Post-Operative Outcomes in 'Monti' Construction for Neurogenic Bladders in an Adult Population

INTRODUCTION AND OBJECTIVE: Various diversion techniques exist for the management of neurogenic bladders. In pediatrics, the appendicovesicostomy is a successful approach but may not be applicable for all patients. An alternative is the Yang-Monti ("Monti") catheterizable conduit, created using a section of small bowel. Although commonly used in pediatrics, there are very few series evaluating adults. This study aims to evaluate "Monti" outcomes in an adult population. METHOD(S): Between 1999 and 2022, "Monti" procedures at a single institution were identified using CPT codes, and the list was reviewed to select for adult patients with neurogenic bladder dysfunction. Preoperative data included indications for surgery and patient demographics. Perioperative (day 0 to end of hospital stay) data included time to return of bowel function, length of stay, and perioperative complications. Long-term complications included infections, hospital admissions, and reoperations. Data are presented as means or percentages. RESULT(S): 21 adult patients (male n=8;female n=13) with neurogenic bladder dysfunction were identified. 14 patients developed neurogenic bladder secondary to trauma, while other indications for surgery included idiopathic urinary retention (n=1), tumors (n=2), congenital abnormalities (n=2), multiple sclerosis (n=1), and autoimmune neuropathy (n=1). The mean follow-up time was 3.13 years and mean age at surgery was 35.5 years. The mean time to return of bowel function was 2.7 days (n=14) and postoperative hospital stay was 4.3 days (n=16). Perioperative complications occurred in 10 patients (47.6%) in the first 30 days including UTIs (n=3), surgical site infection (n=3), ileus (n=1), small bowel obstruction (n=1), and suprapubic tube related complications (n=3). Five emergency room admissions for urologic concerns occurred within this period with a total of 28 visits overall. At six month follow-up, a total of six (28.6%) patients had longer-term complications. These included a takedown, a scheduled revision, a hospitalization for complicated UTI, and three patients who were unable to catheterize. Overall, nine patients (42.9%) required reoperation, including three revisions and one cystectomy with conversion to ileal conduit. Two patients expired during the course of this study due to COVID pneumonia and suspected sepsis. CONCLUSION(S): "Monti" procedures are useful for adult patients with neurogenic bladder dysfunction. However, these procedures are associated with significant complications. This information should be used to aid in presurgical counseling.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Acute Pancreatitis in Early Postpartum Woman with Confirmed Covid-19: A Rare Case Report

Background: The Coronavirus disease 2019 (COVID-19) pandemic is a significant challenge for public health and clinical medicine. COVID-19 mainly impairs the respiratory tract. However, gastrointestinal manifestations of COVID-19 are increasingly being recognized. Although acute viral pancreatitis has been described in other viral infections, pancreatic involvement in SARS-CoV-2 disease is still poorly defined. We reported a case of acute maternal pancreatitis in an early postpartum period woman with confirmed COVID-19. Case Presentation: A 31-year-old woman in term pregnancy had a caesarean section due to acute respiratory distress syndrome (ARDS) caused by COVID-19 pneumonia. One day after surgery, her stomach appeared bloated, bowel sounds were weak, and her abdominal circumference increased. Ultrasound examination did not reveal any suspicion of bleeding or hematoma. Her abdominal contrast-enhanced computerized tomography (CT) scan showed small bowel obstruction and oedematous pancreas. Amylase levels increased to 382 units/litre and lipase levels to 724 units/litre. C-reactive protein and procalcitonin were also increased. The diagnosis of sepsis was made, and she received broad-spectrum antibiotics and treatment for the COVID-19 infection. Recovery was characterized by a gradual resolution of abdominal and pulmonary signs and symptoms. A decline of amylase and lipase was observed by the tenth day. On the 13th day, she was extubated and gradually recovered from respiratory symptoms, with a negative result for COVID-19 RT-PCR. Based on this case, we consider that pregnancy and COVID-19 support each other as the cause of acute pancreatitis. Conclusion(s): Early diagnosis and severity classification are essential steps for successful management because late recognition and treatment may allow a greater prevalence of associated complications.Copyright © 2022, Philippine College of Physicians. All rights reserved.

