ABSTRACT
Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention. Methods A 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. Results The management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted. Conclusions COVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.
ABSTRACT
IntroductionThe use of Virtual clinics are novel to the department and were implemented as a consequence of the social distancing measures introduced during the COVID-19 pandemic. We identified the need to seek feedback from the patients attending these clinics.MethodsWe designed a questionnaire for patients who had attended a virtual clinic in General Surgery, using both Qualitative and Quantitative questions. We contacted 100 patients who attended a range of clinics ran by over 10 different General Surgical Consultants between 25th March 2020 and 30th April 2020. A team of junior doctors and clinical assistants were recruited to contact patients. Patients were contacted via telephone to ask if they would be happy to complete the survey which would be emailed to them, if they did not have an email address a shorter survey was completed over the phone.ResultsIn total we had 73 responses to the survey. Data collected suggests that virtual clinics are well received by patients. 48% (n=35) answered that they were overall ‘very satisfied’ with the care received in the virtual clinic, and 79.6% (n=43) felt that their care did not suffer as a result of non-face to face contact. Most patients would recommend a virtual clinic to their friend or family 77% (n=56), however if given the option 60% (n=43) would prefer a face to face clinic appointment.ConclusionsAs the pandemic progresses it is important to identify ways in which good patient care can be delivered whilst not putting patients at risk of contracting the virus. Virtual clinics not only maintain patient safety but also have many other benefits to patients as identified in this study. This study suggests that perhaps the use of virtual clinics should continue and could be utilised by surgical departments to provide efficient patient centred care.
ABSTRACT
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.