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Akagi T, Endo H, Inomata M, Shiroshita H, Yamaguchi S, Eguchi S, Wada N, Kurokawa Y, Seki Y, Sakai Y, Yamamoto H, Kakeji Y, Kitagawa Y, Taketomi A, Mori M. Investigation of the impact of COVID-19 on postoperative outcomes using a nationwide Japanese database of patients undergoing laparoscopic distal gastrectomy and low anterior resection for gastric cancer and rectal cancer. Ann Gastroenterol Surg 2024; 8:521-529. [PMID: 38707231 PMCID: PMC11066483 DOI: 10.1002/ags3.12776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 05/07/2024] Open
Abstract
Background The COVID-19 outbreak made conventional medical care impossible, forcing changes in both healthcare providers and patients. In Japan, COVID-19 infection began spreading in earnest in 2020 and exploded in 2021. There was concern that the medical impact of COVID-19 in 2021 would differ from that in 2020. We aimed to clarify the impact of COVID-19 on mortality and anastomotic leakage in laparoscopic surgery for gastric cancer and rectal cancer in Japan using the National Clinical Database (NCD). Methods We collected data from patients who underwent laparoscopic distal gastrectomy (LDG) and laparoscopic low anterior resection (LLAR) from January 2018 to December 2021 from the NCD, a web-based surgical registration system in Japan. The number of surgical cases, monthly incidence of mortality and morbidity (anastomotic leakage), standardized mortality ratio (SMR), and standardized morbidity-leakage ratio (SMLR [ratio of observed patients to expected patients calculated using the risk calculator established in the NCD]) were evaluated. Results The numbers of LDG and LLAR cases continued to decline in the first year of the pandemic in 2020 and were as low in 2021 as in 2020. Although the numbers of robot-assisted LDG and LLAR cases increased, the growth rate was lower than the rate of increase prior to the pandemic. Mortality and anastomotic leakage, two of the most important complications, as assessed by SMR and SMLR, did not worsen during the pandemic in comparison to the pre-pandemic period. Conclusions Laparoscopic surgeries were performed safely in Japan and were not affected by the COVID-19 pandemic.
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Affiliation(s)
- Tomonori Akagi
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Hideki Endo
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masafumi Inomata
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Hidefumi Shiroshita
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Shigeki Yamaguchi
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Surgery, Division of Colorectal SurgeryTokyo Women's Medical UniversityTokyoJapan
| | - Susumu Eguchi
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Norihito Wada
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of SurgeryShonan Keiiku HospitalKanagawaJapan
| | - Yukinori Kurokawa
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Yosuke Seki
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Weight Loss and Metabolic Surgery CenterYotsuya Medical CubeTokyoJapan
| | - Yoshiharu Sakai
- Academic committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Japanese Red Cross Osaka HospitalOsakaJapan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of SurgeryKobe University Graduate School of MedicineHyogoJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery IHokkaido University Graduate School of MedicineHokkaidoJapan
| | - Masaki Mori
- Presidentthe Japan Surgical SocietyTokyoJapan
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Shiroshita H, Endo H, Inomata M, Akagi T, Yamamoto H, Yamaguchi S, Eguchi S, Wada N, Kurokawa Y, Seki Y, Sakai Y, Miyata H, Kakeji Y, Kitagawa Y, Taketomi A, Mori M. The clinical impact of COVID-19 on endoscopic surgery in Japan: Analysis of data from the National Clinical Database. Ann Gastroenterol Surg 2023; 7:572-582. [PMID: 37416738 PMCID: PMC10319603 DOI: 10.1002/ags3.12660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/14/2023] [Accepted: 01/20/2023] [Indexed: 07/08/2023] Open
Abstract
Aim This study aimed to evaluate the impact of the coronavirus disease (COVID-19) pandemic on elective endoscopic surgeries in Japan using the National Clinical Database. Methods We retrospectively analyzed the clinicopathological factors and surgical outcomes of laparoscopic cholecystectomy (LC), laparoscopic distal gastrectomy (LDG), and laparoscopic low anterior resection (LLAR) and compared the monthly numbers of each procedure performed in 2020 with those in 2018 and 2019. The degree of infection in prefectures was classified into low and high groups. Results In 2020, the number of LCs (except for acute cholecystitis) was 76 079 (93.0% of that in 2019), the number of LDGs was 14 271 (85.9% of that in 2019), and the number of LLARs was 19 570 (88.1% of that in 2019). Although the number of robot-assisted LDG and LLAR cases increased in 2020, the growth rate was mild compared with that in 2019. There was little difference in the number of cases in the degree of infection in the prefectures. The numbers of LC, LDG, and LLAR cases decreased from May to June and recovered gradually. In late 2020, the proportion of T4 and N2 cases of gastric cancer and the number of T4 cases of rectal cancer increased compared with those in 2019. There was little difference between the proportions of postoperative complications and mortality in the three procedures between 2019 and 2020. Conclusion The number of endoscopic surgeries decreased in 2020 as a result of the COVID-19 pandemic. However, the procedures were performed safely in Japan.
