Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy.

Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. The pathogenesis of CAP in the context of cholecystitis is unknown but is possibly related to the inflammatory process in the vicinity of the cystic artery, leading to weakness in the wall of the artery. Though CAP has been reported in the literature, our patient had a unique presentation in the presence of a cholecystostomy catheter in situ. There were no risk factors for CAP in our patient including usage of anticoagulants, trauma, or surgical procedures. Fortunately, the blood-stained fluid in the cholecystostomy catheter effluent alerted the clinical team to a possible vascular complication in the background of ongoing cholecystitis. This finding should serve as a warning sign to alert clinicians to the possibility of CAP-beware of rattling underfoot.

COVID-19 associated spontaneous hemorrhagic cholecystitis

Hemorrhagic cholecystitis is a rare disorder associated with considerable morbidity and mortality. The clinical presentation of hemorrhagic cholecystitis is non-specific and imaging findings can be difficult to accurately interpret without a high level of suspicion. Most recent reports of hemorrhagic cholecystitis have been associated with concurrent therapeutic anticoagulation. Here, we report imaging findings of a case of acute, spontaneous hemorrhagic cholecystitis in a 67-year-old male patient admitted for hypoxic respiratory failure secondary to COVID-19 pneumonia. © 2022

Acalculous Cholecystitis: A Novel and Lethal Unrecognized Complication in Severe CoVID 19

Background. SARS-COV-2 infection is known to cause tissue damage in several organs outside of the respiratory tract. The pathogenesis of tissue damage is hypothesized to be caused by direct viral damage, endothelial injury, and ischemic or thrombotic events. Gastrointestinal symptoms were first characterized mainly as diarrhea and diffuse abdominal pain and discomfort, which can be hard to interpret in the setting of a generalized inflammatory response;gallbladder injury and inflammation causing acute acalculous cholecystitis has been scarcely reported Methods. Here we discuss five cases of patients presenting with symptoms of cholecystitis. All five patients underwent multiple imaging studies, and all of them were compatible with acute cholecystitis;some of them had an imaging report of lithiasic cholecystitis, while the rest were reported with microlithiasis or biliary sludge. Four out of the five patients underwent laparoscopic cholecystectomy;biopsies were taken, consistently those reported with acalculous cholecystitis. The remaining patient died of CoVID 19 complications prior to surgery, but after a percutaneous cholecystostomy tube was placed. Results. All these patients have in common the prolonged fasting, because they all required invasive mechanical ventilation, consequently, they all developed multiple focal pneumonia and respiratory distress syndrome. This fast is related to the development of gangrenous ischemia in the gallbladder, which manifests as a late complication due to SARS-CoV-2 infection, in addition to being related to angiotensin-2 converting receptors and virus replication proteins, as well as the pro-inflammatory and hypoxia state that in itself causes the infection (9). All showed a cholestatic pattern, highlighting that this complication developed in an average time of 3 weeks after the onset of SARS-CoV2 symptoms, in addition to the fact that in most cases a negative test was already shown at the time of the complication. Conclusion. Acalculous cholecystitis is one of the extrapulmonary complications that has been seen in patients with this infection, not being the most common, but one of those that has generated a higher mortality rate in patients due to its late diagnosis and non-specific clinical picture in certain occasions (9).

A Closed Loop Audit on the Management of Acute Cholecystitis During the Covid-19 Pandemic

