of delayed paediatric emergency presentations in which the parents of all cases reported avoiding the hospital due to fears of contracting COVID-19. Half of the children were admitted to intensive care unit and four died. 2 New York has experienced a significant decline in acute coronary syndrome presentations. 3 Similarly, delays in referral to surgical teams result from awaiting COVID-19 clearance as testing is performed on patients presenting with gastrointestinal symptoms as these symptoms have been associated with COVID-19 infection. 4,5 Similar effects were seen during the severe acute respiratory syndrome (SARS) outbreak at the beginning of the millennium. At the peak of the SARS epidemic, Taiwan saw a significant reduction in ambulatory care, inpatient care and dental care patients. 6 Fear of contracting SARS influenced people's willingness and choice to seek adequate medical care. 6 These concerns were reflected in cancer patients at the Taipei Veterans General Hospital, Taiwan, as 63.8% were afraid of visiting hospital during the SARS infective period and 36.2% felt SARS was more severe and fatal than their underlying cancer. 7 Locally, the impact of COVID-19 has led to significant changes in surgical practice. Non-emergency surgeries (category 2within 90 days and category 3within 365 days) have been suspended, protocols regarding intubation and extubation have been developed and the risk of viral exposure from surgical smoke in laparoscopic surgeries continues to be an issue of growing debate. 8 Acute surgical pathologies, such as appendicitis, usually treated by surgical intervention have been reconsidered towards medical management. 8 The COVID-19 pandemic has drastically changed medical practice worldwide and as focus remains on control of the virus, there are concerns over the toll on non-COVID patients. 3 Fear of contracting the virus will undoubtedly impact non-COVID patients seeking adequate and timely medical care. As face-to-face consults are exchanged for alternate reviews, such as teleconferencing, healthcare workers must consider its implication on adequate clinical assessment. The challenge lies in continuing to deliver optimum care to patients, when patients themselves are too scared to seek assistance in fear of contracting, what they perceive as a more serious illness. From the surgeons' perspective, bacterial sepsis left unchecked will result in death or require intensive care support, in a higher proportion than what has currently been seen with COVID-19 within Australasia. This message needs to reach the community, such that late presentations as described within this article are avoided.
While this method may well be too slow to gain widespread adoption, we hope this report encourages increased research into finding techniques with similar low leak rates.
A 59-year-old male of non-English speaking background with no known medical history presented to the emergency department with sepsis and confusion. He was tachycardic (120 bpm), hypotensive (90/55 mmHg) and febrile (38.4 C) with a large 15 × 13 cm left flank necrotic skin infection with crepitus (Fig. 1). Biochemical findings revealed leucocytosis (32 g/L), anaemia (haemoglobin 51) and C-reactive protein (230 g/L). Venous blood gas was suggestive of a metabolic acidosis: pH (7.39) and lactate (12.17 mmol/L). He
Purpose: Anastomotic leak (AL) is an uncommon but potentially devastating complication after rectal resection. We aim to provide an updated assessment of bowel function and quality of life after AL, as well as associated short- and long-term outcomes.Methods: A retrospective audit of all rectal resections performed at a colorectal unit and associated private hospitals over the past 10 years was performed. Relevant demographic, operative, and histopathological data were collected. A prospective survey was performed regarding patients’ quality of life and fecal continence. These patients were matched with nonAL patients who completed the same survey.Results: One hundred patients (out of 1,394 resections) were included. AL was contained in 66.0%, not contained in 10.0%, and only anastomotic stricture in 24.0%. Management was antibiotics only in 39.0%, percutaneous drainage in 9.0%, operative abdominal drainage in 19.0%, transrectal drainage in 6.0%, combination of percutaneous drainage and transrectal drainage in 2.0%, and combination abdominal/transrectal drainage in 1.0%. The 1-year stoma rate was 15.0%. Overall, mean Fecal Incontinence Severity Instrument scores were higher for AL patients than their matched counterparts (8.06±10.5 vs. 2.92±4.92, P=0.002). Patients with an AL had a mean EuroQol visual analogue scale (EQ-VAS) of 76.23±19.85; this was lower than the matched mean EQ-VAS for non-AL patients of 81.64±18.07, although not statistically significant (P=0.180).Conclusion: The majority of AL patients in this study were managed with antibiotics only. AL was associated with higher fecal incontinence scores in the long-term; however, this did not equate to lower quality of life scores.
, adynamic ileus and chronic constipation presumably related to hyperperistalsis, caecal displacement and colonic distension in anatomically susceptible patients. Intermittent caecal volvulus has been described in patients who have previously undergone caesarean section 6 and laparoscopic salpingectomy. 7 Our cases suggest that prior right oophorectomy may also be a risk factor, particularly as these patients did not have any symptoms prior to oophorectomy. Sometimes, division of the peritoneum around the right adnexa and gonadal vessels may require division of the peritoneal attachment at the caecal pole in the pelvis. Releasing the natural attachments of the ascending colon to the peritoneum inadvertently mobilizes the caecum and ascending colon. A low-lying caecocolic junction or an enlarged ovary may justify the need to dissect these attachments. Caecopexy has been suggested as a treatment option. 8 However, recurrence rate is high as seen in our second case. Right hemicolectomy provides a more definitive treatment approach. Our cases highlight the importance of avoiding division of natural peritoneal attachments around the caecum during pelvic surgery. If this operative step is necessary, reattachment of the caecum and ascending colon to the lateral abdominal wall should be advocated. Intermittent caecal volvulus should also be considered in this group of patients subsequently presenting with chronic right iliac fossa pain.
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