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Affiliation(s)
- Hidefumi Shiroshita
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Hideki Endo
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Masafumi Inomata
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Tomonori Akagi
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological and Pediatric SurgeryOita University Faculty of MedicineOitaJapan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Shigeki Yamaguchi
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Division of Colorectal Surgery, Department of SurgeryTokyo Women's Medical UniversityTokyoJapan
| | - Susumu Eguchi
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Norihito Wada
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of SurgeryShonan Keiiku HospitalFujisawaKanagawaJapan
| | - Yukinori Kurokawa
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Department of Gastroenterological SurgeryOsaka University Graduate School of MedicineOsakaJapan
| | - Yosuke Seki
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Weight Loss and Metabolic Surgery CenterYotsuya Medical CubeTokyoJapan
| | - Yoshiharu Sakai
- Academic Committee of Japan Society for Endoscopic SurgeryTokyoJapan
- Japanese Red Cross Osaka HospitalOsakaJapan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of SurgeryKobe University Graduate School of MedicineKobeHyogoJapan
| | - Yuko Kitagawa
- Department of SurgeryKeio University School of MedicineTokyoJapan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery IHokkaido University Graduate School of MedicineSapporoHokkaidoJapan
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Strohaeker J, Sabrow J, Yurttas C, Königsrainer A, Ladurner R, Hoenes F. Management of Symptomatic Gallstone Disease during COVID-19 Lockdown in a High-Resource Setting: Is There a Need for Treatment Alterations? Visc Med 2022; 38:265-271. [PMID: 36160825 PMCID: PMC9421663 DOI: 10.1159/000519789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/17/2021] [Indexed: 08/03/2023] Open
Abstract
Introduction Cholecystectomy (CCE) is the treatment of choice of symptomatic gallstones. Due to the SARS-CoV-2 pandemic, operating room (OR) capacities have been reduced. The goal of this study was to evaluate the duration of symptoms of patients presenting with gallstone disease during a lockdown, the surgical management, and the severity grade of their disease. Materials and Methods A cohort study of 353 CCEs performed at a university hospital over two 10-week periods during 2 pandemic lockdowns in Germany compared to corresponding periods in 2018 and 2019. Results During the lockdowns, 101 CCEs were performed compared to 252 in the prior years. The number of elective CCEs was reduced to save OR capacities (p < 0.001), and the most common indication for CCE was acute cholecystitis. The median time to CCE after symptom onset was 3 days in both groups for acute cholecystitis. The severity of cholecystitis was comparable (p = 0.760). The time to CCE after choledocholithiasis was shorter during the lockdowns (median of 4 days vs. 9 days; p = 0.006). Conclusions The incidence and severity of acute cholecystitis during the lockdowns were comparable to the prior years. Acute care surgery was provided at the expense of elective procedures, and there was no need for treatment alterations.
