Lactulose Works in the Large Bowel: But How Does It Improve Hepatic Encephalopathy in a Patient Without a Large Bowel?

Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.

Tracheotomy In Patients With Covid-19

Relevance. The coronavirus rush, which has appeared since December 2019, has an impact on economic, medical, and social development in all countries of the world. There are still no standard diagnostic and therapeutic plans aimed at limiting this infection. Purpose. To determine the therapeutic role of tracheostomy with patients with coronavirus infection. Material. The prospective study of 100 patients with coronavirus infection was carried out on the basis of State Budgetary Healthcare Institution "Interdistrict Multidisciplinary Hospital" in Nartkala city. When patients were admitted to the clinic, they were randomized into 2 groups depending on the therapy: the first group (comparison, n=50) - patients received traditional therapy in intensive care;the second (main, n=50) group - patients underwent tracheostomy in addition to standard therapy. The average age was 56.2+/-4.8 years. The women's average age was 55 years (55.0%), and the men's - 45 years (45.0%). Methods. Determination of the syndrome of endogenous intoxication, taxation of lipid peroxidation intensification. The local microcirculation was investigated by the apparatus LAKK-02. The activity of the coagulation-lytic blood system was found by thrombelastograph TEG 5000. Results. Early COVID-19 infection demonstrates signs of intoxication, oxidative depression, phospholipase activity, microcirculatory and hemostatic disorders. These changes were the cause of the development of life-threatening complications (neurological, pulmonary, cardiac, etc.). They were associated with the type of treatment. Traditional treatment and the use of mask oxygen turned out to be ineffective, since the homeostasis system disorders remained throughout the investigation period. The inclusion of tracheostomy in traditional therapy makes it possible to quickly improve the course of pathology as it purposefully affects the pathogenetic links of the homeostasis system. Conclusion. The use of tracheostomy in the scheme of standard treatment of coronavirus infection allows improving the effectiveness of general therapy of COVID-19 patients, especially with severe forms.Copyright © 2023, Codon Publications. All rights reserved.

The Consequences of the COVID-19 Pandemic on Emergency Surgery for Colorectal Cancer.

The aim of this study is to analyze the impact of the COVID-19 pandemic on the emergency treatment of patients with colorectal cancer in a university surgery clinic. Data from patients undergoing emergency surgery during the pandemic period (2020-2021) was taken into consideration and the results were analyzed and compared with the periods 2016-2017 and 2018-2019. A significant decrease in the number of patients undergoing emergency surgery was reported (p = 0.028). The proportion of patients who presented more severe symptoms at the hospital was significantly higher (p = 0.007). There was an increase in the average duration of surgical interventions compared to pre-pandemic periods (p = 0.021). An increase in the percentage of stomas performed during the pandemic was reported. The average duration of postoperative hospitalization was shorter during the pandemic. A postoperative mortality of 25.7% was highlighted. Conclusions: The pandemic generated by COVID-19 had significant consequences on the emergency treatment of patients with colon cancer. A smaller number of patients showed up at the hospital, and with more severe symptoms. In order to reduce the risk of infection with SARS-CoV-2 virus, the postoperative hospitalization period was shortened and a higher number of protective stomas were performed.

Increasing stoma requirements during the COVID-19 pandemic

Aims: The COVID-19 pandemic has ledtoa changein working practices in The diagnosis and management of Colorectal cancer. Guidelines emerged which recommended changing anastomotic practice in favour of forming a defunctioning stoma or end stoma in patients who would have previously had an anastomosis. This study aimed to identify whether these changes have resulted in an increase in patients requiring a stoma and its potential impact. Method(s): All patients diagnosed with Colorectal Cancer in The authors' tertiary surgical unit in three 4-month intervals were included. These corresponded to before The pandemic (March-June 2019), during The UK's first wave of COVID-19 (March-June 2020), and during The second wave (December 2020-March 2021). The incidence of stomas was compared between groups. Result(s): In patients undergoing elective Surgery The incidence of stomas was 13% pre-pandemic. However, this tripled to 39% during The first wave and increased to 54% in The second wave. Similar trends were seen in patients undergoing emergency Surgery with 36% having stomas before The pandemic which rose to 50% during both The waves. Conclusion(s): A change in stoma practice was observed with patients having a stoma when they would usually have had an anastomosis only. As COVID-19 continues to have a severe effect on planned Surgery in The UK, patients requiring stoma reversal adds to The backlog. As The huge task of clearing The backlog begins, surgical teams must be provided with appropriate resources, professional and mental Health support.

Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim: The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients. Method: 22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured. Results: 19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12-14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively. Conclusion: Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

Characteristics and nutritional outcomes of patients recovering from COVID-19 infection post intensive care admission

Patients transferred out of intensive care recovering from COVID-19 infection are at high risk of malnutrition1.Untreated malnutrition has the potential to increase length of stay and increase morbidity and mortality. To inform service planning we aimed to describe nutritional status and dietetic outcomes of patients recovering from COVID-19 infection post ICU admission. Baseline data was collected retrospectively from patient electronic records and included age, gender, comorbidities, weight, height, Body Mass Index (BMI), Vitamin D status, type of nutrition support, length of stay and discharge destination. Of 51 COVID-19 patients transferred out of ICU, 71% remained as inpatients and had further dietetic follow up. [Formula presented] Of those with data sets available, 82% had a decrease in weight during their ICU stay with an average loss of 7.6kg (9% body weight). Thirty percent moved into a lower BMI category over the course of their ICU stay. On discharge from hospital and dietetic service, 50% were weight stable and 29% had gained weight following dietetic input. Seventy two percent of patients required ongoing artificial nutrition support on transfer out of ICU. Prior to discharge home, 82% required advice on a high protein, high calorie diet with 25% of these requiring additional advice for therapeutic diets such as diabetic diets, no added salt diet, dietary advice for stoma management, renal dietary advice and modified consistency dietary advice. In terms of follow up, 11% were referred to community dietetics, 8% returned to dietetic outpatient clinics and 18% were stable on nutrition care plan and discharged from dietetic caseload at ward level. The data obtained highlights the deterioration in nutritional status and risk of malnutrition in this cohort of patients post COVID-19 infection. Ongoing nutrition support and dietetic input should be considered as integral on transfer from ICU to ward level in preventing, treating and diagnosing malnutrition. References 1. Bedock.D, Bel Lassen.P, Mathian.A, Moreau.P, Couffignal.J, Ciangura.C, Poitour-Bernert.C, Jeannin, AC, Mosbah.h, Fadlallahj, Amoura.Z, Oppert.JM, Faucher.P. Prevalence and severity of malnutrition in hospitalized COVID-19 patients. Clinical Nutrition ESPEN. 2020;Vol. 40 214-219 2. Haraj.NE, EL Aziz.S, Chadli. A, Dafir.A, Mjabber. A, Aissaoulo, Barrou.L, EL Kettanie EL Hamidi.C, Nsiri.A, AL Harrar.R, Ezzouine.H, Charra.B, Abdallaoui. Ms, EL Kebbaj.N, Kamal.N, Mohamed Bennouna.M, EL Filali.KM, Ramdani.B, EL Mdaghri.N, Benghanem Gharbim, Hicham Afif. Nutritional status assessment in patients with COVID-19 after discharge from intensive care unit. Clinical Nutrition ESPEN. 2020;2405-4577

COVID-19 pandemic and clinicopathologic characteristics of colorectal cancer in Korea: A multicenter, retrospective study

Background: The coronavirus disease 2019 (COVID-19) pandemic has affected not only the control and management of infectious diseases, but also those of other diseases by deteriorating the general healthcare systems worldwide. In accordance with the suggestion by the WHO for postponement of non-urgent procedures, diagnosis and treatment strategies for the patients with malignancy have been changed. The aim of this study was to investigate the impact of COVID-19 pandemic on primary colorectal cancer (CRC) from multi-institutions in Korea. Methods: Medical records of consecutive patients with CRC between March 2019 and February 2021 in six university hospitals were reviewed. Recurrent diseases, admission for management of complications or enterostomy repair, and other pathologies than adenocarcinoma were excluded. Baseline characteristics and perioperative outcomes were compared after a cohort was divided into the two groups: before and after around March 2020, when the COVID-19 test has been mandatory for all admitted patients in most institutions. Treatment characteristics and pathologic outcomes were also compared between the two groups. Results: A total of 3895 patients with CRC admitted during the study period. After 454 patients were excluded, 1820 and 1621 patients were assigned to the pre-pandemic and pandemic groups. The proportion of patients who could not receive curative or palliative surgery for stage IV diseases was not different (88 vs. 91, P>0.999), and 3262 patients underwent surgery for primary CRC. Among them, the pandemic group showed more previous abdominal surgery (21.2% vs. 15.4%, P<0.001), higher preoperative CEA level (46.7 vs. 16.0 ng/mL, P=0.021), and less stent insertion for obstructive lesion (33% vs. 46.4%, P=0.043). There was no difference in sex, age, the ASA grade, and tumor location between the groups. Perioperative outcomes including operation time, operation method, operation type, and postoperative complication rates were not different, whereas more stoma formation was performed in the pandemic group (15.3% vs. 12.4%, P=0.024). Pathologic outcomes including TNM stage, tumor diameter, harvested lymph nodes, and lymphovascular invasion were not different. However, the pandemic group showed higher tendency of lymph node metastasis (44% vs. 40.6%, P=0.070) and more adjuvant chemotherapy (26.4% vs. 20.1%, P<0.001). Conclusions: Although a few factors indicated more advanced CRC, clinical features and perioperative outcomes of the patients in COVID-19 pandemic seemed not to be aggravated in Korea. The national healthcare system which was not shut down in the pandemic, and relatively small number of COVID-19 prevalence might influence these results, although patients' access and medical checkup seemed to decrease slightly. The cause and effect of decreased medical access would be clarified by long-term follow up data.

