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.

Background: Hospital websites are an important source of information for patients, parents and healthcare providers. There are currently no standardized recommendations for the information provided on paediatric surgery websites. We aimed to assess the information available on each hospital website, in Australia and New Zealand, which provides paediatric surgical care. Methods: Google search was performed of the 16 paediatric surgical centres in Australia and New Zealand to determine whether they had a hospital website and to assess its contents. The presence of patient fact sheets and clinical practice guidelines was recorded. Access to contact information, hospital Facebook page and Twitter handles were noted. Results: We found that 11 (69%) centres had a specific paediatric surgical section to the hospital website, all provided contact information. Five centres (31%) had paediatricspecific guidelines available for health professionals. Six websites (37.5%) provided health information sheets on common paediatric surgical conditions. Facebook and Twitter facilities were present on the majority of the websites (75%). Conclusion: The internet presence of paediatric surgery in Australia and New Zealand is sparse. One-third of centres do not have hospital web presence. The availability of clinical guidelines and patient information sheets on hospital websites is limited. Our findings would suggest that improvement and increase in the internet presence of paediatric surgery in Australia and New Zealand is needed.

Background: In contrast to many countries, the prevalence of COVID-19 in Australia and New Zealand has been low. We hypothesised, however, that a potential secondary effect of the COVID-19 pandemic would be delayed presentation of paediatric appendicitis, with resultant higher rates of complicated appendicitis. This study was an initiative of the Australian and New Zealand Surgery in Children Registrars' Association for Trials collaborative, a trainee-led research group based in Australia and New Zealand. Methods: A binational multicentre, retrospective review was undertaken of paediatric patients with appendicitis early in the COVID-19 pandemic (20 March-30 April 2020), compared with previous years (2018, 2019). Primary outcomes were the duration of symptoms prior to presentation and the severity of disease. Results: A total of 400 patients from six centres were included. Duration of symptoms prior to presentation, sepsis at presentation, complicated disease and presence of complications did not differ significantly between time periods. Duration of intravenous antibiotic treatment and overall antibiotic treatment were both significantly shorter during 2020 (2.4 days versus 3.5 in 2018 and 3.0 in 2019 [P = 0.0038] and 3.7 days versus 5.2 in 2018 and 4.6 in 2019 [P = 0.04], respectively). Management approach did not differ, with the majority of patients managed operatively. Conclusions: We did not demonstrate any difference in duration of symptoms prior to presentation or other markers of disease severity early in the pandemic. Duration of antibiotic treatment was shorter during this period compared with previous years. Management of children with appendicitis, both simple and complicated, did not appear to change as a result of COVID-19.

Magnets are found commonly in children's toys and pose a risk of ingestion. Rare earth-transition metal magnets, such as ironneodymium, have a much greater coercivity than normal magnets. 1 Hence their ingestion is more likely to cause bowel injury. There have been a few case studies describing magnetic attraction between adjacent loops of bowel leading to pressure necrosis and perforation. [2][3][4][5][6][7] There is limited information on surgical technique and precautions in such cases. We report a case of bowel perforation following neodymium magnet ingestion and the operative approach.A 10-year-old boy presented to the emergency department with 24 h of colicky central abdominal pain with associated nausea. His abdomen was soft and non-tender without signs of peritonism. The blood results were normal. The impression was gastroenteritis.He represented 5 days later with persistent colicky abdominal pain. On further questioning he admitted to swallowing seven neodymium magnetic ball-bearings, on two separate occasions, 7 days ago. His abdomen was mildly distended with peri-umbilical tenderness. A plain abdominal radiograph showed metallic foreign bodies in the upper central abdomen (Fig. 1). He was observed overnight, but the abdominal pain progressed and there was evidence of peritonism. Repeat abdominal X-ray showed the magnets to be in the same position. There was concern that the magnets in adjacent loops of small bowel had united together causing pressure necrosis of the bowel wall.He came forward for an emergency laparotomy. This revealed fistulization of three magnetic balls between the proximal jejunum and the transverse colon (Fig. 2). The magnets were adherent and had necrotized and perforated through the bowel wall. The magnets were removed to find seven perforations in total, all of which were oversewn. The extracted magnets were then placed in the cut end of a glove and run over the bowel (Fig. 3). There was resistance over the second part of the duodenum and a further four magnetic balls were removed via an enterotomy. The duodenum was then oversewn. An intraoperative radiograph was performed and this did not show any further foreign bodies. The patient had a good recovery and was discharged on day 5 post operation.A recent systematic review found 98 cases of magnet ingestion in 17 countries. Ninety-six of these had resulted in bowel injury requiring bowel resection or fistula repair. In all such cases there were varying degrees of delay in diagnosis and treatment. 2 Direct questioning about foreign body ingestion may help in early diagnosis, however the history maybe unreliable in children because of their age and unwillingness to admit to foreign body ingestion. 8 Appropriate and timely imaging may be the only way of identifying magnet ingestion. 4 There is a high risk of bowel injury if more than one magnet has been ingested; hence early surgical intervention is indicated. 2,4-7 Fig. 1. Radiograph of ingested magnetic balls. Fig. 2. Fistulization of a magnet through the transverse colon.