Pseudomembranous colitis in patients with COVID-19 (review)

AIM: to estimate the features of pseudomembranous colitis in patients with COVID-19, diagnostics, conservative treatment and surgery for complications. PATIENTS AND METHODS: a retrospective analysis of 396 patients with pseudomembranous colitis (PMC) in patients with new coronavirus infection was carried out for the period from March 2020 to November 2021. Among them there were 156 (39.3%) males, females - 240 (60.6%), moderate and severe forms of COVID-19 occurred in 97.48%. The diagnosis of PMC was established due to clinical picture, laboratory, instrumental methods (feces on Cl. difficile, colonoscopy, CT, US, laparoscopy). RESULT(S): the PMC rate in COVID-19 was 1.17%. All patients received antibiotics, 2 or 3 antibiotics - 44.6%, glu-cocorticoids were received by all patients. At 82.8%, PMC developed during the peak of COVID-19. To clarify the PMC, CT was performed in 33.8% of patients, colonoscopy - 33.08%, laparoscopy - in 37.1% (to exclude bowel perforation, peritonitis). Conservative treatment was effective in 88.8%, 76 (19.1%) patients had indications for surgery (perforation, peritonitis, toxic megacolon). Most often, with peritonitis without clear intraoperative confir-mation of perforation, laparoscopic lavage of the abdominal cavity was performed (60 patients - 78.9%, mortality - 15.0%), colon resection (n = 6 (7.9%), mortality - 66.6%), ileo-or colostomy (n = 8 (10.5%), mortality - 37.5%), colectomy (n = 2 (2.6%), mortality - 50.0%). The overall postoperative mortality rate was 22.4%, the incidence of surgical complications was 43.4%. In addition, in the postoperative period, pneumonia was in 76.3%, thrombosis and pulmonary embolism in 22.3% of patients. In general, the overall mortality in our patients with PMC was 11.4%, with conservative treatment - 8.8%. CONCLUSION(S): pseudomembranous colitis is a severe, life-threatening complication of COVID-19. In the overwhelm-ing majority of patients, conservative therapy was effective, but almost 1/5 of patients developed indications for surgery, the latter being accompanied by high mortality and a high morbidity rate. Progress in the treatment of PMC, apparently, is associated with early diagnosis, intensive conservative therapy, and in the case of indications for surgery, their implementation before decompensation of the patient's condition and the development of severe intra-abdominal complications and sepsis.Copyright © 2022, Association of Coloproctologists of Russia. All rights reserved.

The impact of COVID-19 for postoperative outcomes using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer

Background: The coronavirus disease 2019 (COVID-19) pandemic had resulted in either failure to provide required medical resources or delayed treatment for gastric cancer patients. This study aimed to investigate the impact of COVID-19 on the incidence of postoperative complications using a nationwide Japanese database of patients undergoing distal gastrectomy for gastric cancer. Method(s): We collected the data of patients who underwent distal gastrectomy from January 2018 to December 2021 from the National Clinical Database (NCD), a web-based surgical registration system in Japan. The number of surgical cases, the use of intensive care units, and the incidence of morbidity per month were analyzed. We also calculated the standardized mortality ratio (SMR), defined as the ratio of the number of observed patients to the expected number of patients calculated using the risk calculator established in the NCD, for several morbidities, including pneumonia, sepsis, 30-day mortality, and surgical mortality. Result(s): A decrease of 568 gastrectomies was observed from April 2020 to May 2020. Although the absolute number of patients admitted to intensive care units had declined since 2020, the proportion of patients admitted to the ICU did not change before and after the pandemic. Mortality and critical morbidity (such as pneumonia and sepsis) rates were not worse during the pandemic compared to pre-pandemic periods per the SMR. Conclusion(s): Surgical management was conducted adequately through the organized efforts of the entire surgery department in our country even in a pandemic during which medical resources and staff may have been limited.Copyright © 2023 The Authors. Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.

