The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

SAGES guidelines update to laparoscopy in the era of COVID-19

BACKGROUND

Patients requiring cholecystectomy or appendectomy may present with concomitant COVID infection in both the inpatient and outpatient scenarios. It is unclear whether these patients benefit more from operative or nonoperative management in the setting of active COVID infection. These guidelines seek to address urgent and elective clinical scenarios.

METHODS

A systematic review was conducted to address these questions. These results were then presented to an interdisciplinary panel that formulated recommendations based on the best available evidence or utilized expert opinion when the evidence base was lacking.

RESULTS

Conditional recommendations were made in favor of (1) either operative or nonoperative management of COVID-positive patients with appendicitis or cholecystitis and (2) delaying operations by more than six weeks in patients who test positive for COVID in the elective setting.

CONCLUSIONS

These recommendations should provide guidance regarding the management of surgical patients with concomitant COVID infection. This guideline also identifies important areas where future research should focus to strengthen the evidence base.

COVID-19 infection is a significant risk factor for death in patients presenting with acute cholecystitis: a secondary analysis of the ChoCO-W cohort study

BACKGROUND

During the coronavirus disease (COVID-19) pandemic, there has been a surge in cases of acute cholecystitis. The ChoCO-W global prospective study reported a higher incidence of gangrenous cholecystitis and adverse outcomes in COVID-19 patients. Through this secondary analysis of the ChoCO-W study data, we aim to identify significant risk factors for mortality in patients with acute cholecystitis during the COVID-19 pandemic, emphasizing the role of COVID-19 infection in patient outcomes and treatment efficacy."

METHODS

The ChoCO-W global prospective study reported data from 2546 patients collected at 218 centers from 42 countries admitted with acute cholecystitis during the COVID-19 pandemic, from October 1, 2020, to October 31, 2021. Sixty-four of them died. Nonparametric statistical univariate analysis was performed to compare patients who died and patients who survived. Significant factors were then entered into a logistic regression model to define factors predicting mortality.

RESULTS

The significant independent factors that predicted death in the logistic regression model with were COVID-19 infection (p < 0.001), postoperative complications (p < 0.001), and type (open/laparoscopic) of surgical intervention (p = 0.003). The odds of death increased 5 times with the COVID-19 infection, 6 times in the presence of complications, and it was reduced by 86% with adequate source control. Survivors predominantly underwent urgent laparoscopic cholecystectomy (52.3% vs. 23.4%).

CONCLUSIONS

COVID-19 was an independent risk factor for death in patients with acute cholecystitis. Early laparoscopic cholecystectomy has emerged as the cornerstone of treatment for hemodynamically stable patients.

An explainable predictive machine learning model of gangrenous cholecystitis based on clinical data: a retrospective single center study

BACKGROUND

Gangrenous cholecystitis (GC) is a serious clinical condition associated with high morbidity and mortality rates. Machine learning (ML) has significant potential in addressing the diverse characteristics of real data. We aim to develop an explainable and cost-effective predictive model for GC utilizing ML and Shapley Additive explanation (SHAP) algorithm.

RESULTS

This study included a total of 1006 patients with 26 clinical features. Through 5-fold CV, the best performing integrated learning model, XGBoost, was identified. The model was interpreted using SHAP to derive the feature subsets WBC, NLR, D-dimer, Gallbladder width, Fibrinogen, Gallbladder wallness, Hypokalemia or hyponatremia, these subsets comprised the final diagnostic prediction model.

CONCLUSIONS

The study developed a explainable predictive tool for GC at an early stage. This could assist doctors to make quick surgical intervention decisions and perform surgery on patients with GC as soon as possible.

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.

Microbial characteristics of bile in gallstone patients: a comprehensive analysis of 9,939 cases

Introduction

The exact triggers of gallstone formation remain incompletely understood, but research indicates that microbial infection is a significant factor and can interfere with treatment. There is no consensus on the bile microbial culture profiles in previous studies, and determining the microbial profile could aid in targeted prevention and treatment. The primary aim of this study is to investigate the differences in microbial communities cultured from bile specimens of patients with gallstones.

