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.

Abdominal imaging findings in patients with COVID-19 part 2: solid organs

Since Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) first appeared in China in December 2019, the globe has been dealing with an ever-increasing incidence of COVID-19 (Corona Virus Disease 2019). In addition to respiratory disorders, 40% of patients present with gastrointestinal (GI) involvement. Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography. After GI tract involvement, solid visceral organ infarction is the most prevalent abdominal abnormality in COVID-19. This review aims to gather the available data in the literature about imaging features of solid abdominal organs in patients with COVID-19. Gallbladder wall thickening and distension, cholelithiasis, hyperdense biliary sludge, acalculous cholecystitis, periportal edema, heterogeneous liver enhancement, and liver hypodensity and infarction are among hepatobiliary imaging findings in CT, particularly in patients admitted to ICU. Pancreatic involvement can develop as a result of direct SARS-CoV2 invasion with signs of acute pancreatitis in abdominal CT, such as edema and inflammation of the pancreas. Infarction was the most prevalent renal and splenic involvement in patients with COVID-19 who underwent abdominal CT presenting with areas of parenchymal hypodensity. In conclusion, although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome.

Pancreatitis Secondary to Paxlovid-Induced Tacrolimus Toxicity

Introduction: Pancreatitis is a very common gastrointestinal disease that results in hospital admission. Early detection and treatment leads to better outcomes. This is the first reported case of pancreatitis secondary to elevated tacrolimus in a patient with prior renal transplantation after receiving Paxlovid for a COVID-19 infection. Case Description/Methods: A 57-year-old male with past medical history of 4 renal transplants secondary to posterior urethral valves who presented to the emergency room with acute onset epigastric pain for 24 hours. He was on tacrolimus 5 mg every 48 hours monotherapy for his immunosuppression. 10 days prior to his presentation he had developed chills and anxiety. He tested positive for COVID-19 at that time on a home rapid test. His symptoms had not significantly improved and given his immunosuppressed state he was given Paxlovid (Nirmatrelvir/ritonavir). He took 2 days of Paxlovid, however after his second day of treatment he developed severe epigastric pain requiring him to go to the emergency room. On admission his labs were notable for a lipase of 150 U/L (ULN 63 U/L). He underwent a CT scan was notable for an enlarged pancreatic head and neck with peripancreatic fat stranding (Figure). He also had a right upper quadrant ultrasound without any cholelithiasis and only trace sludge noted. His creatinine was noted to be 1.81 mg/dl which was above his baseline of 1.2 mg/dl. His tacrolimus trough level resulted at a level 45.6 ng/ml and later peaked at 82.2 ng/ml. His liver enzymes were normal. He was treated as acute pancreatitis with hydration and his tacrolimus was held with overall clinical improvement. Discussion(s): Tacrolimus is one of the most common medications used in solid organ transplantation. It is a calcineurin inhibitor that inhibits both T-lymphocyte signal transduction and IL-2 transcription. It is metabolized by the protein CYP3A and levels are monitored closely. Paxlovid is currently prescribed as an antiviral therapy for COVID-19 infection. The ritonavir compound in Paxlovid is potent inhibitor of CYP3A. Currently the guidelines do not recommend Paxlvoid as a therapeutic in patients taking tacrolimus as there is concern about increased drug levels. There have been several case reports of pancreatitis in setting of tacrolimus. This case report helps to demonstrate the need for close monitoring of therapeutics levels, especially in medications with high risk of drug to drug interaction to help prevent serious side effects such as tacrolimus induced pancreatitis.

