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1: Surgical site infection and its associated factors in Ethiopia: A systematic review and meta-analysis
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Posted 30 Dec 2019

Surgical site infection and its associated factors in Ethiopia: A systematic review and meta-analysis
1,997 downloads medRxiv surgery

Wondimeneh Shibabaw Shiferaw, Yared Asmare Aynalem, Tadesse Yirga Akalu, Pammla Margaret Petrucka

BackgroundDespite being a preventable complication of surgical procedures, surgical site infections (SSIs) continue to threaten public health with significant impacts on the patients and the health-care human and financial resources. With millions affected globally, there issignificant variation in the primary studies on the prevalence of SSIs in Ethiopia. Therefore, this study aimed to estimate the pooled prevalence of SSI and its associated factors among postoperative patients in Ethiopia. MethodsPubMed, Scopus, Psyinfo, African Journals Online, and Google Scholar were searched for studies that looked at SSI in postoperative patients. A funnel plot and Eggers regression test were used to determine publication bias. The I2 statistic was used to check heterogeneity between the studies. DerSimonian and Laird random-effects model was applied to estimate the pooled effect size, odds ratios (ORs), and 95% confidence interval (CIs) across studies. The subgroup analysis was conducted by region, sample size, and year of publication. Sensitivity analysis was deployed to determine the effect of a single study on the overall estimation. Analysis was done using STATA Version 14 software. ResultA total of 24 studies with 13,136 study participants were included in this study. The estimated pooled prevalence of SSI in Ethiopia was 12.3% (95% CI: 10.19, 14.42). Duration of surgery > 1 hour (AOR = 1.78; 95% CI: 1.08 -2.94), diabetes mellitus (AOR = 3.25; 95% CI: 1.51-6.99), American Society of Anaesthesiologists score >1 (AOR = 2.51; 95% CI: 1.07-5.91), previous surgery (AOR = 2.5; 95% CI: 1.77-3.53), clean-contaminated wound (AOR = 2.15; 95% CI: 1.52-3.04), and preoperative hospital stay > 7 day (AOR = 5.76; 95% CI: 1.15-28.86), were significantly associated with SSI. ConclusionThe prevalence of SSI among postoperative patients in Ethiopia remains high with a pooled prevalence of 12.3% in 24 extracted studies. Therefore, situation based interventions and region context-specific preventive strategies should be developed to reduce the prevalence of SSI among postoperative patients.

2: The validation of the original and modified Caprini score in COVID-19 patients
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Posted 23 Jun 2020

The validation of the original and modified Caprini score in COVID-19 patients
1,246 downloads medRxiv surgery

Sergey Tsaplin, Ilya Schastlivtsev, Kirill Lobastov, Sergey Zhuravlev, Victor Barinov, Joseph Caprini

Objective. The study aimed to validate the original Caprini score and its modifications considering coronavirus disease (COVID-19) as a severe prothrombotic condition in patients admitted to the hospital with confirmed infection. Methods. The relevant data were extracted from the electronic medical records with the implemented Caprini score and were evaluated retrospectively. The score was calculated twice: by the physician at the admission and by the investigator at discharge or after death. The second calculation at discharge, considered additional risk factors that occurred during inpatient treatment. Besides the original Caprini score (a version of 2005), the modified version added the elevation of D-dimer and specific scores for COVID-19 as follows: 2 points for asymptomatic, 3 points for symptomatic and 5 points for symptomatic infection with positive D-dimer, were evaluated in a retrospective manner. The primary endpoint was symptomatic venous thromboembolism (VTE) confirmed by appropriate imaging testing or dissection. The secondary endpoint included the unfavorable outcome as a combination of symptomatic VTE, admission to the intensive care unit, the requirement for invasive mechanical ventilation, and death. The association of eight different versions of the Caprini score with outcomes was evaluated. Results. Totally 168 patients (83 males and 85 females at the age of 58.3{+/-}12.7 years old) were admitted to the hospital between April 30 and May 29, 2020, and were discharged or died up to the time of data analysis. The original Caprini score varied between 2-12 (5.4{+/-}1.8) at the admission and between 2-15 (5.9{+/-}2.5) at discharge or death. The presence of the virus increased these scores and resulted in an increased score with the maximal value for those including COVID-19 points (10.0{+/-}3.0). Patients received prophylactic (2.4%), intermediate (76.8%), or therapeutic (20.8%) doses of enoxaparin. Despite this, the symptomatic VTE was detected in 11 (6.5%) and unfavorable outcomes in 31 (18.5%) patients. The Caprini score of all eight versions demonstrated a significant association with VTE with the highest predictability for the original scale when assessed at discharge. Supplementation of the original score by elevated D-dimer improved predictability only at the admission. Four versions of the Caprini score calculated at the admission had a significant correlation with the unfavorable outcome with the minor advantages of specific COVID-19 points. Conclusion. The study identified a significant correlation between the Caprini score and the risk of VTE or unfavorable outcomes in COVID-19 patients. All models, including specific COVID-19 scores, showed high predictability with minor differences.

