Delayed diagnosis and subsequently increased severity of acute appendicitis (compatible with clinical-pathologic grounds) during the COVID-19 pandemic: an observational case-control study.

BACKGROUND: During a global crisis like the current COVID-19 pandemic, delayed admission to hospital in cases of emergent medical illness may lead to serious adverse consequences. We aimed to determine whether such delayed admission affected the severity of an inflammatory process regarding acute appendicitis, and its convalescence. METHODS: In a retrospective observational cohort case-control study, we analyzed the medical data of 60 patients who were emergently and consecutively admitted to our hospital due to acute appendicitis as established by clinical presentation and imaging modalities, during the period of the COVID-19 pandemic (our study group). We matched a statistically control group consisting of 97 patients who were admitted during a previous 12-month period for the same etiology. All underwent laparoscopic appendectomy. The main study parameters included intraoperative findings (validated by histopathology), duration of abdominal pain prior to admission, hospital stay and postoperative convalescence (reflecting the consequences of delay in diagnosis and surgery). RESULTS: The mean duration of abdominal pain until surgery was significantly longer in the study group. The rate of advanced appendicitis (suppurative and gangrenous appendicitis as well as peri-appendicular abscess) was greater in the study than in the control group (38.3 vs. 21.6%, 23.3 vs. 16.5%, and 5 vs. 1% respectively), as well as mean hospital stay. CONCLUSIONS: A global crisis like the current viral pandemic may significantly affect emergent admissions to hospital (as in case of acute appendicitis), leading to delayed surgical interventions and its consequences.

The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study.

BACKGROUND: During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed. OBJECTIVE: To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period. METHODS: Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods. RESULTS: Patients' mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03. CONCLUSIONS: Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.

Emergency open surgery with a duodenotomy and successful removal of an impacted basket following a complicated endoscopic retrograde cholangiopancreatography procedure: a case report.

BACKGROUND: Current management of choledocholithiasis entails the use of endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct. A rare complication of this procedure is the impaction of the basket by a large stone, which necessitates lithotripsy. Here we report a case of an impacted basket during ERCP, which was managed by open surgery with a duodenotomy and the manual removal of the basket. CASE PRESENTATION: A 79-year-old Caucasian man was admitted to our department with yellowish discoloration of urine, skin and eyes. Abdominal ultrasonography showed a slightly thickened gallbladder, multiple gallbladder stones, dilated intrahepatic bile ducts and extrahepatic bile extending to 1.1 cm. A computed tomography (CT) scan demonstrated a stone in the common bile duct, which caused dilation of the biliary ducts. The patient was diagnosed with obstructive jaundice secondary to choledocholithiasis; and underwent an ERCP, a sphincterotomy and stone extraction. Four days following discharge, the patient was readmitted with jaundice, abdominal pain, vomiting and fever. He was diagnosed with ascending cholangitis and treated initially with antibiotics. A second ERCP revealed a dilated common bile duct and choledocholithiasis. Stone removal with a basket failed, as did mechanical lithotripsy. Finally, the wires of the basket were ruptured and stacked in the common bile duct together with the stone. During exploratory laparotomy, adhesiolysis, a Kocher maneuver of the duodenum and a subtotal cholecystectomy were performed. Choledochotomy did not succeed in removing the impacted wires together with the stone. Therefore, a duodenotomy and an extension of the sphincterotomy were performed, followed by high-pressure lavage of the common bile duct to remove additional small biliary stones. The choledochotomy and duodenotomy were closed by a one-layer suture, and a prophylactic gastroenterostomy was performed to prevent leakage from the common bile duct and the duodenum. The postoperative course was satisfactory. CONCLUSIONS: This is the first report in the literature of removal of an impacted Dormia basket through the papilla by performing a duodenotomy and an extension of the sphincterotomy, followed by gastroenterostomy.

Microsurgery for management of primary and secondary lymphedema.

OBJECTIVE: The objective of this study was to evaluate the efficacy and safety of lymphaticovenular anastomosis (LVA) in patients with lymphedema. METHODS: A retrospective analysis was conducted of 70 patients suffering from primary or secondary lymphedema who underwent LVA surgery with indocyanine green fluorescence lymphangiography. Postoperative evaluation included qualitative and quantitative volumetric assessment and analysis. Limb volume was measured by circumferential tape measurement volumetric method, in which the limb is subdivided into five segments and each segment's circumference is measured. RESULTS: LVA was performed in 70 patients, 22 with primary lymphedema and 48 with secondary lymphedema. The difference in preoperative upper limb volume was 35% with mean postoperative follow-up of 9 months. The mean number of lymphovenous bypasses was 3.9. The reduction in limb volume at 3, 6, and 12 months was 40.4%, 41%, and 45%, respectively. Patients with early-stage lymphedema had significantly higher volume reductions than patients with late-stage lymphedema at 3, 6, and 12 months (48% vs 18%, 49% vs 22%, and 65% vs 31%; P < .001). For lower extremity lymphedema, the preoperative volume differential was 25.5%. The mean postoperative follow-up was 9 months. The reduction in limb volume at 3, 6, and 12 months was 28%, 37%, and 39%, respectively. CONCLUSIONS: LVA surgery is a safe and effective method of reducing lymphedema severity, especially in upper extremity lymphedema at an earlier disease stage.

Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

OBJECTIVE: We compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open. METHODS: Characteristics of the patients, the hernia and the procedures performed during 2014-2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs. RESULTS: Distributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2-3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001). CONCLUSIONS: This report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.

Resection of an axillary macrocystic lymphatic malformation in a 14-year-old girl using intraoperative indocyanine green lymphography.

Lymphangioma is a malformation of the lymphatic system for which surgical excision is a possible treatment. However, complete excision may be hindered by the lesion's size, anatomic location, unclear borders, and invasion into adjacent tissues. We describe a 14-year-old girl who presented with a rapidly progressing axillary swelling. Magnetic resonance imaging and ultrasound revealed a lymphatic macrocystic multilocular lesion. After preoperative and intraoperative indocyanine green lymphography, a complete surgical excision was achieved without damage to collateral lymphatic channels or surrounding tissues. Intraoperative indocyanine green lymphography may be useful in achieving efficient and safe resection of lymphangioma without damaging unconnected lymphatics.

Chylous ascites as a late complication of one anastomosis gastric bypass-minigastric bypass: case report.

BACKGROUND: One anastomosis gastric bypass- minigastric bypass (OAGB-MGB) is an emerging bariatric surgery that is being endorsed by surgeons worldwide. Internal herniation is a rare and dreaded complication after malabsorptive bariatric procedures, which necessitates early diagnosis and intervention. CASE PRESENTATION: We describe a 29-year-old male with chylous ascites caused by an internal hernia 8 months following laparoscopic one anastomosis gastric bypass. An abdominal CT showed enlargement of lymph nodes at the mesentery, with a moderate amount of liquid in the abdomen and pelvis. An emergent exploratory laparoscopic surgery demonstrated an internal hernia at the Petersen's space with a moderate quantity of chylous ascites. The patient made an uneventful recovery after surgery. CONCLUSIONS: Internal herniation can occur after OAGB-MGB and in extremely rare cases lead to chylous ascites. To our knowledge, this is the first reported case of chylous ascites following one anastomosis gastric bypass.

A unusual case of multifocal pyogenic abscess formation following ERCP procedure.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is essential for managing biliary and pancreatic disorders. Infection is the most morbid complication of ERCP and among the most common causes of ERCP-related death. CASE PRESENTATION: A 69-year-old man presented with right upper quadrant abdominal pain, obstructive jaundice and abnormal liver function tests. Ultrasound revealed cholelithiasis without bile duct dilation. After receiving intravenous antibiotics for acute cholecystitis, the patient was discharged. Two weeks later, an endoscopic ultrasound demonstrated gallstones and CBD dilation of up to 6.4 mm with 2 filling defects. An ERCP was performed with a papillotomy and stone extraction. Twenty-four hours post-ERCP the patient developed a fever, chills, bilirubinemia and elevated liver function tests. Ascending cholangitis was empirically treated using Ceftriaxone and Metronidazole. However, the patient remained febrile, with a diffusely tender abdomen and elevated inflammatory markers. A CT revealed a very small hypodense lesion in the seventh liver segment. Extended-spectrum beta-lactamase positive Klebsiella Pneumonia and Enterococcus Hirae were identified, and the antibiotics were switched to Imipenem and Cilastatin. The hypodense lesion in the liver increased to 1.85 cm and a new hypodense lesion was seen in the right psoas. At day 10 post-ERCP, the patient started having low back pain and difficulty walking. MRI revealed L4-L5 discitis with a large epidural abscess, spanning L1-S1 and compressing the spinal cord. Decompressive laminectomy of L5 was done and Klebsiella pneumonia was identified. Due to continued drainage from the wound, high fever, we performed a total body CT which revealed increased liver and iliopsoas abscess. Decompressive laminectomy was expanded to include L2-L4 and multiple irrigations were done. Gentamycin and Vancomycin containing polymethylmethacrylate beads were implanted locally and drainage catheters were placed before wound closure. Multidisciplinary panel discussion was performed, and it was decided to continue with a non invasive approach . CONCLUSIONS: Early recognition of complications and individualized therapy by a multi-disciplined team is important for managing post-ERCP septic complications. Particular attention should be given to adequate coverage by empiric antibiotics.