Methods

We collected the clinical characteristics and bile microbial status of 9,939 gallstone patients. Statistical analysis was employed to assess the relationship between microbes and clinical features, and a random forest model was utilized to predict recurrence.

Results

Results showed a higher proportion of females among patients, with the age group of 60-74 years being the most prevalent. The most common type of gallstone was solitary gallbladder stones. A total of 76 microbes were cultured from 5,153 patients, with Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis being the most frequently identified. Significant differences in microbial diversity and positive detection rates were observed across different age groups, types of gallstones, and recurrence status. Positive frequencies of E. coli, Enterococcus faecium, and K. pneumoniae varied significantly by age group and gallstone type. The microbial diversity in the recurrence group was significantly lower compared to the non-recurrence group. The recurrence rate was significantly higher in the group with single microbial species compared to those with no microbes or multiple microbes. For the recurrence group, there were significant differences in the frequencies of seven microbes (Aeromonas hydrophila, Enterococcus casseliflavus, Enterococcus faecium, E. coli, K. pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa) before and after recurrence, with these microbes appearing in a higher number of patients after recurrence. Regression analysis identified patient age, stone size, diabetes, venous thrombosis, liver cirrhosis, malignancy, coronary heart disease, and the number of microbial species as important predictors of recurrence. A random forest model constructed using these variables demonstrated good performance and high predictive ability (ROC-AUC = 0.862).

Discussion

These findings highlight the significant role of microbial communities in gallstone formation and recurrence. Furthermore, the identified predictors of recurrence, including clinical factors and microbial diversity, may help develop personalized prevention and recurrence strategies for gallstone patients.

Enhancing the management of acute and gangrenous cholecystitis: a systematic review supported by the TriNetX database

BACKGROUND

Acute cholecystitis (AC) leads to emergency hospital admissions, and is categorized into mild, moderate, or severe grades, and affects hospital stay, surgery rates, costs, and prognosis. Gangrenous cholecystitis (GC) is the severe form and entails gallbladder wall necrosis and infection, possibly leading to emphysematous cholecystitis (EC), a life-threatening variant: early recognition of such a condition is crucial, since its symptoms may mimic uncomplicated AC. The current literature lacks comprehensive reviews on EC and GC due to their rarity and this study aims to bridge this gap by utilizing the TriNetX database, comparing clinical data of AC with GC outcomes.

METHODS

The study involved data retrieval from PubMed and Medline and the TriNetX database. Initially, 981 English articles were identified, focusing on emphysematous and GC and cholecystectomy. After filtering and reviewing, 73 articles were suitable for inclusion. We analyzed electronic medical records of adults diagnosed with AC, comparing demographics, comorbidities, and medications between medical and surgical intervention groups. Propensity score matching balanced cohorts, and Kaplan-Meier analysis estimated outcomes, while other statistical analyses, including risk ratios (RRs) and odds ratios (ORs), were conducted within TriNetX, with significance set at P<0.05. The study aimed to compare 5-year all-cause mortality in AC patients treated with or without surgery.

RESULTS

We found 9 retrospective studies and 3 prospective studies. Additionally, 70 patients from 62 case reports were utilized for descriptive analyses. From the TriNetX database, a total of 245,668 patients hospitalized for AC we identified. Despite, overweight/obesity was more frequent in the surgery group (24% vs. 14%, P<0.001), hypertension, diabetes mellitus, ischemic heart disease, chronic kidney disease and cerebrovascular diseases were more frequent in the non-operated patients (37% vs. 36%; 20% vs. 17%; 19% vs. 13%; 12% vs. 8%; 11% vs. 6%, respectively, all with P<0.001). The data concerning gastric medications are particularly eloquent, since 43% of operated patients were treated with such drugs versus 33% of non-operated subjects, before surgery (P<0.001). As for Kaplan-Meier analyses, patients who underwent surgery for AC presented generally lower mortality rates in the whole period of follow-up extended to 5 years (RR 0.415, 95% CI: 0.403-0.426; OR 0.364, 95% CI: 0.353-0.376; P<0.001) and this was particularly evident in the first 200 days of observation since index event.

