Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
BACKGROUND: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. METHODS: This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. FINDINGS: Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16-30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77-0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50-0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80-0·88; p<0·001), and full lockdowns (0·57, 0·54-0·60; p<0·001), remained independently ...
Background: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods: This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings: Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently ...
Background: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods: This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings: Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation: Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. Funding: National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Abstract Aim: This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic. Methods: This was an international cohort study of patients undergoing elective resection of colon or rectal cancer without preoperative suspicion of SARS-CoV-2. Centres entered data from their first recorded case of COVID-19 until 19 April 2020. The primary outcome was 30-day mortality. Secondary outcomes included anastomotic leak, postoperative SARS-CoV-2 and a comparison with prepandemic European Society of Coloproctology cohort data. Results: From 2073 patients in 40 countries, 1.3% (27/2073) had a defunctioning stoma and 3.0% (63/2073) had an end stoma instead of an anastomosis only. Thirty-day mortality was 1.8% (38/2073), the incidence of postoperative SARS-CoV-2 was 3.8% (78/2073) and the anastomotic leak rate was 4.9% (86/1738). Mortality was lowest in patients without a leak or SARS-CoV-2 (14/1601, 0.9%) and highest in patients with both a leak and SARS-CoV-2 (5/13, 38.5%). Mortality was independently associated with anastomotic leak (adjusted odds ratio 6.01, 95% confidence interval 2.58–14.06), postoperative SARS-CoV-2 (16.90, 7.86–36.38), male sex (2.46, 1.01–5.93), age >70 years (2.87, 1.32–6.20) and advanced cancer stage (3.43, 1.16–10.21). Compared with prepandemic data, there were fewer anastomotic leaks (4.9% versus 7.7%) and an overall shorter length of stay (6 versus 7 days) but higher mortality (1.7% versus 1.1%). Conclusion: Surgeons need to further mitigate against both SARS-CoV-2 and anastomotic leak when offering surgery during current and future COVID-19 waves based on patient, operative and organizational risks. ; Appendix 1 Writing group (*denotes joint first authors) Elizabeth Li*, James C. Glasbey*, Dmitri Nepogodiev*, Joana F. F. Simoes*, Omar M. Omar, Mary L. Venn, Jonathan P. Evans, Kaori Futaba, Charles H. Knowles, Ana Minaya-Bravo, Helen Mohan, Manish Chand, Peter Pockney, Salomone Di Saverio, Neil Smart, Abigail Vallance, Dale Vimalachandran, Richard J. W. Wilkin, Aneel Bhangu (Overall guarantor). 2 Statistical analysis Omar M. Omar (Lead statistician), Elizabeth Li, James C. Glasbey, Aneel Bhangu. 3 CovidSurg Operations Committee Kwabena Siaw-Acheampong, Ruth A. Benson, Edward Bywater, Daoud Chaudhry, Brett E. Dawson, Jonathan P. Evans, James C. Glasbey, Rohan R. Gujjuri, Emily Heritage, Conor S. Jones, Sivesh K. Kamarajah, Chetan Khatri, Rachel A. Khaw, James M. Keatley, Andrew Knight, Samuel Lawday, Elizabeth Li, Harvinder S. Mann, Ella J. Marson, Kenneth A. McLean, Siobhan C. Mckay, Emily C. Mills, Dmitri Nepogodiev, Gianluca Pellino, Maria Picciochi, Elliott H. Taylor, Abhinav Tiwari, Joana F. F. Simoes, Isobel M. Trout, Mary L. Venn, Richard J. W. Wilkin, Aneel Bhangu. 4 International Cancer Leads (*denotes specialty principal Investigator) James C. Glasbey (Chair); Colorectal: Neil J. Smart*, Ana Minaya-Bravo*, Jonathan P. Evans, Gaetano Gallo, Susan Moug, Francesco Pata, Peter Pockney, Salomone Di Saverio, Abigail Vallance, Dale Vimalchandran. 5 Dissemination Committee Joana F. F. Simoes (Chair); Tom E. F. Abbott, Sadi Abukhalaf, Michel Adamina, Adesoji O. Ademuyiwa, Arnav Agarwal, Murat Akkulak, Ehab Alameer, Derek Alderson, Felix Alakaloko, Markus Albertsmeiers, Osaid Alser, Muhammad Alshaar, Sattar Alshryda, Alexis P. Arnaud, Knut Magne Augestad, Faris Ayasra, José Azevedo, Brittany K. Bankhead-Kendall, Emma Barlow, David Beard, Ruth A. Benson, Ruth Blanco-Colino, Amanpreet Brar, Ana Minaya-Bravo, Kerry A. Breen, Chris Bretherton, Igor Lima Buarque, Joshua Burke, Edward J. Caruana, Mohammad Chaar, Sohini Chakrabortee, Peter Christensen, Daniel Cox, Moises Cukier, Miguel F. Cunha, Giana H. Davidson, Anant Desai, Salomone Di Saverio, Thomas M. Drake, John G. Edwards, Muhammed Elhadi, Sameh Emile, Shebani Farik, Marco Fiore, J. Edward Fitzgerald, Samuel Ford, Tatiana Garmanova, Gaetano Gallo, Dhruv Ghosh, Gustavo Mendonça Ataíde Gomes, Gustavo Grecinos, Ewen A. Griffiths, Madalegna Gründl, Constantine Halkias, Ewen M. Harrison, Intisar Hisham, Peter J. Hutchinson, Shelley Hwang, Arda Isik, Michael D. Jenkinson, Pascal Jonker, Haytham M. A. Kaafarani, Debby Keller, Angelos Kolias, Schelto Kruijff, Ismail Lawani, Hans Lederhuber, Sezai Leventoglu, Andrey Litvin, Andrew Loehrer, Markus W. Löffler, Maria Aguilera Lorena, Maria Marta Madolo, Piotr Major, Janet Martin, Hassan N. Mashbari, Dennis Mazingi, Symeon Metallidis, Ana Minaya-Bravo, Helen M. Mohan, Rachel Moore, David Moszkowicz, Susan Moug, Joshua