Superior Mesenteric Arterial Occlusion Following Laparoscopic Partial Fundoplication.

A 62-year-old male with history and endoscopic findings consistent with gastroesophageal reflux underwent elective laparoscopic fundoplication. He developed severe abdominal pain four days postoperatively, and computed tomography (CT) angiogram of the abdomen demonstrated occlusion of the superior mesenteric artery due to dissection. The patient was administered intravenous heparin following vascular surgical advice, resulting in resolution of the pain within an hour and no subsequent complications. Laparoscopy-associated mesenteric vascular events are rare but associated with very high morbidity and mortality. Mesenteric arterial occlusion is most frequently reported following laparoscopic cholecystectomy but may occur following many common laparoscopic procedures. Presentation generally occurs hours to days following the procedure, with severe abdominal pain out of proportion with physical signs. If left unrecognized, patients progress to bowel and visceral ischemia, necrosis, and multiorgan failure. Mechanisms postulated to cause these mesenteric vascular events involve changes in splanchnic blood flow, reduced cardiac output and systemic venous return, and hypercapnia related to carbon dioxide insufflation. Diagnosis may be made promptly with CT angiography, and potentially treated with intravenous heparin alone, avoiding a laparotomy or bowel resection. This is the first reported case of successful anticoagulation causing resolution of the occlusion sufficient to avoid reoperation or bowel resection. Once identified, this condition should be treated in liaison with vascular surgery colleagues, which may require anticoagulation, endovascular, or open intervention.

Proposed delay for safe surgery after COVID-19.

BACKGROUND: Long-term effects after COVID-19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence-based guidance regarding the period of delay necessary for adequate recovery of patients following COVID-19 infection before undergoing surgery. METHODS: A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy. RESULTS: A total of 1020 records were identified, from which 20 studies (12 peer-reviewed) were included. None were randomized trials. The studies comprised one case-control study (level III-2 evidence), one prospective cohort study (level III-2) and 18 case-series studies (level IV). Follow-up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS-CoV-2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID-19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab. CONCLUSION: After laboratory confirmation of SARS-CoV-2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8-12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision-making.

Screening and testing for COVID-19 before surgery.

BACKGROUND: Preoperative screening for coronavirus disease 2019 (COVID-19) aims to preserve surgical safety for both patients and surgical teams. This rapid review provides an evaluation of current evidence with input from clinical experts to produce guidance for screening for active COVID-19 in a low prevalence setting. METHODS: An initial search of PubMed (until 6 May 2020) was combined with targeted searches of both PubMed and Google Scholar until 1 July 2020. Findings were streamlined for clinical relevance through the advice of an expert working group that included seven senior surgeons and a senior medical virologist. RESULTS: Patient history should be examined for potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Hyposmia and hypogeusia may present as early symptoms of COVID-19, and can potentially discriminate from other influenza-like illnesses. Reverse transcription-polymerase chain reaction is the gold standard diagnostic test to confirm SARS-CoV-2 infection, and although sensitivity can be improved with repeated testing, the decision to retest should incorporate clinical history and the local supply of diagnostic resources. At present, routine serological testing has little utility for diagnosing acute infection. To appropriately conduct preoperative testing, the temporal dynamics of SARS-CoV-2 must be considered. Relative to other thoracic imaging modalities, computed tomography has the greatest utility for characterizing pulmonary involvement in COVID-19 patients who have been diagnosed by reverse transcription-polymerase chain reaction. CONCLUSION: Through a rapid review of the literature and advice from a clinical expert working group, evidence-based recommendations have been produced for the preoperative screening of surgical patients with suspected COVID-19.

Personal protective equipment and evidence-based advice for surgical departments during COVID-19.

BACKGROUND: Inconsistencies regarding the use of appropriate personal protective equipment (PPE) have raised concerns for the safety of surgical staff during the coronavirus disease 2019 (COVID-19) pandemic. This rapid review synthesizes the literature and includes input from clinical experts to provide evidence-based guidance for surgical services. METHODS: The rapid review comprised of targeted searches in PubMed and grey literature. Pertinent findings were discussed by a working group of clinical experts, and consensus recommendations, consistent with Australian and New Zealand Government guidelines, were formulated. RESULTS: There was a paucity of high-quality primary studies specifically investigating appropriate surgical PPE for healthcare workers treating patients possibly infected with COVID-19. SARS-CoV-2 is capable of aerosol, droplet and fomite transmission, making it essential to augment standard infection control measures with appropriate PPE, especially during surgical emergencies and aerosol-generating procedures. All biological material should be treated a potential source of SARS-COV-2. Staff must have formal training in the use of PPE and should be supervised by a colleague during donning and doffing. Patients with suspected or confirmed COVID-19 should wear a surgical mask during transfer to and from theatre. Potential solutions exist in the literature to extend the use of surgical P2/N95 respirators in situations of limited supply. CONCLUSION: PPE is advised for all high-risk procedures and when a patient's COVID-19 status is unknown. Surgical departments should facilitate staggered rostering, remote meeting attendance, and self-isolation of symptomatic staff. Vulnerable surgical staff should be identified and excluded from operations with a high risk of COVID-19 infection.

