key: cord-0749877-7rn0klsi
authors: Spinelli, Antonino; Carvello, Michele; Carrano, Francesco Maria; Pasini, Francesco; Foppa, Caterina; Taffurelli, Giovanni; Ugolini, Gianpaolo; Montroni, Isacco
title: Reduced length of stay after elective colorectal surgery during the peak phase of Covid-19 pandemic: a positive effect of infection risk awareness?
date: 2020-12-23
journal: Surgery
DOI: 10.1016/j.surg.2020.12.017
sha: fc8f9aca75b790c43fe1a211a2c29db92b169b02
doc_id: 749877
cord_uid: 7rn0klsi

BACKGROUND: While during the Covid-19 pandemic elective surgery was shut-down of in most settings, some referral centers were designated as surgery hubs. We sought to investigate how the pandemic scenario hasve impacted the quality of a long-established enhanced recovery protocol (ERP) colorectal surgery (CRS) program in two referral center, designated as colorectal surgery hub, located in the epicentral Italian regions hardest hit by the pandemic. METHODS: We have compared short-term outcomes of patients undergoing major colorectal surgery with a long-established ERP during the COVID-19 outbreak (group A) with the correspondent timeframe of 2019 (group B). Primary outcomes were morbidity and mortality, LOS, and readmission rate. RESULTS: Hundred and thirty-six patients underwent major colorectal surgery in group A and 173 in group B. Post-operative complications and readmission rate were comparable between the two groups. Oncologic case-log was predominant in group A comparing with group B (73.5 vs 61%, p=0.01). A significantly shorter overall LOS was found in group A (p<0.001). Uncomplicated patients of group A had a shorter length of stay when compared with uncomplicated patients of group B (p=0.008). CONCLUSION: Under special precautionary measures, major CRS can be undertaken on elective basis even during the COVID-19 pandemic with reasonable results. A reduction of LOS, within a long-established ERP-CRS program, was observed during the Covid-19 pandemic in comparison with the correspondent timeframe of 2019 without compromising short term outcomes. The pandemic uncovered the positive impact of patients’ commitment to reducing LOS as the empowered risk awareness likely promoted their compliance to ERP.

Elective surgery was discontinued in many hospitals during the Covid-19 pandemic. At the same 60 time, some colorectal surgery programs were designated by local governments as referral hubs, 61 to ensure treatment for patients affected by major surgical conditions (colorectal cancers and 62 complicated Inflammatory Bowel Diseases-IBD) 1314 . Enhanced precautionary measures such as 63 screening for SARS-CoV-2 infection before hospital admission, as well as strict adherence to 64 already established Enhanced Recovery Protocols (ERP), have been pursued to safely maintain hubs for oncologic/IBD surgery during the COVID-19 pandemic. The two centers were designated to continue with their major elective colorectal surgery activity prioritizing patients 83 with cancer or severe benign conditions (i.e. severe IBD-related complications). Patients were 84 referred from the catch-area where the two hospitals are located and from neighborhood areas 85 were other hospitals/services were instead focusing on patients affected by Covid-19 infection.

Both CRS units continued their elective CRS programs along with their long-established ERPs.

The routine in both centers, in order to limit the chances of operating electively patients also 88 affected by Covid-19, included that every surgical candidate was first questioned for high-risk for-discharge once all the discharging criteria were met: 1. tolerating oral intake, 2. presence of 100 gastrointestinal function, 3. adequate pain control with oral analgesia, 4. ability to mobilize and 101 self-care, 5. Availability of a caregiver/social support in case of necessity. After hospital Results from all consecutive patients undergoing colorectal surgery during the peak phase of the from all consecutive colorectal patients operated during the same time-frame in 2019 (Group B).

Data were collected from prospectively maintained electronic datasets. Informed consent was 108 obtained by the patients.

The main outcomes measured were LOS, readmission rate, and 90-days morbidity and mortality. Feasibility and safety of laparoscopy during the pandemic was called into question and even 184 discouraged in earliest reports 2122 , due to the potential risk for viral spread through 185 aerosolization. In our experience, the adoption of a minimally invasive approach did not add 186 morbidity for our patients or risks for surgeons. In both Institutions, measures to minimize 187 surgical smoke leaks were routinely followed 2324 . During the pandemic outbreak, 94% of patients 188 in our case series were operated by laparoscopy without affecting any healthcare worker or other 189 patients, while promoting the well-known benefits of a minimally invasive approach.

Interestingly, a significantly higher number of oncologic surgeries was performed during the pandemic. The difference in the oncologic case-log compared to the previous year could be 220 explained because both centers were designated as colorectal cancer hub by local authorities.

However, a significant difference in terms of LOS was maintained when subgroup analysis for 222 benign or cancer surgery was performed.

The strength of our study relies on the inclusion of a considerable cohort of patients in a limited 224 time-frame from two high-volume centers during the peak phase of the COVID-19 pandemic.

Furthermore, despite our study focused on colorectal surgery, the concept of postoperative LOS 226 reduction may be generalized and applied to other surgical subspecialties. It seems once again 227 that patients' engagement in ERP protocols is specifically relevant to improve results.

Our study has some limitations: resource allocation strategies to maintain COVID-free 229 units/hospitals may not apply to every healthcare system due to individual peculiarities or 

Costs of Potential

J o u r n a l P r e -p r o o f Overall length of stay 4.3 ± 2.9 6.2 ± 6.6 <0.001* Length of stay (uncomplicated) 3.3 ± 1.2 4.1 ± 2.1 0.008* Length of stay (complicated) 7 ± 4.1 10 ± 5.7 0.01* *P value < 0.05, statistically significant J o u r n a l P r e -p r o o f 3.6 ± 1.6 4.3 ± 2 0.015* Length of stay (complicated) 6.4 ± 3.7 11 ± 5.8 0.024* *P value < 0.05, statistically significant J o u r n a l P r e -p r o o f

Elective colorectal surgery, under special precautionary measures, can be safely undertaken with reasonable outcome during COVID 19 pandemic. The empowered infection risk awareness may promote patients engagement with enhanced recovery protocol leading to a significative reduction of the postoperative length of stay.