Ongoing Impact of COVID in Gall Stone Disease
on Patients and Surgeons. Is This Just The Tip
of The Iceberg? A Snapshot From An Upper GI
Unit
ISSN: 2754-8880
Published 00 11 0000
Daniel S1* , Chong Y1 , Yeluri S1 , Hussain A1 , Balachandra S 1 , Khetan N1 , and
Samuel N1
1Department of Digestive Surgery, Doncaster Royal Infirmary, Armthorpe Road, Doncaster.
DN2 5LT
* Correspondence author : Sudin Daniel, sudin.daniel@nhs.net.
ORIGINAL
Abstract
Introduction: Covid-19 resulted in a delay to provide cholecystectomy services. We looked at the
effects of the delay on patient morbidity, operative difficulty, and training at our upper GI unit.
Materials And Methods: Data were collected from patients who had cholecystectomy at the
resumption of elective operating services at our DGH. We used Medisec, ICE, and Blue Spire
software to collect data regarding previous admissions, investigations, and operative details. A
proforma was completed after every operation to record the operative findings and difficulty as per
Nassar grades. 101 patients who had cholecystectomy when services resumed from September
2020 after a 5-month pause were included in the study. We looked at the initial presentation,
number of hospital visits, inpatient admissions, diagnoses, operative difficulty, post-operative
complications, hospital stay, 30-day readmissions, and mortality. Results were compared with
Chole S study.
Results: We found a 50% rise in acute cholecystitis, nearly double the number of pancreatitis and
an almost 3 times rise in complications due to choledocholithiasis. Readmissions whilst waiting had
increased by nearly 50%. Nassar grade 4 operations were 50% more, with a significant increase
(p<0.0001, 95% CI) in the operating time. Complications including bile leak were significantly
higher, (p<0.0001, 95% CI). Two-thirds of the operations were done by consultants.
Conclusion: This study from an upper GI unit is a testimony to the adverse effects of delay caused
by covid in terms of morbidity, hospital resources, and training.
OPEN ACCESS
Edited by
A.HussainKeywords : Covid-19, Cholecystectomy, Common Bile Duct stones, Acute Pancreatitis.
Submitted 16 July. 2022
Accepted 17 July. 2022
Introduction
Citation
Daniel S, Chong Y, Yeluri S,
Hussein A, Balachandra S,Covid-19 appears to have introduced a cohort of long waiters for gall stone disease, some of
Khetan N, Samuel N.who had recurrent acute presentations whilst waiting. Our DGH started elective laparoscopic
Ongoing Impact of COVIDcholecystectomies in September 2020, and we looked at a host of issues including the degree
in Gall Stone Disease onPatients and Surgeons. Isof operative difficulty because of the prolonged wait. Studies have shown that the waiting
This Just The Tip of Theperiod increases morbidity and chances of recurrent admissions, especially after the initial acute
Iceberg? A Snapshot Frompresentation (1). Nassar scale could be used to grade operative difficulty in cholecystectomy and
An Upper GI Unitcould be a tool in assessing the effect of prolonged waiting time on cholecystectomy (2).
:BJOSS::2022:(3);65-70
Aims
To look at the effect of cancellation of acute and elective cholecystectomies during covid on
patients who presented acutely or electively in the covid period, who then went on to have
cholecystectomies when services resumed. We looked at the impact of the waiting period enforced
by covid on clinical presentation, the number of recurrent admissions, operative difficulty, duration
of surgery, complications, hospital stay, 30-day readmissions, and 30-day mortality. Results were
compared with the Chole S study, one of the largest studies done in the UK on cholecystectomy.
Materials And methods
101 consecutive patients who had cholecystectomies done when the operations resumed from
Sept 2020 were included in the study. Data were collected prospectively on the day of surgery
and follow-up data from online hospital records, namely Bluespire, Medisec, and ICE. Data collec-
tion was anonymous, and all patients who had cholecystectomy when the service resumed in
September 2020 were included in the study. Relative risk was calculated for the main outcomes
in comparison with Chole S study (3). We excluded any patients who had the previous cholecys-
tectomy but presented with biliary symptoms, and those with pancreatic or bile duct cancer. The
statistical significance of the outcomes of the present study about the waiting time was calculated
using Excel software. Numerical data has been expressed as Median with an interquartile range.
ANOVA and Students T-test were used as appropriate. P values were calculated with 95% C.I.
Results
All elective and acute cholecystectomies were put off at our DGH from April 2020 to August
2020, during the first wave of Covid-19. Operations resumed by mid-September 2020 after a
five-month pause. 101 cases were included in the study, of which females were 71%, (72/101).
The median age was 54, range of 20-84 years. Majority of the patients were ASA 2, 48.5%
(49/101), others being ASA 1, 26.7% (27/101), ASA 3, 23.8% (24/101), and ASA 4, 1% (1/101).