Background: The definitive management of acute cholecystitis is laparoscopic cholecystectomy on the same admission, if the patient is fit. However, as the Covid-19 pandemic emerged, evidence suggested adverse outcomes for asymptomatic Covid positive patients undergoing surgery, including increased mortality risk. Risks to theatre staff were also highlighted. This prompted changes in guidelines produced by the Association of Upper Gastrointestinal Surgeons (AUGIS) in March 2020, which strongly supported the conservative non-surgical management of acute cholecystitis. Method(s): This closed loop audit aimed to establish whether patients with acute cholecystitis were managed in accordance with AUGIS guideline changes at our hospital. It also aimed to assess the clinical outcomes of the guideline changes. This retrospective audit focused on patient admissions with acute cholecystitis at our hospital during the 2 peaks of the Covid-19 pandemic. The timeframe of the initial audit was 17th April - 14th May 2020 (4 weeks). The timeframe of the re-audit was 1st - 28th February 2021 (4 weeks). Handover sheets and clinical software were the data sources. The initial audit was presented at the General Surgery departmental clinical governance meeting in September 2020 and formed the educational intervention. Result(s): 24 patients with acute cholecystitis were included in the initial audit, and 25 patients in the re-audit. The initial audit found that 15 patients (62.5%) with acute cholecystitis were managed conservatively with IV antibiotics, 4 patients (16.6%) had a percutaneous cholecystostomy, and 5 patients (20.8%) underwent laparoscopic cholecystectomy during their index admission. Following our educational intervention, the re-audit found that 22 patients (88%) were treated conservatively, 1 patient (4%) had a percutaneous cholecystostomy, and 2 patients (8%) underwent laparoscopic cholecystectomy. The mean length of hospital stay reduced from 5.67 days in the initial audit, to 3.88 days in the re-audit. 30 day readmission rates also reduced from 5 patients (20.8%) to 0 patients (0%). 2 patients aged >60 years died from unrelated causes during their index admission. They had Charlson Comorbidity Index scores >2. Conclusion(s): Management of acute cholecystitis was more compliant with AUGIS guidelines following the educational intervention. Importantly, overall, conservative non-surgical management did not clinically disadvantage patients, and was not associated with the development of complications of acute cholecystitis, such as gallbladder empyema or perforation. Indeed, the re-audit revealed shorter length of hospital stay and lower 30 day readmission rate than the initial audit. For vulnerable patients at risk of serious complications from contracting Covid-19, this certainly had positive implications for wellbeing, reducing exposure to the hospital environment. There were also further beneficial implications for limited bed resources. Our findings, however, suggest that flexibility is required in decision-making in the management of acute cholecystitis. In carefully selected patients, for example younger patients with fewer comorbidities, emergency laparoscopic cholecystectomy might avoid future readmission with serious complications of gallstones, such as ascending cholangitis and pancreatitis. The evidence from our local audit suggests that AUGIS guideline changes may overall benefit and improve the clinical outcomes of patients with acute cholecystitis. However, decisions about management should be in the interests of, and tailored to, the individual patient.

Management and outcomes of gallstone disease during the SARS-CoV-2 Coronavirus pandemic

Aims: The aim of this study was to compare The patient demographics and management of acute manifestations of gallstone disease during The COVID-19 pandemic with an equivalent period in 2019 and assess The differences in recurrence patterns over The period of first and second wave of The pandemic. Method(s): A retrospective cohort study of all adult patients aged >16 years presenting to The Emergency Department at a large District General Hospital with symptoms related to gallstones was conducted. Data was obtained from electronic patient records. Primary outcome assessed were incidence and management of gallstone disease while secondary outcome studied included length of Stay, re-admission rate and recurrence. Data was tabulated and analyzed using Excel (Microsoft, 2016 version). Chi square, t-test and one way ANoVA tests were used. Result(s): 51 patients presented during The period of first wave and 105 patients during second wave as compared to 71 patients in The study period during 2019. The median age of patients during The first wave of COVID was significantly higher than pre COVID and that in second wave. During both The waves of The pandemic, there was a no significant difference in patients presenting with cholecystitis compared with 2019 (47 and 94 versus 60;P value 0.39). There was no significant increase in use of cholecystostomy. There was no significant difference in recurrence and readmissions. Majority of The patients still await surgery. Conclusion(s): During The pandemic, older patients with higher comorbidity presented with acute gallstone disease. Conservative management was effective in The management of these patients.

How has the management of acute Biliary pathology changed as a result of the SARS COV2 pandemic?

Aims: Gallbladder pathology is a common cause of Emergency admission under General surgery-however management had to be drastically changed given The unexpected pressures of The SARS-CoV-2 pandemic. This study aimed to compare management strategies in patients presenting with Biliary pathology pre and intra-SARS-CoV-2 pandemic in one NHS truSt. Method(s): A database of patients admitted to The acute surgical admissions ward in The months of November 2019 and 2021 was accessed, patients with Biliary presentations were isolated and information about these admissions analysed. Result(s): In 2019 4 of 57 (8.7%) of patients admitted with Biliary pathology had a laparoscopic cholecystectomy during that acute admission, compared to 8 of 65 (12.3%) in 2021. For all interventions (including ERCp and cholecystostomy) these values were 14 of 57 (25%) in 2019 and 24 of 65 (37%) in 2021. of 54 patients in 2019 who did not have laparoscopic cholecystectomy on index admission, 9 were readmitted (16.7%). The median duration of admission for all Biliary patients on index admission was 4 days in 2019 compared to 5.9 days in 2021. Conclusion(s): SARS COV2 has precipitated a change in management of acute Biliary patients. There is now an increased rate of intervention during The index admission and subsequent increase in admission duration. This is seen as an improvement in The pathway for patients in The long term, reducing The burden on The elective waiting list and reducing re-admission which will of fset The modest increase in length of stay on The index admission.