The influence of the national lockdown during the COVID-19 pandemiconSurgical presentations and admissions in a University hospital

Background: The COVID-19 pandemic has significantly revolutionised medical practice around The world. Healthcare resources had to be prioritise for The management of patients infected with The virus whilst routine and elective surgeries were postponed in order to Free up hospital beds in anticipation for The influx of patients with COVID-19 requiring hospital admission. With The government announcing a national lockdown in March 2020, a striking reduction in The number of patients presenting to hospital was noted. Aim(s): Our aim was to establish how The COVID-19 pandemic has impacted on The number and presentations of General Surgical patients in a University hospital. Method(s): We conducted a retrospective study on General Surgical patients who were reviewed by The Surgical team at The University teaching hospital. Data was collected over two 7-weeks periods;between The 23rd March and 10th May 2020 (The first lockdown duration in The UK) and The corresponding 7-weeks in 2019 (that is between 25th March and 12th May 2019). Result(s): The analysis of our data showed that there was a significant reduction in The number of Surgical patients being admitted. 399 patients were admitted between 25th March and 12th May 2019 compared to only 245 patients during The lockdown period. The average admissions per day over The 7-weeks period dropped from 9 admissions per day in 2019 to 5 admission per day during national lockdown. Small bowel obstruction and pancreatitis remained common diagnoses in both 7-weeks periods, however diverticulitis was less common during lockdown.

Phase Ib study of AVB-S6-500 (axl inhibition) in combination with durvalumab (MEDI4736) in patients with platinum-resistant, recurrent epithelial ovarian cancer (NCT04019288) (320)

Objectives: Immune checkpoint blockade (ICB) has demonstrated efficacy in a small fraction of patients with platinum-resistant ovarian cancer (PROC), some with durable responses. The receptor tyrosine kinase AXL and its sole ligand, GAS6, are possible mediators of T cell exclusion and an attractive target due to the expected synergy between AXL inhibition and immune targeting agents. The recommended phase II dose (RP2D), safety, and efficacy of the combination of AXL inhibition via AVB-S6-500 with durvalumab (MEDI4736) were evaluated in patients with PROC. Methods: In this open-label Phase Ib open-label study, patients with PROC received AVB-S6-500 and durvalumab therapy in escalating dosing regimens guided by a Bayesian optimal interval (BOIN) design: durvalumab (1500 mg Q4W) and AVB-S6-500 (10mg/kg Q2W, 15mg/kg Q2W, 20mg/kg Q2W) with durvalumab infused prior to AVB-S6-500. The response was evaluated using modified RECIST v1.1. Pharmacokinetic/pharmacodynamic (PK/PD) studies were collected, and PD-L1 status and tumor/tumor microenvironment AXL and GAS6 staining pre and on-treatment were assessed. Results: Eleven patients with epithelial ovarian cancer (six clear cells [55%], four high-grade serous [36%], one endometrioid histology [1%]) received treatment per protocol. The median number of prior lines of therapy was 3 (range: 1-5);73% (8/11) of patients had received prior bevacizumab. There were no DLTs noted over the 6-week period and no grade ≥3 adverse events attributed to study drugs. Five patients experienced an immune-related AE, most commonly liver enzyme elevations (36%). Infusion reaction with AVB-S6- 500 was noted in the first two subjects, prompting the institution of a premedication regimen, after which only one of the nine additional patients experienced an infusion reaction. Dose delays greater than one week occurred in six (55%) patients;three patients experienced delays for cancer-related complications (small bowel obstruction, pneumonia, severe fatigue), while three patients experienced delays for non-medical causes (COVID/travel, weather). Patients received therapy for a median of two cycles (range: 1-6), and there were no responses noted across all dosing levels. One patient had stable disease, with a duration of response of three months. Only two patients had strong (2+) AXLstaining on pretreatment biopsy, both with high-grade serous histology. The majority of serum AXL levels were within previously demonstrated ranges (range: 5.6-112ng/mL), though two patients had comparatively high levels (102, 112ng/mL). PK/PD analysis revealed expected AVB-S6-500 levels at initial postdose (C1D1), but low levels at trough (C2D1 predose) when compared to prior AVB-S6-500 data [1]. Conclusions: The combination of AVB-S6-500 and durvalumab was tolerable in this PROC patient population at all dosing levels tested. Exploratory studies to correlate lack of response to AXL-GAS6 pathway alterations, tumor microenvironment, and clinical characteristics, such as prior treatment, dosing delays, burden of disease, and ascites, are ongoing.

