LAUSR

The COVID19 pandemic continues to cause significant disruption to our everyday lives and the services that we strive to provide for our patients. Since my last editorial (published September 2020) the world has seen second and third waves (often more catastrophic than the first), new variants of the virus and some clarity on what treatments do and do not work. There have been challenging times in Europe over the past 6 months, but also some grounds for guarded optimism. The development of effective vaccinations and the rollout of successful programmes in many highincome countries have enabled the resumption of some surgical services, but equally questions remain as to why this has not been universal and the iniquitous global distribution of vaccines to low and middle income countries has been a source of much disquiet. The Delta (B.1.6.17.2) variant and its increased propensity for transmission may yet snatch defeat from the jaws of victory and delay the easing of social and travel restrictions in many countries. Other variants of concern may yet come to light, but the hive of activity amongst the surgical community has helped pay dividends regarding how colorectal surgeons may organise their services. Lessons learned from the NHS in England & Wales during the first wave of Covid in 2020 are detailed in this issue and have relevance for health systems around the world as we face repeated waves due to variants [1]. The importance of human factors such as clear communication and strong leadership were consistent themes and surgeons have clear roles to play in both of these organisational facets. Globally, the COVIDSurg group have worked hard to deliver a comprehensive suite of papers that deal with questions directly relevant to the quotidian practice of colorectal surgeons internationally in terms of Covid free pathways, timing of surgery after Covid infection, and vaccination for safe surgery [2– 4]. The benefits of collaboration, whether in terms of local resource allocation or in terms of international research, are directly relevant to our patients. The lasting legacy of this pandemic should be how much we have achieved and how quickly as a medical community by working together in teams for a common goal. Despite the achievements of the medical, research and public health communities during this pandemic, we cannot rest upon our laurels. Now is no time for complacency as there is still much that is unknown and not just that which we know we do not know. Donald Rumsfeld's famous 2002 quote during a Pentagon briefing “But there are also unknown unknowns −the ones we don't know we don't know” may have been lampooned in the lay press at the time but the concept has traction in many fields that rely on probability and uncertainty [5]. A related concept is the Black Swan theory as developed by Taleb, namely that an event is an outlier outside the realm of regular expectations that carries an extreme impact and which is rationalized by hindsight, as if it could have been foreseen [5]. Although the Covid pandemic per se is not a Black Swan, colorectal surgeons now face one related to it, namely vaccine induced thrombosis & thrombocytopenia syndrome. Vaccine induced thrombosis & thrombocytopenia has been defined as a thromboembolic event, in combination with thrombocytopenia, occurring between 5 and 28 days following COVID19 vaccination and has been associated with those vaccines that use an adenovirus vector (AstraZeneca and Johnson & Johnson). Although reports in the lay press were initially focused on cerebral venous sinus thrombosis (the most common site), approximately 30% of patients present with splanchnic vein thrombosis. Those colorectal surgeons who have to provide an emergency general surgery/acute care service will undoubtedly see patients with abdominal pain and thrombocytopaenia within 5– 28 days of COVID19 vaccination over the coming months as vaccine programmes disseminate. Intercollegiate Multidisciplinary Guidance has been developed in collaboration with the Association of Coloproctology of Great Britain & Ireland and provides a clear management algorithm [6]. This rare event will be outside of the realms of experience of almost all colorectal surgeons and the recommendations are largely focused on communication and interdisciplinary collaboration for the benefit of the patient.