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in category surgery

103 results found. For more information, click each entry to expand.

41: Real-world, Prospective, and Multicenter Validation of a microRNA-based Thyroid Molecular Classifier
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Posted 28 Oct 2020

Real-world, Prospective, and Multicenter Validation of a microRNA-based Thyroid Molecular Classifier
38 downloads medRxiv surgery

Marcos Tadeu dos Santos, Bruna Moretto Rodrigues, Satye Shizukuda, David Livingstone Alves Figueiredo, Giulianno Molina de Melo, Rubens Adão da Silva, Claudio Fainstein, Gerson Felisbino dos Reis, Rossana Corbo, Helton Estrela Ramos, Fernanda Vaisman, Mário Vaisman

BackgroundThe diagnosis of cancer in thyroid nodules with indeterminate cytology (Bethesda III/IV) is challenging as fine-needle aspiration (FNA), the gold standard method, has limitations, and these cases usually require diagnostic surgery. As approximately 77% of these nodules are not malignant, a diagnostic test accurately identifying benign thyroid nodules can reduce surgery rates. We have previously reported the development and validation of a microRNA-based thyroid molecular classifier for precision endocrinology (mir-THYpe) with high sensitivity and specificity, which could be performed directly from readily available cytological smear slides without the need for a new dedicated FNA. We sought to evaluate whether the use of this test in real-world clinical routine can reduce the rates of surgeries for Bethesda III/IV thyroid nodules and analyze the test performance. MethodsWe designed a real-world, prospective, multicenter cohort study. Molecular tests were performed in a real-world clinical routine with samples (FNA smear slides) prepared at 128 cytopathology laboratories. Patients were followed-up from March 2018 until surgery or until March 2020 (for those patients not recommended for surgery). The final diagnosis of thyroid tissue samples was retrieved from postsurgical anatomopathological reports. ResultsAfter applying the exclusion criteria, 435 patients (440 nodules) classified as Bethesda III/IV were followed-up. The rate of avoided surgeries was 52.5% for all surgeries and 74.6% for "potentially unnecessary" surgeries. After the statistical treatment of non-resected test-negative samples, the test achieved 89.3% sensitivity (95% CI 82-94.3), 81.65% specificity (95% CI 76.6-86), 66.2% positive predictive value (95% CI 60.3-71.7), and 95% negative predictive value (95% CI 91.7-97) at 28.7% (95% CI 24.3-33.5) cancer prevalence. The test influenced 92.3% of clinical decisions. ConclusionsThe reported data demonstrate that the use of the microRNA-based classifier in the real-world can reduce the rate of thyroid surgery with robust performance and significantly influence clinical decision-making.

42: Adopting a new model of care for treating patients with chronic limb threatening ischaemia: early results of a vascular limb salvage clinic
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Posted 27 Nov 2019

Adopting a new model of care for treating patients with chronic limb threatening ischaemia: early results of a vascular limb salvage clinic
37 downloads medRxiv surgery

Andrew T.O. Nickinson, Jivka Dimitrova, Lauren Rate, Svetlana Dubkova, Hannah Lines, Laura J Gray, John S.M. Houghton, Sarah Nduwayo, Tanya J. Payne, Rob D. Sayers, Robert S.M. Davies

Background Vascular limb salvage services can potentially improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study aims to evaluate the 12-month outcomes for an outpatient-based vascular limb salvage (VaLS) clinic and investigate times-to-treatment. Methods An analysis of a prospectively maintained database, involving all patients diagnosed with CLTI within the VaLS clinic from February 2018-February 2019, was undertaken. Data were compared to two comparator cohorts, identified from coding data; 1) patients managed prior to the clinic, between May 2017-February 2018 (Pre-Clinic [PC]), and 2) patients managed outside of clinic, between February 2018-February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan-Meier plots and adjusted Cox's proportional hazard models (aHR) were utilised to compare outcomes. Results Five-hundred and sixty-six patients (VaLS=158, AP=173, PC=235) were included (median age=74 years). Patients managed within the VaLS cohort were significantly more likely to be free from major amputation (90.5%) compared to both the AP (82.1%, aHR 0.52, 95% CI 0.28-0.98, p=.041) and the PC (80.0%; aHR 0.50, 95% CI 0.28-0.91, p=.022) cohorts at 12 months, after adjustment for age, disease severity and presence of diabetes. Conclusions A limb salvage clinic may help improve the rate of major amputation and provides a reproducible model which delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer-term outcomes.

43: Resource requirements for reintroducing elective surgery in England during the COVID-19 pandemic: a modelling study
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Posted 12 Jun 2020

Resource requirements for reintroducing elective surgery in England during the COVID-19 pandemic: a modelling study
37 downloads medRxiv surgery

A J Fowler, T. D. Dobbs, Yize I Wan, R. Laloo, S. Hui, D. Nepogodiev, A. Bhangu, I S Whitaker, Rupert M Pearse, T E Abbott

