The impact of COVID-19 on emergency cholecystectomy.

BACKGROUNDS: The impact of the SARS-CoV-2 virus (COVID-19) upon the delivery of surgical services in Australia has not been well characterized, other than restrictions to elective surgery due to government directive-related cancellations. Using emergency cholecystectomy as a representative operation, this study aimed to investigate the impact of COVID-19 on emergency general surgery in Australia in relation to in-hours versus after-hours operating. METHODS: A retrospective analysis was conducted of medical records for patients admitted with cholecystitis or biliary colic between 1 March 2019 and 28 February 2021 at Frankston Hospital, Australia. Patient demographics, admission data, imaging findings, operative and post-operative data were compared between pre-COVID-19 and COVID-19 periods. Variables were compared using the Wilcoxon-Mann-Whitney, Chi Squared or Fishers exact test. RESULTS: During the COVID-19 period, emergency cholecystectomy was performed for a greater proportion of patients presenting with cholecystitis or biliary colic (93.5% versus 77.7%, p < 0.01). Despite this, there was concomitant reduction in after-hours cholecystectomy from 14.4% to 7.5% (p = 0.04). Patients requiring after-hours surgery during the COVID-19 period had more features of sepsis (23% more tachypnoeic, 18% more hypotensive), and were more likely to have certain features of cholecystitis on imaging (45% more likely to have pericholecystic fluid). CONCLUSION: Following elective surgery cancellations during the COVID-19 period, an increase was seen in the proportion of patients presenting with gallstone disease who were managed with emergency cholecystectomy due to improved theatre access. Concurrently, there was a decrease in the requirement for surgery to be performed after-hours.

The elusive small bowel adenocarcinoma in the terminal ileum-A case report.

INTRODUCTION: Small bowel malignancies are rare and often present with non-specific symptoms. Because of this, diagnosis of small bowel malignancies is often missed. PRESENTATION OF CASE: 71-year-old male presented with a four-week history of right iliac fossa pain and loss of weight. Laboratory tests showed a raised C-reactive protein, but all other pathology results and tumour-associated antigens were normal. Computed tomography (CT) of the abdomen demonstrated an inflammatory mass extending laterally into the pelvic wall. The patient underwent an elective laparotomy and resection of the small bowel tumour. Intra-operative findings included a small bowel tumour adherent to two loops of small bowel. Histology demonstrated a 50 mm poorly differentiated mucinous adenocarcinoma of the terminal ileum. DISCUSSION: Clinical presentation of small bowel adenocarcinoma is often non-specific, which leads to a delay in diagnosis. As a result, disease is often advanced by the time of diagnosis. Upper and lower endoscopy is useful in detecting tumours in the duodenum and terminal ileum. Video capsule endoscopy allows visualisation of the entire small bowel mucosa. Enteroscopy can also be used to obtain biopsies and perform therapeutic interventions. CT is able to detect abnormalities in 80% of patients, while CT and MR (magnetic resonance) enteroclysis give better visualisation of the mucosa and mural thickness. Surgical exploration may be indicated in patients with a strong clinical suspicion. CONCLUSION: In conclusion, small bowel malignancies are rare and clinicians are reminded to have a high index of suspicion for small bowel malignancies in patients who present with non-specific abdominal symptoms.

Extreme sports: extreme physiology. Exercise-induced pulmonary oedema.

We report five patients who presented to an on-site medical team with concurrent haemoptysis and shortness of breath at a recent triathlon event. After initial management in the field, three of the five patients were transported to hospital via ambulance for further management, resulting in patients with haemoptysis and dyspnoea being 17 times more likely to require hospital transport. It is important to consider the differential diagnoses for this presentation, particularly exercise-induced pulmonary oedema.