TY - JOUR
T1 - Resumption of elective colorectal surgery during COVID-19 and risk of death.
AU - McCarthy, Kathryn
AU - Myint, Phyo Kyaw
AU - Moug, Susan J
AU - Pearce, Lyndsay
AU - Braude, Philip
AU - Vilches-Moraga, Arturo
AU - Hewitt, Jonathan
AU - Carter, Ben
PY - 2020/7/17
Y1 - 2020/7/17
N2 - The ACPGBI have recently released recommendations for re-starting elective colorectal surgery to address the concerns that significant numbers of UK patients with colorectal cancer, inflammatory bowel disease and other colorectal conditions who have been deferred during this pandemic(REF). It is a credit to the specialty that most units have managed to continue with urgent cancer surgery through the pandemic, with leading units undertaking 4 to 5 urgent cases per week . Despite this there is now need to accommodate other patient groups who need colorectal surgery and have been placed on hold. The anxiety from patients about timely widening of services to reduce waiting time, against a backlog of willing surgeons trying to serve this need, in an already bulging set of waiting lists, and whilst stakeholders look on concerned over reduction in clinical activity.
We report on nosocomial or hospital acquired infection with COVID-19(1) . Our study included 1564 patients from 11 hospital sites throughout the UK, and one in Italy, and collected outcomes up to 28th April, 2020. The overall in-hospital mortality rate for patients with COVID was 27.2% (425/1564). Of the COVID-19 cases, the nosocomial infection rate was at least 12.5% (and could be much higher). The median patient age for nosocomial COVID was 80 years old (IQR, 71.5-86.5 years), and 73 years (IQR, 60,82 years) for patients admitted with community derived COVID infection. Nosocomial COVID patients were older and frailer (median level of frailty was moderately frail [CFS=6] versus vulnerable [CFS=4]) than the community acquired COVID group. It is reassuring that the risk of developing of COVID infection as a nosocomial infection after elective surgery is no higher than for other hospital acquired infections. It was also found that patients with nosocomial infection was associated with a modest reduction in risk in mortality, which may be attributed to timely care.
However, the biggest issue, is the significantly increased risk of death this group for patients undergoing routine procedures in the midst of a pandemic. When we consider that the National Bowel Cancer Audit reports a <2% risk of death with elective colorectal surgery for cancer (2), a figure of 27% would be unacceptably high. Similarly, data from CovidSurg reported in the Lancet reports that 30 day post-operative mortality was 23·8% (268 of 1128) in COVID patients rising to 38·0% (219 of 577) for those with pulmonary complications(3).
The decision making regarding the harm patients may come to by delaying surgery needs to be urgently weighed up against the high death rates seen in those who develop nosocomial COVID. Certainly for patients 80 years+ and frail who require elective surgery we would recommend a multi-disciplinary discussion between patient, carer, surgeon and geriatrician regarding delaying surgery longer than previously anticipated. Ahead of the second wave of COVID predicted this winter, we would urge patients 80 years and older to undergo an urgent frailty assessment with their GP in order to optimize their medical and functional status.
AB - The ACPGBI have recently released recommendations for re-starting elective colorectal surgery to address the concerns that significant numbers of UK patients with colorectal cancer, inflammatory bowel disease and other colorectal conditions who have been deferred during this pandemic(REF). It is a credit to the specialty that most units have managed to continue with urgent cancer surgery through the pandemic, with leading units undertaking 4 to 5 urgent cases per week . Despite this there is now need to accommodate other patient groups who need colorectal surgery and have been placed on hold. The anxiety from patients about timely widening of services to reduce waiting time, against a backlog of willing surgeons trying to serve this need, in an already bulging set of waiting lists, and whilst stakeholders look on concerned over reduction in clinical activity.
We report on nosocomial or hospital acquired infection with COVID-19(1) . Our study included 1564 patients from 11 hospital sites throughout the UK, and one in Italy, and collected outcomes up to 28th April, 2020. The overall in-hospital mortality rate for patients with COVID was 27.2% (425/1564). Of the COVID-19 cases, the nosocomial infection rate was at least 12.5% (and could be much higher). The median patient age for nosocomial COVID was 80 years old (IQR, 71.5-86.5 years), and 73 years (IQR, 60,82 years) for patients admitted with community derived COVID infection. Nosocomial COVID patients were older and frailer (median level of frailty was moderately frail [CFS=6] versus vulnerable [CFS=4]) than the community acquired COVID group. It is reassuring that the risk of developing of COVID infection as a nosocomial infection after elective surgery is no higher than for other hospital acquired infections. It was also found that patients with nosocomial infection was associated with a modest reduction in risk in mortality, which may be attributed to timely care.
However, the biggest issue, is the significantly increased risk of death this group for patients undergoing routine procedures in the midst of a pandemic. When we consider that the National Bowel Cancer Audit reports a <2% risk of death with elective colorectal surgery for cancer (2), a figure of 27% would be unacceptably high. Similarly, data from CovidSurg reported in the Lancet reports that 30 day post-operative mortality was 23·8% (268 of 1128) in COVID patients rising to 38·0% (219 of 577) for those with pulmonary complications(3).
The decision making regarding the harm patients may come to by delaying surgery needs to be urgently weighed up against the high death rates seen in those who develop nosocomial COVID. Certainly for patients 80 years+ and frail who require elective surgery we would recommend a multi-disciplinary discussion between patient, carer, surgeon and geriatrician regarding delaying surgery longer than previously anticipated. Ahead of the second wave of COVID predicted this winter, we would urge patients 80 years and older to undergo an urgent frailty assessment with their GP in order to optimize their medical and functional status.
M3 - Article
SN - 1462-8910
JO - COLORECTAL DISEASE
JF - COLORECTAL DISEASE
ER -
