Endoscopic ultrasound-guided gallbladder drainage as a strategy to overcome shortage of operating rooms and intensive care unit beds during Covid-19 crisis.

The Covid-19 outbreak has induced dramatic changes to health care in Italy. Restrictions to intensive care units (ICU) and operating rooms to care for Covid-19 patients has limited the facilities available for infection-free patients 1 2 . We report on a patient with sepsis due to acute cholecystitis who was managed entirely outside the operating room and ICU.

An 80-year-old woman who had been admitted to a rehabilitation institute 20 days earlier following a spinal injury, developed sepsis. Liver enzymes (aspartate aminotransferase 89 U/L), white blood cells (27 000 /mm 3 ), bilirubin (2.9 mg/dL), and C-reactive protein (37.2 mg/dL) were markedly elevated. Her condition worsened overnight and she was referred to hospital. Computed tomography showed marked dilation of the gallbladder with thickened walls and multiple radio-opaque stones. Additionally, complete collapse of the left lung and findings suspicious for Covid-related pneumonia were reported ( Fig. 1 ). As ICU was unavailable, and following multidisciplinary evaluation, she was moved to the endoscopy suite for drainage. Pending Covid-19 results, she was managed as a positive case as a precaution (i. e. negative-pressure room, personal protective equipment) ( Fig. 2 ).

Fig. 1

 Computed tomography images. a Markedly dilated gallbladder, with thickened wall and small stones. b Collapsed left lung and signs of diffuse pneumonia with ground-glass areas in the right lung.

Fig. 2

 Endoscopy room with a dedicated ventilation system (black arrow) to guarantee a negative pressure (asterisk).

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was preferred over percutaneous drainage to allow definitive treatment and, potentially, rapid discharge from hospital 3 4 5 . EUS-GBD was achieved by placement of a 10-mm electrocautery-enhanced lumen-apposing metal stent ( Fig. 3 , Fig. 4 , Video 1 ). The procedure lasted 20 minutes and was conducted under deep sedation. The patient experienced prompt reduction of abdominal pain and remained afebrile. No complications developed and she was discharged 4 hours later. She resumed oral feeding the following day, and biochemical abnormalities started to return to normal.

Fig. 3

 Endoscopic ultrasound image of the gallbladder from the duodenal bulb.

Fig. 4

 Proximal (duodenal) flange after complete release of the lumen-apposing metal stent.

Video 1  Endoscopic ultrasound-guided gallbladder drainage in an 80-year-old patient with suspected Covid-19 infection.

EUS-GBD is established for acute cholecystitis in high-risk surgical patients. During the Covid-19 crisis, indications for this minimally invasive treatment may expand in order to avoid more resource-consuming interventions such as surgery and intensive care admissions.

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