: hospital organization, screening policies, and safety profile of the surgical operation. The investigation periods were divided into the Italian pandemic phases I (March–May 2020), II (June–September 2020), and III (October–December 2020).ResultsOf 447 invited departments, 226 answered the survey. Most hospitals were treating both COVID-19-positive and -negative patients. The reduction in effective beds dedicated to surgical activity was significant, affecting 59% of the responding units. 12.4% of the respondents in phase I, 2.6% in phase II, and 7.7% in phase III reported that their surgical unit had been closed. 51.4%, 23.5%, and 47.8% of the respondents had at least one colleague reassigned to non-surgical COVID-19 activities during the three phases. There has been a reduction in elective (> 200 procedures: 2.1%, 20.6% and 9.9% in the three phases, respectively) and emergency (< 20 procedures: 43.3%, 27.1%, 36.5% in the three phases, respectively) surgical activity. The use of laparoscopy also had a setback in phase I (25.8% performed less than 20% of elective procedures through laparoscopy). 60.6% of the respondents used a smoke evacuation device during laparoscopy in phase I, 61.6% in phase II, and 64.2% in phase III. Almost all responders (82.8% vs. 93.2% vs. 92.7%) in each analyzed period did not modify or reduce the use of high-energy devices.ConclusionThis survey offers three faithful snapshots of how the surgical community has reacted to the COVID-19 pandemic during its three phases. The significant reduction in surgical activity indicates that better health policies and more evidence-based guidelines are needed to make up for lost time and surgery not performed during the pandemic.

Gestión de la actividad quirúrgica electiva de un hospital terciario durante la pandemia por SARS-CoV-2

IntroductionDuring the SARS-CoV-2 pandemic, elective surgical activity was reduced to a minimum. As both the number of cases and the hospitalization needs for this pathology decreased, we thought it appropriate to progressively recover scheduled surgical activity. This work describes how, even with the current alarm state, we were able to practically normalize this activity in a few weeks. MethodsTwo weeks before the intervention, the patients included in the waiting lists were contacted by telephone. After checking their health status and expressing their desire to undergo surgery, they were provided with recommendations to decrease the risk of coronavirus infection. Likewise, an exclusive circuit was established to carry out, 48 hours before the intervention, the detection of SARS-CoV-2 by means of exudates nasopharyngeal PCR. The results were evaluated by each surgical service and the anesthesiology service. In addition, asymptomatic Surgical Area professionals could undergo weekly screening for the early detection of coronavirus according to the recommendations of Occupational Health. ResultsIn the midst of a pandemic, scheduled surgical activity was reduced by 85%. From the week of April 13, the operating rooms available were recovered, which allowed practically all surgical activity to be recovered the week of May 25. ConclusionsThe creation of circuits and procedures to streamline surgical activity, still in full force of the state of alarm, has allowed us, in a few weeks, to recover almost all of it.

Recommendations for acting in elective and urgent thoracic surgery during SARS-CoV-2 pandemic. Spanish Society of Thoracic Surgery

Expansion of the pandemic produced by new coronavirus SATS-CoV-2 has made healthcare focused on patients with COVID-19 disease, leading to discontinue most of elective surgical procedures. Being thoracic surgery eminently oncological, an optimal triage of patients amenable to be safely operated on is mandatory. Moreover, severe pulmonary involvement by COVID-19 causes complications frequently needing urgent thoracic surgical procedures under a new context. The Spanish Society of Thoracic Surgery (SECT) has developed this document to establish basic recommendations to keep up essential elective surgical activity and to guide surgeons facing thoracic urgencies in this new and unknown environment.

In-hospital 3D Printing to Aid Maxillofacial Surgery during the COVID-19 Pandemic.