3: 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
1,035 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.

4: A propensity score matched study: Predictive signs of anastomotic leakage after gastric cancer surgery and the role of CT
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Posted 29 Apr 2020

A propensity score matched study: Predictive signs of anastomotic leakage after gastric cancer surgery and the role of CT
920 downloads medRxiv surgery

Birendra Kumar Sah, Yang Zhang, Huan Zhang, Jian Li, Wentao Liu, Chao Yan, Chen Li, Min Yan, Zheng Gang Zhu

Background: Anastomotic leakage is a critical postoperative complication after gastric cancer surgery. Previous studies have not specified radiological findings of anastomotic leakage. We investigated the potential burden caused by postoperative anastomotic leakage and explored the objective appearances of anastomotic leakage on computed tomography (CT) examination. Methods: Gastric cancer patients who underwent curative gastrectomy and had a CT examination after surgery were included in this study. Propensity score (PS) matching generated 70 cases (35 cases of anastomotic leakage and 35 cases of no anastomotic leak) among 210 eligible cases. Univariate and multivariate analyses were used to identify the predictive variables of CT findings. Results: More severe postoperative complications were observed in patients who had an anastomotic failure than those without anastomotic leakage(p<0.05). The median number of postoperative days (PODs) was 18 days for patients with no anastomotic leak, but the length of stay was almost three times longer (50 days) in patients with anastomotic leakage(p<0.05). In the univariate analysis, we observed a significant association between anastomotic leakage and five CT variables, including pneumoperitoneum, pneumoseroperitoneum (intra-abdominal accumulation of mixed gas and fluid), accumulation of extraluminal gas at the anastomosis site, seroperitoneum and extraluminal fluid collection at the anastomosis site (p<0.05). The multivariate analysis of the CT parameters revealed that the accumulation of extraluminal gas at the anastomosis site is the independent diagnostic parameters of a postoperative anastomotic leakage (p<0.05). Conclusions: The occurrence of an anastomotic leakage significantly compromises the patients and increases the treatment burden. The CT variables of this study are beneficial to rule out anastomotic leakage after gastric cancer surgery. Extraluminal gas at the anastomosis site is highly suggestive of anastomotic leakage.

5: Machine learning to predict early recurrence after oesophageal cancer surgery
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Posted 03 Jul 2019

Machine learning to predict early recurrence after oesophageal cancer surgery
881 downloads medRxiv surgery

Saqib A Rahman, Robert C Walker, Megan A Lloyd, Ben L Grace, Gijs I van Boxel, Feike Kingma, Jelle P. Ruurda, Richard van Hillegersberg, Scott Harris, Simon Parsons, Stuart Mercer, Ewen A Griffiths, J.Robert O’Neill, Richard Turkington, Rebecca C Fitzgerald, Timothy J Underwood, On behalf of the OCCAMS Consortium, the full list of contributors is displayed in acknowledgements

