The role and place of laparoscopic cholecystectomy in pregnant women with a history of COVID-19

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Odessa National Medical University

1Odessa Regional Clinical Hospital

2Poltava State Medical University

The role and place of laparoscopic cholecystectomy in pregnant women with a history of COVID-19

V.V. Mishchenko, V.P. Mishchenko,

P.I. Pustovoit1, R.Yu. Vododіuk, V.V. Velichko,

V.K. Likhachev2, L.M. Dobrovolska2

Odessa, Poltava

Abstract

The purpose of the study was to determine the role and location of laparoscopic cholecystectomy in pregnant women with a history of COVID-19. 19 pregnant women underwent surgery. The mean age of pregnant women was 27±4.9 years. In the post-Covid period, clinical manifestations of the disease appeared in the first two days. Pregnant women who have had Covid-19 and patients with cholelithiasis and acute calculous cholecystitis have clinical manifestations of the disease in the form of hemolysed blood in the abdominal cavity and vesicular rashes on the visceral and parietal peritoneum, which sometimes merged into conglomerates and bled on contact. Pathomorphologically, the changes in the gallbladder wall were phlegmonous or gangrenous in nature. Diagnosis of this pathology in pregnant women who have had COVID-19 should be rapid and accurate. Cholecystectomy should be performed before developing complications of gallstone disease and acute calculous cholecystitis. In the postpartum period in pregnant women, laparoscopic cholecystectomy should become the “gold standard” of surgical treatment.

Key words: gallstone disease, calculous cholecystitis in pregnant women, postpartum period, cholecystectomy, laparoscopy.

Анотація

Роль і місце лапароскопічної холецистектомії у вагітних, які перехворіли на COVID-19

В.В. Міщенко, В.П. Міщенко, П.І. Пустовойт, Р.Ю. Вододюк, В.В. Велічко, В.К. Ліхачов, Л.М.Добровольська

Метою дослідження було визначення ролі і місця лапароскопічної холецистектомії у вагітних, які перенесли COVID-19. Прооперовано 19 вагітних. Середній вік вагітних склав 27±4,9 років. У постковідному періоді клінічні прояви захворювання проявлялися у перші дві доби. У вагітних, що перенесли Covid-19, та хворих на жовчнокам'яну хворобу і гострий калькульозний холецистит, є клінічні прояви хвороби у вигляді гемолізованої крові у черевній порожнині та везикулярних висипань на вісцеральній і парієтальній очеревині, які місцями зливались у конгломерати і при контакті кровоточили. Патоморфологічно зміни у стінці жовчного міхура мали флегмонозний або гангренозний характер. Діагностика цієї патології у вагітних, які перенесли COVID-19, повинна бути швидкою і точною. Холецистектомію слід виконувати ще до розвитку ускладнень з боку жовчнокам'яної хвороби та гострого калькульозного холециститу. В післяковідному періоді у вагітних саме лапароскопічна холецистектомія повинна стати «золотим стандартом» оперативного лікування.

Ключові слова: жовчнокам'яна хвороба, калькульозний холецистит у вагітних, постковідний період, холецистектомія, лапароскопія.

Introduction The article is a fragment of the research project “Development and implementation of new methods of minimally invasive and endovascular interventions in metabolic syndrome, endocrine pathology, diseases of the lungs, oesophagus, liver and extrahepatic ducts, stomach, pancreas, colon and rectum, blood vessels ", state registration no. 0119U003573

Twenty-four pregnant women with GSD and ACC who relapsed COVID- 19 were hospitalized in the Department of Minimally Invasive Interventions of the Odessa Regional Clinical Hospital within 15 to 30 days from the moment of clinical recovery from COVID infection.

In 20 (84.2 %) pregnant women, the diagnosis of ACC was confirmed using ultrasound of the abdominal cavity.

Ultrasound was performed on an Acuson XP 128 ultrasound scanner with a transducer with an operating frequency of 3.5 MHz. Endoscopic examination was performed in the dynamics of the treatment of patients with the Olympus JF-1T10 fibroduodenoscope.

Preoperative and intraoperative antibiotic prophylaxis of infectious complications with protected penicillins was mandatory. We used Clexane in the complex conservative treatment of ACC at a 4000 anti- Xa MO (0.4 mL) dose two times a day subcutaneously for five days. Conservative therapy was used to prolong pregnancy when clinical signs of threatened abortion appeared.

The therapeutic measures complex necessarily included dexamethasone therapy at 4 mg i.m. for 5 days in the postoperative period according to the recommended protocols [4, 13].

In 5 women (20.8 %), the attack of acute calculous cholecystitis was eliminated by conservative methods. Laparoscopic cholecystectomy was performed in 19 pregnant women (79.2 %).

Laparoscopic cholecystectomy was performed using the Olympus OTV-SC endosurgical complex. We performed endotracheal anaesthesia at a pressure of carbon dioxide in the abdominal cavity of 10-12 mm Hg. The Sorometrics 170 Series monitor (Finland) determined the fetal condition.

