Comparison of percutaneous gallbladder aspiration with percutaneous cholecystostomy in acute cholecystostomy patients. Can gall bladder aspiration alone be sufficient?

BACKGROUND: The aim of this study is to compare the efficacy and complication rates of percutaneous gallbladder aspiration (PA) and percutaneous cholecystostomy (PC) in the management of AC and present the experiences of a single third-line center. METHODS: The results of 159 patients with AC who admitted to our hospital between 2015 and 2020, that underwent PA and PC procedures, because they did not respond to conservative treatment and LC could not be performed, were retrospectively analyzed. Clinical and laboratory data before and 3 days after PC and PA procedure, technical success, complications, response to treatment, duration of hospital stay, and reverse transcriptase-polymerase chain reaction (RT-PCR) test results were recorded. RESULTS: Out of 159 patients, 22 (8 men 14 women) underwent PA procedure and 137 (57 men 80 women) underwent PC. No significant difference was detected between the PA and PC groups in terms of clinical recovery (P: 0.532) and duration of hospital stay (P: 0.138) in 72 h. The technical success of both procedures was 100%. While 20 out of 22 patients with PA were having a noticable recovery, only one was treated with twice PA procedures and a complete recovery was observed (4.5%). Complication rates were low in both groups and were statistically insignificant (P: 1.00). CONCLUSION: In this pandemic period, PA and PC procedures are effective, reliable, and successful treatment method that can be applied at the bedside for critical patients with AC who are not compatible with surgery, which are safe for health workers and low-risk minimal invasive procedures for patients. In uncomplicated AC patients, PA should be performed, and if there is no response to treatment, PC should be reserved as a salvage procedure. The PC procedure should be performed in patients with AC who have developed complications and are not suitable for surgery.

Long term Implications in Surgical re-Assisting (L.I.S.A. study) during the Covid-19 outbreak. A retrospective observational cohort study on a rural population.

BACKGROUND: COVID-19 is having a worldwide impact on surgical treatment. Our aim was to investigate the impact of the pandemic in a rural hospital serving a low densely populated area. METHODS: We investigated the volume and type of surgical performed operations during both the pandemic (March 2020 - February 2021) and pre-pandemic periods (March 2019 - February 2020) as well as during the first and second pandemic waves compared to the pre-pandemic period. We compared the volume and timing of emergency appendectomy and cholecystectomy performed during the pandemic with those of the pre-pandemic period, doing the same with the volume, timing and stages of elective gastric and colorectal resections for cancer. RESULTS: In the pre-pandemic period a higher number of appendectomies (42 vs. 24) and urgent and elective cholecystectomies (174 vs. 126) was performed. The patients operated during the pandemic period (both for appendectomy and cholecystectomy) were on average older (58 vs. 52 years old, p=0.006), including for cholecystectomy (73 vs. 66 years old, p=0.01) and appendectomy (43 vs. 30 years old, p =0.04). The logistic regression analysis with regard to the cholecystectomies and appendectomies performed in emergency showed that male sex and age were associated with gangrenous type histology, both in the pandemic and pre-pandemic period. Finally, we found a reduction in the stage I and IIA colorectal cancers operated during the pandemic compared to those of the pre-pandemic period, with no increase of the advanced stages. CONCLUSIONS: The reduction in services imposed by governments during the first months of total lock down could not justify the whole decrease in surgical interventions in the year of the pandemic. Data suggest that greater "non-operative management" for appendicitis and acute cholecystitis does not lead to an increase of cases operated over time, nor to an increase in the "gangrenous" pattern, this seems to depend on age advanced and male population. KEY WORDS: COVID-19, Emergency Surgery, General Surgery, Pandemics.

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.

Acute Cholecystitis and Diverticular Abscess Patient with COVID-19 Infection.

