Background: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. Methods: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. Findings: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35À86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3À4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). Interpretation: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. Funding: This work did not receive funding.
Objective
In the United Kingdom, the COVID-19 pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic.
Methods
Data on all patients undergoing cardiothoracic surgery at a single tertiary referral centre in London was prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19 free environment including the pre-operative screening of all patients, the use of full personal protective equipment in areas with aerosol generating procedures, and separate treatment pathways for patients with and without the virus
Results
A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The pre-operative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on pre-operative screening tested positive post-operatively. However, one thoracic patient tested positive on intra-operative broncho-alveolar lavage.
Conclusion
Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of post-operative COVID-19 infection.
The transdermal therapeutic system (TTS) fentanyl has been designed for rate-controlled drug delivery. When the system is applied, a fentanyl depot concentrates in the upper skin layers. Plasma concentrations are not measurable until 2 hours after application, and it takes an 8-16 hr latency period until full clinical fentany effects are observed. Following removal, serum fentanyl concentrations decline gradually and fall to about 50% in approximately 16 hours. We report the case of a 77-year-old man with a history of severe arthritis, who was receiving transdermal fentanyl and developed respiratory failure after starting epidural diamorphine/bupivacaine for postoperative pain relief following radical nephrectomy.
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