The impact of CoVD-19 on the Surgical management of acute cholecystitis

Aim: The Association of Upper Gastrointestinal Surgeons (AUGIS) recommends performing a laparoscopic cholecystectomy within 72 hours of admission for acute cholecystitis. COVID-19 has drastically affected The way healthcare is able to be delivered worldwide. This project was designed to audit The impact of COVID-19 on The Surgical management of acute cholecystitis against AUGIS guidelines. Method(s): All General Surgical admission from November 2020 were retrospectively analysed. Admission records were screened for those presenting with acute cholecystitis. Those identified had their records analysed for laparoscopic cholecystectomy. Patients who died before surgery, had an alternative procedure performed, or who were unfit for surgery, were excluded. Result(s): During this time, 28 patients were admitted with acute cholecystitis. In total, 3 patients were excluded: 1 died before any possible intervention, 1 was unfit for surgery, and 1 received a cholecystostomy. of The 25 included patients, only 11% (n=3) patients received a laparoscopic cholecystectomy within seven days from their hospital admission. The remaining 89% (n=22) of patients were managed conservatively with fluids, analgesia, and antibiotics. Conclusion(s): It can be concluded that COVID-19 has severely impacted The Surgical management of acute cholecystitis as only 11% of those patients presenting were managed in accordance with AUGIS guidelines. Whether conservative management is an alternative long-term option for management remains to be seen as further long-term studies are needed.

Evaluating the outcomes of patients treated with Surgical vs IR cholecystostomy during the COVID-19 pandemic

Aims: We evaluated The outcomes of patients treated with laparoscopic cholecystostomy versus percutaneous (IR) cholecystostomy during The COVID-19 pandemic. Method(s): Electronic records of patients undergoing cholecystostomy during The COVID-19 peak in 2020 were analysed. Our primary outcomes were The number of readmissions and subsequent completion of laparoscopic cholecystectomy. Result(s): 6 patients underwent laparoscopic cholecystostomy between January and December. 3 were performed following failure of cholecystectomy, 2 were unfit for cholecystectomy and one underwent Surgery due to lack of radiologist availability. 9 IR cholecystostomies occured between March and July. 4 were unfit Surgical candidates, 5 were due to COVID related restrictions on operating. 6 readmissions came from The Surgical cohort, 4 for infection compared to 3 from The IR cohort with only 1 for infection. Notably, of The 4 IR-drained patients deemed unfit, only one had a subsequent gallbladder related admission. 3 Surgical patients underwent definitive surgery, 2 subtotal and 1 total cholecystectomy with a mean time to definitive treatment of 27.5 weeks. 4 IR patients underwent Surgery with 1 abandoned, 1 subtotal and 2 total cholecystectomies with a mean time to definitive management of 20.25 weeks. Conclusion(s): IR cholecystostomy showed reduced readmission rates compared to laparoscopic cholecystostomy, especially related to infection with rates of 11% and 66%, respectively. More patients underwent total laparoscopic cholecystectomy following IR drainage. However, adhesion formation proved troublesome in both methods. IR cholecystostomy showed a reduced time to definitive surgery. Finally, most high-risk patients undergoing IR cholecystostomy had no further gallbladder related admissions therefore proving its utility in such groups.

Global Overview of the Management of Acute CHOLEcystitis during the COVID-19 Pandemic: The CHOLECOVID Study