Predictors, surrogate and patient-reported outcomes in neoadjuvant immunotherapy for lung cancer: A single-center retrospective study

Background Development of immunotherapy/molecular targeted therapy has significantly increased survival/QoL in advanced stages of NSCLC. Aim(s): to analyze outcome predictors, surrogate outcomes, and PROMs after neoadjuvant immunotherapy for initially unresectable NSCLC. Methods Initially unresectable NSCLC (2014-2021) patients who received immunotherapy +/- platinum-based chemo and/or radiotherapy evaluated after response (reduction of primary tumor and/or mediastinal lymphadenopathy/control of distant metastatic disease underwent surgical resection). PROMs were recorded using EORTC QLQ-29. Results 19 underwent salvage surgery after ICI. 14 had partial response (73.6%), 5 stable disease. Diagnosis was achieved by endobronchial ultrasound (EBUS) in 8 (42.1%), fine-needle aspiration biopsy (FNAB) in 7 (36.8%), metastasis biopsy in 4 (21.0%). 11 (57.9%) were treated with neoadjuvant platinum-based chemo before or with ICI, 1 (5.2%) pemetrexed before ICI, 5 (26.3%) radiotherapy for metastatic control. 3 (15.7%) had ICI adverse effects. Radiotherapy was never used preoperatively for pulmonary/mediastinal disease. 7 (36.8%) received adjuvant therapy (5 [26.3%] pembrolizumab, 1 [5.2%] pemetrexed, 1 [5.2%] pemetrexed + pembrolizumab). 4 (21.0%) had local relapse (no systemic relapse). Median OS was 19 months (range: 2-57.4). At 2 months, 94.7% were alive (6 months: 89.5%;31 months: 79.5%). 2 (10.5%) had local recurrence. 2 (10.5%) died due to recurrence, 1 (5.2%) to COVID. 4 (21.0%) relapsed (median DFS: 5.3 months [range: 2.2-13.0]). PROMs were reviewed retrospectively at 30 days/1 year with significant decrease in coughing, side effects of treatment, surgery-related problems. [Formula presented] Conclusions Radical surgical resections following definitive immunotherapy/immune-chemotherapy in selected initially unresectable NSCLC are feasible and safe (low surgical-related mortality and morbidity). Symptoms and surgery-related outcomes were lower with higher QoL due to a selected group of highly motivated patients. Legal entity responsible for the study The authors. Funding Ministero della Salute. Disclosure All authors have declared no conflicts of interest.Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc.

Special considerations in the premature and ex-premature infant

Advances in neonatal medicine have progressively increased the survival of premature infants. Increased survival has however come at the cost of increased number of infants with prematurity-related complications. This is represented by high rates of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), sepsis, periventricular leukomalacia (PVL), intraventricular haemorrhage (IVH), cerebral palsy, hypoxic ischaemic encephalopathy (HIE) and visual and hearing problems in survivors. In addition to prolonged hospital stay after birth, readmission to hospital in the first year of life is common if chronic lung disease exists. Around 3% of newborns have a congenital physical anomaly with 60% of congenital anomalies affecting the brain or heart and around 1% having multiple anomalies. Individual congenital conditions requiring surgical intervention in the neonatal period are rare. Neonates have a higher perioperative mortality risk largely due to the degree of prior illness, the complexity of their surgeries, and infant physiology. The maintenance of oxygenation and perfusion in the perioperative phase is critical as both affect cerebral perfusion and neurocognitive outcome but the triggers for intervention and the thresholds of physiological parameters during neonatal anaesthesia are not well described. After even minor surgical procedures, ex-premature infants are at higher risk for postoperative complications than infants born at term.Copyright © 2022

Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic.

PURPOSE: The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves. METHODS: This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs. RESULTS: Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99). CONCLUSION: Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.

Outcomes of elective cancer surgery in COVID-19 survivors: An observational study

Background and Objectives: Guidelines recommend deferral of elective surgery after COVID-19. Delays in cancer surgeries may affect outcomes. We examined perioperative outcomes of elective cancer surgery in COVID-19 survivors. The primary objective was 30-day all-cause postoperative mortality. The secondary objectives were 30-day morbidity, and its association with COVID-19 severity, and duration between COVID-19 and surgery. Methods: We collected data on age, gender, comorbidities, COVID-19 severity, preoperative investigations, surgery performed, and intra and postoperative outcomes in COVID-19 survivors who underwent elective cancer surgery at a tertiary-referral cancer center. Results: Three hundred and forty-eight COVID-19 survivors presented for elective cancer surgery. Of these, 332/348 (95%) patients had mild COVID-19 and 311 (89%) patients underwent surgery. Among patients with repeat investigations, computerized tomography scan of the thorax showed the maximum new abnormalities (30/157, 19%). The 30-day all-cause mortality was 0.03% (1/311) and 30-day morbidity was 17% (54/311). On multivariable analysis, moderate versus mild COVID-19 (odds ratio [OR]: 1.95;95% confidence interval [CI]: 0.52–7.30;p = 0.32) and surgery within 7 weeks of COVID-19 (OR: 0.61;95% CI: 0.33–1.11;p = 0.10) were not associated with postoperative morbidity. Conclusions: In patients who recover from mild to moderate COVID-19, elective cancer surgery can proceed safely even within 7 weeks. Additional preoperative tests may not be indicated in these patients. © 2022 Wiley Periodicals LLC.

