Surgical Case Volume Research Articles

Hospital case-volume and mortality after lung cancer surgery: A population-based retrospective cohort study

ObjectivesRecent advances in lung cancer treatment warrants reassessment of the volume-outcome association in lung cancer surgery. This study reassessed the relationship between surgical case-volume and both in-hospital and long-term mortality after lung cancer surgery using a current database to reflect recent advances. Materials and methodsUsing the database of the National Health Insurance Service in Korea, data of all adult patients who underwent lung cancer surgery in Korea between 2005 and 2019 were obtained. Hospitals were categorized by the annual number of lung cancer surgeries. Risk-adjusted in-hospital and 1, 3, 5-year mortality after surgery were assessed. ResultsA total of 84,194 lung cancer surgeries were performed in 163 centers during the study period. High-volume centers were defined as > 200 cases/year, medium-volume centers as 60–200 cases/year, and low-volume centers as < 60 cases/year. After adjustment, in-hospital mortality was significantly lower in high-volume centers (1.03%) compared to medium-volume centers (2.06%, adjusted odds ratio [OR], 1.43; 95% confidence interval [CI], 1.23–1.65; P < 0.001), and low-volume centers (3.08%, OR, 1.32; 95% CI, 1.16–1.51; P < 0.001). Long-term mortality was also significantly lower in high-volume centers compared to the other groups. ConclusionHigh-volume centers showed lower in-hospital and long-term mortality compared to centers with less case-volume.

The Impact of the COVID-19 Pandemic on Hepatobiliary and Pancreatic Surgical Services in Singapore: Retrospective Quantitative Study.

BackgroundAt the height of the COVID-19 pandemic, the hepatopancreatobiliary (HPB) unit had to reorganize its surgical case volume due to the rationing of health care resources. We report on a local audit evaluating the impact of COVID-19 on the HPB unit and the HPB surgical oncology practice.ObjectiveThe aim of this study was to review the impact of the COVID-19 pandemic on the HPB unit’s elective and emergency surgical cases. The secondary aims were to investigate the impact on the HPB surgical oncology operative case volume.MethodsWe performed a comparative audit of the HPB unit surgical case volume for January-June 2019 (baseline) and 2020 (COVID-19). Elective and emergency cases performed under general anesthesia were audited. Elective cases included hernia and gallbladder operations and liver and pancreatic resections. Emergency cases included cholecystectomies and laparotomies performed for general surgical indications. We excluded endoscopies and procedures done under local anesthesia. The retrospective data collected during the 2 time periods were compared. This study was registered in the Chinese Clinical Trial Registry (ChiCTR2000040265).ResultsThe elective surgical case volume decreased by 41.8% (351 cases in 2019 compared to 204 cases in 2020) during the COVID-19 pandemic. The number of hernia operations decreased by 63.9% (155 in 2019 compared to 56 in 2020; P<.001) and cholecystectomies decreased by 40.1% (157 in 2019 compared to 94 in 2020; P=.83). The liver and pancreatic resection volume increased by 16.7% (30 cases in 2019 compared to 35 cases in 2020; P=.004) and 111.1% (9 cases in 2019 compared to 19 cases in 2020; P=.001), respectively. The emergency surgical workload decreased by 40.9% (193 cases in 2019 compared to 114 cases in 2020). The most significant reduction in the emergency workload was observed in March (41 to 23 cases, a 43.9% reduction; P=.94), April (35 to 8 cases, a 77.1% reduction; P=.01), and May (32 to 14 cases, a 56.3% reduction; P=.39); however, only April had a statistically significant reduction in workload (P=.01).ConclusionsThe reallocation of resources due to the COVID-19 pandemic did not adversely impact elective HPB oncology work. With prudent measures in place, essential surgical services can be maintained during a pandemic.Trial RegistrationChinese Clinical Trial Registry (ChiCTR2000040265); https://tinyurl.com/ms9kpr6x

Association Between the COVID-19 Pandemic and Disparities in Access to Major Surgery in the US

