Pre-pandemic |
Pandemic |
p-value |
Odds Ratio (I.C. 95%) |
|
Admissions |
408 |
536 |
- |
- |
Age (DE) |
45, 32 (15) |
40, 26 (14) |
0,000 |
- |
Female (%) |
240 (58, 8%) |
332 (61, 9%) |
0,116 |
- |
BMI (DE) |
28, 11 (4) |
28,35 (3,8) |
0,367 |
- |
ASA 2 |
275 (84, 9%) |
246 (80%) |
0,019 |
- |
Acute cholecystitis |
204 (50%) |
252 (47, 01%) |
0,011 |
1,35 (1,07-1,69) |
Acute biliary pancreatitis |
132 (32, 35%) |
144 (26, 87%) |
0,715 |
1,06 (0,81-1,38) |
Extrahepatic cholestasis |
72 (17, 64%) |
128 (24%) |
0,000 |
1,93 (1,41-2,63) |
Acute cholangitis |
0 |
12 (2, 24%) |
- |
- |
Table 2: Risk factors.
Pre-pandemic |
Pandemic |
|
DBT |
7.84% |
10.45% |
HTA |
19.60% |
13.50% |
Hypothyroidism |
1% |
12% |
Embolism |
2% |
3% |
Tobacco |
28, 7% |
37.60% |
Table 3: Results: Type of treatment and readmissions.
Pre-pandemic |
Pandemic |
p-value |
O.R. (I.C. 95%) |
|
Evolutionary complications |
408 (100%) |
536 (100%) |
0,000 |
2, 40 (1.89-3,06) |
Surgical treatment |
324 (79, 4%) |
308 (57, 5%) |
0,000 |
0, 55 (0,26-0,47) |
Readmissions |
36 (8, 82%) |
104 (19, 4%) |
0,000 |
2, 42 (1,62-3,63) |
Length of stay surgical treatment (DE) |
4 (1,6) |
3 (1.3) |
- |
- |
Length of stay non-surgical treatment (DE) |
7 (1,4) |
7 (1, 5) |
- |
- |
In summary, 79.4% of cases were treated surgically during the pre-pandemic period, compared to 57.5% during the pandemic. Percentages of patients managed surgically during the pandemic are as follows by quarters: 40% in the first, 54.2% in the second, 80% in the third, and 73.1% in the last quarter (Table 4). The analysis by quarters showed that the number of hospitalizations and readmissions peaked during the second quarter, while the readmission rate of hospitalized patients was highest during the third quarter (36.5%). In other words, our data suggests that higher incidence of complications were observed following the ASPO phase 1 (March-September 2020), during which only 40% (first quarter) to 54.2% (second quarter) of patients were managed surgically. In contrast, the majority (80%) of patients underwent surgery during the third quarter, which was followed by a substantial decrease in readmission rates to 7.7% during the last quarter. (Table 4).
Table 4: Results during the pandemic period (March 2020-March 2021): Comparison by quarters.
1st quarter |
2nd quarter |
3rd quarter |
4th quarter |
p-value |
|
Admissions |
140 |
240 |
104 |
52 |
- |
Surgical treatment (%) |
56 (40%) |
130 (54, 2%) |
84 (80%) |
38 (73, 1%) |
0,000 |
Re-admissions (%) |
8 (5, 7%) |
54 (22, 5%) |
38 (36, 5%) |
4 (7, 7%) |
0,003 |
DISCUSSION
In March 2020, the WHO declared COVID-19 a pandemic and health emergency. The global trend was to direct resources towards containing the pandemic and caring for affected patients, therefore limiting or canceling those surgeries scheduled for benign pathology. However, postponing the timely resolution of a benign pathology increases the risk of complications and recurrence [17-19]. During the COVID 19 pandemic, international surgical societies, including the ACS and the Royal College of Surgeons of England [20], recommended postponing all elective surgeries for conditions that did not represent an imminent risk of death. For this reason, the number of scheduled cholecystectomies decreased globally by 50 to 100% at the beginning of the pandemic [20, 21]. In some countries, surgical management was reserved exclusively for complicated pathology. In others like ours, the authorities imposed the absolute cessation of cholecystectomies for simple or complicated gallstone disease [19-26].
