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.

Craniomaxillofacial reconstructive surgery is a challenging field. First it aims to restore primary functions and second to preserve craniofacial anatomical features like symmetry and harmony. Three-dimensional (3D) printed biomodels have been widely adopted in medical fields by providing tactile feedback and a superior appreciation of visuospatial relationship between anatomical structures. Craniomaxillofacial reconstructive surgery was one of the first areas to implement 3D printing technology in their practice. Biomodeling has been used in craniofacial reconstruction of traumatic injuries, congenital disorders, tumor removal, iatrogenic injuries (e.g., decompressive craniectomies), orthognathic surgery, and implantology. 3D printing has proven to improve and enable an optimization of preoperative planning, develop intraoperative guidance tools, reduce operative time, and significantly improve the biofunctional and the aesthetic outcome. This technology has also shown great potential in enriching the teaching of medical students and surgical residents. The aim of this review is to present the current status of 3D printing technology and its practical and innovative applications, specifically in craniomaxillofacial reconstructive surgery, illustrated with two clinical cases where the 3D printing technology was successfully used.

Background: Despite specialisation, a small subset of general surgeons continues to provide breast services in the United Kingdom. We aimed to assess breast cancer i) local recurrence rate against the national benchmarks of <5% (for invasive cancer) and <10% (for noninvasive cancer) at 5- year, and ii) net survival rates against national record of 95.8% and 85.3%, at 1-year and 5-year, respectively. Methods: All breast cancers (between 01/05/2012 and 30/04/2013) at a district general hospital in the north-west of England were audited. Two general surgeons provided the breast service. One surgeon performed mostly excisional surgery and acted as a 'generalist'. The second surgeon also performed level 2 oncoplastic procedures and acted as an internal control as a 'specialist'. Results: Out of 270 cancers diagnosed, 203 patients underwent surgery. Six patients (out of 180 invasive cancers) developed local recurrences (3.33%). Two patients (out of 23 patients with Ductal Carcinoma-In-Situ) developed local recurrences (8.69%). There was no signicant intersurgeon variation in practice except a difference in the size of the excised lesions. 1-year and 5-year net survival rates amongst all female breast cancer patients were 97% and 87.3%, respectively. Overall survival at 5-year was 79.1%. Conclusions: The results demonstrate that in an unselected cohort of breast cancer patients, general surgeons with interest in breast surgery can achieve acceptable standards in terms of local recurrence at 5-year, and net survivals at 1-year and 5-year. No conceivable difference in practice between two surgeons with 'generalist' and 'specialist' skill-mix was noted. Low overall survival might reect wider health issues. This has implications in planning a local breast service and utilising constrained human resources in the era of specialisation.

Background Despite consistently low bleeding rates in laparoscopic cholecystectomy (LC) (0.1 – 0.46%), preoperative testing of ABO group and Rh (D) – G&S – remain common practice throughout UK hospitals. Current NICE guidelines for routine pre-operative tests for elective surgery don't include routine G&S. Additionally, there have been few recently published articles regarding elective and emergency LC suggesting that the routine practice of G&S are unnecessary, potentially delaying surgeries with significant financial impact. Based on published data, if a patient undergoing LC requires perioperative blood transfusion there is no time to cross match, therefore the major hemorrhage protocol is activated and patient is transfused O negative. Aim This project aimed to assess the need for routine G&S in laparoscopic cholecystectomy including impact on Trust resources, national shortage of blood tubes. Methods Retrospective data collection regarding 448 patients that underwent LC at Northern General Hospital, Sheffield in 2020. Results Between January and December 2020 401 G&S samples were taken during the preoperative assessment, and 425 second G&S samples taken on the day of surgery. Antibodies were identified in 8 patients, although they were not cross matched. Furthermore, none of the 448 patients required blood transfusion during the perioperative period. Conclusions Our results highlight that current compliance with NICE guidelines/recent published data is suboptimal. Overall, collecting G&S samples perioperatively takes up resources, time and can delay surgery. Furthermore, Trust savings could be in excess of £8000 in one year. Hence, we are currently reviewing our local policy.