BackgroundThe COVID-19 response required the cancellation of all but the most urgent surgical procedures. The number of cancelled surgical procedures in the National Health Service (NHS) England due to COVID-19, and the reintroduction of surgical activity, was modelled. MethodsModelling study using Hospital Episode Statistics data (2014-2019). Using NHS England definitions, surgical procedures were grouped into four urgency classes. Expected numbers of surgical procedures performed between 1st March 2020 and 28th February 2021 were modelled. Procedure deficit was estimated using conservative assumptions and the gradual reintroduction of elective surgery from the 1st June 2020. Costs were calculated using NHS reference costs and are reported as millions(M) or billions(B) of Euros({euro}). Estimates are reported with 95% confidence intervals. Results4 547 534 (3 318 195 - 6 250 771) patients with pooled mean age of 53.5 years were expected to undergo surgery between 1st March 2020 and 28th February 2021. By 31st May 2020, 749 247 (513 564 - 1 077 448) surgical procedures were cancelled. Assuming elective surgery is gradually reintroduced, 2 328 193 (1 483 834 - 3 450 043) patients will be awaiting surgery by 28th February 2021. The cost of delayed procedures is {euro}5.3B ({euro}3.1B - {euro}8.0B). Safe delivery of surgery during the pandemic will require substantial extra resources costing {euro}526.8M ({euro}449.6M - {euro}633.9M). ConclusionReintroduction of elective surgery in NHS England will be associated with substantial treatment delays, and large cost increases. The challenges and costs of reintroducing surgical care in other healthcare settings may differ and further research to monitor the recovery of surgical care is urgently required.

44: A new model to prioritize and optimize access to elective surgery throughout the COVID-19 pandemic: A feasibility & pilot study.
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Posted 26 Jul 2020

A new model to prioritize and optimize access to elective surgery throughout the COVID-19 pandemic: A feasibility & pilot study.
36 downloads medRxiv surgery

Roberto Valente, Stefano Di Domenico, Matteo Mascherini, Gregorio Santori, Francesco Papadia, Giovanni Orengo, Angelo Gratarola, Ferdinando Cafiero, Franco De Cian, Enzo Andorno, Giulia Buzzatti, Susan Campbell, Walter Locatelli, Marco Filauro, Marta Filauro, Marco Frascio, Carlo Introini, Franca Martelli, Guido Moscato, Giorgio Orsero, Giorgio Peretti, Paolo Pronzato, Edoardo Raposio, Mirella Rossi, Stefano Scabini, Nicola Solari, Carlo Terrone, Luca Timossi, Giovanni Ucci

The COVID-19 pandemic burdens non-covid elective surgical patients by reducing service capacity, forcing extreme selection of patients most in need. Our study assesses the SWALIS- 2020 model ability to prioritize access to surgery during the highest viral outbreak peaks. A 2020 March - May feasibility-pilot study tested a software-aided, inter-hospital, multidisciplinary pathway. All specialties patients in the Genoa Surgical Departments referred for urgent elective patients were prioritized by a modified Surgical Waiting List InfoSystem (SWALIS) cumulative prioritization method (PAT-2020) based on waiting time and clinical urgency, in three subcategories: A1-15 days (certain rapid disease progression), A2-21 days (probable progression), and A3-30 days (potential progression). We have studied the models applicability and its ability to prioritize patients by monitoring waiting list and service performance. https://www.isrctn.com/ISRCTN11384058. Following the feasibility study (N=55 patients), 240 referrals were evaluated in 4 weeks without major criticalities (M/F=73/167, Age=68.7 +/- 14.0). Waiting lists were prioritized and monitored. The SWALIS-2020 score (% of waited-against-maximum time) at operation was 88.7 +/- 45.2 at week 1 and then persistently over 100% (efficiency), over a controlled variation (equity), with a difference between A3 (153.29 +/- 103.52) vs. A1 (97.24 +/- 107.93) (p <0.001), and A3 vs. A2 (88.05 +/- 77.51) (p <0.001). 222 patients underwent surgery, without related complications or delayed/failed discharges. The pathway has selected the very few patients with the greatest need, even with +30% capacity weekly modifications, managing active and backlog waiting lists. We are looking for collaboration for multi-center research.

45: Conservative Management of Acute Appendicitis In The Era Of COVID 19: A Multicenter prospective observational study at The United Arab Emirates
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Posted 30 Sep 2020

Conservative Management of Acute Appendicitis In The Era Of COVID 19: A Multicenter prospective observational study at The United Arab Emirates
33 downloads medRxiv surgery

Fatima Y. AL Hashmi, Abeer Al Zuabi, Ibrahim Y. Hachim, Guido H.H. Mannaerts, Omar Bekdache

Background Since its emergence in December 2019, the Novel Coronavirus (COVID-19) pandemic resulted in a profound impact on the health care system worldwide. We propose herein to evaluate the impact of implementing conservative management as an alternative approach to surgical appendectomy in the treatment of proven acute appendicitis during COVID19 pandemic. Methods Our study is a prospective multicenter study that includes a cohort of 160 patients admitted to the surgical departments in both Tawam Hospital and Sheikh Shakhbout Medical City, Abu Dhabi, UAE, for the period from February 2020 till July 2020. Results Our results showed that 56 of our patients (35%) were treated conservatively, while the other 104 (65%) underwent operative management. There was a significant decrease in length of hospital stay (LOS) (2.32 days) among the first group compared to the second (2.8 days). Also, short term follow-up showed that 90% of those patients did not require further operative intervention or developed any serious complications. Out of the 110 patients that were swapped for COVID19, nine (8.18%) were confirmed to be positive. Our protocol was to avoid surgical management for COVID19 positive patients unless indicated. This resulted in (8/9) of COVID19 positive patients to be treated conservatively. Follow up was achieved by using telemedicine-based follow-up with the aim of empowering social distancing and reducing risk of viral exposure to patients as well as the health care providers. In conclusion, our results showed that the implementation of conservative management in treating patients with acute appendicitis who were COVID19 positive is a safe and feasible approach that maybe essential in reducing viral transmission risks as well as avoiding operative risks on COVID19 positive patients.