In the pandemic stage, it is worth noting the notable decrease in the number of consultations in emergency departments and the postponement of elective consultations, even in the face of prolonged illnesses. Wong L.E. et al were among the first to demonstrate that strict adherence to restrictions and limitations to timely surgical access entailed additional risks for the lives of patients [22]. Pirracchio R, et al. considered that severe restriction measures might have a significant negative impact on prognosis, increasing the incidence of complications and their severity [23]. Bozovich G. suggested that the prolonged persistence of the restrictions would result in an inevitable increase in delayed diagnoses and complications [24].
Several studies [1,17,19,26] showed that above measures increased the risk of developing gallstone complications (acute cholecystitis, acute pancreatitis, extrahepatic cholestasis, or cholangitis), resulting in longer and repetitive hospitalizations, with the consequent increase in hospital costs. The delay or lack of surgical management in cases of acute gallstone pancreatitis predisposes to recurrence with a potential for more severe presentation [27-34].
In our hospital, by following the regulations issued by the ministerial authority, the Argentine Association of Surgery, the Argentine Society of Infectious Diseases, and international surgical societies, all non-emergent surgeries scheduled for benign pathologies were suspended beginning March 20, 2020 [20,21,31-32]. The two cohorts that make up the study were comparable in terms of age, gender distribution, ASA category, and associated comorbidities (TBQ, DBT, hypertension, enolism, and hypothyroidism). This suggests that the increase in evolutionary complications during the pandemic is due to the delay or lack of surgical treatment. Due to the predominance of non-surgical over surgical management, an increase in the readmission rates was observed (Table 3).
Complications and readmissions were more frequent during the pandemic period, during which 21 cases (6.82%) of Mirizzi Syndrome, 47 cases (15.26%) of frozen biliary hilum, and 73 cases (23.7%) of gangrenous cholecystitis were detected. Whereas complication rates were much, lower during the pre-pandemic era, as follows: 1.54% for Mirizzi Syndrome, 7.1% for the frozen biliary tract, and 4.63% for gangrenous cholecystitis. Under the directives imposed by the regulatory authorities, all patients who entered the operating room during ASPO phase 1 underwent an epidemiological survey, temperature control, and imaging studies. PCR was performed on close contacts of cases with confirmed COVID 19 and suspected cases of COVID based on the clinical picture. The preoperative systematic PCR was performed on all patients during ASPO phases 2 and phase 3.
COVID-19’s impact has gone far beyond its direct effect on morbidity and mortality. In addition to adversely affecting non-COVID health care utilization, the pandemic has resulted in a deep global economic contraction. As a result, Buenos Aires population was also impacted by higher levels of impoverishment, increasing unemployment, and malnutrition rates. For this affected population, the state public hospitals might represent the only viable access to health care. Given these circumstances, the list of medically necessary surgeries that need emergent attention should be redefined.
Said-Degerli, et al. reported that a patient with gallstone ileus, a rare complication of cholelithiasis, brought by the postponement of elective cholecystectomies. In their report, they concluded that the postponement of elective surgeries should be questioned with some more concrete data [30]. In conclusion, the restriction of scheduled care was understandable in the context of a pandemic due to an unknown new pathogen. However, the allocation of care resources for those affected by COVID-19, resulted in the lack of timely surgical resolution of gallstone disease, increasing the incidence of its complications and readmissions.
Postponing elective surgeries not only affected the patients but also the resident doctors in training by the decreasing number of procedures and increasing level of intraoperative complexity, delaying the development of surgical skills on their part. If a similar circumstance arises in the future, the implementation of surgical restrictions should be critically evaluated for the benefit of our patients.
CONCLUSION
The comparison of both groups showed a higher incidence of gallstone complications during the pandemic, associated with the preference of medical over surgical management. The higher incidence of complications were seen and associated with a decrease in the number of scheduled laparoscopic cholecystectomies.
References:
- Campanile FC, Podda M, Arezzo A, et al. Acute cholecystitis during COVID-19 pandemic: A multi society position statement. World J Emerg Surg. 2020;15(1):38.
- Martínez Caballero J, González González L, Rodríguez Cuéllar E, et al. Multicentre cohort study of acute cholecystitis management during the COVID-19 pandemic. Eur J Trauma Emerg Surg. 2021;47(3):683-692.
- Wakabayashi G, Iwashita Y, Hibi T, et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25(1):73?86.