S. Ng-Kamstra, Mayaba Maimbo, Ionut Negoi, Milagros Niquen, Faustin Ntirenganya, Maricarmen Olivos, Kacimi Oussama, Oumaima Outani, Marie Dione Parreno-Sacdalanm, Francesco Pata, Carlos Jose Perez Rivera, Thomas D. Pinkney, Willemijn van der Plas, Peter Pockney, Ahmad Qureshi, Dejan Radenkovic, Antonio Ramos-De la Medina, Keith Roberts, April C. Roslani, Martin Rutegård, Irène Santos, Sohei Satoi, Raza Sayyed, Andrew Schache, Andreas A Schnitzbauer, Justina O. Seyi-Olajide, Neil Sharma, Richard Shaw, Sebastian Shu, Kjetil Soreide, Antonino Spinelli, Grant D Stewart, Malin Sund, Sudha Sundar, Stephen Tabiri, Philip Townend, Georgios Tsoulfas, Gabrielle H. van Ramshorst, Raghavan Vidya, Dale Vimalachandran, Oliver J. Warren, Duane Wedderburn, Naomi Wright, EuroSurg, European Society of Coloproctology (ESCP), Global Initiative for Children's Surgery (GICS), GlobalSurg, GlobalPaedSurg, ItSURG, PTSurg, SpainSurg, Italian Society of Colorectal Surgery (SICCR), Association of Surgeons in Training (ASiT), Irish Surgical Research Collaborative (ISRC), Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG), Italian Society of Surgical Oncology (SICO). 6 Collaboratoring authors (*denotes site principal investigators) Argentina: Alurralde C., Caram E. L., Eskinazi D* (Sanatorio 9 De Julio Sa); Badra R., García J.S., Lucchini S.M.* (Sanatorio Allende). Australia: Cecire J., Salindera S.*, Sutherland A. (Coffs Harbour Health Campus); Ahn J.H., Chen S., Gauri N., Jang S., Jia F., Mulligan C., Yang W., Ye G., Zhang H. (Concord Repatriation General Hospital); Moss J.*, Richards T., Thian A., Vo U. G. (Fiona Stanley Hospital); Bagraith K., Chan E., Ho D., Jeyarajan E., Jordan S., Nolan G. J., Von Papen M., Wullschleger M. (Gold Coast University Hospital); Egoroff N., Gani J., Lott N., Pockney P.* (John Hunter Hospital); Phan D., Townend D.* (Lismore Base Hospital); Bong C., Gundara J.* (Logan Hospital); Bowman S.*, Guerra G. R. (Queen Elizabeth II Jubilee Hospital); Dudi-Venkata N. N., Kroon H. M.*, Sammour T. (Royal Adelaide Hospital); Mitchell D.*, Swinson B. (Royal Brisbane and Women's Hospital). Austria: Messner F., Öfner D.* (Medical University of Innsbruck); Emmanuel K., Grechenig M., Gruber R., Harald M., Öhlberger L., Presl J.*, Wimmer A. (Paracelsus Medical University Salzburg). Barbados: Barker D., Boyce R., Doyle A., Eastmond A., Gill R., O'Shea M., Padmore G.*, Paquette N., Phillips E., St John S., Walkes K. (Queen Elizabeth Hospital). Belgium: Flamey N., Pattyn P.* (Az Delta); Oosterlinck W.*, Van den Eynde J., Van den Eynde R. (Uz Leuven). Bulgaria: Sokolov M.* (University Hospital Alexandrovska). Canada: Boutros M.*, Caminsky N. G., Ghitulescu G. (Jewish General Hospital); Boutros M.*, Demyttenaere S.*, Garfinkle R. (St Mary's Hospital); Nessim C.*, Stevenson J. (The Ottawa Hospital). Croatia: Bačić G., Karlović D., Kršul D., Zelić M.* (University Hospital Center Rijeka); Bakmaz B., Ćoza I., Dijan E., Katusic Z., Mihanovic J.*, Rakvin I. (Zadar General Hospital). Cyprus: Frantzeskou K., Gouvas N.*, Kokkinos G., Papatheodorou P., Pozotou I., Stavrinidou O., Yiallourou A.* (Nicosia General Hospital). Czechia: Martinek L., Skrovina M.*, Szubota I. (Hospital and Oncological Centre Novy Jicin). Denmark: Ebbehøj A. L., Krarup P., Schlesinger N., Smith H.* (Bispebjerg Hospital). Egypt: Al Sayed M., Ashoush F.*, Elazzazy E., Essam E., Eweda M., Hassan E., Metwalli M., Mourad M., Qatora M. S., Sabry A.*, Samih A., Samir Abdelaal A., Shehata S.*, Shenit K. (Alexandria Main University Hospital); Attia D., Kamal N., Osman N.* (Alexandria Medical Research Institute); Alaa S., Hamza H. M., M. elghazaly S., Mohammed M. M.*, Nageh M. A., Saad M. M.*, Yousof E. A. (Assiut University Hospital); Eldaly A. S.* (El-Menshawy Hospital); Amira G., Sallam I.*, Sherief M., Sherif A. (Misr Cancer Center); Ghaly G.*, Hamdy R., Morsi A., Salem H.*, Sherif G. (National Cancer Institute); Abdeldayem H., Abdelkader Salama I.*, Balabel M., Fayed Y., Sherif A. E.* (National Liver Institute, Menoufia University). Finland: Kauppila J. H.*, Sarjanoja E. (Länsi-Pohja Central Hospital); Helminen O., Huhta H., Kauppila J. H.* (Oulu University Hospital). France: Beyrne C., Jouffret L.*, Marie-Macron L. (Centre Hospitalier Avignon); Lakkis Z.*, Manfredelli S. (CHU Besançon); Chebaro A.*, El Amrani M., Lecolle K., Piessen G.*, Pruvot F. R., Zerbib P. (CHU Lille); Ballouhey Q.*, Barrat B., Taibi A. (Chu Limoges); Bergeat D., Merdrignac A. (CHU Rennes – General Surgery); Le Roy B., Perotto L. O., Scalabre A.* (Chu Saint Etienne); Aimé A., Ezanno A.*, Malgras B. (Hia Begin); Bouche P. A.*, Tzedakis S.* (Hôpital Cochin – APHP); Cotte E., Glehen O., Kepenekian V., Passot G. (Hopital Lyon Sud); D'Urso A., Mutter D., Seeliger B.* (Strasbourg University Hospitals/IHU-Strasbourg); Bonnet S., Denet C., Fuks D., Laforest A., Pourcher G., Seguin-Givelet A.*, Tribillon E. (Institut Mutualiste Montsouris); Duchalais E.* (Nantes University Hospital). Germany: Bork U.*, Fritzmann J., Praetorius C., Weitz J., Welsch T. (Carl-Gustav-Carus University Hospital, TU Dresden); Beyer K., Kamphues C.*, Lauscher J. C., Loch F. N., Schineis C. (Charité University Medicine, Campus Benjamin Franklin); Becker R.*, Jonescheit J. (Heilig-Geist Hospital Bensheim); Pergolini I., Reim D.* (Klinikum Rechts der Isar TUM School of Medicine); Boeker C., Hakami I.*, Mall J.* (KRH Nordstadt-Siloah Hospitals); Albertsmeier M.*, Kappenberger A., Schiergens T., Werner J. (LMU Klinikum Campus Innenstadt); Nowak K.