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. Mannose-binding lectin (MBL) is an important mediator of innate immunity and is synthesized primarily by the liver. Low MBL levels are common, are due primarily to polymorphisms in the ...gene encoding MBL (MBL2), and are associated with an increased risk of infection, particularly when immunity is compromised. We report a large, retrospective study that examined the association between MBL status and clinically significant infection following orthotopic liver transplantation. Methods. One hundred two donor-recipient orthotopic liver transplantation pairs were studied. Five polymorphisms in the promoter and coding regions of MBL2 were examined. MBL levels were measured, using the mannan-binding and C4-deposition assays, in serum samples obtained before and after transplantation. Associations between MBL status, as assessed by serum MBL levels and MBL2 genotype, and time to first clinically significant infection (CSI) after transplantation were examined in survival analysis with consideration of competing risks. Results. The median duration of follow-up after orthotopic liver transplantation was 4 years. Thirty-six percent of recipients developed CSI after transplantation. The presence of MBL2 coding mutations in the donor was significantly associated with CSI in the recipient; the cumulative incidence function of infection was 55% in recipients of deficient livers, compared with 32% for recipients of wild-type livers (P=.002). Infection was not associated with recipient MBL2 genotype. Low MBL levels after orthotopic liver transplantation levels (mannan-binding <1µg/mL or C4 deposition <0.2 C4 U/µL) were also associated with CSI (cumulative incidence function, 52% vs. 20%, P=.003; and cumulative incidence function, 54% vs. 24%, P=.007, respectively). In multivariate analysis, mutation in the MBL2 coding region of the donor (hazard ratio, 2.8; P=.002) and the use of cytomegalovirus prophylaxis (hazard ratio, 2.6; P=.005) were independently associated with CSI. Conclusions. Recipients of MBL-deficient livers have almost a 3-fold greater likelihood of developing CSI and may benefit from MBL replacement.
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.
Background
Variation in cut‐off values for what is considered a high volume (HV) hospital has made assessments of volume‐outcome relationships for pancreaticoduodenectomy (PD) challenging. ...Accordingly, we performed a systematic review and meta‐analysis comparing in‐hospital mortality after PD in hospitals above and below HV thresholds of various cut‐off values.
Method
PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in‐hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random‐effects model was used for meta‐analysis, including meta‐regressions. Registration: PROSPERO, CRD42021224432.
Results
From 1855 records, 17 observational studies of moderate quality were included. Median HV cut‐off was 25 PDs/year (IQR: 20–32). Overall relative risk of in‐hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in‐hospital survival benefit in performing PDs at HV hospitals. Meta‐regressions from included studies found no statistically significant associations between relative risk of in‐hospital mortality and region (USA vs. non‐USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut‐off values. Significant inverse relationships were found between PD hospital volume and other outcomes.
Conclusion
In‐hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut‐off value or region. Future research is required to investigate regions where low‐volume centres have specialized PD infrastructure and the potential impact on mortality.
This systematic review and meta‐analysis objectively demonstrates that in‐hospital survival after pancreaticoduodenectomy (PD) is greater in hospitals performing an annual volume of PDs above a defined high volume (HV) cut‐off threshold compared with hospitals below such a threshold. At HV hospitals the relative risk of in‐hospital survival is more than double that of hospitals below the HV threshold. As both HV cut‐off value and region had no significant association with relative risk of in‐hospital mortality, this in‐hospital survival benefit may apply universally regardless of region or defined HV cut‐off value.
Accurate and simple prognostic criteria based on histopathology following pancreaticoduodenectomy would be helpful in assessing prognosis and considering and evaluating adjuvant therapy. This study ...analysed the histological parameters influencing outcome following pancreaticoduodenectomy for periampullary malignancy.
A total of 110 pancreaticoduodenectomies were performed from 1998 to 2008. The median age of patients was 69 years (range 20–89 years). The median follow-up was 4.9 years. Of the procedures, 87% (96) were performed for malignancies and the remainder (n= 14) for benign aetiologies. Of the 96 malignancies, 60 were pancreatic adenocarcinoma and the rest were ampullary (14), cholangio (9), duodenal (9) carcinomas and others. Statistical analysis was performed using log-rank and Cox regression multivariate analyses.
Patients who underwent resection had 1-, 3- and 5-year survival rates of 70%, 46% and 41%, respectively. The 1-, 3- and 5-year survival rates for periampullary cancers other than pancreatic adenocarcinoma were 83%, 69% and 61%, respectively; those for pancreatic adenocarcinoma were 62%, 31% and 27%, respectively (P < 0.003). Poor tumour differentiation (P < 0.02), tumour size >3cm (P < 0.04), margin ≤2mm (P < 0.02), nodal involvement (P < 0.003), perineural infiltration (P < 0.0001) and lymphovascular invasion (P < 0.002) were associated with poorer prognosis. In a multivariate analysis, histologically identified perineural infiltration (P < 0.03) and lymphovascular invasion (P= 0.05) were significant factors influencing outcome. Five-year survival was 77% in patients negative for both factors and 15% in patients positive for both (P < 0.0001). In the pancreatic adenocarcinoma subgroup, patients who were negative for both factors had a 5-year survival of 71%, whereas those who were positive for both had a 5-year survival of 16% (P < 0.02).
The presence of perineural infiltration and lymphovascular invasion on histopathology is highly significant in predicting 5-year outcomes after pancreaticoduodenectomy for periampullary and pancreatic malignancies.
Warm ischemia reperfusion (IR) injury of the liver is associated with changes in the expression and/or post‐translational modification of numerous proteins. Only a few of these have been identified. ...We used 2‐D DIGE to identify cytosolic proteins altered in the early stage of IR in an established rat model of segmental hepatic ischemia. Proteins in 18 abundant spots altered by IR were identified by LC‐MS/MS and Western blot. Many identified proteins were enzymes involved in glucose and lipid metabolism. Isoamyl acetate‐hydrolysing esterase 1 homolog, not previously characterized in liver, was also identified. A threefold increase in peroxiredoxin 1 (Prx1) and its oxidized forms was observed as was an increase in Prx1 mRNA. Peroxiredoxins and their overoxidation have previously been associated with IR. In contrast to other studies, we did not detect typical overoxidation of Prx1 on the peroxidatic cysteine (Cys52). Instead, we identified novel overoxidation of the resolving cysteine (Cys173) residue by LC‐MS/MS. Our results show that a rapid increase in Prx1 expression is associated with the early phase of IR of the liver, likely contributing to mechanisms that protect the liver against IR damage. Additionally, we have revealed a potential role in liver for a novel lipid‐metabolizing enzyme.
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