Laparoscopic cholecystectomy (LC) remains the treatment of choice for AC, even in the COVID-19 era.
All current guidelines recommend LC as the gold standard of therapy for AC, because of the better results in terms of mortality, morbidity, and postoperative hospital stay compared to open cholecystectomy (OC) [6,7,8].
The Italian guidelines, promoted by SICE in 2012 in collaboration with all the leading Italian scientific societies [8] and our evidence-based guidelines on laparoscopic cholecystectomy published in 2015 [6], reiterated that “patients with acute cholecystitis should be treated with laparoscopic cholecystectomy” with a grade of recommendation A in the former and “strong” in the latter. This indication also applies in the case of elderly patients and those with severe AC. The guidelines from the World Society of Emergency Surgery (WSES) agree with this setting [7, 9].
Several studies have emphasized that many toxic components of the surgical smoke may endanger the operating team’s health.
Blood-borne viruses (HPV, HBV, HIV) are known to be present in the plume produced by electrocautery and other energy devices [10, 11]. However, although the SARS-Cov-2 RNA has recently been detected in the peritoneal cavity [12], there is no evidence to indicate the presence of SARS-CoV-2 in surgical smoke.
No evidence emerged suggesting that the risk of COVID-19 infection related to LC may be higher than that of OC, neither for the patient nor for the health professionals. Therefore, this working group does not consider that patients should be denied the benefits that high-quality studies have shown to be associated with LC. We recommend surgeons to take the necessary safety measures to reduce the risk of viral diffusion in the operating theater and ensure that patients continue to benefit from advantages of laparoscopic surgery [13].
If, on the one hand, laparoscopy contains the surgical smoke within the peritoneal cavity, on the other, the pneumoperitoneum evacuation could put the staff at risk of infection.
We suggest filtering the pneumoperitoneum through filters able to remove most viral particles. The ULPA (ultra-low particulate air) filters are extremely efficient to filter the SARS-CoV-2 virus whose diameter is about 0.06–0.14 μm. According to the ISO standard 29463 (issued to harmonize the European Standard EN 1822 and the US MIL-STD-282), an ULPA filter must have a ≥ 99.9995% efficiency at filtering particles with a MMPS (most penetrating particle size) of 0.12 μm. The MMPS is the particle that the filter is less efficient to remove. Smaller particles are filtered with an even higher efficiency. The use of these filters is recommended [3, 4, 13].
It is crucial nowadays to examine the evidence concerning the timing of LC for AC, which compares the results of “early” cholecystectomy with those of “delayed” cholecystectomy, that is carried out after a period of conservative therapy to overcome the acute phase.
Early cholecystectomy is recommended in all the guidelines mentioned above, based on the results of several meta-analyses of randomized controlled trials that compared the two different approaches. It has been demonstrated that early cholecystectomy (i.e., performed “as soon as possible” after the onset of symptoms and, in any case, not later than the tenth day from it) has not shown inferior results compared with the delayed one in terms of morbidity, mortality, and conversion rate (i.e., six weeks after the acute episode).
Therefore, early cholecystectomy is preferable to the delayed, for its shorter overall length of hospitalization (considering the sum of the stay of the first hospitalization—that is, of acute cholecystitis—and the second—that of the delayed intervention).
The equivalency of the two strategies in terms of morbidity, mortality, and conversion rate cannot justify the systematic use of delayed cholecystectomy. During the COVID epidemic, it may instead be desirable to postpone the surgical act away from the epidemic period, even at the cost of greater use of resources of the health system (length of stay).
The equivalency in terms of morbidity and mortality between the two approaches can be a solid basis for more extensive use of delayed cholecystectomy, based on the analysis of the human and logistical resources of the hospital in which each of us works, the organizational pathways adopted, and the local epidemiological situation.
It is mandatory that during the conservative treatment period, attention must be paid to monitoring sepsis parameters and pain progression despite appropriate analgesic therapy. The danger of progress of the septic state and the risk of progression towards the gangrene, emphysematous cholecystitis, or the rupture of the gallbladder may, anyway, require emergency cholecystectomy.
If it is true that in the pre-COVID period, cholecystectomy in patients classified as high risk according to the various guidelines has a mortality rate that can reach 19% [14], clearly this aspect assumes greater relevance in positive or suspected COVID-19 patients, which are considered at high surgical risk in themselves.
Both the incidence of AC and the mortality from COVID-19 are higher in elderly patients. Although elderly patients are more likely to present with different comorbidities that complicate any postoperative course, early LA for AC is safe and effective in this group of patients, albeit burdened by increasing conversion rates [15].
The Italian guidelines (by SICE, ACOI, SIC, SICUT, SICOP) on LC [6] and the recent WSES guidelines [7, 9] refer as in the case of patients with prohibitive surgical risk (“unfit for surgery”) percutaneous drainage of the gallbladder may be considered after the failure of conservative therapy with antibiotics. However, it must be stressed that advanced age, or other factors of higher COVID-19 risk, cannot be regarded as sufficient to indicate this alternative treatment except in real conditions of the impracticability of cholecystectomy.
The analysis of the international literature, despite being mainly based on observational studies with a low level of evidence, demonstrates a high mortality rate for patients undergoing percutaneous gallbladder drainage. High mortality was also shown in recent extensive retrospective analyzes [16, 17].
Moreover, the CHOCOLATE trial, a randomized controlled trial that had been started to compare the results of percutaneous drainage vs cholecystectomy, was prematurely terminated because the ethical problems arising from the observation of the high mortality in patients who underwent percutaneous drainage did not allow the further continuation of the study [18].
As indicated, the execution of a percutaneous cholecystostomy (only in patients with prohibitive surgical risk) takes place, as specified above, after the failure of conservative therapy, which constitutes the first therapeutic strategy in these particularly fragile patients.
Of all the options currently listed in the literature (percutaneous transhepatic cholecystostomy, transpapillary drainage, transmural drainage), percutaneous transhepatic cholecystostomy is generally the preferred one, due to its simplicity of execution, safety, and reduced costs.
The optimal timing for performing percutaneous cholecystostomy is widely debated. However, when the cholecystostomy is carried out within 24 h from the onset of the clinical presentation is associated with fewer complications in terms of bleeding and lower hospital stay [19]. However, the timing of percutaneous cholecystostomy depends primarily on the clinical indication. Urgent drainage should be considered in case of severe sepsis in a patient not eligible for surgery.
For the remaining patients not eligible for surgery, it is common practice to proceed with cholecystostomy if the patient does not improve within 1–3 days of starting antibiotic therapy.