*, Reinhard T.* (Romed Klinikum Rosenheim); Kleeff J., Michalski C., Ronellenfitsch U.* (University Hospital Halle (Saale)); Bertolani E., Königsrainer A.*, Löffler M. W., Quante M.*, Steidle C., Überrück L., Yurttas C. (University Hospital Tuebingen); Izbicki J., Nitschke C., Perez D., Uzunoglu F. G.* (University Medical Center Hamburg–Eppendorf). Greece: Antonakis P., Contis I., Dellaportas D., Gklavas A., Konstadoulakis M., Memos N.*, Papaconstantinou I.*, Polydorou A., Theodosopoulos T., Vezakis A. (Aretaieion Hospital); Antonopoulou M. I., Manatakis D. K.*, Tasis N. (Athens Naval and Veterans Hospital); Arkadopoulos N., Danias N., Economopoulou P., Frountzas M., Kokoropoulos P., Larentzakis A., Michalopoulos N.*, Parasyris S., Selmani J., Sidiropoulos T., Vassiliu P. (Attikon University General Hospital); Bouchagier K.*, Klimopoulos S., Paspaliari D., Stylianidis G. (Evaggelismos General Hospital); Baxevanidou K., Bouliaris K., Chatzikomnitsa P., Efthimiou M., Giaglaras A., Kalfountzos C.*, Koukoulis G., Ntziovara A. M., Petropoulos K., Soulikia K., Tsiamalou I., Zervas K., Zourntou S. (General Hospital of Larissa 'Koutlimpaneio and Triantafylleio'); Baloyiannis I., Diamantis A., Perivoliotis K., Tzovaras G.* (General University Hospital of Larissa); Christidis P., Ioannidis O.*, Loutzidou L. (George Papanikolaou General Hospital of Thessaloniki); Karaitianos I.*, Tsirlis T. (Henry Dunant Hospital Center); Charalabopoulos A., Liakakos T., Baili E., Schizas D.*, Spartalis E., Syllaios A., Zografos C. (Laiko University Hospital); Athanasakis E., Chrysos E., Tsiaoussis I., Xenaki S.*, Xynos E.* (University Hospital of Heraklion Crete and Interclinic Hospital of Crete). Hong Kong: Futaba K.*, Ho M. F., Hon S. F., Mak T. W. C., Ng S. S. M. (Prince of Wales Hospital); Foo C. C.* (Queen Mary Hospital). Hungary: Banky B.*, Suszták N. (Szent Borbála Kórház). India: Bhat G. A., Chowdri N. A., Mehraj A.*, Parray F., Shah Z. A., Wani R. (Sher-I-Kashmir Institute of Medical Sciences); Ahmed Z., Bali R., Bhat M. A., Laharwal A., Mahmood M., Mir I., Mohammad Z., Muzamil J., Rashid A.* (SMHS Hospital, Government Medical College). Ireland: Aremu M.*, Canas-Martinez A., Cullivan O., Murphy C., Owens P., Pickett L. (Connolly Hospital Blanchardstown); Corrigan M.*, Daly A., Fleming C.*, Jordan P., Killeen S., Lynch N., O'Brien S., Syed W. A. S., Vernon L. (Cork University Hospital); Fahey B. A., Larkin J. O.*, McCormick P., Mehigan B. J., Mohan H., Shokuhi P., Smith. J (St James's Hospital); Bashir Y., Bass G. A., Connelly T. M., Creavin B., Earley H., Elliott J. A.*, Gillis A. E., Kavanagh D. O., Neary P. C., O'Riordan J. M., Reynolds I. S., Rice D., Ridgway P. F., Umair M., Whelan M. (Tallaght University Hospital); Corless K., Finnegan L., Fowler A., Hogan A., Lowery A.*, McKevitt K.*, Ryan É. (University Hospital Galway); Coffey J. C., Cunningham R. M., Devine M., Nally D.*, Peirce C. (University Hospital Limerick); Hardy N. P., Neary P. M., O'Malley S.*, Ryan M. (University Hospital Waterford/University College Cork). Italy: Macina S.* (ASST Mantua); Mariani N. M.*, Opocher E., Pisani Ceretti A. (ASST Santi Paolo E. Carlo); Bianco F.* (ASST Papa Giovanni XXIII – Bergamo); Marino M. V.*, Mirabella A., Vaccarella G. (Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello); Agostini C., Alemanno G., Bartolini I., Bergamini C., Bruscino A., De Vincenti R., Di Bella A., Fortuna L., Maltinti G., Muiesan P.*, Prosperi P.*, Ringressi M. N., Risaliti M., Taddei A.*, Tucci R. (Azienda Ospedaliera Universitaria Careggi); Campagnaro T.*, Guglielmi A., Pedrazzani C., Rattizzato S., Ruzzenente A., Turri G. (Azienda Ospedaliera Universitaria Integrata di Verona); Bellora P., D'Aloisio G., Ferrari M., Francone E., Gentilli S.*, Nikaj H. (Azienda Ospedaliero Universitaria Maggiore della Carità); Bianchini M., Chiarugi M., Coccolini F., Di Franco G., Furbetta N., Gianardi D., Guadagni S., Morelli L.*, Palmeri M., Tartaglia D.* (Azienda Ospedaliero Universitaria Pisana); Anania G.*, Carcoforo P.*, Chiozza M., De Troia A., Koleva Radica M., Portinari M., Sibilla M. G., Urbani A. (Azienda Ospedaliero Universitaria San'anna); Fabbri N., Feo C. V.*, Gennari S., Parini S., Righini E. (Azienda Unità Sanitaria Locale di Ferrara, Università di Ferrara); Annessi V., Castro Ruiz C., Montella M. T., Zizzo M.* (Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia); Grossi U., Novello S., Romano M., Rossi S., Zanus G.* (Ca' Foncello Treviso – DISCOG – Università di Padova); Esposito G., Frongia F., Pisanu A., Podda M.* (Cagliari University Hospital); Belluco C., Lauretta A.*, Montori G., Moras L., Olivieri M.; Feo C. F., Perra T.*, Porcu A.*, Scanu A. M. (Cliniche San Pietro, Aou Sassari); Aversano A., Carbone F., Delrio P.*, Di Lauro K., Fares Bucci A., Rega D.*, Spiezio G. (Colorectal Surgical Oncology Unit – Istituto Nazionale Tumori Fondazione, Pascale IRCCS); Calabrò M.*, Farnesi F., Lunghi E. G., Muratore A.*, Pipitone Federico N. S. (Edoardo Agnelli); De Palma G. D., Luglio G.*, Pagano G., Tropeano F. P. (Federico II University Hospital); Baldari L.*, Boni L.*, Cassinotti E.* (Fondazione IRCCS Ca' Granda – Ospedale Maggiore Policlinico di Milano); Cosimelli M., Fiore M.*, Guaglio M.*, Sorrentino L. (Fondazione IRCCS Istituto Nazionale dei Tumori, Milano); Agnes A., Alfieri S., Belia F., Biondi A., Cozza V., D'Ugo D., De Simone V., Litta F., Lorenzon L., Marra A. A., Marzi F., Parello A., Persiani R., Ratto C., Rosa F., Scrima O., Sganga G. (Fondazione Policlinico Universitario Agostino Gemelli IRCCS); Belli A.