Outcomes of symptomatic gallstone disease in pregnant women: A retrospective study

Gallstone disease with advanced symptoms is one of the common abdominal emergencies during pregnancy and it is considered to be one of the most frequently reported non-obstetric surgical conditions in pregnant women. This study aimed to evaluate the outcomes of surgical cholecystectomy in pregnant women with symptoms of advanced gallstones. This is a retrospective analysis of 2814 pregnant women who attended various wards in government and private hospitals in the governorates of Diyala and Kirkuk in Iraq for more than 2 years, between February 2020 and June 2022. The hospital database was used to confirm the diagnosis of advanced gallstone symptoms in these pregnant women. The incidence of symptomatic gallstones in pregnant women, diagnosis and method of therapeutic management, cholecystectomy according to the pregnancy periods, and perinatal complications of patients according to therapeutic methods were determined. The results confirmed that out of 2814 pregnancies, only 126 (4%) had symptoms of gallstones. It was found that the majority of cases 67 (53%) were within the first trimester of pregnancy and the least 29 (23%) was observed in the second trimester. Acute cholecystitis was the generality 84 (67%) diagnosed in pregnant women with symptomatic gallbladder disease and only 9 (7%) of the patients had undergone prenatal cholecystectomy versus 117 (93%) who were managed conservatively. A total of 20 (16%) cases with undesirable complications were recorded, where 12 cases with low birth weight were noted, where 4 of them underwent surgery and 8 were treated conservatively. It was concluded that a large proportion of women suffer from symptoms of gallstones during pregnancy. Most cases can be managed conservatively, and intervention should be performed as often as needed.Copyright © 2023, Codon Publications. All rights reserved.

A Rare Case of Congenital Choledochal Cyst (CCC) Resulting in Recurrent Acute Pancreatitis in an Otherwise Healthy Young Woman

Introduction: Congenital choledochal cyst (CCC) is a rare cystic dilatation of intrahepatic or extrahepatic biliary ducts. We present a case of a type IVb choledochal cyst presenting as recurrent acute pancreatitis in a young healthy female with initial negative screenings. Case Description/Methods: An 18-year-old-female with a history of COVID-19 presented to the emergency department with one month of persistent abdominal pain, nausea, and vomiting. She was hospitalized once prior for similar symptoms and was diagnosed with acute pancreatitis. This admission, blood work showed elevated lipase, elevated liver enzymes, mild bilirubinemia with a normal lipid panel and urine was significant for infection. She received fluids, antiemetics and was started on prophylactic antibiotics for ascending cholangitis. A right upper quadrant ultrasound ruled out cholelithiasis or acute cholecystitis, but showed dilation of the common bile duct. MRCP confirmed dilation with bulbous termination in the periampullary region diagnosed as type IVb choledochal cyst. Discussion(s): CCCs are rare in Western countries with an incidence between 1 in 100,000 to 150,000. 80% of these cysts are diagnosed in patients under the age of 10. They are difficult to diagnose due to variable clinical presentations. A study of 214 CCC patients demonstrated the most common symptom was abdominal pain, followed by jaundice and fever. When cysts are found in adults, symptoms resemble atypical acute biliary tract disease. Surgical cyst removal may be needed for patients with significant risk factors such as older age and age of symptom onset, due to increased risk of malignant transformation. Longer periods of observation have been documented to be associated with an increased chance of developing late complications, such as anastomotic stricture, biliary calculi and recurrent cholangitis. Type IVb CCCs, as seen in this case, consist of multiple extrahepatic cysts and hepaticojejunostomy is the treatment. This patient's young age and recurrent acute pancreatitis combined with her lab and imaging findings strongly suggest the diagnosis of CCC. The anatomical location of the CCC impeded flow of pancreatic enzymes through the ampulla of vater, leading to recurrent pancreatitis in an otherwise healthy young female. CCC, although very rare, should be considered in the differential of acute pancreatitis when other causes such as gallstones and heavy alcohol consumption cannot be identified, as prompt diagnosis and surgical removal is imperative.

