Introduction The covid‐19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID‐19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID‐19‐infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in‐patient admissions are inevitable. Methods Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre‐COVID‐19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results. Results The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d). Conclusion The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.
Background Acute cholecystitis is an emergency condition, typically arising from gall bladder stones and often leading to unplanned surgical admissions to hospital. In the UK, gall stone disease accounts for approximately one third of all unplanned general surgical admissions. According to the The Royal College of Surgeons' Commissioning guidance, early management of acute cholecystitis in particular is the key to prevent further development of more serious complications that can lead to mortality (up to 10%). Therefore, urgent admission to secondary care and laparoscopic cholecytectomy are recommended once diagnosis is confirmed . Conservative management is not recommended as gallbladder inflammation often persists despite medical therapy which can lead to further attacks and risk of developing gall bladder perforation ( mortality in 30% of cases). Early laparoscopic cholecystectomy is also associated with reduced hospital costs and earlier recovery. During the first wave of COVID-19, the guidelines changed in order to limit the admission rates to free up spaces for possible COVID-19 infected patients. Crisis approach entailed conservative management with pain relief, antibiotics plus or minus cholecystostomy. However, reviews of this approach have not been widely published to assess the results and in turn planning our future management approach in case of other COVID-19 surge. Methods Our study included all the patients diagnosed with acute cholecystitis who needed surgical intervention in one medical Centre in the UK. The time table of the study is divided into 3 periods the pre- COVID era from 16/12/2019 to 15/03/2020 (group I), then during the first lock down era from 16/03/2020 to 30/06/2020 (group II) and, finally after the ease of the lock down from 01/07/2020 to 02/09/2020 (group III). Pre- and post-lockdown time periods the CholeQuIC approach was followed while during the lockdown era, patients were initially treated conservatively followed by surgical managemnt in case of failure to improve. Laparoscopic cholecystectomy was performed, however, in difficult cases conversion to open surgery occurred. The primary outcome was to Compare and perform analysis of the three distinctive periods regarding, delayed presentation, the degree of operative difficulty, which was quantified by analysing the operative time, blood loss, rate of drain insertion and rate of conversion into open surgery. Furthermore, a review of unfavourable intra-operative findings such as extensive adhesion to surrounding organs, hydrops, empyema, gangrene, and/or perforation of the gallbladder was done. The post-operative results were also analysed, according to the length of hospital stay, and the rate of post-operative complications. Results Operative difficulty The mean operative time before the lockdown was 71.6 minutes while it was 81.0 and 78.0 minutes during and post COVID respectively. In terms of conversion to open, the rate reached 10.5 % during the lockdown, while the figures were 4.9% and 3.13% during the pre and after lockdown respectively. Moreover, intra peritoneal drains were used in more than one quarter of the patients (28.9%) during the lockdown era compared to 11.5 % and 12.5% pre and post the lockdown respectively. Considerable blood loss occurred in 10.5%. Intra-operative findings During the lockdown, 28.9 % exhibited extensive adhesions between the gall bladder and surrounding structures. This level is almost three times the percentage during the pre and post-lockdown time periods (8.2% and 9.4% respectively). As for gangrenous cholecystitis, it was 18.4 % during the lockdown, 6.6% before and 6.3% after the lockdown respectively. Post-operative results Before the lockdown the average LOS was 2.9 days which increased to 8.9 days during the lockdown, followed by a decrease to 2.4 days following the ease of lockdown. The lockdown era depicted the highest rate of post-operative complications (bile leakage 7.9%, missed stones 5.3% and duodenal injury 2.6 %). Conclusions During crisis periods tough measures and decisions are made to deal with the situation, however, these decisions can lead to grave consequences on the medical staff and most importantly on patients. As shown in this study and supported by the previous studies, conservative management of acute cholecystitis led to serious complications as many patients were re-admitted for emergency surgery as a result of failure of the non-surgical approach. Moreover, delayed emergency surgery was associated with increased operative difficulties and higher percentage of serious intra and post-operative complications. All this led to longer hospital stay which can prove the failure of this approach. Unfortunately in our Unit, whilst closely studying acute gall bladder disease, we have found that the conservative approach appears to have back-fired and did the exact opposite. Therefore, we believe that there is nil to support conservative treatment of acute cholecystitis in our Unit. We believe that the evidence as displayed suggests that rapid surgery provides best outcome for individual patients and our system, perhaps especially when under strain for other reasons.
