COVID-19 opens the door for right iliac fossa pain treatment pathway

IntroductionThe COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR.MethodsA retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups.ResultsThe mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16–45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%.ConclusionsGreater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

The safety and utility of regional surgical hubs to deliver elective colorectal surgery -is the post pandemic future here?

Introduction: The creation of regional hubs is at the centre of the Royal Colleges' recovery plan to address the waiting list crisis exacerbated by the pandemic. However, the safety and resilience of this approach for major colorectal surgery has not been tested. We investigated the short-term outcomes for patients from 3 hospitals in Birmingham who were operated at a central hub, without on-site critical care, parenteral nutrition, interventional radiology, and blood bank facilities. Method(s): Data collection was from 08/03/2021 following the 2nd COVID peak. Clinically appropriate patients for the hub underwent robust pre-operative assessment and had to self-isolate for 3 days following a negative COVID test prior to admission. Post-operative care was consultant delivered on a weekly basis, with surgeons pooled from across 3 hospitals. Patients requiring adjunctive treatment beyond the scope of the hub were transferred to the parent hospital. Result(s): 35/316 (11.1%) patients were deemed unsuitable for surgery at the hub. The remaining 281 (ASA I-III) patients underwent major resections for both malignant (56.6%) and benign (43.4%) colorectal diseases in the 10 months since 03/2021. Only 2 (0.7%) patients had surgery cancelled because of staff/bed shortage. Median LoS was 6 (IQR: 4-8) days, with a hub-hospital transfer rate of 8.5% (n = 24). Major complications (Clavien-Dindo >3) occurred in 9.6% (n = 27) of patients, with a mortality rate of 1.1% (n = 3). 30-day re-admission rate was 11.7% (n = 33). No patients contracted nosocomial COVID. Conclusion(s): Major colorectal surgery can be safely delivered without interruption at stand-alone surgical hubs, with acceptable and comparable outcomes to existing NHS hospitals.

An Indirect Approach to Analyze the Impact of Working Environment Restrictions Due To COVID 19 on Muscle Fatigue and Strength

The current research work seeks to analyze the changes in the muscle fatigue and strength, if any, due to the restrictions of use of facial mask while at work. The workers are required to perform tasks like lifting and pushing which range from moderate to heavy workloads. Alternative approach had to be used as the shop floor environment did not facilitate the use of standard laboratory setup for measurement of muscle fatigue. © IEOM Society International.

COVID-19 opens the door for right iliac fossa pain treatment pathway.

INTRODUCTION: The COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR. METHODS: A retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups. RESULTS: The mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16-45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%. CONCLUSIONS: Greater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

The impact of the COVID-19 pandemic on patients with complex colorectal polyps -a multicentre analysis

Introduction: The COVID-19 pandemic had an adverse impact on endoscopic services. We set out to evaluate the impact on the complex lower gastrointestinal (LGI) polyp services in two NHS hospitals following revised service arrangements based on BSG's guidance. Methods: We analysed 111 patients with complex LGI polyp defined as SMSA score>9(size, morphology, site, access). Demographics, time interval between first (diagnostic) and second (therapeutic) LGI endoscopy, polyp size (including interval growth) and patient outcomes were evaluated. Procedures performed six months after 23-03- 2020 were classed as affected by the COVID-19 outbreak (group-A). While procedures prior to this formed controls (group-B). Kudo pit patterns I,II and IIIL were classed as low risk and IIIs, IV, and V as high risk. Results: 35 patients were in group-A and 76 in group-B with median age of 69 and 71 respectively (P = 0.725), with no statistical gender difference (P = 0.152). Median time interval between LGI procedures was significantly longer in group-A( 16 [IQR 12-20] vs 8 [IQR 5-13] weeks;P = 0.001). Statistically significant (P = 0.031) increase in polyp size was observed in group-A [20 (15-35) to 40 (20-46) mm] as compared to group-B [25 (20-30) to 30 (20-40) mm], without difference in kudo class. Endoscopic resection attempt was abandoned in 5% of patients in group-A as compared to 1% in group-B (P = 0.12).80% of abandoned procedures in group-A required surgical resection. Conclusions: The COVID-19 pandemic has led to a delay in interval LGI endoscopies for patients with complex colonic polyps with a significant increase in size of polyps resulting in patients requiring surgery.

COVID-19 opens door for new Right Iliac Fossa pain Treatment (RIFT) pathway

Aims: The COVID-19 pandemic has increased pressure on surgical services, increased the risks of surgery, and forced changes in surgical practice. The UK has a high negative appendicectomy rate (NAR) compared to other countries. We aimed to quantify change in the use of pre-operative imaging due to the pandemic in patients with suspected appendicitis and whether this has reduced the NAR. Methods: We performed a retrospective single-centre cohort study including consecutive patients aged 16-45 referred with right iliac fossa pain or suspected appendicitis in 2 periods: from Jan 26th to Mar 25th, and from Mar 26th until Jul 25th, 2020. Patients who had previously had an appendicectomy or were pregnant were excluded. Patients were analysed according to age, sex and risk score. Results: 85 male and 165 female patients were included across both study periods. 94 (37.6%) patients were identified as low-risk, of whom 0 (0%) underwent appendicectomy. The use of CT imaging was significantly greater in high-risk patients post-lockdown, increasing from 24.2% to 56.1% (P = 0.008817) in males and 18.2% to 41.7% in females (P = 0.03108). In high-risk patients across both periods the NAR was 0% in those undergoing pre-operative CT and 33.3% in those not imaged (P = 0.003995). The NAR did not differ between study periods. The number needed to CT to prevent 1 negative appendicectomy was 9. Conclusion: The use of pre-operative CT imaging is associated with a reduction in NAR to 0%. Risk stratification, and pre-operative CT in high-risk adults, should be considered to reduce the NAR.