Comparison of severity and complication rates of acute cholecystitis during pandemic and pre-pandemic periods?

BACKGROUND: Cancellations of surgeries for elective cases and late admissions of symptomatic cases during the pandemic period might have increased the number of cases of acute cholecystitis and its complications. PURPOSE: To compare the severity of acute cholecystitis and complication rates during the pandemic and pre-pandemic periods. MATERIAL AND METHODS: We evaluated the computed tomography (CT) findings observed for the diagnosis of complications for both acute simple and acute complicated cholecystitis during both the pandemic and pre-pandemic periods. Patients admitted to the hospital between March 2020 and December 2020 made up the study group and the corresponding appropriate patients from one year earlier were studied as the control group. In addition to the CT findings, clinical and laboratory findings, co-morbidities such as diabetes, as well as the admission time to hospital from the onset of the initial symptoms to hospital admission were also evaluated. RESULTS: A total of 88 patients were evaluated (54 in the study group, 34 in the control group; mean age = 64.3 ± 16.3 years). The male-to-female ratio was 51/37. The number of patients diagnosed with complicated cholecystitis were significantly higher in the study group (P = 0.03). Murphy finding and diabetes status were similar between the two groups (P = 0.086 and P = 0.308, respectively). Admission time to the hospital was significantly different for study and control groups in simple cholecystitis patients (P = 0.045); with no significant difference in cases of complicated cholecystitis (P = 0.499). CONCLUSION: Our study reveals the course of acute cholecystitis during the pandemic period was much more serious with higher complications.

Impact of COVID-19 outbreak on acute gallbladder disease in the emergency department.

OBJECTIVE: Acute gallbladder disease (AGD) is frequent in the emergency department (ED) and usually requires emergency surgery. However, only a few studies have reported the impact of COVID-19 on AGD. The goal of this study was to evaluate the time between symptom onset and surgery and the perioperative severity of AGD during the COVID-19 pandemic compared to before the era of COVID-19. METHODS: This retrospective, single-center cohort study included patients who presented to the ED with suspected AGD and who underwent emergency cholecystectomy. We designed a before-after comparative study, and the intervention was the COVID-19 outbreak. The 6-month period after the COVID-19 outbreak was defined as the post-COVID group, whereas the pre-COVID group consisted of the same period in the previous year. The primary outcome was the time from symptoms to surgery. We evaluated the time intervals between symptom onset and ED arrival and between ED arrival and surgery. The secondary outcomes were preoperative and postoperative severity indexes. RESULTS: A total of 316 patients was analyzed. The post-COVID group showed longer duration from symptom onset to ED arrival (34.0 hours vs. 15.0 hours, P<0.001) and longer time interval from ED arrival to surgery (16.2 hours vs. 10.2 hours, P<0.001) than the pre-COVID group. The overall time interval between symptom onset to surgery was longer in the post-COVID group than the pre-COVID group (71.5 hours vs. 33.5 hours, P<0.001). The post-COVID group showed higher preoperative Simplified Acute Physiology Score II scores than the pre-COVID group (20.1 vs. 18.2, P=0.045). The proportion of moderate or severe disease increased in the post-COVID group (78% vs. 65%, P=0.017). The durations of hospital stay (7.0 days vs. 5.0 days, P<0.001) and intensive care unit stay (27.1 hours vs. 10.8 hours, P=0.008) were longer in the post-COVID group than in the pre-COVID group. CONCLUSION: During the pandemic, the time interval between symptom onset to surgery was significantly increased among patients with AGD. Concomitantly, higher preoperative severity indexes and longer hospital stay were reported with a delay in emergency surgery.

COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Acalculous Cholecystitis: A Novel and Lethal Unrecognized Complication in Severe CoVID 19

Background. SARS-COV-2 infection is known to cause tissue damage in several organs outside of the respiratory tract. The pathogenesis of tissue damage is hypothesized to be caused by direct viral damage, endothelial injury, and ischemic or thrombotic events. Gastrointestinal symptoms were first characterized mainly as diarrhea and diffuse abdominal pain and discomfort, which can be hard to interpret in the setting of a generalized inflammatory response;gallbladder injury and inflammation causing acute acalculous cholecystitis has been scarcely reported Methods. Here we discuss five cases of patients presenting with symptoms of cholecystitis. All five patients underwent multiple imaging studies, and all of them were compatible with acute cholecystitis;some of them had an imaging report of lithiasic cholecystitis, while the rest were reported with microlithiasis or biliary sludge. Four out of the five patients underwent laparoscopic cholecystectomy;biopsies were taken, consistently those reported with acalculous cholecystitis. The remaining patient died of CoVID 19 complications prior to surgery, but after a percutaneous cholecystostomy tube was placed. Results. All these patients have in common the prolonged fasting, because they all required invasive mechanical ventilation, consequently, they all developed multiple focal pneumonia and respiratory distress syndrome. This fast is related to the development of gangrenous ischemia in the gallbladder, which manifests as a late complication due to SARS-CoV-2 infection, in addition to being related to angiotensin-2 converting receptors and virus replication proteins, as well as the pro-inflammatory and hypoxia state that in itself causes the infection (9). All showed a cholestatic pattern, highlighting that this complication developed in an average time of 3 weeks after the onset of SARS-CoV2 symptoms, in addition to the fact that in most cases a negative test was already shown at the time of the complication. Conclusion. Acalculous cholecystitis is one of the extrapulmonary complications that has been seen in patients with this infection, not being the most common, but one of those that has generated a higher mortality rate in patients due to its late diagnosis and non-specific clinical picture in certain occasions (9).

Management of Obstructive Jaundice in Patients with Periampullary Tumors in a Covid-19 Pandemic Situation

Introduction: The redistribution of hospital resources secondary to SARS-CoV-2(COVID19) produced a reduction and delay in surgical activity. Analysis of the management of obstructive jaundice (OI) in a reference centre during COVID19 in patients with potentially resectable periampullary tumours. Method(s): Observational study, limited to the year 2021, on the management of OI in periampullary pathology. Analysis of the different biliary drainage (BD) techniques (endoscopic/transhepatic) and the associated complications. The indication criteria for BD were: bilirubin levels >10 mg/dl, cholangitis or expectation of surgery >2 weeks from inclusion on the waiting list. Patients with criteria of unresectability or those with neoadjuvant indication were excluded from the study. Result(s): Thirty-five patients were analyzed, with an age range between 45-80 years, who were indicated to undergo a pancreaticoduodenectomy. 51% of these patients required preoperative DB. DB was performed endoscopically (ERCP) in 10 patients and by transparietohepatic approach (TPHD) in 8 patients. In endoscopic approach the majority of stents used were expandable coated metallic (eight patients). The most frequent complications associated with ERCP were cholangitis and acute cholecystitis. The most frequent complication associated with TPHD was cholangitis. Conclusion(s): Preoperative BD associates a greater number of perioperative complications. At present, there is consensus in avoiding preoperative DB, except in cases with cholangitis or hyperbilirubinemia. If DB is necessary, the endoscopic approach (ERCP) would be indicated. Coated Metal stents should be considered for patients with resectable pancreatic cancer, especially if surgery is not immediate.

Management of acute cholecystitis during the Covid-19 pandemic - A complete cycle

