Effect of the COVID-19 pandemic on the care for acute cholecystitis: a Swedish multicentre retrospective cohort study.

OBJECTIVES: The present study aimed to investigate if and how the panorama of acute cholecystitis changed in 2020 in Sweden. Seven aspects were identified, the incidence of cholecystitis, the Tokyo grade, the timing of diagnosis and treatment, the proportion treated with early surgery, the proportion of patients treated with delayed surgery, and new complications from gallstones. DESIGN: Retrospective multicentre cohort study. SETTING: 3 hospitals in Sweden, covering 675 000 inhabitants. PARTICIPANTS: 1634 patients with cholecystitis. OUTCOMES: The incidence, treatment choice and diagnostic and treatment delay were investigated by comparing prepandemic and pandemic patients. RESULTS: Patients diagnosed with cholecystitis during the pandemic were more comorbid (American Society of Anesthesiologists 2-5, 86% vs 81%, p=0.01) and more often had a diagnostic CT (67% vs 59%, p=0.01). There were variations in the number of patients corresponding with the pandemic waves, but there was no overall increase in the number of patients with cholecystitis (78 vs 76 cases/100 000 inhabitants, p=0.7) or the proportion of patients treated with surgery during the pandemic (50% vs 50%, p=0.4). There was no increase in time to admission from symptoms (both median 1 day, p=0.7), or surgery from admission (both median 1 day, p=0.9). The proportion of grades 2-3 cholecystitis was not higher during the pandemic (46% vs 44%, p=0.9). The median time to elective surgery increased (184 days vs 130 days, p=0.04), but there was no increase in new gallstone complications (35% vs 39%, p=0.3). CONCLUSION: Emergency surgery for cholecystitis was not impacted by the pandemic in Sweden. Patients were more comorbid but did not have more severe cholecystitis nor was there a delay in seeking care. Fewer patients non-operatively managed had elective surgery within 6 months of their initial diagnosis but there was no corresponding increase in gallstone complications.

Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis.

BACKGROUND: International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis. METHOD: 1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery. RESULTS: 725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months. CONCLUSION: Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery. TRIAL REGISTRATION: Not applicable.

A randomised, double blind trial of N-Acetylcysteine for hearing protection during stapes surgery.

BACKGROUND: Otosclerosis is a disorder that impairs middle ear function, leading to conductive hearing loss. Surgical treatment results in large improvement of hearing at low sound frequencies, but high-frequency hearing often suffers. A likely reason for this is that inner ear sensory cells are damaged by surgical trauma and loud sounds generated during the operation. Animal studies have shown that antioxidants such as N-Acetylcysteine can protect the inner ear from noise, surgical trauma, and some ototoxic substances, but it is not known if this works in humans. This trial was performed to determine whether antioxidants improve surgical results at high frequencies. METHODS: We performed a randomized, double-blind and placebo-controlled parallel group clinical trial at three Swedish university clinics. Using block-stratified randomization, 156 adult patients undergoing stapedotomy were assigned to intravenous N-Acetylcysteine (150 mg/kg body weight) or matching placebo (1:1 ratio), starting one hour before surgery. The primary outcome was the hearing threshold at 6 and 8 kHz; secondary outcomes included the severity of tinnitus and vertigo. FINDINGS: One year after surgery, high-frequency hearing had improved 2.7 ± 3.8 dB in the placebo group (67 patients analysed) and 2.4 ± 3.7 dB in the treated group (72 patients; means ± 95% confidence interval, p = 0.54; linear mixed model). Surgery improved tinnitus, but there was no significant intergroup difference. Post-operative balance disturbance was common but improved during the first year, without significant difference between groups. Four patients receiving N-Acetylcysteine experienced mild side effects such as nausea and vomiting. CONCLUSIONS: N-Acetylcysteine has no effect on hearing thresholds, tinnitus, or balance disturbance after stapedotomy. TRIAL REGISTRATION: ClinicalTrials.gov NCT00525551.

Pars flaccida displacement pattern in otitis media with effusion in the gerbil.

HYPOTHESIS: Our hypothesis is that otitis media with effusion causes stiffness loss in the pars flaccida of the tympanic membrane. This loss of stiffness may be persistent and may trigger the development of retraction pockets and cholesteatoma. BACKGROUND: Otitis media with effusion is a very common disease in childhood. It can cause minor to moderate hearing loss and delayed speech development. Otitis media with effusion is a risk factor for retraction pocket formation. METHODS: Otitis media with effusion was induced unilaterally in 15 gerbils by obstructing the eustachian tube with glue. The contralateral ears served as normal controls. As a measure of mechanical stiffness, pars flaccida peak displacement versus pressure was used. The displacement measurements were made with moire interferometry. This is a noncontacting optical technique with which the displacement of an object can be measured in real time. RESULTS: The mean peak displacement of the pars flaccida in the group with otitis media with effusion was increased threefold as compared with normal controls. This difference was statistically significant. CONCLUSION: There was a loss of mechanical stiffness in the pars flaccida caused by otitis media with effusion. This loss of stiffness may be persistent and may predispose for retraction pocket formation and cholesteatoma development.

Pars flaccida displacement pattern in purulent otitis media in the gerbil.

HYPOTHESIS: Our hypothesis is that purulent otitis media and otitis media with effusion cause stiffness loss of the tympanic membrane. This loss of stiffness may be persistent and precede the development of retraction pockets and cholesteatoma. BACKGROUND: Postinflammatory changes such as retraction pockets and cholesteatoma develop in the pars flaccida and in the pars tensa of the tympanic membrane. In our previous experimental studies, stiffness changes were shown to develop early in the pars tensa in response to purulent otitis media and otitis media with effusion. These changes are suggested to be precursors to a later development of retraction pockets and cholesteatoma. In the clinical situation, retraction pockets are often found in the pars flaccida only. The aim of the current study was thus to investigate whether stiffness changes appear also in the pars flaccida during purulent otitis media. METHODS: Streptococcus pneumoniae type 3 was injected into the middle ear to induce purulent otitis media. As a measure of pars flaccida stiffness, peak displacement versus middle ear pressure was used. The peak displacement measurements were obtained from full-field moiré; interferometry, which is a noncontacting optical technique for deformation measurements. RESULTS: Ears with purulent otitis media showed increased peak displacement of the pars flaccida at a middle ear pressure of 200 daPa, compared with normal controls. CONCLUSION: There was a decreased mechanical stiffness of the pars flaccida in acute purulent otitis media. This decreased stiffness may predispose for future retraction pocket formation and cholesteatoma development.