ObjectiveTo develop a predictive model for early recurrence after surgery for oesophageal adenocarcinoma using a large multi-national cohort. Summary Background DataEarly cancer recurrence after oesophagectomy is a common problem with an incidence of 20-30% despite the widespread use of neoadjuvant treatment. Quantification of this risk is difficult and existing models perform poorly. Machine learning techniques potentially allow more accurate prognostication and have been applied in this study. MethodsConsecutive patients who underwent oesophagectomy for adenocarcinoma and had neoadjuvant treatment in 6 UK and 1 Dutch oesophago-gastric units were analysed. Using clinical characteristics and post-operative histopathology, models were generated using elastic net regression (ELR) and the machine learning methods random forest (RF) and XG boost (XGB). Finally, a combined (Ensemble) model of these was generated. The relative importance of factors to outcome was calculated as a percentage contribution to the model. ResultsIn total 812 patients were included. The recurrence rate at less than 1 year was 29.1%. All of the models demonstrated good discrimination. Internally validated AUCs were similar, with the Ensemble model performing best (ELR=0.785, RF=0.789, XGB=0.794, Ensemble=0.806). Performance was similar when using internal-external validation (validation across sites, Ensemble AUC=0.804). In the final model the most important variables were number of positive lymph nodes (25.7%) and vascular invasion (16.9%). ConclusionsThe derived model using machine learning approaches and an international dataset provided excellent performance in quantifying the risk of early recurrence after surgery and will be useful in prognostication for clinicians and patients. DRAFT VISUAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=110 SRC="FIGDIR/small/19001073v1_ufig1.gif" ALT="Figure 1"> View larger version (26K): org.highwire.dtl.DTLVardef@2f60b7org.highwire.dtl.DTLVardef@76bfb6org.highwire.dtl.DTLVardef@2469deorg.highwire.dtl.DTLVardef@a27d47_HPS_FORMAT_FIGEXP M_FIG C_FIG Icons taken from www.flaticon.com, made by Freepik, smashicons, and prettycons. Reproduced under creative commons attribution license MINI-ABSTRACTEarly recurrence after surgery for adenocarcinoma of the oesophagus is common. We derived a risk prediction model using modern machine learning methods that accurately predicts risk of early recurrence using post-operative pathology

6: Distinguish Coronavirus Disease 2019 Patients in General Surgery Emergency by CIAAD Scale: Development and Validation of a Prediction Model Based on 822 Cases in China
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Posted 23 Apr 2020

Distinguish Coronavirus Disease 2019 Patients in General Surgery Emergency by CIAAD Scale: Development and Validation of a Prediction Model Based on 822 Cases in China
782 downloads medRxiv surgery

Bangbo Zhao, Yingxin Wei, Wenwu Sun, Cheng Qin, Xingtong Zhou, Zihao Wang, Tianhao Li, Hongtao Cao, Weibin Wang, Yujun Wang