Background: Acute cholecystitis is a common surgical emergency. NICE guidelines recommend early laparoscopic cholecystectomy should be performed within 1 week of diagnosis. Emergency and elective surgical provision was affected during the first wave of the covid pandemic due to high postoperative mortality and pulmonary complications. The objectives of this audit were to assess and improve the local management of acute cholecystitis during the Covid-19 pandemic. Method(s): A retrospective review of all patients who presented with acute cholecystitis over 2 months was performed in April 2020. Several interventions were introduced following the first cycle to improve our adherence with NICE guidelines, including 'green elective surgical pathway', clinical priority coding for elective surgeries, a hot gallbladder pathway, and a dedicated weekend and evening list. A re-audit was performed over 2 months in July 2020. These findings were presented at the departmental meeting. Result(s): 34 patients were reviewed in the first audit and 37 in the re-audit. A higher number of patients with acute cholecystitis in cycle 2 had admission covid swabs (97.3% vs 64.7%) and interval covid swabs (54.1% vs 0%) compared to cycle 1. One patient was tested positive for Covid-19 in cycle 2 and was listed for elective operation. Cycle 2 revealed a higher rate of hot gallbladder (from 8.8% to 10.8%) and a shorter median length from admission to operation (from 4 to 1.5 days). A higher rate of patients was readmitted due to complications of cholecystitis in cycle 2 (29.7% vs 20.6%) compared to cycle 1. Conclusion(s): The overall performance is still behind the NICE guideline recommendation. We have identified factors such as pressure on theatre facilities and resources and cancer fast-track priority surgeries during the Covid-19 pandemic. Ongoing audit and optimisation of the hot gallbladder pathway, elective surgical pathway, extra lists, and clinical priority of operations are important to improve the quality of care for patients with acute cholecystitis.

A Closed Loop Audit on the Management of Acute Cholecystitis During the Covid-19 Pandemic

Background: The definitive management of acute cholecystitis is laparoscopic cholecystectomy on the same admission, if the patient is fit. However, as the Covid-19 pandemic emerged, evidence suggested adverse outcomes for asymptomatic Covid positive patients undergoing surgery, including increased mortality risk. Risks to theatre staff were also highlighted. This prompted changes in guidelines produced by the Association of Upper Gastrointestinal Surgeons (AUGIS) in March 2020, which strongly supported the conservative non-surgical management of acute cholecystitis. Method(s): This closed loop audit aimed to establish whether patients with acute cholecystitis were managed in accordance with AUGIS guideline changes at our hospital. It also aimed to assess the clinical outcomes of the guideline changes. This retrospective audit focused on patient admissions with acute cholecystitis at our hospital during the 2 peaks of the Covid-19 pandemic. The timeframe of the initial audit was 17th April - 14th May 2020 (4 weeks). The timeframe of the re-audit was 1st - 28th February 2021 (4 weeks). Handover sheets and clinical software were the data sources. The initial audit was presented at the General Surgery departmental clinical governance meeting in September 2020 and formed the educational intervention. Result(s): 24 patients with acute cholecystitis were included in the initial audit, and 25 patients in the re-audit. The initial audit found that 15 patients (62.5%) with acute cholecystitis were managed conservatively with IV antibiotics, 4 patients (16.6%) had a percutaneous cholecystostomy, and 5 patients (20.8%) underwent laparoscopic cholecystectomy during their index admission. Following our educational intervention, the re-audit found that 22 patients (88%) were treated conservatively, 1 patient (4%) had a percutaneous cholecystostomy, and 2 patients (8%) underwent laparoscopic cholecystectomy. The mean length of hospital stay reduced from 5.67 days in the initial audit, to 3.88 days in the re-audit. 30 day readmission rates also reduced from 5 patients (20.8%) to 0 patients (0%). 2 patients aged >60 years died from unrelated causes during their index admission. They had Charlson Comorbidity Index scores >2. Conclusion(s): Management of acute cholecystitis was more compliant with AUGIS guidelines following the educational intervention. Importantly, overall, conservative non-surgical management did not clinically disadvantage patients, and was not associated with the development of complications of acute cholecystitis, such as gallbladder empyema or perforation. Indeed, the re-audit revealed shorter length of hospital stay and lower 30 day readmission rate than the initial audit. For vulnerable patients at risk of serious complications from contracting Covid-19, this certainly had positive implications for wellbeing, reducing exposure to the hospital environment. There were also further beneficial implications for limited bed resources. Our findings, however, suggest that flexibility is required in decision-making in the management of acute cholecystitis. In carefully selected patients, for example younger patients with fewer comorbidities, emergency laparoscopic cholecystectomy might avoid future readmission with serious complications of gallstones, such as ascending cholangitis and pancreatitis. The evidence from our local audit suggests that AUGIS guideline changes may overall benefit and improve the clinical outcomes of patients with acute cholecystitis. However, decisions about management should be in the interests of, and tailored to, the individual patient.