THE RELATIONSHIP BETWEEN BOWEL DYSFUNCTION AND BOWELRELATED QUALITY OF LIFE IMPAIRMENT OVER TIME

Purpose/Background: Bowel dysfunction following rectal cancer surgery changes with time and patients adapt to symptoms. The impact of bowel dysfunction on quality of life (QOL) over time is uncertain. Hypothesis/Aim: To evaluate the change in QOL due to bowel dysfunction over time. Methods/Interventions: A prospective database starting in July 2017 of adult patients who had undergone sphincter preserving rectal cancer surgery at a single university-affiliated colorectal cancer referral centre was queried. Patients were excluded if they had local recurrence, metastasis, or persistent stoma beyond 1-year follow-up. Follow-ups were arranged according to current guidelines. Main outcomes were QOL measured by the Short Form-36 survey (8 scales and 2 summary scores), bowel dysfunction was classified using the Low Anterior Resection Syndrome (LARS) score (no LARS, minor LARS and Major LARS), and bowel-related quality of life was evaluated using the single-item Bowel-Related Quality of Life (BQOL) survey. The SF-36 and LARS scores were collected as part of the ongoing registry. Eligible patients were then called at 3 months after their last in-person follow-up and administered the SF-36, LARS score and BQOL. Patients were also asked how they would have answered the BQOL 3-months prior. Changes in LARS and BQOL scores were noted and compared to SF-36 scores. Results/Outcome(s): Overall, 136 patients were included (75% response rate). Mean age 61.8 (+/-10.6 years), 71% male, mean distance from the anal verge was 8.7 cm (+/-4), 54% underwent neoadjuvant radiotherapy, 51% had a diverting loop ileostomy, 87% were laparoscopic, and median follow-up was 35.4 months [23.5-64.3]. There was no significant change in 3-month BQOL (96% of patients had no change, 3% improved, and 1% deteriorated. In patients who reported no change in BQOL, 54% (72/131) had no change in their LARS score, 31% (41/131) scored worse, and 27% (31/131) improved. Patients that showed improvement in their LARS score had an associated increase in their physical component summary, role emotional, role physical, physical functioning and bodily pain. Whereas patients with a deterioration of their LARS score had an associated decrease in their general health, vitality, and mental health. Interestingly, patients with no change in their LARS score reported increases in physical functioning and role emotional, but decreases in their scores for vitality and mental health (Table). Limitations: Recall bias, Covid-19, and volunteer bias. Conclusions/Discussion: Assessment of patients' bowel related QOL is complex. Improvements in bowel dysfunction appears to be associated with improved QOL. Whereas patients with worsening bowel dysfunction had an associated deterioration in QOL. Of note, BQOL scores did not change significantly over the study period. There is currently a paucity of instruments with sensitivity to detect changes specific to bowel dysfunction- related QOL.

