Clinical approach to patients admitted to the emergency room due to acute cholecystitis during the COVID-19 pandemic and percutaneous cholecystostomy experience

BACKGROUND: Acute cholecystitis (AC), a common complication of gallstones, is responsible for a significant part of emergency applications, and cholecystectomy is the only definitive treatment method for AC. Early cholecystectomy has many reported advantages. Operation-related morbidity and mortality have increased during the COVID-19 pandemic. In this study, our aim is to present our general clinical approach to patients who were diagnosed with AC during the pandemic and our percutaneous cholecystostomy experience during this period.
METHODS: This study included 72 patients who were presented to our hospital’s emergency room between March 11 and May 31, 2020, with AC. Patients were divided into three groups based on their treatment: outpatients (Group 1), inpatients (Group 2) and patients undergoing percutaneous cholecystostomy (Group 3). These three groups were compared by their demographic and clinical characteristics.
RESULTS: There were 36 (50%) patients in Group 1, 25 (34.7%) patients in Group 2, and 11 (15.3%) patients in Group 3. The demographic characteristics of the patients were similar. The CRP and WBC levels of the patients in Group 3 were significantly higher compared to the other groups. Moreover, the wall of the gallbladder was thicker and the size of the gallbladder was larger in Group 3. Patients had percutaneous cholecystostomy at the median of 3.5 days and the length of hospital stay was longer compared to Group 2 (3.9 days versus 9.2 days, p=0.00). The rate of re-hospitalization after discharge was similar in Group 2 and Group 3, but none of the patients in Group 1 required hospitalization. None of 72 patients developed an emergency condition requiring surgery, and there was no death.
CONCLUSION: Although many publications emphasize that laparoscopic cholecystectomy (LC) can be performed with low morbidity at the first admission in acute cholecystitis, it is a clinical condition that can be delayed in the COVID-19 pandemic and other similar emergencies. Thus, percutaneous cholecystostomy should be effectively employed, and its indications should be extended if necessary (e.g., younger patients, patients with lower CCI or ASA). This approach may enable us to protect both patients and healthcare professionals that perform the operation from the risk of COVID-19.

COVID-19 pandemisi süresince acil servise baþvuran akut kolesistit hastalarýna genel yaklaþýmýmýz ve perkütan kolesistostomi deneyimi

AMAÇ: Akut kolesistit (AC), safra kesesi taþlarýnýn yaygýn bir komplikasyonu olup acil servis baþvurularýnýn önemli bir bölümünü oluþturur ve kolesistektomi tek kesin tedavi yöntemidir. Erken dönem kolesistektominin bildirilmiþ birçok avantajý mevcuttur. COVID-19 pandemi sürecinde yapýlan operasyonlar ile iliþki morbidite ve mortalite artmýþtýr. Biz bu çalýþmada pandemi sürecinde acil serviste AC tanýsý konulan hastalara genel klinik yaklaþýmýmýzý ve perkütan kolesistostomi deneyimini sunmayý amaçladýk.
GEREÇ VE YÖNTEM: 11 Mart 2020 ile 31 Mayýs 2020 tarihleri arasýnda hastanemiz acil servisine AC nedeniyle baþvuran 72 hasta çalýþmaya dahil edildi. Hastalar ayaktan tedavi edilen (Grup 1), yatýrýlarak tedavi edilen (Grup 2) ve perkütan kolesistostomi ile tedavi edilen (Grup 3) olmak üzere üç gruba ayrýldý. Bu üç grubun demografik ve klinik özellikleri karþýlaþtýrýldý.
BULGULAR: Grup 1’de 36 (%50), Grup 2’de 25 (%34,7) ve Grup 3’te 11 hasta (%15.3) vardý. Hastalarýn demografik özellikleri birbirine benzerdi. Grup 3’teki hastalarýn acil servise baþvuru anýndaki CRP ve WBC deðerleri diðer iki gruba göre belirgin yüksekti. Ayrýca Grup 3’teki hastalarda safra kesesi duvarý daha kalýn, kese boyutu daha büyük saptandý. Hastalara ortanca 3.5 günde perkütan kolesistostomi takýldýðýný ve yatýþ gününün Grup 2’deki hastalara kýyasla daha uzun olduðunu saptadýk (sýrasýyla, 3.9 gün ve 9.2 gün, p=0.00). Taburculuk sonrasý yeniden yatýþ oranlarý birbirine benzerdi. Ayaktan takip yapýlan Grup 1’deki hastalarýn hiçbirinde yatýþ gerekmedi. Yetmiþ iki hastanýn tamamýnda cerrahi gerektiren acil bir durum ortaya çýkmadý ve mortalite izlenmedi.
TARTIÞMA: Birçok yayýn ilk yatýþ anýnda düþük morbidite ile laparoskopik kolesistektomi yapýlabileceðini vurgulasa da, AC COVID-19 pandemisi ve buna benzer acil durumlarda elektif cerrahiye ertelenebilecek bir klinik durumdur. Bu amaçla perkütan kolesistostomi efektif kullanýlmalý ve gerekirse endikasyonlar geniþletilmelidir (Daha genç hastalar, CCI veya ASA daha düþük hastalar gibi). Bu yaklaþým ile hem hastayý hem de operasyonu gerçekleþtirecek saðlýk ekibini COVID-19 riskinden koruyabiliriz.