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Gunn CAW, Alam I. Cholecystostomy Outcomes from a Single Centre During the COVID-19 Pandemic Highlight the Need for Robust Local IR Pathways. Cardiovasc Intervent Radiol 2022; 45:1044-1045. [PMID: 35441240 PMCID: PMC9018052 DOI: 10.1007/s00270-022-03151-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Christopher A W Gunn
- Department of General Surgery, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK.
| | - Imran Alam
- Department of General Surgery, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
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Patel MS, Thomas JJ, Aguayo X, Chaloupkova D, Sivapregasm P, Uba V, Sarwary SH. Outcomes of Acute Gallstone Disease During the COVID-19 Pandemic: Lessons Learnt. Cureus 2022; 14:e26198. [PMID: 35891865 PMCID: PMC9306681 DOI: 10.7759/cureus.26198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 12/07/2022] Open
Abstract
Introduction This study aims 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 throughout the first and second waves of the pandemic in the UK. Methods 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. Data were obtained from electronic patient records. The primary outcomes were incidence and management of gallstone disease, while secondary outcomes studied included length of stay, readmission rate, and recurrence. Data were tabulated and analyzed using Excel (Microsoft, 2016 version). Chi-square and t-test were used as appropriate. One way ANOVA test was used to compare data of three groups. Results Fifty-one patients presented during the period of first-wave and 105 patients during the second wave as compared to 71 patients in the study period in 2019. The median age of patients during the first wave of COVID was significantly higher than pre-COVID in the second wave. During both the waves of the pandemic, there was no significant difference in patients presenting with cholecystitis compared with 2019 (47 and 94 in the first and second wave, respectively, versus 60 in 2019; p-value 0.39). There was no significant increase in the use of cholecystostomy, and the use of radiological investigations was comparable. There was no significant difference in recurrence and readmissions. The majority of the patients still await surgery. Conclusion During the pandemic, older patients with higher co-morbidity presented with acute gallstone disease. Conservative management was effective in the management of these patients.
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Ossola C, Piacentino F, Fontana F, Curti M, Zorzetto G, Coppola A, Carcano G, Venturini M. Pocket-sized, wireless-Bluetooth ultrasound system to perform diagnostic and low-complexity interventional procedures in bedridden patients during the COVID-19 pandemic: from intensive care unit to domiciliary service? Eur Radiol Exp 2022; 6:20. [PMID: 35534781 PMCID: PMC9085369 DOI: 10.1186/s41747-022-00273-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/25/2022] [Indexed: 11/10/2022] Open
Abstract
The use of a pocked-sized, wireless-Bluetooth ultrasound portable system with display images presented on a tablet facilitated the work of our radiologists during the first wave of coronavirus disease 2019 (COVID-19) to perform diagnostic and interventional procedures in bedridden patients. The device is equipped with a battery-powered probe without cables that transmits images to a tablet (or a cell phone) through a dedicated App. We hypothesise in future to extend diagnostic and low-complexity interventional procedures from hospitalised patients to at-home patients who are not able to mobilise out of bed or are difficult to transport. This domiciliary service might also reduce the overhead of hospital accesses.
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Affiliation(s)
- Christian Ossola
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Federico Fontana
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Marco Curti
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Giada Zorzetto
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Andrea Coppola
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Giulio Carcano
- Department of General, Emergency and Transplants Surgery, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy
| | - Massimo Venturini
- Department of Diagnostic and Interventional Radiology, Circolo Hospital and Macchi Foundation, Insubria University, Varese, Italy.
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Siegel R, Hohenstein S, Anders S, Strik M, Kuhlen R, Bollmann A. Access to Surgery and Quality of Care for Acute Cholecystitis During the COVID-19 Pandemic in 2020 and 2021 - an Analysis of 12,545 Patients from a German-Wide Hospital Network. J Gastrointest Surg 2022; 26:1462-1471. [PMID: 35445322 PMCID: PMC9020554 DOI: 10.1007/s11605-022-05318-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE To determine effects on admission, treatment, and outcome for acute cholecystitis during the course of the COVID-19 pandemic in 2020 and 2021. METHODS Retrospective analysis of claims data from 74 German hospitals. Study periods were defined from March 5, 2020 (start of first wave) to June 20, 2021 (end of third wave) and compared to corresponding control periods (March 2018 to February 2020). All in-patients with acute cholecystitis were included. Distribution of cases, type of surgery, comorbidities, surgical outcome, and length of stay of all cases with acute cholecystitis and cholecystectomy were compared. In addition, we analyzed the type of treatment (non-surgical, cholecystostomy, or cholecystectomy) for all cases with main diagnosis of acute cholecystitis. RESULTS We could not demonstrate differences in daily admissions over the course of the pandemic (11.2-12.7 patients vs. 11.9-12.6 patients for control periods). Proportion of patients with non-surgical treatment was low and not increased (11.7-17.3% vs. 14.5-18.4%). Cholecystostomy was rare throughout all periods (0-0.5% of all patients). We did not observe an increase in open surgery (proportion of open cholecystectomies 3.4-5.5%). Mortality was generally low (1.5-1.9%) with no differences between periods. Median length of stay was 4 days throughout all periods. CONCLUSION The numerous restrictions during the COVID-19 pandemic did not result in an increase of admissions or surgery for acute cholecystitis. Laparoscopic cholecystectomy has been safely applied during the pandemic. Our results may assure the ability to maintain high quality of surgical care even in times of disruptions to the health care system.