*, Izzo F., Patrone R. (HPB Surgical Oncology Unit – Istituto Nazionale Tumori Fondazione, Pascale IRCCS); Carrano F. M., Carvello M. M., Di Candido F., Maroli A., Spinelli A.* (Humanitas Clinical and Research Center IRCCS, Rozzano (Mi) and Humanitas University, Department of Biomedical Sciences, Pieve Emanuele (Mi)); Aprile A., Batistotti P., Massobrio A., Pertile D., Scabini S.*, Soriero D. (IRCCS Ospedale Policlinico San Martino); De Manzoni Garberini A.* (Ospedale Civile Spirito Santo); Federico P., Maida P., Marra E., Marte G., Petrillo A., Tammaro P., Tufo A.* (Ospedale del Mare); Berselli M.*, Borroni G.*, Cocozza E., Conti L., Desio M., Rizzi A. (ASST Sette Laghi-Varese); Baldi C.*, Corbellini C., Sampietro G. M. (Ospedale di Rho – ASST Rhodense); Baldini E.*, Capelli P., Conti L., Isolani S. M., Ribolla M. (Ospedale Guglielmo da Saliceto Piacenza); Bondurri A., Colombo F.*, Ferrario L., Guerci C., Maffioli A. (Ospedale Luigi Sacco Milano); Armao T., Ballabio M.*, Bisagni P., Gagliano A., Longhi M., Madonini M., Pizzini P. (Ospedale Maggiore di Lodi); Mochet S.*, Usai A. (Ospedale Regionale Umberto Parini); Bianco F.*, Incollingo P. (Ospedale S. Leonardo – Asl Napoli 3 Sud, Castellammare di Stabia); Mancini S., Marino Cosentino L.*, Sagnotta A.* (Ospedale San Filippo Neri); Nespoli L. C., Tamini N.* (Ospedale San Gerardo); Anastasi A., Bartalucci B., Bellacci A., Canonico G.*, Capezzuoli L., Di Martino C., Ipponi P., Linari C., Montelatici M., Nelli T., Spagni G., Tirloni L., Vitali A. (Ospedale San Giovanni di Dio); Abate E., Casati M.*, Casiraghi T., Laface L., Schiavo M. (Ospedale Vittorio Emanuele III – Carate Brianza); Arminio A., Cotoia A., Lizzi V.*, Vovola F. (Ospedali Riuniti Azienda Ospedaliera Universitaria Foggia); Vergari R.* (Ospedali Riuniti di Ancona); D'Ugo S.*, Depalma N., Spampinato M. G. (Vito Fazzi, Leece); Brachini G., Chiappini A., Cicerchia P. M., Cirillo B., De Toma G., Fiori E., Fonsi G. B., Iannone I., La Torre F., Lapolla P.*, Meneghini S., Mingoli A., Sapienza P., Zambon M. (Policlinico Umberto I Sapienza University of Rome); Capolupo G. T.*, Mazzotta E. (Policlinico Universitario Campus Bio Medico of Rome); Gattolin A., Migliore M., Rimonda R., Sasia D.*, Travaglio E. (Regina Montis Regalis Hospital, Mondovì); Cervellera M., Gori A., Sartarelli L., Tonini V.* (S. Orsola-Malpighi Hospital); Chessa A.*, Fiorini A., Norcini C. (San Giovanni di Dio); Colletti G., Confalonieri M., Costanzi A.*, Frattaruolo C., Mari G., Monteleone M. (San Leopoldo Mandic); De Nardi P.*, Parise P., Vignali A. (San Raffaele Scientific Institute, Milan); Belvedere A., Bernante P., Jovine E., Neri J., Parlanti D., Pezzuto A. P., Poggioli G., Rottoli M.*, Tanzanu M., Violante T. (IRCCS Azienda Ospedaliero – Universitaria di Bologna; Alma Mater Studiorum University of Bologna); Borghi F., Cianflocca D., Di Maria Grimaldi S., Donati D., Gelarda E., Giraudo G., Giuffrida M. C., Marano A.*, Palagi S., Pellegrino L., Peluso C., Testa V.* (Santa Croce E. Carle Hospital, Cuneo); Agresta F.*, Prando D.*, Zese M.* (Santa Maria degli Angeli Hospital ULSS 5 – Adria); Armatura G.*, Frena A., Scotton G.* (St Moritz Hospital); Gallo G.*, Sammarco G., Vescio G. (University 'Magna Graecia' of Catanzaro); Di Marzo F.* (Valtiberina); Fontana T.* ('Vittorio Emanuele' – Gela). Japan: Kanemitsu Y.*, Moritani K. (National Cancer Center Hospital). Jordan: Al Abdallah M.*, Ayasra F., Ayasra Y., Qasem A. (Al-Basheer Hospital); Fahmawee T., Hmedat A., Obeidat K.* (King Abdullah University Hospital); Abou Chaar M. K., Al-Masri M.*, Al-Najjar H., Alawneh F. (King Hussein Cancer Center). Libya: Alkadeeki G.*, Al Maadany F. S. (Al-Jalaa Hospital); Aldokali N., Senossi O., Subhi M. T. (Alkhadra Hospital); Burgan D.*, Kamoka E., Kilani A. I. (National Cancer Institute, Sabratha); Ellojli I.*, Kredan A. (Tripoli University Hospital). Lithuania: Bradulskis S., Dainius E., Kubiliute E., Kutkevičius J., Parseliunas A., Subocius A., Venskutonis D.* (Lithuanian University of Health Sciences Kaunas Clinical Hospital). Madagascar: Rasoaherinomenjanahary F.*, Razafindrahita J. B., Samison L. H. (Joseph Ravoahangy Andrianavalona Hospital). Malaysia: Hamdan K. H., Ibrahim M. R., Tan J. A., Thanapal M. R.* (Hospital Kuala Lumpur); Amin Sahid N., Hayati F.*, Jayasilan J., Sriram R. K.*, Subramaniam S. (Queen Elizabeth Hospital and Universiti Malaysia Sabah, Kota Kinabalu, Sabah); Che Jusoh M. A., Hussain A. H., Mohamed Sidek A. S., Mohd Yunus M. F., Soh J. Y., Wong M., Zakaria A. D.*, Zakaria Z. (School of Medical Sciences and Hospital, Universiti Sains Malaysia); Fathi N. Q., Xavier R. G., Roslani A. C.* (University Malaya Medical Centre). Mexico: Buerba G. A., Mercado M. Á.*, Posadas-Trujillo O. E., Salgado-Nesme N., Sarre C. (Instituto Nacional de Ciencias Médicas y Nutrición 'Salvador Zubirán'). Morocco: Amrani L., El Ahmadi B., El Bouazizi Y., Majbar A. M., Benkabbou A., Mohsine R., Souadka A.* (Institut National d'Oncologie, Université Mohammed V Rabat). Netherlands: Hompes R.*, Meima-van Praag E. M., Pronk A. J. M., Sharabiany S. (Amsterdam UMC, University of Amsterdam); Grotenhuis B.*, Hartveld L. (Antoni Van Leeuwenhoek Ziekenhuis); Posma-Bouman L.* (Slingeland Ziekenhuis); Derksen T., Franken J., Oosterling S.* (Spaarne Gasthuis); Konsten J.*, Van Heinsbergen M. (Viecuri Medisch Centrum). Nigeria: Olaogun J.* (Ekiti State University Teaching Hospital); Abdur-Rahman L.