HOW THE COVID-19 OUTBREAK AFFECTED STOMA SURGERY AND STOMA CLINIC SERVICE IN A REFERRAL HOSPITAL IN JAPAN

Purpose/Background: Impact of the COVID-19 pandemic on medical practice has been often reported from Western countries, but there have been few studies in other areas especially regarding stoma surgery and stoma care. Hypothesis/Aim: We examined COVID-19-induced changes in stoma-related surgery and stoma management in Japan. Methods/Interventions: We investigated the numbers of all operations and stoma-related surgeries in our hospital in 2019 and 2020. The cumulative numbers of consultations at our ostomy clinic and patient population stratified by the period of having a stoma were compared between these calendar years. The frequency of ostomy clinic visit by individual patients within a year after stoma creation, and stoma-related complications per consultation were also analyzed. Results/Outcome(s): The number of elective surgery decreased by approximately 10% from 2019 to 2020, but the numbers of stoma creation and closure did not change. The total numbers of consultations at our ostomy clinic were also similar between these years. However, the percentage of patients with a stoma for less than a year who attended our ostomy clinic increased from 49.7% in 2019 to 53.5% in 2020, whereas other patients showed the opposite tendency. Moreover, patients with a stoma for less than a year visited ostomy clinic more frequently in 2020 (0.42/month) than in 2019 (0.30/month, p=0.032), as shown in Figure a. Grade 2 or severer peristomal complication per consultation decreased from 17% in 2019 to 11% in 2020 (11%) than in 2019 (p<0.001), as shown in Figure b. Limitations: Our situation may not represent the totality of hospitals in Japan. In addition, early postoperative care on the ward before discharge was not counted. There may be several patients too ill to visit our ostomy clinic. As stoma conditions at home were not assessed and follow-up intervals depended on individuals, the complication rates reported here may contain biases. Finally, we did not evaluate quality of life of stoma patients in relation to stoma-related complications, e.g. using questionnaires. Conclusions/Discussion: The COVID-19 outbreak has driven the shift in patient population at ostomy clinic to new stoma patients, which may have led to in a fewer peristomal complication at least in our hospital. Crises sometimes drive innovative methods in healthcare;for example in addition to the current clinic activity, online remote consultation of stoma care may function as a triage for face-to-face outpatient clinics and add a lot of advantages in terms of saving time and reducing healthcare costs. (Figure Presented).

INTERNATIONAL DIFFERENCES IN THE SURGICAL MANAGEMENT OF DIVERTICULITIS: AN AUDIT OF THE DAMASCUS MULTICENTER TRIAL

Purpose/Background: Reported international variability in the index management of acute diverticulitis may contribute to the observed differences in short-term outcomes and drive disparities in guidelines. Hypothesis/Aim: Goal: To compare international practices in initial surgical management for acute diverticulitis Hypothesis: Decision making varies by region in comparable patients, impacting outcomes and guidelines Methods/Interventions: The DAMASCUS study was a 6-month prospective, global observational study on the management and short-term outcomes of patients presenting with acute diverticulitis. For this study, baseline patient and disease covariates were reviewed from the RedCap database for initial surgical decision making by region (North America, Europe, UK, Australasia and Asia/Africa/South America [LMIC's]). The main outcome was the international variation in acute surgical management by region. Results/Outcome(s): Of 5659 patients enrolled internationally, 4472 (79%) were admitted on initial presentation and included in this analysis. The admission rate was significantly lower in North America, where only 39% were admitted (p<0.001). 28% (n=1558) reported a prior diverticular episode;North America had significantly higher rates of prior episodes (47%;p<0.01). Prior episodes were mostly >12 months before current presentation in all regions. 709 patients (15.9%) had emergency surgery for diverticulitis. Rates for surgery at initial presentation varied significantly from 6% (North America) to 24% (LMIC's). Surgery was CT-driven in 98%. 95 patients (13.4%) had a laparoscopic lavage/washout, while 614 (86.6%) had resectional surgery. The most common resection was a Hartmann's procedure (71.6%), performed significantly more than a segmental resection in all regions except Europe (P<0.001). A primary anastomosis was performed in 174 overall (28.3%);rates were similar across regions. An end colostomy- whether described as a Hartmann's, anterior resection, or sigmoid colectomy- was the most common stoma overall at 87.3% (P<0.001). Excluding the Hartmann procedures, 24.1% left a covering stoma. Europe and LMIC were significantly less likely to divert (p=0.002). All other regions were comparable. 67.8% left a surgical drain. Nearly all reported treatment was not affected by Covid 19 (98%). Limitations: Audit design, with differences in definitions of procedures and bias possible from who completed the audit. Conclusions/Discussion: The DAMASCUS study confirmed substantial geographical variation in the index surgical decision making for emergency diverticulitis cases. Despite colorectal expersite, a Hartmann's procedure with end colostomy remains the most common procedure in emergency cases. Lower stoma rates in LMIC may be related to less available resources for subsequent cases. Further analysis will be performed to determine whether such variation is associated with short term clinical outcomes.

