The surgeon's dilemma: Performing cholecystectomy during COVID-19.

To the Editor:

We read with interest the article titled, “Impact of Coronavirus Disease (COVID-19) on In-Hospital Mortality and Surgical Activity in Elective Digestive Resections: A Nationwide Cohort Analysis” by Challine et al. We would first congratulate the authors for an insightful read. The COVID-19 pandemic led to the postponement of elective surgeries, and the article suggests that elective surgeries during the period did not have any implication on in-hospital mortality rate. It also states that elective procedures should be advocated during the pandemic for patients with cancer. However, the results varied for low- and middle-income countries (LMICs) and also depended on the lockdown measures employed by every nation. Only emergency procedures were performed in most LMICs to ensure the effective use of manpower and resources. This article collates the postoperative outcomes, adaptations, and suggestions by surgeons in LMICs during the COVID-19 pandemic, particularly for emergency cholecystectomy.

Conventionally, one of the most common operative procedures performed globally is cholecystectomy. The gold-standard method for gallstone-related pathologies is still laparoscopic cholecystectomy. Kabir et al noted that understanding the new critical view of safety by surgeons during the pandemic is important. These 3 points include: (1) absence of SARS-CoV in bile, (2) evidence favoring safe laparoscopic surgery in COVID-19 infected patients, and (3) implementation of rigorous preoperative screening measures. Vigneswaran et al recommended using smoke evacuation, minimizing use of energy devices, and low pneumoperitoneum pressure to improve outcome and reduce transmission. However, few opponents believe that percutaneous cystostomy is a better approach than laparoscopic cholecystectomy amidst the pandemic. To date, the dilemma continues, and very few studies noted the postoperative outcome of emergency cholecystectomy done during the COVID-19 outbreak period in LMICs.

Subjecting every emergency patient to triage and preoperative screening required crucial hours. Evaluating both emergency and elective patients would further burden the system. In India, a single-center study noted that during lockdown, emergency cholecystectomy procedures and multiorgan dysfunction led to 4 times increment in postoperative morbidity in patients.

Martin Nnaji et al conducted a prospective study of complications seen in cholecystectomy patients during the COVID-19 outbreak period with indications of biliary colic, cholecystitis, cholangitis, gallbladder perforation, gallbladder polyp, and pancreatitis. Postoperative complications noted were an approximate 2-fold increase in bile leak, collection, hospital-acquired pneumonia, and surgical site infections.

In conclusion, the patients after cholecystectomy are at increased risk of bile leak, intraabdominal collection, hospital-acquired pneumonia, and surgical site infection, especially during the COVID-19 outbreak. These complications need to get assessed in follow-up patients and outcomes require proper audits to improve further practice. Segregating patients requiring conservative management during triage with those needing emergency cholecystectomy can reduce the overall workload. Further studies are needed to create a set of uniform practical guidelines on the type, procedure, pre and postoperative considerations of GI and hepatobiliary surgeries. They should consider unique socioeconomic and geopolitical considerations of different nations during the pandemic, which can be further tailored by every institution regularly after practical considerations. This will reduce subjectivity and ensure better implementation of guidelines worldwide.

Funding/Support

None declared.

Conflict of interest/Disclosure

None declared.