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Purpose As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality. Methods Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. Results 44,814 patients from 474 hospitals in 27 countries were available for analysis. Death was more frequent amongst patients admitted directly to critical care after surgery (critical care: 103/4317 patients [2%], standard ward: 99/39,566 patients [0.3%]; adjusted OR 3.01 [2.10–5.21]; p  < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p  = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery ( p  = 0.26), critical care admission to treat complications ( p  = 0.33), or provision of critical care beds ( p  = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. Conclusions We did not identify any survival benefit from critical care admission following surgery.

To mitigate the effects of coronavirus disease 2019 (COVID-19), jurisdictions worldwide ramped down nonemergent surgeries, creating a global surgical backlog. We sought to estimate the size of the nonemergent surgical backlog during COVID-19 in Ontario, Canada, and the time and resources required to clear the backlog. We used 6 Ontario or Canadian population administrative sources to obtain data covering part or all of the period between Jan. 1, 2017, and June 13, 2020, on historical volumes and operating room throughput distributions by surgery type and region, and lengths of stay in ward and intensive care unit (ICU) beds. We used time series forecasting, queuing models and probabilistic sensitivity analysis to estimate the size of the backlog and clearance time for a +10% (+1 day per week at 50% capacity) surge scenario. Between Mar. 15 and June 13, 2020, the estimated backlog in Ontario was 148 364 surgeries (95% prediction interval 124 508–174 589), an average weekly increase of 11 413 surgeries. Estimated backlog clearance time is 84 weeks (95% confidence interval [CI] 46–145), with an estimated weekly throughput of 717 patients (95% CI 326–1367) requiring 719 operating room hours (95% CI 431–1038), 265 ward beds (95% CI 87–678) and 9 ICU beds (95% CI 4–20) per week. The magnitude of the surgical backlog from COVID-19 raises serious implications for the recovery phase in Ontario. Our framework for modelling surgical backlog recovery can be adapted to other jurisdictions, using local data to assist with planning.

Millions of elective surgical procedures were cancelled worldwide during the first wave of the COVID-19 pandemic.1 This enabled redistribution of staff and resources to provide care for patients with COVID-19 and addressed evidence that perioperative SARS-CoV-2 infection increases postoperative mortality.2 Although some hospitals established COVID-19-free surgical pathways to create safe elective surgery capacity,3 the National Health Service (NHS) in England has not returned to pre-pandemic elective surgery activity levels. [...]we did not explore regional variation, which could arise as a result of differences in resource availability, accessibility of COVID-19-free surgical pathways, or baseline surgical case mix. [...]we have not addressed differences between surgical specialties.

Minimally invasive approach for reversal of Hartmann's procedure remains understudied. This study examined the outcomes associated with open and minimally invasive approaches for colostomy reversal in a national cohort. The 2012-2022 American College of Surgeons National Surgical Quality Improvement Program participant use file data was queried to identify all adult (≥18 years) patients undergoing elective open or minimally invasive colostomy takedown. Multivariable regression models were developed to assess the associations between operative modalities and outcomes of interest, including overall complications (cardiac, respiratory, infectious, wound, renal and thromboembolic postoperative sequelae as well as reoperation and transfusion), operative duration, postoperative length of stay, and 30-day Readmissions. Among the 20,163 patients who underwent colostomy takedown during the study period, 6,180 (30.7%) had a minimally invasive reversal. Utilization of minimally invasive colostomy reversal increased from 18.2% in 2012 to 41.9% in 2022 (nptrend < 0.001). Following risk adjustment, minimally invasive colostomy takedown was associated with reduced odds of overall complications compared to the open approach (AOR 0.56, 95% CI 0.51-0.62). The minimally invasive approach was associated with decremental operative duration by 16.9 minutes (95% CI 13.6 to 20.2 minutes) and postoperative length of stay by 1.70 days (95% CI 1.56 to 1.84 days), as well as decreased odds of 30-day readmission (AOR 0.75, 95% CI 0.67-0.85). Over the past decade, utilization of minimally invasive colostomy reversal has more than doubled and yielded lower overall complication rates compared to the open approach. Our findings suggest that the minimally invasive approach may be appropriate for colostomy takedown in suitable cases.

Purpose Due to the lack of evidence, it was the aim of the study to investigate current possible cutbacks in orthopaedic healthcare due to the coronavirus disease 2019 pandemic (COVID-19). Methods An online survey was performed of orthopaedic surgeons in the German-speaking Arthroscopy Society (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA). The survey consisted of 20 questions concerning four topics: four questions addressed the origin and surgical experience of the participant, 12 questions dealt with potential cutbacks in orthopaedic healthcare and 4 questions addressed the influence of the pandemic on the particular surgeon. Results Of 4234 contacted orthopaedic surgeons, 1399 responded. Regarding arthroscopic procedures between 10 and 30% of the participants stated that these were still being performed—with actual percentages depending on the specific joint and procedure. Only 6.2% of the participants stated that elective total joint arthroplasty was still being performed at their centre. In addition, physical rehabilitation and surgeons’ postoperative follow-ups were severely affected. Conclusion Orthopaedic healthcare services in Austria, Germany, and Switzerland are suffering a drastic cutback due to COVID-19. A drastic reduction in arthroscopic procedures like rotator cuff repair and cruciate ligament reconstruction and an almost total shutdown of elective total joint arthroplasty were reported. Long-term consequences cannot be predicted yet. The described disruption in orthopaedic healthcare services has to be viewed as historic. Level of evidence V.

