COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

Background: During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy.” Methods: The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality. Results: The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%). Conclusions: COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study)

Background: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. Methods: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. Results: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). Conclusion: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

O-299 Analyzing the impact of simple wash versus density gradient sperm preparations on intrauterine insemination outcomes. Is the cost-effective and time-efficient option just as good?

Abstract Study question How do different sperm preparations, such as simple-wash (SW) and density-gradient (DG), impact intrauterine insemination (IUI) outcomes among women seeking fertility treatments? Summary answer Using a population from a large, academic medical center, this study discerned no differences in pregnancy outcomes between SW and DG sperm preparations. What is known already IUI with or without ovulation induction (OI) is often a first-line treatment among couples seeking fertility services. SW and DG are two common methods used to prepare sperm for IUI. In comparison to its latter counterpart, the SW technique is lesser-used, yet is more time-efficient, and cost-effective due to its utilization of only a single centrifugation step. Since the impact of sperm preparation techniques on the post-processing sperm yield and its parameters varies by the method used, the cycle outcomes might differ as well. However, limited data exists on various sperm preparations’ impact on IUI clinical outcomes. Study design, size, duration Data from 3378 IUI+OI cycles (from 1503 women of all diagnoses seeking IUI with fresh-ejaculated sperm) that took place at a large academic fertility center between 9/2014 and 3/2021 were retrospectively reviewed. Cycles were either unstimulated (natural) or stimulated with either oral OI agents (clomiphene-citrate &amp; letrozole) or gonadotropins. Cycles were divided in two groups based on sperm preparation technique: SW (n = 1691) and DG (n = 1687) and outcomes were compared between them. Participants/materials, setting, methods Sperm preparation: SW semen were mixed in 10ml MHM (FujiFilm) and centrifuged for 10min. DG semen were layered over 45:90 gradient of Isolate (FujiFilm), centrifuged for 20min, and washed twice (10min) in 10ml MHM. Outcome measures: hCG-positivity (posHCGR), clinical pregnancy (CPR), spontaneous abortion (SABR), and livebirth rates/cycle (LBR). Statistics: Logistic regression with Odds Ratios (OR) adjusted for both partners’ ages, day-3 FSH, stimulation, and sperm score (poor, fair, good, excellent). Sub-analysis limited cohort to first-cycles only.   Main results and the role of chance Groups were comparable in patient [age (maternal, paternal), BMI, day-3 FSH, infertility diagnosis], and cycle characteristics [follicular response (measured as number of preovulatory follicles), and endometrial thickness]. Preprocessing sperm parameters differed slightly with higher mean sperm concentrations and lower total motility among SW cycles (75.3 + 57.0 vs. 71.0 + 51.3 million, p = 0.02; 48.6 + 19.6 vs. 52.5 + 20.2, p &amp;lt; 0.001, for SW and DG, respectively). posHCGR, CPR, SABR, and LBR per cycle did not differ between groups (15.8% vs. 15.4%, p = 0.76;13.7% vs. 13.2%, p = 0.62;18.1% vs. 18.5%, p = 0.93; 9.5 vs. 8.9%, p = 0.56; for SW and DG, respectively). Odds for posHCG, CP, SAB, or LB did not differ between groups [adjOR(95%CI): 1.05(0.87-1.26), p = 0.65; 1.10(0.67-1.83), p = 0.71; 0.98(0.60-1.60), p = 0.94; 1.08(0.85-1.37), p = 0.66, respectively]. When cycles were stratified by type of ovarian stimulation, rather than adjusted for it, no difference was seen in any of the clinical outcomes within individual strata{adjOR(95%CI): [Oral OI: 1.00(0.74-1.37), p = 0.98; 1.78(0.68-4.61), p = 0.25; 0.97(0.40-2.38), p = 0.95; 1.05(0.72-1.53), p = 0.81], [Gonadotropins: 0.99(0.78-1.28), p = 0.96; 0.93(0.49-1.77), p = 0.83; 0.97(0.52-1.80), p = 0.96; 1.03(0.75-1.41), p = 0.87], [Natural: 2.36(0.97-5.76), p = 0.06; 0.08(0.001-6.84), p = 0.26; 0.20(0.003-11.02), p = 0.43; 2.52(0.63-10.00), p = 0.19], for posHCG, CP, SAB, and LB, respectively}. Similarly, no difference was seen in any of the clinical outcomes when cycles were stratified by sperm score or when analysis was limited to first-cycles only. Limitations, reasons for caution LBR were calculated excluding pregnancies with no information after discharge to obstetrics (approximately 16%). Although not significant, there might be minor variations in individual provider’s practices between time frames in which these techniques were implemented. Wider implications of the findings SW is a much simpler, time-efficient, and cost-effective sperm processing technique for IUI compared to DG, however remains infrequently utilized. Adoption of SW, over DG, could yield comparable clinical efficacy, yet optimize teamwork flow and lower healthcare costs, due to its non-labor-intensive and inexpensive nature. Trial registration number not applicable </jats:sec