*, Adeyeye A.*, Bello J., Olasehinde O., Popoola A. (University of Ilorin Teaching Hospital). Pakistan: Jamal A., Kerawala A. A.* (Cancer Foundation Hospital); Memon A. S.*, Nafees Ahmed R., Rai .L* (Dr Ruth K. M. Pfau Civil Hospital); Ayub B., Ramesh P., Sayyed R.* (Patel Hospital); Butt U. I.*, Kashif M., Qureshi A.*, Farooka M. W.*, Ayyaz M.* (Services Hospital Lahore); Ayubi A., Waqar S. H.* (Pakistan Institute of Medical Sciences). Poland: Major P. (Jagiellonian University Medical College). Portugal: Azevedo C., Machado D., Mendes F.* (Centro Hospitalar Cova da Beira); De Sousa X.* (Centro Hospitalar de Setúbal); Fernandes U., Ferreira C.*, Guidi G., Marçal A., Marques R., Martins D., Vaz Pereira R., Vieira B. (Centro Hospitalar de Trás-Os-Montes e Alto Douro, EPE); Afonso J., Almeida J. I., Almeida-Reis R.*, Correia de Sá T., Costa M. J. M. A., Fernandes V., Ferraz I., Lima da Silva C., Lopes L., Machado N., Marialva J., Nunes Coelho M., Pereira C., Ribeiro A., Ribeiro C. G., Santos R., Saraiva P., Silva R., Tavares F., Teixeira M. (Centro Hospitalar do Tamega e Sousa); Almeida A. C., Amaral M. J., Andrade R., Camacho C., Costa M., Lázaro A.*, Nogueira O., Oliveira A., Ruivo A., Silva M., Simões J. (Centro Hospitalar e Universitário de Coimbra); Devezas V., Jácome F., Nogueiro J., Pereira A., Santos-Sousa H.*, Vaz S. (Centro Hospitalar e Universitário de São João); Pinto J., Tojal A.* (Centro Hospitalar Tondela-Viseu); Cardoso P.*, Cardoso N., Domingos J. C., Henriques P., Manso M. I., Martins dos Santos G., Martins R., Morais H.*, Pereira R., Revez T., Ribeiro R., Ribeiro V. I., Soares A. P., Sousa S., Teixeira J. (Centro Hospitalar Universitário do Algarve – Unidade de Faro); Amorim E., Baptista V. H., Cunha M. F.*, Sampaio da Nóvoa Gomes Miguel I. I. (Centro Hospitalar Universitário do Algarve – Unidade de Portimão); Bandovas J. P., Borges N.*, Chumbinho B., Figueiredo de Barros I., Frade S., Gomes J., Kam da Silva Andrade A., Pereira Rodrigues A., Pina S., Silva N.*, Silveira Nunes I., Sousa R. (Centro Hospitalar Universitário Lisboa Central); Azevedo P., Costeira B., Cunha C., Garrido R.*, Miranda P., Peralta Ferreira M., Sousa Fernandes M. (Hospital Beatriz Angelo); Galvão D., Vieira A.* (Hospital de Santo Espirito da Ilha Terceira); Patrício B., Santos P. M. D. D.*, Vieira Paiva Lopes A. C. (Hospital de Torres Vedras – Centro Hospitalar do Oeste); Cunha R., Faustino A., Freitas A., Mendes J. R.*, Parreira R. (Hospital do Divino Espírito Santo); Abreu da Silva A.*, Claro M., Costa Santos D., Deus A. C., Grilo J. V. (Hospital do Litoral Alentejano); Borges F.*, Corte Real J., Henriques S., Lima M. J., Matos Costa P. (Hospital Garcia de Orta); Brito da Silva F., Caiado A.*, Fonseca F. (Instituto Português de Oncologia de Lisboa Francisco Gentil); Ângelo M., Baiao J. M., Martins Jordão D.*, Vieira Caroço T. (IPO Coimbra); Baía C., Canotilho R., Correia A. M., Ferreira Pinto A. P., Peyroteo M., Videira J. F.* (IPO Porto). Réunion: Kassir R.*, Sauvat F. (CHU Réunion). Romania: Bezede C., Chitul A., Ciofic E., Cristian D., Grama F.* (Coltea Clinical Hospital); Bonci E.*, Gata V.*, Titu S.* (Prof. Dr. Ion Chiricuta Institute of Oncology). Russia: Garmanova T., Kazachenko E., Markaryan D., Rodimov S., Tsarkov P.*, Tulina I. (Clinic of Coloproctology and Minimally Invasive Surgery, Sechenov Medical State University); Litvina Y., Provozina A. (Immanuel Kant Baltic Federal University, Regional Clinical Hospital); Agapov M.*, Galliamov E., Kakotkin V., Kubyshkin V., Kamalov A., Semina E. (Moscow Research and Educational Center, Lomonosov Moscow State University). Saudi Arabia: Alshahrani M.*, Alsharif F., Eskander M. (Aseer Central Hospital); Alharthi M., Aljiffry M., Basendowah M., Malibary N.*, Nassif M., Saleem A., Samkari A., Trabulsi N.* (King Abdulaziz University Hospital); Al Awwad S.*, Alghamdi M.*, Alnumani T.* (King Fahad General Hospital); Al Habes H., Alqannas M.*, Alyami M.*, Alzamanan M., Cortés Guiral D.*, Elawad A. (King Khalid Hospital); AlAamer O., Alselaim N.* (King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard, Health Affairs, General Surgery Department); Al-Khayal K., Alhassan N., Alobeed O., Alshammari S., Bin Nasser A.*, Bin Traiki T., Nouh T.*, Zubaidi A. M. (King Saud University). Serbia: Aleksić L., Antic A., Barisic G.*, Ceranic M., Grubač Ž., Jelenkovic J., Kecmanović D., Kmezić S., Knezevic D.*, Krivokapic Z.*, Latinčić S., Markovic V.*, Matić S.*, Miladinov M., Pavlov M.*, Pejovic I., Tadic B., Vasljević J., Velickovic D. (Clinic for Digestive Surgery, Clinical Centre of Serbia); Buta M., Cvetkovic A., Gacic S., Goran M., Jeftic N., Markovic I.*, Milanović M., Nikolic S., Pejnovic L., Savković N., Stevic D., Vucic N., Zegarac M. (Institute for Oncology and Radiology of Serbia); Karamarkovic A., Kenic M., Kovacevic B., Krdzic I.* (Zvezdara University Medical Center). Singapore: Lieske B.* (National University Hospital). South Africa: Almgla N.*, Boutall A., Herman A., Kloppers C.*, Nel D., Rayamajhi S. (Groote Schuur Hospital). Spain: Paniagua García Señorans M.*, Vigorita V. (Álvaro Cunqueiro Hospital); Acrich E., Baena Sanfeliu E., Barrios O., Golda T.*, Santanach C., Serrano-Navidad M., Sorribas Grifell M., Vives R. V. (Bellvitge University Hospital); Escolà D., Jiménez A.* (Comarcal Alt Penedés); Cayetano Paniagua L., Gómez Fernández L.* (Consorci Sanitari de Terrassa); Collera P., Diaz Del Gobbo R., Farre Font R., Flores Clotet R., Gómez Díaz C. J.