Cholecystitis Research Articles

Endoscopic Gallbladder Drainage EUS LAMS vs. ERCP Trans-papillary Drainage.

In this review, we discuss the role of endoscopic gallbladder drainage for acute cholecystitis in non-surgical candidates, describe technical aspects, clinical outcomes, and elaborate on considerations when determining which approach to adopt for a given patient. Cholecystectomy remains the criterion standard for management ofacute cholecystitis in patients who can safely undergo surgery. Fornon-surgical candidates, percutaneous cholecystostomy (PTC-GBD)has been the traditional strategy to drain and decompress the gallbladder. Advances in endoscopy have further expanded the nonsurgicalinterventions and approaches to cholecystitis. Bothendoscopic transpapillary gallbladder drainage (ET-GBD) andendoscopic ultrasound guided gallbladder drainage (EUS-GBD) havebecome acceptable alternatives to PTC-GBD, with growing literaturesupporting their efficacy, safety and improved patient quality of lifewhen compared to a percutaneous approach. Choosing the appropriate endoscopic technique for gallbladder drainage should be tailored to each patient, keeping in view the specific clinical scenarios, endoscopist preference and following a multi-disciplinary approach.

EGS SO15 - The “Not” Cholecystectomy: Barriers to Early Cholecystectomy in a District General Hospital

Abstract Background The benefit of early or “hot” cholecystectomy in acute cholecystitis and pancreatitis is now widely recognised and recommended by NICE guidelines. However, in reality, surgery within the index admission is not always universally practised. We aim to report our experience of barriers to performing emergency cholecystectomy in the context of a district general London hospital. Method Data from patients admitted within a 1 month period with acute calculous cholecystitis, gallstone pancreatitis or recurrent biliary colic were retrospectively collected. Data points included patient demographics, reasons for not having emergency surgery and time to subsequent elective surgery. Any patients who underwent early emergency cholecystectomy were excluded from analysis. Results Twenty six (76.5%) out of 34 admissions did not receive emergency cholecystectomy. Eight (30.8%) were male and mean age was 69. Most common presentation was acute calculous cholecystitis (13, 50%). Reasons for not having surgery included frailty (7, 26.9%), waitlisted for endoscopic investigation (5, 19.2%), lack of emergency theatre capacity (4, 15.4%), unknown (3, 11.5%), severe disease (2, 7.7%), patient refusal (3, 11.5%) and acute medical contraindication (2, 7.7%). Four (15.4%) patients had repeat acute admission. To date, 4 patients subsequently underwent elective cholecystectomy with one procedure within 3 months. Conclusion Early cholecystectomy rates in district general hospitals can be affected by availability of local resources. By identifying the key factors for not proceeding to surgery, we can increase efforts to improve access to emergency theatre space, high-risk anaesthetic input and acute endoscopy services.

HPB SO30 - Evaluation of efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis

Abstract Background Acute cholecystitis is associated with considerable mortality. The risk of mortality ranges between 2.4% to 8.4% according to severity. The main line of managing patient presenting with grade II/ III acute cholecystitis is source control through insertion of cholecystostomy drain (if patient is not suitable for emergency cholecystectomy) and anti-microbial treatment. Tokyo 2018 guidelines recommends against use of Co-Amoxiclav as an empiric antimicrobial therapy for cases of acute cholecystitis as most common organism isolated is E. Coli. The aim of this study is to evaluate the efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis. Method The medical records were searched retrospectively for patient presented with acute severe cholecystitis grade II/ III who treated with cholecystostomy drain insertion as a temporary measure during 2020 and 2021. The culture and sensitivity (C&S) of cholecystostomy drain aspirate at time of insertion of the drains were reviewed to determine the type of appropriate antimicrobial therapy. The results were analysed using both best and worst case scenario to find about the efficacy of Co-Amoxiclav as an empiric antimicrobial treatment. Results 105 sample of cholecystostomy drain aspirate sent for culture and sensitivity, 27 samples were resistant to co-amoxiclav (25%), while 22 samples were sensitive to co-amoxiclav(20.9%) . 56 of samples (53.1%) showed no mention of testing of Co-Amoxiclav. On further analysis on best case scenario basis, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are sensitive to co-amoxiclav. While on worst case scenario, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are resistant to co-amoxiclav. Conclusion Use of co-amoxiclav as an empirical antimicrobial treatment for cases of grade II/ III acute cholecystitis is associated with considerable antimicrobial resistance ranges from 25% in the best case scenario and 79% in worst case scenario. The most common organism isolated from these samples was E.coli. These results are in complete agreement with Tokyo 2018 guidelines, which states that Co-amoxiclav is associated with more than 20% resistance.