CONCLUSIONS

In GC, timely surgical intervention within 72-96 hours reduces complications, such as infections and hospital admissions. Laparoscopic surgery decreases intensive care unit (ICU) admissions and intra-abdominal abscesses. For AC, proton pump inhibitors (PPIs) seem to increase the risk of surgical intervention. In general, surgery is crucial for overall survival in the first 200 days of post-hospitalization. Anyway, confirmation through additional studies is needed.

Expanded analysis for patients with acute cholecystitis indicates outcomes vary based on COVID-19 status and treatment modality

BACKGROUND

The impact of different phases of COVID-19 infection on outcomes from acute calculous cholecystitis (ACC) is not well understood. Therefore, we examined outcomes of acute cholecystitis during the COVID-19 pandemic, comparing the effect of different treatment modalities and COVID-19 infection status. We hypothesized that patients with acute COVID-19 would have worse outcomes than COVID-negative patients, but there would be no difference between COVID-negative and COVID-recovered patients.

METHODS

We used 2020-2023 National COVID Cohort Collaborative data to identify adults with ACC. Treatment (antibiotics-only, cholecystostomy tube, or cholecystectomy) and COVID-19 status (negative, active, or recovered) were collected. Treatment failure of nonoperative managements was noted. Adjusted analysis using a series of generalized linear models controlled for confounders (age, sex, body mass index, Charlson comorbidity index, severity at presentation, and year) to better assess differences in outcomes among treatment groups, as well as between COVID-19 groups.

RESULTS

In total, 32,433 patients (skewed count) were included: 29,749 COVID-negative, 2112 COVID-active, and 572 (skewed count) COVID-recovered. COVID-active had higher rates of sepsis at presentation. COVID-negative more often underwent cholecystectomy. Unadjusted, COVID-active had higher 30-day mortality, 30-day complication, and longer length of stay than COVID-negative and COVID-recovered. Adjusted analysis revealed cholecystectomy carried lower odds of mortality for COVID-active and COVID-negative patients than antibiotics or cholecystostomy. COVID-recovered patients' mortality was unaffected by treatment modality. Treatment failure from antibiotics was more common for COVID-negative patients.

CONCLUSION

Acute cholecystitis outcomes are affected by phase of COVID-19 infection and treatment modality. Cholecystectomy does not lead to worse outcomes for COVID-active and COVID-recovered patients than nonoperative treatments; thus, these patients can be considered for cholecystectomy if their physiology is not prohibitive.

Effects of the COVID-19 pandemic on short-term postoperative outcomes for colorectal perforation: A nationwide study in Japan based on the National Clinical Database

AIM

Possible negative effects of the COVID-19 pandemic on short-term postoperative outcomes for colorectal perforation in Japan were examined in this study.

METHODS

The National Clinical Database (NCD) is a large-scale database including more than 95% of surgical cases in Japan. We analyzed 13 107 cases of colorectal perforation from 2019 to 2021. National data were analyzed, and subgroup analyses were conducted for subjects in prefectures with high infection levels (HILs) and metropolitan areas (Tokyo Met. and Osaka Pref.). Postoperative 30-day mortality, surgical mortality, and postoperative complications (Clavien-Dindo grade ≥3) were examined. Months were considered to have significantly high or low mortality or complication rates, if the 95% confidence interval (CI) of the standardized mortality (morbidity) ratio (SMR) does not contain 1.

RESULTS

In the NCD, postoperative 30-day mortality occurred in 1371 subjects (10.5%), surgical mortality in 1805 (13.8%), and postoperative complications in 3950 (30.1%). Significantly higher SMRs were found for 30-day mortality in November 2020 (14.6%, 1.39 [95% CI: 1.04-1.83]) and February 2021 (14.6%, 1.48 [95% CI: 1.10-1.96]), and for postoperative complications in June 2020 (37.3%, 1.28 [95% CI: 1.08-1.52]) and November 2020 (36.4%, 1.21 [95% CI: 1.01-1.44]). The SMRs for surgical mortality were not significantly high in any month. In prefectures with HILs and large metropolitan areas, there were few months with significantly higher SMRs.

CONCLUSIONS

The COVID-19 pandemic had limited negative effects on postoperative outcomes in patients with colorectal perforation. These findings suggest that the emergency system for colorectal perforation in Japan was generally maintained during the pandemic.

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.

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.