Changes in the Emergency General Surgery Operations in the Setting of COVID-19 and Impact of Strategy of Non-Operative Management on Outcomes in Acute Appendicitis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has posed significant challenges to the provision of elective and emergency general surgical care. Patterns of presentation have changed and management pathways have also been adapted, moving to more non-operative management (NOM) for some conditions. We investigated how COVID-19 changed the volume of emergency general surgery operating in our district general hospital (DGH). We aimed to evaluate the impact of NOM on outcomes in acute appendicitis. METHODS: A retrospective case review of operating lists, patient handover lists, and patient notes was undertaken for patients presented between 1st January 2020 and 3rd June 2020. The study period was divided into two, with the period between 1st January 2020 and 23rd March 2020 representing the pre-COVID cohort. RESULTS: Some 393 emergency general surgery operations were performed in the study period. There was a clear reduction in operating volume after 23rd March 2020. During that same period, 325 patients were assessed with right iliac fossa (RIF) pain. Median age was 21 (range 5-87) and 201 patients were female (61.8%). The rate of NOM for suspected acute appendicitis was 8.8% in the pre-COVID group, which increased to 36.4% in the COVID group. The incidence of normal histology following appendicectomy did not change with this difference in management (16.1% compared to 17.9%, p = 0.78). CONCLUSIONS: This study summarizes the changes brought to the provision of emergency general surgery in the setting of a DGH by the COVID-19 pandemic. In particular, NOM was the preferred option for acute appendicitis but this did not alter the negative appendicectomy rate.

Increased incidence of gallbladder dysplasia and cancer during COVID19 pandemic

Aims Cholecystectomy is one of the most frequently performed operations in the United Kingdom. Following the spread of COVID19 infection, reduced operational capacity has led to lengthen the waiting time for cholecystectomy, which leads to significant readmission rate, growing financial burden and increased complexity of the surgical intervention. Our study aims to identify changes in gallbladder (GB) histopathological findings before and during COVID19 pandemic. Methods Data was collected retrospectively on 337 patients who underwent cholecystectomy between 01/2019–12/2019 (pre-COVID19) and 296 patients between 09/2020–10/2021 (during COVID19) at Princess Alexandra Hospital, including preoperative clinical-radiological, surgery waiting time, operation details, postoperative histology and complications. Statistical analysis performed using chi-square tests (p-value<0.001). Results A total of 2 (0.6%) female cases (average age 75.6) had gallbladder dysplasia (GD) and 1 of them had GB adenocarcinoma found pre-COVID19 versus 8 (2.7%) (7F:1M, average age 46.6) with GD and 5 (1.7%) (3F:2M, average age 72.6) with adenocarcinoma during pandemic. Other histopathological findings were 153 (45.4%) GB with chronic inflammation, 2 (0.5%) with necrosis or perforation pre-COVID19 versus 127 (42.9%) and 6 (2%) respectively during pandemic. The average surgery waiting time for patients with GD or adenocarcinoma was 135 days before COVID19 versus 224.21 (33–676) during pandemic. Conclusions GD is associated with increased cancer risk at GB and other biliary tract sites. Our data demonstrated a statistically significant increase of incidence of GD and adenocarcinoma (p-value<0.00089) in patients who underwent cholecystectomy during pandemic versus pre-COVID19. Further ongoing study is recommended to understand the correlation with prolonged surgery waiting time.

Hybrid Surgical Hot Clinic (HSHC): Evaluation of Surgical Hot Clinic Services during COVID-19 Lockdown.

BACKGROUND: Surgical Hot Clinic (SHC) is an acute, ambulatory service for management provided on an outpatient basis. Following the start of global Novel Coronavirus (COVID-19) pandemic and as per the statement released by the Association of Surgeons of Great Britain and Ireland (ASGBI), we also modified our services to hybrid SHC (HSHC) by mainly providing telephonic follow-up with an occasional face-to-face (F2F) service. We conducted a service evaluation to assess the effectiveness and serviceability of HSHC during a pandemic. METHODS: This service evaluation was conducted from 30th March till 26th May 2020. The pathway was developed to mostly telephonic consultation with selective face-to-face consultation at a designated area in the medical ambulatory unit. The analysis then performed using SPSS version 21. RESULTS: As the overall attendance fell in hospital, 149 patients, including 54(36.2%) male, and 95(63.8%) females, attended SHC during COVID-19 lockdown. Out of these 149, 87(58.3%) were referred from Accident & Emergency (A&E), 2(1.3%) from GP, 9(6.04%) after scan through radiology department, while 51(34.2%) after discharge from hospital. Out of those who have telephonic consultation (n = 98), 12 patients were called in for review with either blood tests or further clinical examination. In total, only 10 out of 149 patients required admission to the hospital, for either intervention or symptomatic treatment. CONCLUSION: Hybrid Surgical Hot Clinic (HSHC) with both telephonic & face-to-face consultation, as per requirement, is flexible, effective and safe patient-focused acute surgical service during COVID-19 like crisis.

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.