Multidisciplinary management of acute cholecystitis during the COVID-19 pandemic

This study demonstrated a significant rise in the incidence of AC, a drop in patient age and CCI, and significant growth in the prevalence of GP, unplanned readmission and the rate of PTGBD during the nationwide lockdown due to the COVID-19 pandemic.

The epidemiological measures taken during the COVID-19 pandemic have transformed the structure and conditions of healthcare considerably. Several medical departments were either closed down or designated as COVID care facilities, resulting in a significant number of clinicians having to provide care for COVID patients. With regard to surgical care, non-emergency procedures, such as elective cholecystectomies, were immediately suspended in compliance with the lockdown measures.

Considering these circumstances, it is not surprising that the number of patients with AC increased substantially in Period II, since patients with gallstones were only treated if acute inflammation was also present and elective cholecystectomies were suspended. An Irish study reported similar findings on the number of AC cases, and it even supposed that a possible reason for this was an excessive consumption of fatty food based on the “stay-at-home” principle⁷.

A study examining elective cholecystectomies from the United Kingdom showed that in the pre-pandemic group a higher proportion of operations were performed for non-inflammatory pathology compared to the post-COVID recovery phase⁸. There was a notable contrast observed in Period II, as the median age of patients receiving care was significantly lower compared to the previous period. Younger patients who had usually undergone surgery with milder symptoms before an acute inflammatory event in Period I required care for AC during the pandemic.

During COVID, healthcare capacities dropped, with every level of the healthcare provision system from general practitioners to tertiary centres focussing on COVID. Patients frequently sought medical attention or accessed suitable healthcare providers after experiencing symptoms for several days and reaching an advanced stage of inflammation⁹. This was well indicated by the significant change in the rates of morphological diagnoses made based on the ultrasound scan. In Period II, the GP rate rose considerably compared to Period I, clearly due to late treatment and lack of elective management. A study conducted at a German tertiary centre yielded a similar result, though the elevated GP rate was characteristic of the older patients under investigation¹⁰.

A significant change was observed in the composition of multidisciplinary management. In Period II, the PTGBD rate was significantly higher, successful conservative therapy showed a significantly lower rate, and there was no significant change in the surgery rate. A systematic review yielded comparable findings; however, the study reported that while the PTGBD rate was higher during the COVID period, there was also a higher rate of conservative therapy and a decrease in the rate of surgical treatment¹¹. A recent article from July 2023 found similar results by examining data from US Academic Centers (comparing 15–15 months pre-pandemic and pandemic periods)¹². The priority given to drainage indicates that in more advanced cases (Grade III AC, high CCI, and bad general condition of the patients), surgery is no longer the first-line option, conservative therapy alone is no longer sufficient, and therefore drainage is the best option. An Italian study clearly recommends PTGBD as primary therapy for COVID-positive patients and even for non-COVID patients for whom conservative therapy has failed or who are not fit for surgery¹³. However, in analysing data from the pre-COVID period and the first two COVID waves, a British study found no difference in the success rate for conservative therapy¹⁴. In addition, it should be noted that as regards surgical therapy at our department (either primary or secondary), CR and LSR were similar in both periods and the rate of laparoscopic procedures did not fall during the pandemic despite the fact that we faced more difficult cases. Laparoscopic cholecystectomy was safely used during the pandemic, as also demonstrated in a large number of cohorts¹⁵.

The median length of hospital stay exhibits significant difference. The implementation of minimal doctor-patient contact and reduced capacity during the COVID pandemic might have accounted for the 1-day earlier discharge of patients in Period II. The high rate of unexpected readmissions during Period II may have been caused by the higher GP rate in addition to the 1-day shorter hospital stay.

Due to the limited number of cases, the mortality data does not allow for any conclusive inferences to be made; larger studies are therefore needed.