This is a case of a 53-year-old African American woman with newly diagnosed concomitant acute cholecystitis, diverticulitis, and SARS-COV-2 infection. She underwent treatment for COVID-19 with antibiotics and supportive treatment, and on day 32 after initial symptoms presented, she had an elective laparoscopic cholecystectomy. Our patient was one of the first cases to present with acute cholecystitis and diverticulitis complicated by COVID-19, and serves as a template for surgical management of non-emergent abdominal pathologies in the midst of the COVID-19 pandemic.

Voici le cas d'une Afro-Américaine de 53 ans chez qui on a diagnostiqué récemment une cholécystite aiguë concomitante, une diverticulite et une infection par le SRAS-COV-2. Elle a été traitée pour l'infection COVID-19 avec des antibiotiques et un traitement de soutien, et le 32e jour après l'apparition des premiers symptômes, elle a subi une cholécystectomie laparoscopique élective. Notre patiente a été l'un des premiers cas à présenter une cholécystite et une diverticulite aiguës compliquées par le COVID-19, et sert de modèle pour la gestion chirurgicale des pathologies abdominales non urgentes au milieu de la pandémie de COVID-19. Mots-clés: COVID-19, Diverticulite, Cholécystite, SARCOV-2.

Access to Surgery and Quality of Care for Acute Cholecystitis During the COVID-19 Pandemic in 2020 and 2021 - an Analysis of 12,545 Patients from a German-Wide Hospital Network.

PURPOSE: To determine effects on admission, treatment, and outcome for acute cholecystitis during the course of the COVID-19 pandemic in 2020 and 2021. METHODS: Retrospective analysis of claims data from 74 German hospitals. Study periods were defined from March 5, 2020 (start of first wave) to June 20, 2021 (end of third wave) and compared to corresponding control periods (March 2018 to February 2020). All in-patients with acute cholecystitis were included. Distribution of cases, type of surgery, comorbidities, surgical outcome, and length of stay of all cases with acute cholecystitis and cholecystectomy were compared. In addition, we analyzed the type of treatment (non-surgical, cholecystostomy, or cholecystectomy) for all cases with main diagnosis of acute cholecystitis. RESULTS: We could not demonstrate differences in daily admissions over the course of the pandemic (11.2-12.7 patients vs. 11.9-12.6 patients for control periods). Proportion of patients with non-surgical treatment was low and not increased (11.7-17.3% vs. 14.5-18.4%). Cholecystostomy was rare throughout all periods (0-0.5% of all patients). We did not observe an increase in open surgery (proportion of open cholecystectomies 3.4-5.5%). Mortality was generally low (1.5-1.9%) with no differences between periods. Median length of stay was 4 days throughout all periods. CONCLUSION: The numerous restrictions during the COVID-19 pandemic did not result in an increase of admissions or surgery for acute cholecystitis. Laparoscopic cholecystectomy has been safely applied during the pandemic. Our results may assure the ability to maintain high quality of surgical care even in times of disruptions to the health care system.

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>.

Clinical Presentation of Acute Cholecystitis during the COVID-19 Outbreak.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on healthcare systems worldwide. The fear of seeking medical attention to avoid the possibility of being infected may have altered the course of some diseases. OBJECTIVES: To describe our experience with the management of patients with acute cholecystitis during the pandemic at our medical center. METHODS: We compared patients treated for acute cholecystitis between 1 March and 31 August 2020 (Group I) to patients admitted with the same diagnosis during the same months in 2019 (Group II). We evaluated demographics, presenting symptoms, laboratory and imaging findings at presentation, the disease's clinical course, management, and outcome. RESULTS: Group I consisted of 101 patients and group II included 94 patients. No differences were noted for age (66 years, IQR 48-78 vs. 66 years, IQR 47-76; P = 0.50) and sex (57.4% vs. 51.1% females; P = 0.39) between the two groups. The delay between symptom onset and hospital admission was longer for Group I patients (3 days, IQR 2-7 vs. 2 days, IQR 1-3; P = 0.002). Moderate to severe disease was more commonly encountered in Group I (59.4% vs. 37.2%, P = 0.003). Group I patients more often failed conservative management (36% vs. 6%, P = 0.001) and had a higher conversion rate to open surgery (15.4% vs. 0%, P = 0.025). CONCLUSIONS: Patients presenting with acute cholecystitis during the COVID-19 pandemic more often presented late to the emergency department and more showed adverse outcomes.

