[The COVID-19 pandemic had significant impact on duration of surgery and hospitalization time for patients after cholecystectomy]. / Die Auswirkungen der COVID-19 Pandemie führten zu signifikanten Veränderungen der Operations- und Liegezeiten bei Patienten nach Cholezystektomie.

BACKGROUND: The COVID-19 pandemic made substantial changes in medical care necessary. The aims of this study were to find out what influence the pandemic had on the perioperative course in patients with cholecystectomy (CHE) and to highlight possible residual consequences. METHOD: From 1 July 2018 to 31 December 2021 a total of 735 patients with CHE were analyzed. Up to 21 March 2020 patients were assigned to the regular patient group (Reg, n = 430), patients after this date (first lockdown 22 March 2020) to the Cov19 patient group (Cov19, n = 305) and the 2 groups were compared. RESULTS: The average age of all patients was 59 years and 63% were women. The average length of hospitalization (KrVD, time period between surgery and discharge) was 4.4 days. The patient groups Reg and Cov19 did not differ with respect to age, gender or KrVD. The total number of CHEs carried out was reduced by 21.4% in the Cov19 group. This affected elective and emergency CHE to the same extent. The length of surgery significantly increased in the Cov19 group from 64 min (SD 34 min) to 71 min (SD 38 min). The number of short and long hospital stays (KrVD 2 or >4 days) significantly increased in the Cov19 group from 4 % to 20 % (short stay, p < 0.01) and from 23 % to 27 % (long stay, p < 0.01). This was particularly observed for patients >70 years old with an increase in long stays from 43 % to 56 % in the Cov19 group. CONCLUSION: The COVID-19 pandemic led to a clear reduction in CHE both for elective and emergency interventions. Furthermore, a significant lengthening of the surgery and hospitalization times could be observed for older patients. The residual consequences of the pandemic could be shortened hospitalization times after uncomplicated CHE and more interventional treatment procedures in complex cases.

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>.

The impact of COVID-19 on emergency cholecystectomy.

BACKGROUNDS: The impact of the SARS-CoV-2 virus (COVID-19) upon the delivery of surgical services in Australia has not been well characterized, other than restrictions to elective surgery due to government directive-related cancellations. Using emergency cholecystectomy as a representative operation, this study aimed to investigate the impact of COVID-19 on emergency general surgery in Australia in relation to in-hours versus after-hours operating. METHODS: A retrospective analysis was conducted of medical records for patients admitted with cholecystitis or biliary colic between 1 March 2019 and 28 February 2021 at Frankston Hospital, Australia. Patient demographics, admission data, imaging findings, operative and post-operative data were compared between pre-COVID-19 and COVID-19 periods. Variables were compared using the Wilcoxon-Mann-Whitney, Chi Squared or Fishers exact test. RESULTS: During the COVID-19 period, emergency cholecystectomy was performed for a greater proportion of patients presenting with cholecystitis or biliary colic (93.5% versus 77.7%, p < 0.01). Despite this, there was concomitant reduction in after-hours cholecystectomy from 14.4% to 7.5% (p = 0.04). Patients requiring after-hours surgery during the COVID-19 period had more features of sepsis (23% more tachypnoeic, 18% more hypotensive), and were more likely to have certain features of cholecystitis on imaging (45% more likely to have pericholecystic fluid). CONCLUSION: Following elective surgery cancellations during the COVID-19 period, an increase was seen in the proportion of patients presenting with gallstone disease who were managed with emergency cholecystectomy due to improved theatre access. Concurrently, there was a decrease in the requirement for surgery to be performed after-hours.

Clinical approach to patients admitted to the emergency room due to acute cholecystitis during the COVID-19 pandemic and percutaneous cholecystostomy experience.