Laparoscopic cholecystectomy in pregnant women required the correct choice of laparoscopic operative approaches. As a rule, these are three trocar approaches, which localization depends on the gestational age.

Until the 14th week of pregnancy, carbon dioxide insufflation into the abdominal cavity was performed at the classic Olym point 2 cm below the navel, along the midline of the abdomen, after opening the skin transversely to 1 cm through a Veress needle. The first port for a video camera was installed with a 10-mm trocar.

If necessary, for the first trocar, we used the Hasson open laparoscopy method - the trocar was inserted along the midline 2 cm below the navel through an incision of the anterior abdominal wall under visual control. A second port with a 5-10 mm diameter was installed in the right hypochondrium, laterally to the mid-clavicular line. The third port with a diameter of 10 mm was installed under the xiphoid process along the midline.

In the second trimester of pregnancy, the first trocar was inserted along the midline 3-4 cm above the height of the bottom of the pregnant uterus through an incision using the Hasson open laparoscopy method. The 2nd port was installed in the right hypochondrium, laterally to the mid-clavicular line. The 3rd port with a diameter of 10 mm was established under the xiphoid process along the median line or to its right under the control of a video camera.

In the third trimester of pregnancy, the longer the gestation period, the closer the ports were applied to the right hypochondrium. A fourth auxiliary port with a diameter of 5 mm was placed in the right hypochondrium. A laparoscopic clamp was inserted for a more detailed revision of the hepatobiliary area.

Coagulation is bipolar in standard exposure modes. The surgery was completed by installing safety drainage in the right hypochondrium to the gallbladder bed. pathology cholecystectomy gallstone disease

The obtained results were processed using the MS Excel XP software package, Statistica 6.0 using the Student's parametric criterion. Differences were significant at p<0.05.

Results of the study and their discussion

We studied the time frame in which patients were ill with COVID-19 and ACC, the severity of the disease, clinical manifestations, duration of the illness, therapy, anamnestic data, laboratory parameters.

The age of pregnant women ranged from 18 to 36 years (on average, 27±4.9 years). The gestation period ranged from 9 to 39 weeks, with one patient (4.2 %) in the first trimester of pregnancy, 11 (45.8 %) in the second trimester, and 12 women (50.0 %) in the third trimester of pregnancy. Thus, in pregnant women who had a history of COVID-19, the incidence of ACC mainly manifested itself in the second and third trimesters.

The duration of the main symptoms of the disease before hospitalization up to 24 hours was noted in 4 pregnant women (16.7 %), from 25 to 48 hours - in 16 pregnant women (66.7 %), more than 48 hours - in 4 pregnant women (16.7 %). For ACC in post-pregnancy pregnant women, clinical manifestations of the disease manifested themselves in the first two days before hospitalization in 83.3 % of cases.

In 4 (16.7 %) pregnant women, the duration of preoperative follow-up, diagnosis and treatment was more than 12 hours. In 20 (83.3 %) pregnant women, diagnosis of GSD with ACC and preparation for laparoscopic cholecystectomy required from 6 to 12 hours.

The results obtained indicate a high percentage of preoperative hospital follow-up for up to 12 hours in patients with GSD and ACC. They have had COVID-19, despite the problematic diagnosis of ACC in the post-Covid period.

Pathomorphological changes in the removed gallbladder due to acute calculous cholecystitis in pregnant women who had a history of COVID-19 were characterized by the presence of phlegmonous inflammation in 63.2 % of cases gangrenous - in 21.1 %. Catarrhal changes were detected only in 3 (15.8 %) cases.

Analysis of laboratory parameters in pregnant women with GSD with ACC who underwent COVID-19 is presented in table 1.

In pregnant women diagnosed with GSD and ACC on the background of COVID infection, clinical signs of anaemia were confirmed in the laboratory by determining haemoglobin, ferritin, and erythrocytes (table 1).

The presence of an inflammatory process and its severity in pregnant women with GSD and ACC who have had a history of COVID-19 is indicated by leukocytosis and ESR in a detailed blood test. Patients were characterized by elevated levels of fibrinogen and platelets - signs of hypercoagulation. COVID infection was accompanied by a slight increase in bilirubin content without clinical manifestations of jaundice and increased liver function tests on the background of GSD and ACC.

Elevated creatinine levels were diagnosed in 20 % of GSD patients with ACC who had COVID- 19 and had asymptomatic bacteriuria.

Table 1

Laboratory parameters in the post-Covid period before surgery - initial data (n=24)

A previous COVID infection is indicated by M and G antibodies to SARS Cov-2 (COVID-19), which were determined in 100 % of cases from 15 to 30 days after the transferred COVID disease (table 2).

Table 2

Laboratory diagnostics of PCR RNA Coronavirus 2019-nCoVSARS-CoV (n=24)

At the time of hospitalization for GSD and ACC, all patients underwent PCR testing for SARSCov-2 (COVID-19). The test was 100 % positive in the absence of clinical manifestations of COVID disease. RNA determination of coronavirus 2019-nCoVSARS-CoV in clinically healthy pregnant women who have had COVID-19 was regarded as a post-Covid syndrome in patients.