An Immunocompetent Adult With Adenovirus Hepatitis

Introduction: In the US there has been a recent outbreak of adenovirus hepatitis in the pediatric population. However, to our knowledge, there has been only one reported case of adenovirus hepatitis in an immunocompetent adult. We have identified another such case. Case Description/Methods: A 25 year old female with no medical history presented with abdominal pain, nausea, vomiting, diarrhea, and subjective fevers for two weeks and was found to have transaminitis 25-30x the upper limit of normal, which were: AST 791, ALT 542, ALP 92, and total bilirubin of 2.9. The patient reported no prior history of liver disease. She denied alcohol, tobacco, illicit drugs, or herbal medications, but did report taking acetaminophen 1500 mg daily for two weeks. Serum acetaminophen levels were normal and serum and urine toxicology were negative. US with doppler was unremarkable, CT showed cholelithiasis, MRCP showed a normal common bile duct without obstructive calculus. Autoimmune causes of hepatitis, ceruloplasmin and alpha-1 antitrypsin were all unremarkable. HAV, HBV, HCV, HDV, HEV, CMV, HSV, VZV, EBV, HIV, and COVID19 were all negative. Ultimately, the serology for adenovirus was positive. After a week of supportive treatment, the patient's labs trended down and symptoms resolved. Discussion(s): Adenovirus is confirmed by a rise in antibody titer or by virus detection. Coagulative necrosis in histopathology is a finding in liver biopsies if they are pursued in unexplained cases of liver injury. Ultimately, adenovirus hepatitis can be diagnosed once all common causes of hepatitis have been excluded. In the current outbreak, only children have been getting adenovirus hepatitis. In adults, a high prevalence of neutralizing antibodies contributes to immunity, and therefore only in immunocompromised states, do adults get such an infection. Supportive care with IV fluids, electrolyte correction, and antiemetics usually is enough with eventual symptomatic and laboratory improvement as it was for our patient. Studies have shown that extensive disease can be treated with antiviral drugs, cidofovir, and ribavirin. Our patient's history of acetaminophen use is a confounder, however, her normal serum level and her symptoms suggestive of an infectious cause made acetaminophen less of a culprit. We hypothesize that our patient's use of acetaminophen when she was initially exposed to the virus is what made her susceptible to developing adenovirus hepatitis and we hope this case adds insight for clinicians dealing with future adult cases.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Analysis on occurrence and risk factors of drug-induced liver injury in patients with novel coronavirus pneumonia.

Objective: To analyze the occurrence and risk factors of drug-induced liver injury (DILI) in patients with novel coronavirus pneumonia (COVID-19). Method(s): The medical records of patients with COVID-19 who were discharged from the First Hospital of Changsha from January 15 to March 7, 2020 were collected and the patients were divided into the DILI group and the non-DILI group based on DILI diagnostic criteria. Basic information of patients in the 2 groups including gender, age, underlying diseases, classification of COVID-19, liver function test results on admission and after medication, drug use, time to DILI onset after medication, and treatments and outcomes of DILI were recorded and compared. The incidence of DILI in patients with COVID-19 was calculated, and the factors whose P<0.05 in inter-group comparison were included in the multivariate logistic regression analysis to calculate the odds ratio (OR) and95% confidence interval (CI). Result(s): A total of 203 discharged patients with COVID-19 met the inclusion criteria. Of them, 36 patients developed DILI, the incidence was 17.73%. Between the DILI group and the non-DILI group (167 patients), the differences were statistically significant in gender distribution, proportion of patients with underlying diseases such as hypertension, fatty liver, and cholelithiasis, clinical classification of COVID-19, and the kinds of drug use (P<0.05 for all), but not statistically significant in levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBil) on admission (P>0.05 for all). The levels of ALT and AST in patients in the DILI group after medication were higher than those before medication, and the differences were statistically significant (P<0.001 for all). The median time for time to DILI onset after medication was 8 (6, 11) days and none of the patients had obvious clinical signs and symptoms. After the occurrence of DILI, 16 patients stopped the suspicious drugs and received liver-protective treatments, 6 patients only stopped the suspicious drug without additional treatments, and 14 patients received liver-protective treatments without drug withdrawal. Among the 36 patients in the DILI group, liver function were improved in 34 patients but did not returned to normal in 2 patients when they were discharged from the hospital. Multivariate logistic regression analysis showed that male (OR=3.939, 95%CI: 1.426-10.883, P=0.008), being severe and critical in clinical classification (OR=6.433, 95%CI: 2.411-17.162, P<0.001), fatty liver (OR=3.815, 95%CI: 1.298-11.215, P=0.015), cholelithiasis (OR=16.347, 95%CI: 1.267-210.990, P=0.032), and the kinds of drug use >8 (OR=10.181, 95%CI: 3.606-28.744, P<0.001) were the independent risk factors of DILI in patients with COVID-19. Conclusion(s): The incidence of DILI in COVID-19 patients discharged from the First Hospital of Changsha is 17.73%. Male, being severe and critical in clinical classification of COVID-19, fatty liver, cholelithiasis, and the kinds of drug use >8 are the independent risk factors for DILI patients with COVID-19.Copyright © 2020 by the Chinese Medical Association.

