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...

Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and mortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra-and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.

No abstract

Primary hepatic tuberculosis is a rare entity and can closely mimic malignancy with respect to clinical presentation and imaging features. We identified five patients at a high volume tertiary care cancer center, whose clinical features and imaging closely mimicked primary liver malignancy or metastases but final histopathology was suggestive of hepatic tuberculosis. Three patients underwent a surgical resection whereas two were diagnosed on a biopsy. Anti-tuberculosis therapy was started for all the patients which was well tolerated. All patients are doing well at the time of the last follow up. This case series stresses the importance of having a high index of suspicion and preoperative biopsy in cases where imaging features are equivocal.

Background and Objectives There are reports of outcomes of elective major cancer surgery during the COVID‐19 pandemic. We evaluated if reinforcement of hand hygiene, universal masking, and distancing as a part of pandemic precautions led to a decrease in the incidence of surgical site infections (SSIs) in major oncologic resections. Methods Propensity score matching using the nearest neighbor algorithm was performed on 3123 patients over seven covariates (age, comorbidities, surgery duration, prior treatment, disease stage, reconstruction, and surgical wound type) yielding 2614 matched (pre‐COVID 1612 and COVID 1002) patients. Conditional logistic regression was used to identify if SSI incidence was lower amongst patients operated during the pandemic. Results There was a 4.2% (p = 0.006) decrease in SSI in patients operated during the pandemic. On multivariate regression, surgery during the COVID‐19 period (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.61–0.98; p = 0.03), prior chemoradiation (OR = 2.46; CI = 1.45–4.17; p < 0.001), duration of surgery >4 h (OR = 2.17; 95%CI = 1.55–3.05; p < 0.001) and clean contaminated wounds (OR = 2.50; 95% CI = 1.09–2.18; p = 0.012) were significantly associated with SSI. Conclusion Increased compliance with hand hygiene, near‐universal mask usage, and social distancing during the COVID‐19 pandemic possibly led to a 23% decreased odds of SSI in major oncologic resections. Extending these low‐cost interventions in the post‐pandemic era can decrease morbidity associated with SSI in cancer surgery.

PURPOSE The 2018 WHO health workforce report analyzing gender equity in 104 countries reported that although women constituted 70% of the workers, they were less likely to be employed full-time and faced a 28% gender pay gap. The ongoing COVID-19 pandemic has affected professional as well as personal lives of physicians. We conducted a survey among Indian physicians to understand this impact. METHODS A 31-point anonymized survey to evaluate the impact of the COVID-19 pandemic and resultant lockdown on physicians' domestic responsibilities was disseminated via e-mail and text messaging applications. Our aim was to evaluate whether the impact was gender-based and to look for differences in aspects of domestic work, childcare, and professional commitments. RESULTS We obtained 1,041 responses, of which 643 identified themselves as men and 393 as women. An increase in the domestic responsibilities during the lockdown was confirmed by 90% of the women compared with 82% men. More women than men were solely responsible for domestic chores (38.7% v 23.7%), managed their children's education (74% v 31%), and felt an adverse impact of the pandemic on their professional work (60.8% v 42.6%). Fewer women's spouses (57/359) than men's (174/594, P = .00001) were forced to take leave or work reduced hours, and double the proportion of women (3.5% v 1.5%) had to quit their jobs to manage responsibilities at home. CONCLUSION As the COVID-19 pandemic and the lockdown measures threw newer challenges, more women physicians than men (81% v 63%) shouldered the burden of increased domestic work and childcare. This survey highlights the need to re-examine the specific challenges faced by women physicians and identify means to support and empower them.

Background and Objectives Guidelines recommend deferral of elective surgery after COVID‐19. Delays in cancer surgeries may affect outcomes. We examined perioperative outcomes of elective cancer surgery in COVID‐19 survivors. The primary objective was 30‐day all‐cause postoperative mortality. The secondary objectives were 30‐day morbidity, and its association with COVID‐19 severity, and duration between COVID‐19 and surgery. Methods We collected data on age, gender, comorbidities, COVID‐19 severity, preoperative investigations, surgery performed, and intra and postoperative outcomes in COVID‐19 survivors who underwent elective cancer surgery at a tertiary‐referral cancer center. Results Three hundred and forty‐eight COVID‐19 survivors presented for elective cancer surgery. Of these, 332/348 (95%) patients had mild COVID‐19 and 311 (89%) patients underwent surgery. Among patients with repeat investigations, computerized tomography scan of the thorax showed the maximum new abnormalities (30/157, 19%). The 30‐day all‐cause mortality was 0.03% (1/311) and 30‐day morbidity was 17% (54/311). On multivariable analysis, moderate versus mild COVID‐19 (odds ratio [OR]: 1.95; 95% confidence interval  [CI]: 0.52–7.30; p = 0.32) and surgery within 7 weeks of COVID‐19 (OR: 0.61; 95% CI: 0.33–1.11; p = 0.10) were not associated with postoperative morbidity. Conclusions In patients who recover from mild to moderate COVID‐19, elective cancer surgery can proceed safely even within 7 weeks. Additional preoperative tests may not be indicated in these patients.

Background and Objectives The COVID‐19 pandemic, with high rate of asymptomatic infections and increased perioperative complications, prompted widespread adoption of screening methods. We analyzed the incidence of asymptomatic infection and perioperative outcomes in patients undergoing cancer surgery. We also studied the impact on subsequent cancer treatment in those with COVID‐19. Methods All patients who underwent elective and emergency cancer surgery from April to September 2020 were included. After screening for symptoms, a preoperative test was performed from nasopharyngeal and oropharyngeal swabs before the procedure. Patients were followed up for 30 days postoperatively and complications were noted. Results 2108 asymptomatic patients were tested, of which 200 (9.5%) tested positive. Of those who tested positive, 140 (70%) underwent the planned surgery at a median of 30 days from testing positive, and 20 (14.3%) had ≥ Grade III complications. Forty (20%) patients did not receive the intended treatment; 110 patients were retested in the Postoperative period, and 41 (37.3%) tested positive and 9(22%) patients died of COVID‐related complications. Conclusion Routine preoperative testing for COVID‐19 helps to segregate patients with asymptomatic infection. Higher complications occur in those who develop COVID‐19 in postoperative period. Prolonged delay in surgery after COVID infection may influence planned treatment.