key: cord-1003015-e2cejj95
authors: Smart, Neil
title: Colorectal Surgery in the time of Covid 19
date: 2020-09-23
journal: Colorectal Dis
DOI: 10.1111/codi.15299
sha: 3a707e7cb6aae12f3889e0b88210620660e98845
doc_id: 1003015
cord_uid: e2cejj95

nan

At the time of writing (early August 2020) the world is still in the middle of the Covid 19 pandemic with over 18 million recorded cases and nearly 700 000 deaths [1] . Those countries (e.g. parts of the UK and Spain) that had seen peaks in March, April & May had started to see the onset of second waves. The Australian State of Victoria had declared a state of disaster with lockdown imposed in Melbourne and the virus was widespread across the USA. Low & Middle Income Countries (LMICs) had seen rising numbers of cases and the head of the World Health Organisation, Tedros Adhanom Ghebreyesus, had declared that there is 'no silver bullet at the momentand there might never be'. Advances in Covid 19 research over the preceding months had focused on various drug combinations [2] and vaccine development [3] with each development hailed as a major victory. Despite the positive news stories with no paucity of hyperbole in the lay press, the reality remains a grossly disrupted health sector that has been crippled by the greatest public health crisis in a generation. The political fallout of the (mis)management of the pandemic continues to ripple across the world and the resultant economic recession in many nations has seen the prospect of rising health expenditure slip away as unemployment levels surge and government borrowing rockets to prop up stuttering economies.

Set against this backdrop, patients with colorectal conditions both benign and malignant continue to have health needs that must be met in a timely fashion or they face becoming collateral damage in health systems that were never designed to function on a crisis setting for longer than a few months. Estimates for NHS England include increased deaths from colorectal cancer of 15-16% due to the Covid 19 pandemic [4] . Investment in underfunded health services and new technologies cannot be assumedgovernments with financial reserves depleted by the pandemic are likely to be parsimonious at best. In this context, colorectal surgeons are faced with three major challenges that have been brought into sharp relief by recent events:

1 Delivering high quality care in a timely fashion with the resources they have 2 Ensuring the resources they have are used wisely and to the greatest effect 3 Ensuring the delivery of such care is safe for their patients, their colleagues and themselves.

Although each point has always been central to the ethical codes of medical practice in westernised societies for decades, they have been debated extensively and with renewed vigour since the onset of the pandemic in Europe in February 2020, often without conclusive resolution and usually without any high quality evidence to inform surgeons as to how to proceed in their own environments. Exactly how such challenges are met will depend upon the vagaries of health services in individual nations and the inevitable complexity of local in-hospital factors that exist purely to spite common sense and frustrate clinicians. No one size solution will ever fit all, but this edition of Colorectal Disease collates some of the pearls of wisdom contributed from around the globe. I hope that each reader finds something that may be of benefit to their quotidian practice.

Covid 19 is here to stay for the foreseeable future. We will have to adapt to its presence within our communities and implement systems and processes within our health services that allow patients with colorectal problems to receive the care and surgery they require. Clinical input from colorectal surgeons in the design of those systems will be of fundamental importance for those services to flourish. As surgeons, there is far more that unites us than divides due to political systems and funding arrangements of our respective health services. As a community we owe it to our patients to embrace collaboration and share best practice, consigning malignant competition to the past. We have seen encouraging signs that such spirit exists within the surgical family during the Covid 19 pandemic. The CovidSurg collaborative has yielded data from over 41 000 patients from 1000 centres in greater than 85 countries and will no doubt continue to deliver meaningful outputs based on real life data that will inform our everyday work for years to come [5, 6] .

The year 2020 will quite simply be the annus horribilis for many but the alternative view is that diamonds are made under pressure. The challenges for colorectal services that are this generation's to solve in the most inclement of circumstances are likely to provide real dividends for our patients in the long-term. To all of you on the frontline, thank you for your efforts and your contribution to your local communities and profession as a whole.

The Association of Coloproctology of Great Britain and Ireland. 22, 983-984 2 RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19 -preliminary report

Oxford COVID Vaccine Trial Group. Safety and immunogenicity of the ChA-dOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial

The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

The Association of Coloproctology of Great Britain and Ireland