"Inside out" - An exceptional intussusception

Introduction: We present the first case of appendiceal intussusception associated with myeloid sarcoma in a young patient. Minimally invasive techniques used along the clinical course are highlighted. Case description: A 2.5-year-old boy was admitted after three weeks of COVID-19 infection with ongoing symptoms of MIS-C. Due to constipation, distended belly and vomiting, US was done which showed ileocolic intussusception. After unsuccessful hydrostatic reduction laparoscopic exploration was performed, where the vermiform appendix was found to be thickened and partially intussuscepted into the coecum. The ileocecal region was exteriorized transumbilically. After manual reduction of the intussusception, a long, thickened, fragile appendix was removed. Histopathology revealed myeloid sarcoma. Bone marrow investigation identified acute myeloid leukemia. During the oncological treatment, laparoscopic cholecystectomy was necessary due to cholecystitis and cholelithiasis. The child recovered uneventfully in terms of surgical complications, with good cosmetic result. Conclusion(s): No similar case in childhood was found in the English literature. Unusual symptoms and radiological findings of intussusception can conceal unexpected disorders. Minimally invasive technique offered advantages in the treatment of the presented patient and can be recommended to treat intussusception or cholelithiasis, if applicable, during an ongoing oncological treatment as well.Copyright © 2023 The Authors

Management of Hepato- biliary-pancreatic Surgery during the COVID-19 Pandemic

Purpose: We examined the effect of COVID-19 on diseases treated with hepato- biliary- pancreatic surgery from the experience of nosocomial infection at our hospital. Method(s): We examined the treatment of 106 patients admitted by the Division of Hepato- Biliary- Pancreatic Surgery to The Jikei University Hospital for elective surgery from January through May 2020. Result(s): Of the 106 operations, 90 (85%) were performed as scheduled and did not include COVID-19-positive patients. Operations for 16 patients (15%) were postponed, but 5 (31%) of these operations were urgent or quasiurgent and were performed during the study period. Of 95 patients who underwent surgery, 50 (53%) had a malignant tumor, 3 (3%) had a borderline malignant tumor, and 42 (44%) had a benign lesion, of which 41 were gallstones or gallbladder polyps and 1 was an intraductal papillary mucinous neoplasm that caused pancreatitis. Surgery for the latter tumor was postponed while conservative treatment improved conditions, but pancreatitis recurred 2 weeks after discharge, leading to a quasiurgent surgery. Conclusion(s): Owing to COVID-19, 15% of the scheduled elective hepato- biliary- pancreatic operations were postponed. Even lesions considered benign or not requiring emergency surgery should be treated promptly. Thus, the timing of treatment should be determined so that the risks of exacerbation and COVID-19 can be balanced.Copyright © 2022 Jikei University School of Medicine. All rights reserved.

A review of emergency laparoscopic cholecystectomies during the COVID-19 pandemic compared to pre-pandemic. Is there a difference in patient and financial outcomes?

