COVID-19 Pandemic and the Cholecystitis Experience at a Major Urban Safety-Net Hospital

Pediatric Cholecystectomy Case Volume and Complexity Following the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic.

METHODS

A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis.

RESULTS

Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients.

CONCLUSIONS

Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.

Gallbladder perforation causing local peritonitis in left upper abdomen: A case report

INTRODUCTION AND IMPORTANCE

Type 1 gallbladder perforation (GBP) in the free abdominal cavity causes pan-peritonitis, which is both rare and difficult to diagnose.

CASE PRESENTATION

An 80-year-old man presented to our hospital with acute left upper abdominal pain. Twenty days prior to presentation, he had been admitted for 12 days with coronavirus disease 2019 (COVID-19). The patient had mild cholecystitis and received conservative therapy for COVID-19. Upon readmission, his abdomen was flat and soft except for local peritonitis in the left upper abdomen. An emergency laparoscopy revealed a perforation in the ventral wall of the gallbladder neck discharging pus under the lateral lobe of the liver without a gastrointestinal perforation. Therefore, a laparoscopic cholecystectomy and intra-abdominal lavage were performed. Based on the clinical and pathological findings, the GBP was suspected to be a rupture of the abscess in the Rokitansky-Aschoff sinus observed on magnetic resonance imaging during the first admission.

DISCUSSION

In this case, acute cholecystitis was suppressed by conservative therapy, leaving adhesions of the surrounding tissue and viscus to the gallbladder fundus and body as well as an abscess in the wall of the neck. This was the cause of the GBP and resulted in local peritonitis within the left upper abdomen.

CONCLUSION

Type 1 GBP develops suddenly and cannot be predicted. In cases of acute cholecystitis once suppressed by conservative therapy and accompanied by cystic formation in the gallbladder wall, early cholecystectomy is recommended considering the risk of GBP.

Multimorbidity in middle-aged women and COVID-19: binary data clustering for unsupervised binning of rare multimorbidity features and predictive modeling

BACKGROUND

Multimorbidity is typically associated with deficient health-related quality of life in mid-life, and the likelihood of developing multimorbidity in women is elevated. We address the issue of data sparsity in non-prevalent features by clustering the binary data of various rare medical conditions in a cohort of middle-aged women. This study aims to enhance understanding of how multimorbidity affects COVID-19 severity by clustering rare medical conditions and combining them with prevalent features for predictive modeling. The insights gained can guide the development of targeted interventions and improved management strategies for individuals with multiple health conditions.

METHODS

The study focuses on a cohort of 4477 female patients, (aged 45-60) in Piedmont, Italy, and utilizes their multimorbidity data prior to the COVID-19 pandemic from their medical history from 2015 to 2019. The COVID-19 severity is determined by the hospitalization status of the patients from February to May 2020. Each patient profile in the dataset is depicted as a binary vector, where each feature denotes the presence or absence of a specific multimorbidity condition. By clustering the sparse medical data, newly engineered features are generated as a bin of features, and they are combined with the prevalent features for COVID-19 severity predictive modeling.

RESULTS

From sparse data consisting of 174 input features, we have created a low-dimensional feature matrix of 17 features. Machine Learning algorithms are applied to the reduced sparsity-free data to predict the Covid-19 hospital admission outcome. The performance obtained for the corresponding models are as follows: Logistic Regression (accuracy 0.72, AUC 0.77, F1-score 0.69), Linear Discriminant Analysis (accuracy 0.7, AUC 0.77, F1-score 0.67), and Ada Boost (accuracy 0.7, AUC 0.77, F1-score 0.68).

CONCLUSION

Mapping higher-dimensional data to a low-dimensional space can result in information loss, but reducing sparsity can be beneficial for Machine Learning modeling due to improved predictive ability. In this study, we addressed the issue of data sparsity in electronic health records and created a model that incorporates both prevalent and rare medical conditions, leading to more accurate and effective predictive modeling. The identification of complex associations between multimorbidity and the severity of COVID-19 highlights potential areas of focus for future research, including long COVID and intervention efforts.

Increases in pediatric cholecystectomy during the COVID-19 pandemic: An interrupted time series analysis

BACKGROUND

Historically, cholecystectomy is infrequently performed in children. Lifestyle changes, delays in healthcare access, and increases in childhood obesity occurred during the COVID-2019 pandemic. It is unclear whether these changes impacted pediatric gallbladder disease and the need for cholecystectomy.

METHODS

A retrospective study of children ≤18 years old undergoing cholecystectomy from January 1, 2016, to July 31, 2022, at a tertiary children's hospital was conducted. On March 19, 2020, a statewide mandatory coronavirus disease 2019 stay-at-home policy began. Differences in children undergoing cholecystectomy before and during the pandemic were identified using bivariate comparisons. An interrupted time series analysis identified differences in case volume trends.

RESULTS

Overall, 633 children were identified-293 pre-pandemic and 340 pandemic. A majority were female sex (76.3%) and Hispanic (67.5%), with a median age of 15 years (interquartile range: 13.0-16.0). Children who underwent cholecystectomy during the pandemic had significantly higher body mass index (28.4 versus 25.8, P = .002), and obesity (body mass index >30) was more common (45.3% versus 31.7%, P = .001). During the pandemic, significant increases in complicated biliary disease occurred-symptomatic cholelithiasis decreased (41.5% versus 61.8%, P < .001) and choledocholithiasis (17.9% versus 11.6%, P = .026), gallstone pancreatitis (17.4% versus 10.6%, P = .015), and chronic cholecystitis (4.7% versus 1.0%, P = .007) increased. The number of cholecystectomies performed per month increased during the pandemic, and on interrupted time series analysis, there was a significant increase in month-to-month case count during the pandemic (P = .003).