Laparoscopic cholecystectomy during the COVID-19 pandemic in a tertiary care hospital in Germany: higher rates of acute and gangrenous cholecystitis in elderly patients.

BACKGROUND: The COVID-19 pandemic caused a global health crisis in 2020. This pandemic also had a negative impact on standard procedures in general surgery. Surgeons were challenged to find the best treatment plans for patients with acute cholecystitis. The aim of this study is to investigate the impact of the COVID-19 pandemic on the outcomes of laparoscopic cholecystectomies performed in a tertiary care hospital in Germany. PATIENTS AND METHODS: We examined perioperative outcomes of patients who underwent laparoscopic cholecystectomy during the pandemic from March 22, 2020 (first national lockdown in Germany) to December 31, 2020. We then compared these to perioperative outcomes from the same time frame of the previous year. RESULTS: A total of 182 patients who underwent laparoscopic cholecystectomy during the above-mentioned periods were enrolled. The pandemic group consisted of 100 and the control group of 82 patients. Subgroup analysis of elderly patients (> 65 years old) revealed significantly higher rates of acute [5 (17.9%) vs. 20 (58.8%); p = 0.001] and gangrenous cholecystitis [0 (0.0%) vs. 7 (20.6%); p = 0.013] in the "pandemic subgroup". Furthermore, significantly more early cholecystectomies were performed in this subgroup [5 (17.9%) vs. 20 (58.8%); p = 0.001]. There were no significant differences between the groups both in the overall and subgroup analysis regarding the operation time, intraoperative blood loss, length of hospitalization, morbidity and mortality. CONCLUSION: Elderly patients showed particularly higher rates of acute and gangrenous cholecystitis during the pandemic. Laparoscopic cholecystectomy can be performed safely in the COVID-19 era without negative impact on perioperative results. Therefore, we would assume that laparoscopic cholecystectomy can be recommended for any patient with acute cholecystitis, including the elderly.

Global overview of the management of acute cholecystitis during the COVID-19 pandemic (CHOLECOVID study).

BACKGROUND: This study provides a global overview of the management of patients with acute cholecystitis during the initial phase of the COVID-19 pandemic. METHODS: CHOLECOVID is an international, multicentre, observational comparative study of patients admitted to hospital with acute cholecystitis during the COVID-19 pandemic. Data on management were collected for a 2-month study interval coincident with the WHO declaration of the SARS-CoV-2 pandemic and compared with an equivalent pre-pandemic time interval. Mediation analysis examined the influence of SARS-COV-2 infection on 30-day mortality. RESULTS: This study collected data on 9783 patients with acute cholecystitis admitted to 247 hospitals across the world. The pandemic was associated with reduced availability of surgical workforce and operating facilities globally, a significant shift to worse severity of disease, and increased use of conservative management. There was a reduction (both absolute and proportionate) in the number of patients undergoing cholecystectomy from 3095 patients (56.2 per cent) pre-pandemic to 1998 patients (46.2 per cent) during the pandemic but there was no difference in 30-day all-cause mortality after cholecystectomy comparing the pre-pandemic interval with the pandemic (13 patients (0.4 per cent) pre-pandemic to 13 patients (0.6 per cent) pandemic; P = 0.355). In mediation analysis, an admission with acute cholecystitis during the pandemic was associated with a non-significant increased risk of death (OR 1.29, 95 per cent c.i. 0.93 to 1.79, P = 0.121). CONCLUSION: CHOLECOVID provides a unique overview of the treatment of patients with cholecystitis across the globe during the first months of the SARS-CoV-2 pandemic. The study highlights the need for system resilience in retention of elective surgical activity. Cholecystectomy was associated with a low risk of mortality and deferral of treatment results in an increase in avoidable morbidity that represents the non-COVID cost of this pandemic.