Reports on emergency surgery performed soon after a COVID-19 infection that are not controlled for premorbid risk-factors show increased 30-day mortality and pulmonary complications. This contributed to a virtual cessation of elective surgery during the pandemic surge. To inform evidence-based guidance on the decisions for surgery during the recovery phase of the pandemic, we compare 30-day outcomes in patients testing positive for COVID-19 before their operation, to contemporary propensity-matched COVID-19 negative patients undergoing the same procedures. This prospective multicentre study included all patients undergoing surgery at 170 Veterans Health Administration (VA) hospitals across the United States. COVID-19 positive patients were propensity matched to COVID-19 negative patients on demographic and procedural factors. We compared 30-day outcomes between COVID-19 positive and negative patients, and the effect of time from testing positive to the date of procedure (≤10 days, 11–30 days and >30 days) on outcomes. Between March 1 and August 15, 2020, 449 COVID-19 positive and 51,238 negative patients met inclusion criteria. Propensity matching yielded 432 COVID-19 positive and 1256 negative patients among whom half underwent elective surgery. Infected patients had longer hospital stays (median seven days), higher rates of pneumonia (20.6%), ventilator requirement (7.6%), acute respiratory distress syndrome (ARDS, 17.1%), septic shock (13.7%), and ischemic stroke (5.8%), while mortality, reoperations and readmissions were not significantly different. Higher odds for ventilation and stroke persisted even when surgery was delayed 11–30 days, and for pneumonia, ARDS, and septic shock >30 days after a positive test. 30-day pulmonary, septic, and ischaemic complications are increased in COVID-19 positive, compared to propensity score matched negative patients. Odds for several complications persist despite a delay beyond ten days after testing positive. Individualized risk-stratification by pulmonary and atherosclerotic comorbidities should be considered when making decisions for delaying surgery in infected patients. •COVID-19 infection does not increase 30-day postoperative mortality.•COVID-19 patients have higher postoperative pulmonary, ischemic, and septic complications.•Odds of perioperative complications elevated for up to 1 month after positive test.

ObjectThe COVID-19 pandemic has disrupted all aspects of society globally. As healthcare resources had to be preserved for infected patients, and the risk of in-hospital procedures escalated for uninfected patients and staff, neurosurgeons around the world have had to postpone non-emergent procedures. Under these unprecedented conditions, the decision to defer cases became increasingly difficult as COVID-19 cases skyrocketed.MethodsData was collected by self-reporting surveys during two discrete periods: the principal survey accrued responses during 2 weeks at the peak of the global pandemic, and the supplemental survey accrued responses after that to detect changes in opinions and circumstances. Nine hypothetical surgical scenarios were used to query neurosurgeons’ opinion on the risk of postponement and the urgency to re-schedule the procedures. An acuity index was generated for each scenario, and this was used to rank the nine cases.ResultsThere were 494 respondents to the principal survey from 60 countries. 258 (52.5%) reported that all elective cases and clinics have been shut down by their main hospital. A total of 226 respondents (46.1%) reported that their operative volume had dropped more than 50%. For the countries most affected by COVID-19, this proportion was 54.7%. There was a high degree of agreement among our respondents that fast-evolving neuro-oncological cases are non-emergent cases that nonetheless have the highest risk in postponement, and selected vascular cases may have high acuity as well.ConclusionWe report on the impact of COVID-19 on neurosurgeons around the world. From their ranking of the nine case scenarios, we deduced a strategic scheme that can serve as a guideline to triage non-emergent neurosurgical procedures during the pandemic. With it, hopefully, neurosurgeons can continue to serve their patients without endangering them either neurologically or risking their exposure to the deadly virus.

Background To calculate hospital surge capacity, achieved via hospital provision interventions implemented for the emergency treatment of coronavirus disease 2019 (COVID-19) and other patients through March to May 2020; to evaluate the conditions for admitting patients for elective surgery under varying admission levels of COVID-19 patients. Methods We analysed National Health Service (NHS) datasets and literature reviews to estimate hospital care capacity before the pandemic (pre-pandemic baseline) and to quantify the impact of interventions (cancellation of elective surgery, field hospitals, use of private hospitals, deployment of former medical staff and deployment of newly qualified medical staff) for treatment of adult COVID-19 patients, focusing on general and acute (G&A) and critical care (CC) beds, staff and ventilators. Results NHS England would not have had sufficient capacity to treat all COVID-19 and other patients in March and April 2020 without the hospital provision interventions, which alleviated significant shortfalls in CC nurses, CC and G&A beds and CC junior doctors. All elective surgery can be conducted at normal pre-pandemic levels provided the other interventions are sustained, but only if the daily number of COVID-19 patients occupying CC beds is not greater than 1550 in the whole of England. If the other interventions are not maintained, then elective surgery can only be conducted if the number of COVID-19 patients occupying CC beds is not greater than 320. However, there is greater national capacity to treat G&A patients: without interventions, it takes almost 10,000 G&A COVID-19 patients before any G&A elective patients would be unable to be accommodated. Conclusions Unless COVID-19 hospitalisations drop to low levels, there is a continued need to enhance critical care capacity in England with field hospitals, use of private hospitals or deployment of former and newly qualified medical staff to allow some or all elective surgery to take place.

BackgroundWe aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. Methods: Vizient 2015–2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0.Results9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR.ConclusionOur analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.

BACKGROUND:An association between weekend health care delivery and poor outcomes has become known as the “weekend effect.” Evidence for such an association among surgery patients has not previously been synthesized. OBJECTIVE:To systematically review associations between weekend surgical care and postoperative mortality. METHODS:We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models. RESULTS:Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97–1.11); Wednesday OR=1.08 (95% CI=0.98–1.19); Thursday OR=1.12 (95% CI=1.03–1.22); Friday OR=1.24 (95% CI=1.10–1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08–1.49). CONCLUSIONS:Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.