Racial minority groups account for 70% of excess deaths not related to COVID-19. Understanding the association of the Centers for Medicare & Medicaid Services' (CMS's) moratorium delaying nonessential operations with racial disparities will help shape future pandemic responses. To evaluate the association of the CMS's moratorium on elective operations during the first wave of the COVID-19 pandemic among Black individuals, Asian individuals, and individuals of other races compared with White individuals. This cross-sectional study assessed a 719-hospital retrospective cohort of 3 470 905 adult inpatient hospitalizations for major surgery between January 1, 2018, and October 31, 2020. The first wave of COVID-19 infections between March 1, 2020, and May 31, 2020. The main outcome was the association between changes in monthly elective surgical case volumes and the first wave of COVID-19 infections as a function of patient race, evaluated using negative binomial regression analysis. Among 3 470 905 adults (1 823 816 female [52.5%]) with inpatient hospitalizations for major surgery, 70 752 (2.0%) were Asian, 453 428 (13.1%) were Black, 2 696 929 (77.7%) were White, and 249 796 (7.2%) were individuals of other races. The number of monthly elective cases during the first wave was 49% (incident rate ratio [IRR], 0.49; 95% CI, 0.486-0.492; P < .001) compared with the baseline period. The relative reduction in unadjusted elective surgery cases for Black (unadjusted IRR, 0.99; 95% CI, 0.97-1.01; P = .36), Asian (unadjusted IRR, 1.08; 95% CI, 1.03-1.14; P = .001), and other race individuals (unadjusted IRR, 0.97; 95% CI, 0.95-1.00; P = .05) during the surge period compared with the baseline period was very close to the change in cases for White individuals. After adjustment for age, sex, comorbidities, and surgical procedure, there was still no evidence that the first wave of the pandemic was associated with disparities in access to elective surgery. In this cross-sectional study, the CMS's moratorium on nonessential operations was associated with a 51% reduction in elective operations. It was not associated with greater reductions in operations for racial minority individuals than for White individuals. This evidence suggests that the early response to the pandemic did not increase disparities in access to surgical care.

Decreased Case Volume for Orthopaedic Sports Medicine Fellows During the Early Stages of the Coronavirus Disease 2019 Pandemic

PurposeTo compare the surgical case volume for orthopaedic sports medicine fellows in the most recent classes with one another and in years preceding the pandemic.MethodsThe Accreditation Council for Graduate Medical Education case log reports of key procedures for orthopaedic sports medicine fellows during academic years 2018-2019, 2019-2020, and 2020-2021 were extracted. Comparisons between these years in adult, pediatric, and total case volumes were performed using a 2-sample t-test to detect significant changes in the average number of key procedures completed between consecutive years.ResultsThere was a significant decrease in the total number of cases completed by fellows during the 2020 academic year (P = .043) compared with 2019, immediately followed by a significant increase in case volume in 2021 (P < .001) (2019, 339 ± 123; 2020, 316.2 ± 108; 2021, 356.5 ± 117). There was a significant increase in adult case volume from 2020 to 2021 (2020, 295.7 ± 106; 2021, 332.9 ± 117; P < .001), whereas no trends were noted in pediatric case volume. Between the prepandemic year of 2019 and the first year of the pandemic, significant decreases were noted in case volume for several procedures, including multiligamentous knee injuries, knee instability and pediatric hip arthroscopy. From the first to the second years of the pandemic (2019-2020 to 2020-2021), significant increases were observed in case volume for rotator cuff, acromioclavicular instability, elbow instability, knee cartilage, and meniscal surgeries.ConclusionsOrthopaedic sports medicine fellows experienced significant decreases in volume for several key case categories between the year preceding the coronavirus disease 2019 pandemic and the first academic year during the pandemic. There were subsequent increases in cases between the first year of the pandemic and the second year, which may be associated with resuming elective surgical cases.Level of EvidenceIV, retrospective database analysis.

