Do We "Do No Harm" in the Management of Acute Cholecystitis in COVID-19 Patients?

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Surgical treatment of acute cholecystitis in patients with confirmed COVID-19: Ten case reports and review of literature

BACKGROUND

Research concerning postoperative outcomes of confirmed coronavirus disease 2019 (COVID-19) patients revealed unfavorable postoperative results with increased morbidity, pulmonary complications and mortality. Case reports have suggested that COVID-19 is associated with more aggressive presentation of acute cholecystitis. The aim of the present study is to describe the perioperative assessment and postoperative outcomes of ten patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with concomitant acute cholecystitis who underwent cholecystectomy.

CASE SUMMARY

We report a total of 10 SARS-CoV-2 positive patients with concomitant acute cholecystitis that underwent cholecystectomy. Six patients were males, the mean age was 47.1 years. Nine patients had moderate acute cholecystitis, and one patient had severe acute cholecystitis. All patients were treated with urgent/early laparoscopic cholecystectomy. Regarding the Parkland grading scale, two patients received a Parkland grade of 3, two patients received a Parkland grade of 4, and six patients received a Parkland grade of 5. Eight patients required a bail-out procedure. Four patients developed biliary leakage and required endoscopic retrograde cholangiopancreatography with biliary sphincterotomy. After surgery, five patients developed acute respiratory distress syndrome (ARDS) and required intensive care unit (ICU) admission. One patient died after cholecystectomy due to ARDS complications. The mean total length of stay (LOS) was 18.2 d. The histopathology demonstrated transmural necrosis (n = 5), vessel obliteration with ischemia (n = 3), perforation (n = 3), and acute peritonitis (n = 10).

CONCLUSION

COVID-19 patients with acute cholecystitis had difficult cholecystectomies, high rates of ICU admission, and a prolonged LOS.

Does COVID-19 infection change the need for future surgical interventions? An exploratory analysis

Background: It is unknown whether recovery from coronavirus disease 2019 (COVID-19) infection leads to an increased need for common surgical procedures. Our objective was to conduct an exploratory analysis of surgical procedures performed after a documented COVID-19 infection.  Methods: We conducted a retrospective cohort study using routinely collected data from the province of Ontario, Canada. We identified individuals with a positive COVID-19 test between February 1 2020 and May 31 2020, and matched them 1:2 with individuals who had a negative COVID-19 test during the same period. We used physician billing codes to identify the ten most frequent surgical procedures in the COVID-19 cohort. An at-risk period 30 days after the first positive COVID-19 swab (or matched index date in the control group) until November 30 2020 was used. Cox proportional hazard models (adjusted for important baseline differences) are reported with hazard ratios (HR) and 95% confidence intervals.   Results: After exclusions and matching, we had 19,143 people in the COVID-19 cohort, and 38,286 people in the control cohort. The top ten surgical procedures were hand/wrist fracture fixation, cesarean-section, ureteral stent placement, cholecystectomy, treatment of an upper tract urinary stone, hysterectomy, femur fracture repair, hip replacement, transurethral prostatectomy, and appendectomy. There was a significantly reduced hazard of requiring upper tract renal stone surgery (adjusted hazard ratio [aHR] 0.50, 95% confidence interval [CI] 0.29-0.87) or ureteral stent placement (aHR 0.54, 95%CI 0.36-0.82), or undergoing a cholecystectomy (aHR 0.43, 95%CI 0.26-0.71) among those with a prior positive COVID-19 test.   Conclusions: After a COVID-19 infection there is not an increased risk of needing several common surgical procedures. There appears to be a reduced risk of renal stone disease treatment and ureteral stent placement, and a reduced risk of cholecystectomy, however understanding the reasons for this will require further study.

Comparison of outcomes of the patients with acute cholecystitis treated in the COVID-19 pandemic and pre-pandemic period

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has affected the health care system in an unpredictable way. In this study, we aimed to analyze the effects of the pandemic process on the disease severity on admission, management strategies, and outcomes of patients.

METHODS

The medical records of the patients who applied to the emergency department and consulted to the general surgery clinic from March 2020 until January 2021 were retrospectively reviewed as the pandemic period. For the control group, patients' medical records in the same time interval of 2019 were evaluated as the pre-pandemic period.

RESULTS

A total of 88 patients in the pre-pandemic period and 89 patients in the pandemic period were treated for acute cholecystitis. There was no statistically significant difference between the two groups in terms of the treatment strategies and length of hospital stay between the two periods (p=0.087 and p=0.587, respectively).

CONCLUSIONS

In the pandemic period, it is thought that postponing and bridging treatments may replace surgery for reducing the risk of contamination of both patients and health care workers.

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

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.