*, Guàrdia N., Guariglia C. A., Osorio A., Sanchez Jimenez R., Sanchon L., Soto Montesinos C. (Fundació Althaia – Xarxa Assistencial Universitària de Manresa); Alonso-Lamberti L., García-Quijada J., Jimenez Miramón J., Jimenez V.*, Jover J. M., Leon R., Rodriguez J. L., Salazar A., Valle Rubio A. (Getafe University Hospital); Aguado H.* (Hellín Hospital); Bravo Infante R., De Lacy F. B., Lacy A. M.*, Otero A., Turrado-Rodriguez V.*, Valverde S. (Hospital Clinic Barcelona); Anula R., Cano-Valderrama O., Del Campo Martín M., Díez-Valladares L., Domínguez I., Dziakova J., García Alonso M., García Romero E., Gómez Latorre L., Muguerza J.M.*, Pizarro M. J., Saez Carlin P., Sánchez del Pueblo C., Sánchez-Pernaute A., Sanz Ortega G., Sanz-Lopez R., Torres A. (Hospital Clínico de Madrid); Garcés-Albir M.*, Lopez F.*, Martín-Arévalo J., Moro-Valdezate D.*, Pla Marti V. (Hospital Clínico Universitario de Valencia); Beltrán de Heredia J., De Andrés Asenjo B.*, Gómez Sanz T., Jezieniecki C., Nuñez del Barrio H., Ortiz de Solórzano Aurusa F. J., Romero de Diego A., Ruiz Soriano M., Trujillo Díaz J., Vázquez Fernández A. (Hospital Clínico Universitario de Valladolid); Lora-Cumplido P., Sosa M. V.* (Hospital de Cabueñes); Gonzalez-Gonzalez E., Minaya Bravo A. M.* (Hospital del Henares); Alonso de la Fuente N., Jimenez Toscano M.* (Hospital del Mar); Grau-Talens E. J., Martin-Perez B.* (Hospital Don Benito-Villanueva); Benavides Buleje J. A., Carrasco Prats M.*, Giménez Francés C.*, Muñoz Camarena J. M., Parra Baños P. A., Peña Ros E., Ramirez Faraco M., Ruiz-Marín M.*, Valero Soriano M. (Hospital General Reina Sofía); Estaire Gómez M.*, Fernández Camuñas Á., Garcia Santos E. P., Jimenez Higuera E., Martínez-Pinedo C., Muñoz-Atienza V., Padilla-Valverde D.*, Picón Rodríguez R., Sánchez-García S., Sanchez-Pelaez D. (Hospital General Universitario de Ciudad Real); Colombari R. C., del Valle E., Fernández M., Lozano Lominchar P.*, Martín L., Rey Valcarcel C., Zorrilla Ortúzar J. (Hospital General Universitario Gregorio Marañón); Alcaide Matas F., García Pérez J. M., Troncoso Pereira P.* (Hospital Mateu Orfila); Mora-Guzmán I.* (Hospital Santa Bárbara); Achalandabaso Boira M.*, Sales Mallafré R. (Hospital Universitari de Tarragona Joan XXIII); Marín H., Prieto Calvo M., Villalabeitia Ateca I.* (Hospital Universitario Cruces); De Andres Olabarria U., Durán Ballesteros M., Fernández Pablos F. J., Ibáñez-Aguirre F. J., Sanz Larrainzar A., Ugarte-Sierra B.* (Hospital Universitario de Galdakao); Correa Bonito A., Delgado Búrdalo L., Di Martino M.*, García Septiem J.*, Maqueda González R., Martin-Perez E. (Hospital Universitario de la Princesa); Calvo Espino P.*, Guillamot Ruano P. (Hospital Universitario de Móstoles); Colao García L., Díaz Pérez D.*, Esteban Agustí E., Galindo Jara P., Gutierrez Samaniego M.*, Hernandez Bartolome M. A.*, Serrano González J. (Hospital Universitario de Torrejón de Ardoz); Alonso Poza A., Diéguez B., García-Conde M., Hernández-García M., Losada M.* (Hospital Universitario del Sureste); Alvarez E., Chavarrias N., Gegúndez Simón A., Gortázar S., Guevara J., Prieto Nieto M. I., Ramos-Martín P., Rubio-Perez I.*, Saavedra J., Urbieta A. (Hospital Universitario la Paz); Cantalejo Diaz M., De Miguel Ardevines M. D. C., Duque-Mallén V.*, Gascon Ferrer I., González-Nicolás Trébol M. T., Gracia-Roche C., Herrero Lopez M., Martinez German A., Matute M., Sánchez Fuentes N., Sánchez-Rubio M., Santero-Ramirez M. S., Saudí S. (Hospital Universitario Miguel Servet); Blazquez Martin A., Diez Alonso M.*, Hernandez P., Mendoza-Moreno F., Ovejero Merino E., Vera Mansilla C. (Hospital Universitario Principe de Asturias); Acebes García F., Bailón M., Bueno Cañones A. D., Choolani Bhojwani E., Marcos-Santos P., Miguel T., Pacheco Sánchez D., Pérez-Saborido B., Sanchez Gonzalez J., Tejero-Pintor F. J.* (Hospital Universitario Río Hortega); Cano A., Capitan-Morales L., Cintas Catena J., Gomez-Rosado J.*, Oliva Mompean F., Pérez Sánchez M. A., Río Lafuente F. D., Torres Arcos C., Valdes-Hernandez J. (Hospital Universitario Virgen Macarena); Cholewa H., Frasson M., Martínez Chicote C., Sancho-Muriel J.* (Hospital Universitario Y Politécnico la Fe); Abad Gurumeta A., Abad-Motos A., Martínez-Hurtado E., Ripollés-Melchor J.*, Ruiz Escobar A. (Infanta Leonor University Hospital); Cuadrado-García A.*, Garcia-Sancho Tellez L.*, Heras Aznar J.*, Maté P., Ortega Vázquez I.*, Picardo A. L., Rojo López J. A., Sanchez Cabezudo Noguera F.*, Serralta de Colsa D.* (Infanta Sofía University Hospital); Cagigas Fernandez C., Caiña Ruiz R., Gomez Ruiz M., Martínez-Pérez P., Poch C., Santarrufina Martinez S.*, Valbuena Jabares V. (Marqués de Valdecilla University Hospital); Blas Laina J. L., Cros B., Escartin J.*, Garcia Egea J., Nogués A., Talal El-Abur I., Yánez C. (Royo Villanova); Cagigal Ortega E. P., Cervera I., Díaz Peña P., Gonzalez J., Marqueta De Salas M., Perez Gonzalez M.*, Ramos Bonilla A., Rodríguez Gómez L. (Severo Ochoa University Hospital); Blanco-Colino R., Espin-Basany E.*, Pellino G. (Vall d'Hebron University Hospital). Sri Lanka: Arulanantham A., Bandara G. B. K. D., Jayarajah U.*, Ravindrakumar S., Rodrigo V. S. D. (District General Hospital Chilaw); Srishankar S.* (Teaching Hospital Anuradhapura). Sudan Ali Adil A. K. (Al-Rajhi). Sweden: Älgå A.*, Heinius G., Nordberg M., Pieniowski E. (Stockholm South General Hospital); Löfgren N., Rutegård M.* (Umea University Hospital). Switzerland: Arigoni M., Bernasconi M., Christoforidis D.