American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Surgical Skills Vary Widely: A Gap Waiting to Be Filled

Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient Outcomes. JAMA Surg. 2020.

Lancaster EM, Wick E. Integrating Surgical Skills Assessment Into Quality and Safety Measures. JAMA Surg. 2020.

Stulberg and colleagues report on a study of the association of surgeon skill ratings with patient outcomes. Peers and expert raters assessed surgeon skills based on video recordings of operative procedures. Skills were quantified using accepted skill-rating systems. Outcomes were compared to risk-adjusted outcomes drawn from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database.

The data analysis showed that surgeon skills vary significantly; higher skill ratings were associated with fewer unplanned reoperations, lower complication rates and reductions in mortality and morbidity. The authors noted that these data were produced as part of a quality improvement initiative in their department of surgery. It is anticipated that additional data will be forthcoming that will focus on the feasibility and costs of implementing skills assessment and coaching for surgeons.

In the accompanying editorial, Lancaster and Wick stress that improved technology will lead to new surgical procedures, as well as easier, more cost-effective means of assessing skills, providing coaching, and improving the quality of surgical care. Surgeons are encouraged to participate in these emerging opportunities.

COVID-19 Patients Should Be Carefully Assessed for Surgical Complications

Doglietto F, Vezzoli M, Gheza F, et al. Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy. JAMA Surg. 2020.

This report provides data on 44 patients who underwent urgent or emergent operative procedures performed by multiple surgical specialists. Patients were known to have COVID-19 infection (n=33) or were diagnosed within five days of the procedure (n=11). Rates of early (within 30 days) mortality were compared with patients undergoing similar procedures but who did not have COVID-19. Patients were matched according to American Society of Anesthesiologists scores, frailty scores, and the ACS Surgical Risk Calculator. Mortality risk was significantly higher in the COVID-19 group when compared with the matched patient group (19.5 percent versus 2.44 percent); complication rates also were higher in the COVID group. Pulmonary complications were the most common. Because the factors that contribute to increased risk and the duration of increased risk have yet to be elucidated in detail, these data support the need to exercise careful risk assessment when considering elective and urgent/emergent operations in COVID-19 patients.

Studies Explore the Causes of Thrombotic Complications and Bleeding in COVID-19 Patients

Al-Samkari H, Karp Leaf RS, Dzik WH, et al. COVID-19 and coagulation: Bleeding and thrombotic manifestations of SARS-CoV-2 infection. Blood. 2020;136(4):489-500.

Nicolai L, Leunig A, Brambs S, et al. Immunothrombotic Dysregulation in COVID-19 Pneumonia Is Associated with Respiratory Failure and Coagulopathy. Circulation. 2020.

Al-Samkari and colleagues report data from 400 hospitalized patients with COVID-19 infection—144 of whom were critically ill. Thrombotic complications and rates of bleeding were recorded. Various laboratory markers were examined to determine risk factors for thrombotic complications and bleeding. The overall thrombotic complication rate was 9.5 percent, and the bleeding rate was 2.3 percent. Rates were higher in critically ill patients. D-dimer levels greater than 2500 ng/mL were predictive of thrombotic complications. Bleeding complications were observed more frequently in patients receiving therapeutic anticoagulation compared with prophylactic anticoagulation. The authors suggest that the decision to use therapeutic anticoagulation in the absence of a proven thrombotic complication should be made cautiously.

Nicolai and co-authors compare platelet and neutrophil function as well as coagulation tests in patients with (n=38) and without (n=24) COVID-19 infection to elucidate the mechanisms of COVID-19-related coagulopathy. The data analysis showed that patients with severe disease have excessive neutrophil and platelet activation leading to an immunothrombosis phenotype that contributes to pulmonary tissue damage and thrombotic complications. Recognition of the roles of platelets and neutrophils in the production of micro- and macrovascular thrombosis could lead to the development of therapies that target these cells.

Additional Readings

JAMA Pediatrics, Clinical Characteristics and Viral RNA Detection in Children With Coronavirus Disease 2019 in the Republic of Korea

New England Journal of Medicine, Developing Safe and Effective Covid Vaccines—Operation Warp Speed’s Strategy and Approach

BMJ, Two metres or one: What is the evidence for physical distancing in COVID-19?

Journal of the American College of Cardiology, Anticoagulation, Mortality, Bleeding and Pathology Among Patients Hospitalized with COVID-19: A Single Health System Study