Background
COVID-19 is a respiratory tract infection caused by the new SARS-CoV-2 virus, firstly recognized in December 2019 in Wuhan city, Hubei, China.
Globally, on January 2021, there have been 85.929.428 confirmed cases of COVID-19, including 1.876.100 deaths, reported to WHO [
1]. The first Italian case has been notified in Codogno (Lodi, Lombardy) on the 21
st of February 2020 [
2].
After that, the infection rapidly spread throughout Italy and we are currently counting a total of 2.201.945 confirmed cases with 76.877 deaths [
1]. Among Italian regions, COVID-19 struck Lombardy the most with 493.022 positive cases, of which 73.069 in the city of Milan [
3].During the first two months of the pandemic, from March to April 2020, our Emergency Department (ED) has been quickly re-adapted in order to face the incoming crisis. The majority of human and economic resources were allocated for the symptomatic patients’ care in the ED. The activity of the different surgical specialties was temporarily reorganized by incorporating the urgent and oncologic cases of all surgical branches into one single common ward (30 beds).
The beginning of the pandemic represented a challenge under many aspects, most importantly ensuring the safety for both patients and healthcare workers. Clear instructions on the management of acute surgical disease in COVID-19 patients were initially lacking.
We often deviated from the traditional therapeutic pathway because lack of resources, namely nurses, anaesthesiologists and availability of ICU beds. In this context of general unpreparedness, the secular Hippocrates principle of “
primum non nocere” became even harder to achieved, as witnessed by other colleagues [
4].
Afterward, thanks to a better understanding of the evolution of the global pandemic, we adopted COVID-19 specific guidelines published as time passed by.
In our study, we retrospectively analysed our temporary management strategy for acute cholecystitis (AC) and how it has been influenced by the initial acute phase of COVID-19 pandemic in Italy.
Discussion
The first acute phase of SARS-CoV-2 outbreak (from February to April 2020) had a significant impact on elective and emergency surgical care in Italy and especially in Lombardy.
Chinese preliminary data reported that asymptomatic COVID-19-positive patients undergoing surgery early developed pneumonia with increased global mortality rate and unfavorable clinical outcomes [
11]. Therefore, most elective surgery has been postponed, especially procedures that would have required intensive care support [
12].
Our Surgical Departments were completely reorganized: urgent and oncologic cases of all surgical branches (General, Vascular, Otolaryngology, Maxillofacial Surgery, Urology and Thoracic Surgery) were incorporated in a single surgical ward. This led to competition among different specialists for access to the limited operating rooms. Oncologic patients at high risk of COVID-19 complications (elderly with many comorbidities) were offered neoadjuvant treatments, while definitive surgery was delayed. At first, there was lack of evidence and guideline about the management of the patients admitted in the emergency room (ER) with acute surgical pathologies. On the other hand, several surgical societies have only later released their position statements [
8,
9,
13,
14].
The British Intercollegiate General Surgery Guidance (BIGSG) on COVID-19 stated that during the COVID-19 pandemic, whenever non-operative management is possible (such as for early appendicitis and acute cholecystitis), this should be pursued [
9].
BIGSG recommended either non-surgical management or the utilization of a percutaneous cholecystostomy tube for the management of acute biliary disease [
9].
This new approach clashed on gold standard approach, where early laparoscopic cholecystectomy was recommended, while cholecystostomy was reserved only for those patients considered unfit for surgery [
4,
15].
According to this, other surgical societies, such as the Società Italiana di Chirurgia Endoscopica (SICE), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) have recommended a more patient/hospital-centered and conservative approach [
13,
14].
According to those advices, we adopted a paradigm shift towards a non-operative management for some acute surgical pathologies, including acute biliary diseases, in our Surgical Department during the first pandemic phase.
We shifted 3 patients with acute cholecysitits towards a PC instead of urgent laparoscopic cholecystectomy; one case was due to SARS-CoV-2 positivity, and two cases because of unavailability of operative room and post-operative ICU beds. In the other 5 patients, the choice to perform PC fulfilled Tokyo guidelines, regardless pandemic conditioning.
In the following months, a great deal of papers has been published and they now constitute a solid knowledge about the management of surgical patients in the COVID-19 era [
16‐
22].