CONCLUSION

Cholecystectomy case volume significantly increased during the coronavirus disease 2019 pandemic, possibly secondary to increases in childhood obesity. Future studies are needed to determine whether this increased frequency of pediatric cholecystectomy is representative of broader shifts in pediatric health and healthcare use after coronavirus disease 2019.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

A retrospective single-institution review of the impact of COVID-19 on severity of biliary disease

BACKGROUND

The COVID-19 pandemic possessed far-reaching health implications beyond the public health impact that have yet to be fully elucidated. We hypothesized that the COVID-19 pandemic led to an increase in biliary disease complexity and incidence of emergency cholecystectomy.

METHODS

We reviewed our institutional experience with cholecystectomy from February 2019-February 2021, n = 912. Pre COVID-19 pandemic patients were compared to patients after the onset of the pandemic. Baseline characteristics were compared between groups. A Cochran-Armitage test for trend assessed the temporal impact of COVID-19 on emergency presentation and gallbladder disease complexity.

RESULTS

We identified 442 patients pre-pandemic and 470 patients during the pandemic. No significant differences were noted in demographics. COVID-19 significantly impacted emergency presentation (43.2% vs. 56.8%, p= <0.01), cholecystitis (53.2% vs 61.8%; p=<0.01), and gangrenous cholecystitis (2.8% vs 6.1%; p=<0.01). Both groups had similar clinical outcomes.

CONCLUSIONS

The COVID-19 pandemic affected an increased incidence of emergency presentation and complexity of gallbladder disease but did not significantly impact clinical outcomes. These findings may have broader implications for other diseases possibly affected by COVID-19.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the presentation of paediatric acute appendicitis: an observational study

Aim

To determine whether there were differences in the clinical presentation of patients imaged to evaluate for acute appendicitis in 2020 compared to 2019 with the hope that this information might better identify patients who should undergo imaging work-up and those who should not.

Materials and methods

This retrospective observational study included patients <18 years who were evaluated for appendicitis between 1 March and 31 May 2019 and 2020. A total of 465 patients were stratified by final diagnosis (appendicitis versus not appendicitis) and compared based on presenting symptoms, physical examination findings, vital signs, and laboratory test results.

Results

Symptoms and physical examination findings that were significant in the positive cohort in both years included right lower quadrant pain, pain with movement, migration of pain, right lower quadrant tenderness, and peritoneal findings. Reporting upper respiratory symptoms was an independent predictor of negative results among all patients and in 2019. Both negative cohorts were more likely to have negative physical examinations. Anorexia and nausea/vomiting were more likely among positive cases in 2019 whereas diarrhoea was more likely among positive cases in 2020.

Conclusions

The COVID-19 pandemic did not significantly change the presenting features of acute appendicitis. The results of the present study emphasise the importance of the physical examination. The ambiguity of symptoms that mimic gastroenteritis justifies imaging in these patients.

Management of Symptomatic Gallstone Disease during COVID-19 Lockdown in a High-Resource Setting: Is There a Need for Treatment Alterations?

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.

The Impact of COVID-19 Pandemic upon Non-Elective Admissions and Surgery at a Safety-Net Hospital

Introduction

Materials and Methods

Results

Conclusions

Acute Cholecystitis Management During the COVID-19 Pandemic – A Systematic Review and Meta-analysis

<br><b>Aim:</b> The aim of this study is to evaluate the prevalence of acute cholecystitis (AC) and review its possible management options during the COVID-19 pandemic.</br> <br><b>Methods:</b> The present systematic review and meta-analysis was done in accordance with the PRISMA guideline. In August 2021, two independent reviewers reviewed a number of articles with the aim of finding studies on the management of acute cholecystitis during the COVID-19 pandemic. Articles were searched in the Cochrane, Embassies, and Medline libraries. Using the Stata statistical software 14, the estimated pooled rates were calculated. Funnel plot and I2 indices were applied for evaluating the heterogeneity between the studies.</br> <br><b>Results:</b> An overall of 8 studies consisting of 654 patients suspected for AC were included. The prevalence of COVID-19 among our included patients was 82% (95% CI: 79–84%, I2: 99.2%). Regarding the type of management, 35% (95% CI: 26–45%, I2: 46.9%) of patients undergone cholecystectomy, 47% (95% CI: 43–51%, I2: 54.4%) were managed by non-surgical methods, and 19% (95% CI: 14–23%, I2: 68.1%) of patients were treated by percutaneous cholecystostomy. The prevalence of grade 2 and 3 among our patients was 44 and 15%, respectively.</br> <br><b>Conclusions:</b> Considering the fact that due to the current pandemic, the number of patients referring with higher grades is assumed to be increased, early cholecystectomy remains the best management option for AC patients. However, LC seems not to be the most favorable option since it is associated with a relatively higher risk of contamination with COVID-19. PC can also be considered as a temporary and safe method in high-risk patients which might enable us to protect both patients and healthcare providers.</br>