COVID-19 presenting as acute adominal pain: A case series.

The coronavirus infection presents primarily as a respiratory illness, however, extra-pulmonary manifestations are known to occur, including gastrointestinal manifestations. Hereby, we report three cases of the COVID-19 infection who presented with acute-onset abdominal pain during illness. All three patients had respiratory symptoms suggestive of COVID-19 and abdominal symptoms consistent with acute pancreatitis, acute cholecystitis, and acute appendicitis. All three patients improved in terms of acute abdominal pain; however, the overall clinical course, the three illnesses were variable because of differences in underlying organ involment and pathophysiology.

Index admission cholecystectomy with or without single session bile duct exploration for Emergency gall stone complications neutralised the adverse effects of COVID

Aims: The COVID-19 pandemic impacted surgical practice globally. We aim to study The effects this had on The presentations, practice and results of Biliary Surgery on a unit adopting index admission laparoscopic cholecystectomy (LC) and single session management of bile duct stones for Emergency presentations. Method(s): Prospectively collected data of Biliary Surgery over a period of 12 months pre-COVID (PRE) and 12 months post-COVID (PoST) was analysed. The presentation, type of admission, type of operating list and operative and postoperative data were compared. Result(s): 257 LCs were done PRE and 270 PoSt. All Emergency presentations increased;acute cholecystitis 8.5% to 25.9%, acute pancreatitis 6.2% to 11.8% and jaundice 22.5% to 27.7%. Elective LC decreased from 53% to 20%. With an increase in patients with previous admissions (13.6% PRE vs 20.7% PoST), 87% of PRE vs 80% PoST had index admission LC, utilising 192 Emergency theatre sessions and 29 CEpoD lists. In spite of increased LC difficulty grades (grades 4 and 5 from 20.2% to 30.5%), bile duct explorations (34%), operating time and median total hospital stay The morbidity, mortality and median presentation to resolution intervals were not affected. Conclusion(s): COVID-19 caused an increase in all acute Biliary presentations requiring Emergency admissions, almost certainly The result of a significant decline in elective LC. However, similar numbers of LC PRE and PoST were maintained due to a policy of index admission Surgery and bile duct exploration, utilising Emergency theatre scheduling, optimised clinical outcomes in spite of some logistical parameters being affected.

Difficulties in managing acute gallstone disease at a Tertiary Referral Centre admist COVID-19

Background: Acute Biliary disease, a surgical emergency, is predominantly treated conservatively initially. Specialist units aim to follow guidelines set by The Royal College of Surgeons and NICE to provide a cholecystectomy within a set time. Clinical practice at St Thomas' Hospital was reviewed along with The difficulties during The COVID-19 pandemic. Aim(s): Reassess practice at a specialist unit failing to meet guidelines during The start of COVID-19. Prospective data collection, on patients booked for a laparoscopic cholecystectomy (LC) after Emergency attendances. Method(s): Initial retrospective data analysis, reviewing pre-COVID (PC19) practice (03/19-02/20), initial COVID-19 (IC19) management (03/20-12/20). Prospective data (01/21-11/21) after implementing changes (AC19). Identifying demographics, pathology, length of stay during acute admission, average wait for Surgery and readmission rate prior to surgery. Patients receiving Surgery within 6 weeks, which has been set by our Trust as an acceptable standard. Result(s): Patients with acute presentation (acute cholecystitis, gallstone pancreatitis, cholangitis) 162 (PC19), 80 (IC19), 145 (AC19). Gender Ratio M:F 1:2 for all groups. Average wait to Surgery 93 (PC19), 44 (IC19), 69 (AC19) days. Patients receiving Surgery within 6 weeks 24.7% (PC19), 32.5% (IC19), 51.7% (AC19). Patients who were still awaiting Surgery at The end of each time frame 49% (PC19), 51% (IC19), 48% (AC19). Mean length of surgical stay 1.75 (AC19) days. Conclusion(s): Further changes are required, as guidelines are still not being met, with average wait times significantly above The recommended wait to undergo laparoscopic cholecystectomy.