46: Training surgery residents in underwater colonoscopies is more effective than training them in air-insufflation colonoscopies
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Posted 08 Jun 2020

Training surgery residents in underwater colonoscopies is more effective than training them in air-insufflation colonoscopies
31 downloads medRxiv surgery

Dinesh Vyas, Josiah Chang, Megha Goyal, Nashwan Obad, Prakash Ramdass, Soujanya Sodavarapu

Background: Colonoscopy screenings are the most valuable tool in preventing colorectal mortalities. The traditional technique uses air-insufflation, but water-infusion is a newer colonoscopy technique which is rapidly becoming standard of care, as it may decrease patient discomfort and the need for analgesics and anesthetics. Research is still ongoing as to the comparability of detection rates between the two techniques. The purpose of this study was to determine if training residents in underwater colonoscopies is more effective than training them in traditional air-insufflation colonoscopies. Methods: This study was a retrospective, single-institution study that compared the patient-related and procedure-related variables of 183 colonoscopies performed by two cohorts of physicians. In the first cohort, the gastroenterologist with a resident trainee performed an air colonoscopy. In the second, the gastroenterologist and resident trainee performed an underwater colonoscopy. Results: For patient-related variables, there was no significant difference in age, previous abdominal surgeries, or bowel preparation. There were more females in the underwater group, which is significant as females tend to be harder to scope due to the increased tortuosity of their colon. For procedural outcomes, there was no significant difference in adenoma detection rate, cecal intubation rate, or procedural complications (hypotension, bradycardia). On average, the water colonoscopies required less midazolam and fentanyl, although they did have a longer procedural time. Conclusions: Overall, these findings suggest that training residents in underwater colonoscopies may increase patient comfort and decrease complications with comparable success rates.

47: Rationalising neurosurgical head injury referrals: The development and implementation of the Liverpool Head Injury Tomography Score (Liverpool HITS) for mild traumatic brain injury
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Posted 17 Aug 2019

Rationalising neurosurgical head injury referrals: The development and implementation of the Liverpool Head Injury Tomography Score (Liverpool HITS) for mild traumatic brain injury
31 downloads medRxiv surgery

Conor SN Gillespie, Christopher M Mcleavy, Abdurrahman I Islim, Sarah Prescott, Catherine J McMahon

ObjectivesTo develop and implement a radiological scoring system to define a surgically significant mild Traumatic Brain Injury (TBI), stratify neurosurgical referrals and improve communication between referral centres and neurosurgical units. DesignRetrospective single centre case-control analysis of ten continuous months of mild TBI referrals. SettingA major tertiary neurosurgery centre in England, UK. ParticipantsAll neurosurgical referrals with a mild TBI (GCS 13-15) during the period of 1st January to 30th October 2017 were eligible for the study. 1248 patients were identified during the study period, with 1444 being included in the final analysis. InterventionsAll patients CT head results from the referring centres were scored retrospectively using the scoring system and stratified according to their mean score, and if they were accepted for transfer to the neurosurgical centre or managed locally. Main outcome measureDetermine the discriminatory and diagnostic power, sensitivity and specificity of the scoring system for predicting a surgically significant mild TBI. ResultsMost patients referred were male (59.4%, N=681), with a mean age of 69 years (SD=21.1). Of the referrals to the neurosurgical centre, 17% (n=195) were accepted for transfer and 83% (n=946) were not accepted. The scoring system was 99% sensitive and 51.9% specific for determining a surgically significant TBI. Diagnostic power of the model was fair with an area under the curve of 0.79 (95% CI 0.76 to 0.82). The score identified 495 (52.2%) patients in ten months of referrals that could have been successfully managed locally without neurosurgical referral if the scoring system was correctly used at the time of injury. ConclusionThe Liverpool Head Injury Tomography Score (HITS) score is a CT based scoring system that can be used to define a surgically significant mild TBI. The scoring system can be easily used by multiple healthcare professionals, has high sensitivity, will reduce neurosurgical referrals, and could be incorporated into local, regional and national head injury guidance.

48: Protection of health care workers from exhaled air of patients operated under local, regional, spinal or epidural anaesthesia during COVID 19 pandemic
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Posted 02 Dec 2020

Protection of health care workers from exhaled air of patients operated under local, regional, spinal or epidural anaesthesia during COVID 19 pandemic
31 downloads medRxiv surgery

Kuldeep Atodaria, Mayank Singh, Vimalkumar S Prajapati, Kush Shaileshkumar Shahkush, Pradipkumar Raghuvirsinh Atodaria

The SARS-CoV-2 (COVID-19) pandemic mandates the use of N-95/FFP-2 masks for healthcare workers, especially in operation room (OR) for surgical or aerosol producing pro-cedures. During pandemic, surgical interventions such as limb trauma, limb amputations, and limb malignancies continued to flow into the hospitals and are normally performed un-der local, regional or spinal anaesthesia. N-95/FFP-2 masks normally do not prevent escape of exhaled air to surrounding and to avoid the escape of exhaled unfiltered air, sealing masks by taping its edges to face possibly serves the purpose, but causes significant discomfort to patients. HEPA filters, high vacuum suction apparatus, and negative pressure operating-room may protect partially against the-risk of infection if patients exhaled air is infected. In order to reduce risk of transmission from patients exhaled air to the healthcare workers, a technique has been designed to divert the patients exhaled air to outside the-OR using a suction machine. This technique is easy, simple and cost-effective and trial has been per-formed with four-volunteers to see feasibility to breathe through N-95 mask sealed by stick-ing its edges to face using tape. The trial reflected reduction in SpO2, causing increased res-piratory-rate, tachycardia and hypertension, in-addition an un-acclimatized volunteers had difficulty in breathing through sealed N-95 masks, which was relieved by supplying oxygen to them. Attaching suction system to remove the-exhaled air aids to comfort levels. Treating exhaled-air with sodium-hypochlorite and diverting it externally to an open-space outside the-OR added to safety for the patients, surgical team and the hospital surroundings.