IMPORTANCE In the epidemic, surgeons cannot distinguish infectious acute abdomen patients suspected COVID-19 quickly and effectively. OBJECTIVE To develop and validate a predication model, presented as nomogram and scale, to distinguish infectious acute abdomen patients suspected coronavirus disease 2019 (COVID-19). DESIGN Diagnostic model based on retrospective case series. SETTING Two hospitals in Wuhan and Beijing, China. PTRTICIPANTS 584 patients admitted to hospital with laboratory confirmed SARS-CoV-2 from 2 Jan 2020 to15 Feb 2020 and 238 infectious acute abdomen patients receiving emergency operation from 28 Feb 2019 to 3 Apr 2020. METHODS LASSO regression and multivariable logistic regression analysis were conducted to develop the prediction model in training cohort. The performance of the nomogram was evaluated by calibration curves, receiver operating characteristic (ROC) curves, decision curve analysis (DCA) and clinical impact curves in training and validation cohort. A simplified screening scale and managing algorithm was generated according to the nomogram. RESULTS Six potential COVID-19 prediction variables were selected and the variable abdominal pain was excluded for overmuch weight. The five potential predictors, including fever, chest computed tomography (CT), leukocytes (white blood cells, WBC), C-reactive protein (CRP) and procalcitonin (PCT), were all independent predictors in multivariable logistic regression analysis (p[&le;]0.001) and the nomogram, named COVID-19 Infectious Acute Abdomen Distinguishment (CIAAD) nomogram, was generated. The CIAAD nomogram showed good discrimination and calibration (C-index of 0.981 (95% CI, 0.963 to 0.999) and AUC of 0.970 (95% CI, 0.961 to 0.982)), which was validated in the validation cohort (C-index of 0.966 (95% CI, 0.960 to 0.972) and AUC of 0.966 (95% CI, 0.957 to 0.975)). Decision curve analysis revealed that the CIAAD nomogram was clinically useful. The nomogram was further simplified into the CIAAD scale. CONCLUSIONS We established an easy and effective screening model and scale for surgeons in emergency department to distinguish COVID-19 patients from infectious acute abdomen patients. The algorithm based on CIAAD scale will help surgeons manage infectious acute abdomen patients suspected COVID-19 more efficiently.

7: Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study
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Posted 20 Feb 2021

Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study
767 downloads medRxiv surgery

T E Abbott, A J Fowler, T. D. Dobbs, J Gibson, T. Shahid, P. Dias, A. Akbari, I S Whitaker, R M Pearse

ObjectivesTo confirm the incidence of perioperative SARS-CoV-2 infection and associated mortality after surgery. Design and settingAnalysis of routine electronic health record data from National Health Service (NHS) hospitals in England. MethodsWe extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between 1st January 2020 and 31st October 2020. The exposure was SARS-CoV-2 infection defined by ICD-10 codes. The primary outcome measure was 90-day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson co-morbidity index, index of multiple deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals. ResultsWe identified 1,972,153 patients undergoing surgery of whom 11,940 (0.6%) had SARS-CoV-2. In total, 19,100 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 2,618/11,940 [21.9%] vs No SARS-CoV-2: 16,482/1,960,213 [0.8%]; OR: 5.8 [5.5 - 6.1]; p<0.001). Amongst patients undergoing elective surgery 1,030/1,374,985 (0.1%) had SARS-CoV-2 of whom 83/1,030 (8.1%) died, compared with 1,092/1,373,955 (0.1%) patients without SARS-CoV-2 (OR: 29.0 [22.5 -37.3]; p<0.001). Amongst patients undergoing emergency surgery 9,742/437,891 (2.2%) patients had SARS-CoV-2, of whom 2,466/9,742 (25.3%) died compared with 14,817/428,149 (3.5%) patients without SARS-CoV-2 (OR: 5.7 [5.4 - 6.0]; p<0.001). ConclusionsThe low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed. Summary boxesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIHigh mortality rates have been reported amongst surgical patients who develop COVID-19 but we dont know how this compares to the concurrent surgical population unaffected by COVID-19. C_LIO_LIStrict infection prevention and control procedures have substantially reduced the capacity of surgical treatment pathways in many hospitals. C_LIO_LIThe very large backlog in delayed and cancelled surgical procedures is a growing public health concern. C_LI What this study addsO_LIFewer than 1 in 100 surgical patients are affected by COVID-19 in the English National Health Service. C_LIO_LIElective surgical patients who do develop COVID-19 are 30 times more likely to die while in hospital. C_LIO_LIInfection prevention and control procedures in NHS surgical pathways are highly effective but cannot be safely relaxed. C_LI

8: Perforated appendicitis: can it be a bedside diagnosis?
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Posted 01 May 2020

Perforated appendicitis: can it be a bedside diagnosis?
738 downloads medRxiv surgery

Maham Taraiq, Sara Malik, Eesha Yaqoob, Mehwish changez, Saad Javed, Ramlah Ghazanfor, Ghulam Khadija, Javaria Malik, Bilal Ahmad, Khawaja Rafay Ghazanfor