Protecting Their Privacy: Teenagers & Telemedicine

Introduction: Telemedicine utilization has grown exponentially since the start of the COVID-19 pandemic. Virtual encounters provided a safe platform to continue patient care while mitigating the spread of COVID-19. However, we present a case that highlights the limitations and challenges of telemedicine, especially amongst sexually active teenagers. Case Description: A 15-year-old female presented to the ED with worsening abdominal pain and new onset bilious emesis. Six weeks earlier, she developed diarrhea and abdominal pain which was diagnosed as C. diff colitis. During this time, she had 10 virtual encounters between her pediatrician and GI team. Antibiotics were completed for C. diff with partial improvement, but were restarted after symptoms returned. She also reported vaginal discharge that was treated empirically with antifungals. Given the onset of bilious emesis and acute worsening abdominal pain, she was directed to the ED. She tested positive for COVID-19 and computed tomography of the abdomen/pelvis showed a partial small bowel obstruction (SBO). The first HEADSS exam during this illness was done on admission;she initially denied recent sexual activity. However, when expectations around confidentiality were clarified, she disclosed sexual intercourse ten weeks ago. Chlamydia trachomatis testing was positive and diagnostic laparoscopy for her SBO revealed diffuse adhesive disease consistent with pelvic inflammatory disease (PID) and Fitz-Hugh-Curtis syndrome. Adhesions were successfully lysed, she was started on appropriate antibiotics, her abdominal pain resolved and she was discharged home. Discussion: Telemedicine allows patients access to their physicians with the click of a button. It can prevent delays in diagnosis that would otherwise occur due to the inability to come into the clinic or hospital. However, managing patients through telemedicine can be challenging;this case highlights some of the difficulties. Firstly, there is no physical exam to aid diagnosis. It can also be difficult to discuss sensitive issues over video. Even during inperson visits, confidentiality remains an important yet challenging component for adolescents. With the added component of telemedicine and more family members at home, teen privacy may be at risk and needs to be confirmed during every encounter. Despite the ease, telemedicine must be carefully utilized to ensure adequate adolescent sexual healthcare and confidentiality. Conclusion: This case illustrates a rare presentation of SBO caused by PID in an adolescent female and should remind clinicians to approach abdominal pain in a sexually active adolescent with a broad differential. Moreover, the increased utilization of telemedicine during the COVID-19 pandemic creates opportunities for patient care, though comes with its imperfections. As telemedicine is here to stay, pediatricians must recognize these current limitations to avoid delays in diagnosis and care. (Figure Presented).