Background: The COVID-19 pandemic was declared the greatest challenge the NHS would face since its creation. As a means of combatting the unprecedented strains COVID-19 was expected to force upon hospitals and their staff, NHS England sanctioned the postponement of all non-urgent elective surgery during the first wave of the COVID-19 pandemic. Approximately 70 000 cholecystectomies are performed every year in the UK, with the vast majority of these being elective laparoscopic cholecystectomies (LC). However, in the early stages of the pandemic, both national and international surgical bodies warned of the potential risks of aerosol virus transmission with the use of laparoscopy. Therefore, conservative management for emergency general surgical pathologies was recommended where possible. Delays in performing LC are associated with recurrent cholecystitis, pancreatitis and cholangitis;all of which present as emergencies with significant associated morbidity and mortality. This in turn has an economic impact on the NHS. We aimed to evaluate if patients undergoing emergency LC during the COVID-19 pandemic at our site, had different outcomes compared to those treated prior to the pandemic. Has the COVID-19 pandemic negatively impacted their patient journey? Furthermore, has the pandemic led to increased costs for our site? Methods: A retrospective data collection was performed to identify all patients who had an emergency LC from March 2019 - March 2021. Patients were subsequently categorised into 'pre-COVID-19' and 'during COVID-19' groups. Hospital computer systems were used to review operative admission length of stay (LoS), rate of conversion to open surgery/subtotal cholecystectomy, operative time, post-operative complications/return to theatre and readmission rate. Histopathology reports were analyzed to assess if the 'during COVID-19' cohort had a higher rate of complicated cholecystitis. Finally costs of the operative admission and associated admissions (pre and post-operatively), as well as the tariff for investigations performed for gallstone disease were calculated for each cohort of patients. Result(s): 158 patients were included in the study. A 42% reduction in emergency LC cases was observed during the COVID-19 pandemic compared to pre-pandemic. No statistically significant differences were seen between the two groups when reviewing the rate of conversion to open surgery or the incidence of post-operative complications/need to return to theatre. The rate of subtotal cholecystectomy was higher in the 'during COVID-19' group (12% vs. 3%) and this was found to be statistically significant (p-value 0.024). Operating times were longer during the pandemic (93 vs. 80 mins), as was the LoS for the operative admission (5 vs. 6 days), however these results were not statistically significant. Interestingly, same day emergency care (SDEC) reviews were more frequent in the 'during COVID-19' group (13.1 vs. 29.3%) and this was statistically significant (p-value 0.015). There was no statistically significant difference between the groups in relation to histopathology results. The most prevalent histopathology of both cohorts was chronic cholecystitis (58 vs. 48.28%). Acute on chronic cholecystitis (23 vs. 25.86%) and necrotising/gangranous changes (11 vs. 12.07%) were more prevalent in the 'during COVID-19' group. When reviewing costs between the two groups, no statistically significant differences in LoS, nor investigation tariffs was observed. Conclusion(s): Our study shows that the COVID-19 pandemic has had a negative impact on two clinical aspects of emergency LC - an increase in the rate of subtotal cholecystectomy, as well as SDEC reviews. This could be explained by delays in elective surgery encountered during the pandemic, leading to patients experiencing recurrent infections, or other associated complications of gallstone disease and consequently requiring more frequent clinician/SDEC reviews. These complications can also result in unclear anatomy, diffuse scarring, necrosis and abscess formation, all of which n lead to increasingly complex cases encountered intra-operatively. If surgeons are unable to safely achieve a critical view of safety, guidance recommends subtotal cholecystectomy as a bail out procedure, in order to avoid serious damage to the bile duct or blood vessels. This could justify the statistically significant higher rate of subtotal cholecystectomy in the 'during COVID-19' group. Currently, there are approximately 6 million patients on NHS surgical waiting lists and this issue must be addressed urgently in the COVID-19 recovery phase, so as to prevent adverse outcomes for both patients and the NHS.

Tackling a post-COVID-19 cholecystectomy waiting list, are we meeting the challenge?