Ultrasonic dissection versus electrocautery dissectionin laparoscopic cholecystectomy for acute cholecystitis: a randomized controlled trial (SONOCHOL-trial).

Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis. A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18years with acute cholecystitis lasting ≤ 7days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment. From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025). Ultrasonic dissectionand electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis. The trial was registered prior to conducting the research on http://clinical. gov , NCT03014817.

HPB SO48 - Evaluating the timeframe for the provision of laparoscopic cholecystectomy in acute cholecystitis patients at a regional hospital

Abstract Background Acute biliary disease comprised a substantial proportion of the general emergency surgical workload. AUGIS and NICE guidelines recommend early laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) patients as it is associated with reduced readmission rates, healthcare costs and faster recovery without notable complication risks. According to the local trust policy, it advocates early LC to be performed within 72 hours of admission for AC patients. If this is not possible a delayed LC should be performed within 8 weeks of admission. Our aim is to examine variations in the provision of LC between current practice and local trust/ NICE guidelines. Method This is a retrospective audit looking at the total number of surgical patients diagnosed with AC between Jan and Dec 2023. The number of patients who had LC in 2023, unfit for surgery and did not consent for the procedure were also included. This data was obtained from electronic patient records (investigative reports, discharge letters, outpatient letters) and then collated on a Microsoft Excel sheet for analysis. Surgical patients who were not diagnosed with AC such as those with biliary pancreatitis, cholelithiasis or cholangitis but subsequently underwent LC were excluded. Results The number of AC patients who were fit and consented to surgical intervention in 2023 was 88. The total number of delayed procedures done was 75 (85.2%). The number of patients who had early LC within 1 week was 13 (14.8%). Of the 75 patients who had delayed LC, 19 (25.3%) patients had delayed LC within 8 weeks from the diagnosis date. The remaining 56 (74.7%) patients had delayed LC after 8 weeks. For patients who had delayed LC, the readmission rate within 6 months of their discharge while waiting for their operative dates was 29 (38.7%). Conclusion One-third of AC patients were readmitted while waiting for LC, some had complications of gallstone disease such as perforation/ gallstone ileus. Therefore, the early provision of LC is crucial in minimising the readmission and complication rates. This data was highlighted in a departmental meeting and teaching session for consultants and junior doctors. We plan to liaise with stakeholders and theatre managers in implementing further solutions to improve compliance where possible. One critical area is auditing the condition of surgical patients in order to be put on the hospital’s twice-weekly hot gallbladder list to consider prioritising AC patient surgical time.

EGS SO08 - How best to time the operative management of acute cholecystitis: Is there a difference in outcomes between hot and smouldering cholecystectomy?

