Perforated Marginal Ulcer in a COVID-19 Patient. Laparoscopy in these Trying Times?
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LETTER TO THE EDITOR
Perforated Marginal Ulcer in a COVID-19 Patient. Laparoscopy in these Trying Times? A. Galvez 1
&
K. King 1 & M. El Chaar 1 & L. Claros 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
We present a 59-year-old male with a past medical history significant a previous laparoscopic Roux-en-Y gastric bypass (RYGB) in 2012. He has lost approximately 80 lbs, with a current body mass index (BMI) of 30.34 kg/m2. Frequent naproxen use for chronic right shoulder pain was reported, but tobacco use was denied. On 4/7/2020, COVID-19 testing was ordered by his family physician due to dry cough, daily fevers, myalgia, and headaches for 1 week. There was known contact to COVID-19 positive patients at work. A nasopharyngeal swab returned positive in 24 h. Three days later, the patient is brought to the ED via ambulance due to a fever, severe headaches, and shortness of breath. On evaluation, the patient’s vital signs were temperature of 101.7 °F, pulse of 101 bpm, blood pressure of 139/93 mmHg, respirations of 30/min, and O2 saturation of 91% via 6 L nasal cannula. Initial laboratory work was notable for a white blood cell count (WBC) of 10.91, with a low relative lymphocyte count of 7%. C-reactive protein and D-dimer were elevated at 264.8 mg/L and 0.84 μg/ml, respectively. The full admission laboratory panel is presented in (Table 1). A portable chest xray found bilateral diffuse lung infiltrates concerning for a multifocal pneumonia (Fig. 1). The patient was admitted to the specialty COVID-19 floor and treated for severe COVID19 as per our institutional protocol, which includes
* A. Galvez [email protected] K. King [email protected] M. El Chaar [email protected] L. Claros [email protected] 1
St Luke’s University Health Network, St Luke’s Weight Management Center, North, 240 Cetronia Rd, Allentown, PA, USA
methylprednisolone at 1 mg/kg/day. For the next 4 days, supplemental oxygen need and WBC count would steadily increase. On hospital day 5, the patient reported a sudden onset left upper quadrant abdominal pain with chest and neck radiation. There was worsening shortness of breath with even higher oxygen requirements. A contrasted CT of the chest, abdomen, and pelvis was ordered. Laboratory values for that day are shown on Table 1. The CT scan found worse pulmonary ground-glass opacities and a large amount of pneumoperitoneum (Fig. 2). Perforated viscus was suspected and surgical consultation was placed. An extensive multidisciplinary discussion between the surgical and pulmonary service was had. Despite current surgical recommendations [1] advising against routine laparoscopy in COVID-19 patients for aerosolization concerns; a laparoscopic approach was decided given availability of laparoscopic high-efficiency particulate air (HEPA) filters (PlumePort® ActiV®. Buffalo filter LLC, CONMED. Lancaster, NY. USA) at our institution. Recent reports of poor outcomes in COVID-19 patients undergoing extensive open abdominal surgery [2] were also taken into accou
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