Streamlining brain tumor surgery care during the COVID-19 pandemic: A case-control study

Abstract

Background The COVID-19 pandemic forced a reconsideration of surgical patient management in the setting of scarce resources and risk of viral transmission. Herein we assess the impact of implementing a protocol of more rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication for patients undergoing brain tumor surgery. Methods A case-control retrospective review was undertaken at a community hospital with a dedicated neurosurgery and otolaryngology team using minimally invasive surgical techniques, total intravenous anesthesia (TIVA) and early post-operative imaging protocols. All patients undergoing craniotomy or endoscopic endonasal removal of a brain, skull base or pituitary tumor were included during two non-overlapping periods: March 2019–January 2020 (pre-pandemic epoch) versus March 2020–January 2021 (pandemic epoch with streamlined care protocol implemented). Data collection included demographics, preoperative American Society of Anesthesiologists (ASA) status, tumor pathology, and tumor resection and remission rates. Primary outcomes were ICU utilization and hospital length of stay (LOS). Secondary outcomes were complications, readmissions and reoperations. Findings Of 295 patients, 163 patients were treated pre-pandemic (58% women, mean age 53.2±16 years) and 132 were treated during the pandemic (52% women, mean age 52.3±17 years). From pre-pandemic to pandemic, ICU utilization decreased from 92(54%) to 43(29%) of operations (p<0.001) and hospital LOS≤1 day increased from 21(12.2%) to 60(41.4%), p<0.001, respectively. For craniotomy cohort, median LOS was 2 days for both epochs; median ICU LOS decreased from 1 to 0 days (p<0.001), ICU use decreased from 73(80%) to 29(33%),(p<0.001). For endonasal cohort, median LOS decreased from 2 to 1 days; median ICU LOS was 0 days for both epochs; (p<0.001). There were no differences pre-pandemic versus pandemic in ASA scores, resection/remission rates, readmissions or reoperations. Conclusion This experience suggests the COVID-19 pandemic provided an opportunity for implementing a brain tumor care protocol to facilitate safely decreasing ICU utilization and accelerating discharge home without an increase in complications, readmission or reoperations. More rigorous patient education, recovery room assessment for non-ICU admission, earlier mobilization and post-discharge communication, layered upon a foundation of minimally invasive surgery, TIVA anesthesia and early post-operative imaging are possible contributors to these favorable trends.

COVID-19 and rhinological surgery

“…were not sent to the ICU. 34 Their protocol resulted in significant decrease in LOS while not increasing complication, reoperation, or 30-day readmission rates. 34 …”

“… 28 Given the potential for false negative tests from nasopharyngeal swabs and other methods for SARS-CoV-2 testing, several institutions test twice for patients preoperatively and recommend adopting certain safety techniques universally for both SARS-CoV-2 positive and negative patients. 33 , 34 Several studies have evaluated staff SARS-CoV-2 infections in the postoperative setting. Taha et.…”

“…such that it can be distributed elsewhere. 34 To facilitate streamlining, Mallari et. al shared the benefits of their care protocols in reducing resource utilization during the pandemic.…”

“…al shared the benefits of their care protocols in reducing resource utilization during the pandemic. 34 Their pandemic protocol included clearly communicating their goal for postoperative day (POD) one discharge to both the patient and family and to all members of the care team, ensuring prompt evaluations by staff and encouraging early mobilization by patients. 34 Furthermore, patients evaluated in the recovery room with normal postoperative courses (expected changes on CT, stable neurological exam, etc.)…”

Critical appraisal of minimally invasive keyhole surgery for intracranial meningioma in a large case series

“…For over a decade, we have used several minimally invasive approaches for brain tumors, particularly for skull base and parafalcine meningiomas that eliminate the need for fixed brain retraction by relying on gravity assistance and endoscopic visualization [ 27 – 35 ]. Except for our recent report on elderly meningioma patients and that by Burks et al, to our knowledge, there are no prior studies with over 40 patients treated with a minimally invasive keyhole paradigm for all intracranial meningiomas [ 26 , 33 ].…”