925 Maintenance of Elective Surgical Care During Covid-19 Pandemic

Introduction

Recent publications demonstrate significant morbidity in surgical patients with concurrent COVID-19 infection. This, combined with the redistribution of resources to support the pandemic, led to abrupt cessation in planned operating. COVID-19-free ‘cold’ sites were established to enable elective surgery to resume with reduced risk. We evaluate the outcomes and limitations of a newly established cold site.

Method

Data were collected retrospectively for all patients operated between June and September 2020 by either General Surgery or Urology. Primary outcomes were 30-day COVID-19 infection and 30-day mortality. Secondary outcomes included length of stay, 30-day complications, and need for transfer to ‘hot’ hospital sites.

Results

881 patients were included. No patients had a positive COVID-19 test within 30 days of their operation. 30-day mortality was 0.01% (n = 1). The mean (+/-SD) length of stay was 1.69+/-3.42 days. 12.15% (n = 107) of patients experienced a complication within 30 days and 11.7% (n = 103) were readmitted within 30 day of discharge. 3.3% (n = 29) of patients required transfer to a ‘hot’ hospital site. 44.8% of these were admitted to level 2 or level 3 care, 17.2% required total parenteral nutrition, and 20.7% returned to theatre.

Conclusions

‘Cold’ surgical sites are effective in preventing peri-operative COVID-19 infection. Elective surgery can therefore continue safely through the pandemic with such precautions. Further development of on-site resources, including provision for total parenteral nutrition and access to higher level care, will help to minimise the need for patient transfers to COVID-19 exposed sites.

Development and early outcomes of the national training initiative for transanal total mesorectal excision in the UK

AIM

Transanal total mesorectal excision (TaTME) has attracted substantial interest amongst colorectal surgeons but its technical challenges may underlie the early reports of visceral injuries and oncological concerns. The aim of this study was to report on the feasibility, development and the outcome of the national pilot training initiative for TaTME-UK.

METHODS

TaTME-UK was successfully launched in September 2017 in partnership with the healthcare industry and endorsed by the Association of Coloproctology of Great Britain and Ireland. This multi-modal training curriculum consisted of three phases: (i) set-up; (ii) selection of pilot sites; and (iii) formal proctorship programme. Bespoke Global Assessment Scoring (GAS) forms were designed and completed by both trainees and mentors. Data were collected on patient demographics, tumour characteristics and perioperative clinical and histological outcomes.

RESULTS

Twenty-four proctored cases were performed by 10 colorectal surgeons from five selected pilot sites. Median operative time was 331 ± 90 (195-610) min which was reduced to 283 ± 62 (195-340) min in the final case. Independent performance (GAS score of 5) was achieved for most operative steps by case 5. There was one conversion (4.2%), but no visceral injuries. Pathological data confirmed no bowel perforation and intact quality of the mesorectal TME specimens with clear distal margin in all cases and circumferential margins in 23/24 cases (96%).

CONCLUSION

This exploratory study demonstrates acceptable early outcomes in a small cohort suggesting that a competency-based multi-modal training programme for TaTME can be feasible and safe to implement at a national level.

Engaging with Faith Councils to Develop Stoma-specific Fatawās: A Novel Approach to the Healthcare Needs of Muslim Colorectal Patients

Intestinal stomas are common. Muslims report significantly lower quality of life following stoma surgery compared to non-Muslims. A fatwā is a ruling on a point of Islamic law according to a recognised religious authority. The use of fatawās to guide health-related decision-making has becoming an increasingly popular practice amongst Muslims, regardless of geographic location. This project aimed to improve the quality of life of Muslim ostomates by addressing faith-specific stoma concerns. Through close collaboration with Muslim ostomates, a series of 10 faith-related questions were generated, which were posed to invited local faith leaders during a stoma educational event. Faith leaders received education concerning the realities of stoma care before generating their fatawās. The event lead to the formulation of a series of stoma-specific fatawās representing Hanafi and Salafi scholarship, providing faith-based guidance for Muslim ostomates and their carers. Enhanced communication between healthcare providers and Islamic faith leaders allows for the delivery of informed fatawās that directly benefit Muslim patients and may represent an efficient method of improving health outcomes in this faith group.

Tongue-tie assessment and division: a time-critical intervention to optimise breastfeeding

OBJECTIVES

Recent reports have highlighted the benefits of surgical division of tongue-tie (frenulotomy) in infants with breastfeeding difficulties. There is no clear consensus defining the appropriate age for this procedure to be undertaken in selected infants. We aimed to evaluate the impact of delays in time between referral and frenulotomy in relation to maternal abandonment of breastfeeding.

