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

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

COVID-19 pandemic: is it time for shared surgical guidelines? A systematic review of the literature.

INTRODUCTION: The recent COrona Virus Disease 2019 (COVID-19) pandemic caused a massive disruption of surgical activity and after a year from its first outbreak surgeons still struggle to keep their regular activity coexisting with the virus exhausting requests of healthcare resources. The aim of this paper is to offer a comprehensive overview of the most important recommendations by the International Guidelines about general surgery, and possibly to invite building common shared guidelines to preserve the potential to provide surgical assistance despite the pandemic. EVIDENCE ACQUISITION: This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. PubMed, Embase, Cochrane and Web of Science databases were searched. EVIDENCE SYNTHESIS: The searches revealed a total of 18579 articles published up to the end of February 2021. Five articles published between March and May 2020, were included in the present study: Guidelines from The European Society of Trauma and Emergency Surgery (ESTES), The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and The European Association for Endoscopic Surgeons (EAES), The Endoscopic and Laparoscopic Surgeons of Asia (ELSA), The European Hernia Society (EHS) and The International Organization for the Study of Inflammatory Bowel Disease (IOS-IBD). CONCLUSIONS: In the likely scenario that the SARS-CoV-2 pandemic will become an endemic chronic problem, we should not be forced to choose between COVID-19 or surgery in the future and find a way to make both coexisting.

Ostomy closure rate during COVID-19 pandemic: an Italian multicentre observational study.

During the corona virus disease 2019 (COVID-19) pandemic, most of the surgical procedures were performed for emergencies or oncologic reasons to the detriment of the remaining elective procedures for benign conditions. Ileostomy or colostomy creation are sequelae of oncologic or emergency colorectal surgery, but their closure does not fall within the definition of oncologic or emergency surgery. The aim of this retrospective multicentre observational study is to report the impact of COVID-19 pandemic on the ostomy closure rate in Italy. Data regarding ileostomy and colostomy creation and closure from 24 Italian centres, during the study period (March 2020-February 2021) and during the control period (March 2019-February 2020) were collected. Three hospitals (12.5%) were COVID free. The number of colostomies and ileostomies created and closed in the same period was lower ( -18.8% and -30%, respectively) in the study period in comparison to the control period (p = 0.1915 and p = 0.0001, respectively), such as the ostomies closed in the analysed periods but created before (colostomy -36.2% and ileostomy -7.4%, p = 0.2211 and p = 0.1319, respectively). Overall, a 19.5% reduction in ostomies closed occurred in the study period. Based on the present study, a reduction in ostomy closure rate occurred in Italy between March 2020 and February 2021. During the pandemic, the need to change the clinical practice probably prolonged deterioration of quality of life in patients with ostomies, increasing number of stomas that will never be closed, and related management costs, even if these issues have not been investigated in this study.

Telemedicine in surgery during COVID-19 pandemic: are we doing enough?

INTRODUCTION: The aim of this systematic review was to report and to analyze if there is and what is the impact of telemedicine in the surgical practice during COVID-19 pandemic. Many authors have posited that the pandemic urged a high implementation of the telemedicine service even in surgical specialties, however, the impact of this change of the clinical practice has been variably reported and its utilization in general surgery is uncertain. EVIDENCE ACQUISITION: All articles from any country written in English, Italian, Spanish, or French, about the use of telemedicine for indication to surgical treatment or for 30-day postoperative follow-up in general surgery during the COVID 19 outbreak, from the March 1, 2020, to December 1, 2020, were included. EVIDENCE SYNTHESIS: Two hundred nine articles were fully analyzed, and 207 further articles were excluded. Finally, 2 articles, both published in October 2020, were included in the present systematic review. CONCLUSIONS: In conclusion, the rapid spread of SARS-CoV-2 pandemic has forced to review the traditional methods to deliver surgical assistance and urged surgeons to find alternative methods to continue their practice. The literature about this topic is yet scarce and many questions regarding its efficacy in improving patients' health, cost-effectiveness and user satisfaction remain unsolved.

Laparoscopic repair of giant Morgagni hernia by direct suturing with V-Loc.

BACKGROUND: Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien). METHODS: This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected. RESULTS: Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m². The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences. CONCLUSIONS: Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.

Surgical management protocol during the COVID-19 pandemic in an Italian non-referral center.

BACKGROUND: In the surgical scenario, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion worldwide entails on the one hand the need to continue to perform surgery at least in case of emergency or oncologic surgery, in patients with or without COronaVIrus Disease 2019 (COVID-19); and on the other hand, to avoid the pandemic diffusion both between patients and medical and nursing team. The aim of this study was to report our surgical management protocol during the COVID-19 pandemic in an Italian non-referral center. METHODS: Data retrieved during the outbreak for the COVID-19 pandemic, from March 8 to May 4, 2020 (study period) were analyzed and compared to data obtained during the same period in 2019 (control period). RESULTS: During the study period, 41 surgical procedures (24 electives, 17 emergency surgical procedures) underwent surgery in comparison to 99 procedures in the control period. Stratifying the procedures in elective and emergency surgery, and based on the indication for surgery, the only statistically significant difference was observed in the elective surgery regarding the abdominal wall surgery (0 vs. 13 procedures, P=0.0339). Statistically significant differences were not observed regarding the colorectal and the breast oncologic surgery. All stuff members were COVID-19 free. CONCLUSIONS: The present protocol proved to be safe and useful to prevent SARS-CoV-2 infection before and after surgery for both patients and stuff. The pandemic was responsible for the reduction in number of procedures performed, anyway for the oncologic surgery a statistically significant volume reduction in comparison to 2019 was not observed.