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Summary Background The coronavirus disease-2019 (COVID-19) pandemic has generated enormous pressure on healthcare establishments, prompting the restructuring of services to rationalise resources. Complex head and neck reconstructive surgery in this setting may carry substantial risk to patients and staff. This paper outlines the management strategy and outcomes of major head and neck oncological cases at a single regional tertiary referral centre. Methods A database review was undertaken of consecutive patients undergoing major head and neck surgery and reconstruction during the COVID-19 pandemic at St Andrew's Centre for Plastic Surgery & Burns, Chelmsford UK. Patient demographics, tumour and reconstruction characteristics as well as peri‑operative information were determined. Patients were prospectively contacted with regard to COVID-related symptoms and investigations. Results Twenty-two patients (15 males and 7 females) with a mean age of 67 years (range: 36–92 years) were included between March 1 and June 13, 2020. Patients underwent pre-operative throat swabs at 72 h and 24 h as well as chest CT scanning as part of a robust protocol. Twelve free flaps, four loco-regional flaps, four parotidectomies and 23 cervical lymphadenectomies were performed. Two patients required a return to theatre. No post-operative deaths occurred and flap survival rate was 100%. A single patient tested positive for COVID-19 pre-operatively and no post-operative COVID-19 infections occurred. Conclusion Although head and neck surgery represents a high-risk procedure to patients and healthcare professionals, our institutional experience suggests that in the presence of a robust peri‑operative protocol and judicious patient selection, major head and neck surgery, including free tissue transfer reconstruction, may be performed safely.

Summary Introduction This study evaluates COVID-19 related patient risk, when undergoing management within one of the largest specialist centres in Europe, which rapidly implemented national COVID-19 safety guidelines. Method A prospective cohort study was undertaken in all patients who underwent surgical (n = 1429) or non-operative (n = 191) management during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. A representative sample of elective/trauma/burns patients (surgery group, n = 729) were selected and also sub-analysed within a controlled cohort study design. Comparison was made to a random selection of non-operatively managed (non-operative group, n = 100) or waiting list (control group, n = 250) patients. These groups were prospectively followed-up and telephoned from the end of June (control group) or at 30 days post-first assessment (non-operative group)/post-operatively (surgery group). Results Complex general (9.2%, 136/1483) or regional (5.0%, 74/1483) anaesthesia cases represented 14.2% (210/1483) of operations undertaken. There were no 30-day post-operative (0/1429)/first assessment (0/191) COVID-19 related deaths. Neither the three sub-speciality plastic surgery, or non-operative groups, displayed increases in post-operative/first assessment symptoms in comparison to each other, or to control. The proportion of COVID-19 positive tests were: 7.1% (1/14) (non-operative), 5.9% (2/34) (burns) and 3.0% (3/99) (trauma); there were however no significant differences between these groups, the elective (0%, 0/54) and control (0%, 0/24) groups (p = 0.236). Conclusion We demonstrate that even heterogeneous sub-speciality patient groups, who required operative/non-operative management, did not incur an increased COVID-19 risk compared to each other or to control. These highly encouraging results were achieved with described, rapidly implemented service changes that were tailored to protect each patient group and staff.

The ileal conduit for urinary diversion after radical cystectomy is a well-described procedure. Furthermore, parastomal hernias, prolapse, stenosis, and retraction of the stoma have been reported as some of the more common complications of this procedure. The subsequent repair of parastomal hernias with a biological mesh and the potential of the conduit to “tunnel” through it has also been described. In this case report, we present a combined repair of a large incisional hernia with a cystectomy and a pelvic lymphadenectomy for invasive bladder cancer, with the use of a biological mesh for posterior component abdominal wall primary repair as well as for support to the ileal conduit used for urinary diversion.

We report the diagnosis and surgical management of the interesting case of a patient with a gastrointestinal stromal tumour (GIST).

We would like to comment on the case report by Kim and colleagues concerning the surgical treatment of a gastrointestinal stromal tumour in the posterior mediastinum [1]. Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract (5000 new cases per year in the United States) [2]. They can be found in patients with a median age of 60 y, with frequent occurrence (70%) in the muscular wall of the stomach, followed by small bowel (10-20%), oesophagus, omentum, mesentery and retroperitoneum [2,3]. GISTs can range from small benign tumours to sarcomas at all sites of occurrence. Tumours that have metastasized at presentation have a very poor prognosis. The 5-year survival in patients with malignant GISTs is less than 40% [2]. There are three key prognostic factors: mitotic rate, tumour size, and site. Tumours that are small (=2 cm) and show mitotic activity not exceeding 5 mitoses per 50 high-power fields, have an excellent prognosis. This prognosis probably is independent of site, although this has not been shown specifically for all sites. In the stomach, most epithelioid GISTs are benign. However, we have to bear in mind that a small proportion of tumours apparently lacking mitotic activity do metastasize [2,3]. GISTs in association with paragangliomas and pulmonary chondromas constitute the Carney triad. In fact, the ‘Carney triad’ is a multiple neoplasia syndrome affecting mostly females. This syndrome - or Carney complex - predisposes to a variety of tumours including adrenocortical adenomas (unilateral or bilateral) that are usually non-functioning [2,4]. Carney and Stratakis, in 2002, distinguished the inherited GISTs with paraganglioma syndrome from the Carney triad as an autosomal dominant condition in adult patients. This condition has been called Carney-Stratakis syndrome [5]. These two syndromes, even though quite rare, have entered the realm of multiple endocrine neoplasias in the last years. Carney-Stratakis syndrome is probably more frequent and may be prevalent amongst patients with GISTs that are negative for KIT/PDGFRA mutations [2]. A high index of suspicion is required by surgeons who are dealing with patients with isolated or sporadic GISTs or paragangliomas. They have to be aware of the Carney and Carney-Stratakis syndromes. A multidisciplinary diagnostic approach regarding the medical and family history of the patients is of paramount importance (especially in the younger patient with KIT or PDFGRA mutation-negative GISTs) [2]. Conflict of Interest: None declared