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.

No abstract

This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.

Complications from a Meckel's diverticulum include diverticulitis, bleeding, intussusception, bowel obstruction, a volvulus, a vesicodiverticular fistula, perforation or very rarely as a tumour. We report a case where a Meckel's diverticulum presented with a terminal ileal volvulus in a 32-year-old man without the presence of a typical vitelline band or axial torsion of the diverticulum causing the volvulus. It was successfully managed laparoscopically. KEYWORDSMeckel's diverticulum -Ileal volvulus -Small bowel obstruction -Minimally invasiveLaparoscopic Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract.1 Although it presents more commonly in a paediatric age group, a diverticulum can become symptomatic in adults, presenting as diverticulitis, bleeding, intussusception, bowel obstruction, a volvulus, a vesicodiverticular fistula, perforation or very rarely as a tumour. We report a case where a MD presented with a terminal ileal volvulus without the existence of the typical vitelline band or axial torsion of the diverticulum causing the volvulus that was successfully managed laparoscopically. Case HistoryA 32-year-old man presented with colicky right-sided abdominal pain associated with vomiting and absolute constipation for the preceding 24 hours. He reported many previous episodes of similar abdominal pain, associated with vomiting and constipation, that were followed by diarrheoa, which resolved spontaneously. The patient had required admission two years previously with similar symptoms, at which point a computed tomography of the abdomen and pelvis (CTAP) demonstrated small bowel obstruction with a transition point at the distal ileum, suggestive of ileal volvulus. As the patient's symptoms resolved spontaneously, he was discharged within 24 hours. Owing to persistent epigastric pain, outpatient ultrasonography of the upper abdomen and upper gastrointestinal endoscopy were requested, both of which were unremarkable. The patient was reviewed in the outpatient clinic at three months and as he was symptom free, he was discharged with advice to return if symptoms recurred.On examination, there were no hernias. The patient was tender to deep palpation in the epigastrium and right side of the abdomen. The inflammatory markers were elevated (white cell count 11.5 Â 10 9 /l, C-reactive protein 16mg/l). Urgent CTAP was requested, which demonstrated similar findings to the previous imaging with high grade small bowel obstruction secondary to volvulus of terminal ileum with the whirlpool sign of the small bowel mesentery (Fig 1).A diagnostic laparoscopy was performed. The infraumbilical Hasson technique was used to generate the pneumoperitoneum. Two further ports were inserted under vision: a 12mm port for the left iliac fossa and a 5mm port in the right upper quadrant. The intraoperative findings were twisted small bowel mesentery adherent to the anterior abdominal wall at the right iliac fossa (Fig 2) and minimal adhesions in the left iliac fossa. On further di...