EFFECT of SEROSTATUS on the EFFICACY of SOTROVIMAB in PREVENTING COVID-19 PROGRESSION

Background: Sotrovimab is a pan-sarbecovirus monoclonal antibody clinically evaluated for prevention of progression of COVID-19 in high-risk patients early in the course of infection. We investigated the rate of prevention of hospitalization or death by baseline anti-SARS-CoV-2 serostatus. Methods: COMET-ICE (NCT04545060) was a multicenter, double-blind, Phase III trial in nonhospitalized adults with symptomatic COVID-19 and ≥1 risk factor for disease progression. Participants were randomized 1:1 to an IV infusion of sotrovimab 500 mg or placebo. The primary efficacy endpoint was all-cause hospitalization >24 hours or death due to any cause within 29 days. Anti-nucleocapsid SARS-CoV-2 antibody was measured by the Abbott SARS-CoV-2 IgG assay run on the Architect i2000SR immunoassay analyzer. Results: In the final dataset (N=1057), the adjusted relative risk (RR) reduction in all-cause hospitalization or death due to any cause in the sotrovimab group compared to the placebo group was 79% (p<0.001) at Day 29. 70% and 19% of participants were seronegative and seropositive for anti-nucleocapsid protein at baseline, respectively. 11% of participants had unknown antibody status and were excluded. In the seronegative subgroup, 4/365 (1%) participants in the sotrovimab group met the primary endpoint compared to 26/375 (7%) in the placebo group (84% reduction in risk [RR: 0.16;95% CI: 0.06, 0.45]). Of the 4 seronegative participants who received sotrovimab and met the primary endpoint, 1 participant was hospitalized for small intestinal obstruction that was likely unrelated to COVID-19. Two of the 26 seronegative participants in the placebo arm who met the primary endpoint died compared to no deaths in the sotrovimab group. In the seropositive subgroup, conclusions are limited by small numbers. Numerically fewer participants in the sotrovimab group (2/105, 2%) were hospitalized compared to the placebo group (4/97, 4%). Importantly, both hospitalized seropositive participants in the sotrovimab group had an alternative reason for their hospitalization that was likely unrelated to COVID-19 (diabetic foot ulcer, non-small cell lung cancer). Progression rates in the sotrovimab arm were low and similar regardless of serostatus (1% seronegative, 2% seropositive). Safety profile by serostatus was consistent with that reported in the overall population. Conclusion: Sotrovimab appeared to consistently reduce the likelihood of a COVID-19-related hospitalization or death regardless of baseline serostatus.

CMV enteritis causing small bowel obstruction in the picture of COVID-19 pneumonia

Cytomegalovirus (CMV) is a prevalent opportunistic viral pathogen. It may cause gastrointestinal disease in susceptible hosts, mostly either intrinsically or pharmacologically immunosupressed. One unusual presentation of gastrointestinal CMV is obstructing enteritis. The current report presents a case of small-bowel obstruction caused by CMV enteritis in a stable immunocompetent SARSCoV-2 positive patient managed surgically at East Tallinn Central Hospital.

Hypofractionated radiotherapy to the pancreas: U.K. experience

Background: During the COVID19 pandemic, many centres in the UK, shifted towards utilising hypofractionated radiotherapy (RT) to pancreas. We aim to report the UK experience hypofractionated (3-5 fractions) RT to the pancreas from 7 centres in the UK. Rates of toxicity, progression, death and potential prognostic factors were assessed. Univariate and multivariate Cox proportional hazards analyses were performed. Results: 92 patients from 7 centres were included in the analysis (median age 71 (range 49-88). 90% had performance status of 0-1. 66% had locally advanced disease. 53% had RT delivered over 3- 5 fractions (n = 49, median: 30Gy/5f, range:30- 40Gy in 3-5f). The rest had 15-fraction RT with or without concurrent chemotherapy (n = 43, median: 45Gy/15f, range: 36-45Gy/15f). Induction chemotherapy (CT) was used in 64% (FOLFIRINIOX -42/59). Median follow-up was 13 months from first treatment (induction CT or RT). Median overall survival (OS) among all patient was 17 months, (95% CI-14.5-19.5 months). On multivariable analysis, induction CT was the only predictor of improved PFS (median survival (MS) 12 vs 5 months;hazard ratio [HR] 0.23;95% confidence interval [CI]: 0.12-0.44, p < 0.001) and OS (MS 24 vs 11 months;HR 0.15;95% CI: 0.07 - 0.34, p < 0.001). There were no deaths. 4 patients had grade 3+ toxicities (transaminitis, cholecystitis and gall bladder perforation, small bowel obstruction and diarrhoea) -all had concurrent CT. Conclusions: Our survival outcome appears to be comparable with published data from CT + concurrent chemoradiotherapy. Induction CT appears to improve outcome. Careful selection of patients can help maximise advantage in this patient population.