The median BMI was 30, range of 19-50 Kg/m2 The acute initial presentation was noted in 64%
(64/101), as opposed to 36% (37/101) outpatient presentation. Acute cholecystitis and Biliary
Colic were the commonest initial presentations, 40.6% (41/101) each, followed by pancreatitis
17.8% (18/101). GB dyskinesia, 1% (1/101).( Table 1)
Altogether, 25% (25/101) of patients had at least one repeat admission whilst waiting for surgery.
20% (8/37) of those presented to outpatients, and 26% (18/64) who presented initially with an
acute episode had recurrent admissions whilst waiting. Amongst those who presented initially
with acute pancreatitis, 33% (6/18) had recurrent admissions with the same. The median waiting
time was 196 days (1-1185days). The median operating time was 75 minutes, (32 -394 min).
Table 2. shows the frequency and category of operations and surgeons who performed them.
Approximately 80% of the planned IP, Hot Gall Bladders, and 65% of day case surgeries were
done by consultants. Nearly 2/3rd of the operation was in Nassar Grades 1 or 2. 19.8% (20/101)
were Nassar 3, and 13.9% (14/101) Nassar 4.( Figure 1)
The majority had no postoperative complications, 91% (92/101), 9% (9/101), had complications,
including two bile duct injuries and four minor bile leaks, and 3 intraoperative bleeding. Only
three patients (3%) had an open conversation, and two of them were for the above complications.
The median length of stay was 1 day, range 0-17 days. The 30-day readmission rate was 3%
(3/101). No mortality was reported. The results were compared with Choles S study.( Table 3).
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Table 1. Patient characteristics and pre-operative findings, comparing Choe S and Present Study.
Chole S (n=8909)Present study (n=101)
N8909101
Age51(38-64)54 (20-84)
F:M74:26:0071:29:00
BMI30
ASA 1 and 2789(89.4%)76(75.2%)
ASA >/=>37937 (10.6%)25(24.8)
Indications
Biliary colic4683 (52.6%)41(40.6%)
Cholecystitis2581 (29%)41(40.6%)
Pancreatitis851 (9.6%)18(17.8%)
CBD stone589 (6.6%)24(23.8%)
GB Dyskinesia31 (0.3%)1 (1%)
Polyps etc174 (1.9%)0
Admissions before surgery
05196 (58.3%)40 (39.6%)
12859 (32.1%)41(40.6%)
2623 (7.0%)16 (15.8%)
3 or more231 (2.6%)4 (4%)
Waiting time196 (1-1185)
Thickness of GB
Thickwalled2835 (32.8%)56 (55.5%)
CBD diameter
Dilated CBD1398 (16%)29 (28.7%)
pre-op ERCP’s960 (10.9%)24 (23.8%) includes 4 pts with
2 ercp’s
Table 2. Distribution of operation category and surgeon category.
surgeon
OperationConsSt7-8St3-6Total
Day case
Planned inpatient
Hot GB		47
11
11		21
3
1		4
0
3		72
14
15
Total69257101
Figure 1. Nassar operating grades of cases. N=101.
67/70
Table 3. Morbidity, operative difficulty, and post operative complications. Comparison with
Chole S study. * Median time calculated separately for day cases, delayed and elective
cholecystectomy.
Chole S (%)Present
study (%)		relative
risk		Relative
Risk In-
crease		p value
95% CI
Indications
surgery		for
Biliary colic4863 (52.6)41 (40.6)0.7
Cholecystitis2581 (29)41 (40.6)1.4 40%
pancreatitis851 (9.6)18 (17.8)1.9 90%
CBD stone589 (6.6)24 (23.8)3.6 260%
GB dyskinesia31 (0.3)1 (1)
Polyps etc174 (1.9)0
Admissions before
surgery		p=0.0338
1 acute admission2859 (32.1)41 (40.6)1.3
2 acute admissions623 (7)16 (15.8)2.3130%
3 or more ac admis-
sions		231 (2.6)4 (4)1.550%
Operative difficulty
grades		p=0.6726
Nassar 13554 (40.2)36 (35.6)0.9
Nassar 22644 (29.9)31 (30.7)1
Nassar 31814 (20.5)20 (19.8)0.97
Nassar 4821 (9.3)14 (13.9)1.550%p=0.6726
Operating time60-80 min*
(50-110)		75 min
394 min)		(32-p<0.0001
All complications962 (10.8)9 (9)0.8p<0.0001
Bile leak121 (1.3)4 (4)3.1210%
Bile duct injury24 (0.9)2 (2)2.2120%
Bleeding754 (8.4)3 (3)0.36
open conversion297 (3.3)3 (3)0.9
intraabdominal col-
lection		189 (2.1)3 (3)1.440%
SSI192 (2.1)1 (1)0.5
CVS/ pulmonary127 (1.4)1 (1)0.7
CBD stone89 (0.9)1 (1)1
Length
stay		ofhospital1 day
days)		(0-17p=0.0006
30-day
sions		readmis-633 (7.1)3 (3)0.4p=0.9161
30-day mortality11 (0.1)00
Discussion
Most hospitals in the UK, paused all elective work during the first wave, with some exceptions.