The PROPHER Study: Patient reported outcomes after parastomal hernia treatment

Purpose/Background: The reported rates of stoma patients who develop a parastomal hernia (PSH) are between 5% to 50%. PSHs are symptomatic in 75% of these patients, causing a significant impact on quality of life. There remains a pressing need to establish the optimum treatment of PSH. We don't know if PSH repair improves patients QoL as it's not something that has been reliably looked at in previous PSH studies. of the eleven studies published between 2004 and 2017 only two included QoL. Fleshman (2014) used the Stoma QoL questionnaire, and Brandsma (2017) used SF36 and EQ5D. The problem with these tools is that SF36 and EQ5D are generic health status, and Stoma QoL covers generic stoma problems, and is not PSH specific. PROPHER is a prospective international cohort study of PSH treatment. The primary aim is to explore differences in surgical techniques, outcomes and QoL across operated and non-operated patients with PSH to identify areas of variability, and whether this results in differences in outcomes and impact on patients QoL that would warrant further study. Methods/Interventions: All patients over the age of 18 with a bowel stoma who are referred for consideration of PSH treatment will be eligible to enrol in the study. We will capture data from patients undergoing surgical intervention and having conservative treatment. For patients who undergo a surgical repair, we will record data on surgical techniques, mesh, and postoperative complications. We will also capture QoL data for both cohorts of patients. PROMS are a primary outcome measure in PROPHER. We will be utilising novel technology to complete the patient follow up, with the use of a mobile phone app, which will send notifications to the patients to complete the questionnaires. The patient reported outcomes will include re-admission, re-intervention, quality of life, PSH specific symptoms, and decisional regret. PROPHER is also the first colorectal study to use MYMOP (Measure Yourself Medical Outcomes Profile), a patient generated outcome measure questionnaire. Results/Outcomes: PROPHER will open for recruitment in September 2021, having been delayed due to the COVID19 pandemic. By the time of the Tripartite meeting we will have the first 6 months of data on patients entered into the study. of particular interest will be the baseline MYMOP data, allowing us to fully understand the decision drivers for patients undergoing parastomal hernia treatment. Conclusion/Discussion: PROPHER will provide a wealth of contemporaneous information that will improve our ability to counsel patients and facilitate improved selection of appropriate and personalised interventions for those with a PSH.

IMPACT-ReCaP: Rectal cancer management during the COVID-19 pandemic

Purpose/Background: With enhanced strain on healthcare systems and avoidance of routine surgery and systemic therapy during the COVID-19 period due to increased morbidity and mortality alternative oncological approaches have been employed. We aimed to determine the variation in strategies adopted nationally across the United Kingdom (UK) and long-term associated outcomes. Methods/Interventions: A UK multi-centre prospective observational study was performed from the date of National Governmental lockdown (23/3/20) until the lifting of restrictions (17/5/21). Patients with a new diagnosis of rectal cancer or those rediscussed at MDT on an existing treatment pathway were eligible for inclusion. Results/Outcomes: The first 900 patients were reported from 70 registered sites;65.4% male, 73.6% >60 years old. 62.4% of patients were diagnosed following lockdown. 65.8% of MDTs had a partial or entirely virtual format. 22.8% of tumours were T4, with 4.3% local recurrence. Following lockdown there was a significant increase in the use of SCRT + delay from 10.0% to 18.7% (p < 0.0005), with a rate of 26.7% during the first wave. Comparably the rate of LCRT fell 53.3% to 18.0% (p < 0.0001). 86.2% of those undergoing surgery during the first wave had stoma formation, 26.0% of which due to COVID-19 concerns alone. 18.6% of patients were deemed to have received different management plans due to COVID-19. Conclusion/Discussion: The COVID-19 pandemic has led to variation in oncological treatment strategies for rectal cancer, most notably an increase in the use of SCRT radiotherapy, deferral of surgery and stoma formation. Whilst short-term data appears to suggest equivalence in outcomes compared to LCRT, caution needs to be shown whilst awaiting longer-term outcomes and ensuring robust follow up and safety netting to avoid long term harm.

