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

Abstract

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.

COVID-19 and Acute Cholecystitis Management: A Systematic Review of Current Literature

“…A total of 334 potential articles were identified from the search of electronic databases. A total of 39 full-text articles were assessed for eligibility and 15 articles dated since 2019 were included in the study ( 11 – 25 ) ( Figure 1 ). Three research studies were conducted in Italy, three in Turkey, two in Spain, one in the United Kingdom, one in New Zealand, one in the United States, one in Egypt, one in Austria, one in Switzerland, and one in Ireland.…”

“…Three studies, which only presented surgical data concerning acute cholecystitis management, reported, in total, 107 patients previously managed operatively vs. 68 patients during the pandemic ( 14 , 15 , 25 ). Another study showed that there was a shift toward the initial surgical approach of the patients ( 11 ). During the pre-COVID-19 era, a total of 458 patients admitted with confirmed cholecystitis were managed surgically following an average of 2.21 days from clinical presentation, whereas during the COVID-19-era, a total of 389 admitted patients were initially managed conservatively with intravenous antibiotics followed by oral antibiotics and PC when required.…”

“…Out of the 389 non-surgically managed patients, 311 (79.94%) failed to comply with these treatments and were on average operated within 16.74 days from clinical presentation. The results revealed that after the initial conservative management, the inflammatory status progressed and equally the severity score significantly worsened, thus increasing the difficulties and complications during the intraoperative and postoperative periods ( 11 ). Finally, another study indicated a shift toward conservative treatment.…”

“…In general, all studies reported an increase in the mean LOS during the COVID-19 period, which suggests an unsuccessful approach for the management of acute cholecystitis during the pandemic. Two studies found a statistically significant increase in the average LOS during the pandemic period compared to the pre-COVID-19 era ( 11 , 15 ). Fouad et al ( 11 ) reported the most significant difference in the average LOS between the two periods (13.5 days in 2020 vs. 2.6 days in 2019).…”

“…Two studies found a statistically significant increase in the average LOS during the pandemic period compared to the pre-COVID-19 era ( 11 , 15 ). Fouad et al ( 11 ) reported the most significant difference in the average LOS between the two periods (13.5 days in 2020 vs. 2.6 days in 2019). It is of high importance to mention that the low average LOS of the pre-COVID-19 period is a result of a complete surgical strategy, whereas, in 2020, conservative management was also applied.…”