MATERIALS AND METHODS

This was a prospective cohort study done in out-patient Neonatal Surgery Department, Birmingham Heartlands Hospital, Birmingham, UK, between April 2013 and July 2013. All infants, referred to our tongue-tie clinic between April and July 2013, were studied prospectively. Referral time lags were calculated using computer records; details regarding breastfeeding were collected by an independent interviewer completing a questionnaire.

RESULTS

Seventy patients were included. The median infant age at clinic was 28.5 days [range 1-126]. Fifty eight [82%] of mothers had breastfeeding difficulty and their infants were confirmed to have a prominent tongue-tie. By the time of their clinic attendance, breastfeeding had either not been established or abandoned in 21%. Despite difficulty, 61% of mothers persisted breastfeeding and all these mothers consented for frenulotomy. At time of clinic, median age of infants whose mothers had abandoned breastfeeding was 37 days [range 1-80] compared to 27 days [range 1-126] in infants whose mothers had persisted.

CONCLUSIONS

We demonstrated a time-critical dimension for frenulotomy: delay beyond 4-weeks from referral to assessment of neonatal tongue-tie is more likely to be associated with abandonment of breastfeeding. Timely assessment and division of tongue-tie in selected infants can therefore play an important role in a birthing unit's breastfeeding strategy.

Tongue-Tie Assessment and Division: A Time-Critical Intervention to Optimise Breastfeeding

Objectives: Recent reports have highlighted the benefits of surgical division of tongue-tie (frenulotomy) in infants with breastfeeding difficulties. There is no clear consensus defining the appropriate age for this procedure to be undertaken in selected infants. We aimed to evaluate the impact of delays in time between referral and frenulotomy in relation to maternal abandonment of breastfeeding.Materials and Methods: This was a prospective cohort study done in out-patient Neonatal Surgery Department, Birmingham Heartlands Hospital, Birmingham, UK, between April 2013 and July 2013. All infants, referred to our tongue-tie clinic between April and July 2013, were studied prospectively. Referral time lags were calculated using computer records; details regarding breastfeeding were collected by an independent interviewer completing a questionnaire.Results: Seventy patients were included. The median infant age at clinic was 28.5 days [range 1-126]. Fifty eight [82%] of mothers had breastfeeding difficulty and their infants were confirmed to have a prominent tongue-tie. By the time of their clinic attendance, breastfeeding had either not been established or abandoned in 21%. Despite difficulty, 61% of mothers persisted breastfeeding and all these mothers consented for frenulotomy. At time of clinic, median age of infants whose mothers had abandoned breastfeeding was 37 days [range 1-80] compared to 27 days [range 1-126] in infants whose mothers had persisted.Conclusions: We demonstrated a time-critical dimension for frenulotomy: delay beyond 4-weeks from referral to assessment of neonatal tongue-tie is more likely to be associated with abandonment of breastfeeding. Timely assessment and division of tongue-tie in selected infants can therefore play an important role in a birthing unit’s breastfeeding strategy.

Cloacogenic polyps in an adolescent: a rare cause of rectal bleeding

Cloacogenic polyps are rare inflammatory lesions occurring around the anal transitional zone and in the lower rectum which can mimic neoplasia. They should be given diagnostic consideration in patients presenting with symptoms of rectal bleeding, tenesmus, and altered bowel habits.

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE

The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH).

METHODS

This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007.

RESULTS

Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001).

CONCLUSION

Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

Necrotizing fasciitis of chest wall complicating empyema thoracis

Necrotizing fasciitis affecting the chest wall is a rare condition and carries high mortality. It spreads rapidly, requiring early diagnosis and immediate extensive surgical debridement. The case of a 32 year old man afflicted with this uncommon condition following tube thoracostomy for empyema thoracis is described and literature reviewed.

Glutathione S-transferase GSTT1 genotypes and susceptibility to cancer: studies of interactions with GSTM1 in lung, oral, gastric and colorectal cancers

Allelism in glutathione S-transferase GSTM1 and GSTT1 has been suggested as a risk factor in various cancers. Accordingly, we describe a group of case-control studies carried out to identify associations between GSTT1 genotypes and susceptibility to lung, oral, gastric and colorectal cancers. The frequencies of the putatively high risk GSTT1 null genotype were not increased in the lung, oral or gastric cancer cases compared with controls but the frequency of this genotype was significantly increased (P = 0.0011, odds ratio = 1.88) in the colorectal cancer cases. No significant interactions between the GSTT1 and GSTM1 null genotypes types were identified in the cancer groups studied. Indeed, no significant associations between GSTM1 genotypes and susceptibility were identified though further evidence was obtained that the protective effect of GSTM1*A and GSTM1*B is not equal. The data complement studies showing that GSTT1 null is associated with an increased susceptibility to total ulcerative colitis and suggests that this enzyme is important in the detoxification of unidentified xenobiotics in the large intestine.

