European Society of Anaesthesiology.

Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.

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PurposeStereotactic-fractionated radiotherapy and radiosurgery (RS) for benign and malignant intracranial lesions relies on a very high degree of accuracy in dose alignment due to the ablative dose delivered, and therefore requires a high-precision image guidance modality. The aim of this review is to investigate the localisation and verification accuracy performance of ExacTrac (ET) and Novalis Tx System.Materials and methodsA systematic review of the database Science Direct was carried out using search terms ‘stereotactic radiotherapy (SRT)’ and ‘ET’. All articles before 2000 were excluded. Only articles that involved intracranial lesions, with the exception of one article, were included in the final review.ResultsResults from gold standard Hidden Target Tests and patient data show that patient position can be reproduced within 1·0 mm with the use of ET imaging. In addition, the 6 degrees of freedom algorithm function of ET allows for better translational accuracy as well optimal positioning when rotations are corrected for. Studies showed excellent correlation (p<0·01) between bony ET images and cone beam computed tomography (CBCT) soft tissue registration, evidencing the safe reliance of bony anatomy for image guidance via ET. Shifts were found to be comparable between CBCT and ET.ConclusionThere is the need for regular calibration to prevent systematic errors and potential geographic miss. However, due to ET’s additional benefits, including reduced concomitant dose and faster imaging time, ET is the superior image guidance modality for RS/SRT in the treatment of intracranial lesions.

Introduction: Patients with oligometastases are candidates for targeted therapy (1) , such as SABR. This allows delivery of biologically more potent dose, which may provide better local control and is advantageous for these patients (2). A disadvantage of SABR however is the lengthy time to deliver each high dose treatment (3). Clinicians currently supervise treatment delivery but this is insufficient use of a clinician's time (4). With SABR treatments likely to increase over coming years implementation of a Radiographer-led SABR service in Belfast is key to confidently treating complex high dose treatments, similar to our established Lung SABR service. Methods and Materials: SABR service for oligometastases commenced in Belfast in January 2018 with 36 various metastases treated to date. SABR treatment competent Radiographers deliver treatment under supervision of clinician with a SABR competent Band 7 or above in attendance. Patients are scheduled to one treatment machine and one team leader has predominantly been involved since commencement of the service. She has undertaken the MSc Expert Practice Module at Sheffield Hallam University which has facilitated development of portfolio with detailed case studies and future development plan to expand this area of clinical expertise. Results: 15 bone, 11 node, 3 liver, 2 pelvic masses and 5 spine metastases have been treated to date. Establishment of and regular attendance at the weekly MDT allows Radiographer input, increased involvement and collaboration with clinicians, radiologists and physicists. This involvement and completion of competencies with direct and indirect supervision from a clinical mentor through the MSc module has deemed this team leader clinically competent in supervision and delivery of SABR for oligometastases. Conclusion and Discussion: Clinician and Radiographer competence and confidence is now well established for the treatment of bone and node metastases. The Team Leader with this clinical competence and level of knowledge and experience that has been achieved is in a position now to develop treatment and supervision competencies, train staff and supervise these treatments thus enabling implementation of a Radiographer-Led service. Numerical References (1).