Background Postoperative hemorrhage is one of the most severe complications after pancreatic surgery. Due to the lack of an internationally accepted, universal definition of postpancreatectomy ...hemorrhage (PPH), the incidences reported in the literature vary considerably, even in reports from randomized controlled trials. Because of these variations in the definition of what constitutes a PPH, the incidences of its occurrence are not comparable. Methods The International Study Group of Pancreatic Surgery (ISGPS) developed an objective, generally applicable definition of PPH based on a literature review and consensus clinical experience. Results Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (≤24 hours after the end of the index operation) or late (>24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades of PPH (grades A, B, and C) are defined according to the time of onset, site of bleeding, severity, and clinical impact. Conclusions An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH. Such a definition also would allow comparisons of results from future clinical trials. Such standardized definitions are necessary to compare, in a nonpartisan manner, the outcomes of studies and the evaluation of novel operative treatment modalities in pancreatic surgery.
Background Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies ...considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible. Methods After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact. Results DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management. Conclusion The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.
Background
Long‐term effects after COVID‐19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence‐based guidance regarding the period of delay necessary for ...adequate recovery of patients following COVID‐19 infection before undergoing surgery.
Methods
A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy.
Results
A total of 1020 records were identified, from which 20 studies (12 peer‐reviewed) were included. None were randomized trials. The studies comprised one case–control study (level III‐2 evidence), one prospective cohort study (level III‐2) and 18 case‐series studies (level IV). Follow‐up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS‐CoV‐2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID‐19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab.
Conclusion
After laboratory confirmation of SARS‐CoV‐2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8–12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision‐making.
A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand to produce evidence‐based guidance regarding the period of delay necessary for adequate recovery of patients following COVID‐19 infection before undergoing surgery. We found that follow‐up periods containing observable clinical characteristics ranged from 3 to 16 weeks and SARS‐CoV‐2 may impact the immune system for multiple months after laboratory confirmation of infection. Therefore, after laboratory confirmation of SARS‐CoV‐2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8–12 weeks, if patient outcome is not compromised; additionally comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision‐making.
Surgery triage during the COVID‐19 pandemic Babidge, Wendy J.; Tivey, David R.; Kovoor, Joshua G. ...
ANZ journal of surgery,
September 2020, Letnik:
90, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Background
The novel coronavirus, SARS‐CoV‐2, caused the COVID‐19 global pandemic. In response, the Australian and New Zealand governments activated their respective emergency plans and hospital ...frameworks to deal with the potential increased demand on scarce resources. Surgical triage formed an important part of this response to protect the healthcare system's capacity to respond to COVID‐19.
Method
A rapid review methodology was adapted to search for all levels of evidence on triaging surgery during the current COVID‐19 outbreak. Searches were limited to PubMed (inception to 10 April 2020) and supplemented with grey literature searches using the Google search engine. Further, relevant articles were also sourced through the Royal Australasian College of Surgeons COVID‐19 Working Group. Recent government advice (May 2020) is also included.
Results
This rapid review is a summary of advice from Australian, New Zealand and international speciality groups regarding triaging of surgical cases, as well as the peer‐reviewed literature. The key theme across all jurisdictions was to not compromise clinical judgement and to enable individualized, ethical and patient‐centred care. The topics reported on include implications of COVID‐19 on surgical triage, competing demands on healthcare resources (surgery versus COVID‐19 cases), and the low incidence of COVID‐19 resulting in a possibility to increase surgical caseloads over time.
Conclusion
During the COVID‐19 pandemic, urgent and emergency surgery must continue. A carefully staged return of elective surgery should align with a decrease in COVID‐19 caseload. Combining evidence and expert opinion, schemas and recommendations have been proposed to guide this process in Australia and New Zealand.
In response to the coronavirus disease 2019 (COVID‐19) pandemic, the Australian and New Zealand governments have activated their respective emergency plans and hospital frameworks to deal with the potential increased demand on scarce resources. Surgical triage is an important part of this response to protect the healthcare system's capacity to respond to COVID‐19.This rapid review summarises advice from Australian, New Zealand and international speciality groups regarding triaging of surgical cases, as well as the peer‐reviewed literature, and was utilised by the Royal Australasian College of Surgeons COVID‐19 Working Group of expert surgeons to formulate evidence‐based recommendations.
Background
Preoperative screening for coronavirus disease 2019 (COVID‐19) aims to preserve surgical safety for both patients and surgical teams. This rapid review provides an evaluation of current ...evidence with input from clinical experts to produce guidance for screening for active COVID‐19 in a low prevalence setting.
Methods
An initial search of PubMed (until 6 May 2020) was combined with targeted searches of both PubMed and Google Scholar until 1 July 2020. Findings were streamlined for clinical relevance through the advice of an expert working group that included seven senior surgeons and a senior medical virologist.