Cystic artery pseudoaneurysm-a rare complication of acute cholecystitis: review of literature.

OBJECTIVE: To acquaint with the presentation and management of the cystic artery aneurysm by enriching the reviewed literature with our own experience. BACKGROUND: Cystic artery pseudoaneurysm is an uncommon entity with varied clinical presentation. Inflammation and trauma are associated with most of the cases. Limited experience with the condition challenges the management of individual cases. MATERIALS AND METHODS: We retrieved all the reported cases of cystic artery pseudoaneurysm, published up to December 2019, from the PubMed database and excluded those arising as postoperative complications. A total of 59 cases were analyzed, and we also included our experience of managing a case of cystic artery pseudoaneurysm. RESULTS: Abdominal pain (77.9%) was the most common presentation followed by upper GI bleed (64.4%), while 19 patients (32.2%) had presented with classic Quincke's Triad. Most of the cases were diagnosed following the rupture of the pseudoaneurysm (n = 49, 83.05%). Fifteen patients presented with shock. Hyperbilirubinemia (59.3%) and anemia (55.9%) were the commonest laboratory findings. Although CT angiogram remains the investigation of choice, a conventional angiogram is the gold standard and sufficed as the definitive management in 20 cases. Cholecystectomy formed the definitive management in the rest of the cases. We successfully managed a middle-aged female patient of cystic artery aneurysm with xanthogranulomatous cholecystitis by open cholecystectomy. CONCLUSION: Cystic artery pseudoaneurysms are amenable to successful management with careful evaluation and timely cholecystectomy or angioembolization or a combination of both.

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.

Long Term Implications in Surgical Re-assisting (L.I.S.A. study) During Covid-19 Outbreak: A Retrospective Observational Study on a Rural Population. (preprint)

Background: The spread of the COVID-19 is having a worldwide impact on surgicaltreatment. Our aim was to investigate the impact of the pandemic in a rural hospital in a lowdensely populated area.MethodsWe investigated the volume and type of surgical operations during the pandemic(March 2020 - February 2021) versus pre-pandemic period (March 2019 - February 2020) aswell as during the first and second pandemic waves compared to the pre-pandemic period.We compared the volume and timing of emergency appendectomy and cholecystectomyduring the pandemic versus pre-pandemic period, the volume, timing and stages of electivegastric and colorectal resections for cancer during the pandemic versus the pre-pandemicperiod.ResultsIn the prepandemic versus pandemic period, 42 versus 24 appendectomies and 174versus 126 cholecystectomies (urgent and elective) were performed. Patients operated onbefore as opposed to during the pandemic were older (58 vs. 52 years old, p=0.006),including for cholecystectomy (73 vs. 66 years old, p=0.01) and appendectomy (43 vs. 30years old, p = 0.04).The logistic regression analysis with regard to cholecystectomy and appendectomy performedin emergency showed that male sex and age were both associated to gangrenous typehistology, both in pandemic and prepandemic period. Finally, we found a reduction in cancerstage I and IIA in pandemic versus prepandemic period, with no increase in the moreadvanced stages.Conclusionsthe reduction in services imposed by governments during the first months oftotal lock down did not justify the whole decrease in surgical interventions in the year of thepandemic. Data suggest that greater "non-operative management" for cases of appendicitisand acute cholecystitis does not lead to an increase in cases operated over time, nor to anincrease in the "gangrenous" pattern, which seems to depend on age advanced and malepopulation.

Effect of the COVID-19 Pandemic on the Management of Acute Cholecystitis and Assessment of the Crisis Approach: A Multicenter Experience in Egypt.