- Kabir T, Kam JH, Chew MH. Cholecystectomy during the COVID-19 pandemic: current evidence and an understanding of the “new” critical view of safety: Correspondence. International Journal of Surgery. 2020; 79: 307-308.
- Tommaso MM, Angelico R, Parente A, et al. Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease-An International survery. Ann Med Sur. 2020;57:95-102.
- Almora CCL, Arteaga PY, et al. Clinical and epidemiological diagnosis of bladder stone. Medical literature review. Rev Ciencias Médicas. 2012;16:200-214.
- Cai JS, Qiang S, Bao-Bing Y. Advances of recurrent risk factors and management of choledocholithiasis. Scand J Gastroenterol. 2017;52(1):34-43.
- Shabanzadeh DM. Incidence of gallstone disease and complications. Curr Opin Gastroenterol. 2018;34(2):81-89.
- Carraro A, Mazloum DE, Bihl F. Health-related quality of life outcomes after cholecystectomy. World J Gastroenterol. 2011;17(45):4945-4951.
- Mayumi T, Okamoto K, Takada T, Strasberg SM, Solomkin JS, Schlossberg D, and Miura F. Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2017;25(1):96-100.
- Miura F, Okamoto K, Takada T, et al. Tokyo Guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25(1):31-40.
- Mukai S, Itoi T, Baron TH, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci. 24(10):537-549.
- Okamoto K, Suzuki K, Takada T, et al. Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72.
- Yokoe M, Hata J, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J HepatoBiliary Pancreat Sci. 2018;25(1):41-54.
- Banks PA, Bollen TL, Dervenis C, et al. Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis 2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.
- Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis. J Hepatobiliary Pancreat Sci. 2018; 25(1):17-30.
- Fu SJ, George EL, Maggio PM, et al. The consequences of delaying elective surgery: surgical perspective. Ann Surg. 202;272(2):e79-e80.
- https://apps.who.int/iris/handle/10665/331561
- Isherwood J, Karki B, Chung WY, et al. Outcomes of gallstone complications during the COVID pandemic. Br J Surgery. 2021;108(1):e29-e30.
- https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2
- https://www.facs.org/for-medical-professionals/covid-19/clinical-guidance/triage
- Wong LE, Hawkins JE, Langness S, et al. Where are all the patients? Addressing Covid-19 fear to encourage sick patients to seek emergency care. NEYM Catalyst. 2020.
- Pirracchio R, Mavrothalassitis O, Mathis M. Response of US hospitals to elective surgical cases in the COVID-19 pandemic. Br J Anaesth. 2020;126(1):e46-e48.
- Bozovich G, Alves DLA, Fosco M. Daño colateral de la pandemia por Covid-19 en centros privados de salud de Argentina. Medicina. 2020;80:37-41.
- Manzia TM, Angelico R, Parente A, Muiesan P, Tisone G. Global management of a common, underrated surgical task during the COVID-19 pandemic: Gallstone disease-An international survery. Ann Med Surg (Lond). 2020;57:95-102.
- European association for the study of the liver (EASL) Clinical practice guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016;65(1):146-181.
- Tazuma S, Unno M, Igarashi Y, et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017;52(3):276-300.
- Roberts SE, Morrison-Rees S, John A, Williams JG, Brown TH, and Samuel DG. The incidence and etiology of acute pancreatitis across Europe. Pancreatology. 2017;17(2):155-165.
- Said-Degerli M, Hogir A, Kandaz OF, et al. How correct is the postponed cholecystectomy during the coronavirus disease-19 pandemic process? Gallstone ileus is not a myth anymore. Cir Cir. 2021;89:390-393.
- https://normas.gba.gob.ar/ar-b/resolucion/2021/1297/234566
- https://facme.es/wp-content/uploads/2020/03/AEC-Recomendaciones_AEC_en_CIRUGIA_DE_URGENCIAS1.pdf
- Salazar M, Ituarte C, Abriata MG, Santoro F, Arroyo G. Gallbladder cancer in South America: epidemiology and prevention. Chin Clin Oncol. 2019;8(4):32.
- https://www.equator-network.org/reporting-guidelines/strobe/
- Yawar B, Marzouk A, Ali H, et al. Acute Pancreatitis during COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in an Acute District Hospital in Northern Ireland. Cureus. 2021;13(10):e18520.