Impact of the COVID-19 pandemic on surgical care in the Netherlands.

BACKGROUND: The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. METHODS: A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. RESULTS: Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). CONCLUSION: The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.

COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018­2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. These data provide no insight into the burden endured by patients who had postponed or cancelled operations.

Utility of Shock Index for Suspected Rupture of Abdominal Aortic Aneurysms.

BACKGROUND: A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition, with high mortality rates. The Shock Index (SI) is an easy tool and a useful predictor of hemodynamic instability in trauma patients. We aimed to assess the predictive and prognostic value of the SI for patients with a suspected rAAA in the prehospital and hospital setting. METHODS: This was a retrospective, observational, single-center study. Patients >18 years old who visited the emergency department with a suspected rAAA between January 2009 and December 2018 were included. Prehospital and hospital SI were calculated and analyzed for its predictive value on the presence of a rAAA, need for packed cells (PCs) and mortality. RESULTS: A total of 313 patients met the inclusion criteria, of which 71 patients (22.6%) presented with a rAAA. Prehospital and hospital SI were significantly increased in the rAAA group. A SI ≥ 1.0 was estimated as an optimal cutoff point for the presence of a rAAA (AUROC 0.74, 95% CI 0.67-0.82; p < 0.001) with an adjusted Odds Ratio (OR) of 5.3 (95% CI 2.13-13.39) for the prehospital SI and an adjusted OR of 18.2 (95% CI 5.83-56.73) for the hospital SI. Both prehospital and hospital SI ≥ 1.0 were associated with a higher need for PCs and amount of PCs (p < 0.05). A hospital SI ≥ 1.0 was associated with higher in-hospital mortality rates (39.0% vs 68.0%, p = 0.022). CONCLUSIONS: The prehospital and hospital SI were significantly elevated in the rAAA group. As such, the SI showed promising results as a predictive and prognostic tool, with SI ≥ 1.0 as cutoff point.

Outcome of rectus femoris muscle flaps for groin coverage after vascular surgery.

OBJECTIVE: The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage. METHODS: All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay. RESULTS: A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%). CONCLUSIONS: This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.

A systematic review on the use of muscle flaps for deep groin infection following vascular surgery.

OBJECTIVE: The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage. METHODS: The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated. RESULTS: A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences. CONCLUSIONS: Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.

Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry.

INTRODUCTION: Despite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease. METHODS AND ANALYSIS: This multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1-3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves. ETHICS AND DISSEMINATION: This study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United 'MEC-U' (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally. TRIAL REGISTRATION NUMBER: NTR7332; Pre-results.

Electrocardiographic-guided tip positioning technique for peripherally inserted central catheters in a Dutch teaching hospital: Feasibility and cost-effectiveness analysis in a prospective cohort study.

INTRODUCTION:: Peripherally inserted central catheters are venous devices intended for short to medium periods of intravenous treatment. Positioning of the catheter tip at the cavoatrial junction is necessary for optimum performance of a peripherally inserted central catheter. In this study, safety, effectiveness and cost-effectiveness of electrocardiographic-guided peripherally inserted central catheter positioning in a Dutch teaching hospital were evaluated. METHODS:: All patients who received a peripherally inserted central catheter in 2016 using electrocardiographic guidance were compared to those where fluoroscopy guidance was used in a prospective non-randomized cohort study. Relevant data were extracted from electronic health records. Cost-effectiveness analysis was performed. RESULTS:: A total of 162 patients received a peripherally inserted central catheter using fluoroscopy guidance and 103 patients using electrocardiographic guidance in 2016. No significant difference was found in malposition, infection or other complications between these groups. Due to personnel reduction and omission of fluoroscopy costs, cost reduction for each catheter insertion was €120 in the first year and, as a result of discounted acquisition costs, €190 in subsequent years. DISCUSSION:: The positioning results and complication rate are comparable to the previously reported literature. The cost reduction may vary in different hospitals. Other benefits of the electrocardiographic-guided technique are omission of X-ray exposure and improved patient service. CONCLUSION:: Implementation of electrocardiographic-guided tip positioning for peripherally inserted central catheter was safe and effective in this study and led to an improved high value and cost-conscious care.

Clinical presentation, diagnosis, and treatment of venous aneurysms.

Venous aneurysms have been reported in most major veins and are often asymptomatic but can cause serious complications. Three patients with symptomatic venous aneurysms of the internal jugular vein, portal vein, and popliteal vein are presented, and their treatment and outcomes are discussed. Furthermore, presentation and management of the most frequent venous aneurysms, based on available literature, are evaluated. The literature supports conservative treatment of asymptomatic and nonthrombotic jugular, subclavian, thoracic, and visceral venous aneurysms. Surgery should be considered only for symptomatic venous aneurysms or in case of progressive expansion on follow-up. Prophylactic surgery is recommended for all patients with lower extremity deep venous aneurysms, by means of tangential aneurysmectomy with lateral venorrhaphy, because of the increased risk of pulmonary embolization. Postoperative anticoagulation is recommended for a period of at least 3 months after operative treatment.