*, Di Giuseppe M., La Regina D., Mongelli F. (Ente Ospedaliero Cantonale); Chevallay M., Dwidar O., Gialamas E., Sauvain M. (Pourtales Neuchatel Hospital); Adamina M.*, Crugnale A. S., Guglielmetti L., Peros G. (Kantonsspital Winterthur). Turkey: Aghayeva A.*, Hamzaoglu I., Sahin I. (Acibadem Altunizade Hospital); Akaydin E., Aliyeva Z., Aytac E., Baca B., Ozben V.*, Ozmen B. B. (Acibadem Atakent Hospital); Arikan A. E.*, Bilgin I. A.*, Kara H., Karahasanoğlu T., Uras C. (Acibadem Maslak Hospital); Dincer H. A., Erol T. (Hacettepe University Hospital); Alhamed A., Ergün S.*, Özçelık M. F., Sanli A. N., Uludağ S. S.*, Velidedeoglu M.*, Zengin A. K. (Istanbul Universty – Cerrahpaşa Medical Faculty); Bozkurt M. A., Kara Y.*, Kocataş A. (Kanuni Sultan Suleyman Training and Research Hospital); Azamat İ. F., Balik E.*, Buğra D., Kulle C. B. (Koç University Medical School); Gözal K., Güler S. A., Köken H., Tatar O. C.*, Utkan N. Z., Yıldırım A., Yüksel E. (Kocaeli University Teaching Hospital); Akin E., Altintoprak F.*, Cakmak G., Çelebi F., Demir H., Dikicier E., Firat N., Gönüllü E., Kamburoğlu M. B., Küçük I. F., Mantoglu B. (Sakarya University Faculty of Medicine); Çolak E.*, Kucuk G. O., Uyanik M. S. (Samsun Training and Research Hospital); Göksoy B.* (Sehit Prof. Dr. İlhan Varank Training and Research Hospital); Bozkurt E., Mihmanli M., Tanal M.*, Yetkin S. G. (Sisli Hamidiye Etfal Training and Research Hospital); Akalin M., Arican C., Avci E. K., Aydin C., Demirli Atıcı S.*, Emiroglu M., Kaya T.*, Kebabçı E., Kilinc G., Kirmizi Y., Öğücü H., Salimoğlu S., Sert İ., Tugmen C., Tuncer K., Uslu G., Yeşilyurt D. (University of Health Sciences Tepecik Training and Research Hospital); Yildiz A.* (Yildirim Beyazit University Yenimahalle Training and Research Hospital). Uganda: Lule H.*, Oguttu B.* (Kampala International University Teaching Hospital). UK: Agilinko J., Ahmeidat A., Bekheit M.*, Cheung L. K., Kamera B. S., Mignot G., Shaikh S.*, Sharma P. (Aberdeen Royal Infirmary); Al-Mohammad A., Ali S., Ashcroft J., Baker O., Coughlin P., Davies R. J.*, Kyriacou H., Mitrofan C. G., Morris A., Raby-Smith W., Rooney S., Singh A., Tan X. S., Townson A., Tweedle E. (Addenbrooke's Hospital); Angelou D., Choynowski M., McAree B.*, McCanny A., Neely D. (Antrim Area Hospital – Northern Health and Social Care Trust); Mosley F.* (Bradford Royal Infirmary); Arrowsmith L.*, Campbell W.* (Causeway Hospital); Grove T., Kontovounisios C., Warren O.* (Chelsea and Westminster Hospital); Clifford R., Eardley N., Krishnan E., Manu N., Martin E., Roy Mahapatra S., Serevina O. L., Smith C., Vimalachandran D.* (Countess of Chester Hospital); Emslie K.*, Labib P.*, Minto G., Natale J., Panahi P., Rogers L.* (Derriford Hospital); Abubakar A.*, Akhter Rahman M. M., Chan E., O'Brien H., Sasapu K.* (Diana Princess of Wales Hospital Grimsby); Ng H. J.* (Dumfries and Galloway Royal Infirmary); Day A.* (East Surrey Hospital); Hunt A., Laskar N.* (East Sussex Healthcare (Conquest Hospital and Eastbourne District General Hospital)); Gupta A.*, Steinke J., Thrumurthy S. (Epsom and St Helier University Hospitals NHS Trust); Massie E., McGivern K., Rutherford D., Wilson M.* (Forth Valley Royal Hospital); Handa S., Kaushal M., Kler A., Patel P.*, Redfern J., Tezas S. (Furness General Hospital); Aawsaj Y., Barry C., Blackwell L., Emerson H., Fisher A.*, Katory M., Mustafa A. (Gateshead Health NHS Foundation Trust); Kretzmer L.*, Lalou L., Manku B., Parwaiz I., Stafford J. (George Eliot Hospital); Abdelkarim M., Asqalan A., Gala T., Ibrahim S., Maw A.*, Mithany R., Morgan R.*, Sundaram Venkatesan G. (Glan Clwyd Hospital); Boulton A. J. (Good Hope Hospital); Hardie C., McNaught C.* (Harrogate District Hospital); Karandikar S.*, Naumann D. (Heartlands Hospital); Ayorinde J., Chase T., Cuming T., Ghanbari A., Humphreys L., Tayeh S.* (Homerton University Hospital); Aboelkassem Ibrahim A., Evans C., Ikram H., Loubani M.*, Nazir S., Robinson A., Sehgal T., Wilkins A. (Hull University Teaching Hospitals NHS Trust); Dixon J.*, Jha M., Thulasiraman S. V., Viswanath Y. K. S.* (James Cook University Hospital); Curl-Roper T., Delimpalta C., Liao C. C. L.*, Velchuru V., Westwood E. (James Paget University NHS Foundation Trust Hospital); Bond-Smith G.*, Mastoridis S., Tebala G. D., Verberne C. (John Radcliffe Hospital); Bhatti M. I., Boyd-Carson H., Elsey E., Gemmill E., Herrod P.*, Jibreel M., Lenzi E., Saafan T., Sapre D., Sian T., Watson N. (King's Mill Hospital); Athanasiou A.*, Burke J., Costigan F., Elkadi H., Johnstone J., Nahm C. (Leeds Teaching Hospitals Trust); Annamalai S., Ashmore C., Kourdouli A. (Leicester Royal Infirmary); Askari A., Cirocchi N., Kudchadkar S., Patel K., Sagar J.*, Talwar R.* (Luton and Dunstable University Hospital); Abdalla M., Ismail O., Newton K., Stylianides N.* (Manchester Royal Infirmary); Aderombi A., Bajomo O., Beatson K., Garrett W.*, Ng V. (Medway Hospital); Al-Habsi R., Divya G S., Keeler B.* (Milton Keynes University Hospital); Egan R., Fabre I., Harries R.*, Li Z., Parkins K., Spencer N., Thompson D. (Morriston Hospital Swansea); Gemmell C., Grieco C., Hunt L.* (Musgrove Park Hospital); Mahmoud Ali F. (Newcastle Upon Tyne Hospitals NHS Foundation Trust.); Seebah K., Shaikh I.*, Sreedharan L., Youssef M.* (Norfolk and Norwich University Hospital); Shah J.* (North Manchester General Hospital); McLarty N., Mills S.*, Shenfine A. (Northumbria NHS Hospital Trust); Sahnan K. (Northwick Park Hospital); Michel M., Patil S., Ravindran S., Sarveswaran J.