ABSTRACT INTRODUCTION: Appendicitis remains one of the most common causes of acute abdomen worldwide. It presents as a spectrum of disease ranging from an acutely inflamed appendix to a perforated one. where acutely inflamed can be managed conservatively, a perforated appendix always needs surgery to prevent complications like pelvic abscesses. Bedside diagnosis remains relevant in our setup. AIMS AND OBJECTIVES: To determine whether history, clinical examination, and basic laboratory investigations can help in confident bedside diagnosis of perforated appendicitis especially in the absence of sophisticated diagnostic modalities. MATERIALS AND METHODS: A retrospective case-control study was conducted. Hospital records of patients who underwent open appendectomy in the year 2016 were reviewed. Two groups of 100 patients each were made based on per operative findings. Appendices having macroscopic holes in the base or tip were labeled as perforated. Group A had acutely inflamed appendix and group b had perforated appendix. The patient's demographic details were taken from hospital admission tickets. Findings of history and examination were retrieved from treating resident and operating surgeon's notes. Data were analyzed through SPSS. RESULTS: Out of 200 patients the total number of males was 102 (51%) and females were 98 (49%). Mean age was 24.13+9.73 in males and 18.7+ 6.4 in females of group A and 26.0+10.1 in males and 20.56+7.53 in females of Group B. Group B showed a significant delay in presentation to emergency after the onset of pain (P = 0.022). Upon history and clinical examination, the presence of anorexia, malaise, generalized abdominal pain, guarding, mass in right iliac fossa were significantly associated with perforation. Whereas gender, fever, vomiting, and dysuria showed no association with perforation. CONCLUSION: Bedside conventional methods of history taking and examination remain a useful tool in anticipating perforated appendicitis. This helps surgeons in planning incisions and prioritizing patients on heavy operating lists. This remains especially relevant in resource-constrained setups where sophisticated modalities like CT scans are largely unavailable. KEYWORDS: Perforated appendicitis, Acute appendicitis

9: 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
682 downloads medRxiv surgery

A J Fowler, T. D. Dobbs, Yize I Wan, R. Laloo, S. Hui, D. Nepogodiev, A. Bhangu, I S Whitaker, R 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.

10: Enhanced recovery after surgery (ERAS) protocols is extermely beneficial in liver surgeries. A metaanalysis.
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Posted 16 Apr 2020

Enhanced recovery after surgery (ERAS) protocols is extermely beneficial in liver surgeries. A metaanalysis.
651 downloads medRxiv surgery


BACKGROUND: Enhanced recovery after surgery (ERAS) programs aim to improve postoperative outcomes.. This metaanalysis aims to evaluate the impact of ERAS programmes on outcomes following liver surgeries. METHODS: EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for studies comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those patients receiving conventional care. The primary outcome was occurrence of 30 day morbidity and mortality. Secondary outcomes included length of stay , functional recovery ,readmission rates,time to pass flatus,blood loss and hospital costs. RESULTS: Ten articles were included in the metaanalysis. 30 days morbidity and mortality was significantly less in ERAS group.Hospital stay, time to pass flatus, time to complete recovery and hospital costs were also significantly reduced due to ERAS protocols. Blood loss and readmission rates were also significantly less in ERAS group. CONCLUSIONS: The adoption of ERAS protocols significantly reduced morbidity, mortality hospital stay, readmission rates, time to recovery, hospital costs, time to pass flatus, blood loss and readmission rates.

