Biliary Research Articles

Solitary fibrous tumor of the gallbladder: a case report

Abstract Background Primary solitary fibrous tumors (SFTs) of the gallbladder are rare. Here, we report the case of a patient who underwent surgical treatment for a primary SFT originating in the gallbladder. Case presentation A 48-mm gallbladder tumor was detected in a 70-year-old man using abdominal ultrasonography at a primary hospital, and he was subsequently referred to our department. A 50-mm enhanced tumor in the gallbladder was identified using computed tomography. Magnetic resonance imaging revealed a smooth-marginated tumor with hyperintensity on T2-weighted imaging. 18F-Fluorodeoxyglucose positron emission tomography confirmed high-level fluorodeoxyglucose uptake in the gallbladder tumor in the early phase without increasing uptake in the later phase. Surgical resection was planned to evaluate the tumor diagnosis. Initially, we performed open cholecystectomy with wedge resection of the gallbladder bed. Intraoperative pathological examination suggested gallbladder cancer; therefore, we performed radical surgery, including resection of the common bile duct, extended radical lymphadenectomy, and choledochojejunostomy. Ultimately, the final pathological examination revealed an SFT originating from the gallbladder with a negative surgical margin. Postoperatively, the patient developed bile leakage that was treated with tube drainage. The patient recovered satisfactorily and was discharged on postoperative day 20. At 24 months postoperatively, the patient was in good general condition without recurrence. Conclusions We report a rare case of a primary SFT originating in the gallbladder. Clinicians should be aware that SFT can be found in the gallbladder, and when it is difficult to make a preoperative diagnosis, surgical treatment should be considered.

The long-term impact of post-cholecystectomy major bile duct injury on liver stiffness

The long-term impact of post-cholecystectomy major bile duct injury on liver stiffness

Melatonin Ameliorates Cadmium‐Induced Liver Fibrosis Via Modulating Gut Microbiota and Bile Acid Metabolism

ABSTRACTCadmium (Cd) is a widespread environmental contaminant with high toxicity to human health. Melatonin has been shown to improve Cd‐induced liver damage. However, its mechanism has not yet been elucidated. In this study, we aimed to investigate the effects of melatonin on Cd‐induced liver damage and fibrosis. A combination of 16S rRNA gene sequencing and mass spectrometry‐based metabolomics was adopted to investigate changes in the gut microbiome and its metabolites on the regulation of melatonin in Cd‐induced liver injury and fibrosis of mice. Further, nonabsorbable antibiotics, a fecal microbiota transplantation (FMT) program and intestine‐specific farnesoid X receptor (FXR) knockout mice were employed to explore the mechanism of melatonin (MT) on liver injury and fibrosis in Cd treated mice. MT significantly improved hepatic inflammation, bile duct hyperplasia, liver damage, and liver fibrosis, with a notable decrease in liver bile acid levels in Cd‐exposed mice. MT treatment remodeled the gut microbiota, improved gut barrier function, and reduced the production of gut‐derived lipopolysaccharide (LPS). MT significantly decreased the intestinal tauro‐β‐muricholic acid levels, which are known as FXR antagonists. Notably, MT prominently activated the intestinal FXR signaling, subsequently inhibiting liver bile acid synthesis and decreasing hepatic inflammation in Cd‐exposed mice. However, MT could not ameliorate Cd‐induced liver damage and fibrosis in Abx‐treated mice. Conversely, MT still exerted a protective effect on Cd‐induced liver damage and fibrosis in FMT mice. Interestingly, MT failed to reverse liver damage and fibrosis in Cd‐exposed intestinal epithelial cell‐specific FXR gene knockout mice, indicating that intestinal FXR signaling mediated the protective effect of MT treatment. MT improves Cd‐induced liver damage and fibrosis through reshaping the intestinal flora, activating the intestinal FXR‐mediated suppression of liver bile acid synthesis and reducing LPS leakage in mice.

Urgent Versus Elective Laparoscopic Cholecystectomy Following Percutaneous Transhepatic Gallbladder Drainage for Moderate Acute Cholecystitis: A Meta-Analysis

