SARS-CoV-2 infection in acute pancreatitis increases disease severity and 30-day mortality: COVID PAN collaborative study.

OBJECTIVE: There is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and coexistent SARS-CoV-2 infection. DESIGN: A prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups. RESULTS: 1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection. CONCLUSION: Patients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.

Paraoesophageal herniation: a review.

BACKGROUND: Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available. METHODS: A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies. RESULTS: Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described. CONCLUSION: Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.

Successful management of an aorto-gastric fistula occurring 15 years after oesophagectomy with covered aortic stent graft placement followed by open surgery.

Aorto-gastric fistula (AGF) is an uncommon and life threatening complication of oesophagectomy. Usually occurring in the immediate weeks following the procedure at anastomosis lines, this case describes a rare development of an AGF 15 years after an oesophagectomy due to the presence of a benign ulcer. Initially successful endovascular stenting of the thoracic aorta was followed by re-bleed, further stenting but eventually open surgery was required.

Pelvic Actinomyces israelii abscess: a differential diagnosis of a pelvic mass.

A 52-year-old woman was admitted to our district general hospital, with a rapidly growing, increasingly tender mass in the right iliac fossa, difficulty mobilising with a fixed flexion deformity of the right hip and 15 kg weight loss in 5 months. Her 8-month long surgical history for investigation of a pelvic mass stemmed from the removal of an intrauterine device. It included radiological and surgical investigations. We report the second case in the literature, of a patient presenting with abdominal wall abscess, psoas abscess and hydronephrosis as a long-term complication of Actinomyces israelii infection of the ipsilateral ovary with a favourable outcome having excluded ovarian malignancy.

Systematic reaction to electrolytic treatment of pig livers in vivo.

BACKGROUND: Only a minority of secondary liver tumours are amenable to segmental resection and as a result, considerable research has been focused on developing ablative methods to destroy liver metastases. Many of these methods are limited by the development of a systemic inflammatory response mediated by cytokines such as interleukin-8 (IL-8) and tumour necrosis factor alpha (TNF-alpha). The aim of the present study was to determine if a systemic reaction occurred following electrolytic treatment of pig livers in vivo, by measuring biochemical indices of liver function and cytokines such as IL-8 and TNF-alpha. METHODS: Seventeen white domestic pigs were subjected to varying electrolytic doses ranging from 100 C to 800 C. Blood samples were taken at hourly intervals before, during and after electrolysis. Blood parameters measured included markers of liver enzyme activity; albumin, alkaline phosphatase, gammaglutaryl transferase and aspartate transaminase. Cytokine response to electrolysis was measured using enzyme-linked immunosorbent assays for IL-8 and TNF-alpha. RESULTS: Aspartate transaminase levels showed a clear and progressive rise post-electrolysis peaking at 2 h post-procedure. IL-8 and TNF-alpha levels showed only very mild variation with no significant response to electrolysis. This lack of association was borne out regardless of the electrolytic dose administered. CONCLUSION: Electrolysis is not accompanied by a significant systemic inflammatory response, reducing the risk of systemic inflammatory response, acute respiratory distress syndrome and other immune response mediated end-organ damage. Follow-up studies are needed in human trials.

Spontaneous cholecystocutaneous fistula: a rare presentation of gallstones.

Spontaneous cholecystocutaneous fistula, one of the rarest complications of acute cholecystitis, has been reported in fewer than 25 cases over the past 50 years. Not only is this case rare but interestingly the patient experienced no pain or symptoms consistent with gallbladder pathology leading up to her hospitalisation. Furthermore, laboratory studies, microbiology and computed tomography scanning did not establish a diagnosis until the fistula passed calculi. An 85-year-old lady with multiple co-morbidities presented to the Emergency Department with an erythematous soft and non-tender mass in her right flank. The mass had spontaneously ruptured and was discharging a serous-like material. Prior to further investigation a working diagnosis of an eroding/fungating caecal tumour was made. The lesion continued to discharge over a 3 month period which heralded the passage of 11 small, brown calculi thought to be gallstones. At this point spontaneous cholecystocutaneous fistula was diagnosed and was later confirmed by magnetic resonance imaging cholangiopancreatography.