Perioperative COVID-19 Research Articles

Modeling the Impact of Delaying the Diagnosis of Non-Small Cell Lung Cancer During COVID-19

BackgroundThe novel coronavirus (COVID-19) pandemic has led surgical societies to recommend delaying diagnosis and treatment of suspected lung cancer for lesions less than 2 cm. Delaying diagnosis can lead to disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a suspicious lung nodule less than 2 cm.MethodsA decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker with chronic obstructive pulmonary disease presenting for surgical biopsy of a 1.5 to 2 cm lung nodule highly suspicious for cancer during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival.ResultsImmediate surgical resection resulted in a similar but slightly higher 5-year overall survival when compared with delayed resection (0.77 versus 0.74) owing to the risk of disease progression. However, if the probability of acquired COVID-19 infection is greater than 13%, delayed resection is favorable (0.74 vs 0.73).ConclusionsImmediate surgical biopsy of lung nodules suspicious for cancer in hospitals with low COVID-19 prevalence likely results in improved 5-year survival. However, as the risk of perioperative COVID-19 infection increases above 13%, a delayed approach has similar or improved survival. This balance should be frequently reexamined at each health care facility throughout the curve of the pandemic.

Abstract PO-025: Management of breast cancer surgery during de-escalation of COVID-19 infection

Abstract Purpose: Spain has been one of the countries most severely affected by the Covid-19 pandemic, and Madrid has reported the highest number of cases and deaths. A safe management of breast cancer (BC) surgery in the de-escalation is a priority. Patients and Methods: Surgery was considered depending on the epidemic trend. 28 BC surgeries were performed in our BC Unit inside San Carlos Clinical Hospital, from 23rd April-4th June, with a reduction of 25-50-75% surgical resources until availability of complete resources. We created a practical tool based on a "traffic light" system to prioritize surgical time. Every patient was evaluated according to the different stages (comorbidities, tumor biology, and cancer treatments): Red = Surgical procedures in maximum two weeks; Amber = Surgical procedures in maximum four weeks; Green = Surgical procedures in more than four weeks. All benign, cosmetic, and risk-reducing procedures was deferred, and microsurgeries were not performed because high levels of resources are needed. Every patient was checked by a telephone call with our hospital preoperative COVID-19 protocol. All patients were screened for symptoms and PCR test prior to surgery. Results: Minimal surgical procedures (including patient preferences) were performed, avoiding surgical complications and reducing hospital stay to minimize the risk of occupational exposure. 2 asymptomatic patients who underwent chemotherapy were delayed by positive COVID-19 test and were referred for further evaluation. Surgical procedures were performed in 28 patients with a negative COVID-19 PCR test. 4/18 conservative surgeries required minimal use of oncoplastic procedures and in 3/10 mastectomies, an immediate breast reconstruction with an implant were considered. The surgery was more minor than planned in 3 patients, and due to the reduced risk surgery was deferred. 20 surgical procedures were performed in patients who received neoadjuvant chemotherapy and in 4 patients with endocrine therapy and with low 21 gene recurrence score (RS) (<25). Sentinel lymph node biopsy was performed in 14 patients with clinically node-negative BC, and axillary lymph node dissection was necessary in 10 patients who underwent neoadjuvant chemotherapy. We also performed this surgical treatment in 6 patients with in situ ductal carcinoma along usual production was establishment. After the surgery, the patients were hospitalized in COVID-19-free areas, and no perioperative complications or COVID-19 infection were reported. Conclusions: In the de-escalation period, an expert committee evaluation case by case must be performed for surgical procedures. Treatment decision-making should balance risk and benefits of the surgical treatment, and a “traffic light” scale could be a useful tool for the medical team. A preoperative COVID-19 protocol is necessary for a safe surgical procedure. Citation Format: Juana María Brenes Sánchez, Amanda López Picado, María Eugenia Olivares Crespo, José Ángel García Sáenz, Rosa María De La Plata Merlo, María Herrera De La Muela. Management of breast cancer surgery during de-escalation of COVID-19 infection [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-025.

30-day mortality for fractured neck of femur patients with concurrent COVID-19 infection.

IntroductionRisk factors for mortality associated with COVID-19 have been reported to include increased age, male sex and certain comorbidities. Fracture neck of femur (NOF) patients is high-risk surgical patients, often with multiple comorbidities and advanced age. We quantify the 30-day mortality rate in fractured NOF patients with a positive peri-operative COVID-19 antigen test and identify risk factors for increased mortality.MethodsThis is a retrospective multi-centre review of all patients admitted with a fractured NOF and a confirmed laboratory diagnosis of COVID-19 between 1 March and 26 April 2020. Demographic data, comorbidities, ASA grade and date of death (if applicable) were collected.ResultsThere were 64 patients in the cohort with an overall 30-day mortality rate of 32.8% (n = 21). Thirty-five (55%) were female, and mean age was 83 (SD 9, range 46–100) years. There was significantly increased mortality for those with a history of myocardial infarction (p = 0.03). Sixty-four percent of patients underwent surgery within the 36-h target, which is comparable to previous data for the same time of year. Overall mortality increased to 50% (n = 32) at 45 days post-operatively.ConclusionThis is a large review of 30-day mortality in NOF patients with concurrent COVID-19 infection. We report a substantial increase from the pre-COVID-19 mean 30-day mortality rate (6.5% in 2019). We highlight the need for counselling patients when presenting with a NOF in relation to peri-operative COVID-19 infection and the associated increased risks.

The impact of COVID-19 on trauma and orthopaedic patients requiring surgery during the peak of the pandemic: a retrospective cohort study.

AimsCOVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department.MethodsWe retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19.ResultsA total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019.ConclusionBased on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient.Cite this article: Bone Joint Open 2020;1-9:520–529.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Perioperative COVID-19 testing for orthopaedic patients: Current evidence

The recent COVID-19 pandemic has brought the whole world to a standstill, especially affecting the healthcare systems around the globe, with a heavy toll not just on the patients but the healthcare workers as well. The worldwide number of reported cases has crossed 4 million with a further anticipated increase in the contagion.1

Retrospective Diagnosis of COVID-19 in an Asymptomatic Patient Undergoing Emergency Surgery

Background: With reports of higher mortality and complications occurring in patients with perioperative 2019 novel coronarvirus disease (COVID-19), most elective surgeries have been postponed. However, evidence regarding emergency surgeries in patients with COVID-19 remains scarce. We report the case of a patient with asymptomatic perioperative COVID-19, presenting with an acute abdomen requiring surgery. Case: A 25-year-old male, with a prior nasopharyngeal swab that was negative for SARS-CoV-2, presented with classical signs and symptoms of acute appendicitis. Clinical examination and investigations were not suggestive of COVID-19 infection. He underwent laparoscopic appendicectomy with infection control precautions. Post-operatively, he was found to be positive for SARS-CoV-2 but remained asymptomatic and had an uneventful recovery. Conclusion: In asymptomatic individuals with higher risks, negative test results should be viewed cautiously. The benefits of urgent surgical interventions must be weighed against the risks of complications due to perioperative COVID-19 in these patients.