COVID-19 outbreak and acute cholecystitis in a Hub Hospital in Milan: wider indications for percutaneous cholecystostomy

Abstract

Background COVID-19 pandemic has impacted the Italian National Health Care system at many different levels, causing a complete reorganization of surgical wards. In this context, our study retrospectively analysed the management strategy for patients with acute cholecystitis. Methods We analysed all patients admitted to our Emergency Department for acute cholecystitis between February and April 2020 and we graded each case according to 2018 Tokyo Guidelines. All patients were tested for positivity to SARS-CoV-2 and received an initial conservative treatment. We focused on patients submitted to cholecystostomy during the acute phase of pandemic and their subsequent disease evolution. Results Thirty-seven patients were admitted for acute cholecystitis (13 grade I, 16 grade II, 8 grade III). According to Tokyo Guidelines (2018), patients were successfully treated with antibiotic only, bedside percutaneous transhepatic gallbladder drainage (PC) and laparoscopic cholecystectomy (LC) in 29.7%, 21.6% and 48.7% of cases respectively. Therapeutic strategy of three out of 8 cases, otherwise fit for surgery, submitted to bedside percutaneous transhepatic gallbladder drainage (37.5%), were directly modified by COVID-19 pandemic: one due to the SARS-CoV-2 positivity, while two others due to unavailability of operating room and intensive care unit for post-operative monitoring respectively. Overall success rate of percutaneous cholecystostomy was of 87.5%. The mean post-procedural hospitalization length was 9 days, and no related adverse events were observed apart from transient parietal bleeding, conservatively treated. Once discharged, two patients required readmission because of acute biliary symptoms. Median time of drainage removal was 43 days and only 50% patients thereafter underwent cholecystectomy. Conclusions Percutaneous cholecystostomy has shown to be an effective and safe treatment thus acquiring an increased relevance in the first phase of the pandemic. Nowadays, considering we are forced to live with the SARS-CoV-2 virus, PC should be considered as a virtuous, alternative tool for potentially all COVID-19 positive patients and selectively for negative cases unresponsive to conservative therapy and unfit for surgery.

Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

“…Aside from this, this belief was not validated in our study and male sex alone once adjusted for other preoperative factors was not positively associated with a difficult ELLC. Cholecystostomy has been used more frequently during the COVID pandemic and has been described as "an effective and safe treatment thus acquiring an increased relevance" [12]. However, patients in this series who had undergone a prior cholecystostomy had a significantly longer post-operative stay.…”

COVID-19 and Acute Cholecystitis Management: A Systematic Review of Current Literature

“…Somuncu et al ( 21 ) compared the mean LOS between PC and laparoscopic approach and subsequently reported an increase of LOS in the PC group. In a third study, the researchers found a similar post-procedural mean LOS of 9 days in patients who underwent PC ( 12 ). Finally, Martínez Caballero et al ( 18 ) after comparing the mean LOS between surgical and non-surgical approaches revealed a statistically significant increase in the mean LOS, when non-surgical management was applied (9.74 vs. 4.48, p = 0.001).…”

“…More specifically, in the study by Somuncu et al ( 21 ) there was one (7.1%) mortality due to cardiac arrest in the group of patients who underwent PC. Moreover, in the study by Barabino et al ( 12 ) one out of the 8 patients who underwent a cholecystostomy experienced an immediate complication (transient parietal bleeding) requiring conservative treatment (blood transfusion and intravenous infusion of tranexamic acid). The study by Martínez Caballero et al ( 18 ) reported an overall postoperative complications rate of 26%, with the most frequent ones classified as Clavien–Dindo grade I (70.1%, p < 0.01), while severe complications (grades IV–V) were noticed in 14.9% of patients.…”

“…As a matter of fact, PC was frequently preferred on many occasions as a combination of potentially life-saving and less invasive treatment options, taking into consideration that it can serve as a bridge therapy allowing patients to survive severe disease and stabilize until they undergo a cholecystectomy ( 21 ). Moreover, in some cases, PC was chosen over surgery, taking into consideration the severity of pulmonary complications related to the disease ( 12 , 33 ).…”

Predictors of biliary intervention in patients hospitalized for COVID-19

“…During the first surge of the COVID-19 pandemic in early 2020, effective patient and resource management ensuring the safety of both the patients and healthcare providers represented an unprecedented challenge. Percutaneous cholecystostomy tube placement, traditionally performed for treatment of acalculous cholecystitis or as a bridge to laparoscopic cholecystectomy in patients who are poor surgical candidates, had a relative increase in volume [ 7 – 10 ]. This trend likely reflected both a shift toward non-surgical treatment of acute cholecystitis during the pandemic, as well as an increase in the number of critically ill patients on mechanical ventilation, which itself is a risk factor for acalculous cholecystitis due to biliary stasis and gallbladder ischemia [ 11 ].…”