BACKGROUND: Acute cholecystitis (AC), a common complication of gallstones, is responsible for a significant part of emergency applications, and cholecystectomy is the only definitive treatment method for AC. Early cholecystectomy has many reported advantages. Operation-related morbidity and mortality have increased during the COVID-19 pandemic. In this study, our aim is to present our general clinical approach to patients who were diagnosed with AC during the pandemic and our percutaneous cholecystostomy experience during this period. METHODS: This study included 72 patients who were presented to our hospital's emergency room between March 11 and May 31, 2020, with AC. Patients were divided into three groups based on their treatment: outpatients (Group 1), inpatients (Group 2) and patients undergoing percutaneous cholecystostomy (Group 3). These three groups were compared by their demographic and clinical characteristics. RESULTS: There were 36 (50%) patients in Group 1, 25 (34.7%) patients in Group 2, and 11 (15.3%) patients in Group 3. The demographic characteristics of the patients were similar. The CRP and WBC levels of the patients in Group 3 were significantly higher compared to the other groups. Moreover, the wall of the gallbladder was thicker and the size of the gallbladder was larger in Group 3. Patients had percutaneous cholecystostomy at the median of 3.5 days and the length of hospital stay was longer compared to Group 2 (3.9 days versus 9.2 days, p=0.00). The rate of re-hospitalization after discharge was similar in Group 2 and Group 3, but none of the patients in Group 1 required hospitalization. None of 72 patients developed an emergency condition requiring surgery, and there was no death. CONCLUSION: Although many publications emphasize that laparoscopic cholecystectomy (LC) can be performed with low morbidity at the first admission in acute cholecystitis, it is a clinical condition that can be delayed in the COVID-19 pandemic and other similar emergencies. Thus, percutaneous cholecystostomy should be effectively employed, and its indications should be extended if necessary (e.g., younger patients, patients with lower CCI or ASA). This approach may enable us to protect both patients and healthcare professionals that perform the operation from the risk of COVID-19.

Histopathological findings in a COVID-19 patient affected by ischemic gangrenous cholecystitis.

BACKGROUND: Since its first documentation, a novel coronavirus (SARS-CoV-2) infection has emerged worldwide, with the consequent declaration of a pandemic disease (COVID-19). Severe forms of acute respiratory failure can develop. In addition, SARS-CoV-2 may affect organs other than the lung, such as the liver, with frequent onset of late cholestasis. We here report the histological findings of a COVID-19 patient, affected by a tardive complication of acute ischemic and gangrenous cholecystitis with a perforated and relaxed gallbladder needing urgent surgery. CASE PRESENTATION: A 59-year-old Caucasian male, affected by acute respiratory failure secondary to SARS-CoV-2 infection was admitted to our intensive care unit (ICU). Due to the severity of the disease, invasive mechanical ventilation was instituted and SARS-CoV-2 treatment (azithromycin 250 mg once-daily and hydroxychloroquine 200 mg trice-daily) started. Enoxaparin 8000 IU twice-daily was also administered subcutaneously. At day 8 of ICU admission, the clinical condition improved and patient was extubated. At day 32, patient revealed abdominal pain without signs of peritonism at examination, with increased inflammatory and cholestasis indexes at blood tests. At a first abdominal CT scan, perihepatic effusion and a relaxed gallbladder with dense content were detected. The surgeon decided to wait and see the evolution of clinical conditions. The day after, conditions further worsened and a laparotomic cholecystectomy was performed. A relaxed and perforated ischemic gangrenous gallbladder, with a local tissue inflammation and perihepatic fluid, was intraoperatively met. The gallbladder and a sample of omentum, adherent to the gallbladder, were also sent for histological examination. Hematoxylin-eosin-stained slides display inflammatory infiltration and endoluminal obliteration of vessels, with wall breakthrough, hemorrhagic infarction, and nerve hypertrophy of the gallbladder. The mucosa of the gallbladder appears also atrophic. Omentum vessels also appear largely thrombosed. Immunohistochemistry demonstrates an endothelial overexpression of medium-size vessels (anti-CD31), while not in micro-vessels, with a remarkable activity of macrophages (anti-CD68) and T helper lymphocytes (anti-CD4) against gallbladder vessels. All these findings define a histological diagnosis of vasculitis of the gallbladder. CONCLUSIONS: Ischemic gangrenous cholecystitis can be a tardive complication of COVID-19, and it is characterized by a dysregulated host inflammatory response and thrombosis of medium-size vessels.

Acute cholecystitis during COVID-19 pandemic: a multisocietary position statement.

Following the spread of the infection from the new SARS-CoV2 coronavirus in March 2020, several surgical societies have released their recommendations to manage the implications of the COVID-19 pandemic for the daily clinical practice. The recommendations on emergency surgery have fueled a debate among surgeons on an international level.We maintain that laparoscopic cholecystectomy remains the treatment of choice for acute cholecystitis, even in the COVID-19 era. Moreover, since laparoscopic cholecystectomy is not more likely to spread the COVID-19 infection than open cholecystectomy, it must be organized in such a way as to be carried out safely even in the present situation, to guarantee the patient with the best outcomes that minimally invasive surgery has shown to have.