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Affiliation(s)
- Robert Siegel
- grid.412581.b0000 0000 9024 6397Faculty of Health, Witten/Herdecke University, Witten, Germany ,grid.491869.b0000 0000 8778 9382Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Sven Hohenstein
- grid.9647.c0000 0004 7669 9786Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Stefan Anders
- grid.491869.b0000 0000 8778 9382Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Martin Strik
- grid.491869.b0000 0000 8778 9382Department of General, Visceral and Cancer Surgery, Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | | | - Andreas Bollmann
- grid.9647.c0000 0004 7669 9786Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
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The impact of COVID-19 on surgical procedures in Japan: analysis of data from the National Clinical Database. Surg Today 2021; 52:22-35. [PMID: 34783905 PMCID: PMC8592826 DOI: 10.1007/s00595-021-02406-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 12/25/2022]
Abstract
Background and purpose The spread of COVID-19 has restricted the delivery of standard medical care to surgical patients dramatically. Surgical triage is performed by considering the type of disease, its severity, the urgency for surgery, and the condition of the patient, in addition to the scale of infectious outbreaks in the region. The purpose of this study was to evaluate the impact of the COVID-19 pandemic on the number of surgical procedures performed and whether the effects were more prominent during certain periods of widespread infection and in the affected regions. Methods We selected 20 of the most common procedures from each surgical field and compared the weekly numbers of each operation performed in 2020 with the respective numbers in 2018 and 2019, as recorded in the National Clinical Database (NCD). The surgical status during the COVID-19 pandemic as well as the relationship between surgical volume and the degree of regional infection were analyzed extensively. Results The rate of decline in surgery was at most 10–15%. Although the numbers of most oncological and cardiovascular procedures decreased in 2020, there was no significant change in the numbers of pancreaticoduodenectomy and aortic replacement procedures performed in the same period. Conclusion The numbers of most surgical procedures decreased in 2020 as a result of the COVID-19 pandemic; however, the precise impact of surgical triage on decrease in detection of disease warrants further investigation. Supplementary Information The online version contains supplementary material available at 10.1007/s00595-021-02406-2.
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Isherwood J, Karki B, Chung WY, AlSaoudi T, Wolff J, Malde D, Bhardwaj N, Garcea G, Dennison AR. Outcomes of gallstone complications during the COVID pandemic. Br J Surg 2021; 108:e29-e30. [PMID: 33640947 DOI: 10.1093/bjs/znaa068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 12/31/2022]
Abstract
As data and metadata from the SARS-CoV-2 pandemic mature, the true impact on non-cancer, non-emergency surgical practice is becoming apparent. The authors present data on the impact of gallstone disease in their unit during 5 months of the COVID-19 pandemic (March 2020 to August 2020) compared with the equivalent period in 2019. Although the total number of patients presenting with gallstone disease was comparable, there was a decrease in patients with cholecystitis and perforation (although it is possibly too early for these to have presented), and there was a small but worrying increase in patients with gallstone pancreatitis. With the recent increase in alert level to 4 and increased government restrictions in an attempt to avoid a second national lockdown, a consistent national approach is required to mitigate these risks.
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Affiliation(s)
- J Isherwood
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - B Karki
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - W Y Chung
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - T AlSaoudi
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - J Wolff
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - D Malde
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - N Bhardwaj
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
| | - A R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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