Polyadenylation polymorphism in the acetyltransferase 1 gene (NAT1) increases risk of colorectal cancer

Exposure to carcinogens present in the diet, cigarette smoke, or the environment may be associated with increased risk of colorectal cancer. Aromatic amines (aryl- and heterocyclic) are a class of carcinogens that are important in these exposures. These compounds can be N- or O-acetylated by the NAT1 or NAT2 enzymes, resulting in activation or in some cases detoxification. Recent studies have shown that both NAT2 and NAT1 genes exhibit variation in human populations and that rapid acetylation by the NAT2 enzyme may be a risk factor for colorectal cancer. In this study we have analyzed for genetic polymorphism in both NAT1 and NAT2 in a group of 202 colorectal cancer patients and 112 control subjects from Staffordshire, England. We find significantly increased risk (odds ratio, 1.9; 95% confidence interval, 1.2-3.2; P = 0.009) associated with the NAT1*10 allele of NAT1, an allele that contains a variant polyadenylation signal. Individuals with higher stage tumors (Duke's C) were more likely to inherit this variant allele (odds ratio, 2.5; 95% confidence interval, 1.3-4.7; P = 0.005). In contrast, rapid acetylation genotypes of NAT2 were not a significant risk factor in this English population. However, we found that the risk associated with the NAT1 variant allele (NAT1*10) was most apparent among NAT2 rapid acetylators (odds ratio, 2.8; 95% confidence interval, 1.4-5.7; P = 0.003), suggesting a possible gene-gene interaction between NAT1 and NAT2 (test for interaction; P = 0.12). This is the first study to test for cancer risk associated with the NAT1 gene, and these positive findings suggest that NAT1 alleles may be important genetic determinents of colorectal cancer risk.

Enteric alpha-1-antitrypsin loss and comparison with Okokit II and Haemoccult for the detection of colorectal cancer

Faecal samples from patients with symptomatic colorectal cancer (n = 19) and from control subjects (n = 54) were analysed for alpha-1-antitrypsin (A1AT) and compared with Haemoccult and Okokit II. A1AT was also measured in paired samples of normal colonic mucosa and cancer tissue (n = 16) and in media from four human colorectal cell lines (COLO 320 DM, SW620, HT29, LS 174T). Faecal A1AT concentrations were greater than controls (P < 0.0001) and detected 12 (63%) patients with cancer compared to 10 (53%) by Okokit II and 7 (37%) by Haemoccult (P > 0.05). A1AT concentrations from colonic mucosa (median, range: 0.46, 0.17-0.79 mg/g wet wt) were greater (P = 0.01) than cancer tissue (0.29, 0.13-0.74 mg/g wt wt). Adjusting for albumin, A1AT concentrations from mucosa (12.0, 3.8-32.2 mg/g albumin) remained greater (P = 0.003) than for cancer tissue (5.9, 2.4-21.4 mg/g albumin). A1AT was not detected in any of the cell-line media. The most likely mechanisms for increased faecal A1AT concentrations, apart from increased blood loss, are increased cell turnover or leakage from epithelial tight junctions. The use of faecal A1AT measurement for the detection of colorectal cancer deserves further assessment.

Reduction of mucosal crypt cell proliferation in patients with colorectal adenomatous polyps by dietary calcium supplementation

The crypt cell production rate was measured in 14 patients with adenomatous colorectal polyps, 17 patients with colorectal cancer and 12 control subjects. The median (interquartile range) rate (cells per crypt per hour) was found to be significantly higher (P less than 0.001) in the polyp (2.45 (1.94-3.20)) and cancer (3.01 (2.35-3.68)) groups compared with controls (1.25 (0.70-1.85)). A double-blind cross-over study was performed in patients with adenomatous polyps consisting of 2 months' treatment, 2 weeks' washout, followed by 2 months' treatment with dietary calcium supplementation (1.25 g day-1) versus placebo. A significant reduction in the crypt cell production rate occurred with calcium treatment compared with the placebo (1.25 (0.6-2.25) versus 2.15 (1.58-3.08) cells per crypt per hour, P = 0.035). This study demonstrates a significant reduction in mucosal cell proliferation by dietary calcium supplementation in patients with adenomatous polyps. Such treatment may be worthy of further investigation in patients at high risk of developing colorectal polyps.