49: The impact of patient body mass index on surgeon posture during simulated laparoscopy
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Posted 27 Nov 2020

The impact of patient body mass index on surgeon posture during simulated laparoscopy
30 downloads medRxiv surgery

Ryan Sers, Massimiliano Zecca, Steph Forrester, Esther Moss, Stephen Ward

Laparoscopy is a cornerstone of modern surgical care. Despite clear advantages for the patients, it has been associated with inducing upper body musculoskeletal disorders amongst surgeons due to the propensity of non-neutral postures. Furthermore, there is a perception that patients with obesity exacerbate these factors. Therefore, novice, intermediate and expert surgeon upper body posture was objectively quantified using inertial measurement units and the LUBA ergonomic framework was used to assess the subsequent postural data during laparoscopic training on patient models that simulated BMIs of 20, 30, 40 and 50 kg/m^2. In all experience groups, the posture of the upper body significantly worsened during simulated surgery on the BMI 50 kg/m^2 model as compared to on the baseline BMI model of 20 kg/m^2. These findings suggest that performing laparoscopic surgery on patients with severe obesity increases the prevalence of non-neutral upper body posture and may further increase the risk of musculoskeletal disorders in surgeons.

50: Management of Acute Appendicitis in Children: Takeaway from Coronavirus Disease-2019, a Perspective of Pediatric Surgeons from South Asia
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Posted 27 Oct 2020

Management of Acute Appendicitis in Children: Takeaway from Coronavirus Disease-2019, a Perspective of Pediatric Surgeons from South Asia
30 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Md Mozammel Hoque, Tanvir Kabir Chowdhury, Md Samiul Hasan, Alak Nandy

BackgroundNon-operative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and potentially influenced by the preferences of the physician. Owing to the effects of the COVID pandemic on healthcare, practice of NOT has generally increased by necessity and may, in a post-COVID world, change surgeons perceptions of NOT. ObjectiveThe objective was to determine if the practice of NOT has increased in usage in South Asia and whether these levels of practice would be sustained after the pandemic subside. MethodsA survey was addressed to pediatric surgeons regarding their position, institute, country, number of appendicitis cases managed and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). It also directly posed the question as to whether they would continue with the COVID imposed level of NOT after the effect of the pandemic diminishes. ResultsA total of 134 responses were collected. A significant increase in the practice of NOT was observed for the entire cohort, though no effect was observed when grouped by country or institute. When grouped by position, seniors increased the practice of NOT the most, while juniors reported the least change. The data suggests that only Professors would be inclined to maintaining the COVID level of NOT practice after the pandemic. ConclusionsIncreased practice of NOT during the COVID pandemic was observed in South Asia, particularly by senior surgeons. Only Professors appear inclined to consider maintaining this increased level of practice in the post-COVID world.

51: PREOPERATIVE SERUM ALBUMIN LEVEL AS A PREDICTOR OF MORTALITY AND MORBIDITY AFTER VALVE REPLACEMENT SURGERY
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Posted 15 Oct 2020

PREOPERATIVE SERUM ALBUMIN LEVEL AS A PREDICTOR OF MORTALITY AND MORBIDITY AFTER VALVE REPLACEMENT SURGERY
29 downloads medRxiv surgery

Md. Noor-E-Elahi Mozumder, Md. Mostafizur Rahman, Md. Rezwanul Hoque, Muhammad Nasif Imtiaz, Abu Jafar Md. Tareq Morshed, Md. Zanzibul Tareq, Md. Nahedul Morshed

BackgroundSerum albumin has a close correlation with degree of malnutrition which is associated with poor outcome and quality of life after cardiac surgery. Hypoalbuminemia is associated with increased wound infection, prolonged hospital stay and death after major surgery. Hence, preoperative serum albumin level can be utilized to upgrade risk models which will further benefit the cardiac surgical patients without extra financial burden. Objective of this study was to evaluate the role of serum albumin as a predictor of morbidity and mortality after valve replacement surgery. MethodsThis comparative cross-sectional study was carried out at the department of cardiac surgery in BSMMU. The study population was 50, with two groups having 25 patients each. Grouping of patients were done with respect to a preset cut off value for serum albumin. The period of study was from August, 2018 to February, 2020 and purposive sampling method was applied for this study. Data was collected by using a standardized semi-structured questionnaire and face to face interview. ResultsBy demographic characteristics, mean age was significantly higher in group B (49.96{+/-}8.69 years) than in group A (41.60{+/-}11.16 years) (p=0.005). Mean BMI was lower in group B (20.88{+/-}3.71 kg/m2) than in group A (22.26{+/-}1.67 kg/m2), which was found statistically significant (p=0.006). In terms of postoperative outcome, total chest drain collection was significantly higher in group B (968.80{+/-}183.49 ml) than in group A (816.00{+/-}113.40 ml), (p=0.001). Duration of ICU stay were significantly longer in group B (4.60{+/-}0.76 days) than in group A (3.92{+/-}0.86 days) (p=0.005). Similarly, duration of hospital stay was significantly longer in group B (9.88{+/-}1.56 days) than in group A (8.64{+/-}0.81 days) (p=0.001). Overall morbidity was significantly higher in group B (48%) than in group A (20%) (p<0.05). Mortality rate was higher in group B (12%) than in group A (4%), but that was not found statistically significant (p>0.05). Pearson co-efficient correlation test showed strong inverse relationship of serum albumin with total chest drain, ICU stay and hospital stay following valve replacement surgery (r= -0.473, r= -0.448 & r= -0.487 respectively), which was most significant than age and BMI (p[&le;]0.001). Multivariate logistic regression analysis was done to assess the predictive value of serum albumin level, age and BMI, where preoperative serum albumin level was found to be the most valuable predictor of postoperative morbidity after valve replacement surgery (B= -2.251, OR 0.105, 95% CI 0.011-0.986, p<0.05). ConclusionThis study demonstrated that preoperative low serum albumin level is associated with increased morbidity and mortality after valve replacement surgery. Hence, preoperative serum albumin level can be used as a reliable predictor of postoperative outcome following valve replacement surgery.

