BACKGROUND Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.Members of the BJS Commission Team are co-authors of this study and are listed under the heading Collaborators.

There is little information about the effect of an alteration of low-density lipoprotein (LDL) turnover on chylomicron and very–low-density lipoprotein (VLDL) metabolism, yet chylomicron remnant particles are thought to be particularly atherogenic. This study examined the effect of inhibition of cholesterol synthesis on postprandial lipoproteins. Eight type 2 diabetic patients were examined before treatment with the 3-hydroxy-3-methyl glutaryl coenzyme A (HMGCoA) reductase inhibitor cerivastatin, after 4 weeks on active treatment, and 4 weeks after stopping treatment. On each occasion, blood was collected fasting and at 2-hour intervals for up to 8 hours after a high-fat meal. Chylomicrons and VLDLs were isolated by sequential ultracentrifugation. Compositional analysis was performed including the measurement of apolipoprotein B48 (apo B48) and apo B100 using polyacrylamide gradient gel electrophoresis. During statin treatment, there was a significant reduction in the postprandial chylomicron apo B48 area under the curve (AUC) from 23 ± 16 to 17 ± 10 (P < .01) and apo B100 in the chylomicron fraction from 166 ± 148 to 70 ± 70 (P < .05). Postprandial cholesterol (362 ± 193 to 74 ± 39, P < .005), triglyceride (2,222 ± 1,440 to 746 ± 329), and phospholipid (518 ± 267 to 205 ± 94) also decreased (P < .005). In the VLDL fraction, the postprandial cholesterol and triglyceride AUC were significantly reduced by statin (316 ± 228 to 171 ± 78, P < .05, and 1,733 ± 833 to 857 ± 468, P < .02, respectively). Four weeks after cessation of treatment, the chylomicron fraction triglyceride AUC had returned to the pretreatment level, but postprandial chylomicron cholesterol and VLDL cholesterol, triglyceride, and phospholipid were significantly lower than baseline (P < .05). Plasma total cholesterol and LDL cholesterol were significantly reduced with treatment (6.2 ± 0.5 to 4.3 ± 1.0 mmol/L, P < .001, and 4.5 ± 0.4 to 2.8 ± 1.0 mmol/L, P < .01, respectively) and returned to baseline following cessation of treatment. Fasting plasma triglycerides decreased significantly on treatment (2.4 ± 1.0 to 1.7 ± 0.2 mmol/L, P < .05) but remained significantly lower than baseline 4 weeks later (1.8 ± 0.3 mmol/L, P < .05). This study suggests major postprandial lipoprotein changes on statin therapy which may account, in part, for the beneficial effects of statins in the prevention of myocardial infarction.

Aims Low-dose continuous oestrogen/progestogen may increase patient compliance long-term but the cardioprotective effects in diabetes are unknown. The aim of this study was to compare the effect of low-dose oral oestrogen (1 mg, 17-beta-estradiol) treatment with oestrogen (1 mg 17-beta-estradiol) in combination with low-dose (0.5 mg) continuous norethisterone acetate (NETA) on lipoproteins in Type 2 diabetic patients.Methods Thirty-four post-menopausal Type 2 diabetic patients in moderate control (mean haemoglobin A(1c) 7.7%) who had a serum oestradiol level of < 50 pg/ml were examined over a 6-month period. Serum lipids, and lipoprotein composition of very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL) were measured. Serum lipoprotein(a) was determined by an ELISA method, LDL fatty acids by gas-liquid chromatography and LDL oxidizability by thiobarbituric acid reactive substances (TBARS assay). Cholesteryl ester transfer protein (CETP), and cell cholesterol were measured.Results There was a reduction in serum cholesterol on both treatments but no significant difference between treatment groups. LDL cholesterol decreased by 17% in each group. There was a no significant difference between the groups in serum VLDL or HDL cholesterol or serum triglycerides during the study. The change in lipoprotein(a) during the study was not significantly different between the groups. There was no significant difference in 4 h LDL oxidizability between groups. Although CETP increased with time in both groups there was no significant difference in the change between the groups.Conclusion In this small study, the addition of continuous low-dose NETA did not reduce the potentially beneficial effects of low-dose 17-beta-estradiol on the progression of atherosclerosis in diabetes.