During surgery in 2 (10.5 %) patients, findings revealed a small amount of hemolyzed blood in the right hypochondrium and vesicular rash on the visceral and parietal peritoneum up to 0.5 cm in size, which sometimes merged into conglomerates and bled on contact.

During the pathomorphological study of the removed gall bladders, it was found that in pregnant women with GSD and ACC, in the post-Covid period, changes in the gallbladder wall had a phlegmonous or gangrenous character, which indicates immune disorders in the body of a sick pregnant woman and may explain her high sensitivity to the banal infectious process [4].

In pregnant women with GSD and ACC, who had a history of COVID-19, the postoperative period was 2-5 days. No complications were observed in the early postoperative period. There were no fatalities.

In 18 (94.7 %) cases among operated women, pregnancy ended with physiological labor through the natural birth canal within 37 to 41 weeks. Intrauterine growth retardation, acute or chronic fetal distress were not observed. Caesarean section was performed according to obstetric indications in 1 (5.3 %) woman. The connection between the indications for cesarean section and laparoscopic cholecystectomy has not been established.

Children were born with an Apgar Score of 7 to 9 points and a weight of 2.750 to 3.900 grams.

We have not established any contraindications to laparoscopic cholecystectomy in patients with GSD and ACC in the post-Covid period.

In pregnant women who have had a covid infection, GSD with ACC is characterized by “volatile” pain in the right hypochondrium with radiation to the right subscapular and right supraclavicular areas, nausea, sometimes vomiting, bitterness in the mouth, subfebrile temperature, leukocytosis with a shift of the leukocyte formula to the left and ultrasound data. Similar complaints can be observed in early toxicosis of pregnant women, severe preeclampsia, HELLP-syndrome [5].

Antibiotic prophylaxis of infectious complications, prevention of thromboembolic complications and hormone therapy should be carried out in pregnant women with GSD and ACC. They have had COVID-19, with caution, especially in the early stages of pregnancy [10].

Surgery (laparoscopic cholecystectomy) should be performed under endotracheal combined anaesthesia with carbon dioxide pressure in the abdominal cavity at the level of 10-12 mm Hg. The location of trocars is determined by the need to adhere to the basic principle of triangulation [1, 6].

Given the blurred clinical picture of GSD complicated by ACC the inability to fully use instrumental and radiation research methods in pregnant women in the post-Covid period, the diagnosis of GSD and ACC is difficult. The choice of treatment tactics also requires a balanced approach. It is not fully understood how to assess the situation if 15 days - 4 weeks after recovery from COVID-19 in pregnant women with GSD and ACC in the presence of IgMSARSCov-2 (COVID-19) and IgGSARSCov-2 (COVID-19) antibodies, a PCR test for the presence of RNA residues of the virus is determined in 100 % of cases. Is this situation dangerous for other patients and staff? It is likely that in such cases, the basic antiepidemic principles of treating patients with COVID-19 should be observed.

Among the features of clinical manifestations of GSD with ACC in pregnant women who are in the post-Covid period, it should be noted the presence of hemolysed blood in the abdominal cavity and vesicular rashes on the visceral and parietal peritoneum, which sometimes merged into conglomerates and bled upon contact. Pathomorphologically, it was established that in pregnant women with GSD and ACC, in the post-Covid period, changes in the gallbladder wall were phlegmonous or gangrenous [7, 8].

Thus, laparoscopic cholecystectomy in pregnant women with GSD and ACC who have a history of COVID-19 allows to eliminate acute surgical pathology (acute calculous cholecystitis), avoid excessive trauma to the anterior abdominal wall, abdominal organs, uterus, achieve more minor injuries to cellular structures and faster recovery of impaired functions of the body of the pregnant woman and fetus. This promotes a favourable postoperative period in pregnant women and reduces the possibility of premature termination of pregnancy.

Conclusions

1. In pregnant women who have had COVID-19, the diagnosis of cholelithiasis and acute calculous cholecystitis should be rapid and accurate, based on anamnestic data and examinations obtained before pregnancy, complaints, objective analysis at the time of hospitalization using other imaging technologies only in the form of ultrasound.

2. In such pregnant women, cholecystectomy should be performed before developing complications of gallstone disease and acute calculous cholecystitis by reducing the duration of the diagnostic phase and making a timely decision on surgery.

3. Pregnant women with cholelithiasis and acute calculous cholecystitis who have suffered Covid- 19 have post-Covid disease manifestations in the form of hemolysed blood in the abdominal cavity vesicular rashes on the visceral and parietal peritoneum, which sometimes merged into conglomerates and bled on contact. Pathomorphological changes in the gallbladder wall were phlegmonous or gangrenous, which can be explained by the influence of a previous Covid infection.

4. Laparoscopic cholecystectomy, due to its advantages over open cholecystectomy, is a guarantee of safety for the health of the pregnant woman and the course of pregnancy. It should be the gold standard for gallstones and acute calculous cholecystitis surgery in pregnant women who have undergone COVID-19.

Prospects for further research are aimed at studying the features of laparoscopic surgery in pregnant women who underwent COVID-19, for other acute surgical pathology.

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