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Acute cholecystitis (AC) is a common emergency presentation in the UK and the 2015 AUGIS guidelines recommend emergency cholecystectomy within 72 hours of admission if the patient is fit. On a practical level this can sometimes be difficult to implement and often patients are discharged to return for an elective procedure (the smouldering gallbladder). We aimed to analyse our practice at a large district general hospital for the management of patients with AC and their post-operative outcomes. Method All patients undergoing LC between 1st July 2020 and 30th June 2022 were identified. Patients with an ICD-10 code of K81 (AC) associated with an inpatient stay within a year of their operation were included. Those admitted and operated on during that admission were classified as hot cholecystectomies (HC), whereas those admitted and discharged for an elective procedure were termed smouldering cholecystectomies (SC). Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Statistical analysis was performed using SPSS with Chi-squared tests performed for categorical data and ANOVA for continuous data. Results 276 patients underwent cholecystectomy for AC with 52.2% elective and 47.8% emergency (91% within 72 hours of admission). HC patients were younger (52.3 vs. 57.5, p<0.01) and less-comorbid (1.67 vs 2.12, p<0.05). The subtotal cholecystectomy rate was comparable between the groups (9.8% vs 16.0%, p=0.131). HC patients had more post-operative drains (38.6% vs 27.1%, p<0.05) and thick-walled gallbladders (92.4% vs 64.6%, p<0.001). Median post-operative length of stay was 1 day for HC and 0 days for SC. No difference was observed for 30-day readmission (4.5% vs 7.6%, p=0.286), morbidity (12.9% vs 11.8%, p=0.786) or mortality (0.8% vs 0.7%, p=0.951). Conclusion This study adds to the evidence that emergency cholecystectomy is as safe an option as discharging patients to return for an elective procedure in the future. Although a proportion of those discharged to return for an elective operation will have thin-walled gallbladders, the rate of subtotal cholecystectomy remains similar, if not slightly higher in the elective group (although not reaching statistical significance). Most emergency cholecystectomy patients were discharged the following day, therefore demonstrating that they do not significantly contribute to bed blocking and reduce the burden on already strained elective waiting lists.

MS O01 - HPB Outcomes following Cholecystostomy Insertion for Acute Cholecystitis: A National Registry-based Study

Abstract Background Acute cholecystitis (AC) is a commonly encountered surgical emergency. In cases of severe AC or cholangitis, or in patients with significant comorbidities, percutaneous cholecystostomy (PC) may be employed. International data suggest PC is associated with significantly worse patient outcomes, but limited data exist in the Irish context. Method All patients with AC presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics including age, co-morbidities, length of stay/LOS, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. All patients managed with PC were identified, and their outcomes compared to patients managed without PC. Results In total, 20,886 patients were admitted with AC. 975 (5%) patients underwent PC and 19,911 patients (95%) were managed without percutaneous cholecystostomy. In comparison to non-cholecystostomy cohort, the PC cohort was older (median 72 v 58 years, p<0.001), less likely to be female (39% v 57% p<0.001), had proportionally longer LOS (<0.001), higher mortality rates (<0.001), were more likely to be admitted to critical care (<0.001), and more likely to be re-admitted to hospital within 30 days (<0.001). Conclusion Cholecystostomy insertion occurs in older patients with more comorbidities. These patients have higher in-hospital mortality rates, higher rates of critical care admission, longer LOS, and increased 30-day readmission rates.

EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis

Abstract Background Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms. Method This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards. Results Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups. Conclusion This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.

HPB SO29 - Outcomes of Percutaneous Image-Guided and Laparoscopic Cholecystostomies in High-Risk Patients With Acute Calculus Cholecystitis: A Five-Year District General Hospital Experience