The Uk Paediatric Liver Transplant Programme during the Covid-19 Pandemic

Introduction The UK has been severely affected by the COVID-19 pandemic. The impact on the adult population has been disproportionately higher when compared to children with consequent challenges to organ donation and liver transplantation (LT). Across the three UK paediatric liver centres there has only been a very small number of patients who tested positive for COVID-19 and all made a speedy and full recovery. We report here the response during the pandemic across the 3 paediatric LT centres. Methods A series of nationally agreed policy changes affecting the liver procurement, listing and transplant process were agreed during regular meetings with LT centre directors and NHSE. Actions at a local and national level were agreed to protect and maintain the paediatric LT programmes. Data were collected from 27/03/20 until 26/11/20 and compared with same time period for the years 2016-19. Results During the study period, there was a significant reduction in the adult population in the mean number of weekly liver offers, donors and LTs compared to before the pandemic with signs of recovery between the 1st and 2nd UK lockdown periods (figure 1). More specifically the number of livers offered nationally was reduced from an average 30-40/week to only <10/week during the 1st wave in the March-April period. The number of children on the LT list during the study period across all 3 centres was 74 in total with 17 (23%) super-urgent and 57(77%) electives, which was comparable to previous years. Overall, 65-80 paediatric LTs are performed annually across the UK's 3 paediatric centres. From March-November 2020 there were 58(82%) elective and 13(18%) super urgent (acute liver failure & hepatoblastoma) paediatric LTs performed. Donor Brain Dead (DBD) and Donor Cardiac Dead (DCDC) LTs were 54(76%) and 3(4%), respectively. Living related LT (LRLT) programme was sustained comprising 20% of LTs performed. The number of paediatric LTs performed during the pandemic was comparable to those performed yearly since 2016. The number of LT per paediatric centre for King's College Hospital (KCH), Birmingham Children's Hospital (BCH) and Leeds Liver Unit were 40 (56%), 15(21%) and 16(23%), respectively with excellent outcome. A 15-year-old girl from KCH diagnosed with Wilson disease presented with liver failure and became COVID-19 positive whilst listed. She underwent LT soon after becoming COVID-19 negative. No perioperative mortality was reported with excellent outcome so far in all. Conclusion The current COVID-19 pandemic had a significant impact on the UK adult LT programme. The paediatric programme LT was preserved despite a decrease in organ offering and retrieval nationally plus limitations on adult intensive care resources at a regional level. Overall, paediatric LT outcome remained very good.

CHALLENGES IN THE NEUROSURGICAL CARE OF PEDIATRIC PATIENTS WITH CENTRAL NERVOUS SYSTEM TUMORS DURING THE COVID-19 PANDEMIC

INTRODUCTION: Central nervous system (CNS) tumors account for 20 - 30% of all childhood cancers. The Philippines is a lower-middle income country, wherein brain centers are located mostly in urban areas. We aimed to identify challenges that pediatric patients with CNS tumors encountered during the COVID-19 pandemic, which aggravated delays in their diagnosis and treatment. METHODS: This is a retrospective review of all pediatric patients who underwent neurosurgery for CNS tumors at the Jose R. Reyes Memorial Medical Center, a tertiary referral center, from January 2020 until December 2021. We summarized patients' demographic data, clinical course, and perioperative outcomes. RESULTS: A total of 38 pediatric patients underwent neuro-oncologic surgery in our center during the study period. There were 18 males and 20 females, with a mean age of 7.5 ± 4.9 years. Tumor was biopsied and/or resected in 35 cases (92%). The most common histologic diagnoses were medulloblastoma (n=8, 21%) and high-grade glioma/glioblastoma (n=5, 13%). Median preoperative length of stay and total length of stay were 10 (IQR: 17) and 28 (IQR 33.75), respectively. There was a high perioperative mortality rate in 2020 (71%), but this decreased to 20% in 2021. Six patients (16%) developed COVID-19 infection during the perioperative period. There were nine patients (24%) who had documented tumor progression because of delays in adjuvant therapy. DISCUSSION: Aside from geographic barriers and catastrophic health expenditure, the major challenges that disrupted the care of pediatric patients with CNS tumors in our center during the COVID-19 pandemic were delays in neuroimaging for diagnosis, unavailability of operating room slots, deficiency in critical care beds, and workforce shortage due to COVID-19 infection among health workers. Health care systems must adapt to the changes brought about by the pandemic, so that children with CNS tumors are not neglected.

