Introduction In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low-and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis. Methods We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low-and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future. Results Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis. Conclusions If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low-and middle-income countries responsive to ''old threats and new challenges''. Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.

The intestinal microbiota has been implicated in the pathogenesis of complications following colorectal surgery, yet perioperative changes in gut microbiome composition are poorly understood. The objective of this study was to characterize the perioperative gut microbiome in patients undergoing colonoscopy and colorectal surgery and determine factors influencing its composition. Using Illumina amplicon sequencing coupled with targeted metabolomics, we characterized the fecal microbiota in: (A) patients (n = 15) undergoing colonoscopy who received mechanical bowel preparation, and (B) patients (n = 15) undergoing colorectal surgery who received surgical bowel preparation, composed of mechanical bowel preparation with oral antibiotics, and perioperative intravenous antibiotics. Microbiome composition was characterized before and up to six months following each intervention. Colonoscopy patients had minor shifts in bacterial community composition that recovered to baseline at a mean of 3 (1–13) days. Surgery patients demonstrated substantial shifts in bacterial composition with greater abundances of Enterococcus, Lactobacillus, and Streptococcus. Compositional changes persisted in the early postoperative period with recovery to baseline beginning at a mean of 31 (16–43) days. Our results support surgical bowel preparation as a factor significantly influencing gut microbial composition following colorectal surgery, while mechanical bowel preparation has little impact.

The indocyanine green fluorescence imaging system is a surgical tool with increasing applications in colon and rectal surgery that has received growing acceptance in various surgical disciplines as a potentially valid method to enhance surgical field visualization, improve lymph node retrieval, and decrease anastomotic leak. Small noncomparative prospective trials have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion and that its use may impact anastomotic leak rates. However, larger prospective and randomized studies are required to validate its role and impact in colorectal surgery. The purpose of this article is to review the current status of the use of immunofluorescence in colon and rectal surgery, as well as new applications in robotic colon and rectal resections.

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visual representation and ability to detect quick changes within the data. However, no surgical literature has explicitly advocated the use of CUSUM over grouped analysis. METHODS: In this case series review of a prospectively maintained database, we examine the results of both grouped analysis and CUSUM analysis for the operating room time of robotic distal pancreatectomy (RDP), robotic pancreaticoduodenectomy (RPD), and robotic Heller myotomy (RHM). Each group consisted of 10 to 11 cases for the grouped analysis. CUSUM analysis plot identified the 3 phases of learning, which successively determined the groups. RESULTS: Using the traditional grouped analysis, only one statistical significance was achieved for RPD (p<0.0001) (compared to RDP [p¼0.274] and RHM [p¼0.384]). With CUSUM analysis however, the different phases of learning were identified and subsequent statistical analysis between these phases showed statistical significance for RDP (p<0.005), RPD (p<0.0001), and RHM (p¼0.0129). CONCLUSION: CUSUM analysis can reveal statistical findings for learning curves that grouped analysis cannot. Therefore, it is crucial when establishing surgical learning curves that CUSUM analysis is implemented.

Preoperative radiotherapy has improved outcomes in rectal cancer patients, however, the optimal interval between radiation and proctectomy is unknown. A review of contemporary literature suggests an 8–12 week interval between radiation and surgery likely improves tumor response rates for rectal cancer patients undergoing proctectomy, which may convey modest improvements in long‐term oncologic outcomes. Prolonged radiation‐surgery intervals may expose surgeons to pelvic fibrosis, however, which may impact later‐term proctectomies and compromise perioperative and oncologic outcomes.

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