Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.
SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
Linea arcuate herniae (LAH) are rare and usually asymptomatic but can present with generalized abdominal pain in the absence of bulging and are impalpable. Diagnosis is dependent on cross-sectional imaging, and operative approach to their management is debatable. Here, we report the case of a 56-year-old female with abdominal pain diagnosed with a linea arcuate hernia by computed tomography (CT) scan. She went on to have laparoscopic primary suture closure of the hernial defect with reinforcing underlay mesh. LAH are effectively elucidated with CT. Although there are concerns regarding mesh-related complications, we advocate a laparoscopic approach and repair with prosthetic mesh reinforcement, fixated with sutures. Long-term follow-up of these patients is still required.
Aims To compare achalasia treatment outcomes at one and two years post intervention. Methods A decision-tree model was populated with data from 36 randomised controlled trials to compare: pneumatic dilation, botulinum toxin injection, Heller myotomy (+/- Dor or Toupet), Dor and peroral endoscopic myotomy (POEM). Freeman-Tukey arcsine square root transformation under random effects model, to account for heterogeneity, was used to calculate weighted pooled model transition probabilities. Utility was 1, 0.5 and 0 for treatment success without significant complication, success with significant complications and treatment failure respectively. Deterministic sensitivity analysis and Monte Carlo Probabilistic Sensitivity Analysis (PSA) set to 10000 iterations tested model uncertainty. Results Laparoscopic Heller myotomy had marginally superior utility over POEM but only if the risk of significant complications remained less than 7.2% and 7.9% at one and two years respectively. Conclusion Superior treatment selection depends on individual risk of complications. Future research should therefore focus on personalised risk stratification and cost-effectiveness implications.
Aim The impact of appendicectomy on the natural history of ulcerative colitis (UC) is unclear. We aimed to assess our cohort of patients with UC to examine the incidence of appendicectomy and association with disease severity. We also examined association of social deprivation with disease severity. Method Patients with UC in the health board region were identified by the Gastroenterology consultants. These were divided into moderate-severe (defined as current biologic therapy) and mild-moderate disease (no or 5-ASA therapy only). Two cohorts were sex-matched on a 1:1 basis. Demographic data was identified by review of the patients’ Electronic Patient Record (EPR) and the Scottish Index of Multiple Deprivation 2020. The EPR was reviewed for evidence of previous appendicectomy. Results A total of 664 patients were identified: 328 mild-moderate and 336 moderate-severe. 145 patients (44%) in the mild-moderate group and 145 patients (43%) in the moderate-severe group were female. The majority of patients had left-sided disease. There were no significant differences in smoking status. Rates of appendicectomy in the moderate to severe group were double that of the mild to moderate group (8 v 4; p= .25). Mild-moderate disease was associated with increased social deprivation (X2 (2, N = 664) = 10.60, p = .03) (Fig. 3). Conclusions There were double the number of appendicectomies in the mild-moderate cohort, however the relationship between severity and previous appendicectomy was not significant. Disease severity appears to be negatively associated with social deprivation. Further collaborative work across Scotland is planned.
Aim This study aims to describe the personality differences between trainees at different stages prior to and during surgical training. Method The Mental Muscle Diagram Indicator was distributed electronically to doctors in training in South West London. A total of 553 trainees completed the personality questionnaire. Specifically, there were general surgery specialty (n = 53), core surgical (n = 254), and foundation trainees (n = 246). 52% of trainees were female. Results Women scored significantly higher in the Extraversion, Sensing and Judging personality domains (p < 0.0001), there were no significant differences between genders for ‘Thinking’. One-way ANOVA only showed a significant difference in the ‘Judging’ domain between grades. Tukey's test was performed showing the difference arose from FT to CST (p = 0.008). Two-way ANOVA showed an interaction between gender and grade for ‘Judging’ and as such simple main effects were performed, with alpha = 0.017 to control for type 1 errors. Significant differences were found in the Judging domain between genders during in FT (p=0.002) and CST (p=0.002), and there was no significant difference for SpRs (p=0.15). Conclusions This study demonstrated differences in personality types between trainee stages and gender. These differences appear to decrease as trainees progress through their training, although the cause of this is unclear.
A 54-year-old female presented to a secondary care hospital with right upper quadrant pain, headache, and persistent dysuria after empirical antibiotic treatment for a urinary tract infection (UTI). Her brother had died under the age of 50 from aneurysmal disease associated with Polyarteritis nodosa (PAN). Urinalysis demonstrated erythrocytes, leucocytes, and nitrites. Her CRP was 428mg/L and ESR 102 mm/hr. CT of the abdomen and pelvis showed reduced attenuation within both kidneys, and she was treated as acute bilateral pyelonephritis with IV antibiotics. Her abdominal pain changed, she described a “pop” in her right hypochondrium, and she developed a new visual disturbance, despite normalisation of her inflammatory markers. This warranted a repeat CT scan which showed an occlusion of the left hepatic artery with surrounding inflammation and an 8mm aneurysm proximally. MRI and CT venogram of the head was unremarkable. PAN was diagnosed on remote consultation with a tertiary care hospital. It is a necrosing vasculitis affecting small to medium sized arteries with aneurysmal dilatation. There is no genetic cause known, though familial cases have been described. The patient was started on treatment dose Dalteparin and transferred to a tertiary hospital. Selective embolisation of the hepatic artery aneurysm was not undertaken, but she was treated with glucocorticoids and cyclophosphamide. This case highlights a rare condition presenting similarly to a treatment refractory UTI requiring multidisciplinary patient care and the need for repeat imaging following clinical deterioration/change.
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