Abstract Background Acute cholecystitis (AC), inflammation of the gall bladder, is one of the most common emergency surgical presentations. In the UK, approximately 15% of the population is estimated to have gallstones, and approximately 20% of them can develop AC. Laparoscopic cholecystectomy (LC) is considered the definitive management of AC. However, cholecystectomy carries a very high risk of morbidity and mortality in high-risk frail patients with multiple comorbidities who are deemed unfit for surgery. Percutaneous cholecystostomy (PC), both image-guided and laparoscopic, is generally acknowledged as an interim treatment measure before definitive management, which is the LC. Method This retrospective study from the Royal Albert Edward Infirmary in Wigan, UK, analyzed medical records of patients who underwent percutaneous cholecystostomy (PC) between January 2017 and December 2022. Excluded were patients with prior hepato-pancreato-biliary malignancy, those who had open cholecystostomy, or those with abdominal ascites. Data collected included age, gender, American Society of Anaesthesiologists (ASA) grades, procedure success rates (temporary or definitive), hospital stay duration, 30-day and 1-year mortality rates, timing of the procedure, and long-term complications, particularly those related to cholecystostomy tube dislodgment or blockage. Results In this study, 27 patients who underwent percutaneous cholecystostomy (PC) were divided into two groups: Group A (10 patients) had laparoscopic cholecystostomies, and Group B (17 patients) had ultrasound-guided cholecystostomies. The mean ages were 66.7 for Group A and 75.1 for Group B. Most patients were in ASA groups III (14) and IV (10). About 74% had procedures during the day, 26% at night. The mean hospital stay was 13.5 days. Around 55% had elective laparoscopic cholecystectomy (LC) as definitive management. Two patients died within 30 days, and eight within a year. About 40% experienced tube dislodgment or blockage complications. Conclusion This study concludes that PC, using both laparoscopic and US-guided techniques, can serve as an interim as well as a definitive measure, particularly in patients who are at high risk for anesthesia and the procedure itself and have multiple comorbidities.

BN SO07 - Percutaneous cholecystostomy in patients with severe acute calculous cholecystitis. What next? An analysis of 102 cases

Abstract Background Percutaneous cholecystostomy (PC) can be a life-saving treatment for patients presenting with fulminant acute calculous cholecystitis (ACC). In the case of those who make a good recovery and are fit for surgery, PC is often advocated. However, in those who are higher risk for surgery, there is currently no strong consensus regarding further management. The aim of this study was to evaluate the long-term outcomes of PC and interval LC versus PC alone in patients with ACC. Method We conducted a single-centre retrospective case-control evaluation of the outcomes of patients who have undergone a PC due to severe ACC, comparing those who have gone on to have an interval LC versus those who had PC only. The primary outcomes were the rate of readmissions with recurrent biliary disease and late mortality. Results While the rate of readmissions did not differ between groups (p= 0.583), in the surgical cohort most recurrent gallstone events occurred before LC. ASA score >2 and Tokyo grade 3 were significant positive predictors of all-cause mortality (95% CI 1.6 to 12.6, OR 4.5, p=0.004, and 95% CI 1.2 to 12.2, OR 3.8, p=0.027, respectively). Surgery was found to be a negative predictor of mortality (95% CI 0.04 to 0.5, OR 0.2, p=0.003). Conclusion Those who do not go on to have their gallbladder removed after PC, face significantly worse outcomes. Every effort should be made to optimise these patients to facilitate operative management.

Scrub typhus masquerading as acute acalculous cholecystitis in a child - a case report.

We describe a case of scrub typhus in a 12-year old boy who presented with symptoms mimicking acute acalculous cholecystitis. He tested positive for anti-scrub typhus IgM antibodies. Treatment with oral azithromycin led to significant improvement and resolution of symptoms. Thus it is important to consider scrub typhus as a differential diagnosis for an acute abdomen in endemic areas. Timely diagnosis may avoid unnecessary suffering.

HPB SO75 - Burden and Pattern of Gallstone-Related Acute Surgical Admissions

Abstract Background Gallstone disease accounts for nearly one-third of emergency general surgery admissions, with a considerable number resulting from recurrent episodes. Laparoscopic cholecystectomy (LC) is the only definitive treatment for gallstones. This study aimed to examine the burden and patterns of acute biliary admissions. Method This prospective cohort study was conducted over a continuous 12-week period in 2022 within a single surgical unit, focusing on all gallstone-related admissions. The total number of admissions for various surgical pathologies was documented, and the proportion due to biliary disease was determined. The analysis encompassed patient demographics, reasons for biliary admission, prior gallstone history, and any planned laparoscopic cholecystectomies (LC). Results There were 532 acute admissions, 98 (18.4%) were gallstones related. Median age was 62 years (IQR 47-72) and 58 (59.2%) were female. 40 (40.8%) had acute cholecystitis, 24 (24.5%) had gallstone pancreatitis, 16 (16.3%) had bile duct stones, 10 (10.2%) had biliary colic and 8 (8.2%) had ascending cholangitis. 43 (43.9%) patients were known to have gallstones and 26 (26.5%) patients had prior admission related to gallstones. 35.7% patients had outpatient LC, 23.5% had no documentation, 19.4% had inpatient LC, 18.4% were not fit candidates and 3.1% patients declined LC. Median total length of stay was 6 days (IQR 4-11). Conclusion In our study, the rate of biliary-related admissions was lower than previously reported in the literature. This reduction may be attributed to our semi-aggressive management approach for gallstone disease. To further improve patient outcomes, we suggest implementing more aggressive management strategies for gallstones during the initial admission for patients who are deemed fit for surgery. Such an approach could potentially reduce the recurrence of biliary admissions and enhance overall treatment efficacy.