What a difference a year makes: Long-term follow-up of non-operative management in acute cholecystitis

Aim: Surgery is currently The recommended treatment for acute cholecystitis and The Association of Upper Gastrointestinal Surgeons (AUGIS) recommends that laparoscopic cholecystectomy be performed within 72 hours of admission. However, given The impact of The COVID-19 pandemic on healthcare delivery, this is not always possible. So, what happens to those who are managed conservatively? We observed The long-term impact of conservative management of patients admitted with acute cholecystitis over The course of one year. Method(s): Twenty-eight patients were admitted with acute cholecystitis to a large tertiary hospital in November 2020;twenty-three were discharged without having had a cholecystectomy. These patients were followed up for one year and observed for The development of any gallstone-related admissions and Surgical procedures. Result(s): of The 23 patients observed, 30% (n=7) were admitted for gallstone-related complications. Biliary colic was responsible for 43% of these admissions with pancreatitis (14%), cholangitis (14%), choledocholithiasis (14%), and cholecystitis (14%) causing The reSt. only 9% (n=2) received a laparoscopic cholecystectomy. In both cases, it was in an Emergency setting during admission for Biliary colic. Conclusion(s): Long-term observation of conservatively managed acute cholecystitis was possible in around two-thirds of patients as no gallstone-related hospital admissions were observed. Biliary colic was The most common cause of gallstone-related admissions. Longer observation is required to assess The feasibility of long-term non-operative management in acute cholecystitis.

The impact of CoVD-19 on the Surgical management of acute cholecystitis

Aim: The Association of Upper Gastrointestinal Surgeons (AUGIS) recommends performing a laparoscopic cholecystectomy within 72 hours of admission for acute cholecystitis. COVID-19 has drastically affected The way healthcare is able to be delivered worldwide. This project was designed to audit The impact of COVID-19 on The Surgical management of acute cholecystitis against AUGIS guidelines. Method(s): All General Surgical admission from November 2020 were retrospectively analysed. Admission records were screened for those presenting with acute cholecystitis. Those identified had their records analysed for laparoscopic cholecystectomy. Patients who died before surgery, had an alternative procedure performed, or who were unfit for surgery, were excluded. Result(s): During this time, 28 patients were admitted with acute cholecystitis. In total, 3 patients were excluded: 1 died before any possible intervention, 1 was unfit for surgery, and 1 received a cholecystostomy. of The 25 included patients, only 11% (n=3) patients received a laparoscopic cholecystectomy within seven days from their hospital admission. The remaining 89% (n=22) of patients were managed conservatively with fluids, analgesia, and antibiotics. Conclusion(s): It can be concluded that COVID-19 has severely impacted The Surgical management of acute cholecystitis as only 11% of those patients presenting were managed in accordance with AUGIS guidelines. Whether conservative management is an alternative long-term option for management remains to be seen as further long-term studies are needed.

Outcomes of Cholecystostomy in the Management of Acute Cholecystitis in Surgically Unfit Patients: An Audit in a Large Tertiary Centre

Background: The Royal Infirmary of Edinburgh (RIE), receives 10,000 emergency surgery consults annually. Typically 800 patients each year require acute cholecystectomy. Surgically unfit patients may undergo cholecystostomy insertion. Our audit aimed to assess the efficacy and health economics of this treatment. Method(s): A national radiology database search identified 86 cholecystostomy procedures performed at the RIE, between June 2018 and May 2020. Clinical notes were reviewed to obtain specific surgical and radiological data to input into a large dataset, allowing retrospective analysis. Result(s): During the study period approximately 2,800 patients underwent cholecystectomy and 1,600 of these were acute cholecystectomies. 82 patients (5% of acute cholecystectomies) underwent cholecystostomy. Cholecystostomy procedural morbidity was 12% (5% Grade III Clavien-Dindo or above). Figure 1 summarises patient follow up. Outpatient appointments for cholecystostomy removal occur 8 weeks after drain insertion. 11% of patients died on initial presentation and 6% had no appointment due to the COVID-19 pandemic. 41% of patients re-presented before their appointment, at a median of 30 days after discharge. Drain-related issues made up half of these consults and 3 patients underwent emergency surgery. Another 41% attended their appointment without prior issue, with 85% undergoing drain removal. 13% of patients re-presented after their drains had been removed, with 4% requiring reinsertion. Conclusion(s): Cholecystostomy treatment is associated with significant burdens in terms of morbidity for patients and health resources for providers. Alternative procedures such as endoscopic ultrasound gallbladder drainage require evaluation and may have potential to alleviate these burdens and improve patient outcomes. [Formula presented] Copyright © 2022