Surgeons around the world share the same goal: providing the best care to their patients. In recent years, the complexity of procedures has increased, and so has the need for enhanced planning, training, and education. A growing number of interventionists and surgeons are using 3D-printed patient-specific models in their practice to prepare for procedures with more confidence. In 2018 we considered to implement 3D printing in our hospital, and we have created a virtual planning and 3D printing LAB within the maxillofacial surgery department at Città della Salute e della Scienza Hospital, University of Torino, Italy. (See Video [online], which displays the planning, printing and intraoperative cutting guides.) The laboratory is equipped with a CAD station and two 3D printers (Ultimaker 3 Extended and Formlabs Form 3). {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"Video 1 from “In-Hospital 3d Printing in Maxillofacial Surgery during the Covid-19 Pandemic”","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_wgikhelf"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Protective visor 3D model to print.3D-printing and advanced visualization techniques have been proved to assist clinicians develop tailored surgical approaches for patients. Hospitals, clinicians, and patients can all benefit from 3D printing regardless of whether the process is handled in-hospital or outsourced. Nevertheless, having a dedicated facility in-house can cut days off the process, support innovation initiatives, and lower the overall costs incurred by the hospital. From the beginning of 2019 until the period before the start of the COVID-19 pandemic, the laboratory within the department worked at full capacity for the virtual planning of selected cases and for the printing of models. According to Jacobs and Lin,1 3D-printing technologies in cranio-maxillofacial surgery were divided into 4 categories: Type 1 contour models, Type 2 guides, Type 3 splints, and Type 4 implants. In the period between January 2019 and the start of the pandemic, we printed a total of 331 models. In 79 cases, only type 1 models were printed; in 68 cases, type 1 models were printed together with type 2 and 3 models.2 At the start of the lockdown, elective surgical activity was drastically reduced, as well as hospital resources. Surgical activity was therefore limited only to handling trauma and tumors. However, the activity of the 3D laboratory has not suffered a limitation: in addition to the planning and realization of the surgical models, the production of protective visors has been started to support the surgical departments of the entire hospital (Fig. 1). During the period of the lockdown, 650 pieces of personal protective equipment were produced in our 3D laboratory at the Division of Maxillofacial Surgery. The creation of an in-hospital 3D lab has been shown to be an effective tool both for routine surgery and during the pandemic. The ability to customize devices and surgeries proved to be a possibility for the immediate production of emergency devices within the department.

Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study.

Maintaining safe elective surgical activity during the global coronavirus disease 2019 (COVID-19) pandemic is challenging and it is not clear how COVID-19 may impact peri-operative morbidity and mortality in this population. Therefore, adaptations to normal care pathways are required. Here, we establish if implementation of a bespoke peri-operative care bundle for urgent elective surgery during a pandemic surge period can deliver a low COVID-19-associated complication profile. We present a single-centre retrospective cohort study from a tertiary care hospital of patients planned for urgent elective surgery during the initial COVID-19 surge in the UK between 29 March and 12 June 2020. Patients asymptomatic for COVID-19 were screened by oronasal swab and chest imaging (chest X-ray or computed tomography if aged≥18years), proceeding to surgery if negative. COVID-19 positive patients at screening were delayed. Postoperatively, patients transitioning to COVID-19 positive status by reverse transcriptase polymerase chain reaction testing were identified by an in-house tracking system and monitored for complications and death within 30days of surgery. Out of 557 patients referred for surgery (230 (41.3%) women; median (IQR [range]) age 61 (48-72 [1-89])), 535 patients (96%) had COVID-19 screening, of which 13 were positive (2.4%, 95%CI 1.4-4.1%). Out of 512 patients subsequently undergoing surgery, 7 (1.4%) developed COVID-19 positive status (1.4%, 95%CI 0.7-2.8%) with one COVID-19-related death (0.2%, 95%CI 0.0-1.1%) within 30days. Out of these seven patients, four developed pneumonia, of which two required invasive ventilation including one patient with acute respiratory distress syndrome. Low rates of COVID-19 infection and mortality in the elective surgical population can be achieved within a targeted care bundle. This should provide reassurance that elective surgery can continue, where possible, despite high community rates of COVID-19.

Guidelines for Resuming Elective Hip and Knee Surgical Activity Following the COVID-19 Pandemic: An Italian Perspective.

Guidelines for Resuming Elective Hip and Knee Surgical Activity Following the COVID-19 Pandemic: An Italian Perspective.

Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic.

We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.