key: cord-0733269-23x5rke9
authors: Lovece, Andrea; Asti, Emanuele; Bruni, Barbara; Bonavina, Luigi
title: Subtotal laparoscopic cholecystectomy for gangrenous gallbladder during recovery from COVID-19 pneumonia
date: 2020-06-13
journal: Int J Surg Case Rep
DOI: 10.1016/j.ijscr.2020.06.038
sha: daea9802bc887a99aa47835de32c5e5b43a74a1d
doc_id: 733269
cord_uid: 23x5rke9

INTRODUCTION: Management of acute abdomen during COVID-19 pandemic may be challenging. Presentation of case. A 42-year old man was hospitalized for Covid-19 pneumonia. Fever, respiratory symptoms and hypoxemia significantly improved over the next 2 weeks, but the patient developed abdominal pain, nausea, and low-grade fever. Computed tomography scan revealed absence of contrast enhancement of gallbladder wall and a micro-perforation of the fundus. At laparoscopy, gallbladder gangrene was confirmed and a subtotal cholecystectomy performed. Special precautions were adopted for patient transportation from the ward to a dedicated operating room, and two teams with adequate personal protective equipment took charge of the procedure. The patient was discharged home on postoperative day 7 under protective lockdown measures for 2 weeks. DISCUSSION: The pathogenesis of acute acalcolous gangrenous cholecystitis is multifactorial. It is unknown whether a prothrombotic state induced by COVID-19 contributes to wall ischemia and perforation. Percutaneous cholecystostomy should be avoided in patients with gallbladder gangrene. Contraindications to laparoscopy are not evidence-based since aerosolization is produced during both open and laparoscopic surgical procedures. However, personal protective equipment is key for prevention CONCLUSION: Early diagnosis and surgical therapy are critical in patients with gangrenous cholecystitis. Subtotal laparoscopic cholecystectomy for gangrenous gallbladder is safe and effective.

Special precautions were adopted for patient transportation from the ward to a dedicated operating room, and two teams with adequate personal protective equipment took charge of the procedure.

The patient was discharged home on postoperative day 7 under protective lockdown measures for 2 weeks.

Discussion. The pathogenesis of acute acalcolous gangrenous cholecystitis is multifactorial. It is unknown whether a prothrombotic state induced by COVID-19 contributes to wall ischemia and perforation. Percutaneous cholecystostomy should be avoided in patients with gallbladder gangrene.

Contraindications to laparoscopy are not evidence-based since aerosolization is produced during both open and laparoscopic surgical procedures. However, personal protective equipment is key for prevention Conclusion. Early diagnosis and surgical therapy are critical in patients with gangrenous cholecystitis. Subtotal laparoscopic cholecystectomy for gangrenous gallbladder is safe and effective.

Covid-19 has rapidly become a global pandemic with high lethality rates. Italy has been an epicenter of this outbreak, with more than 170000 cases recorded to date from February 20 th , 2020, and an estimated 13% overall mortality (www.protezionecivile.gov.it ). The impact of this outbreak on the hospital health-care system has been devastating, with most resources being allocated to patients with proven or suspected infection and elective surgery canceled or delayed. There are significant implications of the pandemic also on the emergency surgery activity due to the potential spread of infection in the nosocomial environment. Surgical teams are obviously at high risk for Covid-19 exposure. The virus can survive in aerosol for at least 3 hours and can be found on different surfaces J o u r n a l P r e -p r o o f for days. It is also likely that the virus can spread in smoke generated by electrocautery and ultrasonic devices. Therefore, protocols for protecting both the patient and the surgical team are mandatory. The exposure risk is potentially higher in laparoscopic surgery, given the need establish an artificial pneumoperitoneum and the consequent aerosolization of the operating room (OR) environment. It is recommended that the team is able to wear and remove safely all personal protective equipment (PPE), that traffic in and out the OR is restricted, that aerosol exposure in the OR is minimized, and that at least 30 minutes of air exchange between cases is allowed if negative pressure operating rooms are not available (1,2).