Background: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity, with over six million people on waiting lists and only 64% of patients meeting the 18-week elective standard. Our Hospital Trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Method(s): A prospective observational study was undertaken investigating patients who received a cholecystectomy at large UK hospital Trust, between February 2021 and February 2022. There were multiple phased strategies to tackle a 533 patient waiting list: Private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. An additional 364 patients were added and 145 removed, for multiple reasons, from the list during the study period. Correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Result(s): 657 patients underwent a procedure, of which 628 (95.6%) were completed electively. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. Thirty (4.6%) patients were listed post gallstone pancreatitis, 380 (57.8%) for cholelithiasis, and 228 (34.7%) for cholecystitis. The median length of stay was zero days (IQR 0-1), with 30-day complication (C-D >=3, 1.8%), readmission (3.0%) and mortality (0.0%) rates noted. The current waiting list includes 95 patients, with median waiting times reduced from 428 days (IQR 373-508) to 49 (IQR 34-96), R2=0.654, p<0.001. For pancreatitis specifically, waiting times have dropped from a median of 218 days (IQR 139-239) to 28 (IQR 24-40), R2=0.613, p<0.001. Conclusion(s):We have safely and effectively tackled the cholecystectomy waiting list locally utilising a number of phased strategies. Significant progress is being made towards once again meeting the gold-standard target for gallstone pancreatitis patients. The approach utilised here has potential to be adapted to other units, or other operation types in order to reduce elective waiting times.We have safely and effectively tackled the cholecystectomy waiting list locally utilising a number of phased strategies. Significant progress is being made towards once again meeting the gold-standard target for gallstone pancreatitis patients. The approach utilised here has potential to be adapted to other units, or other operation types in order to reduce elective waiting times.

Covid-19's impact on delays to elective Cholecystectomy

Background: Patients waiting for elective cholecystectomy for symptomatic gallstone disease may need admission with biliary symptoms or complications whilst on the waiting list. The longer the length from listing to procedure the higher the risk of symptoms and possible admission with complications. Many elective operations were cancelled or delayed during the pandemic leading to increased waiting times. The trust noticed a significant number of patients presenting to hospital who were already listed for surgery. This study looks at emergency admission data of 100 patients awaiting elective cholecystectomy. Method(s): Hospital admission data on 100 successive patients from the cholecystectomy waiting list were analysed from Dec 2021-January 2022. Data was collected on when were they added to the list and whether they had presented to hospital in the waiting period before cholecystectomy. Of those that were admitted, reasons for admission, demographics of people who needed admission and length of stay in hospital were recorded. Result(s): Of the 100 patients many had been waiting more than a year with Covid 19 a predominant delaying factor (cholecystectomy is a P3 or P4 procedure and many elective procedures were cancelled or delayed during the pandemic). This cohort of patients had 32 separate presentations to hospital while on the waiting list (some patients presenting multiple times). 9 patients required emergency hospital admission for clinical reasons such as pancreatitis and cholecystitis. This totaled 67 bed days for the admitting hospital, some data was unavailable due to admissions to other hospitals. Conclusion(s): NICE guidelines recommend laparoscopic cholecystectomy within 1 week for patients presenting with acute gallstone disease. Early elective cholecystectomy is recommended for patients with symptomatic gallstones. Delays in elective cholecystectomy operations during Covid 19 have caused delays to definitive treatment and led to excess bed usage during the treatment pathway with the associated financial costs and patient morbidity.

Is there still a role for routine histology in cholecystectomies for benign disease?

Background: A movement towards selective histology for benign gallbladder disease is evolving in the United Kingdom (UK). Studies propose the reliance on macroscopic features to identify incidental gallbladder cancer (IGBC). We aimed to investigate the rate of dysplastic gallbladder histology, the rate of subtotal cholecystectomy and identify any selection criteria for selective histology. Method(s): A retrospective observational study examining patients who underwent a cholecystectomy, amid the COVID-19 pandemic, between January 2020 and June 2021. This study was carried out in a large Trust in the West Midlands, UK. Multivariate logistical regression models were used to identify patient factors associated with IGBC and compare outcomes between total and subtotal cholecystectomy. Result(s): There were 959 patients;631 (65.8%) elective and 328 (34.2%) emergency cholecystectomies. Median age was 48 (35-59) years, and 724 (75.5%) patients were female. 27 (2.8%) patients had a subtotal cholecystectomy with worse post-operative complications (Clavien-Dindo grade 3+, OR 4.69, p=0.026), however no patient suffered a common bile duct injury. Eight (0.8%) patients had IGBC of which 6/8 were diagnosed as cholelithiasis on ultrasound. Five IGBCs had no macroscopic features. One patient needed further surgery and chemotherapy. Gallbladder polyps on ultrasound was the only patient factor associated with increased likelihood of IGBC (OR 14.49, p=0.014). Conclusion(s): We support the current recommendation of the UK Royal College of Pathologists to routinely examine all cholecystectomies removed for benign disease, given that macroscopic features may be absent in IGBC and no clear patient factors to support a selective approach.