The impact of the COVID-19 pandemic on colorectal cancer diagnosis and management: A binational colorectal cancer audit study

Purpose/Background: The COVID-19 pandemic has resulted in global disruptions to the delivery of healthcare.(1) The national responses of Australia and New Zealand has resulted in unprecedented changes to the care of colorectal cancer patients, amongst others. This paper aims to determine the impact of COVID-19 on colorectal cancer diagnosis and management in Australia and New Zealand. Methods/Interventions: This is a multicentre retrospective cohort study using the prospectively maintained Binational Colorectal Cancer Audit (BCCA) registry. Data is contributed by over 200 surgeons in Australia and New Zealand. Patients receiving colorectal cancer surgery during the pandemic were compared to averages from the same period over the preceding three years. Results/Outcomes: There were fewer operations in 2020 than the historical average. During April to June patients were younger, more likely to have operations in public hospitals and more likely to have urgent or emergency operations. By October to December proportionally less patients had stage I disease, proportionally more had stage II or III disease and there was no difference in stage IV disease. Patients were less likely to have rectal cancer, were increasingly likely to have urgent or emergency surgery and more likely to have a stoma created. Conclusion/Discussion: This study shows that the response to COVID-19 has had measurably negative effects on the diagnosis and management of colorectal cancer in two countries that have had significantly fewer COVID-19 cases than many other countries. The long-term effects on survival and recurrence are yet to be known, but could be significant. Findings will be updated with 2021 data at the completion of the year. (Figure Presented).

Impact of the COVID-19 Pandemic on Colorectal Cancer Care in the Netherlands: A Population-based Study.

INTRODUCTION: The COVID-19 pandemic disrupted health care services worldwide. In the Netherlands, the first confirmed COVID-19 infection was on February 27, 2020. We aimed to investigate the impact of the pandemic on colorectal cancer care in the Netherlands. METHODS: Colorectal cancer patients who were diagnosed in 25 hospitals in weeks 2 to 26 of the year 2020 were selected from the Netherlands Cancer Registry (NCR) and divided in 4 periods. The average number of patients treated per type of initial treatment was analyzed by the Mantel-Haenszel test adjusted for age. Median time between diagnosis and treatment and between (neo)adjuvant therapy and surgery were analyzed by the Mann Whitney test. Percentages of (acute) resection, stoma and (neo)adjuvant therapy were compared using the Chi-squared test. RESULTS: In total, 1,653 patients were included. The patient population changed during the COVID-19 pandemic regarding higher stage and more clinical presentation with ileus at time of diagnosis. Slight changes were found regarding type of initial treatment. Median time between diagnosis and treatment decreased on average by 4.5 days during the pandemic. The proportion of colon cancer patients receiving a stoma significantly increased with 6.5% during the pandemic. No differences were found in resection rate and treatment with (neo)adjuvant therapy. CONCLUSION: Despite the disruptive impact of the COVID-19 pandemic on global health care, the impact on colorectal cancer care in the Netherlands was limited.

Adaptation of a stoma care pathway and use of telephone clinics during the pandemic: patient experience survey.

With the arrival of the COVID-19 pandemic, outpatient clinics had to adjust and reduce the number of face-to-face appointments. The Cambridge stoma service has a recognised pathway of stoma care but needed to adjust this in line with government guidelines. The team took the opportunity to audit the current pathway and complete a patient experience survey to determine the future of the service and potential adaptations to the pathway in the future. AIM: To determine the need for adaptation and improvement of the standard stoma clinics pathway. METHOD: A survey was conducted using a postal questionnaire to all patients who attended stoma clinics between April and June 2020. FINDINGS: 160 questionnaires were sent and 72 responses returned (45%). All elements of the virtual clinic were rated positive by more than 80% of respondents, with nearly 90% of them feeling that all their stoma care needs were met. When asked to indicate their preferred consultation methods (patients were allowed to choose more than one), face to face received 50 votes, telephone 32 votes and video clinic 5 votes. CONCLUSION: There is a need to adapt the standard clinic pathway to be able to offer standardised care but with flexibility to adjust to circumstances and patients' preferences.

Implementing digital technology during the pandemic: impact on stoma nursing services at a tertiary referral centre.