We present an exemplary case of a Covid-19 positive patient who suffered from acute surgical abdomen during hospitalization for pneumonia and required emergency laparoscopic cholecystectomy for gangrenous, acalcolous cholecystitis.

The case of a 42-year-old man referred to our hospital on March 14, 2020 for acute dyspnea and fever was reviewed and reported herein according to the SCARE guidelines (3). He had been complaining of fever and fatigue for the last 7 days, and was treated at home with amoxicillin. His past medical history and physical examination were unremarkable. Body mass index was 28. Body temperature was 37,5 °C, respiratory rate 20/min, and heart rate 105 beats/min. Peripheral blood saturation was 92% on air. Blood pressure was 130/95mmHg, and the ECG showed normal sinus rhythm. Blood gas analysis under oxygen therapy 4L/min showed pH 7,41, pCO2 42,6 mmHg, pO2 95,5 mmHg, sO2 97%. Laboratory blood tests showed WBC 5,6x10 3 /μL, Hb 12,7 g/dL, platelets 226x10 3 /μL, CRP 13,9 mg/dL, procalcitonin 0.11 ng/ml, d-dimer 0.6 u/L. A chest film showed bilateral pulmonary opacities and thickenings, and a ground-glass opacity in the right hilum. 

An Internal Reviewed Board approved pathway was adopted to reduce exposure to SARS-COV-2 and to provide protection for hospital personnel (Figure 1 ). Special precautions were taken for patient transportation from the ward to the OR, and back to the ward. Two teams, one inside the OR and the other outside, took charge of the procedure. A dedicated OR was used. Personal protective equipment (PPE) for the OR personnel consisted of double air cap, face shield, waterproof gown, double gloves, shoe covers, and N95 mask (Ffp2). Inside the OR, two staff surgeons, one anesthesiologist and 2 nurses were in charge of the procedure. Rapid sequence orotracheal intubation by video-laryngoscopy was performed, and maximal care was used to minimize aerosolization and contamination throughout the surgical procedure.

Pneumoperitoneum was establish with a Veress needle. Two 12 mm and two 5 mm trocars were inserted through minimal wall incisions. Intra-operative pneumoperitoneum was set at 9 mmHg to minimize CO2 leakage without compromising exposure of the surgical field. Use of electrocautery was minimized, and smoke was aspirated through a smoke-evacuation system with filters. After lysis of dense inflammatory adhesions, a severe, gangrenous cholecystitis with a small perforation J o u r n a l P r e -p r o o f of the fundus was identified. Because a retrograde approach was deemed at risk, the gallbladder was opened and the infundibulum was transected with a stapler after identifying the cystic duct from inside ( Figure 2 ). The pneumoperitoneum was evacuated by the suction device before trocar removal and specimen extraction to prevent aerosol dispersal. The procedure lasted 85 minutes. The patient was extubated immediately after the procedure without complications. Special precautions were again adopted by the surgical team and the scrub nurse to take off the gowns and remove the face mask afterwards. Postoperative course was uneventful, and the patient was discharged home on day 5 under protective lockdown measures. Pathology confirmed transmural gallbladder necrosis ( Figure 3 ). At one-month follow-up the patient is doing well and two consecutive swabs resulted negative.

The clinical course of this young patient was favorable due to immediate diagnosis and surgical therapy of a gangrenous acalcolous cholecystitis. There were no specific risk factors accounting for this surgical emergency, except prolonged Covid-19 related hospitalization due to pneumonia. A recent study from China showed that 16% of confirmed COVID-19 patients present with gastrointestinal symptoms from the onset, and abdominal pain was reported by 25% of these patients (4) . By contrast, in our patient, abdominal pain manifested later during the course of the disease and the pathogenesis of cholecystitis in this context remains obscure. A possible hypothesis is that a distended gallbladder from prolonged fasting may have led to bile stasis and subsequent wall ischemia (5) . Another plausible hypothesis is that some degree of systemic inflammation (6) 

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