PD30-09 IMPACT AND IMPLICATIONS OF THE COVID-19 PANDEMIC ON UROLOGIC TRAINING

You have accessJournal of UrologyCME1 May 2022PD30-09 IMPACT AND IMPLICATIONS OF THE COVID-19 PANDEMIC ON UROLOGIC TRAINING Brandon Piyevsky, John Maclean, Anqing Li, Stephen Rhodes, Megan Prunty, Erin Jesse, Anood Alfahmy, Ramy Abou-Ghayda, Michael Zell, and Michael Callegari Brandon PiyevskyBrandon Piyevsky More articles by this author , John MacleanJohn Maclean More articles by this author , Anqing LiAnqing Li More articles by this author , Stephen RhodesStephen Rhodes More articles by this author , Megan PruntyMegan Prunty More articles by this author , Erin JesseErin Jesse More articles by this author , Anood AlfahmyAnood Alfahmy More articles by this author , Ramy Abou-GhaydaRamy Abou-Ghayda More articles by this author , Michael ZellMichael Zell More articles by this author , and Michael CallegariMichael Callegari More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002578.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has impacted many facets of healthcare in the United States. Changes in public health and hospital policies led to changes in the surgical care of patients and caused disruptions in medical training. Currently, there is limited understanding of how significantly the pandemic impacted urology resident education across the U.S.. The aim of this project is to examine the trends in urologic procedures, as captured by the Accreditation Council for Graduate Medical Education (ACGME) performed by residents before, during and after the peak of the COVID-19 pandemic. METHODS: A retrospective review was performed of publicly available urology resident case logs between July 1 2016 and June 30 2021. Cases were divided into subcategories defined by ACGME and analyzed with linear regression models using year and category as predictors. Statistical calculations were conducted using R (version 4.0.2). RESULTS: Statistical analysis of the national average number of procedures performed by urology residents indicate an upward trend of urology cases. Starting in 2016, the national average of general urology procedures performed by residents has increased by 4-5 each year except for 2020, which saw a drop in case volume. However, in 2021 the case volume dramatically increased to the same rate as projected had there not been a disruption in 2020. The same analysis applied to other categories of urology procedures resulted in the same findings of a decrease in 2020 followed by a quick rebound in 2021. CONCLUSIONS: Trends in ACGME urologic resident case logs suggest that despite widespread pandemic-related disruptions in surgical case volume, there has been minimal detriment to urologic resident training over time. Urologic care is essential and in high demand as evidenced by the uptick in volume across training programs within the U.S. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e513 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brandon Piyevsky More articles by this author John Maclean More articles by this author Anqing Li More articles by this author Stephen Rhodes More articles by this author Megan Prunty More articles by this author Erin Jesse More articles by this author Anood Alfahmy More articles by this author Ramy Abou-Ghayda More articles by this author Michael Zell More articles by this author Michael Callegari More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP32-15 MORTALITY RELATED TO THE USE OF STAPLER DEVICES AND CLIP APPLIERS: ANALYSIS OF THE FDA MAUDE DATABASE

You have accessJournal of UrologyCME1 May 2022MP32-15 MORTALITY RELATED TO THE USE OF STAPLER DEVICES AND CLIP APPLIERS: ANALYSIS OF THE FDA MAUDE DATABASE Balaji Reddy, Shirin Razdan, and Sanjay Razdan Balaji ReddyBalaji Reddy More articles by this author , Shirin RazdanShirin Razdan More articles by this author , and Sanjay RazdanSanjay Razdan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002581.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical staplers and clip appliers are commonly used. These devices have a potential to malfunction, which may result in serious injury or death. This study characterizes mortality related to surgical stapler and clip applier failure reported in the FDA’s MAUDE database. METHODS: The FDA’s MAUDE database was reviewed between 1992 and 2016 based on the following product codes: GAG, FZP, GDO, GDW, KOG and GCJ. Adverse events including death and the type of device failure were reviewed. Temporal trends in reported deaths related to device failure were analyzed and the Healthcare Cost and Utilization Project database was used to adjust for annual surgical case volume using linear regression analysis. We identified temporal trends in mortality associated with surgical stapler and clip applier malfunction. RESULTS: A total of 75,415 malfunctions, 21,115 injuries, and 676 deaths were associated with the use of surgical stapler and clip applier devices. Most deaths occurred post-operatively (N=516, 76.3%) and were due to infection/sepsis (N=89, 17.2%) or vascular injuries (N= 110, 21.3%). Intra-operative mortality (N=79, 11.69%) was primarily due to vascular injuries (N=73, 92.4%). Device failures resulting in death were recognized both intra-operatively (N=268, 39.6%) and post-operatively (N=325, 48.1%). In post hoc root cause analysis, a surgical stapler and clip applier device problem was the most common attributed cause of death (N=238, 65%). In the linear regression analysis, there was a significant increase in the mortality from device failure in recent years after adjusting for annual surgical volume (p <0.01). CONCLUSIONS: Mortality related to the use of surgical stapler and clip applier is increasing. Most deaths occurred post operatively, and an increased awareness of potential life threatening complications is warranted when these devices are utilized. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e537 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Balaji Reddy More articles by this author Shirin Razdan More articles by this author Sanjay Razdan More articles by this author Expand All Advertisement PDF DownloadLoading ...