A survey of anaesthetists at Royal Surrey County Hospital regarding approaches to analgesia in patients undergoing emergency laparotomy: pilot of a national survey

Emergency laparotomy is associated with relatively high mortality and morbidity. Initiatives have contributed to improved outcomes, but with limited focus on analgesia. Opioids provide flexible, titratable analgesia, but are poorly tolerated and can be harmful. The reference standard may be thoracic epidural, although most evidence relates to elective surgery. Emergency surgical candidates are likely to have physiological differences compared with elective patients (volume status, infection and coagulation [1]), which may affect analgesic choices. We undertook a pilot survey of anaesthetists at our hospital to assess approaches and variations in practice regarding analgesia for emergency laparotomy. Methods We presented two hypothetical patients to all anaesthetists at our Trust. Patient 1 was young with inflammatory bowel disease with recent high-dose steroid use, evidence of perforated viscera and features in keeping with a systemic inflammatory response. Patient 2 was older with chronic obstructive respiratory disease, presenting with features of small bowel obstruction and evidence of a respiratory tract infection. He had been taking rivaroxaban prophylaxis recently. Respondents were asked questions regarding their primary choice of analgesia as well as any adjuncts they might consider. Results We received 21 responses from 67 surveyed (31%) and results are presented in Table 1. Discussion A low response rate was obtained from all anaesthetic grades, which was possibly due to the survey being undertaken during the first wave of COVID-19. The evidence-base relating to improved peri-operative outcomes with epidural use mainly relates to elective surgery, although this evidence base is growing in the emergency setting [2]. Potential signs of infection (patient 1) were not a deterrent to epidural use, possibly reflecting a risk/benefit consideration by those respondents, although fewer chose epidural for patient 1 than patient 2 with respiratory disease (despite the recent oral anticoagulant use), who would presumably benefit from a reduced likelihood of pulmonary complications. A low choice of adjuncts, such as ketamine and intravenous lidocaine, perhaps reflects uncertainty regarding their efficacy and safe use. Opioid use remains relatively high, perhaps reflecting their established and familiar role of providing effective analgesia, alongside a less established evidence-base for alternatives. We plan a national survey to build on these findings.

The utility of Computerized Axial Tomography (CT) investigation in two week waits colorectal referral pathway: Should it be done more often during the pandemic?

Aim: Colorectal two week wait pathway investigations have been majorly affected due to Covid 19 especially with regards to endoscopy as well as virtual colonoscopy procedures in comparison to CT scan. We aimed to analyze the CT scan findings of colorectal rapid access patients. Method: A total of 1900 patients was referred via the straight to test pathway in the year 2020.A retrospective analysis of CT scan investigation performed in these patients was analyzed. Results: A total of 90 (4.74%) patients had a CT Scan as part of the work.20 patients (22%) of the CT scan revealed malignancy. 10 patients (50%) had metastatic disease on the scan. Among them, 6 (60%) were due to colorectal primary and another 2 (20%) was due to thoracic cancers. The remaining were diagnosed with widespread metastatic disease of unknown origin. Among the remaining 10 patients, Curative surgery was offered to 5 patients with colorectal primary and one patient with hepatocellular carcinoma. The remaining patients were diagnosed with High grade B cell lymphoma, Neuroendocrine tumor, pancreatic mass and primary renal cell carcinoma. One patient had high grade small bowel obstruction due to a band adhesion resulting in emergency surgery and 5% of the patient needed a vascular referral for Abdominal aneurysm. Conclusion: CT scan in two week colorectal referral patients play a significant role in diagnosis of advanced disease. The ease of the procedure makes it more attractive during the pandemic in contrast to endoscopy and virtual-colonoscopy which has been significantly impacted by COVID 19.