Impact of the COVID-19 Pandemic on Urologic Oncology Surgery: Implications for Moving Forward

The COVID-19 pandemic has caused the destruction of routine hospital services globally, leading to an increase in the backlog of elective surgery cases. The aim of the study was to retrospectively investigate the pandemic’s impact on the urologic oncology surgical activity of a high-volume center located in Milan, Italy. The number and type of procedures performed in 2020 during the COVID-19 pandemic was evaluated using 2019 data as control. Waiting times for each surgical procedure were compared, on a bimonthly basis, between the two different years. Overall, a 26.7% reduction in the number of urologic oncology surgeries between 2019 and 2020 was observed (2019: 720, 2020: 528). Both the main indication for surgery and the type of procedure performed significantly differed between 2019 and 2020 (all p < 0.0001), with a decrease in the number of radical prostatectomies and an increase in the number of radical cystectomies and radical nephrectomies/nephroureterectomies performed in 2020. Waiting time decreased by 20% between 2019 and 2020, with the most significant reduction seen after the first wave of the COVID-19 pandemic (July-October 2020), in particular for partial nephrectomy and radical prostatectomy, possibly due to the underdiagnosis of cases. In conclusion, in accordance with recommendations by international urological societies on prioritization strategies for oncological procedures, a higher proportion of surgeries for high-risk tumors was performed in 2020 at our center at the expense of procedures for lower risk diseases; however, future implications for patients’ prognosis still need to be determined.

Colonoscopic Treatment of a Fecaloma at the Anastomotic Site after Colectomy

Fecalomas most commonly occur in constipated patients and are rarely reported after colectomy. A 55-year-old Japanese female presented with a fecaloma after colectomy, which was impacted at a functional end-to-end anastomosis (FEEA) site. Four and a half years ago, she underwent sigmoidectomy for colon cancer. A follow-up computed tomography (CT) scan revealed an 11 cm incidental fecaloma. The patient was advised to undergo surgery, but she desired nonoperative management because of minimal symptoms, and was referred to our institution. On the day of admission (day 1), mechanical fragmentation of the fecaloma was attempted during the first colonoscopy. Although a large block of stool was evacuated after a second colonoscopic fragmentation on day 8, the third colonoscopy on day 21 and CT scan on day 22 showed no significant change in the fecaloma. Frequent colonoscopic fragmentation was performed, with a fourth, fifth, and sixth colonoscopy on days 24, 29, and 31, respectively. After the size reduction was confirmed at the sixth colonoscopy, the patient was discharged home on day 34. The fecaloma completely resolved after the seventh colonoscopic fragmentation on day 44. Sixteen months after treatment, there is no evidence of recurrent fecaloma. According to the literature, risk factors for fecaloma after colectomy include female gender, left-side colonic anastomosis, and FEEA. FEEA might not be recommended for anastomoses in the left colon, particularly in female patients, to avoid this complication. Colonoscopic fragmentation is recommended for fecalomas at an anastomotic site after colectomy in patients without an absolute indication for surgery.

Hyponatremia at the onset of necrotizing enterocolitis is associated with intestinal surgery and higher mortality

It has previously been shown that hyponatremia reflects the severity of inflammation in pediatric gastrointestinal diseases. Interpretation of electrolyte disorders is a common, but not well studied challenge in neonatology, especially in the context of early detection of necrotizing enterocolitis and bowel necrosis. The aim of this study was to assess if hyponatremia, or a decrease in plasma sodium level, at the onset of necrotizing enterocolitis (NEC) is associated with intestinal ischemia/necrosis requiring bowel resection and/or NEC-related deaths. This was a retrospective cohort study including patients with verified NEC (Bell’s stage ≥ 2) during the period 2009–2014. Data on plasma sodium 1–3 days before and at the onset of NEC were collected. The exposure was hyponatremia, defined as plasma sodium < 135 mmol/L and a decrease in plasma sodium. Primary outcome was severe NEC, defined as need for intestinal resection due to intestinal ischemia/necrosis and/or NEC-related death within 2 weeks of the onset of NEC. Generalized linear models were applied to analyze the primary outcome and presented as odds ratio. A total of 88 patients with verified NEC were included. Fifty-four (60%) of them had severe NEC. Hyponatremia and a decrease in plasma sodium at onset of NEC were associated with increased odds of severe NEC (OR crude 3.91, 95% CI (1.52–10.04) and 1.19, 95% CI (1.07–1.33), respectively). Also, a sub-analysis, excluding infants with pneumoperitoneum during the NEC episode, showed an increased odds ratio for severe NEC in infants with hyponatremia (OR 23.0, 95% CI (2.78–190.08)).Conclusions: The findings of hyponatremia and/or a sudden decrease in plasma sodium at the onset of NEC are associated with intestinal surgery or death within 2 weeks. What is Known:• Clinical deterioration, despite optimal medical treatment, is a relative indication for surgery in infants with necrotizing enterocolitis.• Hyponatremia is a common condition in preterm infants from the second week of life. What is New:• Hyponatremia and a decrease in plasma sodium level at the onset of necrotizing enterocolitis are positively associated with need of surgery or death within 2 weeks.• In infants with necrotizing enterocolitis, without pneumoperitoneum, where clinical deterioration despite optimal medical treatment is the only indication for surgery, hyponatremia, or a decrease in plasma sodium level can predict the severity of the disease.