Minimum Case Numbers: The New Pandemic in a Changing Clinical Environment.

Minimum Case Numbers: The New Pandemic in a Changing Clinical Environment.

Impact of Covid-19 pandemic on volume and surgeon professional fees generated by emergency general surgery procedures.

IntroductionThe COVID-19 pandemic has changed the dynamics of healthcare in the USA. In early 2020, most states issued orders to stop non-emergent elective surgeries. This contracted the overall revenue generated by the hospital systems. The impact of COVID-19 pandemic on volume has not been well studied but effects on surgeon professional fees generated remains unexplored. The goal of this study was to assess if COVID-19 pandemic has affected surgeon professional fees and revenues generated from emergency general surgeries.MethodsThis is a retrospective review to compare surgical case volume in 2019 and 2020. We obtained our data from a tertiary care referral center database. Data were collected from February to April of 2019 and 2020, corresponding to the duration of statewide ban on non-emergent surgical cases. We used the most reported current procedural terminology (CPT) Code for each surgical procedure to calculate the surgeon professional fees generated. We calculated the percentage difference in surgeon professional fees between 2019 and 2020 for comparison.ResultsThere was a statistically significant decrease in daily emergent operations between 2019 and 2020 time periods (6.13/day vs 4.64/day). There was a statistically significant decrease in hospital admissions for appendicitis, cholecystitis, diverticulitis, skin and soft tissue infections, small bowel obstruction and GI bleed. Additionally, a statistically significant decrease in number of appendectomy, cholecystectomy, sigmoid colectomy with anastomosis, small bowel resection, operation for incarcerated and reducible hernia procedures was observed. There is a decline in surgeon professional fees generated in 2020 compared to 2019 for all emergent surgeries. When compared to 2019, we observed an increase of 238 more inquests in February to April of 2020, which is the same time period when we noticed a significant decrease in hospital admissions and procedures for emergency general surgery.ConclusionThe COVID-19 pandemic has negatively impacted surgical case volumes in 2020 compared to 2019. This includes both emergent and non-emergent cases. There is a need for more broad cost analysis which considers hospital expenditures and cost benefit analysis.

301 1000 Cases of Surgically Treated Aneurysmal Subarachnoid Haemorrhage: Changes in Practice and Clinical Outcomes

INTRODUCTION: Aneurysmal subarachnoid haemorrhage (aSAH) remains a complex and multidisciplinary pathology. With endovascular methods expanding fewer patients are treated surgically. METHODS: All patients following surgery for aSAH between 2007 - 2019 were included. Baseline characteristics outcomes were analysed. We compared outcomes between experienced (=50 independent cases) and non-experienced surgeons (&lt;50 independent cases), and high-volume (=20 cases/year) and low-volume surgeons (&lt;20 cases/year). RESULTS: 970 patients with 1003 aneurysms were identified with median age 56. 73.8% were WFNS grade 1 or 2. The majority of aneurysm were on the middle cerebral artery (41.4%), anterior communicating artery (27.6%) and posterior communicating artery (17.5%). 37.4% of aneurysm were &lt;7 mm in size. Technical error rate was 6%, resulting in a post-operative infarct in 4.9% of patients. 19 patients (2%) died within 30 days of admission. There were no significant changes in technical error rates or post-operative infarcts or death (p = 0.79 and p = 0.77 respectively) over the study period. There was no difference in post-operative infarctions between experienced and non-experienced surgeons (p = 0.28), but there was a difference when comparing high-volume vs. low-volume surgeons (p = 028). CONCLUSION: We present real world data on surgical indications and outcomes after aSAH. We believe that this constitutes important data demonstrating good retention of skills and good clinical outcomes in a very dynamic field of cerebrovascular surgery. We also demonstrate a relationship between surgical case volume and outcomes.

