Surgical treatment of acute cholecystitis in patients with confirmed COVID-19: Ten case reports and review of literature

Table 1 Demographic information of confirmed coronavirus disease 2019 patients with acute cholecystitis (n = 10) (mean ± SD)

Classification	n = 10
Sex, n (%)
Female	4
Male	6
Age (yr), mean (range)	47.1 (20-74)
BMI (kg/m2), mean (range)	28.4 (20-43)
Current Smokers, n (%)	3
ASA classification, n (%)
I	2
II	4
III	4
Comorbidities, n (%)
Diabetes	2
Hypertension	4
CRD	2
Lupus	1
No	6
Preoperative qSOFA score, n (%)
Not high risk (0-1)	4
High risk (> 2)	6
COVID-19 symtoms
Yes	6
No	4
Preoperative studies
Hemoglobin (g/dL)	12.8 (2.8)
Platelets (n × 103/μL)	284 (128.7)
Leucocytes (n/μL)	11.95 (5.6)
CRP (mg/dL)	20.1 (12.5)
Total Bilirubin (mg/dL)	1.29 (1.7)
Gamma-glutamyl transferase (IU/L)	163.1 (198.1)
Alanine aminotransferase (IU/L)	86.1 (102.8)
Aspartate aminotransferase (IU/L)	59.9 (46.7)
Alkaline fosfatase (IU/L)	199 (189.7)
LDH (IU/L)	215.1 (63.3)
Albumin (g/dL)	4.17 (0.4)
Ferritin (ng/mL)	565 (304.5)
Creatinine (md/dL)	1.02 (0.5)

BMI: Body mass index; CRD: Chronic renal disease; qSOFA: Quick Sequential Organ Failure Assessment; CRP: C-reactive protein.

Table 2 Description of postoperative complications according with the Clavien-Dindo classification (n = 10)

Grade
Grade I
Hydroelectrolytic imbalance	8
Antiemetics	3
Antipyretic (for fever ≥ 38.3)	4
Grade II
Blood transfusions	3
Total parenteral nutrition	3
Postoperative Ileus	1
Pneumonia	6
Delirium	4
Biliar leak	5
Wound infection	3
Grade IIIb
Evisceration	1
Bleeding	1
ERCP	3
Grade IVa
Respiratory	5
Renal	3
Hepatic	2
Cardiovascular	5
Dialysis	2
Grade IVb	5
Multiorganic failure
Grade V	1
Death of a patient

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Perioperative outcomes of coronavirus disease 2019 patients with acute cholecystitis

Perioperative outcomes
ERCP result
Preop Mirizzi syndrome 1	1
Preop Cholangitis + CBD stones	1
Postoperative Biliary leak	3
ERCP Biliary stent	3
Modality of cholecystectomy, n (%)
Laparoscopic	8
Lap converted to open	2
Type of cholecystectomy
Total	4
Sub-total	6
Parkland grading scale, n (%)
3	2
4	2
5	6
Estimated blood loss (mL), mean (range)	258 (30-500)
Operative time (min), mean (range)	133.5 (70-190)
Intraabdominal drainage, n (%)	8
ICU admission, n (%)
Yes, Preoperative	1
Yes, Postoperative	4
ICU treatment, n (%)
Invasive ventilation	5
Vasopressors	5
Hospital LOS (days), mean (range)	18. 2 (3-50)
Histopathology results, n (%)
Ischemic/segmental necrosis	3
Transmural necrosis	5
Perforated	3
Mucosal ulcerations	1
Acute peritonitis	10
GB empyema	4
Hemorrhagic	2

ERCP: Endoscopic retrograde cholangiopancreatography; CBD: Common bile duct; Lap: Laparoscopic; ICU: Intensive care unit; LOS: Length of stay; GB: Gallbladder.

Table 4 Review of previous studies reporting coronavirus disease 2019 and acute cholecystitis treatment approach