52: Outcome of COVID-19 with co-existing surgical emergencies in children: our initial experiences and recommendations
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Posted 04 Aug 2020

Outcome of COVID-19 with co-existing surgical emergencies in children: our initial experiences and recommendations
29 downloads medRxiv surgery

Md Samiul Hasan, Md Ayub Ali, Umama Huq

Background: COVID 19 has changed the practice of surgery vividly all over the world. Pediatric surgery is not an exception. Prioritization protocols allowing us to provide emergency surgical care to the children in need while controlling the pandemic spread. The aim of this study is to share our experiences with the outcome of children with COVID 19 who had a co existing surgical emergency. Methods: This is a retrospective observational study. We reviewed the epidemiological, clinical, and laboratory data of all patients admitted in our surgery department through the emergency department and later diagnosed to have COVID 19 by RT PCR. The study duration was 3 months (April 2020 to June 2020). A nasopharyngeal swab was taken from all patients irrespective of symptoms to detect SARS CoV 2 by RT PCR with the purpose of detecting asymptomatic patients and patients with atypical symptoms. Emergency surgical services were provided immediately without delay and patients with positive test results were isolated according to the hospital protocol. We divided the test positive patients into 4 age groups for the convenience of data analysis. Data were retrieved from hospital records and analyzed using SPSS (version 25) software. Ethical permission was taken from the hospital ethical review board. Results: Total patients were 32. Seven (21.9%) of them were neonates. Twenty four (75%) patients were male. The predominant diagnosis was acute abdomen followed by infantile hypertrophic pyloric stenosis (IHPS), myelomeningocele, and intussusception. Only two patients had mild respiratory symptoms (dry cough). Fever was present in 13 (40.6%) patients. Fourteen (43.8%) patients required surgical treatment. The mean duration of hospital stay was 5.5 days. One neonate with ARM died in the postoperative ward due to cardiac arrest. No patient had hypoxemia or organ failure. Seven health care workers (5.51%) including doctors & nurses got infected with SARS Co V2 during this period. Conclusion: Our study has revealed a milder course of COVID 19 in children with minimal infectivity even when present in association with emergency surgical conditions. This might encourage a gradual restart to mitigate the impact of COVID 19 on children surgery. Keywords: COVID 19, COVID 19 in children, Children Surgery, Surgical emergency, Surgery in COVID 19 positive patients.

53: Evaluation of 30-day mortality for 500 patients undergoing non-emergency surgery in a COVID-19 cold site within a multicentre regional surgical network during the COVID-19 pandemic
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Posted 12 Jun 2020

Evaluation of 30-day mortality for 500 patients undergoing non-emergency surgery in a COVID-19 cold site within a multicentre regional surgical network during the COVID-19 pandemic
29 downloads medRxiv surgery

Veeru Kasivisvanathan, Jamie Lindsay, Sara Rakhshani-moghadam, Ahmed Elhamshary, Konstantinos Kapriniotis, Georgios Kazantzis, Bilal Syed, John Hines, Axel Bex, Daniel Heffernan Ho, Martin Hayward, Chetan Bhan, Nicola MacDonald, Simon Clarke, David Walker, Geoff Bellingan, James Moore, Jennifer Rohn, Asif Muneer, Lois Roberts, Fares Haddad, John D. Kelly

Background Two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems. Objective To determine whether it is feasible and safe to continue non-emergency surgery in the COVID-19 pandemic Design, setting and participants This is a cohort study of 500 consecutive patients undergoing non-emergency surgery in a dedicated COVID-19 cold site following the first case of COVID-19 that was reported in the institution. The study was carried out during the peak of the pandemic in the United Kingdom, which currently has one of the highest number of cases and deaths from COVID-19 globally. We set up a hub-and-spoke surgical network amongst 14 National Health Service institutions during the pandemic. The hub was a cancer centre, which was converted into a COVID-19 cold site, performing urological, thoracic, gynaecological and general surgical operations. Outcomes The primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days. Results 500 patients underwent surgery with median age 62.5 (IQR 51-71). 65% were male and 60% had a known diagnosis of cancer. 44% of surgeries were performed with robotic or laparoscopic assistance and 61% were considered complex or major operations. None of the 500 patients undergoing surgery died from COVID-19 at 30-days. 30-day all-cause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19. Conclusion It is safe to continue non-emergency surgery during the COVID-19 pandemic with appropriate service reconfiguration.