Elective versus Emergency management of gallstone disease at a tertiary referral centre amidst the COVID-19 pandemic-should the protocol be altered?

Background: Gallstones are a common pathology affecting approximately 15% of The population in UK, 20% of which are symptomatic. It is suggested symptomatic patients undergo cholecystectomies. Guidelines recommend this is performed within one week of initial Emergency presentation or 52 weeks for elective case. Surgical capacity to manage Emergency cholecystectomies was limited due to The COVID pandemic. We assessed wait time discrepancy between elective and Emergency cholecystectomies. Method(s): A retrospective review of all patients undergoing cholecystectomies between January and November 2021 in a major tertiary referral centre in London was undertaken. Initial pathology at The time of presentation, elective vs Emergency presentation, pre-surgical Biliary complications along and wait times were reviewed. Result(s): 219 (74 elective, 145 emergency) patients underwent surgery, mean age 48 years (23% Male and 77% Female). Average wait times for elective cholecystectomies were 69.7 days (min 0, max 246) in Comparison to 68.9 days (min 1, max 253) for Emergency surgery. 22 (15%) of The patients of initial Emergency presentation re-attended hospital and 6 (4%) had adverse events such as gallbladder perforation or pancreatitis due to delayed treatment. Comparatively, 9 (12%) elective patients attended A&E due to pain, with no adverse outcomes. Conclusion(s): Overall wait time of Emergency vs elective cholecystectomies were similar. This review indicates Emergency cases require prioritisation over elective cholecystectomies due to The higher number of re-attendance and adverse events. Emergency cases need to be prioritised to meet guidelines, which could also reduce complication rates whilst awaiting Surgery and lead to fewer adverse outcomes.

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.

Management and outcomes of gallstone disease during the SARS-CoV-2 Coronavirus pandemic

Aims: The aim of this study was to compare The patient demographics and management of acute manifestations of gallstone disease during The COVID-19 pandemic with an equivalent period in 2019 and assess The differences in recurrence patterns over The period of first and second wave of The pandemic. Method(s): A retrospective cohort study of all adult patients aged >16 years presenting to The Emergency Department at a large District General Hospital with symptoms related to gallstones was conducted. Data was obtained from electronic patient records. Primary outcome assessed were incidence and management of gallstone disease while secondary outcome studied included length of Stay, re-admission rate and recurrence. Data was tabulated and analyzed using Excel (Microsoft, 2016 version). Chi square, t-test and one way ANoVA tests were used. Result(s): 51 patients presented during The period of first wave and 105 patients during second wave as compared to 71 patients in The study period during 2019. The median age of patients during The first wave of COVID was significantly higher than pre COVID and that in second wave. During both The waves of The pandemic, there was a no significant difference in patients presenting with cholecystitis compared with 2019 (47 and 94 versus 60;P value 0.39). There was no significant increase in use of cholecystostomy. There was no significant difference in recurrence and readmissions. Majority of The patients still await surgery. Conclusion(s): During The pandemic, older patients with higher comorbidity presented with acute gallstone disease. Conservative management was effective in The management of these patients.

