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.

Patients who undergo APR of rectum are prone to impaired healing of the perineal wound if radiotherapy is used to treat malignancy prior to surgery and wound closure is delayed. In addition, the wound may not heal in patients with distant metastases, excessive alcohol consumption, present and past smokers and those who suffer adverse effects of preoperative chemoradiation and require blood transfusion.

Although first described almost half a century ago, parastomal varices are not easily recognised as a cause of stomal bleeding even though they occur in up to 5% of all people who have a stoma. The main challenges associated with this condition are diagnosis and management. For that reason, the aim of the present study was to perform a systematic review of all the available literature pertaining to this topic. The primary end point was recurrent variceal haemorrhage after a particular mode of management. Several secondary endpoints focused on means of diagnosis and pathological conditions of abdominal organs that could contribute to both the formation of these varices and the rate of re-bleeding. Sixty-six articles comprising 210 patients were analysed. Parastomal varices tend to be more frequent in men manifesting with bleeding in the fifth decade of life. The majority (72.0%) of patients who bleed from parastomal varices do so from an ileostomy. The most common pathology leading to stoma formation is ulcerative colitis (57.8%). Liver cirrhosis is the most common cause of portal hypertension leading to the development of parastomal varices and primary sclerosing cholangitis is in second place. A third of patients with parastomal varices also have co-existent oesophageal varices. There are no pathognomonic symptoms or signs of parastomal varices and only the minority of patients have a raspberry appearance of the stoma, visibly dilated submucosal veins and bluish discoloration and hyperkeratosis of the skin around it. Venous phase contrast angiography or portal venography is the most successful radiological investigation to confirm the diagnosis. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has the highest success rate in preventing recurrent haemorrhage and local measures, either non-operative or surgical, are the least effective. Comparison of TIPS with non-operative and local surgical treatment groups produced a risk reduction in 4.60 and 3.85, respectively. Treatment of 1.37 people with a TIPS procedure prevents one person suffering from recurrent variceal bleeding and using TIPS can reduce the likelihood of re-bleeding by 78.5%. Surgical portosystemic shunting or embolisation alone leaves patients with approximately 50% chance of re-bleeding. Although TIPS has gained popularity over the last two decades almost three quarters of patients with parastomal varices are still treated with local measures as first-line management. Liver transplantation as a treatment of the primary cause of parastomal varices remains very rare.

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.

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