11: The global impact of the first Coronavirus Disease 2019 (COVID-19) pandemic wave on vascular services
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Posted 17 Jul 2020

The global impact of the first Coronavirus Disease 2019 (COVID-19) pandemic wave on vascular services
640 downloads medRxiv surgery

Vascular and Endovascular Research Network, Ruth A Benson, Sandip Nandhra

Background: The Coronavirus Disease 2019 (COVID-19) pandemic is having an unprecedented impact on healthcare delivery. This international qualitative study captured the global impact on vascular patient care during the first pandemic wave. Methods: An online structured survey was used to collect regular unit-level data regarding the modification to a wide range of vascular services and treatment pathways on a global scale. Results: The survey commenced on 23rd March 2020 worldwide. Over six weeks, 249 vascular units took part in 53 countries (465 individual responses). Overall, 65% of units stopped carotid surgery for anyone except patients with crescendo symptoms or offered surgery on a case-by-case basis, 25% only intervened for symptomatic aortic aneurysms cancelling all elective repairs. For patients with symptomatic peripheral arterial disease 60% of units moved to an endovascular-first strategy. For patients who had previously undergone endovascular aortic aneurysm repair, 31.8% of units stopped all postoperative surveillance. Of those units regularly engaging in multidisciplinary team meetings, 59.5% of units stopped regular meetings and 39.1% had not replaced them. Further, 20% of units did not have formal personal protective equipment (PPE) guidelines in place and 25% reported insufficient PPE availability. Conclusions: The COVID-19 pandemic has had a major impact on vascular services worldwide. There will be a significant vascular disease burden awaiting screening and intervention after the pandemic.

12: 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.
598 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.

13: Multifocal breast cancers are more prevalent in BRCA2 versus BRCA1 mutation carriers
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Posted 13 Sep 2019

Multifocal breast cancers are more prevalent in BRCA2 versus BRCA1 mutation carriers
575 downloads medRxiv surgery

Alan D McCrorie, Susannah Ashfield, Aislinn Begley, Colin Mcilmunn, Patrick J. Morrison, Clinton Boyd, Bryony Eccles, Stephanie Greville-Heygate, Ellen R Copson, Ramsey I. Cutress, Diana M Eccles, Kienan I Savage, Stuart A McIntosh

Multifocal breast cancer is generally considered to be where two or more breast tumours are present within the same breast, but are clearly separated with no intervening in situ or invasive disease. It is seen in [~]10% of breast cancer cases. This study investigates multifocality prevalence in BRCA1/2 mutant patients via cross-sectional analysis. Data from 211 women with BRCA1/2 mutations (BRCA1 - 91), (BRCA2 - 120), with breast cancer were collected including age, tumour focality, size, type, grade, and receptor profile. The prevalence of multifocality within this group was 25%, but within subgroups, prevalence amongst BRCA2 carriers was more than double that of BRCA1 carriers (p=0.001). Women affected by multifocal tumours had proportionately higher oestrogen receptor positivity (p=0.001), lower triple negativity (p=0.004), and were more likely to be younger at diagnosis compared with those with unifocal tumours (p=0.039). Odds of a BRCA2 carrier developing multifocal cancer were almost four-fold higher than a BRCA1 carrier (OR: 3.71, CI: 1.77-7.78, p=0.001). BRCA2 carriers show much greater multifocality than those carrying BRCA1 - multifocal tumours are strongly associated with being both BRCA2 mutant and oestrogen receptor positive.

14: 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
555 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.

15: 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
548 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.

16: Minimizing Population Health Loss in Times of Scarce Surgical Capacity
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Posted 30 Jul 2020

Minimizing Population Health Loss in Times of Scarce Surgical Capacity
546 downloads medRxiv surgery

Benjamin Gravesteijn, Eline Krijkamp, Jan Busschbach, Geert Geleijnse, Isabel Retel Helmrich, Sophie Bruinsma, Celine van Lint, Ernest van Veen, Ewout Steyerberg, Cornelis Verhoef, Jan van Saase, Hester Lingsma, Robert Baatenburg de Jong, Value Based Operation Room Triage team collaborators

