Mitigating surgical emergency practice during COVID-19 pandemic?

PURPOSE: To define the change in Emergency Surgical Unit (ESU) workload during the COVID-19 pandemic. METHODS: Patient data for a three-week period was prospectively collected for ESU patients during lockdown period and compared to the ESU workload for the same time period prior to lockdown. RESULTS: Surgical emergencies admissions reduced by 2.5 times during our study period (p value = 0.001). In this changed paradigm, the overall number of surgical emergencies were reduced. A high mortality (n = 4, 5.7%) was noted during lockdown period as compared to pre-lockdown period (n = 1, 0.58%, p value = 0.025). Almost half of surgical admissions were tested for COVID-19 based on their symptoms and more than third (n=14, 38.9%) of them were positive. Gastrointestinal symptoms were common in COVID-19 positive group (85.7%) and only a third (36%) of COVID-19 positive patients needed surgical attention. Chest x-ray findings were comparable to PCR testing in terms of sensitivity and specificity but CT chest was more sensitive. CONCLUSIONS: It remains unclear how COVID-19 reduced surgical emergencies. A significant proportion of COVID-19 presented with gastrointestinal symptoms. In a new outbreak all General Surgical patients should be tested with CRP and WCC used as a triage adjunct. KEY WORDS: Coronavirus, COVID-19, Emergency Surgery Pandemic, General Surgery.

Laparoscopic cholecystectomy for gallstone pancreatitis in a patient with situs inversus totalis.

We present the case of a 53-year-old lady with acute gallstone pancreatitis and situs inversus totalis, who underwent emergency laparoscopic cholecystectomy. We describe our operative approach for this challenging anatomy and discuss the advantages our particular technique confers with reference to the current literature.

Single-stage laparoscopic management of acute gallstone pancreatitis: outcomes at different timings.

BACKGROUND: Definitive therapy for gallstone pancreatitis requires eradication of gallstones with cholecystectomy and common bile duct (CBD) clearance. Current guidelines recommend this be done within the same admission and preferably by laparoscopic cholecystectomy and CBD exploration. We report our experience of laparoscopic single-stage management with cholecystectomy and intraoperative cholangiogram followed by laparoscopic bile duct exploration (LBDE) when necessary performed at three different stages. METHODS: From January 1998 to December 2012, 134 patients (100 females and 34 males) underwent single-stage laparoscopic management of gallstone pancreatitis. Patients were classified according to the timing of surgery: "A", ≤7 days from symptom onset (n=27); "B", 8 to 30 days (n=58) and "C", >30 days (n=49). RESULTS: LBDE was performed in 30 patients with a success rate of 100%. CBD stones were found in 25 patients (A: 22.2%, B: 22.4%, C: 12.2%). CBD stones were more common in patients undergoing surgery within 30 days of presentation than after this time point (P=0.35). Multiple choledocholithiasis was more frequent in patients treated within 7 days (P=0.04). The 30-day mortality after surgery was 0, with no conversion to an open approach. Overall complication rate was 11.9%, which did not differ significantly between patients treated within 7 days or after this time point (P=0.83). CONCLUSIONS: This study demonstrated the feasibility and reproducibility of single-stage laparoscopic management of acute gallstone pancreatitis, which has a low complication rate at any stage. Patients undergoing early treatment have a higher incidence of choledocholithiasis and multiple stones than those treated after 30 days, supporting the passage of stones with time.

Laparoscopic common bile duct exploration. Lessons learned after 200 cases.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is a reliable, reproducible and cost-effective treatment for common bile duct stones. Several techniques have been described for choledochotomy closure. AIMS: To present our experience and the lessons learned in more than 200 cases of LCBDE. PATIENTS AND METHODS: Between January 1999 and July 2012, 206 patients with common bile duct stones underwent LCBDE. At the beginning of the series, we performed the closure of the CBD over a T-tube (36 patients), subsequently we favoured closure over an antegrade stent (133 patients) but due to a high incidence of acute pancreatitis in the last 16 patients we have performed primary closure. RESULTS: The 3 closure groups were matched for age and sex. Jaundice was the most frequent presentation. A total of 185 (88,5%) patients underwent choledochotomy whereas in 17 (8,7%) patients the transcystic route was used. The group that underwent choledochotomy had a larger size of stones compared to the transcystic group (9,7 vs 7,6mm). In the stented group we found an 11,6% incidence of pancreatitis and 26,1% of hyperamylasemia. In the primary closure group we found a clear improvement of complications and hospital stay. The increased experience of the surgeon and age (younger than 75) had a positive impact on mortality and morbidity. CONCLUSIONS: Primary closure of the common bile duct after LCBDE seems to be superior to closure over a T tube and stents. The learning curve seems to have a positive impact on the outcomes making it a safe and reproducible technique especially for patients aged under 75.