Early versus delayed laparoscopic cholecystectomy for gallbladder perforation

BACKGROUND Gallbladder perforation occurs in 2% to 11% of patients with acute cholecystitis, with associated mortality estimated to be at 12% to 42%. Because of its low incidence, the data on management remain sparse. There is a lack of evidence to suggest whether early or delayed cholecystectomy is superior in the treatment of perforated cholecystitis. We hypothesize that an early definitive operation is associated with decreased total hospital length of stay (THLOS). METHODS Using the National Surgical Quality Improvement Program database from the American College of Surgery, we identified patients who underwent laparoscopic cholecystectomy for gallbladder perforation on an urgent or emergent basis from 2012 to 2021. We divided them into those who underwent early (<2 days from the date of admission to the date of operation) and delayed cholecystectomy (≥2 days from the date of admission to the date of operation). Our primary outcome was the THLOS. We created multivariate regression models to assess for the association of early versus delayed operation and THLOS. RESULTS The THLOS was found to be 2.94 days longer in the delayed group compared with the early group (p < 0.05). In those who did not present with sepsis on admission, the THLOS was noted to be 4.71 days longer in the delayed group compared with the early group (p < 0.05). Early versus delayed operation was not associated with a difference in the postoperative length of stay, 30-day postoperative complications, rate of readmission, and reoperation, regardless of preoperative sepsis status. CONCLUSION Early laparoscopic cholecystectomy for gallbladder perforation is associated with decreased THLOS, and there were no other differences in outcomes compared with delayed laparoscopic cholecystectomy. Patients with gallbladder perforation would likely benefit from an early operation within 2 days of admission. LEVEL OF EVIDENCE Therapeutic/Care management; Level III.

BN SO51 - Complications from operative cholangiogram during emergency laparoscopic cholecystectomy: A retrospective, observational cohort study in a UK single centre

Abstract Background Laparoscopic cholecystectomy (LC) is a common surgical procedure, with >60,000 undertaken annually in the UK. One serious complication of cholecystectomy is bile-duct-injury (BDI), with an incidence of 0.28–1.5%. The use of intraoperative-cholangiogram (OTC) has been shown to aid in earlier diagnosis and treatment of BDI. Although advocated as routine by many, no studies have assessed the morbidity caused by OTC. With newer modalities available, such as indocyanine-green-fluorescent-cholangiography (ICGC) and three-dimensional laparoscopy, it is important to consider each method's risks and benefits, including OTC. We decided to investigate the morbidity caused by OTC with an emphasis on post-OTC acute pancreatitis. Method We conducted a retrospective cohort study of a prospectively collected cohort of patients aged 18 and over who have undergone emergency LC, defined as LC within seven days from admission with acute cholecystitis, over three years in a UK district general hospital. The primary outcome studied was the incidence of complications following OTC, including acute pancreatitis (AP), acute cholangitis, extra-hepatic biliary tree injury and hepatic abscess. The STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist was utilised. We used GraphPad Prism 10.2.3. for statistical analysis. Results 472 cases were analysed. Median age was 54(A), BMI 31(C), ASA grade 2(D), clinical frailty score 2(E), Charlson Comorbidity Index 1(F), Tokyo severity grade 1(K) and female-to-male ratio 0.83(B). 14.31% of cases had pre-op CBD dilatation, 0.42% CBD stones and 6.19% both, with most having ultrasound pre-op (J-I). The median Nassar score was 3(L). 24.57 % of cases had an OTC done, with a median volume of contrast-media used of 11(6;24.5) mls, with 17 cases having CBD stones diagnosed(M-O). Four cases, or 3.44% of the total OTCs, developed acute pancreatitis (P). Conclusion Emergency laparoscopic cholecystectomy with intraoperative cholangiogram may increase the risk of postoperative acute pancreatitis.