Global Overview of the Management of Acute CHOLEcystitis during the COVID-19 Pandemic: The CHOLECOVID Study

Introduction: National guidance issued in response to COVID-19 resulted in adoption of non-surgical modes of treatment in emergency surgery, including acute cholecystitis (AC). The CHOLECOVID Study is the definitive global audit of the management and outcomes of AC during COVID19. Method(s): Patients >18 years with acute cholecystitis during two predefined 8-week time periods, pre-pandemic (P1, 12/09/19- 12/11/19) and during the pandemic (P2, 12/03/20-12/05/20), were included. The primary outcome was 30-day all-cause mortality. Secondary outcomes included severity of AC, radiological diagnostic modalities implemented, definitive management and pulmonary complications. Result(s): 9,783 patients were included from 40 countries. 30-day mortality was higher in P2 (1.7%vs2.4%;p<0.015). Higher rates of moderate and severe AC were seen in P2 (30.1%vs35.1%, p<0.001;3.7%vs4.1%, p<0.001). First-line CT imaging was more common in P2 (36.3%vs46.3%;p<0.001). Cholecystostomy rates were higher in P2 (5.8%vs8.8%;p<0.001), with a reduction in cholecystectomy (23.4% vs 44.2%, p<0.001). Overall 4.6% (n=193) of P2 patients were COVID-19 positive, with overall mortality of 0.7% (n=30). Following adjustment using a natural effects mediation analysis, a diagnosis of acute cholecystitis during the pandemic was associated with almost 30% higher odds of death compared to the pre-pandemic. Conclusion(s): During the COVID-19 pandemic, a small increase in mortality among AC patients was noted, when compared to the pre-pandemic cohort. Patients during the COVID-19 pandemic presented with more severe AC, resulting in altered trends in diagnosis and management. Clear pathways are required to prevent disruption of services and safely manage AC moving forward, in the face of the ongoing COVID-19 pandemic. Copyright © 2022