Background COVID-19 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model that supports prioritization of care from a utilitarian perspective, which is to minimize population health loss. Methods A cohort state-transition model was developed and applied to 43 semi-elective non-paediatric surgeries commonly performed in academic hospitals. Scenarios of delaying surgery from two weeks were compared with delaying up to one year, and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization global burden of disease study. For each surgery, the urgency was estimated as the average expected loss of Quality-Adjusted Life-Years (QALYs) per month. Results Given the best available evidence, the two most urgent surgeries were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 QALY loss/month, 95%-CI: 0.09-0.24) and transaortic valve implantation (0.15 QALY loss/month, 95%-CI: 0.09-0.24). The two least urgent surgeries were placing a shunt for dialysis (0.01, 95%-CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95%-CI: 0.01-0.02): these surgeries were associated with a limited amount of health lost on the waiting list. Conclusion Expected health loss due to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgeries to minimize population health loss in times of scarcity. This tool should yet be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.

17: Early Impact of COVID-19 Pandemic on Paediatric Surgical Practice in Nigeria: a National Survey of Paediatric Surgeons.
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Posted 25 May 2020

Early Impact of COVID-19 Pandemic on Paediatric Surgical Practice in Nigeria: a National Survey of Paediatric Surgeons.
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Ibukunolu O Ogundele, Felix M Alakaloko, Collins C Nwokoro, Emmanuel A Ameh

Introduction The novel Coronavirus disease has had significant impact on healthcare globally. Knowledge of this virus is evolving, definitive care is not yet known, and mortality is increasing. We assessed its initial impact on paediatric surgical practice in Nigeria, creating a benchmark for recommendations and future reference. Methods Survey of 120 paediatric surgeons from 50 centres to assess socio-demographics and specific domains of impact of COVID-19 on their services and training in Nigeria. Seventy four surgeons adequately responded. Responses have been analysed. Duplicate submissions for centres were excluded by combining and averaging the responses from centres with multiple respondents. Results Forty-six (92%) centres had suspended elective surgeries. All centres continued emergency surgeries but volume reduced in March by 31%. Eleven (22%) centres reported 13 suspended elective cases presenting as emergencies in March, accounting for 3% of total emergency surgeries. Nine (18%) centres adopted new modalities for managing selected surgical conditions: non-operative reduction of intussusception in 1(2%), antibiotic management of uncomplicated acute appendicitis in 5(10%), more conservative management of trauma and replacement of laparoscopic appendectomy with open surgery in 3(6%) respectively. Low perception of adequacy of Personal Protective Equipment (PPE) was reported in 35(70%) centres. Forty (80%) centres did not offer telemedicine for patients follow up. Twenty-nine (58%) centres had suspended academic training. Perception of safety to operate was low in 37(50%) respondents, indifferent in 24% and high in 26%. Conclusion Majority of paediatric surgical centres reported cessation of elective surgeries whilst continuing emergencies. There is however an acute decline in the volume of emergency surgeries. Adequate PPE need to be provided and preparations towards handling backlog of elective surgeries once the pandemic recedes. Further study is planned to more conclusively understand the full impact of this pandemic on children's surgery. Key words pandemic, COVID-19, children's surgery.

18: Efficacy and safety of erythropoietin for traumatic brain injury: a meta-analysis of randomized controlled trials
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Posted 23 Sep 2019

Efficacy and safety of erythropoietin for traumatic brain injury: a meta-analysis of randomized controlled trials
529 downloads medRxiv surgery