Intraductal papilloma of the male breast: A case report and review of the literature

Intraductal papilloma is a benign neoplasm rarely found in the male breast. In this report, we present the case of a 55-year-old Caucasian man who presented with spontaneous bloody nipple discharge of the right breast. Ultrasonic and mammographic investigations revealed a sub-centimetre solid mass within a dilated duct. He underwent a total duct excision. Histopathologic examination confirmed a benign intraductal papilloma with no evidence of atypia or malignancy. A systematic review of the literature revealed six published cases of intraductal papillomas in men. Clinical presentation is the same as in women with single duct blood stained discharge being the most common presenting symptom. Surgical excision offers both histologic confirmation and definitive treatment. There is one case where the lump was not removed and progressed to malignancy years later. Male intraductal papillomas may be associated to medical treatments with hormonal activity given for other reasons or endocrine abnormalities. © The Author(s) 2019

O-184 The impact of cryopreserved sperm on Intrauterine Insemination (IUI) outcomes: Is frozen as good as fresh?

Abstract Study question Are the outcomes of IUI cycles [with or without ovarian stimulation (OS)] comparable when frozen instead of fresh-ejaculated sperm is utilized? Summary answer Overall, clinical outcomes did not differ significantly between frozen and fresh sperm IUI cycles, although specific subgroups might benefit from fresh sperm utilization. What is known already At present, data from animal studies point towards less favorable outcomes with frozen sperm utilization, implicating cryopreservation-induced damages to the cytoskeleton, DNA, and acrosome leading to adverse effects on spermatozoa’s motility, viability, and ability to fuse with the oocyte. Assisted Reproductive Technology (ART) data, mostly focusing on severe male factor infertility diagnoses, suggest no major differences between in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles utilizing frozen over fresh sperm, often surgically extracted. Nevertheless, contemporary data from IUI(±OS) cycles are still scarce. Study design, size, duration Data from 5335 IUI(±OS) cycles (time-period: 01/2004-12/2021) from a large academic fertility center were retrospectively reviewed. Cycles were stratified in two groups based on utilization of frozen instead of fresh-ejaculated sperm for the IUI [FROZEN (n = 1871, all infertility diagnoses), and FRESH (n = 3464, idiopathic infertility diagnosis only), respectively]. Cycle outcomes were compared between groups. Participants/materials, setting, methods Participants: women seeking IUI (±OS) treatments. Outcome Measures: HCG-positivity, clinical pregnancy (CP), spontaneous abortion (SAB) rates. Initial analysis included all cycles irrespective of OS regimen.  Cycles were then stratified by OS regimen into three subgroups [injectable gonadotropins, oral medications (OM): clomiphene-citrate and letrozole, and unstimulated/natural]. Odds ratios (OR) for all relevant outcomes were calculated utilizing logistic regression and adjusted for maternal age, day-3 FSH, and OS regimen. Time-to-pregnancy and first-cycle only analyses were also performed. Main results and the role of chance Unadjusted HCG-positivity, and CP were lower in the FROZEN compared to the FRESH group (12.2% vs. 15.6%, p &amp;lt; 0.001; 9.4% vs. 13.0%, p&amp;lt;.001, respectively), which persisted only among OM after stratification (9.9% vs. 14.2% HCG-positivity, p=.030; 8.1% vs. 11.8% CPR, p=.041, for FROZEN compared to FRESH, respectively). Among all cycles, adjOR(95%CI) for HCG-positivity and CP were respectively: 0.75(0.56-1.02), and 0.77(0.57-1.03), ref: FRESH). Following stratification by OS regimen, adjOR(95%CI) for HCG-positivity and CP showed no difference between groups among gonadotropin and natural cycles but favored the FRESH group in OM cycles [HCG-positivity: 0.55(0.30-0.99); CP: 0.49(0.25-0.95), ref.: FRESH]. SAB odds did not differ between groups among OM and natural cycles but were lower in the FROZEN compared to FRESH group among gonadotropin cycles [adjOR(95%CI): 0.13(0.02-0.98), ref.: FRESH]. However, regarding the latter comparison, numbers were small and the 95%CI wide.  When analysis was limited to first-cycles only and further stratified by OS regimen, the previously noted differences in CP and SAB odds no longer existed within the OS subgroups. Nevetheless, time-to-conception was slightly longer in the FROZEN compared to the FRESH group (3.84 vs. 2.58 cycles, p&amp;lt;.001). Limitations, reasons for caution Study is limited by its retrospective nature. The two groups differed somewhat in age, infertility diagnosis, utilized OS regimen, and as expected in total motile sperm counts. Despite the less favorable characteristics of the FROZEN group, no detrimental effect of sperm cryopreservation on IUI outcomes was noted. Wider implications of the findings Our study, the largest to date, showed no significant difference in IUI outcomes between cycles utilizing frozen instead of fresh-ejaculated sperm. Although, specific subgroups might benefit from fresh sperm utilization and time-to-pregnancy might be shorter with fresh over frozen sperm, patients should be counselled about the non-inferiority of frozen sperm. Trial registration number Not applicable </jats:sec

P–034 Social distancing protocol changes during the COVID–19 pandemic; the effect of at-home semen collection on intrauterine insemination outcomes

