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: Postoperative pain represents an important issue in traditional hemorrhoidectomy. Optimal pain control is mandatory, especially in a surgical day care setting. OBJECTIVE: The aim of this study was to investigate the use of pudendal nerve block in patients undergoing hemorrhoidectomy. DATA SOURCES: PubMed, Google Scholar, Cochrane Library, and Web of Science databases were searched up to December 2020. STUDY SELECTION: Randomized trials evaluating the pudendal nerve block effect in patients undergoing hemorrhoidectomy were selected. INTERVENTIONS: Hemorrhoidectomy under general or spinal anesthesia with or without pudendal nerve block was performed. MAIN OUTCOME MEASURES: Opioid consumption, pain on the visual analogue scale, length of hospital stay, and readmission rate were the main outcomes of interest and were plotted by using a random-effects model. RESULTS: The literature search revealed 749 articles, of which 14 were deemed eligible. A total of 1214 patients were included, of whom 565 received the pudendal nerve block. After hemorrhoidectomy, patients in the pudendal nerve block group received opioids less frequently (relative risk, 0.364; 95% CI, 0.292–0.454, p < 0.001) and in a lower cumulative dose (standardized mean difference, –0.935; 95% CI, –1.280 to –0.591, p < 0.001). Moreover, these patients experienced less pain at 24 hours (standardized mean difference, –1.862; 95% CI, –2.495 to –1.228, p < 0.001), had a shorter length of hospital stay (standardized mean difference, –0.742; 95% CI, –1.145 to –0.338, p < 0.001), and had a lower readmission rate (relative risk, 0.239; 95% CI, 0.062–0.916, p = 0.037). Sensitivity analysis excluded the occurrence of publication bias on the primary end point, and the overall evidence quality was judged “high.” LIMITATIONS: Occurrence of publication bias among some secondary end points and heterogeneity are the main limitations of this study. CONCLUSIONS: This systematic review and meta-analysis show significant advantages of pudendal nerve block use. A reduction in opioid consumption, postoperative pain, complications, and length of stay can be demonstrated. Despite the limitations, pudendal nerve block in patients undergoing hemorrhoidectomy should be considered.

HighlightsUnderline the possibility that a gallstone ileus can be a possibility of bowel obstruction in the elderly population.Stimulate discussion about the surgical management of gallstone ileus and cholecystic-duodenal fistula.Abdominal CT scan is the preferred investigation for a timely diagnosis.

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