54: Pediatric surgical services in Bangladesh during the COVID 19 pandemic: How they are affected and how to overcome the backlog, keeping healthcare professionals safe.
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Posted 21 Aug 2020

Pediatric surgical services in Bangladesh during the COVID 19 pandemic: How they are affected and how to overcome the backlog, keeping healthcare professionals safe.
27 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Md Samiul Hasan

Background: Severe Acute Respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, has turned into a pandemic. All countries have implemented multiple strategies to try mitigating the losses caused by this virus. To stop the rapid spread of the disease and in compliance with the World Health Organizations social distancing policy, the government of Bangladesh has implemented a number of strategies, one of which is to limit the spread of the virus in hospitals by postponing elective procedures and providing only emergency services in the hospitals. The objective of this survey was to assess the current status of pediatric surgical procedures in different hospitals in Bangladesh and assess the effects of the current restrictions along with their implications in the long run. Materials and Methods: A survey was performed among doctors from public and private hospitals in Bangladesh to evaluate the status on pediatric surgery. Results: The results clearly revealed the lack of a significant reduction in doctors exposure to SARS-CoV-2 by postponing elective procedures. Conclusion: Keeping in mind the socioeconomic and health care conditions of the country, the author recommend resuming elective surgical procedures. Keywords: COVID 19, Pediatric surgery, Surgery during pandemic, Pediatric surgery in Bangladesh, COVID 19 and pediatric surgery.

55: Early detection of physiological deterioration in post-surgical patients using wearable technology combined with an integrated monitoring system: a pre- and post-interventional study
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Posted 02 Dec 2020

Early detection of physiological deterioration in post-surgical patients using wearable technology combined with an integrated monitoring system: a pre- and post-interventional study
27 downloads medRxiv surgery

Peter J Watkinson, Marco Pimentel, Lei Clifton, David Clifton, Sarah Vollam, Duncan Young, Lionel Tarassenko

Objectives: Late recognition of physiological deterioration is a frequent problem in hospital wards. We assessed whether ambulatory (wearable) physiological monitoring combined with a system that continuously merges physiological variables into a single 'risk' score (VSI), changed care and outcome in patients after major surgery. Design: Pre- and post-interventional study. Setting: A single centre tertiary referral university hospital upper-gastrointestinal service. Participants: Patients who underwent major upper-gastrointestinal surgery. Interventions: Phase-I (pre-intervention phase): Patients received continuous wearable monitoring and standard care, but the VSI score was not available for clinical use. Phase-II (post-intervention phase): Patients received continuous wearable monitoring. In addition to standard care the VSI score was displayed for use in clinical practice. Measurements and Main Results: 200 participants were monitored in phase-I. 207 participants were monitored in phase-II. Participants were monitored (median, interquartile range, IQR) for 30.2% (13.8-49.2) of available time in phase-I and 58.2% (33.1-75.2) of available time in phase-II. Clinical staff recorded observations more frequently in the 36 hours prior to a major adverse event (death, cardiac arrest or unplanned admission to intensive care) for phase-II participants (median, IQR, time between observations of 1.00, 0.50-2.08 hours) than phase-I participants (1.50, 0.75-2.50 hours, p<0.001). There was no difference in observation frequency between the two phases for participants who did not undergo an adverse event (p=0.129). 6/200 participants died before hospital discharge in phase-I, 1/207 participants died in hospital in phase-II. 20 (10.0%) patients in phase-I and 26 (12.6%) patients in phase-II had an unplanned admission to intensive care. Ward length-of-stay was unaltered (8.91, 6.71-14.02 days in phase-I, vs. 8.97, 5.99-13.85 days in phase-II, p=0.327). Conclusion: The combination of the integrated monitoring system with ambulatory monitoring in high-risk post-surgical patients improved recognition and management of deteriorating patients without increasing the observation rate in those patients who did not deteriorate.

56: THE INFLAMMATORY MICROENVIRONMENT IN SCREEN-DETECTED PREMALIGANT ADENOMATOUS POLYPS: EARLY RESULTS FROM THE INTEGRATED TECHNOLOGIES FOR IMPROVED POLYP SURVEILLANCE (INCISE) PROJECT
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Posted 17 Aug 2020

THE INFLAMMATORY MICROENVIRONMENT IN SCREEN-DETECTED PREMALIGANT ADENOMATOUS POLYPS: EARLY RESULTS FROM THE INTEGRATED TECHNOLOGIES FOR IMPROVED POLYP SURVEILLANCE (INCISE) PROJECT
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David Mansouri, Stephen T McSorley, James H Park, Clare Orange, Paul G Horgan, Donald C McMillan, Joanne Edwards

Introduction Around 40% of patients who attend for colonoscopy following a positive stool screening test have adenomatous polyps. Identifying which patients have a higher propensity for malignant transformation is currently poorly understood. The aim of the present study was to assess whether the type and intensity of inflammatory infiltrate differs between high-grade (HGD) and low-grade dysplastic (LGD) screen detected adenomas. Methods A representative sample of 207 polyps from 134 individuals were included from a database of all patients with adenomas detected through the first round of the Scottish Bowel Screening Programme (SBoSP) in NHS GG&C (April 2009 to April 2011). Inflammatory cell phenotype infiltrate was assessed by immunohistochemistry for CD3+, CD8+, CD45+ and CD68+ in a semi-quantitative manner at 20x resolution. Immune-cell infiltrate was graded as absent, weak, moderate or strong. Patient and polyp characteristics and inflammatory infiltrate were then compared between HGD and LGD polyps. Results CD3+ infiltrate was significantly higher in HGD polyps compared to LGD polyps (74% vs 69%, p<0.05). CD8+ infiltrate was significantly higher in HGD polyps compared to LGD polyps (36% vs 13%, p<0.001) where as CD45+ infiltrate was not significantly different (69% vs 64%, p=0.401). There was no significant difference in CD68+ infiltrate (p=0.540) or total inflammatory cell infiltrate (calculated from CD3+ and CD68+) (p=0.226). Conclusions This study reports an increase in CD3+ and CD8+ infiltrate with progression from LGD to HGD in colonic adenomas. It may therefore have a use in the prognostic stratification and treatment of dysplastic polyps.

