RESUMEN
BACKGROUND: There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation. OBJECTIVE: To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change. DESIGN: An online survey of colorectal cancer service change globally in May and June 2020. PARTICIPANTS: Attending or consultant surgeons involved in the care of patients with colorectal cancer. MAIN OUTCOME MEASURES: Changes in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region. RESULTS: 191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need. CONCLUSIONS: The COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/terapia , Infecciones por Coronavirus/epidemiología , Procedimientos Quirúrgicos Electivos , Asignación de Recursos para la Atención de Salud , Neumonía Viral/epidemiología , Betacoronavirus/fisiología , COVID-19 , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Femenino , Gastroenterología/organización & administración , Gastroenterología/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud , Humanos , Masculino , Pandemias , Seguridad del Paciente , SARS-CoV-2RESUMEN
BACKGROUND: Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons' experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities. METHODS: An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate. RESULTS: The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities. CONCLUSIONS: Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic.
Asunto(s)
Betacoronavirus , Investigación Biomédica , Infecciones por Coronavirus , Endoscopía , Pandemias , Neumonía Viral , Investigación Biomédica/métodos , Investigación Biomédica/organización & administración , COVID-19 , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Europa (Continente) , Asignación de Recursos para la Atención de Salud/métodos , Asignación de Recursos para la Atención de Salud/estadística & datos numéricos , Humanos , Control de Infecciones/métodos , Pandemias/prevención & control , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , Pautas de la Práctica en Medicina/tendencias , SARS-CoV-2 , Sociedades Médicas , Cirujanos , Encuestas y CuestionariosRESUMEN
BACKGROUND: Surgical Site Infection (SSI) occurs in 9 % of laparoscopic colorectal surgery. Warming and humidifying carbon dioxide (CO2) used for peritoneal insufflation may protect against SSI by avoiding postoperative hypothermia (itself a risk factor for SSI). This study aimed to assess the impact of CO2 conditioning on postoperative hypothermia and SSI and to perform a cost-effectiveness analysis. METHODS: A retrospective cohort study of patients undergoing elective laparoscopic colorectal resection was performed at a single UK specialist centre. The control group (n = 123) received peritoneal insufflation with room temperature, dry CO2, whereas the intervention group (n = 123) received warm, humidified CO2 (using HumiGard™, Fisher & Paykel Healthcare). The outcomes were postoperative hypothermia, SSI and costs. Multivariate analysis was performed. RESULTS: A total of 246 patients were included in the study. The mean age was 68 (20-87) and mean BMI 28 (15-51). The primary diagnosis was cancer (n = 173), and there were no baseline differences between the groups. CO2 conditioning significantly decreased the incidence of postoperative hypothermia (odds ratio 0.10, 95 % CI 0.04-0.23), with hypothermic patients found to be at increased risk of SSI (odds ratio 4.0, 95 % CI 1.25-12.9). Use of conditioned CO2 significantly decreased the incidence of SSI by 66 % (p = 0.04). The intervention group incurred costs of £155 less per patient. The incremental cost-effectiveness ratio was negative. CONCLUSION: CO2 conditioning during laparoscopic colorectal surgery is a safe, feasible and a cost-effective intervention. It improves the quality of surgical care relating to SSI and postoperative hypothermia.
Asunto(s)
Neoplasias Colorrectales/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Calor , Humedad , Hipotermia/epidemiología , Laparoscopía/métodos , Neumoperitoneo Artificial/métodos , Infección de la Herida Quirúrgica/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Dióxido de Carbono , Estudios de Casos y Controles , Estudios de Cohortes , Colitis Ulcerosa/cirugía , Cirugía Colorrectal , Análisis Costo-Beneficio , Enfermedad de Crohn/cirugía , Procedimientos Quirúrgicos del Sistema Digestivo/economía , Diverticulitis del Colon/cirugía , Procedimientos Quirúrgicos Electivos , Estudios de Factibilidad , Femenino , Humanos , Hipotermia/economía , Insuflación , Laparoscopía/economía , Masculino , Persona de Mediana Edad , Análisis Multivariante , Peritoneo , Neumoperitoneo Artificial/economía , Periodo Posoperatorio , Estudios Retrospectivos , Infección de la Herida Quirúrgica/economía , Reino Unido/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Robotic equipment can greatly add to the ergonomics of a surgical procedure and pre-operative simulation can provide risk-free training of the surgeon leading to precision surgery and less trauma to the patient. Freehand(®) is a second-generation robotic camera-holding device, which has recently become available to laparoscopic surgeons. It is controlled by the operator selecting a direction using head movement followed by activation with a foot pedal. The purpose of this study was to assess the rate of skill acquisition in the use of the FreeHand(®) robotic laparoscope holder by a group of laparoscopic surgeons by enrolling them into a programme of training modules at The ICENI Centre, Colchester Hospital University, UK. MATERIAL AND METHODS: Twenty surgical registrars performed a series of exercises, escalating in difficulty, to test their skill in controlling the FreeHand(®) robot. Subjective and objective assessments were evaluated by an observer and by tracking analysis software created for this trial. RESULTS: The observed number of head movements showed a Percentage Performance Score (PPS) of 98% by the end of the third repetition of all exercises, the mean Total Head Movements Score (HMS) reached a plateau of performance at 72%. Fifty per cent of the participants selected 'Effective control of movements without difficulty' in the subjective evaluation by the end of the third repetition of exercises, while 35% selected 'competent intuitive movements'. CONCLUSION: The FreeHand(®) robotic laparoscope holder is a useful device, which is easy to operate and requires a very short course of training to achieve competence in its use.
Asunto(s)
Competencia Clínica , Laparoscopía/educación , Laparoscopía/métodos , Procedimientos Quirúrgicos Robotizados/educación , Procedimientos Quirúrgicos Robotizados/métodos , Diseño de Equipo , Humanos , Movimiento , Factores de TiempoRESUMEN
BACKGROUND: Manubriosternal joint (MSJ) dislocation is a rare but potentially serious injury that can be associated with concurrent injuries to ribs, lungs, or myocardium. Two distinct types of MSJ dislocation have been described in the literature: type I, involving posterior dislocation of the sternum due solely to direct trauma; and type II, involving the sternum being pushed anteriorly as a result of indirect trauma. Until now, the relationship between the nature of the forces acting on the sternum and the type of MSJ dislocation that results has been absolute, whereby indirect forces never cause a type I dislocation, and direct forces never result in a type II dislocation. OBJECTIVES: To describe a case demonstrating that type I MSJ dislocation can occur without direct trauma. CASE REPORT: A 14-year-old boy developed sternal pain accompanied by an audible crack while executing a maneuver on a trampoline that required hyperflexion of the thorax. A lateral chest radiograph demonstrated a type I manubriosternal dislocation normally associated with direct trauma, as opposed to the more typical type II dislocation pattern one would expect to find in a hyperflexion injury. CONCLUSION: MSJ dislocations are classified into two groups, depending on the position of the sternum in relation to the manubrium. Each type of dislocation has been ascribed to either direct forces (for type I dislocation) or indirect forces (for type II dislocation). This case highlights that it is possible to have a type I dislocation in the absence of any direct sternal trauma.