The COVID-19 pandemic has been one of the greatest challenges to the NHS, creating turmoil in the public health workforce and for all of those who use its services. Its immediate impact was a rapid change in how care in the NHS is planned, delivered and accessed, with no concession for stoma care services. Investment in global resources detailing COVID-19 recovery plans and the steady increase in national data related to the transmission and treatment of the virus has allowed stoma care nurses to better understand the long-term effects of the pandemic and mitigate future risk to specialist nursing services. This article describes how this crisis has provided an opportunity to radically change systems and processes in stoma care through the use of digital technology to continue interaction with patients, communicate with the multidisciplinary team and collaborate with relatives or carers, and as a platform to enhance personal development, training and education.

[Advance of digitalization for specialized care?] / Digitalisierungsvorschub für spezialisierte Pflege?: Arbeitsbedingungen der Pflegeexperten Stoma, Kontinenz und Wunde während der SARS-CoV-2-Pandemie.

For years the influence of progressive digitalization has become noticeable in the work areas of care experts in ostomy, continence and wounds (PSKW). A few years ago the feasibility of tele-healthcare and the resulting quality of care for ostomates in the out of hospital area were also tested in international studies. The driving forces included the insurance companies in the healthcare system who wanted to build a cost-effective supply structure for the insured people using digital aids. Even before the corona crisis a health insurance service contract included the requirement that service providers also offer stoma care for ostomates via online access. For the first time, the option of remote care for people with an ostomy by service providers in the outpatient area was defined as part of the contract. In this article the possibility of telecare stomatherapy as a supplement to face to face care of ostomates by SKW care experts is presented and the situation under the current corona pandemic is considered.

The effect of preoperative stoma site marking on risk of stoma-related complications in patients with intestinal ostomy-protocol of a systematic review and meta-analysis.

BACKGROUND: An intestinal ostomy is an artificial bowel opening created on the skin. Procedure-related mortality is extremely rare. However, the presence of an ostomy may be associated with significant morbidity. Complications negatively affect the quality of life of ostomates. Preoperative stoma site marking can reduce stoma-related complications and is recommended by several guidelines. However, there is no consensus on the procedure and recommendations are based on low-quality evidence. The objective of the systematic review will be to investigate if preoperative stoma site marking compared to no preoperative marking in patients undergoing intestinal stoma surgery reduces or prevents the rate of stoma-related complications. METHODS: We will include (cluster-) randomised controlled trials and cohort studies that involve patients with intestinal ostomies comparing preoperative stoma site marking to no preoperative marking and report at least one patient-relevant outcome. For study identification, we will systematically search MEDLINE/PubMed, EMBASE, CENTRAL and CINHAL as well as Google Scholar, trial registries, conference proceedings and reference lists. Additionally, we will contact experts in the field. Two reviewers will independently perform study selection and data extraction. Outcomes will be prioritised based on findings from telephone interviews with five ostomates and five ostomy and wound nurses prior to conducting the review. Outcomes may include but are not limited to stoma-related complications (infection, parastomal abscess, hernia, mucocutaneous separation, dermatological complications, stoma necrosis, stenosis, retraction and prolapse) or other patient-relevant postoperative endpoints (quality of life, revision rate, dependence on professional care, mortality, length of stay and readmission). We will use the ROBINS-I or the Cochrane risk of bias tool to assess the risk of bias of the included studies. We will perform a meta-analysis and assess the certainty of evidence using the GRADE approach. DISCUSSION: With the results of the systematic review, we aim to provide information for future clinical guidelines and influence clinical routine with regard to preoperative stoma site marking in patients undergoing ostomy surgery. When the evidence of our systematic review is low, it would still be a useful basis for future clinical trials by identifying data gaps. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number: CRD42021226647.

Care of Patients With a Laryngectomy During the COVID-19 Pandemic.

Patients with a laryngectomy are at increased risk for droplet-transmitted diseases and, therefore, COVID-19, which has now caused a worldwide pandemic. Adaptive measures to protect patients with a laryngectomy and their families were designed and implemented in the Hong Kong SAR (HK). Driven by the fear of severe acute respiratory syndrome in 2003, hospitals in HK have since modified infection control routines to prevent a repeat public health nightmare. To face COVID-19, caused by SARS-CoV-2, we have adapted guidelines for our patients with a laryngectomy. Contact precautions, droplet precautions with physical barriers, and hand and equipment hygiene are our mainstays of prevention against COVID-19, and sharing these routines is the aim of this article. The COVID-19 pandemic is still roaring ahead. Awareness and precautions for patients with a laryngectomy who may be at higher risk are outlined here and should be maintained during the current pandemic.