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      Colorectal Surgery Outcomes in the United States during the COVID-19 Pandemic

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          Abstract

          Background

          The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic.

          Methods

          Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The pre-pandemic time period was defined from April 1, 2019-December 31, 2019. The pandemic time period was defined from April 1, 2020-December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression.

          Results

          Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery pre-pandemic, and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% pre-pandemic vs. 15.2% pandemic, p<0.001), with fewer laparoscopic cases (54.0% vs. 51.0%, p<0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity, as well as in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic.

          Conclusions

          Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.

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          Most cited references27

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          Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

          Daniel Dindo, Nicolas Demartines, Pierre-Alain Clavien (2004)
          Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
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            Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy

            Francesco Doglietto, Marika Vezzoli, Federico Gheza … (2020)
            Article 0 comments Cited 170 times – based on 0 reviews     Review now
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              Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study

              Eva Morris, Raphael Goldacre, Enti Spata … (2021)
              Background There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England. Methods Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated. Findings As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53–71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89–95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8–34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19–42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17–76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020. Interpretation The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England. Funding Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Surg Res
                Journal ID (iso-abbrev): J Surg Res
                Title: The Journal of Surgical Research
                Publisher: Published by Elsevier Inc.
                ISSN (Print): 0022-4804
                ISSN (Electronic): 1095-8673
                Publication date PMC-release: 23 January 2023
                Publication date (Electronic): 23 January 2023
                Affiliations
                [1 ]Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
                [2 ]Department of Surgery, NYU Langone Health, New York, NY, United States
                Author notes
                [∗ ]Corresponding Author: Bashar Safar, MBBS, Professor of Surgery, Chief of the Division of Colon and Rectal Surgery, NYU Langone Health, 530 First Ave, Suite 7V, New York, NY 10016
                Article
                Publisher Item ID: S0022-4804(23)00016-1
                DOI: 10.1016/j.jss.2022.12.041
                PMC ID: 9868386
                SO-VID: 37243569-b53f-4db1-88ea-e2e0a7be3185
                Copyright © © 2023 Published by Elsevier Inc.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 7 July 2022
                Date revision received : 2 December 2022
                Date accepted : 25 December 2022
                Categories
                Subject: Article

                Keywords: covid-19,colorectal surgery,morbidity,hospital length of stay,discharge destination,skilled care facilities
                Data availability:
                Keywords: covid-19, colorectal surgery, morbidity, hospital length of stay, discharge destination, skilled care facilities

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