A review of emergency laparoscopic cholecystectomies during the COVID-19 pandemic compared to pre-pandemic. Is there a difference in patient and financial outcomes?

ABSTRACT

Background: The COVID-19 pandemic was declared the greatest challenge the NHS would face since its creation. As a means of combatting the unprecedented strains COVID-19 was expected to force upon hospitals and their staff, NHS England sanctioned the postponement of all non-urgent elective surgery during the first wave of the COVID-19 pandemic. Approximately 70 000 cholecystectomies are performed every year in the UK, with the vast majority of these being elective laparoscopic cholecystectomies (LC). However, in the early stages of the pandemic, both national and international surgical bodies warned of the potential risks of aerosol virus transmission with the use of laparoscopy. Therefore, conservative management for emergency general surgical pathologies was recommended where possible. Delays in performing LC are associated with recurrent cholecystitis, pancreatitis and cholangitis;all of which present as emergencies with significant associated morbidity and mortality. This in turn has an economic impact on the NHS. We aimed to evaluate if patients undergoing emergency LC during the COVID-19 pandemic at our site, had different outcomes compared to those treated prior to the pandemic. Has the COVID-19 pandemic negatively impacted their patient journey? Furthermore, has the pandemic led to increased costs for our site? Methods: A retrospective data collection was performed to identify all patients who had an emergency LC from March 2019 - March 2021. Patients were subsequently categorised into 'pre-COVID-19' and 'during COVID-19' groups. Hospital computer systems were used to review operative admission length of stay (LoS), rate of conversion to open surgery/subtotal cholecystectomy, operative time, post-operative complications/return to theatre and readmission rate. Histopathology reports were analyzed to assess if the 'during COVID-19' cohort had a higher rate of complicated cholecystitis. Finally costs of the operative admission and associated admissions (pre and post-operatively), as well as the tariff for investigations performed for gallstone disease were calculated for each cohort of patients. Result(s) 158 patients were included in the study. A 42% reduction in emergency LC cases was observed during the COVID-19 pandemic compared to pre-pandemic. No statistically significant differences were seen between the two groups when reviewing the rate of conversion to open surgery or the incidence of post-operative complications/need to return to theatre. The rate of subtotal cholecystectomy was higher in the 'during COVID-19' group (12% vs. 3%) and this was found to be statistically significant (p-value 0.024). Operating times were longer during the pandemic (93 vs. 80 mins), as was the LoS for the operative admission (5 vs. 6 days), however these results were not statistically significant. Interestingly, same day emergency care (SDEC) reviews were more frequent in the 'during COVID-19' group (13.1 vs. 29.3%) and this was statistically significant (p-value 0.015). There was no statistically significant difference between the groups in relation to histopathology results. The most prevalent histopathology of both cohorts was chronic cholecystitis (58 vs. 48.28%). Acute on chronic cholecystitis (23 vs. 25.86%) and necrotising/gangranous changes (11 vs. 12.07%) were more prevalent in the 'during COVID-19' group. When reviewing costs between the two groups, no statistically significant differences in LoS, nor investigation tariffs was observed. Conclusion(s) Our study shows that the COVID-19 pandemic has had a negative impact on two clinical aspects of emergency LC - an increase in the rate of subtotal cholecystectomy, as well as SDEC reviews. This could be explained by delays in elective surgery encountered during the pandemic, leading to patients experiencing recurrent infections, or other associated complications of gallstone disease and consequently requiring more frequent clinician/SDEC reviews. These complications can also result in unclear anatomy, diffuse scarring, necrosis and abscess formation, all of which n lead to increasingly complex cases encountered intra-operatively. If surgeons are unable to safely achieve a critical view of safety, guidance recommends subtotal cholecystectomy as a bail out procedure, in order to avoid serious damage to the bile duct or blood vessels. This could justify the statistically significant higher rate of subtotal cholecystectomy in the 'during COVID-19' group. Currently, there are approximately 6 million patients on NHS surgical waiting lists and this issue must be addressed urgently in the COVID-19 recovery phase, so as to prevent adverse outcomes for both patients and the NHS.