Introduction: National guidance issued in response to COVID-19 resulted in adoption of non-surgical modes of treatment in emergency surgery, including acute cholecystitis (AC). The CHOLECOVID Study is the definitive global audit of the management and outcomes of AC during COVID19. Method(s): Patients >18 years with acute cholecystitis during two predefined 8-week time periods, pre-pandemic (P1, 12/09/19- 12/11/19) and during the pandemic (P2, 12/03/20-12/05/20), were included. The primary outcome was 30-day all-cause mortality. Secondary outcomes included severity of AC, radiological diagnostic modalities implemented, definitive management and pulmonary complications. Result(s): 9,783 patients were included from 40 countries. 30-day mortality was higher in P2 (1.7%vs2.4%;p<0.015). Higher rates of moderate and severe AC were seen in P2 (30.1%vs35.1%, p<0.001;3.7%vs4.1%, p<0.001). First-line CT imaging was more common in P2 (36.3%vs46.3%;p<0.001). Cholecystostomy rates were higher in P2 (5.8%vs8.8%;p<0.001), with a reduction in cholecystectomy (23.4% vs 44.2%, p<0.001). Overall 4.6% (n=193) of P2 patients were COVID-19 positive, with overall mortality of 0.7% (n=30). Following adjustment using a natural effects mediation analysis, a diagnosis of acute cholecystitis during the pandemic was associated with almost 30% higher odds of death compared to the pre-pandemic. Conclusion(s): During the COVID-19 pandemic, a small increase in mortality among AC patients was noted, when compared to the pre-pandemic cohort. Patients during the COVID-19 pandemic presented with more severe AC, resulting in altered trends in diagnosis and management. Clear pathways are required to prevent disruption of services and safely manage AC moving forward, in the face of the ongoing COVID-19 pandemic. Copyright © 2022

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Acute bacterial myocarditis due to Salmonella bacteremia is a rare cause of ST-segment elevation that can manifest as acute decompensated heart failure, life threatening arrhythmias, and sudden cardiac death. CASE PRESENTATION: A 62-year-old male with a past medical history of HTN, HLD, DM2, and TIA presented with nausea, vomiting, nonbloody diarrhea, and right upper quadrant pain for five days. He quickly decompensated in the ED, becoming increasingly hypotensive, tachycardic, and lethargic concerning for sepsis. Broad spectrum antibiotics and IV fluids were initiated. Chest X-ray revealed multifocal pneumonia. Labs revealed a metabolic acidosis consistent with acute hypoxic respiratory failure warranting emergent intubation. CTA chest showed multifocal pneumonia and Covid-19 antigen testing was negative. Troponin I was elevated at.211 ng/mL (n <.08) and ECG showed new onset atrial fibrillation, for which cardiology was consulted. On admission to the ICU, repeat labs showed acute renal failure and he was anuric warranting hemodialysis initiation. Despite medical optimization, his Troponin I trended up to 1.458 ng/mL, and repeat ECG showed 2:1 atrial flutter with new ST-elevations in leads II, III, and aVF, consistent with an acute inferior STEMI. Labs did not show hyperkalemia nor hypercalcemia. Transthoracic echocardiography revealed normal systolic and diastolic function, with a left ventricle ejection fraction of 65-70%. A heparin infusion was started and he was taken for a cardiac catheterization which showed no evidence of occlusive CAD. His blood cultures revealed Salmonella enteritidis for which he was switched to ciprofloxacin. Abdominal ultrasound appeared benign, but CT abdomen with contrast showed findings of cholecystitis, which was confirmed on HIDA scan. Gastroenterology and Surgery were consulted who recommended a cholecystostomy tube placement, with a delayed laparoscopic cholecystectomy (LC) when stable. Repeat ECG following the LC showed complete resolution of the previous STEMI. He was discharged to a rehabilitation facility where he made a full recovery. DISCUSSION: Acute bacterial myocarditis can mimic acute coronary syndromes and warrants a high index of suspicion in the setting of Salmonella bacteremia. Our patient presented with signs of acute cholecystitis and an ECG concerning for acute STEMI. Bacterial etiologies of myocarditis are less reported in the literature compared to viral infections, and are seen more often in patients with severe sepsis such as our patients. Common findings associated with Salmonella myocarditis include ST-segment elevation on ECG and elevated troponin levels. Serial ECG findings can distinguish myocarditis from acute myocardial infarction. Early diagnosis is essential to improve outcomes and reduce mortality. CONCLUSIONS: Acute bacterial myocarditis can mimic acute coronary syndromes. Reference #1: Villablanca P, Mohananey D, Meier G, Yap JE, Chouksey S, Abegunde AT. Salmonella Berta myocarditis: Case report and systematic review of non-typhoid Salmonella myocarditis. World J Cardiol. 2015;7(12):931-937. doi:10.4330/wjc.v7.i12.931 Reference #2: Sundbom P, Suutari AM, Abdulhadi K, Broda W, Csegedi M. Salmonella enteritidis causing myocarditis in a previously healthy 22-year-old male. Oxf Med Case Reports. 2018;2018(12):omy106. Published 2018 Nov 26. doi:10.1093/omcr/omy106 Reference #3: Majid A, Bin Waqar SH, Rehan A, Kumar S. From Gut to Heart: Havoc in a Young Patient with Typhoid-associated Cardiomyopathy. Cureus. 2019;11(7):e5049. Published 2019 Jul 1. doi:10.7759/cureus.5049 DISCLOSURES: No relevant relationships by Mohamed Faher Almahmoud No relevant relationships by JONATHAN BROWN No relevant relationships by Hytham Rashid No relevant relationships by Syed Raza