*, Scott L. (Pinderfields Hospital); Bhangu A.*, Cato L. D., Kamal M., Kulkarni R., Parente A., Saeed S., Vijayan D. (Queen Elizabeth Hospital Birmingham); Kaul S., Khan A. H., Khan F., Mukherjee S.*, Patel M., Sarigul M., Singh S. (Queen's Hospital Romford); Adiamah A., Brewer H., Chowdhury A.*, Evans J., Humes D.*, Jackman J., Koh A., Lewis-Lloyd C., Oyende O., Reilly J., Worku D. (Queens Medical Centre); Bisset C., Moug S. J.* (Royal Alexandra Hospital); Math S., Sarantitis I., Timbrell S., Vitone L.* (Royal Blackburn Hospital); Faulkner G.* (Royal Bolton Hospital); Brixton G., Findlay L., Majkowska A., Manson J.*, Potter R. (Royal Bournemouth Hospital); Bhalla A.*, Chia Z., Daliya P., Grimley E., Malcolm F. L., Theophilidou E. (Royal Derby Hospital); Daniels I. R., Fowler G., Massey L., McDermott F.*, Rajaretnam N. (Royal Devon and Exeter Hospital); Beamish A., Magowan D., Nassa H., Price C., Smith L., Solari F., Tang A. M., Williams G.* (Royal Gwent Hospital); Davies E.*, Hawkin P., Raymond T., Ryska O. (Royal Lancaster Infirmary); Baron R. D.*, Gahunia S., McNicol F.*, Russ J., Szatmary P., Thomas A. (Royal Liverpool University Hospital); Jayasinghe J. D., Knowles C., Ledesma F. S., Minicozzi A.*, Navaratne L., Ramamoorthy R., Sohrabi C., Thaha M.*, Venn M. (Royal London Hospital); Atherton R.*, Brocklehurst M., McAleer J., Parkin E.* (Royal Preston Hospital); Aladeojebi A., Ali M., Gaunt A.* (Royal Stoke University Hospital); Hammer C., Stebbing J. (Royal Surrey County Hospital); Bhasin S., Bodla A. S., Burahee A., Crichton A., Fossett R., Yassin N.* (Royal Wolverhampton NHS Trust); Brown S.*, Lee M., Newman T., Steele C. (Sheffield Teaching Hospital NHS Foundation Trust); Baker A., Konstantinou C., Ramcharan S.*, Wilkin R. J. W. (South Warwickshire NHS Foundation Trust); Lawday S., Lyons A.* (Southmead Hospital); Chung E., Hagger R., Hainsworth A., Karim A., Owen H., Ramwell A., Williams K.* (St George's Hospital); Hall J. (Stepping Hill Hospital); Harris G., Royle T.*, Watson L. J. (Sunderland Royal Hospital); Asaad P., Brown B., Duff S.*, Khan A., Moura F., Wadham B. (The University Hospital of South Manchester); McCluney S., Parmar C.*, Shah S. (The Whittington Hospital); Babar M. S., Goodrum S., Whitmore H. (Torbay and South Devon NHS Trust); Balasubramaniam D.*, Jayasankar B.*, Kapoor S., Ramachandran A. (Tunbridge Wells Hospital); Beech N., Chand M.*, Green L., Kiconco H., McEwen R. (University College London Hospital); Pereca J.* (University Hospital Ayr); Gash K.*, Gourbault L., MacCabe T., Newton C.* (University Hospitals Bristol NHS Foundation Trust); Baig M., Bates H., Dunne N., Khajuria A., Ng V., Sarma D. R., Shortland T., Tewari N.* (University Hospitals Coventry and Warwickshire NHS Trusts); Akhtar M. A.*, Brunt A., McIntyre J., Milne K., Rashid M. M., Sgrò A., Stewart K. E., Turnbull A. (Victoria Hospital Kirkcaldy); Aguilar Gonzalez M.*, Talukder S.* (West Suffolk Hospital); Eskander P., Hanna M., Olivier J.* (Weston General Hospital); Magee C.*, Powell S.* (Wirral University Teaching Hospital); Flindall I., Hanson A., Mahendran V. (Worcestershire Royal Hospital); Green S., Lim M., MacDonald L., Miu V., Onos L., Sheridan K., Young R.* (York Teaching Hospitals NHS Trust); Alam F., Griffiths O., Houlden C., Kolli V. S., Lala A. K., Seymour Z.* (Ysbyty Gwynedd). USA: Haynes A.*, Hill C., Leede E., McElhinney K., Olson K. A., Riley C., Thornhill M. (Dell Seton Medical Center at the University of Texas); Etchill E., Gabre-Kidan A.*, Jenny H., Kent A., Ladd M. R., Long C., Malapati H., Margalit A., Rapaport S., Rose J., Stevens K., Tsai L., Vervoort D., Yesantharao P., Bigelow B. (Johns Hopkins Hospital); Klaristenfeld D.* (Kaiser Permanente San Diego Medical Center); Huynh K. (Kaiser Permanente West Los Angeles); Azam M., Choudhry A.*, Marx W. (SUNY Upstate University Hospital); Abel M. K., Boeck M., Chern H., Kornblith L.*, Nunez-Garcia B., Ozgediz D., Glencer A., Sarin A., Varma M. (University of California, San Francisco (UCSF)); Abbott D., Acher A., Aiken T., Barrett J., Foley E., Schwartz P., Zafar S. N.* (University of Wisconsin); Hawkins A.*, Maiga A. (Vanderbilt University Medical Center).
BACKGROUND Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. METHODS This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. FINDINGS Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16-30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77-0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50-0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80-0·88; p<0·001), and full lockdowns (0·57, 0·54-0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. INTERPRETATION Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services. FUNDING National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.
Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restrictions. Methods This international, prospective, cohort study enrolled 20 006 adult (>= 18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926. Findings Of eligible patients awaiting surgery, 2003 (10middot0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16-30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0middot6% non-operation rate (26 of 4521), moderate lockdowns with a 5middot5% rate (201 of 3646; adjusted hazard ratio [HR] 0middot81, 95% CI 0middot77-0middot84; p Funding National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research. Copyright (c) 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. ; Peer reviewed
