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...

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OBJECTIVES: Atrial tachyarrhythmias occur in up to 25% of patients after major thoracic surgery. We examined risk factors for newonset atrial fibrillation (AF) following oesophagectomy in an attempt to guide prophylactic use of anti-arrhythmic strategies. METHODS: Data were extracted from a database of patients who underwent oesophagectomy between 1991 and 2009. Patients with pre-operative arrhythmias were excluded leaving 997 patients for further analysis. Univariate and multivariate logistic regression analyses were performed to identify factors predicting AF, and receiver operating characteristic curves were generated from a model using these predictors. Statistical significance was reflected in a P-value of <0.05. RESULTS: Patients who developed AF (n = 209; 20.96%) were older (median age 70.54 years vs. 66.9 years; P < 0.01) and included 141 males (67.4%) (P = 0.11). Patients with AF were noted to have a higher in-hospital mortality rate (n = 17; 8.1% vs. n = 34; 4.8%) (P = 0.04) and a longer stay in hospital (14 days vs. 12 days; P < 0.01). Multivariate analysis identified advanced age and neo-adjuvant chemotherapy to be independent predictors of the risk of developing AF. Assessment of discriminative ability of a predictive model revealed a cstatistic of just 0.62. CONCLUSIONS: Despite the identification of age and neo-adjuvant chemotherapy as predictors of AF, the moderate discriminative ability of predictive modelling does not support the use of prophylactic anti-arrhythmic drugs. However, the high incidence of AF after major thoracic surgery makes it necessary to understand its underlying mechanisms better before prophylactic strategies are considered.

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