828 The Impact of a Night Float System on Neurosurgery Resident Operative Experience

INTRODUCTION: Traditionally, resident call had been based on alternating call between residents in the call pool, requiring residents to work 24-hour shifts multiple times per week. However, to comply with an 80-hour work week, many programs moved toward different “float” systems, dedicating one resident to be on call for a given period of time. For surgical subspecialities, however, there has been some reticence to adopt night float due to concern for the loss of operative experience. In this study, we describe our training program’s transition to the night float system and its impact on the resident operative experience. METHODS: We conducted a single program study of resident surgical case volume before and after the implementation of night float 3 of the 5 hospitals at our program over a 6-year period from 2014 to 2020. Surgical cases were obtained from the ACGME case log database. Overall surgical cases were collected from individual hospital databases. RESULTS: After the implementation of night float, there was a significant decrease in overnight call burden, specifically for senior residents who saw a decrease in call from 112 calls a year to 16. Across the three hospitals involved in the night float rotation, an average of 33 pages and 5 consults occurred each night, with a case occurring once every once every 2.75 days. Logged procedures significantly increased after the initiation of night float for participating hospitals (p&lt;0.05, t-test), while cases at non-night float hospitals remained the same. This rise was commiserate with a global increase in hospital cases, suggesting that residents were able to take advantage of increasing opportunities. This difference was mainly driven by senior resident cases (p=0.010, t-test), as juniors and chiefs did not show significant differences in case logs (p&gt;0.40, t-test). CONCLUSIONS: The transition to a night float call system improved our residents’ operative experience by increasing their opportunities to participate in cases. In particular, senior residents had fewer night time call requirements and showed a significant increase in logged case volume.

Changes in Surgical Pathology Case Volume and Amendment Rates During the COVID-19 Pandemic

ObjectivesSurgical pathology volume decreased during the peak of the coronavirus disease 2019 (COVID-19) pandemic. We looked at the 4 months with the greatest reduction in surgical pathology volume during the COVID-19 pandemic and compared them with those same months in 2019 to determine changes in specimen volume. We compared the amendment rates during those periods and types of amendments issued (identification [ID], report defect [RD], diagnostic information [DI]).MethodsAll pathology reports between March to June 2019 and March to June 2020 were extracted from the pathology information system. All amendments issued were extracted over the same period and then subclassified by two pathologists.ResultsThere was a 52.1% reduction in surgical pathology volume between the 4-month periods in 2019 and 2020 (P = .04). The amendment rate was 0.9% in 2019 compared with 1.4% in 2020, representing a 65.5% increase in amendments overall. There was a 53.3% reduction in amendments issued for ID, a 3.8% reduction in RD, and a 23.2% increase in amendments issued for DI. The change in amendments was not statistically significant.ConclusionsThese findings suggest that a reduction in workload would not improve error rates. The circumstances of the pandemic highlight the many factors contributing to error rates in surgical pathology.

Changes in Surgical Volume and Outcomes During the Coronavirus Disease 2019 Pandemic at Two Tertiary Hospitals in Ethiopia: A Retrospective Cohort Study.

Limited data exist concerning how the coronavirus disease 2019 (COVID-19) pandemic has affected surgical care in low-resource settings. We sought to describe associations between the COVID-19 pandemic and surgical care and outcomes at 2 tertiary hospitals in Ethiopia. We conducted a retrospective observational cohort study analyzing perioperative data collected electronically from Ayder Comprehensive Specialized Hospital (ACSH) in Mekelle, Ethiopia, and Tibebe Ghion Specialized Hospital (TGSH) in Bahir Dar, Ethiopia. We categorized COVID-19 exposure as time periods: "phase 0" before the pandemic (November 1-December 31, 2019, at ACSH and August 1-September 30, 2019, at TGSH), "phase 1" starting when elective surgeries were canceled (April 1-August 3, 2020, at ACSH and March 28-April 12, 2020, at TGSH), and "phase 2" starting when elective surgeries resumed (August 4-August 31, 2020, at ACSH and April 13-August 31, 2020, at TGSH). Outcomes included 28-day perioperative mortality, case volume, and patient district of origin. Incidence rates of case volume and patient district of origin (outside district yes or no) were modeled with segmented Poisson regression and logistic regression, respectively. Association of the exposure with 28-day mortality was assessed using logistic regression models, adjusting for confounders. Data from 3231 surgeries were captured. There was a decrease in case volume compared to phase 0, with adjusted incidence rate ratio (IRR) of 0.73 (95% confidence interval [CI], 0.66-0.81) in phase 1 and 0.90 (95% CI, 0.83-0.97) in phase 2. Compared to phase 0, there were more patients from an outside district during phase 1 lockdown at ACSH (adjusted odds ratio [aOR], 1.63 [95% CI, 1.24-2.15]) and fewer patients from outside districts at TGSH (aOR, 0.44 [95% CI, 0.21-0.87]). The observed 28-day mortality rates for phases 0, 1, and 2 were 1.8% (95% CI, 1.1-2.8), 3.7% (95% CI, 2.3-5.8), and 2.9% (95% CI, 2.1-3.9), respectively. A confounder-adjusted logistic regression model did not show a significant increase in 28-day perioperative mortality during phases 1 and 2 compared to phase 0, with aOR 1.36 (95% CI, 0.62-2.98) and 1.54 (95% CI, 0.80-2.95), respectively. Analysis at 2 low-resource referral hospitals in Ethiopia during the COVID-19 pandemic showed a reduction in surgical case volume during and after lockdown. At ACSH, more patients were from outside districts during lockdown where the opposite was true at TGSH. These findings suggest that during the pandemic patients may experience delays in seeking or obtaining surgical care. However, for patients who underwent surgery, prepandemic and postpandemic perioperative mortalities did not show significant difference. These results may inform surgical plans during future public health crises.

