Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...
Takedown of a temporary ostomy has a low mortality but a nonnegligible morbidity. The stoma location (large vs. small bowel) has a higher impact than the type of stoma construction (end vs. loop) on the incidence and severity of complications.
BACKGROUND: Given the significant perioperative risks and costs of total mesorectal excision, minimally invasive transanal surgical approaches have grown in popularity for early rectal cancer and rectal polyps. This article discusses a transanal robotic surgery technique to perform full-thickness resections of benign and malignant rectal neoplasms. OBJECTIVE: The purpose of this study was to describe an initial experience with robotic transanal minimally invasive surgery. DESIGN: This was a retrospective cohort study of consecutive patients who underwent robotic transanal minimally invasive surgery. SETTINGS: The study was conducted at a high-volume colorectal surgery practice with a large health maintenance organization. PATIENTS: Patients at Southern California Kaiser Permanente with early rectal cancer and rectal polyps amenable to transanal excision were included. INTERVENTIONS: Transanal resection of rectal tumors were removed using robotic transanal minimally invasive surgery. MAIN OUTCOME MEASURES: Local recurrence of rectal pathology was measured. RESULTS: A total of 58 patients underwent robotic transanal minimally invasive surgery with full-thickness rectal resection by 4 surgeons for the following indications: rectal cancer (n = 28), rectal polyp (n = 18), rectal carcinoid (n = 11), and rectal GI stromal tumor (n = 1). Mean operative time was 66.2 minutes (range, 17–180 min). The mean tumor height from the anal verge was 8.8 cm (range, 4–14 cm), and the mean specimen size was 3.3 cm (range, 1.3–8.2 cm). A total of 57 (98.3%) of 58 specimens were intact, and 55 (94.8%) of 58 specimens had negative surgical margins. At a mean follow-up of 11.5 months (range, 0.3–33.3 mo), 3 patients (5.5%) developed local recurrences, and all underwent successful salvage surgery. LIMITATIONS: The study was limited by being a retrospective, nonrandomized trial with short follow-up. CONCLUSIONS: Robotic transanal minimally invasive surgery is a safe, oncologically effective surgical approach for rectal polyps and early rectal cancers. It offers the oncologic benefits and perioperative complication profile of other transanal minimally invasive surgical approaches but also enhances surgeon ergonomics and provides an efficient transanal rectal platform. See Video Abstract at http://links.lww.com/DCR/A759.
With a reasonable time commitment, surgical residents are capable of learning about palliative and end-of-life care. Surgical residents think that understanding palliative care is a useful part of their training, a sentiment that is still evident 3 months later.
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