HPB SO61 - Benefits of Dual-surgeon On-call team on Emergency Laparoscopic Cholecystectomy – a Single Centre Experience

Abstract Background Since 2015, UK national guidance from National Institute for Health and Care Excellence (NICE) has been to offer laparoscopic cholecystectomy for patients presenting with acute cholecystitis within 7 days of admission. The aim of this study was to measure the benefits of a second team of surgeons doing emergency operations (first team dealt with emergency admissions and referrals) in terms of length of stay, conversion to open, morbidity, mortality, bile duct injury and rate of early cholecystectomy in a UK based district general hospital. Method Retrospective analysis of a prospectively maintained database was collected from electronic health records, admission and operative notes. Results were extracted in terms of index laparoscopic cholecystectomy, rate of conversion, intra-operative cholangiography, associated morbidity, mortality, bile duct injury, conversion to open, readmission rate and length of stay. The numbers and rates of cholecystectomy over the last six years duration was collected and compared year-on-year period, since early 2019 after the implementation of dual-surgeon on-call cover. Results Altogether, there was 944 cholecystectomy performed within 14 days, out of which 74% of cases was operated within the first week of presentation <8 days since admission. Majority of cholecystectomy was performed laparoscopically, there were twenty-three (2.43%) conversion to open, forty-six sub-total cholecystectomies (4.87%),intraoperative cholangiography was performed in 28.4% of cases and Indocyanine green (ICG) cholangiography was used in 50.5% of all cases. Average length-of-stay (LOS) was 2.2 days, there were eight cases (0.84%) of post-op bile leak, one bile-duct injury, one case of post-operative bleed, one case of small bowel injury and two deaths. Conclusion With the adoption of dual-surgeon on call, early laparoscopic cholecystectomy benefits both patient and hospital. It reduces time to surgery for patients, decreases overall length of stay, and reduces readmission rates and cost, with similar morbidity and mortality.

EGS SO04 - Gastrodoudenal Artery Pseudoaneurysm Secondary to blunt abdominal trauma: A rare case report

Abstract Background Visceral artery pseudoaneurysms (VAPAs) are rare, potentially life-threatning aneurysms found in the celiac, superior, or inferior mesenteric arteries. They are most common in the splenic artery (60-70%), followed by hepatic arteries (20%) and celiac or mesenteric arteries (10%). Usually asymptomatic, VAPAs are often discovered incidentally during abdominal imaging. They pose a high risk of rupture and haemorrhage. Risk factors include iatrogenic injury and abdominal trauma. Traumatic VAPAs are extremely rare with unclear management guidelines. Treatment options vary from observation to endovascular therapy or surgical repair. This report presents a case of a gastoduodenal artery psuedoaneurysm due to blunt abdominal trauma. Method A case report: a 68-year-old male with a high BMI and atrial fibrillation managed with edoxaban, presented with severe upper abdominal pain following a fall. Initial examination and laboratory results suggested acute pancreatitis or cholecystitis, but a CT angiography revealed a GDA pseudoaneurysm with active extravasation. The patient was referred for urgent therapeutic embolization; however, the pseudoaneurysm had spontaneously thrombosed, precluding the need for embolization. The patient was managed conservatively, with close monitoring in the high dependency unit (HDU), analgesics, proton pump inhibitors, and mechanical venous thromboembolism prophylaxis. He remained hemodynamically stable and was discharged with instructions for follow-up care. Results GDA pseudoaneurysms are rare, accounting for 0.01-1% of all visceral artery aneurysms, with trauma being an exceptionally infrequent cause. The management of VAPAs, particularly in hemodynamically stable patients, can range from conservative observation to endovascular interventions. This case underscores the importance of a multidisciplinary approach involving surgery, interventional radiology, and vascular teams for optimal management. Conclusion Gastroduodenal artery pseudoaneurysms secondary to blunt abdominal trauma can be effectively managed conservatively in stable patients. Comprehensive history-taking, appropriate imaging, and multidisciplinary discussions are crucial for successful outcomes. Continued monitoring is essential to ensure patient safety and address potential complications.