Effects of the COVID-19 Pandemic on Cardiac Surgery Practice and Outcomes.

BackgroundWhile the coronavirus disease 2019 (COVID-19) pandemic has affected all aspects of health care, its impact on cardiac surgical practice and outcomes is yet to be determined. We compared the outcomes of our cardiac surgical practice from the past year during the pandemic to those in a similar pre-pandemic period.MethodsRetrospective data were collected from 307 patients who were involved in all adult cardiac surgical procedures performed between March 2020 and February 2021, which was considered the pandemic period, at Amrita Institute of Medical Sciences, India. These were compared with data from the 1-year period between March 2019 and February 2020. During that earlier period, 491 patients underwent surgery, and the surgical outcomes were assessed. Outpatient visit data were also collected to evaluate the effect of COVID-19 on outpatient follow-up visits.ResultsA 37% decrease in surgical case volume was observed during the study period. No difference was found in operative mortality between the 2 time periods (3.3% vs. 2.6%, p=0.383). Overall postoperative complications were less frequent during this period, at 23% compared to 38% the previous year (p<0.001).ConclusionThe COVID-19 pandemic caused a dramatic decrease in surgical volume and outpatient medical follow-up. However, the pandemic and its attendant social restrictions did not yield a significant change in the surgical outcomes of our patients. Hence, it is reasonable to continue cardiac surgical care during global health crises, and this can be done with good results.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System.

Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

The Impact of COVID-19 on the Surgical Wait Times for Plastic and Reconstructive Surgery in Ontario.

Purpose: The aim of this study was to assess the impact of COVID-19 on surgical wait times for Plastic and Reconstructive Surgery (PRS) in Ontario, Canada. Methods: Ontario's wait time data has fourteen reporting categories for PRS. For each category, the mean wait time for consultation and for surgery were reported. Each category was given a priority ranging from 1 to 4. Two periods, three-month and six-month, were selected and compared to the same calendar months of the previous year. Wait times, surgical volume and percent change to the provincial wait time target were reported and compared to the baseline data. Results: This study reviewed 9563 consults and 15,000 operative cases. There was a 50% reduction in the volume of surgical consults during the study period compared to the baseline period (P = 0.004). The reduction ranged from 46% to 75% based on the reporting category. The volume of surgical cases decreased by 43% during the study period compared to the baseline period (P = 0.005). A statistically significant increase in the mean wait times for surgery was observed, involving priorities 2 to 4 (overall mean = 32 days, P ≤ 0.01). There was a 15% decrease in the percentage of surgeries meeting the provincial target times (P < 0.0001). Conclusion: COVID-19 has caused a significant reduction in the volume of cases performed in the majority of PRS categories with an overall increase in the wait times for consultation and for surgery. Recovery following COVID-19 will require strategies to address the growing volume of cases and wait times for surgery across all PRS categories.

Trends in Surgical Case Volume During Pacific Partnership Missions Onboard USNS Mercy.

Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician-gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Decreases in Elective and Non-Elective Surgical Case Volumes During the COVID-19 Pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on surgical healthcare delivery systems. Multiple surgical organizations outlined recommendations on the performance of surgeries to minimize viral transmission, prioritize resource allocation, and avoid perioperative complications. This study aims to characterize the changes in surgical volume during the COVID-19 pandemic. Methods: A retrospective chart review was performed at a large public hospital to characterize the surgical case volume, specialties performing surgeries, case urgency (elective vs. non-elective), patient presentation (emergency room, clinic, inpatient), and patient demographics. Data were collected between January 17 and May 8, 2020, 8 weeks prior to and 8 weeks after the declaration of COVID-19 as a national emergency in the USA. For comparison, data between January 17 and May 8, 2019 were also collected. A univariate analysis was performed via paired tests between the two years. Results: There was a statistically significant decrease in both elective and non-elective cases in 2020. When compared to 2019, the weekly case volume in 2020 is significantly higher prior to the declaration of COVID-19 a national emergency (weeks 1 - 8) and significantly lower after the declaration of COVID-19 as a national emergency (weeks 9 - 16). Additionally, there appeared to be statistically significant decrease in non-elective surgical case volumes. Conclusions: In facing the challenges presented by the COVID-19 pandemic, clinician leaders have been tasked with making difficult decisions regarding patient care. While leading surgical organizations provided guidelines for best practices at the start of the pandemic, the long-term implications of these decisions are unknown. This study has found that the COVD-19 pandemic has resulted in decreased volume of both elective and non-elective surgeries, raising concerns that necessary care may be delayed for marginalized populations. J Curr Surg. 2021;11(4):73-81 doi: https://doi.org/10.14740/jcs452

The Impact of Coronavirus Disease 2019 Restrictions on an Academic Hand Surgery Practice

PurposeThe impact of the severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) has been felt worldwide. We examined the quantitative impact during the first 4 weeks of hospital system and state-mandated restrictions on an academic, urban hand surgery practice. We hypothesized that the volume of clinic encounters, office procedures, and surgical cases would decrease and that the volume of nonelective care would remain unchanged.MethodsWe retrospectively reviewed all encounters at a hand surgery practice from March 16, 2020, through April 12, 2020 and compared those to two 4-week control time periods. Weekly encounter volumes and work relative value units (RVUs) were obtained for clinic encounters, office procedures, and surgical cases. The type of ambulatory visit was also identified. Surgical cases were categorized into 4 types (fracture or dislocation, acute soft tissue or nerve injury, infection, or elective/nonurgent) for the most recent time periods. We performed t tests to compare weekly volumes and RVUs between time periods.ResultsAfter the implementation of mandated restrictions on elective health care, ambulatory hand surgery clinic encounters decreased 72% to 73%, clinic procedures decreased by 87% to 90%, and surgical cases decreased by 87% to 88%. The percentage of ambulatory visits performed via telemedicine increased from 0.06% to 74%. Similar impacts on RVUs were seen. Surgeries for fractures and dislocations declined by 58% and those for acute soft tissue or nerve injury declined by 40%; the number of surgical procedures for infection remained unchanged.ConclusionsThe coronavirus restrictions on elective healthcare led to an immediate, substantial impact on hand surgery practice. There were significant decreases in the volumes of ambulatory encounters, office procedures, and surgical cases. The long-term financial impact of this change in practice is still to be determined but, based on the quantitative impacts seen, is likely to be significant.Type of study/level of evidenceEconomic/Decision Analysis IV.

Surgical Case Volume has an Impact on Outcomes for Patients with Lateral Neck Disease in Thyroid Cancer.

This study aimed to assess whether surgical case volume for lateral neck dissection has an impact on the survival of patients who have well-differentiated thyroid cancer (WDTC) with lateral cervical node metastases. The authors used a population-based cohort study design. The study cohort consisted of WDTC patients in Ontario Canada who underwent thyroidectomy and lateral neck dissection. These patients were identified using both hospital- and surgeon-level administrative data between 1993 and 2017 (n = 1832). Surgeon and hospital volumes were calculated based on the number of cases managed in the year before the procedure by the physician and at the institution managing each case, respectively, and divided into tertiles. Multilevel Cox regression models were used to estimate the effect of volume on disease-free survival (DFS). A crude model without patient or treatment characteristics demonstrated that DFS was associated with both higher surgeon volume tertiles (p < 0.01) and higher hospital volume tertiles (p < 0.01). After control for clustering, patient/treatment covariates, and hospital volume, the lowest surgeon volume tertile (range, 0-20/year; mean, 6.5/year) remained an independent statistically significant negative predictor of DFS (hazard ratio, 1.71; 95 % confidence interval, 1.22-2.4; p < 0.01). Surgeon lateral neck dissection case volume is a predictor of better DFS for thyroid cancer patients, with the lowest surgeon volume tertile (<20 neck dissections per year) demonstrating poorer DFS.