57: IMPACT OF THE CORONAVIRUS DISEASE 2019 PANDEMIC ON SURGICAL VOLUME IN JAPAN: A COHORT STUDY USING ADMINISTRATIVE DATA
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Posted 20 Nov 2020

IMPACT OF THE CORONAVIRUS DISEASE 2019 PANDEMIC ON SURGICAL VOLUME IN JAPAN: A COHORT STUDY USING ADMINISTRATIVE DATA
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Takuya Okuno, Daisuke Takada, Shin Jung-ho, Tetsuji Morishita, Hisashi Itoshima, Susumu Kunisawa, Yuichi Imanaka

BackgroundInternationally, the Coronavirus Disease (COVID-19) pandemic has caused unprecedented challenges for surgical staff to minimise the exposure to COVID-19 or save medical resources without harmful outcomes for patients, in accordance with the statement of each surgical society. However, no research has empirically validated declines in Japanese surgical volume or compared decrease rates of surgeries during the COVID-19 pandemic. Material and MethodsWe extracted 672,772 available cases of patients aged > 15 years who were discharged between July 1, 2018, and June 30, 2020. After categorisation of surgery, we calculated descriptive statistics to compare the year-over-year trend and conducted interrupted time series analysis to validate the decline. ResultsThe year-over-year trend of all eight surgical categories decreased from April 2020 and reached a minimum in May 2020 (May: abdominal, 68.4%; thoracic, 85.8%; genitourinary, 78.6%; cardiovascular, 90.8%; neurosurgical, 69.1%; orthopaedic, 62.4%; ophthalmologic, 52.0%; ear/nose/throat, 27.3%). Interrupted time series analysis showed no significant trends in oncological and critical benign surgeries. ConclusionWe demonstrated and validated a trend of reduction in surgical volume in Japan using administrative data applying interrupted time series analyses. Low priority surgeries, as categorised by the statement of each society, showed obvious and statistically significant declines in case volume during the COVID-19 pandemic.

58: Non surgical procedure related postoperative complications independently predicts perioperative mortality, in gastrointestinal and Hpb surgeries.- A retrospective analysis of prospectively maintained data.
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Posted 22 Apr 2020

Non surgical procedure related postoperative complications independently predicts perioperative mortality, in gastrointestinal and Hpb surgeries.- A retrospective analysis of prospectively maintained data.
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BHAVIN VASAVADA, Hardik Patel

Aim: The Aim of the study was to evaluate relationship between non surgical procedure related complication and 30 days mortality. Material and Methods: All gastrointestinal and hepatobiliary procedures performed in last 3 years have been evaluated retrospectively. Non surgical procedure related postoperative complications were defined as perioperative complications non related to surgical procedures or techniques and related to patients physiological health or comorbidities (e.g acute kidney injury, ARDS, acute respiratory failure, pre existing sepsis , etc.), Surgical related complications were defined as perioperative complications related to surgical procedures or techniques (e.g. bleeding, leaks, sepsis due to leaks etc.). Factors affecting 30 days mortality and morbidity were analysed using univariate and multivariate analysis. Chi square test was used for categorical values, Mann Whitney U test was used for numerical values. Multivariate logistic regression analysis was used for multivariate analysis. Statistical analysis was used suing SPSS version 21. Results: Total 325 major hepatobiliary and pancreatic surgery was done in our institute in last 2 years. 30 days overall mortality rate was 6.4%. In univariate analysis mortality was significantly associated with nonsurgical procedure related complications. (p < 0.0001). Surgical complications were not associated with mortality. On univariate analysis other factors associated with mortality were emergency surgeries, high CDC grade of surgery, higher ASA grades, increase operative duration, increased blood product requirements. However on multivariate analysis only nonsurgical procedure related postoperative complications independently predicted mortality. (p=0.001). Conclusions: Non surgical procedure related post operative complications (Physiological) is strongly associated with 30 days mortality, suggesting improved perioperative care can help to reduce post operative mortality.

59: Brain growth and neurodevelopment after surgical treatment of infant postinfectious hydrocephalus in sub-Saharan Africa
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Posted 13 Nov 2020

Brain growth and neurodevelopment after surgical treatment of infant postinfectious hydrocephalus in sub-Saharan Africa
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Steven J. Schiff, Abhaya V. Kulkarni, Edith Mbabazi Kabachelor, John Mugamba, Peter Ssenyonga, Ruth Donnelly, Jody Levenbach, Vishal Monga, Mallory Peterson, Venkateswararao Cherukuri, Benjamin C Warf