Abstract Study question How have the coronavirus 2019 (COVID–19)-driven changes in semen collection protocols, from on-site to at-home collection, impacted intrauterine insemination (IUI) cycle outcomes? Summary answer Our data suggest that at-home semen collection within 2 hours of processing does not negatively impact semen parameters and IUI pregnancy outcomes. What is known already: There are mixed reports regarding the effect of at-home semen collection on IUI outcomes. In a study of 633 cycles, no differences in semen parameters or pregnancy rates were observed between home and clinic collections1. Conversely, in a smaller cohort, at-home collection was associated with worse pregnancy outcomes when IUI was coupled with gonadotropin stimulation, but not when coupled with clomiphene2. We previously reported no differences in semen parameters and in-vitro fertilization (IVF) embryo transfer outcomes, when cycles using semen collected at-home were compared to cycles with on-site collection3. However, such findings cannot necessarily be extended to the IUI setting. Study design, size, duration This is a retrospective cohort study of all 529 IUI cycles that took place in 2020 at an academic fertility center. Semen collected at the “clinic” was used for 143 cycles before the COVID–19 pandemic, and “at-home” collected specimens were used for the 386 cycles following the revised semen collection protocol. Participants/materials, setting, methods: Prior to the COVID–19 pandemic, semen was collected at our “clinic” and processed within ∼30 minutes. Post-COVID, in order to maintain social distancing, semen was collected “at-home”, at an IUI-approved cup, and transported to our center within 2 hours, while maintained to room temperature. Logistic regression models were performed to evaluate the effect of “at-home” collection on achieving pregnancy (positive pregnancy test-PPT) and clinical pregnancy (sonographic confirmation-CP), adjusting for age and anti-Mullerian hormone (AMH). Main results and the role of chance The mean age (SD) (years) of the female partner was 35.4 (4.2) vs. 35.4 (4.4) (p = 0.978) and of the male partner 36.6 (4.4) vs. 37.1 (p = 0.328) for the “clinic” vs. “at-home” groups, respectively. There were no significant differences in day–3 follicle stimulating hormone and AMH. In both groups the most common diagnoses were idiopathic and combined factors infertility (27.3% and 18.9% &amp; 24.1% and 25.1%, respectively for the “clinic” &amp; “at-home” groups, p = 0.376). Similarly, there were no differences regarding ovarian stimulation, and gonadotropins were the most common medication used in both groups (“clinic”: 44.1% vs. “at-home”: 39.4%, p = 0.775). Semen analysis parameters (volume, motility, forward progression, total motile count) were comparable between the 2 groups, with the exception of concentration (mil/ml) which was higher with “at-home” collection [66.1 (45.0) vs. 81.1 (63.0), p = 0.009]. In unadjusted