Background Sentinel lymph node biopsy is the gold standard for axillary assessment of patients with clinically node negative breast cancer. The current internationally accepted methods comprise of the usage of either a radioactive tracer, vital stains or the combination of both. However, in developing countries radioactive tracer is not widely used due to its high cost and limited availability. In addition, the classic retro-areolar blue dye injection has a high failure rate.Objective Our study aimed to assess the efficacy of patent blue dye injection in the upper outer quadrant of the breast after validation by concurrent usage of radioactive nanocolloid, in comparison with the classic retro-areolar injection in identifying the sentinel node. Methods A randomized control study involving 279 patients randomly divided into two groups. In group A lateral injection of 1% patent blue dye (validated by radioactive nanocolloid) was used, while subdermal patent blue dye injection in the retro-areolar space was performed in group B. ResultsThe new technique showed the promising results with lower failure rate (3.4%) in comparison with the classic retro-areolar patent blue injection (13.7%). Conclusions The lateral injection technique can be result in comparable results to the combination technique with the added benefit of being widely available and a cheaper option especially in developing countries.
Background Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with intermediate-stage hepatocellular carcinoma (HCC). Drug-eluting bead (Deb)-TACE is associated with a reduction in liver toxicity and drug-related adverse effects compared with chemotherapy-TACE. This retrospective paired cohort study compares the outcomes of DEB-TACE in patients with HCC greater than and less than 5 centimeters. Methods Sixty-nine patients had Deb-TACE as the primary treatment for HCC over a 3-year period from May 2019 -to May 2022. Patients were paired into two unmatched groups according to tumour size. Group A; tumour size > 5cm and group B tumour size < 5cm. Each group was then compared following a single or repeated treatment of Deb-TACE. Tumour response was evaluated using the standardised modified Response Evaluation Criteria in Solid Tumours (mRECIST) to detect evidence of tumour size regression. Patients were classified as having either a complete response (CR), partial response (PR), stable disease (SD),or progressive disease (PD). Also, any adverse outcomes including hepatic decompensation were recorded Results Group A,(34.48%) 10 patients had a single session of Deb-TACE. Post-treatment surveillance showed that 4 patients (44.44%) showed CR, PR in 2 patients (22.22%), SD in 1 patient (11.11%), 2 patients (22.22%) had PD, one patient was still waiting for his follow-up surveillance. On the other hand,(65.52%)19 patients had repeated sessions, CR was evident in 2 patients (10.5%), PR in 1 patient (5.2%), SD in 3 patients (15.7%), PD in 2 patients (10.5%), 7 patients (36.84%) had initial PR followed by CR, 2 patients (10.5%) showed initial SD then PD and finally 2 patients (10.5%) were PR and became PD. Group B, 18 (45%) patients had single Deb-TACE, Patients showing CR were 7(58.3%), PR was detected in 2 patients (16.67%), one patient (8.33%) had SD, 2 patients (16.67%%) showed PD, and 6 patients were still waiting for their surveillance, no response recorded for them. (55%) 22 patients had repeated Deb-TACE sessions. 3 patients(13.6%) showed CR, PR were 4 patients (18.18%), one patient (4.5%) had SD, PD were 6 patients (27.27%). However, 3 patients (13.6%) were PR then showed CR,3 patients (13.6%) were PR became PD and finally 2 patients (9%) were PD became CR. Conclusions DEB-TACE is effective for HCCs > 5cm with a response rate of 66.67% in patients who had a Single DEB-TACE dose as their first treatment and it increased to 79% in patients who had repeated deb-TACE; however, that was not statistically significantly different (P = 0.48). The Patients group who had HCC <5 cm showed responses up to 83% with single-dose compared to 59% for repeated DEB-TACE, this was not statistically significant with (P = 0.25) . There was no difference in complications between the two groups.
Opioids are derived from opiates they include also synthetic and semi-synthetic drugs. Opioids have both recreational and medical uses. Opioid abuse is a worldwide problem with numerous and increasing mortality due to overdose. Opioids act on the opiate receptors as a potent mu receptor agonist resulting in a complex intracellular signals leading to dopamine release causing euphoria, and pain signal blocking. In cases of overdose, there is an excessive effect on respiratory center, resulting in respiratory depression and eventually death. Opioids can lower the perception of pain and in some cases decrease the pain stimulus. Stimulation of opiate receptors results in suppression of pain sensation. Opioids have an extremely wide diversity of durations of action, the intensity and quality of response to opioids can vary significantly between patients. Diagnosis of acute opioid toxicity is mainly clinically and naloxone is the cornerstone of therapy. Opioid addiction traditional treatment includes setting of counseling and mentorship besides drug treatment. Opioid prescription for pain management can have a major impact on future development of opioid use disorder but with careful monitoring and patient education about the potential opioid toxicity and risk of addiction to overcome addiction or overdose development. Opioid addiction has deep impact on workforce productivity in the form of increased absenteeism rate, decreased productive hours and higher rate of work place injuries that lead to economic burden. Our aim is studying the approach for preventing drug abuse and supporting drug users to get their lives back on track and boost workforce productivity.
Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.
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