Reduction in rates of reversal of temporary stoma after anterior resection, another building crisis post COVID-19?

Purpose: Diverting loop-ostomies are sometimes formed in patients undergoing resection for rectal cancer with primary anastomosis. Timing to reversal is commonly reported between 3-6 months of original surgery, with longstanding issues of delays secondary to low-surgical prioritisation. Our retrospective study over a 5-year period aims to understand the effect on timing to reversal of the COVID-19 pandemic. Method(s): All patients undergoing resection for rectal cancer were identified from the Hospital Episode Statistics data between 01.01.2018 and 01.07.2021. Data was then cross-referenced with patients undergoing reversal surgery. Demographics, time to surgery, length of stay and post-operative morbidity data were collected. Result(s): There were 262 anterior resections performed. 192 patients had resection with primary anastomosis (PA): 85 had formation of loop ileostomy, 23 formation of loop colostomy. Results before March 2020: 65 resections with PA and ileostomy. 34 (52.3%) reversed with median time to reversal of 266 days, (range 98-1015). 16 resections with PA and colostomy. 7 reversed (44%), median time to reversal 476 days (range 104-768). Results after March 2020: 20 resections with PA and loop-ileostomy. 3 have been reversed (15%), with median time to reversal of 211 days, (range 103-449). 7 resections with PA and colostomy, none reversed. Showing reduction in overall stoma-reversal in the post pandemic period (p = 0.000297). Conclusion(s): We will experience ongoing conflicts with prioritisation of caseloads as the ongoing effects of COVID continue. This is the time for novel solutions to a building crisis, such as ring-fenced lists or same-day surgery with ambulatory follow-up.

TCTAP C-005 Conundrum of a ‘Primary’ Angioplasty: Provisional Stenting of Left Main Stem / Left Anterior Descending During STEMI With Double Bifurcation

Clinical Information Patient Initials or Identifier Number: R Relevant Clinical History and Physical Exam: A 64-year-old lady with underlying dyslipidemia presented to our emergency department with typical chest pain. Immediate electrocardiogram was performed which showed sinus rhythm, ST elevation at lead 1, aVL and V1, hyperacute T wave at V2 till V3 with ST depression at leads II, III and aVF. Hence a diagnosis of acute anterolateral myocardial infarction, Killip 1 was given and urgent referral to cardiologist was made. Subsequently, she was subjected for primary angioplasty. Relevant Test Results Prior to Catheterization: Blood results showed sodium of 134 mmol/L, potassium of 3.5 mmol/L, urea of 3.2 mmol/L and creatinine of 67 mmol/L. Liver enzymes were within normal limits with aspartate transaminase of 38 U/L and alkaline phosphatase of 91 U/L. Creatinine kinase was 330 U/L but increased to 2861 U/L during subsequent day. In addition, COVID-19 RTK antigen was negative. Relevant Catheterization Findings: Coronary angiogram revealed mild disease at proximal right coronary artery and proximal left circumflex. Minimal disease was noted at distal left main stem, but severe disease was observed from proximal left anterior descending till mid left anterior descending. Heterogenous plague suggesting thrombus was seen at ostial first diagonal as well. [Formula presented] [Formula presented] Interventional Management Procedural Step: Right femoral assess was obtained with 7Fr sheath, and SL 3.5 7Fr guiding catheter was engaged to left coronary artery. Intracoronary heparin and tirofiban were given prior to wiring. First diagonal was wired with Sion Blue while left anterior descending was wired with Runthrough Floppy. Post-wiring both vessels, coronary flow remained TIMI 3 and hence we decided to proceed with IVUS. From IVUS, noted fibrous elastic plague with heavy thrombus burden. Intracoronary streptokinase was given and noted improvement of thrombus from IVUS. BMW wired to left circumflex. Lesion predilated with scoring balloon and associated with no reflow events, resolved post vasodilators. Left main stem was stented with Onyx 3.5 x 26 mm and deployed at 16 atm. Both side branches wires were rewired into same branches via Crusade microcatheter. LMS stent was post dilated with NC Euphora 4.5 mm at nominal pressure. Noted impingement of both ostium diagonal and circumflex branches. Balloon kissing inflation was performed for both LAD/Diagonal bifurcation and LMS/LAD/circumflex bifurcation. POT was performed post balloon kissing inflation with NC Euphora 3.5 mm and 4.5 mm for both LAD and LMS respectively. Next, IVUS was repeated for mid LAD stent length and Onyx 3.0 mm X 15 mm was deployed at nominal pressure. IVUS repeated and noted under-expansion of overlapped segments and post dilated with NC Euphora 3.0 mm at high pressure. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Our clinical vignette demonstrated few learning points including utilization of IVUS during primary angioplasty. Understanding of plague characteristic ensures adequate stents expansion especially with fibro elastic plague. In addition, we also demonstrated several precautions in dealing with bifurcation lesions including usage of double lumen microcatheter for wiring the side branches. Even though we opted for provisional stenting, balloon kissing inflation played pivotal role in preserving flow into side branches.