INTRODUCTION: The covid-19 pandemic has had a drastic impact on all medical services. Acute cholecystitis is a serious condition that accounts for a considerable percentage of general surgical acute admissions. Therefore, the Royal College of Surgeons' Commissioning guidance' recommended urgent admission to secondary care and early cholecystectomy. During the first wave of hospital admissions associated with COVID-19, most guidelines recommended conservative treatment in order to limit the admission rates and free up spaces for COVID-19-infected patients. However, reviews of this approach have not been widely done to assess the results and, in turn, planning our future management approach when future pressures on in-patient admissions are inevitable. METHODS: Our study included all acute cholecystitis patients who needed surgical intervention in one Centre in the UK over three distinct periods (pre-COVID-19, during the first lockdown, and lockdown ease). Comparison between these groups were done regarding intraoperative and postoperative results. RESULTS: The conservative management led to a high rate of readmission. Moreover, delayed cholecystectomy was associated with increased operative difficulties such as extensive adhesions, intraoperative blood loss, and/or complicated gall bladder pathologies such as perforated or gangrenous gall bladder (29.9%, 16.7%, and 24.8%, respectively). The resulting postoperative complications of surgical and nonsurgical resulted in a longer hospital stay (13.5 d). CONCLUSION: The crisis approach for acute cholecystitis management failed to deliver the hoped outcome. Instead, it backfired and did the exact opposite, leading to longer hospital stays and extra burden to the patient and the healthcare system.

How correct is the postponed cholecystectomy during the coronavirus disease-19 pandemic process? Gallstone ileus is not a myth anymore.

Posponer cirugías electivas durante el proceso pandémico de Covid-19 aumentó el riesgo de complicaciones graves de enfermedades benignas. El íleo biliar es una de las raras complicaciones de la colelitiasis (0,3-0,5%). Los episodios recurrentes de colecistitis aguda están involucrados en la fisiopatología. La demostración de la tríada de Rigler en tomografía computarizada es diagnóstica. Para reducir la morbilidad se recomienda la cirugía dos etapas: extirpar el cálculo por enterotomía en la primera operación, cirugía biliar en la segunda operación. El íleo biliar debe estar en el diagnóstico diferencial de las obstrucciones intestinales mecánicas, especialmente en pacientes con antecedentes de ataques de colecistitis durante el proceso pandémico de Covid-19 porque las cirugías electivas se detuvieron.Postponing elective surgeries during the coronavirus disease-19 (COVID-19) pandemic process increased the risk of severe complications of benign diseases. Gallstone ileus is one of the rare complications of cholelithiasis (0.3-0.5%). Recurrent episodes of acute cholecystitis are involved in pathophysiology. Demonstration of Rigler's triad on computed tomography is diagnostic. To reduce morbidity stepped surgery is recommended: remove the stone by enterotomy at the first operation and biliary surgery at the second operation. Gallstone ileus should be in the differential diagnosis of mechanical intestinal obstructions, especially in patients with a history of cholecystitis attacks during the COVID-19 pandemic process because elective surgeries stopped.

Impact of lockdown on emergency general surgery during first 2020 COVID-19 outbreak.

PURPOSE: To evaluate and analyze the impact of lockdown strategy due to coronavirus disease 2019 (COVID-19) on emergency general surgery (EGS) in the Milan area at the beginning of pandemic outbreak. METHODS: A survey was distributed to 14 different hospitals of the Milan area to analyze the variation of EGS procedures. Each hospital reported the number of EGS procedures in the same time frame comparing 2019 and 2020. The survey revealed that the number of patients during the COVID-19 pandemic outbreak in 2020 was reduced by 19% when compared with 2019. The decrease was statistically significant only for abdominal wall surgery. Interestingly, in 2020, there was an increase of three procedures: surgical intervention for acute mesenteric ischemia (p = 0.002), drainage of perianal abscesses (p = 0.000285), and cholecystostomy for acute cholecystitis (p = 0.08). CONCLUSIONS: During the first COVID-19 pandemic wave in the metropolitan area of Milan, the number of patients operated for emergency diseases decreased by around 19%. We believe that this decrease is related either to the fear of the population to ask for emergency department (ED) consultation and to a shift towards a more non-operative management in the surgeons 'decision making' process. The increase of acute mesenteric ischaemia and perianal abscess might be related to the modification of dietary habits and reduction of physical activity related to the lockdown.

Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis in elderly patients with COVID-19 and high comorbidity.

BACKGROUND: The purpose of the study was to review the efficacy, safety, and outcomes of percutaneous cholecystostomy (PC) in elderly patients with acute calculous cholecystitis (ACC), high comorbidity, and COVID-19. METHODS: The hospital registry data were examined of patients aged >65 years who were diagnosed with ACC and COVID-19 between March 2020 and June 2020 and who underwent PC treatment in the interventional radiology unit. RESULTS: A total of 18 patients were diagnosed with ACC and COVID-19, then underwent PC. The patients comprised 14 (78%) males and 4 (22%) females with an average age of 73.4 years (range, 67-81 years). In 17 (94%) patients, symptoms associated with acute cholecystitis decreased within 48-72 h of the PC treatment and a clinical improvement was determined. The success rate of PC was 100% and no complications. In 3 (16.6%) patients followed up with intubation in intensive care after the procedure, mortality developed due to COVID-19-associated pneumonia and subsequent acute respiratory distress syndrome, and 15 (83.4%) patients were discharged with an elective cholecystectomy plan. CONCLUSION: COVID-19 infection can be fatal especially in patients over 65 years of age due to additional comorbidities. PC treatment, which can be performed under local anesthesia as a minimally invasive procedure, is an alternative treatment option in this patient group. PC can also act as a bridge in transition to elective surgery in this process management.

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.

Multicentre cohort study of acute cholecystitis management during the COVID-19 pandemic.

PURPOSE: To analyse acute cholecystitis (AC) management during the first pandemic outbreak after the recommendations given by the surgical societies estimating: morbidity, length of hospital stay, mortality and hospital-acquired SARS-CoV-2 infection rate. METHODS: Multicentre-combined (retrospective-prospective) cohort study with AC patients in the Community of Madrid between 1st March and 30th May 2020. 257 AC patients were involved in 16 public hospital. Multivariant binomial logistic regression (MBLR) was applied to mortality. RESULTS: Of COVID-19 patients, 30 were diagnosed at admission and 12 patients were diagnosed during de admission or 30 days after discharge. In non-COVID-19 patients, antibiotic therapy was received in 61.3% of grade I AC and 40.6% of grade II AC. 52.4% of grade III AC were treated with percutaneous drainage (PD). Median hospital stay was 5 [3-8] days, which was higher in the non-surgical treatment group with 7.51 days (p < 0.001) and a 3.25% of mortality rate (p < 0.21). 93.3% of patients with SARS-CoV-2 infection at admission were treated with non-surgical treatment (p = 0.03), median hospital stay was 11.0 [7.5-27.5] days (p < 0.001) with a 7.5% of mortality rate (p > 0.05). In patients with hospital-acquired SARS-CoV-2 infection, 91.7% of grade I-II AC were treated with non-surgical treatment (p = 0.037), with a median hospital stay of 16 [4-21] days and a 18.2% mortality rate (p > 0.05). Hospital-acquired infection risk when hospital stay is > 7 days is OR 4.7, CI 95% (1.3-16.6), p = 0.009. COVID-19 mortality rate was 11.9%, AC severity adjusted OR 5.64 (CI 95% 1.417-22.64). In MBLR analysis, age (OR 1.15, CI 95% 1.02-1.31), SARS-CoV-2 infection (OR 14.49, CI 95% 1.33-157.81), conservative treatment failure (OR 8.2, CI 95% 1.34-50.49) and AC severity were associated with an increased odd of mortality. CONCLUSION: In our population, during COVID-19 pandemic, there was an increase of non-surgical treatment which was accompanied by an increase of conservative treatment failure, morbidity and hospital stay length which may have led to an increased risk hospital-acquired SARS-CoV-2 infection. Age, SARS-CoV-2 infection, AC severity and conservative treatment failure were mortality risk factors.