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“If we keep on giving boosters to those who have a controversial role in prevention of disease, we are trying to put the cart ahead of the horse. Those who are at high risk of infection like transplant recipients, can lay their hands on the vaccination, it is a good alternative, but not across the board. Let everybody be vaccinated with the second shot before talking about the boosters,” stated Dr Anil Arora, Senior Consultant from Institute of Liver Gastroenterology of Sir Gangaram Hospital, in an exclusive interview with Medically Speaking on administration of booster shots for Covid-19.

Here are a few snippets from the interview:

Tell us really about the tumour, which had been removed by you during the 100^th live webcast surgery through an endoscopic invasion. Tell us a little more about the same layman’s terms.

Dr. Anil Arora: This was a patient who had been going around with the tumour in the summer for almost a year. He had earlier been reluctant to get operated because of the ongoing covid-19. He went to a surgeon who thought the tumour was superficial and maybe it was may be amenable to endoscopy. So, we spent about six hours and fortunately, we were able to remove the whole tumour without any surgery from within the stomach. This is a new technique, called endoscopic submucosal dissection. That is not new in terms of Indian scenario, but to have an early malignancy in the stomach is uncommon in Indian scenario. Most of our patients come late in the course of the illness and they are not fit for endoscopic surgeries. So, this is one of the uncommon varieties of early stomach cancer, which has been very well handled by endoscopic removal without having been subjected to surgery at all.

Many people are delaying their much required surgeries due to this endemic fear of Covid. Even though the top experts and scientists have said that the third we may actually not come the number at an all-time low, why is this fear still remaining?

 Dr. Anil Arora: If you look at the devastating effects of the Covid-19 second wave, it has still not been off of our conscience. People have been affected mentally, physically, socially and economically. People are still recuperating. This is once in a century pandemic. I think most of us will never be able to see it again. And we have experiences and then we are the lucky ones we have survived. We’re still trying to come out of the ripple effects of the second wave.

Do you think that a booster shot is needed perhaps at a later stage at least for the comorbid?

Dr Anil Arora: Anybody who is immunocompromised, or has not had the exposure to protective jabs certainly needs a vaccination. And those who have not got the antibodies made, they are the subgroup of the patients who will certainly need boosters. But having said that, the disease tends to spread among those people who have not been vaccinated. If you look at the Indian data, only one fourth of the population has got the second jab, they still do not have adequate protection.

If on top of that due to lack of availability of the vaccines, if we keep on giving boosters to those who have a controversial role in prevention of disease, we are trying to put the cart ahead of the horse. Those who are at high risk of infection like transplant recipients, can lay their hands on the vaccination, it is a good alternative, but not across the board. Let everybody be vaccinated with the second shot before talking about the boosters.

Talking about the gallbladder gangrene, a rare case you saw, how could it develop? How is it post-Covid symptom?

Dr Anil Arora: See we recently reported a large number of complications occurring in the peri-Covid era, primarily after recovery from Covid. We reported white fungus, black fungus, cytomegalovirus induced colitis and finally we were baffled by influx of the 5 patients with severe inflammation of the gallbladder, leading to the gangrene, four out of which, developed perforation of the gall bladder requiring emergency surgery. We believe that the antigens, which may be persisting in the body or antibodies which have been formed against the virus, may have an affinity for the wild of the epithelium. Now Ace 2 receptors which are conducive to the entry of the virus into the alveolar cells of the lung, which is the most important site of involvement of the covid-19 infection or equally prevalent, in abundance in the bile duct epithelium. So, we believe the combination of effect of Ace 2 receptors will dysregulated immune mechanism would have resulted in severe inflammation involving the bile duct epithelium, as well as compromising the vascular supply causing vasculitis. Combination of the two-event resulting in the double whammy resulted in acalculous cholecystitis, which means these patients had inflammation of the gallbladder, even in the absence of the stones. Acalculous cholecystitis to a stage where it almost lead to gangrene requiring surgery is almost unheard of in covid. We reviewed the literature, there have been five to seven more cases reported in the world literature and we thought we will make everybody conscious of it.

What really is the reason for a condition like this developing? Isn’t it quite fatal as well as whatever little I understand of it?

 Dr. Anil Arora: Of all the cases of cholecystitis is 10% likely to occur in the absence of the gospels and the typical and classical setting for acalculous cholecystitis is a sick patient who is in ICU on prolonged ventilation. Surprisingly these were the patients who had recover from covid, they were at home and presented with fever and symptoms of cholecystitis. So it was not the traditional causes of acalculous cholecystitis in gallbladder gangrene. So, the lesson is, if you have symptoms of inflammation of the gallbladder after recovering from the covid, even in the absence of the gall stones, do not ignore it. Maybe a timely intervention with IV fluids and antibiotics may herald the progress of disease to gangrene requiring surgery.