Financial implications of gallstone-related complications whilst awaiting elective cholecystectomy: A single institution experience of 900 patients

Aims: Over 65,000 cholecystectomies are performed each year in The United Kingdom with increasing waiting-list times due to The CoVID-19 pandemic. This study set out to understand The cost to The NHS of complications experienced whilst awaiting cholecystectomy. Method(s): A retrospective cohort study was carried out for all patients who had been awaiting elective cholecystectomy for more than 20 weeks On The 17th September 2021 at a large NHS Foundation Trust. Demographic data was collected at The time of listing. Re-admission data was collected from patient notes. It included clinical history, blood results and imaging investigations. Associated costs were calculated. Result(s): 900 patients included in The study (median age 56 years, 71.7% female). 138 patients (15.3%) re-presented to hospital whilst On The waiting list with complications of gallstone disease. Of these, 51 had more than one presentation to hospital with 18 patients having more than three presentations. This was equivalent to 625 days in hospital, with only 79 same day discharges, and multiple investigations were performed (ultrasound scan = 79;CT scan = 31, MRCp = 47, ERCp = 21). This was estimated to have cost a minimum of 364,917. Assuming an average time for an elective cholecystectomy of 90 mins at a cost of 1,200 per hour, 202 additional cholecystectomies could have been performed. Conclusion(s): This study highlights The enormous potential to reduce patient suffering by increasing The number of elective cholecystectomy lists, and at no overall additional cost to The trust.

Tirzepatide (Mounjaro) for Type 2 Diabetes

The FDA has approved tirzepatide (Mounjaro - Lilly), a peptide hormone with activity at both glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors, to improve glycemic control in adults with type 2 diabetes. Tirzepatide, which is injected subcutaneously once weekly, is the fi rst dual GIP/GLP-1 receptor agonist to become available in the US. Selective GIP receptor agonists are not available in the US;GLP-1 receptor agonists have been available for years. Copyright © 2022, Medical Letter Inc.. All rights reserved.

THE PROPER STUDY: A 48-WEEK ANALYSIS of A PAN-EU REAL-WORLD STUDY of SB5 BIOSIMILAR FOLLOWING TRANSITION from REFERENCE ADALIMUMAB in PATIENTS with RHEUMATOID ARTHRITIS, AXIAL SPONDYLOARTHRITIS or PSORIATIC ARTHRITIS

Background: SB5, a biosimilar to reference adalimumab (ADL), received EU marketing authorisation in 2017, based on pre-clinical and clinical phase I and III studies that demonstrated bioequivalence and comparable efficacy, safety and immunogenicity to ADL. Objectives: The real-world study 'PROPER' is designed to provide insights into outcomes of the transition from ADL to SB5 outside the randomised, controlled, clinical trial setting. Methods: Under an umbrella design, 1000 patients with immune-mediated infammatory disease were enrolled at centres in Belgium, Germany, Ireland, Italy, Spain and the UK, and followed for 48 weeks post-transition. Eligible patients with a diagnosis of rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), ulcerative colitis or Crohn's disease had been transitioned to SB5 as part of routine treatment following a minimum of 16 weeks' treatment with ADL. Data were captured from patient charts retrospectively for 24 weeks prior to and prospectively and/or retrospectively up to 48 weeks after SB5 initiation. This analysis of the rheumatology cohort reports clinical characteristics, disease scores, persistence on SB5, clinical management and safety up to the closing date of November 30th, 2021. Results: Of the 496 patients included in this analysis, the majority were enrolled in UK (n=174), Germany (n=145) and Spain (n=73);Italy, Ireland and Belgium enrolled 45, 44 and 15 patients respectively. At study close, 487 patients had completed 48 weeks of follow-up;397 of those remained on SB5 throughout. Methotrexate was received as concomitant therapy by 37% of patients and 20% had received a biologic therapy prior to reference ADL. Most patients (89.3% of RA, 92.1% of axSpA, 97.3% of PsA) transitioned to SB5 at the same dose regimen received for ADL. Clinical characteristics, SB5 dose and fare are detailed in Table 1, disease scores in Figure 1. Fifteen patients each experienced one unrelated Serious Adverse Event (SAE): 2 in the axSpA cohort [tachycardia, intracranial haemorrhage];6 in the PsA cohort [myocardial infarct (2), breast carcinoma, COVID-19, gallbladder calculus, dyspnoea];7 in the RA cohort [facial numbness, depression, COVID-19, pneumonia, diverticulitis, parvovirus, coronary occlusion]. Tw o patients reported SAEs considered causally related to SB5: Herpes zoster and pneumonia (RA cohort), and ALS with worsening (PsA cohort). Conclusion: This analysis of a large, contemporary cohort of EU patients with established RA, axSpA or PsA shows treatment effectiveness maintained at 48 weeks after switching from ADL to SB5, with most patients continuing on SB5 Q2W throughout. Episodes of fare were uncommon, and the importance of patient-reported symptoms in recognition of fare is evident. No new safety signals were observed.