The Management of Popliteal Artery Aneurysms With Acute Limb Ischemia in the Vascular Quality Initiative

Objective: Endovascular popliteal artery aneurysm (PPA) repair has acceptable outcomes compared with open repair for elective therapy. However, endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well studied. This project compares the outcomes of urgent endovascular and open repair of PAA presenting with ALI. Methods: The Vascular Quality Initiative database for peripheral vascular interventions and infrainguinal bypass was reviewed for popliteal artery aneurysms presenting with ALI. The characteristics and outcomes of patients undergoing urgent open and endovascular repair were compared. Results: Urgent PAA repair for ALI constituted 10.5% (N = 571) of all PAA repairs with no change in proportion during the study period. The majority (80.6%, n = 460) of urgent repairs were open. However, the proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021 with a sharp increase after 2019 (Fig). Patients undergoing endovascular repair were more likely to be African American (3.6% vs 3.3%, P =.044) and older (71.2 ± 12.5 vs 68.0 ± 11.8) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%, P =.006) but less likely to have chronic kidney disease (66.1% vs 69.6%, P =.027) compared with patients undergoing open repair (Table). Open PAA repair was more likely to be associated with bleeding (20.8% vs 2.7%, P <.001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days, P <.001), and less likelihood of discharge home (64.9% vs 70.3%, P =.051). The perioperative major amputation rate was 7.5% with no difference in major amputations between the two treatment strategies even at 1 year. However, patients receiving endovascular repair had significantly higher inpatient (1.1% vs 0%, P <.001), 30-day (6.3% vs 0.4%, P <.001), and 1-year (16.5% vs 8.4%, P =.02) mortality compared with open repair (Table). Multivariable regression analysis suggested that endovascular repair was independently associated with increased 30-day mortality, but not 1-year mortality compared with open repair. Conclusions: The utilization of endovascular PAA has exponentially increased during the coronavirus pandemic. Even though endovascular repair is associated with decreased complications and resource utilization, it should be offered selectively in the urgent setting for ALI because of concern with perioperative mortality. [Formula presented] [Formula presented]

Femoral neck fracture surgery: Should it be delayed?

Femoral neck fracture is a national health care issue in western countries due to the increase number of aged patients in the whole population. Mortality increases when the operative delay is higher than 24 hours in patients without associated morbidity. Patients with co-morbidities have to be evaluated using specific scores. Preoperative check up have to be planned in order to improve patient’ condition without compromising the time for surgery. Relatives have to be questioned about preoperative patient’ autonomy and quality of life. A recent Sars-Cov-2 infection increases postoperative mortality. Operative delay depends on the severity of the disease. Anti-platelets and anticoagulants may also delay surgery. The choice of regional vs. general anaesthesia has no documented effect on mortality.

Do the surgical outcomes differ between Non- COVID pulmonary mucormycosis and COVID associated pulmonary mucormycosis after surgical resection A comparative analysis