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

Introduction: Since the beginning of the COVID-19 pandemic, many patients with clinically acute presentations have been approached differently. The fear of viral transmission along with the short period of study made patients delay their hospital visits and doctors reassess the approach of certain acute situations. This study aimed to assess the changes in the management of patients with acute cholecystitis before and during COVID-19. Methods: A systematic review of the literature using PubMed (MEDLINE), Scopus, and ScienceDirect databases was performed until 01 September 2021. Totally, two kinds of studies were included, those assessing the management of acute cholecystitis during COVID-19 and those comparing the periods before and during the pandemic. The outcomes recorded include management approaches, complications, and mean length of stay. Results: A number of 15 eligible articles were included in the study. During the pandemic, six studies revealed a shift toward conservative management of acute cholecystitis and five of them reported that conservative management was opted in 73% of the patients. On the contrary, data from all studies revealed that the surgical approach was preferred in only 29.2% of patients. Furthermore, when comparing the periods before vs. during COVID-19, the conservative approach was reported in 36.3 and 43.2% before vs. during COVID-19, respectively, whereas surgical intervention was performed in 62.5% of patients before COVID-19 and 55.3% during the pandemic. The length of stay was delayed when a non-surgical approach was selected in most studies. Complications, mainly classified by the Clavien-Dindo scale, were higher in the pandemic period. Conclusion: A tendency toward more conservative approaches was observed in most studies, reversing the previously used surgical approach in most cases of acute cholecystitis. In most of the examined cases during the COVID-19 pandemic, antibiotic treatment and percutaneous cholecystostomy were much more considered and even preferred.

Cholecystitis treatment and reimbursement trends

Purpose: Cholecystitis accounts for more than 200,000 hospital admissions per year in the United States with increasing rates and hospital charges over the past two decades (Wadhwa et al. 2017). Recent evidence-based guidelines have advocated for early surgical cholecystectomy (SC), reserving percutaneous cholecystostomy (PC) for the critically ill or patients with prohibitive co-morbidities. Purpose: To identify management trends of cholecystitis to validate current practice patterns and reimbursement rates Materials and Methods: All patients undergoing PC placement in a tertiary care hospital from 2010 to 2020 were reviewed. Inclusion criteria consisted of age >18, indication of cholecystitis, and no past PC. Additionally, all patients undergoing SC (laparoscopic or open approach) were reviewed, with surgical data becoming available in 2014. Inclusion criteria included age >18 and indication of cholecystitis. Medicare reimbursement was determined by Current Procedural Terminology (CPT) code. Years with multiple reimbursement rates were averaged. Linear regression analysis was performed. Results: A total of 2522 patients presenting for procedural treatment of cholecystitis were included. 391 underwent PC with interventional radiology with an average age (± stdev) of 64 ± 14.9 years (range: 20-96). 2131 patients underwent SC, average age 55.1 ± 17.6 years (range: 20-100). Over the follow up period, there was a significant increasing trend in PC placement (R2=0.58, P=0.006). Trend of surgical data is notable for a non-linear, though upward trend, increasing from a rate of 181 cases/year in 2014 and 2015, peaking at 481 in 2018, then followed by sharp decline over the subsequent two years, with 260 cases in 2020. From 2010-2020, Medicare reimbursement stayed relatively stable with overall small decreases in payment. There were notable declines for PC reimbursement from 2010 to 2011, decreasing from $551.2 to $392.77 and laparoscopic cholecystectomy reimbursement from $817.28 to $728.69 between 2012 and 2013. Conclusion: The increasing rate of cholecystitis over the past decades is associated with increases in both PC and SC and declines in the rates of reimbursement. After trending upward, surgical intervention was shown to decline after 2018, possibly secondary to availability of PC, or macroeconomic factors such as changes in management guidelines, reimbursement rates, or the COVID-19 pandemic.

