The impact of COVID-19 pandemic on access to medical services and its consequences on emergency surgery.

Background: On March 9, 2020, the Italian Prime Minister announced the lockdown, which was officially closed on May 4. This extraordinary measure was necessary to contain the COVID-19 pandemic spread in Italy. During this phase, a significant decrease in patients' access to Emergency Department (ED) was observed. Delayed access to treatment determined a delay in the diagnosis of acute surgical conditions, as already documented in other clinical areas, with consequences on surgical outcome and survival. Aim of this study is to provide a detailed description of abdominal urgent-emergent conditions surgically treated and surgical outcomes during the lockdown in a tertiary referral Italian hospital, compared with historical data. Methods: A retrospective review of urgent-emergent patients surgically treated in our department was conducted in order to compare patients' characteristics and surgical outcomes during the period March 9th-May 4th, 2020 with the same period of the previous year. Results: 152 patients were included in our study, 79 patients in 2020 group and 77 patients in 2019. We found no significant differences between the groups regarding ASA score, age, gender, and disease prevalence. Significant differences were found in symptom duration before ER access and abdominal pain as the main symptom in non-traumatic conditions. We also performed a sub-analysis on peritonitis which showed significant differences in: hospital length of stay, presence of colostomy vs. ileostomy, and fatal events in 2020. No differences were found in the use of laparoscopy. Conclusions: While the overall number of ER accesses has decreased in 2020 group, the number of patients surgically treated in emergency-urgency conditions has not decreased. However, those patients waited significantly more before the hospital access. This diagnostic delay was associated with a more severe clinical condition and a consequent significantly worse prognosis.

Circumferential mucosal dissection and esophageal perforation in a patient with eosinophilic esophagitis.

A young man with a previous history of episodes of mild solid food dysphagia was admitted with a total dysphagia. The esophagogastroduodenoscopy (EGDS) showed an extensive disruption of mucosal layer with a cul-de-sac in the lower part of the esophagus. Soon after the procedure, the patient suffered from an acute chest pain and subsequent CT scan demonstrated an intramural circumferential dissection of thoracic esophagus, and a mediastinal emphysema. An emergency right thoracotomy was performed, followed by a total esophagectomy with esophagogastroplasty and jejunostomy. The histopathology confirmed that mucosal and submucosal layers were circumferentially detached from muscular wall and showed an eosinophilic infiltration of the whole organ with necrosis and erosions of mucosal, submucosal and muscular layers. The diagnosis was esophageal perforation in eosinophilic esophagitis.

Patterns and operative treatment of recurrent Crohn's disease: a prospective longitudinal study.

BACKGROUND: It is believed commonly that Crohn's recurrences always occur at the site of a previous intestinal anastomosis; yet this concept is probably inaccurate and not mindful of the panintestinal nature of the disease. MATERIALS AND METHODS: Between October, 1984 and March, 2003, we carried out 1,132 procedures (464 for primary and 668 for recurrent disease) on 981 consecutive patients. Patients in whom we carried out both the original procedure as well as the procedure for recurrent disease constitute this study population. Operative procedures for perineal complications were excluded from this analysis. Data were accrued prospectively. RESULTS: Seventy-eight patients met the study inclusion criteria. They had a total of 149 sites of disease (duodenum, n = 3; jejunum/ileum, n = 53; terminal ileum/neo terminal ileum, n = 67; colon and rectum, n = 26). One hundred thirty-four sites required operative intervention (85 resections and 49 strictureplasties) and 15 did not. Crohn's disease recurred in 79 sites after a mean of 48.4 months (range, 1-161 months, median, 41 months). Site of operative intervention and operative technique influenced patterns of recurrence: when an anastomosis or strictureplasty was constructed with small bowel, the majority of recurrences were limited to the anastomotic line (17/29, 59%); when it was constructed with small bowel and colon, the majority of recurrences extended to the proximal limb (29/35, 83%). The difference in recurrence pattern is significant (P < .01). In addition, fewer recurrences occurred at strictureplasty than resection sites (22/49, 45%, vs 57/85, 70%, respectively, P < .05). At the time of the second procedure, 40 additional recurrences were identified distant from the original operative site. Four of these represented progression of disease at the 15 sites that did not originally need operative intervention. Of 119 total recurrences, 115 required 73 resections, 40 strictureplasties, and 2 other procedures. CONCLUSIONS: The site of the original operative intervention is the most common site for recurrence, although as many as one-third of recurrences occur separate from it. Pattern of recurrence is influenced by site of the operative intervention (anastomotic for small bowel, proximal limb for ileocolonic) and by operative technique (fewer recurrences occurred at strictureplasty than resection sites). Disease progression occurred in 25% of the sites not addressed operatively at the original procedure. The operative strategy applied to Crohn's complications in different intestinal sites was similar for primary and recurrent disease.