Objectives: This study aims at reporting the surgical outcomes of COVID Associated Pulmonary Mucormycosis (CAPM) with special emphasis on surgical mortality. This study also compares the surgical outcomes between Non-COVID Pulmonary Mucormycosis (NCPM) and CAPM. Methods: This prospective observational study was conducted in a dedicated thoracic surgical unit in Gurugram over 18 months which includes 25 patients. An analysis of demography, perioperative variables including complications were carried out. Various parameters were analysed to assess the factors affecting mortality. Results: Out of 25 patients, male-female ratio was 16:9 (64%:36%), with a mean age of 54.8 years (range, 33-72 years). Diabetes was the most common predisposing factor in 17 patients (68%). A total of 8 patients (32%) were on supplemental oxygen (1-4 lit/min) at the time of surgery. Extent of surgery was non-anatomical wedge resection in 5 patients (20%), lobectomy/bi-lobectomy in 18 patients (72%) and pneumonectomy in 2 patients (8%). Commonest complication was prolonged air leak (> 7 days) in 5 patients (20%). There were 5 peri-operative deaths (20%), all due to persistent fungal sepsis. ECOG scale > 2 (P = <0.001) and pneumonectomy (P = 0.02) were the predictors of mortality. On comparison with NCPM, no difference in the postoperative complications (P = 1.00) and mortality (P = 1.00) was observed. Conclusion: Aggressive surgical resection with clear margins should be offered in CAPM whenever feasible. In appropriately selected patients, surgical resection is safe and efficacious. Surgery for CAPM was not associated with higher post-operative complications including mortality compared to NCPM.

Factors affecting mortality after surgery for COVID-19 related empyema

Introduction: Crores of people worldwide have been afflicted with Covid 19 since the pandemic started in 2019. Pleural Empyema in Covid 19 patients is a challenging problem and requires a multidisciplinary approach for adequate management. There are very few published studies in the literature that evaluated this issue. In this study, we aim to report the surgical outcomes of post covid pleural empyema and to analyse factors predicting mortality. Methods: This study is a retrospective analysis of prospectively maintained data of cases of post covid empyema operated between May 20 to November 2021. A total of 37 patients were included for analysis. The demographic characteristics along with intra and postoperative variables were recorded including post-operative complications. Mortality was the primary outcome measure. Results: A total of 37 patients aged 22-68 years underwent surgery for Pleural Empyema during the study period. All patients underwent VATS decortication. There were 32 males and 5 females. The mean operative time was 284 minutes with the mean intraoperative blood loss of 522 ml. Average chest tube removal time was 9.5 days with an average hospital stay of 8.2 days. No recurrence was noted in any of the patients. Postoperative mortality 8.1% and morbidity was observed in 13.51% of patients. Conclusion: Post covid pneumothorax can be safely and effectively managed in selected patient with failed conservative management. The timing of the surgical intervention, requirement of ventilatory support and high oxygen requirement (>5 lit) were found to factors that significantly affect the mortality.

Consenting surgical patients for the risk associated with contracting COVID-19 during their stay at the hospital

Aim: Literature is suggesting significant perioperative mortality and morbidity associated with COVID-19. Therefore, the Royal College of Surgeons (RCS) has produced guidance detailing additional considerations in consenting for surgery whilst COVID-19 is prevalent within society. Section 3A of this document emphasizes the need to discuss the risk of contracting COVID-19 while patients are in hospital. We conducted a multi-cycle closed-loop audit to examine the adherence to this guidance. Method: We completed four audit cycles, each comprising data collection and educational intervention to disseminate the guidance. Data was obtained from consent forms for patients who had consented to both emergency and elective surgery over a two-month period at a large NHS Trust in London. The intervention consisted of teaching sessions, regular emails to the general surgical department, and posters displayed in common areas. Results: Consent forms from 139 patients were reviewed over the four cycles (n=38, 41, 28, and 32). The proportion of patients consented for the risk of contracting COVID-19 during the perioperative period rose serially between the cycles (37%, 61%, 71%, and 85% respectively), and was significantly increased between the first and last cycle (p , 0.01, two-sided Z-test). The interventions proved most effective for senior house officers who improved from consenting 8% initially to 100% on completion of the audit. Conclusions: We demonstrate the marked effectiveness of simple interventions combined with serial auditing to disseminate this message. The same practice may help improve consenting practice at other centres whilst COVID-19 is prevalent in society.

Diagnosis and robotic-assisted, minimally invasive, autologous pericardial patch repair of a sinus venosus atrial septal defect (ASD) with repair of partial anomalous pulmonary venous connection