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Acute bacterial myocarditis due to Salmonella bacteremia is a rare cause of ST-segment elevation that can manifest as acute decompensated heart failure, life threatening arrhythmias, and sudden cardiac death. CASE PRESENTATION: A 62-year-old male with a past medical history of HTN, HLD, DM2, and TIA presented with nausea, vomiting, nonbloody diarrhea, and right upper quadrant pain for five days. He quickly decompensated in the ED, becoming increasingly hypotensive, tachycardic, and lethargic concerning for sepsis. Broad spectrum antibiotics and IV fluids were initiated. Chest X-ray revealed multifocal pneumonia. Labs revealed a metabolic acidosis consistent with acute hypoxic respiratory failure warranting emergent intubation. CTA chest showed multifocal pneumonia and Covid-19 antigen testing was negative. Troponin I was elevated at.211 ng/mL (n <.08) and ECG showed new onset atrial fibrillation, for which cardiology was consulted. On admission to the ICU, repeat labs showed acute renal failure and he was anuric warranting hemodialysis initiation. Despite medical optimization, his Troponin I trended up to 1.458 ng/mL, and repeat ECG showed 2:1 atrial flutter with new ST-elevations in leads II, III, and aVF, consistent with an acute inferior STEMI. Labs did not show hyperkalemia nor hypercalcemia. Transthoracic echocardiography revealed normal systolic and diastolic function, with a left ventricle ejection fraction of 65-70%. A heparin infusion was started and he was taken for a cardiac catheterization which showed no evidence of occlusive CAD. His blood cultures revealed Salmonella enteritidis for which he was switched to ciprofloxacin. Abdominal ultrasound appeared benign, but CT abdomen with contrast showed findings of cholecystitis, which was confirmed on HIDA scan. Gastroenterology and Surgery were consulted who recommended a cholecystostomy tube placement, with a delayed laparoscopic cholecystectomy (LC) when stable. Repeat ECG following the LC showed complete resolution of the previous STEMI. He was discharged to a rehabilitation facility where he made a full recovery. DISCUSSION: Acute bacterial myocarditis can mimic acute coronary syndromes and warrants a high index of suspicion in the setting of Salmonella bacteremia. Our patient presented with signs of acute cholecystitis and an ECG concerning for acute STEMI. Bacterial etiologies of myocarditis are less reported in the literature compared to viral infections, and are seen more often in patients with severe sepsis such as our patients. Common findings associated with Salmonella myocarditis include ST-segment elevation on ECG and elevated troponin levels. Serial ECG findings can distinguish myocarditis from acute myocardial infarction. Early diagnosis is essential to improve outcomes and reduce mortality. CONCLUSIONS: Acute bacterial myocarditis can mimic acute coronary syndromes. Reference #1: Villablanca P, Mohananey D, Meier G, Yap JE, Chouksey S, Abegunde AT. Salmonella Berta myocarditis: Case report and systematic review of non-typhoid Salmonella myocarditis. World J Cardiol. 2015;7(12):931-937. doi:10.4330/wjc.v7.i12.931 Reference #2: Sundbom P, Suutari AM, Abdulhadi K, Broda W, Csegedi M. Salmonella enteritidis causing myocarditis in a previously healthy 22-year-old male. Oxf Med Case Reports. 2018;2018(12):omy106. Published 2018 Nov 26. doi:10.1093/omcr/omy106 Reference #3: Majid A, Bin Waqar SH, Rehan A, Kumar S. From Gut to Heart: Havoc in a Young Patient with Typhoid-associated Cardiomyopathy. Cureus. 2019;11(7):e5049. Published 2019 Jul 1. doi:10.7759/cureus.5049 DISCLOSURES: No relevant relationships by Mohamed Faher Almahmoud No relevant relationships by JONATHAN BROWN No relevant relationships by Hytham Rashid No relevant relationships by Syed Raza

Service Evaluation of the Management of Acute Cholecystitis in the Royal Gwent Hospital Pre and During the COVID-19 Pandemic

Aim: NICE guidelines set out the criteria for the treatment of patients with acute cholecystitis and the operative timescales for cholecystectomy. These targets were greatly affected during the Covid-19 pandemic. Therefore, we aimed to assess the impact that COVID-19 had on patients presenting with acute cholecystitis at a busy district general hospital. June 2020, compared with patients who presented with the same in June 2019. Method: Patient cohorts were identified for matching seasons pre- and post-covid-19 (June 2019 and June 2020). Data of all patients who presented with acute cholecystitis was obtained using an electronic patient management system. Statistical analyses were performed using a Wilcoxon test. Results: The results of the study indicate that waiting times post-covid are going down (p<0.05). Thus, days until cholecystectomy have decreased but the number of patients being operated on too has decreased thus further worsening waiting times for elective patients. The median and IQR's of days to surgery post-covid are 198 (121.5-278) and pre-covid are 251 (89.5-586.5). Presentations of gallstone complications almost doubled post-covid and the percentage of patients operated on decreased by over 20%. Conclusions: It is clear from the data that the NICE guidance on the management of acute cholecystitis has been difficult to adhere to during the pandemic. While the time from diagnosis to operation has reduced post-covid the total number of operations has decreased drastically, putting further strain on elective waiting lists. This, inevitably, will result in further presentations of complications from gallstones and adverse patient outcomes.