Despite traumatic abdominal wall hernia (TAWH) being a rare entity, the incidence of associated intra-abdominal injuries is extremely common. With only few cases published, TAWH remains a diagnostic as well as a therapeutic challenge. We present an obese 47-year-old female, front seat passenger, that was transferred to our hospital from a neighbouring DGH with a diagnosis of TAWH after a 30mph road traffic collision. On arrival, she was haemodynamically stable, abdominal examination showed a large hernia, extensive bruising but the abdomen was otherwise unremarkable. The CT performed before transfer showed a large hernia but no obvious other injury, no free fluid or gas was identified. Hernia repair was planned for the following day. Overnight there was a transient period of hypotension responsive to transfusion of multiple RBC units. The surgical approach was over the hernia site. Within the sac a transected end of small bowel was found and so laparotomy was undertaken, which demonstrated a bucket handle mesenteric tear of terminal ileal mesentery with infarction of 20 cm of small bowel and a complete transverse tear of mid sigmoid colon and its mesentery. Remarkably there was no intraperitoneal contamination from either injury. Our clinical case highlights that although the CT scan is the gold standard for initial diagnosis of intra-abdominal injuries in TAWH, these can still be missed. To note that failure to make a timely diagnosis can result in delayed complications with significant morbidity and mortality. Therefore, a high clinical suspicion, despite of negative imaging, is crucial to provide appropriate management.

Background Oesophageal foreign body impaction in adults is fairly common. Although, dentures being often accidentally ingested among the elderly, it is very unusual to develop a broncho-oesophageal fistula (BOF) secondary to a retained denture. The few cases reported in the literature were mostly managed with thoracotomy. We present a clinical case of a BOF successfully treated by endoscopic approach following a combined assessment and planning between intervention radiology, general and cardiothoracic surgery. Case Report A 60-year-old male was transferred from neighbouring DGH to our centre due to worsening of dysphagia. Patient reported that he had swallowed a denture 6 month earlier. The CT scan showed the denture along with a left BOF. Imaging was further reviewed and discussed amongst interventional radiology, cardiothoracic, and upper gastrointestinal surgeons. Endoscopic retrieval of impacted denture plate was successful, followed by the insertion of left bronchial stent, and percutaneous gastrostomy tube. The left bronchial stent was removed after three months with successful closure of the fistula. Conclusion Our clinical case highlights that multidisciplinary team discussion is crucial in the management of complex surgical cases in order to achieve the best outcome possible. Additionally, endoscopic management of BOF is a safe alternative option to thoracotomy when the required resources are available.

Background Emphysematous cholecystitis (EC) is a rare life-threatening variant of acute cholecystitis. It is commonly seen in elderly men who are immunocompromised, known diabetes mellitus or peripheral vascular disease. EC is caused by gas-forming organisms such as Escherichia coli, Clostridium perfringens and Bacteroides fragilis and has a reported mortality of up to 25%. Computed Tomography is the most sensitive diagnostic imaging study for the detection of intraluminal or intramural gallbladder gas. Methods We report a diagnostic dilemma and multidisciplinary management of a case of emphysematous cholecystitis with unusual presentation in a young, healthy patient with no risk factors. Results A 47-year-old male chef, otherwise fit and well, presented with a clinical picture of sepsis and abdominal pain. Initial investigations were normal apart from bilateral basal atelectasis, hence he was treated for pneumonia, although without clinical improvement. Due to persistent fever, patient underwent further investigations that established the diagnosis of emphysematous cholecystitis. His clinical condition improved dramatically after urgent laparoscopic cholecystectomy with patient being safely discharged home 6 days post-op, with an uneventful postoperative recovery. Conclusion A high index of clinical suspicion and multidisciplinary team management including surgery, radiology, and microbiology is crucial for early diagnosis of the rare life-threatening condition of EC. Our clinical case highlights that EC is not limited to elderly morbid patients and urgent laparoscopic cholecystectomy is the best treatment when feasible.