Case Report Sinus venosus ASDs are usually associated with one or more anomalous right sided pulmonary veins. Diagnosis by transthoracic echocardiogram (TTE) and confirmation with transesophageal echocardiogram (TEE) and right heart catherization can lead to a multidisciplinary approach for appropriate surgical correction. Case A 21-year-old male with no PMH presented to clinic for a routine physical to return to collegiate athletics post COVID-19 infection. His only complaint during this time was residual dyspnea (NYHA Class 1). An ECG was obtained and showed an incomplete right bundle branch block and TTE revealed an ASD with moderate RV dilation. Repeat TTE at our institution showed an interatrial shunt on injection of agitated saline via the right arm within three beats after injection. Subsequent right heart catheterization with shunt series revealed a step in oxygen saturation from 75% in the superior vena cava (SVC) to 88% in the right atrium. Additional imaging obtained with TEE confirmed a sinus venosus ASD. Cardiovascular surgery was engaged and further imaging with computed tomography angiography (CTA) of the chest confirmed a large superior sinus venosus ASD measuring 16 mm in diameter as well as partial anomalous right pulmonary venous drainage into the SVC. The heart team decided on a minimally invasive robotic approach and performed an autologous pericardial patch repair of the ASD with redirection of the right and superior pulmonary veins into the left atrium. Intra-op TEE showed no residual shunt across the interatrial septum. The patient had an uncomplicated post-operative course and was discharged home on day 4. Decision-Making Sinus venosus ASDs and associated anomalous pulmonary veins are often missed on TTE. In our patient, TEE and CTA assisted in the detection of anomalous pulmonary venous connection. A multidisciplinary heart team approach helped determine and tailor the best option for surgical correction in our patient's case. Conclusion Sinus venosus defects account for up to 10% of ASDs and can lead to pulmonary hypertension if left uncorrected. TTE remains the first imaging modality in assessing for ASDs, but TEE, RHC, and CTA can assist in comprehensive diagnosis and planning for procedural correction. Surgical closure in patients less than 25 years old without pulmonary hypertension is associated with low postoperative mortality, and a multidisciplinary approach can help ensure the most optimal method of surgical correction. (Figure Presented).

Regional anaesthesia for infra-inguinal revascularisation in patients with symptomatic peripheral arterial disease

Introduction: General anaesthesia is considered to be an aerosol generating procedure. The global Covid-19 pandemic has resulted in review of practice to reduce risk to both patients and health care workers. The outcome of regional anaesthesia (RA) for infra-inguinal arterial reconstruction in patients with symptomatic occlusive atherosclerotic has been explored and compared with patients managed with general anaesthesia (GA). Methods: Patients undergoing infra-inguinal revascularisation between 2019-2020 were identified from a prospectively maintained administrative theatre dataset. Case-linkage was used to complete the dataset. Specific end points included to critical care admission and peri-operative mortality. Results: There were 204 patients identified (46 RA and 158 GA). The mean age of patients in both groups was 67-years and procedures were commonly performed in male patients (although the male:female ratio was higher in the RA group 2.8:1 than in the GA group 1.4:1). More patients in the RA had intervention for chronic limb threatening ischaemia (80% versus 59%). The interventions performed were comparable in both groups. The mean length of procedure was less in the RA group (142-minutes versus 160-minutes). No patients in the RA required admission to critical care (10 patients managed with GA required admission to critical care). The 30-day mortality was comparable in the RA and GA groups (2.2% and 1.9% respectively). Conclusions: Regional anaesthesia would appear to be feasible for patients undergoing infra-inguinal arterial reconstruction with a reduction in operating time and critical care admission without increased peri-operative risk.

Vaccination prior to gynaecological oncology surgery : Vaccine compliance and peri-operative outcomes in a tertiary cancer institute in india

