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. 2024 Nov 27;9(3):505-517.
doi: 10.1002/ags3.12887. eCollection 2025 May.

Effects of an increase in emergency cases with difficulties in transport to hospital during the COVID-19 pandemic on postoperative short-term outcomes of colorectal perforation: A study based on the National Clinical Database

Shimpei Ogawa  1   2 , Hideki Endo  3 , Masahiro Yoshida  1   4 , Tomomitsu Tsuru  1   5 , Michio Itabashi  1   2 , Hiroyuki Yamamoto  3 , Yoshihiro Kakeji  6   7 , Hideki Ueno  6   8 , Ken Shirabe  9   10 , Taizo Hibi  11   12 , Akinobu Taketomi  11   13 , Norihiko Ikeda  11   14 , Masaki Mori  11   15
Affiliations

Effects of an increase in emergency cases with difficulties in transport to hospital during the COVID-19 pandemic on postoperative short-term outcomes of colorectal perforation: A study based on the National Clinical Database

Shimpei Ogawa et al. Ann Gastroenterol Surg. .

Abstract

Aim: During the COVID-19 pandemic, there were delays in transport of emergency cases to hospital by ambulance due to increased difficulties in obtaining hospital acceptance. The aim of this study was to examine if this had a negative effect on postoperative short-term outcomes in patients with colorectal perforation.

Methods: The National Clinical Database (NCD) includes >95% of surgical cases in Japan. Postoperative 30-day mortality, surgical mortality, and postoperative complications (Clavien-Dindo grade ≥3) were examined in 17 770 cases of colorectal perforation registered from 2019 to 2022 in the NCD. These outcomes were compared for cases with new COVID-19 infection and emergency cases with difficulties in transport to hospital. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) did not contain 1.

Results: Postoperative 30-day mortality occurred in 1826 cases (10.3%), surgical mortality in 2382 cases (13.4%), and postoperative complications in 5276 cases (29.7%). Significantly higher SMRs were found for 30-day mortality in November 2020 (1.44 [95% CI: 1.07-1.89]) and February 2021 (1.54 [95% CI: 1.14-2.03]), and for postoperative complications in June 2020 (1.27 [95% CI: 1.07-1.50]). In 2022, there were marked increases in new COVID-19 cases and in emergency cases with difficulties in transport to hospital, but no month had a significantly high SMR.

Conclusions: Emergency cases with difficulties in transport markedly increased during the COVID-19 pandemic but had little effect on short-term outcomes of colorectal perforation.

Keywords: COVID‐19; National Clinical Database; colorectal perforation; emergency cases with difficulties in transport to hospital; postoperative short‐term outcomes.

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Conflict of interest statement

Hideki Endo and Hiroyuki Yamamoto are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo. The department is a social collaboration department supported by grants from the National Clinical Database, Intuitive Surgical Sarl, Johnson & Johnson K.K., and Nipro Co. Masaki Mori is Emeritus Editor‐in‐Chief of Annals of Gastroenterological Surgery. Hideki Ueno is Associate Editor of Annals of Gastroenterological Surgery dealing with the lower digestive tract. Yoshihiro Kakeji and Ken Shirabe are editorial members of Annals of Gastroenterological Surgery. The other authors declare no conflict of interest for this article.

Figures

FIGURE 1
FIGURE 1
Flowchart of the patient selection process.
FIGURE 2
FIGURE 2
(A) New COVID‐19 patient. (Data [Information on infectious disease outbreak trends, etc.] from the website has been quoted and modified [Ministry of Health, Labour and Welfare, Japan. https://covid19.mhlw.go.jp/public/aboutdata.html. Accessed 15 March 2024]); (B) Emergency case with difficulties in transport to hospital. (Data [Results of a survey on difficult emergency transport cases from each fire department.] from the website has been quoted and modified [Fire and Disaster Management Agency. Survey on the difficulty in hospital acceptance during the novel corona virus pandemic. https://www.fdma.go.jp/disaster/coronavirus/post‐1.html. Accessed 15 March 2024]). First wave: weeks 3–23 in 2020 (13 Jan–7 Jun 2020). Second wave: weeks 24–39 in 2020 (8 Jun–27 Sep 2020). Third wave: week 40 in 2020 to week 8 in 2021 (28 Sep 2020–28 Feb 2021). Fourth wave: weeks 9–24 in 2021 (29 Feb–20 Jun 2021). Fifth wave: weeks 25–47 in 2021 (21 Jun–28 Nov 2021). Sixth wave: week 48 in 2021 to week 24 in 2022 (29 Nov 2021–19 Jun 2022). Seventh wave: weeks 25–40 in 2022 (20 Jun–9 Oct 2022). Eighth wave: week 41 in 2022 to week 13 in 2023 (10 Oct 2022–2 May 2023).
FIGURE 3
FIGURE 3
Standardized mortality (morbidity) ratio (SMR) by month for all subjects. (A) Top: 30‐day mortality and number of patients. Bottom: SMR and expected mortality. (B) Top: surgical mortality and number of patients. Bottom: SMR and expected mortality. (C) Top: postoperative complications (Clavien–Dindo classification grade ≥3) and number of patients. Bottom: SMR and expected morbidity. → indicates months when the SMR was significantly higher.
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