HPB SO73 - Histopathological Patterns in Emergency and Elective Cholecystectomy

Abstract Background Laparoscopic cholecystectomy (LC) is one of the most frequently performed general surgical procedures. In the United Kingdom, gallbladder specimens are routinely submitted for histopathological analysis to detect occult pathologies, such as carcinoma in situ and early-stage carcinomas. This study aims to assess the results of routine histopathological examination of LC specimens. Method A prospectively collected database of all LCs and laparoscopic common bile duct exploration (LCBDE) performed between August 2022 and June 2024 was analysed. The database was populated from a single benign biliary center by two specialized biliary surgeons. Electronic case notes were analysed for the demographics, indication(s), operative findings and the histopathological results. All gallbladder specimens were sent for histopathology analysis, irrespective of their gross appearance. Results Of the 201 eligible patients, 164 patients had histopathology results available. Median age was 56 years (IQR 41-66) and 100 (61%) were female. 72 (43.9%) were emergency cases. 48 (29.3%) had cholecystectomy, 70 (42.7%) also had intraoperative cholangiogram and 46 (28%) had LCBDE. Conclusion Chronic calculus cholecystitis was the most frequent histopathological finding, followed by acute on chronic cholecystitis and gangrenous acute cholecystitis. Dysplasia was identified in 1.8% of patients, warranting multidisciplinary team discussion. This study underscores the significance of routine histopathological examination after cholecystectomy, as early incidental detection of dysplasia and carcinoma can modify postoperative management and improve patient outcomes.

BN SO14 - Evaluation of local cholecystectomy service and outcomes (Local Data for GECKO study)

Abstract Background Cholecystectomy is a common procedure performed for different biliary pathologies. Patients have their procedure as elective, emergency, or prioritised bases (Hot Gall bladder service). Method GECKO is a prospective, international, observational collaborative cohort study Consecutive patients undergoing cholecystectomy, between 23rd Oct – 19th Nov 2023 with follow-up at 30-day and one-year postoperatively Results Over a 4-week period , 38 cholecystectomies were performed, with 47.5% of patients having prior cholecystitis or cholangitis and multiple admissions. Half of the surgeries occurred within 6 months, and the longest wait was 13 months. Procedures were split equally between elective and emergency cases. Indications included acute cholecystitis (13), biliary colic (11), and others. All surgeries were laparoscopic, with 2 subtotal cholecystectomies. Complications included bile or stone spillage (12) and bleeding (7). Postoperative follow-up showed 16 patients discharged within 24 hours, 3 readmissions, and a 37% complication rate. No bile leaks or CBD injuries were reported. Conclusion Emergency and hot cholecystectomy services not only cut down waiting lists but also reduce costs of reoccurring admissions and treatments, with no significant associated complications. Selective gall bladder histological examination may help cost reduction with no significant recognised risks in the literature.