Motao Liu, Amy J. Wang, Gexin Zhao, Hua He, Ziv M Williams, Kejia Hu

ObjectiveRecent studies regarding the effects of erythropoietin (EPO) for treating traumatic brain injury (TBI) have been inconsistent. This study conducts a meta-analysis of randomized controlled trials (RCTs) to assess the safety and efficacy of EPO for TBI patients at various follow-up time points. MethodsA literature search was performed using PubMed, Web of Science, MEDLINE, Embase, Google Scholar and the Cochrane Library for RCTs studying EPO in TBI patients published through March 2019. Non-English manuscripts and non-human studies were excluded. The assessed outcomes include mortality, neurological recovery and associated adverse effects. Dichotomous variables are presented as risk ratios (RR) with a 95% confidence interval (CI). ResultsA total of seven RCTs involving 1197 TBI patients were included in this study. Compared to the placebo arm, treatment with EPO did not improve acute hospital mortality or short-term mortality. However, there was a significant improvement in mid-term (6 months) follow-up survival rates. EPO administration was not associated with neurological function improvement. Regarding adverse effects, EPO treatment did not increase the incidence of thromboembolic events or other associated adverse events. ConclusionsThis meta-analysis indicates a slight mortality benefit for TBI patients treated with EPO at mid-term follow-up. EPO does not improve in-hospital mortality, nor does it increase adverse events including thrombotic, cardiovascular and other associated complications. Our analysis did not demonstrate a significant beneficial effect of EPO intervention on the recovery of neurological function. Future RCTs are required to further characterize the use of EPO in TBI.

19: 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
496 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.

20: Study protocol for COvid-19 Vascular sERvice (COVER) study: The impact of the COVID-19 pandemic on the provision, practice and outcomes of vascular surgery
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Posted 29 May 2020

Study protocol for COvid-19 Vascular sERvice (COVER) study: The impact of the COVID-19 pandemic on the provision, practice and outcomes of vascular surgery
484 downloads medRxiv surgery

Vascular and Endovascular Research Network, Ruth A Benson, Dave C Bosanquet, Sandip Nandhra, Joseph Shalhoub, Athanasios Saratzis, Rachel Forsythe, Sarah Onida, George Dovell, Louise Hitchman, Nikesh Dattani, Ryan Preece, Graeme K Ambler, Christopher Imray

Background: The novel Coronavirus Disease 2019 (COVID-19) pandemic is having a profound impact on global healthcare. Shortages in staff, operating theatre space and intensive care beds has led to a significant reduction in the provision of surgical care. Even vascular surgery, often insulated from resource scarcity due to its status as an urgent specialty, has limited capacity due to the pandemic. Furthermore, many vascular surgical patients are elderly with multiple comorbidities putting them at increased risk of COVID-19 and its complications. There is an urgent need to investigate the impact on patients presenting to vascular surgeons during the COVID-19 pandemic. Methods and Analysis: The COvid-19 Vascular sERvice (COVER) study has been designed to investigate the worldwide impact of the COVID-19 pandemic on vascular surgery, at both service provision and individual patient level. COVER is running as a collaborative study through the Vascular and Endovascular Research Network (VERN) with the support of numerous national (Vascular Society of Great Britain and Ireland, British Society of Endovascular Therapy, British Society of Interventional Radiology, Rouleaux Club) and an evolving number of international organisations (Vascupedia, SingVasc, Audible Bleeding (USA), Australian and New Zealand Vascular Trials Network (ANZVTN)). The study has 3 Tiers: Tier 1 is a survey of vascular surgeons to capture longitudinal changes to the provision of vascular services within their hospital; Tier 2 captures data on vascular and endovascular procedures performed during the pandemic; and Tier 3 will capture any deviations to patient management strategies from pre-pandemic best practice. Data submission and collection will be electronic using online survey tools (Tier 1: SurveyMonkey for service provision data) and encrypted data capture forms (Tiers 2 and 3: REDCap for patient level data). Tier 1 data will undergo real-time serial analysis to determine longitudinal changes in practice, with country-specific analyses also performed. The analysis of Tier 2 and Tier 3 data will occur on completion of the study as per the pre-specified statistical analysis plan. Ethical Approval: Ethical approval from the UK Health Research Authority has been obtained for Tiers 2 and 3 (20/NW/0196 Liverpool Central). Participating centres in the UK will be required to seek local research and development approval. Non-UK centres will need to obtain a research ethics committee or institutional review board approvals in accordance with national and/or local requirements. ISRCTN: 80453162 (https://doi.org/10.1186/ISRCTN80453162) Ethical Approval: 20/NW/0196 Liverpool Central, IRAS: 282224

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