Abnormalities in endothelial function may be associated with increased cardiovascular risk in diabetic patients. We examined the effect of an oleic-acid-rich diet on insulin resistance and endothelium-dependent vasoreactivity in type 2 diabetes. Eleven type 2 diabetic patients were changed from their usual linoleic-acid-rich diet and treated for 2 months with an oleic-acid-rich diet. Insulin-mediated glucose transport was measured in isolated adipocytes. Fatty acid composition of the adipocyte membranes was determined by gas-liquid chromatography and flow-mediated endothelium-dependent and -independent vasodilatation were measured in the superficial femoral artery at the end of each dietary period. There was a significant increase in oleic acid and a decrease in linoleic acid on the oleic-acid-rich diet (p<0.0001). Diabetic control was not different between the diets, but there was a small but significant decrease in fasting glucose/insulin on the oleic-acid-rich diet. Insulin-stimulated (1 ng/ml) glucose transport was significantly greater on the oleic- acid-rich diet (0.56+/-0.17 vs. 0.29+/-0.14 nmol/10(5) cells/3 min, p<0.0001). Endothelium-dependent flow-mediated vasodilatation (FMD) was significantly greater on the oleic-acid-rich diet (3.90+/-0.97% vs. 6.12+/-1.36% p<0.0001). There was a significant correlation between adipocyte membrane oleic/linoleic acid and insulin-mediated glucose transport (p<0.001) but no relationship between insulin-stimulated glucose transport and change in endothelium-dependent FMD. There was a significant positive correlation between adipocyte membrane oleic/linoleic acid and endothelium-dependent FMD (r=0.61, p<0.001). Change from polyunsaturated to monounsaturated diet in type 2 diabetes reduced insulin resistance and restored endothelium-dependent vasodilatation, suggesting an explanation for the anti-atherogenic benefits of a Mediterranean-type diet.

Postprandial lipoproteins are raised in diabetes and there is increasing evidence for the atherogenicity of the chylomicron remnant. Increased postprandial cholesteryl ester transfer has also been demonstrated in diabetes and may contribute to the atherogenic lipoprotein profile. The present study examined the effect of improving metabolic control on postprandial lipoproteins in 13 Type 2 diabetic patients. Blood was taken fasting and at 2-h intervals following a high fat, 1100 kcal meal. Patients were brought into good control by intensified dietary advice and oral hyperglycaemic agents or insulin if blood glucose failed to respond. Fasting and postprandial cholesteryl ester transfer protein (CETP) and lecithin:cholesteryl acyltransferase (LCAT) were determined in six patients. Lipoproteins were isolated by sequential ultracentrifugation. Chylomicron and very low density lipoprotein (VLDL) apolipoprotein B-48 and apolipoprotein B-100 were isolated by polyacrylamide gradient gel electrophoresis and quantified by densitometric scanning. CETP and LCAT were determined by an endogenous method which determined cholesterol esterification and transfer between the patients' lipoproteins. There was a significant reduction in postprandial chylomicron apo B-48 (P<0.005), apo B-100 (P<0.0005) and chylomicron cholesterol (P<0.001) following improved diabetic control. The chylomicron lipid/apo B ratio increased with improved control (P<0.01). Postprandial CETP and LCAT were significantly reduced in good control (P<0.01 and P<0.05, respectively) and there were significant changes in HDL composition. The study shows that improvement in metabolic control in Type 2 diabetic patients leads to a reduction in postprandial chylomicron particles and less transfer of cholesterol to apo B-containing lipoproteins.

The chylomicron remnant particle is thought to be particularly atherogenic and we have previously shown alterations in post-prandial lipoproteins which could contribute to their atherogenicity. Cholesterol metabolism is disturbed in diabetes, yet the effect of diabetes on intestinal cholesterol synthesis and absorption has rarely been investigated. The aim of this study was to examine cholesterol absorption and intestinal synthesis of cholesterol in the streptozotocin diabetic rat. Twelve diabetic rats were paired with 12 control rats. [14C]-Cholesterol emulsion was administered and the lymph duct was canulated. Lymph was collected for 4 h. At sacrifice blood was taken for plasma lipoprotein measurements. Chylomicrons were prepared from the lymph by ultracentrifugation and [14C]-cholesterol content was determined by liquid scintillation counting. Lymph apolipoprotein B48 was isolated by gradient gel electrophoresis, and quantified by densitometric scanning. Serum triglyceride and cholesterol were greatly elevated in diabetic compared to control animals (260 ± 90 and 9.8 ± 8.0 mg/ml vs. 1.0 ± 0.4 and 0.6 ± 0.3 mg/ml, p < 0.0001 respectively). Lymph chylomicron apo B48 was similar in the two groups. Cholesterol absorption was not significantly different in diabetic compared to control rats but cholesterol synthesis was significantly, higher in the diabetic animals (550 ± 352 vs. 322 ± 113 μg/h p < 0.03). There was a positive correlation between apo B48 and cholesterol absorption (r = 0.70, p < 0.01) in the diabetic rats and control rats (r = 0.71, p < 0.01) but no correlation between apo B48 and cholesterol synthesis in either group. This study demonstrates that cholesterol synthesis was increased in diabetes whereas cholesterol absorption was unaffected suggesting that intestinal cholesterol synthesis made an important contribution to the hypercholesterolaemia seen in the diabetic animals.