Results
Patient history should be examined for potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Hyposmia and hypogeusia may present as early symptoms of COVID‐19, and can potentially discriminate from other influenza‐like illnesses. Reverse transcription‐polymerase chain reaction is the gold standard diagnostic test to confirm SARS‐CoV‐2 infection, and although sensitivity can be improved with repeated testing, the decision to retest should incorporate clinical history and the local supply of diagnostic resources. At present, routine serological testing has little utility for diagnosing acute infection. To appropriately conduct preoperative testing, the temporal dynamics of SARS‐CoV‐2 must be considered. Relative to other thoracic imaging modalities, computed tomography has the greatest utility for characterizing pulmonary involvement in COVID‐19 patients who have been diagnosed by reverse transcription‐polymerase chain reaction.
Conclusion
Through a rapid review of the literature and advice from a clinical expert working group, evidence‐based recommendations have been produced for the preoperative screening of surgical patients with suspected COVID‐19.
On the basis of a rapid review of the literature and advice from a clinical expert working group containing seven senior surgeons and a senior medical virologist, evidence‐based recommendations have been produced along with a proposed schema for the preoperative screening of surgical patients suspected of having active COVID‐19. A printable questionnaire has also been developed for verbally screening patients for COVID‐19 during either face‐to‐face or telemedicine consultations.
Background
Inconsistencies regarding the use of appropriate personal protective equipment (PPE) have raised concerns for the safety of surgical staff during the coronavirus disease 2019 (COVID‐19) ...pandemic. This rapid review synthesizes the literature and includes input from clinical experts to provide evidence‐based guidance for surgical services.
Methods
The rapid review comprised of targeted searches in PubMed and grey literature. Pertinent findings were discussed by a working group of clinical experts, and consensus recommendations, consistent with Australian and New Zealand Government guidelines, were formulated.
Results
There was a paucity of high‐quality primary studies specifically investigating appropriate surgical PPE for healthcare workers treating patients possibly infected with COVID‐19. SARS‐CoV‐2 is capable of aerosol, droplet and fomite transmission, making it essential to augment standard infection control measures with appropriate PPE, especially during surgical emergencies and aerosol‐generating procedures. All biological material should be treated a potential source of SARS‐COV‐2. Staff must have formal training in the use of PPE and should be supervised by a colleague during donning and doffing. Patients with suspected or confirmed COVID‐19 should wear a surgical mask during transfer to and from theatre. Potential solutions exist in the literature to extend the use of surgical P2/N95 respirators in situations of limited supply.
Conclusion
PPE is advised for all high‐risk procedures and when a patient's COVID‐19 status is unknown. Surgical departments should facilitate staggered rostering, remote meeting attendance, and self‐isolation of symptomatic staff. Vulnerable surgical staff should be identified and excluded from operations with a high risk of COVID‐19 infection.
Inconsistencies regarding the use of appropriate personal protective equipment have raised concerns for the safety of surgical staff during the coronavirus disease 2019 pandemic. This rapid review synthesises the literature that includes input from clinical experts to provide evidence‐based guidance for surgical services.
Background
Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ...ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.
Methods
A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.
Results
A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.
Conclusions
These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
Surgical care has been impacted by the coronavirus disease 2019 pandemic, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential ...aerosol transmission of severe acute respiratory syndrome coronavirus 2, precautions during aerosol‐generating procedures and production of surgical plume are paramount for the safety of surgical teams. From a rapid review on the topic, a working group of expert surgeons developed evidence‐based guidance to support safe surgical practice in the current environment.
Background
Coronavirus disease 2019 (COVID‐19), caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has created a global pandemic. Surgical care has been impacted, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential aerosol transmission of SARS‐CoV‐2, precautions during aerosol‐generating procedures and production of surgical plume are paramount for the safety of surgical teams.
Methods
A rapid review methodology was used with evidence sourced from PubMed, Departments of Health, surgical colleges and other health authorities. From this, a working group of expert surgeons developed recommendations for surgical safety in the current environment.
Results
Pre‐operative testing of surgical patients with reverse transcription‐polymerase chain reaction does not guarantee lack of infectivity due to a demonstrated false‐negative rate of up to 30%. All bodily tissues and fluids should therefore be treated as a potential source of COVID‐19 infection during operative management. Caution must be taken, especially when using an energy source that produces surgical plumes, and an appropriate capture device should also be used. Limiting the use of such devices or using lower energy devices is desirable. To reduce perceived risks association with desufflation of pneumoperitoneum during laparoscopic surgery, an appropriate suction irrigator system, attached to a high‐efficiency particulate air filter, should be used. Additionally, appropriate use of personal protective equipment by the surgical team is necessary during high‐risk aerosol‐generating procedures.
Conclusions
As a result of the rapid review, evidence‐based guidance has been produced to support safe surgical practice.
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