Natural Orifice Non-Descent Hysterectomy - Revisiting Fading Surgical Art

BACKGROUND We wanted to assess the feasibility of natural orifice non-descent hysterectomy (NONH) for various benign gynaecological indications. METHODS This retrospective study was conducted at a tertiary care centre including patients requiring hysterectomy for various gynaecological indications over 12 months. Outcomes including time of surgery, blood loss, intraoperative surgical technique, complications, and conversion to the abdominal route were noted. RESULTS A total of 68 cases of natural orifice non-descent hysterectomy were performed. The uterine fibroid was the most common (50 %) indication for surgery followed by adenomyosis. Uteri with previous multiple surgeries were also successfully operated vaginally. The average surgical time was 60 min, with minimal blood loss. Post-operative recovery was good and patients were discharged after 48 hours. CONCLUSIONS This article concludes that natural orifice is a safe route of non-descent hysterectomy even for larger and scarred uteri using various debulking and surgical techniques but requiring good anatomical knowledge, surgical expertise and teamwork. KEY WORDS Natural Orifice Non-Descent Hysterectomy (NONH); Surgical Variations; Debulking Technique; Post-Operative Recovery

691. Infective Endocarditis with an Indication for Cardiac Surgery in a Tertiary Care Educational Hospital: Does Cardiac Surgery Improve Outcomes?

Background In this retrospective cohort study, it was aimed to compare the clinical characteristics and outcomes of IE cases without and with an indication for cardiac surgery in terms of whether they have been operated or not, in a tertiary-care educational hospital. Methods Patients that were followed up for definite IE (diagnosed according to modified Duke criteria between March 2007 and November 2020) with an indication for cardiac surgery according to European Society of Cardiology Guidelines, comprised the study group. Subjects were evaluated in terms of whether these cases have been operated or not, demographic features, underlying diseases, risk factors, clinical and laboratory findings, therapy responses, complications, and mortality. The timing of surgery is defined as emergency; surgery performed within 24 hours, urgent; within a few days, elective; after at least one-two weeks of antibiotic therapy. Statistical analysis was performed via Chi square and Student T tests and a p value &lt; 0.05 was considered significant. Results A total of 90 patients with an indication for surgery, 33.3% patients in underwent surgery, 66.6% patients in not underwent surgery group fulfilled the study criteria. The most frequently seen complaints in patients were fever (91.1%), cold-shiver (56.6%), weight-loss (27.7%), dyspnea (25.5%), and tachycardia (20%). Heart murmur was detected during cardiac auscultation of 44 patients. Mean blood leukocyte count, C-reactive protein and erythrocyte sedimentation rate were 12324 ± 6558/mm3 (1408-30330), 11.46 ± 8.38 mg/dl (0.18-34.6) and 61.43 ± 33.4 mm/h (2-130), respectively. There was no significant difference between two groups in terms of cardiac/non-cardiac risk factors, age, gender, etiologic agents, laboratory findings, septic embolisms and complaints (Table 1). In total IE with an indication for surgery mortality was 27.7%. Mortality rate was significantly less and heart murmur was significantly higher in cases who underwent surgery than those did not undergo surgery (p: 0.0447). Table 1. Comparison of basic characteristics of patients in the two operated / unoperated cohorts. Conclusion These data support the importance of the guidelines’ criteria for cardiac surgery in the management of IE. Assuming that only 1/3 of the surgery needing cases received surgery, more interventions are needed to decrease the barriers against surgery. Disclosures All Authors: No reported disclosures

Is there an indication for surgery in patients with spinal deformities? – A critical appraisal

Background: High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment.Objective: The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities.Method: A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann’s disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome.Results: No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery.Conclusions: A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities.Clinical implications: In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.