Acute Necrotizing Pancreatitis in COVID-19 Disease: A Case Report

Aims and objectives: Gastrointestinal symptoms like abdominal pain can be atypical presentations associated with coronavirus disease. This case report describes the presentation of acute pancreatitis in a patient with moderate COVID-19 infection. Materials and methods: Data were collected from a patient who was admitted with acute pancreatitis as sequelae of COVID-19 infection in our intensive care unit in June 2021. Case presentation: A 25-year-old female with no comorbidities presented to our emergency department with complaints of fever and dry cough for 10 days for which she had taken treatment at home. COVID RTPCR was negative and CT severity was 10/25. She also complained of abdominal pain with vomiting for 2 days. So she was admitted to our hospital on the tenth day of her illness. Laboratory analysis showed >3 times elevation of serum lipase. CT abdomen showed acute pancreatitis with gallbladder sludge. Causes of pancreatitis like gallbladder stones, alcohol, hypercalcemia, and hypertriglyceridemia were excluded by history and investigations. She was diagnosed with acute pancreatitis due to COVID-19. C-reactive protein and D dimer was highly elevated. She was admitted in ICU and was started on conservative management with IV fluids and bowel rest. Oral intake was resumed gradually as tolerated. The patient was maintaining adequate oxygen saturation on room air. Her repeat COVID RTPCR was again negative. However, her CT severity had increased to 14/25. Her total antibody SARS-CoV-2 was highly reactive. She had severe pain which was not improving despite multimodal analgesia which included opioid infusion. She had bilateral minimal pleural effusion and consolidation and required 2-4 L oxygen support. Repeat CT abdomen after a week showed acute necrotizing pancreatitis with gross pancreatic ascites and partial splenic vein thrombosis (modified CT severity index 8). On day 7 of admission, she developed a fever. Blood and urine cultures were sent and empirical antibiotic was started. Urine culture showed Klebsiella pneumoniae and antibiotic was escalated as per sensitivity pattern. Her pain scores persisted to be high despite all measures. On day 14, she developed abdominal distension. Intra-abdominal pressures were normal and repeat CT abdomen showed extensive free fluid with dilated bowel loops which was likely paralytic ileus. A CT-guided pigtail was inserted for continuous drainage of fluid. The ascitic fluid culture showed no organism. Her abdominal distension gradually reduced. We tapered the requirement of opioids day by day and she got symptomatically better. She could tolerate oral feeds better, off oxygen support, and was shifted to wards with pigtail catheter in situ. She stayed in ICU for 26 days. She was doing better in wards and was discharged home after 5 days with oral anticoagulant and other symptomatic medications and was adviced for gastroenterology follow-up after 10 days. Results: A patient was diagnosed with acute pancreatitis associated with SARS-CoV-2 and was treated accordingly. Other causes of acute pancreatitis were excluded in the patient including alcohol, biliary obstruction/gall stones, drugs, trauma, hypertriglyceridemia, hypercalcemia, and hypotension. Conclusion: This case highlights acute pancreatitis as a complication associated with COVID-19 and underlines the importance of evaluating and treating patients with COVID-19 and abdominal pain.