Introduction/Background India experienced a deadly second wave of COVID-19 pandemic starting mid-February 2021 with test positivity rate of 25-45 % suggesting high community transmission. Indian COVID-19 vaccination program for 60 years + and above 45 years with co-morbidities began on 1st March 2021. As per COVIDsurg collaborative data, between 0.6% and 1.6% of patients develop COVID-19 infection after elective surgery. Even after use of mitigation measures like pre-surgery RT/PCR and COVID free surgical pathways, COVID-19 is a significant nosocomial infection with 4- and 8-fold increased risk of death in the 30 days following surgery. Our aim was to study vaccine compliance in patients counselled to be vaccinated before surgery, pre-surgery RT/PCR positivity rate, 30-day post-operative SARS Cov-2 rate and peri-operative outcomes. Methodology In this prospective observational study, patients waitlisted for major gynaecological cancer surgeries who were also eligible for COVID-19 vaccination were enrolled. Patients were counselled to get atleast one dose vaccinated 2 weeks before elective surgery. In cases of neo-adjuvant chemotherapy, vaccination was advised atleast 2 weeks after the last dose of chemotherapy. Patients vaccinated with atleast 1 dose - 2 weeks prior to surgery or those with both doses vaccinated atleast a week prior to surgery were eligible for study. Mitigation measures of negative pre-surgery RT/PCR (within 24 hours prior to surgery) and COVID free surgical pathway were used. Result(s) In the overall cohort of 53 patients, 34 got vaccinated suggesting compliance of 64%. In the unvaccinated cohort, 52.6% were pře-surgery RT/PCR +ve against 5.8% vaccinated patients (p = 0.0001). Thirty- day post-operative SARS Cov-2 rate was 44.4% and 0% in the unvaccinated and vaccinated cohort respectively (p = 0.0001). No cases of severe COVID-19 requiring hospitalisation were seen in the vaccinated cohort. There was no 30-day post-operative mortality in either cohorts. Conclusion Counselling regarding COVID-19 vaccination prior to surgery should be an essential part of pre-operative work up. COVID-19 vaccination prior to surgery has two-fold advantage. It prevents the postponement of elective cancer surgeries which are time bound. There is a significant decreased risk of severe COVID-19 infection and related morbidity post-operatively in the vaccinated population. (Figure Presented).

Perioperative care in gynaecological cancer surgery during the covid pandemic in a low resource centre-role of enhanced recovery protocols

Introduction/Background ∗ ERAS (Enhanced Recovery after Surgery) is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures. This study aimed to analyse the feasibility of ERAS in the era of pandemic and to find its effect on the post-operative outcome of patients undergoing surgery for gynaecological cancer during the COVID pandemic Methodology This observational study was done on patients who underwent gynaecological cancer surgery during COVID pandemic in a tertiary cancer centre in South India. Data was collected including patient demographics, nature of surgery, adherence to each of the components of ERAS programme and outcomes. Post operative complications were graded according to the Clavien-Dindo classification Result(s)∗ 152 patients were included in the study period from June to December 2020. 85 patients had cancer ovary, 59 cancer endometrium, 6 cancer cervix and 1 cancer vulva and 7 patients had benign tumours. In the pre operative component of ERAS protocols,82% patients received pre surgery counselling, 97% received thromboembolic prophylaxis, 94% received carbohydrate loading and none of the patients received mechanical bowel preparation. 8% received blood components during and after surgery. In the post operative phase on Day 1, 62% patients had urinary catheter removed, 88% received normal diet and 92% had early ambulation. The complication rate was 26%, but majority 79% had grade 1 and 2 complications. There was one postoperative mortality due to sepsis. The mean hospital stay was 6.6 days. Conclusion∗ The study confirms the feasibility and benefits of following ERAS pathway in enhancing patient recovery during COVID pandemic.

Surgical Treatment and Outcomes of Colorectal Cancer Patients During the COVID-19 Pandemic: A National Population-based Study in England.

To compare the management and outcomes of colorectal cancer (CRC) patients during the first 2 months of the COVID-19 pandemic with the preceding 6 months. BACKGROUND: The pandemic has affected the diagnosis and treatment of CRC patients worldwide. Little is known about the safety of major resection and whether creating "cold" sites (COVID-free hospitals) is effective. METHODS: A national study in England used administrative hospital data for 14,930 CRC patients undergoing surgery between October 1, 2019, and May 31, 2020. Mortality of CRC resection was compared before and after March 23, 2020 ("lockdown" start). RESULTS: The number of elective CRC procedures dropped sharply during the pandemic (from average 386 to 214 per week), whereas emergency procedures were hardly affected (from 88 to 84 per week). There was little change in characteristics of surgical patients during the pandemic. Laparoscopic surgery decreased from 62.5% to 35.9% for elective and from 17.7% to 9.7% for emergency resections. Surgical mortality increased slightly (from 0.9% to 1.2%, P = 0.06) after elective and markedly (from 5.6% to 8.9%, P = 0.003) after emergency resections. The observed increase in mortality during the first phase of the pandemic was similar in "cold" and "hot" sites (P > 0.5 elective and emergency procedures). CONCLUSIONS: The pandemic resulted in a 50% reduction in elective CRC procedures during the initial surge and a substantial increase in mortality after emergency resection. There was no evidence that surgery in COVID-free "cold" sites led to better outcomes in the first 2 months.