Background There is still controversy regarding the treatment strategy for moderate acute cholecystitis (AC). Percutaneous transhepatic gallbladder drainage (PTGBD) followed laparoscopic cholecystectomy (LC) has shown advantages compared to emergency LC (ELC). However, the results are controversial. Therefore, we conducted this updated meta-analysis to clarify this issue. Materials and Methods A comprehensive literature search for relevant studies comparing the PTGBD + LC and ELC for moderate AC was performed. The statistical analysis was conducted using Stata. Results A total of 14 studies were included. The pooled analysis revealed that PTGBD + LC group had a shorter operation time (SMD = −1.07, 95%CI = −1.19 to −0.95), lower amount of intraoperative bleeding (SMD = −0.93, 95%CI = −1.07 to −0.79), lower conversion rate (OR = 0.28, 95% CI = 0.17-0.44), lower postoperative complications (OR = 0.45, 95% CI = 0.23-0.88) shorter postoperative hospital stay (SMD = −1.20, 95%CI = −1.33 to −1.07), lower wound infection rate (OR = 0.41, 95%CI = 0.23-0.74) and higher hospitalization expenses (SMD = 1.13, 95%CI = 0.96 to 1.29) compared with ELC group. There was no significant difference in the incidence of bile leak, bile duct injury and total hospital stay. Conclusion This meta-analysis suggested that PTGBD + LC has significant advantages over ELC for moderate AC patients, including lower surgical difficulty, lower conversion rate, fewer postoperative complications, and shorter hospital stay.

REVISÃO DE LITERATURA: MANEJO DO PACIENTE COM COLANGITE ESCLEROSANTE PRIMÁRIA

The primary sclerosing cholangitis (PSC) is a progressive, idiopathic, immune mediated disease, characterized by intra or extrahepatic cholestasis, Inflammation and fibrosis of the bile ducts, which may progress to liver cirrhosis or cholangiocarcinoma (CCA) in the vast majority of patients. Objective: Analyze what the current literature discusses about the management of PSC. Method: A systematic review was carried out using the PubMed and SciELO database, applying the descriptors "Primary Sclerosing Cholangitis" AND "Cholangite" AND "Clinical management" AND Cholangiocarcmoma. Discussion: It is more common in men, with an average diagnosis at 35 years old. The PSC has a wide range of symptoms and stages of the disease. In the beginning, symptoms are rare and patients may be asymptomatic. The most commonly found symptoms are pruritus, fatigue, right upper quadrant abdominal pain, jaundice, fever, and weight loss. In about 75% of patients with PSC, liver function tests are chronically abnormal and fluctuating with a most commonly found pattern of cholestatic condition with elevation of alkaline phosphatase (AF) and yglutamyl transferase (GGT). Although endoscopic retrograde cholangiopancreatography (ERCP) is conventionally considered the gold standard test for the diagnosis of PSC, the main modality of choice currently for Imaging diagnosis in patients with suspected PSC is magnetic resonance cholangiopancreatography (CPRM). Due to the absence of effective medical therapy for PSC, liver transplantation (LT) remains the only curative option. There is little evidence for the use of medications as a way to inhibit the progression of the disease. Still several new drugs are under investigation, representing the potential to improve survival and clinical outcomes in PSC. Final considerations: We conclude that it is extremely important to approach the management of PSC. The diagnosis is a great challenge since its clinical, laboratory and imaging aspects overlap, as it was portrayed during this exposure. Nevertheless, due to the various differential diagnoses ofjaundice with cholestatic pattern, the etiological search is crucial and the absence of effective medical therapy, with several new drugs under analysis, should guide further studies to improve the survival and clinical outcomes of these patients. Another point to be considered is that there is a scarcity of data in the literature that address the PSC in the Brazilian population.

Enhancing patient outcomes through nursing care in laparoscopic common bile duct exploration; a randomized control trail.

When compared to open surgery, laparoscopic common bile duct exploration (LCBDE) is known to cause less discomfort and a faster recovery. This study examines the effect of the Enhanced Recovery After Surgery (ERAS) strategy on LCBDE outcomes. In March 2021 to May 2024, 400 patients with LCBDE participated in randomized research. The six patient groups were: Multimodal Pain Management (n = 50), Standard Pain Management (n = 50), ERAS (n = 50), Preoperative Assessment (n = 100), Standard Preoperative Assessment (n = 100), and Standard Care (n = 50). The patient's satisfaction, long-term recovery, pain, anxiety, and complication rates were among the outcomes that were measured. After the intervention, the mean anxiety level of the ERAS group was significantly lower (P < 0.05), and their rates of complications were also decreased. Reduced postoperative pain scores, which were 5 on day 1 and decreased to 3 by day 3, were the consequence of the multimodal pain management strategy inside ERAS. A 90% satisfaction rating and an average recovery period of five days were reported by the ERAS group. Long-term results in ERAS showed that the average time to return to work was only 25 days, and there was a decreased incidence of chronic pain. The ERAS protocol enhances the short- and long-term course of recovery for patients with LCBDE, leading to increased satisfaction and better clinical outcomes. These results suggest that the ERAS method should be used as the gold standard for postoperative care for patients with LCBDE.