Aims / hypothesis . The aim of this study was to examine factors involved in chylomicron production in the streptozotocin diabetic rat, our hypothesis being that the synthesis of the chylomicron is abnormal in diabetes. Methods . Diabetic rats ( n = 20) were paired with control rats ( n = 20). Cholesterol emulsion was given by gavage and the lymph duct was cannulated. Lymph was collected for 4 h. Chylomicrons were prepared from the lymph by ultracentrifugation. Lymph apolipoprotein B48 was isolated by gradient gel electrophoresis and quantified by densitometric scanning. Intestinal microsomal triglycerol transfer protein mRNA was measured by solution hybridisation nuclease protection, using a rat specific [ 32 P]-labelled cRNA probe. Results . Serum triglyceride and cholesterol were greatly increased in diabetic compared with control animals (258 ± 77 and 8.9 ± 6.4 mg/ml vs 1.04 ± 0.37 and 0.54 ± 0.03 mg/ml, p < 0.0001). Lymph chylomicron triglyceride and cholesterol were also higher in diabetic rats (29.4 ± 27.3 and 0.28 ± 0.3 mg/h vs 16.8 ± 10.6 and 0.18 ± 0.09 mg/h, p < 0.05). Lymph chylomicron apo B48 was similar in the two groups. Intestinal microsomal triglycerol transfer protein mRNA was higher in the diabetic rats (12.6 ± 3.2 vs 3.8 ± 3.0 amol/μg RNA, p < 0.0001) and there was a positive correlation between lymph triglyceride and microsomal triglycerol transfer protein mRNA in the whole group ( r = 0.65, p < 0.01). Conclusion / interpretation . The study shows that microsomal triglycerol transfer protein mRNA is raised in diabetes without an increase in apolipoprotein B48 in the lymph suggesting that microsomal triglycerol transfer protein regulates chylomicron triglyceride content but not particle number. [Diabetologia (1999) 42: 944–948]

Atherosclerosis is commonly found in diabetes. There is an association between small dense low density lipoprotein (LDL) phenotype, which is more prevalent in the diabetic state, and atherosclerosis. Small dense LDL is more easily oxidised and it is possible that fatty acid compositional changes, particularly an increase in polyunsaturated fatty acids, could underlie this association. However, there is little information about fatty acids in the different LDL phenotypes in the literature. This study examined LDL subfraction composition in 18 non-insulin-dependent diabetic (NIDDM) patients and 11 control subjects. LDL was isolated and fractionated into LDL 1, 2 and 3 by density gradient ultracentrifugation. NIDDM patients had significantly more fatty acids in all LDL subfractions than control subjects (P<0.01). Palmitic and linoleic acid were significantly greater in all subfractions in the diabetic patients compared to control subjects (P<0.01) and palmitoleic and oleic acids were also greater in LDL1 and LDL2 in diabetic patients (P<0.01). We conclude that in NIDDM fatty acids are increased in all LDL subfractions and this may be the reason for the increased atherosclerosis in diabetes irrespective of phenotype.

Hyperinsulinaemia is a risk factor for atherosclerosis. We have previously demonstrated a relationship between hyperinsulinaemia and cellular cholesterol synthesis. In this paper we examine the separate relationship of glucose and insulin to cholesterol synthesis in three groups of obese patients. The first group was a group of non-insulin-dependent diabetic patients with a low post-prandial insulin response (n=8). The second group had non-insulin-dependent diabetes and a high insulin response (n=9). The third group were non-diabetic patients with a high post-prandial insulin (n=12). Six diabetic and seven non-diabetic patients who were hyperinsulinaemic on initial analysis, were re-examined following an 8% body weight reduction. Insulin resistance was defined as the ratio of area under curve for insulin/area under curve for glucose. Cellular cholesterol synthesis was measured in freshly isolated mononuclear leucocytes. Fasting cholesterol synthesis was similar in the three groups. In both diabetic and non-diabetic high insulin subjects cholesterol synthesis rose significantly after the meal (p < 0.05). Both hyperinsulinaemic groups showed a significantly greater change from baseline than did the non-hyperinsulinaemic group. There was a positive correlation between post-prandial cellular cholesterol synthesis and insulin resistance (p < 0.05). Following weight reduction patients were divided into two groups, those who did reduce insulin resistance (group 1) and those who did not reduce insulin resistance (group 2). The significant post-prandial increase in cholesterol synthesis was no longer seen in group 1 after weight loss whereas in group 2 after a similar weight loss the post-prandial cholesterol synthesis remained elevated. These results demonstrate that post-prandial hyperinsulinaemia is associated with increased cellular cholesterol synthesis. This increase in cholesterol synthesis is no longer seen in those patients in whom insulin resistance improved with weight reduction. This study suggests a mechanism for the association between insulin resistance and atherosclerosis.