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 Carcinoma of the uterine cervix (cervical cancer) metastasising to the thyroid gland is a rare phenomenon and only a few cases have been reported. We discuss a patient with cervical cancer presenting with thyroid and cervical lymph node metastasis, exploring the diagnostic difficulty, evaluation and treatment options. Case presentation A previously well 56-year-old female presented with multiple neck lumps for 4 months duration. Examination of the neck revealed multiple firm/hard left cervical lymph nodes with a hard thyroid nodule. There were no abdominal masses however, vaginal examination revealed a hard, unhealthy cervix. Contrast enhanced computed tomography revealed a growth in the uterine cervix with lymph node enlargement in the abdomen, chest and neck along with multiple thyroid nodules. Biopsy of the cervix and cervical lymph node and fine needle aspiration cytology of the thyroid nodules were performed, all revealing a squamous cell carcinoma. Pan-endoscopy performed to rule out any concurrent cancer of the upper aerodigestive tract was negative. The patient was started on palliative therapy, but succumbed to the disease after 6 months. Discussion and conclusion Patients who present with a thyroid nodule along with multiple cervical lymph nodes should be thoroughly assessed for possible metastatic cancers. Metastasis to the thyroid gland indicates a poor prognosis in the background of carcinoma or the uterine cervix. More awareness among the public and primary care providers is necessary regarding freely available screening programmes for early detection of cervical cancer.

Introduction Laparoscopic appendicectomy (LA) is considered as the mainstay of treatment in acute appendicitis. LA is a basic laparoscopic procedure and therefore can be used as a training tool for surgical trainees. It is considered an index operation for junior surgical trainees. This study aims to assess whether LA is safe to be carried out by a junior surgical trainee. Methodology The study was conducted at a tertiary care unit in Colombo. Data were collected retrospectively. A total of 152 LA (including those which were converted to open appendicectomy) performed between January 2018 to May 2019, by surgical trainees (both junior and senior) were included. Gender, age, initial investigation findings, intraoperative findings, operative time, hospital stay, postoperative complications and histology data were analysed. Findings were compared in two groups-operated by junior and senior surgical trainees. Results One hundred and three surgeries were performed by junior trainees while 49 were performed by senior trainees. There was no significant difference in complicated appendicitis (21.4% vs 34.7%), operative time (71m vs 68m), conversion rate (12.6% vs 16.3%) and hospital stay (3d vs 3d) between these two groups. The overall complication rate was 3.9%. Conclusion Our findings were comparable to previously published data and no statistically significant difference was noted between the two trainee groups in terms of operative finding, hospital stay and postoperative complications. The results suggest that LA can safely be performed by the junior surgical trainees with acceptable outcomes.