The most important findings concerned mortality and pulmonary complications in patients undergoing surgery with pre- or peri-operative SARS-CoV-2 infection [
16,
19].
In an Italian matched cohort study, surgical mortality and complications were higher in patients with COVID-19 compared with patients without coronavirus infection [
16].
A large international cohort study (COVIDSurg Collaborative Group) proved that pulmonary complications occurred in half of COVID-19 patients with higher mortality, especially in men aged 70 years and older [
19]. These data suggest also that there was an increased postoperative mortality in COVID-19 patients even if the infection was acquired in the postoperative period [
16,
19].
Therefore, we’ve strengthened ourselves that PC continues to be the best therapeutic strategy for acute cholecystitis in COVID-19 positive patients during all the pandemic.
On the other hand, we do not consider PC as an “a priori” choice in SARS-CoV-2 negative patients otherwise fit for surgery.
In several studies, the SARS-CoV-2 RNA has been detected in the peritoneal cavity [
23,
24], however there is no evidence that indicates the presence of SARS-CoV-2 in surgical smoke [
25], therefore the potential risk of virus transmission to the healthcare staff during laparoscopy has not yet been confirmed.
Moreover, there are no data reporting higher rates of COVID-19 infection related to laparoscopic cholecystectomy with respect to the open approach.
For this reason, we think that patients should not be denied the benefits of laparoscopy in terms of mortality, morbidity, and postoperative hospital stay also during COVID-19 period [
26‐
28].
We adopted a standard laparoscopic approach and, in order to limit any possible spread of the virus due to nebulization during laparoscopy, the surgical team was provided with adequate personal protective equipment (FFP2 masks and visors). We also implemented a specific filtration system for a safe carbon dioxide evacuation at the end of the laparoscopic procedure. The filtration system is composed of a small rubber tube connecting the gas outlet of one of the trocars to a filter usually mounted on mechanical ventilation machines (Minz’s device) [
29].
Anyway, in SARS-CoV-2 negative patients unfit for surgery, percutaneous drainage of the gallbladder remained a safe and often temporary effective (success rate of 85%) [
30] option after failure of conservative antibiotic therapy.
Among the various techniques such as transpapillary, transmural and percutaneous transhepatic drainage of the gallbladder, the latter is the more frequently chosen due to its lower risk of bile leakage, simplicity of execution and reproducibility at the patient’s bedside [
31].
In literature the correct timing for performing PC is still debated and the scientific community is divided between the early (within 24 h from the admission) and the late (after 24 h from the admission) approach [
32‐
34].
When the procedure is performed within the first 24 h following the onset of symptoms, gallbladder drainage is related to shorter hospital stay and low complication rate (0.5%), especially bleeding [
31].
In our experience, we performed cholecystostomy in all patients within 72 h from the onset of clinical signs and we did not observe any peri-procedural complication apart from one case of transient parietal bleeding.
The Rose Surgical Collaborative UK retrospective cohort study on 864 patients with a diagnosis of cholecystitis shows that 22 out of 63 patients (35,2%) undergoing cholecystostomy experienced a complication of which 4,7% were immediate while 85,3% occurred later [
35].
Wrong site PC placement and displacement was reported respectively in 2 (10,5%) and 12 (63,2%) cases [
35]. Moreover, Lei et al. reported a drainage occlusion rate of 10% [
36].
Cholecystostomy drain management is not standardized yet. Some authors suggest a check tubogram before discharge [
35], but it could represent a trigger for cholangitis/cholecystitis relapse before elective surgery. In the series published by Lu et al. 42,9% of patients undergoing PC required readmission to hospital for relapsing biliary symptoms (range 1 to 4 times each) [
35].
In our experience, we obtained the complete remission of symptoms within 24 h after percutaneous drainage in 87.5% of cases. Only one patient underwent urgent LC due to a persistent septic status 5 days after PC. Cholecystostomy drain remained in place for a median time of 43 days without any routine imaging check before its removal. In 2 cases a readmission was needed to manage symptoms relapse, thus conditioning extended time before scheduled LC.
Our study has some limitations: the relatively small sample size, the retrospective nature and the single-center involvement. Despite the shortness of cases, this study wants to draw a picture of an ongoing view of strategy adopted along the actual pandemic in one of the first and most affected country in the world.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.