ImportancePost-infectious hydrocephalus in infants is a major public health burden in sub-Saharan Africa. ObjectiveTo determine long-term brain growth and cognitive outcome after surgical treatment of infant post-infectious hydrocephalus in Uganda. DesignProspective follow-up of a previously randomized cohort. SettingSingle center in Mbale, Uganda. ParticipantsInfants (<180 days old) with post-infectious hydrocephalus. InterventionsEndoscopic or shunt surgery. Main outcomesBayley Scales of Infant Development (BSID-3) and brain volume on computed tomography (raw and normalized for age and sex) at 2 years after treatment. ResultsEighty-nine infants were assessed for 2-year outcome. There were no significant differences between the two surgical treatment arms, so they were analyzed together. Raw brain volumes increased between baseline and 24 months (median change=361 cc, IQR=293 to 443, p<0.001), but almost all of this increase was seen in the first year (median change=381 cc, IQR=310 to 442, p<0.001), with very little change between 12 and 24 months (median change=-5 cc, IQR=-52 to 42, p=0.66). The fraction of those with a normal brain volume increased from 15% at baseline to 50% at 1 year, but then declined to 18% at 2 years. Substantial normalized brain volume loss was seen in 21% between baseline and year 2 and in 77% between years 1 and 2. The extent of brain growth in the first year was not associated with extent of brain volume changes in the second year. There were significant positive correlations between 2-year brain volume and all BSID-3 scores and BSID-3 changes from baseline. Conclusions and RelevanceIn sub-Saharan Africa, even after successful surgical treatment of infant post-infectious hydrocephalus, post-treatment brain growth stagnates in the second year. While the reasons for this are unclear, this emphasizes the importance of primary infection prevention strategies along with optimizing the childs environment to maximize brain growth potential. Trial RegistrationClinicalTrials.gov number, NCT01936272 KEY POINTSO_ST_ABSQuestionC_ST_ABSWhat is the brain growth and cognitive trajectory of infants treated for post-infectious hydrocephalus in Uganda? FindingsIn this prospective follow-up of a cohort of 89 infants, early normalization of brain volume after treatment was followed by brain growth stagnation in the second year, with many falling back into the sub-normal range. Poor brain growth was associated with poor cognitive outcome. MeaningSuccessful surgical treatment of hydrocephalus is not sufficient to allow for adequate brain growth and cognitive development. Interventions aimed at primary infection prevention and reducing comorbidities are needed to improve brain growth potential.

60: A hemodynamic model to predict regional cerebral blood flow and blood flow reserve in patients with carotid stenosis
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Posted 22 Jul 2020

A hemodynamic model to predict regional cerebral blood flow and blood flow reserve in patients with carotid stenosis
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joseph p archie

Joseph P Archie Jr, PhD, MD Abstract Purpose. Patients with 50% or greater diameter stenosis are at risk for ischemic stroke due to embolization and/or reduced cerebral blood flow. The hemodynamics of progressive carotid stenosis on cerebral blood flow and blood flow reserve has not been adequately measured or predicted. This information is needed for stroke risk stratification in patients with carotid stenosis. The aim of this hemodynamic model study is to predict the contribution of carotid and collateral blood flows to regional cerebral blood flow and cerebral blood flow reserve in patients with moderate to severe carotid stenosis. Methods. A one-dimensional three-parameter fluid mechanics model for the carotid, collateral and brain vascular systems is used to predict regional cerebral blood flow and blood flow reserve as a function of percent diameter carotid stenosis. The model is based on the principal of conservation of energy as employed by Bernoulli to describe fluid flow on a streamline. When applied to the human cerebrovascular system there are three vascular resistance components; carotid, collateral and brain. Carotid artery vascular resistance is assumed to be a function of fractional percent carotid artery area stenosis. This is not a complex modern computational fluid mechanics study. The model blood flow algebraic equations have simple solutions, one of which gives patient specific collateral resistance values. The solutions are given as patient specific cerebral blood flows and flow reserve as a function of percent diameter stenosis. Established normal clinical values of regional cerebral blood flow, cerebral blood flow auto-regulation and the lower threshold of cerebral perfusion pressure for cerebral auto-regulation are used. Carotid vascular resistance is assumed to be proportional to percent area carotid stenosis. Theoretical solutions use mean systemic arterial pressure of 100mmHg and key clinical values of patient collateral vascular resistance. Clinical solutions use patient measured systemic arterial pressures and carotid stump pressures. The solutions are given as patient specific cerebral blood flow and reserve cerebral blood flow curves over the range of diameter carotid stenosis. Results. Normal regional cerebral blood flow of 50ml/min/100g is predicted to be maintained up to 65% diameter carotid stenosis as reserve blood flow is reduced. With further progression of carotid stenosis to occlusion approximately half of patients are predicted to develop some reduction in cerebral blood flow. However, only about 20% of patients have a decrease in cerebral blood flow below the 30ml/min/100g threshold for cerebral ischemic symptoms. Approximately 10% of patients are predicted to develop regional cerebral blood flow less than the 18ml/min/100g threshold for irreversible ischemic injury. The model predicts critical carotid artery stenosis to be between 65% and 71% diameter depending on mean systemic arterial pressure. With higher degrees of stenosis carotid artery blood flow cannot maintain normal cerebral flow without the contribution of collateral flow. The predicted magnitude of carotid energy dissipation between 60% and 90% stenosis is consistent with observed cervical bruit intensity. Predicted patient specific cerebral blood flow reserve is adequate to prevent significant cerebral ischemia in the majority of patients. Conclusions. Patient specific collateral vascular resistance blood flow curves predict regional cerebral blood flow and blood flow reserve as a function of the degree of diameter carotid artery stenosis. The carotid component of cerebral blood flow is predicted to maintain normal cerebral blood flow up to a critical carotid diameter stenosis of 65% to 71%. Collateral blood flow is necessary to maintain normal cerebral flow at higher degrees of carotid stenosis. The clinical model predicts that many patients do not have sufficient collateral flow to prevent a decrease in cerebral flow should carotid stenosis progress to high grade or occlusion. However, only about 10% of patients are predicted to develop irreversible regional cerebral ischemic injury. Estimated carotid stenosis energy dissipation magnitudes agree with observed cervical bruit intensity. Correlation of predicted cerebral reserve blood flow curves with clinically measured cerebrovascular reactivity/reserve has the potential to predict the probability of future cerebral ischemia in asymptomatic patients with 60% to 80% stenosis.

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