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

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          Abstract

          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. Endoscopy_UCTN_Code_TTT_1AS_2AD

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          Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response

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            Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review.

            The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.
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              EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version).

              The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).
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                Author and article information

                Journal
                Endoscopy
                Endoscopy
                10.1055/s-00000012
                Endoscopy
                © Georg Thieme Verlag KG (Stuttgart · New York )
                0013-726X
                1438-8812
                July 2020
                06 May 2020
                : 52
                : 7
                : E263-E264
                Affiliations
                [1 ]Gastroenterology Unit, Hospital of Imola, Imola, Italy
                [2 ]Department of Medical and Surgical Sciences – DIMEC, University of Bologna, Bologna, Italy
                [3 ]Intensive Care Unit, Hospital of Imola, Imola, Italy
                [4 ]Surgery Unit, Hospital of Imola, Imola, Italy
                Author notes
                Corresponding author Pietro Fusaroli, MD Gastroenterology Unit, Hospital of Imola Department of Medical and Surgical Science, University of Bologna Via Montericco 440026 Imola (BO)Italy+39-054-2662409 pietro.fusaroli@ 123456unibo.it
                Article
                10.1055/a-1158-9102
                7356084
                32375190
                d5a4742d-fb7f-4575-aad8-e7ffa97813b0
                Copyright @ 2020

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

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