Effects of COVID-19 pandemic on management of acute cholecystitis: A single tertiary center's experience

Following the spread of novel coronavirus (COVID-19) pandemic, surgical associations have issued their different recommendations for managing the acute cholecystitis (AC) clinic during the pandemic. We aimed to examine the effects of the COVID-19 pandemic period on our clinical approach in patients who presented to the emergency department with abdominal pain and were diagnosed with AC. Medical records of patients diagnosed with AC in the emergency room between 11 March 2020 and 10 March 2021 and in the same period of one year before the pandemic were retrospectively reviewed. Patients were divided into 2 groups as COVID-19 period (Group 1) and non-COVID period (Group 2). Demographics and clinical characteristics, treatment modalities, and outcomes of these two groups were compared. The number of patients diagnosed with AC in the emergency department decreased during the ongoing COVID-19 pandemic. When the time between the onset of the complaints and the admission to the emergency service was evaluated, no statistically significant difference was found between the groups (p>0.05). The distribution of cholecystitis type and TG18 severity grading for AC were similar in both groups (p>0.05). While percutaneous cholecystostomy (PC) is more preferred in the treatment of AC during the pandemic period and the number of delayed interval laparoscopic cholecystectomy decreased, AC management was similar in both periods with no significant statistical difference (P>0.05). In conclusion, our clinical approach and management in the treatment of AC did not differ when compared to the pre-pandemic period.

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>.

Percutaneous Cholecystostomy for Acute Cholecystitis: A Three-Year Single-Centre Experience Including During COVID-19.

Introduction Percutaneous cholecystostomy is a recognised treatment modality for acute cholecystitis. Traditionally, its use was reserved for patients deemed unfit for surgery. However, the coronavirus disease 2019 (COVID-19) pandemic had a detrimental effect on both elective and emergency surgery. The utilisation of cholecystostomy thus increased. Unanswered questions remain over timing with respect to interval cholecystectomy. We evaluated our local practice over the preceding three years. Methods A retrospective analysis was performed of all patients who had a percutaneous cholecystostomy inserted over a three-year period (1 January 2018-1 January 2021). The primary outcome was time to cholecystectomy. Secondary outcomes were cholecystostomy-related complications, 30-day mortality, cholecystectomy-related complications and length of postoperative hospital stay. Results A total of 31 patients were identified during the period. Thirteen (42%) patients went on to have a laparoscopic cholecystectomy. The median time interval from cholecystostomy to cholecystectomy was 97 days (interquartile range [IQR]: 81-140, minimum: 47 and maximum: 791). One case was complicated by small bowel perforation; this occurred after an interval of 106 days. The median length of postoperative stay was one day (IQR: 1-1, minimum: 0 and maximum: 4). Cholecystostomy-related complications were observed in four (13%) patients, whereby three became displaced and one developed blockage. Thirty-day mortality following cholecystostomy insertion was zero. Conclusions Percutaneous cholecystostomy is a safe and effective intervention for the management of acute cholecystitis. Interval cholecystectomy should be carefully considered; it may be safer to perform prior to 90 days.

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.

Acute acalculous cholecystitis on a COVID-19 patient: a case report.

INTRODUCTION: We report an extremely rare case of acute acalculous cholecystitis on a COVID-19 patient. In our knowledge, this is the first report of laparoscopic cholecystectomy performed on a COVID-19 patient. PRESENTATION OF CASE: A COVID-19 patient was diagnosed with acute acalculous cholecystitis and a multidisciplinary team decided to perform a percutaneous transhepatic biliary drainage (PTBD) as the first treatment. SARS-CoV-2 RNA was not found in the bile fluid. Because of deterioration of the patient's clinical conditions, laparoscopic cholecystectomy had to be performed and since the gallbladder was gangrenous, the severe inflammation made surgery difficult to perform. DISCUSSION: Acalculous cholecystitis was related with mechanical ventilation and prolonged total parenteral nutrition, in this case the gangrenous histopathology pattern and the gallbladder wall ischemia was probably caused by vascular insufficiency secondary to severe acute respiratory distress syndrome of COVID-19 pneumonia. The percutaneous transhepatic gallbladder drainage (PTBD) was performed according to Tokyo Guidelines because of high surgical risk. Laparoscopic cholecystectomy was next performed due to no clinical improvement. The absence of viral RNA in the bile highlights that SARS-CoV-2 is not eliminated with the bile while it probably infects small intestinal enterocytes which is responsible of gastrointestinal symptoms such as anorexia, nausea, vomiting, and diarrhoea. CONCLUSIONS: Although the lack of evidence and guidelines about the management of patient with acute cholecystitis during COVID-19 pandemic, laparoscopic cholecystectomy, at most preceded by PTGBD on high surgical risk patients, remains the gold standard for the treatment of acute cholecystitis on COVID-19 patients.