Ref.	Study design	Country	Sample size, n (%)	Age/sex (F:M)	COVID-19 diagnosis	Tokyo class	Treatment	Morbidity/PO complications	ICU, n (%)	LOS (d)	Mortality	Findings/histopathology
Çakır and Kabuli[8], 2021	Retrospective study	Turkey	18	M: 14 (78%); F: 4 (22%); Age: 73.3 (67-81)	RT-PCR	GI: 3 (16.7%); GII: 9 (50%); GIII: 6 (33.3%)	THGD	No complications	3 (16.6%)	16 (3-32)	3 (16.6%)	NR
Barabino et al[9], 2021	Retrospective study	Italy	37: 36 non-COVID; 1 COVID	64 (38-94); Male: 21 (56.7%); Female 16 (43.3%)	RT-PCR	GI: 13 (35.1%); GII: 15 (40.5%); GIII: 8 (21.6%); COVID: GII	Antibiotic only 11 (29.7%); THGD 8 (21.6%); L 18 (48.7%); COVID: THGD 1	Emergency LC 1; Bleeding 1; Cholangitis 2	2	9 (2-12)	-	-
Martínez Caballero et al[10], 2021	Multicentre-combined (retrospective–prospective) cohort study	Spain	42	Age: COVID: 83 (65-87); COVID: 28 M/14 F	Clinics 10.9%; Imaging test 11.3%; RT-PCR 12.5%	GI: 112 (43.6%); GII: 121 (47.1%); GIII: 24 (9.3%)	Antibiotic therapy 47.9%; Surgical treatment 31.5%; THGD 20.6%. COVID: 93.3% non surgical treatment	Gallblader perforation 8.4%; Biliar setic shock 8.4%	23%	Non-COVID: 5 d (3–8). COVID: 11.0 d (7.5–27.5)	Non-COVID: 3.25%; COVID: 11.9%	-
Çiyiltepe et al[11], 2021	Retrospective study	Turkey	65 non-COVID; 7 COVID	Age: 57.3; F: 40 (55.6)/M: 32 (44.4)		GI: 35 (48.6%); GII: 37 (51.3%)	11 THGD	-	-	9.2 (6-20)	-	-
Somuncu et al[12], 2021	Retrospective study	Turkey	4 COVID; 32 non-COVID	Age: 53 (26-78); M: 17/F: 19	Thorax CT	-	Antibiotic therapy 14; THGD 14 (39%); LC 8	-	-	7 (2-20)	1: Cardiac arrest	-
Puig et al[13], 2021	Case report	Spain	2	M: 65/57	RT-PCR	GIII: 2	Percutaneous cholecystostomy 2	Pulmonary tromboemboly 2	2	34	0	-
Abaleka et al[14], 2021	Case report	United States	1	Age: 76; F	RT-PCR	Grade II	Antibiotics	-	-	-	-	-
Lovece et al[15], 2020	Case report	Italy	1	Age: 42/M	RT-PCR	Grade III	LC	Gallblader perforation	-	-	-	-
Famularo and Spada[16], 2021	Letter/case report	Italy	1	90/M	RT-PCR +	NR	THGD	No	No	26	No	NR
Vaishnav and Patel[17], 2021	Observational/prospective	India	16	50/F: 7 (29%); M: 17 (70%)	RT-PCR + CT +	GIII	LC	No	NR	4.9	NR	NR
Alhassan et al[18], 2020	Case report	Qatar	1	40/F	Confirmed 14 d prior	AAC	Antibiotics	No	Yes (1, 100%)	NR	No	-
Asti et al[19], 2020	Letter/case report	Italy	3	40-86/F: 1 (33%); M: 2 (66%)	Confirmed	AAC	LC	NR	NR	NR	NR	Acalculous, gangrene
Balaphas et al[20], 2020	Letter/case report	Switzerland	2	83-84/F: 1 (50%); M: 1 (50%)	RT-PCR +	AAC	LC/Antibiotics	NR	Yes (1, 50%)	NR	Yes (1, 50%)	qRT-PCR revealed the presence of SARS-CoV-2 in the gallbladder wall
Bruni et al[21], 2020	Case report	Italy	1	59/M	RT-PCR +	AC/GIII	OC	NR	Yes (1, 100%)	44	No	Gangrenous, Hemorrhagic, vasculitis
Cirillo et al[22], 2020	Letter/case report	Italy	1	79/M	Confirmed	AAC	Cholecystectomy	No	NR	NR	No	Perforated acalculous cholecystitis
Giulio et al[23], 2020	Letter/case report	Italy	1	45/F	RT-PCR +	AC/GI	LC	No	NR	30	No	NR
Gupta et al[24], 2020	Retrospective original article	India	5	53.2/NR	Confirmed	AC	OC	Bile leak	NR	4-9	No	Acute on chronic calculous cholecystitis, gangrenous acalculous cholecystitis
Kabir et al[25], 2020	Letter/case report	Singapore	1	Middle-aged/M	RT-PCR +	Gangrenous cholecystitis	Subtotal reconstituting OC	NR	NR	NR	NR	NR
Lisotti et al[26], 2020	Case report	Italy	1	80/F	CT suspicious	AC/GII	EUS-GBD	No	No	1	NR	NR
Mattone et al[27], 2020	Case report	Italy	1	66/M	RT-PCR +	AAC	Initially THGDLC	No	Yes	NR	No	Gangrenous gallbladder
F Narvaez et al[28], 2020	Brief report/review	United States	1	NR/F	Confirmed	AC	LC	No	No	NR	No	Near-gangrenous gallbladder
Safari et al[29], 2020	Case report	Iran	1	75/F	RT-PCR +CT +	AC/GII	LC	NR	Yes (1, 100%)	9	Yes	NR
Ying et al[30], 2020	Case report	China	1	68/F	RT-PCR +	AC/GII	THGD	No	No	25	No	NR

COVID-19: Coronavirus disease 2019; LOS: Length of stay; RT-PCR: Real-time reverse-transcriptase polymerase-chain reaction; NR: Non-reported; AC: Acute cholecystits; AAC: Acute acalculous cholecystitis; LC: Laparoscopic Cholecystectomy; OC: Open Cholecystectomy, GI: Tokyo Class Grade I; GII: Tokyo Class Grade II; GIII: Tokyo Class Grade III; qRT-PCR: Quantitative reverse transcriptase PCR; THGD: Trans-Hepatic Gallbladder Drainage; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; F: Female; M: Male; ICU: Intensive care unit.