The optimal treatment for acute, stone-related cholecystitis is considered antibiotic therapy followed by early cholecystectomy(5–11). In selected cases, when surgery is not feasible due to concomitant sepsis, severe comorbidities, poor performance status or bad timing (> 72 h from the onset of symptoms), the treatment of choice is represented by a conservative strategy consisting of antibiotic therapy, with success rate of 76% and recurrence of symptoms of 18%(11). When antibiotic therapy alone is unsuccessful, PTGBD is considered a safe and valid therapeutic option as a temporary and sometimes definitive alternative to surgery, especially in elderly patients (> 80 y o) with high surgical risk (12–14).
In the present COVID era, this conservative approach has regained its relevance in our country, especially in Milan, which is one of the most affected districts. Indeed, the conservative strategy mentioned above fits into a context of resource optimization and review of surgical indications, since almost 90% of our operating theatres were used for the treatment of COVID ventilated patient. In our present series we successfully treated 51.3% of patients affected by AC conservatively. In particular, 29.7% of cases were treated through antibiotic therapy alone and 37.5% of patients were treated through PTGBD. The latter represents a significantly increased percentage as compared to the rate of PTGBD interventions performed in the non-COVID era (9%) found in the literature (15). There are several possible reasons explaining the increased number of PTGBD interventions performed. First, the use of PTGBD is related to a delayed diagnosis of the disease in patients fearing to visit hospital facilities at the early stage of the pandemic. Second, the reduced availability of hospital beds and medical/nursing staff resources, actively tackling the treatment of COVID patients, forced physicians to apply a more conservative approach to patient management.
In line with the hypothesis that patients presented themselves with significant delay at the ER for a clinical evaluation, we observed that only 13 patients had grade I AC according to TG-18, while the remaining 24 patients had a more aggressive and advanced disease manifestation (grade II or III).
We approached each patient according to the Tokyo guidelines.
Table 2 shows how surgical approach was the treatment of choice for grade I patients (Lap-C 84.6%vs PTGBD 15.4%); on the other hand, increasing grade and disease severity mirrored a more conservative strategy (grade III: Lap-C 12.5%vs antibiotic +/- PTGBD 87.5%). The COVID-19 pandemic forced us to adopt a more conservative approach with respect to what has been established in the Tokyo guidelines. In particular, 3 out of 8 patients submitted to PTGBD (37.5%) would have been optimal candidates for Lap-C in a non-COVID era. One grade I patient, theoretically fit for surgery, turned out to be SARS-CoV-2 positive; therefore, he underwent PTGBD for two main reasons. First, the percutaneous approach represented a less invasive, yet valid alternative to a more labored surgical management in a SARS-CoV-2 positive patient. Moreover, data from a Chinese report, seem to highlight how surgical stress in SARS-CoV-2 positive patients may promote and accelerate the respiratory disease, with a subsequent increased post-operative mortality rate(16). For these reasons and according to the international scientific community consensus, we pursued the idea of implementing non-operative management for acute cholecystitis whenever possible(9).
In one patient with a grade II AC, Lap-C was precluded due to the unavailability of operating room staff, which was engaged in the management of COVID-19 patients. Moreover, we had to exclude from Lap-C a 37 years old woman with grade III AC, due to severe asthma. In fact, being at higher risk of post-operative respiratory failure, the patient would have needed post-operative ICU monitoring at a time when beds were not available because fully occupied by COVID-19 ventilated patients.
Other reasons to rely on PTGBD are represented by its efficacy, safety and reproducibility at the patient’s bedside. The major advantage of this approach was to release additional workload from the operating room staff, which was almost totally deployed to deal with COVID patients. Our analysis showed that PTGBC did not influence the average length of stay of our patients. This result may be related to two main reasons. First, our outcome is severely affected by outliers, such as duration of hospitalization of the only SARS-CoV-2 positive patient in this series. The post-procedural course was uneventful, with fast recovery from symptoms related to AC. However, the patient had to wait the negativization of the nasopharyngeal swab before being discharged home, thus increasing the length of hospital stay. Moreover, the mean length of stay was affected by severe delay in the transfer of elderly patients to nursing homes or rehabilitation facilities after the resolution of AC. In fact, also these structures have been severely impaired in their receptive ability due to the pandemic side-effects.
When the procedure is performed within the first 24 hours following the onset of symptoms, PTGBD is related to short hospital stay and low complication rate (0.5%), such as bleeding(5). International literature describes a drainage occlusion rate of 10% and a dislocation in 15% of cases(17), while success rate is 85% (characterized by complete clinical remission and infection resolution)(18). In our experience, we performed cholecystostomy in all patients within 72 hours from the onset of clinical signs and we did not observe any peri-procedural complication. In 87.5% of cases we obtained complete regression of symptoms after percutaneous drainage within 24 hours; only one patient underwent urgent Lap-C due to a persistent septic status 5 days after PTGBD. Eventually, it is essential to highlight how the bedside approach we adopted for percutaneous drainage allowed the reduction of unnecessary transfers of patients to the radiology department, thus minimizing the risk of virus spread.