All elective gall bladder operations were paused, which resulted in a bulging waiting list for
laparoscopic cholecystectomies when the operation lists were reinstated. Covid free elective
pathways allowed to catch up with the waiting lists (4). Previous studies have shown that the
average waiting time for cholecystectomy could be around 80 to 170 days (1; 5). In the present
study the median waiting time was 196 days. Various studies done in the UK have shown that
readmissions with acute complications of gall stone disease could be around 10% (1). In the
68/70
present study the readmission rates were twice reported in the literature, 25%, and a third of
acute pancreatitis represented the same whilst waiting for surgery. This does keep in line with
other studies reporting reduced quality of life with prolonged waiting times (6).
There are several grading systems to assess the operative difficulty of cholecystectomy. Nassar
grading has been found to be simple and easy to use by all grades of surgeons. The operative
difficulty is graded into four.( Table 4) (2).
Table 4. Nassar Grading of operative difficulty. Adopted from Griffiths, E.A., Hodson, J., Vohra,
R.S. et al. Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy.
Surg Endosc 33, 110–121 (2019). http://creativecommons.org/licenses/by/4.0/
Grade 1 Gallbladder—floppy, non-adherent Cystic pedicle—thin and clear Adhesions—Simple
up to the neck/Hartmann’s pouch
Grade 2 Gallbladder—Mucocele,PackedwithstonesCysticpedicle—FatladenAdhe-
sions—Simple up to the body
Grade 3 Gallbladder—Deep fossa, Acute cholecystitis, Contracted, Fibrosis, Hartman’s adher-
ent to CBD, Impaction Cystic pedicle—Abnormal anatomy or cystic duct—short, dilated or
obscured Adhesions—Dense up to fundus; Involving hepatic flexure or duodenum
Grade 4 Gallbladder—Completely obscured, Empyema, Gangrene, MassCystic pedi-
cle—Impossible to clarify Adhesions—Dense, fibrosis, wrapping the gallbladder, Duodenum, or
hepatic flexure difficult to separate
We used this grading as Chole S study also used the same, and hence useful in comparison. A third
of all cholecystectomies in the present study were Grades 3 or 4, 33.7% (34/101). This increase
in Grade 3 and 4 cholecystectomies in the present study was marginal compared to the CholeS
study but could be clinically significant. It should be borne in mind that the CholeS study had
specialist and non-specialist operating surgeons, whilst in the present study, all cholecystectomies
were done or led by specialist (UGI) surgeons. This would make the results of operative difficulty
more relevant in the present study. Consultants did 70% of all operations and 80% of Grade 3
and 4 cholecystectomies. The median operating time was 75minutes, range (of 32-394min). The
reported incidence of complications like bile duct injury, and major bleeding, in the literature is
less than 1%. Conversion to open varied from 1-5%. The complications could be lower when
operations are done in specialist units (7). The present study showed an increased incidence
of complications like bile duct injury, 2%. This was statistically significant, p,0.0001, (95% C.I).
Operating time, p<0.0001and length of hospital stay, p=0.0006, were also statistically significant
at 95% C.I.
The study benefits in being a prospective one, done at the reinstating of operating lists which
adds to its relevance. However, the sample is relatively small compared to the enormity of gall
stone disease load in the population. This however represents a snapshot of the bigger picture,
highlighting the potential impact of increased waiting times on patients, surgeons, and health
care management. The fact that this study has been done in a specialist upper GI unit adds to the
significance of the results. It is quite possible that the small sample size would have resulted in an
exaggeration of complication rates. Nevertheless, the study highlights the importance of getting
the waiting list down and implementing hot gall bladder pathways to reduce the negative impact
of increased waiting times. We haven’t calculated the increased financial burden from this, but
that should be obvious. The training was also affected because the consultant had to take over
cases due to increased difficulty, with less than a third done by trainees.
Conclusion
The delay caused by covid-19 from April to August 2020, has significantly increased the operating
time, complication rates, and hospital stay in gall stone disease. It has also increased the number
of acute admissions with gall stone complications and had a negative impact on training. This is
likely to have influenced all NHS trusts, and even in units with specialist Upper GI input as shown
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in this study. A larger study or a multicenter study should throw more light on the impact caused
by Covid-19 delays in cholecystectomy. Measures should be taken urgently to reduce waiting
lists and encourage hot gall bladder pathways.
Conflict Of Interest
All authors declare no conflict of interest of any kind.
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