models, “at-home” collection had no significant effect on the odds for a PPT [OR (95%CI): 0.691 (0.427–1.119), p = 0.133] or CP [0.751 (0.447–1.263), p = 0.281]. These results persisted even when adjusting for maternal age and AMH: PPT [0.708 (0.435–1.153), p = 0.165] and CP [0.773 (0.455–1.312), p = 0.340]. When sub-analysis was performed within the different medication groups, the above findings persisted for both gonadotropin and oral medication cycles. Limitations, reasons for caution The limitations of the study include its retrospective design and the absence of livebirth data, given the limited follow up period. However, regarding the latter, one can use the ongoing clinical pregnancy rate as an accurate estimate of livebirth. Wider implications of the findings: At-home semen collection within 2 hours of processing did not negatively impact semen analysis parameters or pregnancy outcomes following IUI. These data constitute an important addition to the current limited literature on the subject and provides an additional level of safety for our patients and staff during the COVID–19 crisis. Trial registration number Not applicable </jats:sec

Identifiable risk factors for lymph node metastases in grade 1 endometrial carcinoma

Objective: The aim of this study was to evaluate the clinicopathological features related to lymph node metastases in grade 1 endometrial carcinomas. Materials and Methods: Five hundred ninety-nine cases of endometrial carcinoma treated with total hysterectomy bilateral salpingo-oophorectomy and pelvic lyphadenectomy between 2001 and 2015 were retrieved from the pathology files of IASOWomen&apos;s Hospital, Athens, Greece. Of these, 345 were grade 1 endometrioid carcinomas and were included in the study. Features such as the age of the patients, the stage, the location, and size of the tumors, as well as the existence of microcystic, elongated, and fragmented pattern invasion or lymph vascular space invasion, were estimated. Results: In our cohort of endometrial carcinomas, features related to an increased risk of lymph node metastases were stages IB or higher; the location of the tumor in the lower uterine segment; the identification of microcystic, elongated, and fragmented pattern of invasion; and the existence of lymph vascular emboli. When considering the size of the tumors, only stage IAmyoinvasive cancers of larger than 4 cmin diameter were significantly associated with nodal disease. In addition, a statistically significant relationship was found between the number of excised lymph nodes and the possibility to detect nodal disease. Conclusions: Full surgical staging carries a substantial risk of operative complications, and, indeed, it can be avoided in most cases of grade 1 endometrial carcinomas. Nevertheless, even in the low-risk group of patients, there are clinicopathological parameters that should alert the clinician for the possibility of a more disseminated disease. Copyright © 2017 by IGCS and ESGO