HPB SO68 - Evaluating the Outcome of Laparoscopic Cholecystectomy Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Laparoscopic cholecystectomy (LC) presents inherent challenges and potential for significant complications, influenced by both patient factors and surgical expertise. Recognizing this variability, the British Benign Upper GI Surgical Society (BBUGSS) has established Key Performance Indicators (KPIs) aimed at enhancing LC outcomes. This study conducts an audit of LC outcomes in a single centre district general hospital (DGH) in accordance with BBUGSS KPIs and thus aims to determine if quality LC by modern standards is achievable in a DGH. Method The present retrospective observational study examined all adult LC conducted between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH, which also serves as a referral center of biliary cases from affiliated hospitals. The analysis encompassed preoperative assessments, intraoperative observations, and postoperative outcomes, with a focus on aligning these findings against the benchmarks established by the BBUGSS KPIs. Results 141 patients were included; median age was 54 years (IQR 41-64) and 59.6% were female. 37.6% were emergency cases, 44.2% were for acute cholecystitis, 22.7% for gallstone pancreatitis and 63.1% underwent intra-operative cholangiogram. KPIsBBUGSS StandardOur resultDay case for elective cases50%42%Readmission (within 30 days)<10%4.3%Laparoscopic cholecystectomy for acute cholecystitis (within 7 days)>35%97%Laparoscopic cholecystectomy for gallstone pancreatitis (within 2 weeks)>95%100%Conversion to open<5%0.7%Morbidity<10%1.4%Bile leak after elective surgery<1.5%0%Retained bile duct stones<2.5%0%Bile duct injury<0.3%0%Mortality<0.1%0% Conclusion This study shows that with the exception of day-case rate in elective LC, all KPIs were satisfactorily achieved, indicating that high quality LC is achievable within a DGH. The majority of readmissions within 30 days were related to inadequate postoperative analgesia. We have since enhanced pain management pathways. It is hoped that this will also improve same day discharge for elective cases to achieve BBGUGS standard. We are committed to conducting annual audits to monitor and optimize surgical outcomes and would encourage other centers to consider adopting the same approach.

BN SO21 - Factors influencing subtotal cholecystectomy

Abstract Background Laparoscopic Cholecystectomy (LC) is the main treatment for symptomatic gallstone disease. Sub-total cholecystectomy (SC) has become increasingly utilised as a safe alternative to conversion to open when unable to visualise the critical view of safety. This avoids the morbidity of an open operation whilst minimising the risk of iatrogenic injury to the common bile duct. Male sex, increasing age, previous acute cholecystitis and ERCP have previously been identified as independent risk factors for SC. We aim to identify factors that increased the likelihood of SC within our cohort and the effect of SC on post-operative morbidity. Method All patients who had LC as either an elective or emergency procedure between 1st July 2020 and 30th June 2022 were identified and included in this study. Patient and operative details were retrieved from their electronic record and a Charlson co-morbidity index was calculated. Any post-operative complication was noted and graded according to the Clavien-Dindo classification. Statistical analysis was performed using SPSS with ANOVA analysis being performed for continuous data. Odds ratios were calculated with a 95% confidence interval. Statistical significance was taken as a p value < 0.05. Results 974 patients underwent LC with 4.8% having SC. Factors associated with increased risk of SC included: previous acute cholecystitis (OR 9.37 (4.69-18.70), increased age (mean = 58.7 vs 50.9), higher Charlson co-morbidity index (mean = 2.60 vs 1.43) male sex (OR 2.49 (1.38-4.48), emergency operation (OR 2.30 (1.23-4.30), Diabetes Mellitus (OR 2.58 (1.23-5.36); and previous ERCP (OR 2.62 (1.13-6.11). 30-day morbidity was higher for SC (25.5% vs 8.1%) with major complication (Clavien-Dindo > 2) being significantly more frequent (OR 6.64(2.53-17.4). Median post-operative length of stay was 2 days for SC and 0 days for LC. Conclusion Although regarded as a safe option in difficult cholecystectomy, our study shows that there is significant morbidity associated with subtotal cholecystectomy. However, the majority of patients only require a short hospital stay post-operatively. Multiple risk factors were identified for SC with previous acute cholecystitis being the most strongly associated with SC. Diabetes was identified as an independent risk factor alongside higher Charlson co-morbidity index as a generic marker of co-morbidity. Interestingly, CBD diameter > 8mm on pre-operative imaging was not shown to increase risk of SC.