A novel laparoscopic approach to lesions related to the posterior aspect of the pancreatic head.

The posterior aspect of the pancreatic head has proven to be a technically demanding region to approach laparoscopically. Previously, this region was approached through the gastrocolic ligament with the patient in a left semilateral position. We believe that this makes the laparoscopic approach to the posterior pancreatic head extremely difficult. In the technique presented here, which has been successfully used in 4 patients, the patient was in full left lateral position, and Nathanson retractors were used to retract the liver and right kidney. This allowed full exposure of the second part of the duodenum before any major dissection. The duodenum was then Kocherized, and the posterior aspect of the pancreatic head, along with the inferior vena cava, left renal vein, and aorta, was exposed. We describe here a safe and feasible laparoscopic method for access to and management of lesions related to the posterior aspect of the pancreatic head.

Emergency laparoscopic repair of an obstructed Bochdalek hernia in an adult.

Bochdalek hernia can occur in adults and is a complex diagnostic problem. This article presents the case of a 27-year-old man who successfully underwent emergency laparoscoptic repair of an obstructed Bochdalek hernia with the involvement of a herniated spleen.

[Advantages of laparoscopic stented choledochorrhaphy. Six years experience]. / Ventajas de la coledocorrafia laparoscópica sobre el stent. Experiencia tras seis años.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is nowadays a valid option in the management of common bile duct stones. T tube and primary closure have been used to close the choledochotomy, but these methods are not free of complications. We present our experience with the stented choledochorrhaphy. MATERIAL AND METHOD: We retrospectively reviewed the data of 104 patients, who underwent LCBDE between January 1999 and February 2007. T tube was used in the first period. From July 2001 the method of choice has been the closure of the CBD over an endoprosthesis placed under direct view and later removed by gastroscopy. RESULTS: The technique was performed on 70 consecutive patients. Median operation time was 90 minutes. There was no conversion to open surgery. Stones could not be retrieved in 4.2% of patients. The median hospital stay was 4 days. Morbidity was 7%, although only 2.8% was related to the stent (acute pancreatitis). Postoperative mortality was 1.4%. CONCLUSIONS: The stented laparoscopic choledochorrhaphy allows an efficient biliary decompression, and seems to avoid the complications of the T tube and primary closure. This method should be considered as a valid option after choledochotomy.

Rejection of goretex mesh used in prosthetic cruroplasty: a case series.

INTRODUCTION: In recent years prosthetic cruroplasty with PTFE has been advocated as the optimal way to reduce hernia recurrence when repairing large hiatal hernia. However, we have found in our series a significant incidence of rejection and mesh erosion. MATERIALS AND METHODS: Standard, tension-free ePTFE hiatal hernia repair was performed in 15 patients with large hiatal hernia. Three of these patients subsequently went on to develop complications with the mesh. Here we present these cases: 2 females and 1 male aged 84, 66 and 69 years, respectively. Each underwent prosthetic hiatal hernia repair using dual goretex mesh. After 7, 12, and 34 months each of the cases presented with dysphagia. RESULTS: In all three of these cases initial endoscopy revealed narrowing at the lower end of the oesophagus, with inflammatory changes and erosion. In two of the cases, the mesh was noted to have eroded into the distal oesophagus, and in the third case relaparoscopy showed a peri-oesophageal collection including the mesh surrounded with fibrosis. Each of the complications was managed using minimally invasive techniques. In one instance the eroded mesh was removed by endoscopy without further complication. While in the second, due to the patient's age and comorbidities the eroded mesh was left in-situ and a covering stent was endoscopically sited. In the case of the peri-oesophageal collection, this was drained laparoscopically and the mesh was removed, with the patient making an excellent recovery. In each instance the patient's dysphagia was corrected and there was no recurrence of the hiatus hernia. CONCLUSIONS: We conclude by acknowledging that in spite of the fact that Gore-Tex (ePTFE) is currently being recommended as one of the choice materials for the prosthetic reconstruction of the hiatus. Our experience suggests that it should be used with great caution in the peri-oesophageal region.

Laparoscopic drainage of bilateral tuberculous psoas abscesses.

Psoas abscess secondary to Mycobacterium tuberculosis infection is rare in industrialized countries. Standard treatment options for psoas abscess of any etiology include percutaneous drainage under radiographic guidance and surgery, which is reserved for failure of conservative therapy. A case of bilateral tuberculous psoas abscesses is reported and a surgical method of drainage utilizing a totally extraperitoneal laparoscopic approach is described.