Surgery triage during the COVID-19 pandemic.

BACKGROUND: The novel coronavirus, SARS-CoV-2, caused the COVID-19 global pandemic. In response, the Australian and New Zealand governments activated their respective emergency plans and hospital frameworks to deal with the potential increased demand on scarce resources. Surgical triage formed an important part of this response to protect the healthcare system's capacity to respond to COVID-19. METHOD: A rapid review methodology was adapted to search for all levels of evidence on triaging surgery during the current COVID-19 outbreak. Searches were limited to PubMed (inception to 10 April 2020) and supplemented with grey literature searches using the Google search engine. Further, relevant articles were also sourced through the Royal Australasian College of Surgeons COVID-19 Working Group. Recent government advice (May 2020) is also included. RESULTS: This rapid review is a summary of advice from Australian, New Zealand and international speciality groups regarding triaging of surgical cases, as well as the peer-reviewed literature. The key theme across all jurisdictions was to not compromise clinical judgement and to enable individualized, ethical and patient-centred care. The topics reported on include implications of COVID-19 on surgical triage, competing demands on healthcare resources (surgery versus COVID-19 cases), and the low incidence of COVID-19 resulting in a possibility to increase surgical caseloads over time. CONCLUSION: During the COVID-19 pandemic, urgent and emergency surgery must continue. A carefully staged return of elective surgery should align with a decrease in COVID-19 caseload. Combining evidence and expert opinion, schemas and recommendations have been proposed to guide this process in Australia and New Zealand.

Safe surgery during the coronavirus disease 2019 crisis.

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a global pandemic. Surgical care has been impacted, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential aerosol transmission of SARS-CoV-2, precautions during aerosol-generating procedures and production of surgical plume are paramount for the safety of surgical teams. METHODS: A rapid review methodology was used with evidence sourced from PubMed, Departments of Health, surgical colleges and other health authorities. From this, a working group of expert surgeons developed recommendations for surgical safety in the current environment. RESULTS: Pre-operative testing of surgical patients with reverse transcription-polymerase chain reaction does not guarantee lack of infectivity due to a demonstrated false-negative rate of up to 30%. All bodily tissues and fluids should therefore be treated as a potential source of COVID-19 infection during operative management. Caution must be taken, especially when using an energy source that produces surgical plumes, and an appropriate capture device should also be used. Limiting the use of such devices or using lower energy devices is desirable. To reduce perceived risks association with desufflation of pneumoperitoneum during laparoscopic surgery, an appropriate suction irrigator system, attached to a high-efficiency particulate air filter, should be used. Additionally, appropriate use of personal protective equipment by the surgical team is necessary during high-risk aerosol-generating procedures. CONCLUSIONS: As a result of the rapid review, evidence-based guidance has been produced to support safe surgical practice.

Sentinel lymph node biopsy for squamous cell carcinoma of the anal canal.

BACKGROUND: The current Trans-Tasman Radiation Oncology Group (TROG) protocol for T1 and T2 anal cancers is combination chemotherapy and radiotherapy excluding the inguinal region from the field. Several centres worldwide irradiate both inguinal regions as there is a small incidence of involvement with early stage tumours. The presence of inguinal lymph node metastases is not accurately detected using clinical and most radiological assessment modalities. We have developed a method of sampling the sentinel node in the groin using established node mapping techniques. METHODS: A combination of radio-labelled Antimony Sulphide and Patent Blue dye injected around the anal cancer enable identification of the sentinel node in the groin, using a gamma probe and direct visualization of the blue node. RESULTS: This technique has been used in four patients. A groin sentinel node was identified and removed in three of these, with pathological assessment excluding metastatic disease in the inguinal region. The fourth patient had a sentinel node mapped to a meso-rectal node. This was not sampled. CONCLUSIONS: The application of this effective technique will allow accurate staging of anal cancers to better plan future treatment regimes.