Expression of activin A in liver tissue and the outcome of patients with biliary atresia

Biliary atresia (BA) is a rare disease of unknown etiology which leads to cirrhosis and death if left untreated. The standard of care is an early hepatoportoenterostomy (HPE). Long-term follow-up is mandatory, during which most patients will require a liver transplant. Activin A belongs to the transforming growth factor-β (TGF-β) superfamily. TGF-β is a central regulator in chronic liver disease. We have studied the expression of activin A in liver tissue collected intraoperatively during the HPE. We included patients who underwent HPE in a single medical center. Clinical, ultrasonographic, and pathohistological data were collected. Activin A immunostaining was performed. Expression in the bile duct epithelium and hepatocytes was scored as either weakly positive, moderately positive, or strongly positive. Patients were then divided into three groups accordingly. We observed the outcome after the HPE at 3 months, 2 years, and at the end of follow-up. The study encompassed 37 patients. At 3 months after HPE, 92.3% of those with a weakly positive activin A reaction (group A) achieved good jaundice clearance, whereas only 44.4% of those with a moderately (group B) and 40% of those with a strongly positive reaction (group C) achieved good jaundice clearance (p = 0.008). Furthermore, 2 years after the HPE, 92.3% of those in group A survived with native liver (SNL), but only 33.3% of those in group B and 46.7% of those in group C had SNL (p = 0.007). At the end of follow-up, 83.3% of those in group A survived with native liver, as did 33.3% in group B and 40% in group C. Activin A is a valuable pathohistological predictor of the outcome of BA after an HPE.

DynaCT biliary reconstruction via a 3D C-arm cholangiography system: clinical application in hepatolithiasis.

Dyna computed tomography (DynaCT) is an innovative clinical imaging tool used to obtain three-dimensional (3D) images of biliary structures via the Artis Zee DSA system (SIEMENS Company, Germany). DynaCT is a type of 3D cone beam computed tomography (CBCT) reconstruction produced from a two-dimensional (2D) cholangiography system by rotating the C-arm without moving the patient. The aim of this study was to evaluate the technical approach and application value of DynaCT to diagnosis hepatolithiasis and biliary stenosis. This was a retrospective single-centre series of 37 hepatolithiasis patients with tubes receiving one-step percutaneous transhepatic cholangioscopic lithotripsy (one-step PTCSL) between October 2021 and October 2022: twenty-one patients were guided by CT (CT group) and sixteen by DynaCT biliary reconstruction (DynaCT group). We compared DynaCT biliary reconstruction technology with computed tomography (CT) in the application of bile ducts. DynaCT biliary reconstruction was successfully performed in 37 patients. Biliary stenosis, including anatomy, morphology, and size, was visualized via DynaCT. Compared with the CT group, the DynaCT group was characterized by significantly more target biliary branches with stones (92 vs. 48, P < 0.05), a higher percentage of secondary stenosis (75.76% vs. 24.24%, p < 0.05), a greater percentage of biliary infection (37.5% vs. 9.5%, P = 0.041), a shorter overall stone clearance time (26.38 ± 13.49 vs. 52.67 ± 30.10, P = 0.001), and a lower rate of reoperation for residual stones (25.00% vs. 66.67%, P = 0.012). DynaCT had a lower contrast agent (25.61 ± 5.13 vs. 42.69 ± 11.15, p < 0.05). However, DynaCT increased radiation exposure (38.12 ± 10.59 vs. 25.79 ± 4.76, p < 0.05). There were no significant differences between the two groups regarding the clearance ratio of the calculus or several postoperative complications. DynaCT for biliary reconstruction has the potential to be a powerful evaluation tool for one-step PTCSL surgery and could lead to new possibilities for hepatobiliary surgery. DynaCT was used for the first time in patients with hepatolithiasis and biliary stenosis. Compared with CT, DynaCT for biliary reconstruction results in higher-quality 3D biliary, blood vessel and liver images. On the basis of the DynaCT biliary model, one-step PTCSL has the potential to improve the stone clearance ratio and shorten the stone clearance time and reoperation ratio.

Case Reports of Type 1 Cystic Biliary Atresia- A rare variant of Biliary atresia along with review of literature

Abstract Cystic biliary atresia is a rare (5-10%) variant of type I biliary atresia. The present report intends to share our experience with cystic variant of biliary atresia along with a review of pertinent literature. The first case was a 3-month-old infant with cholestatic jaundice with preoperative diagnosis of an infantile type of choledochal cyst. The second case was a 4-month-old twin infant with cholestatic jaundice and with preoperative differential diagnoses of either cystic biliary atresia or an infantile type of choledochal cyst (cyst located within the hepatic hilum). Cystic biliary atresia was confirmed intra-operatively in both the patients. In first infant, Kasai portoenterostomy procedure was performed, while in the second patient hepaticoduodenostomy procedure was performed. At 6 months follow-up, there was no episode of cholangitis in first and two episodes in second case. In both patients’ total bilirubin was trending down on follow-up. Cystic biliary atresia presents with cystic dilatation of proximal biliary tract. Type I cystic biliary atresia may masquerade as infantile variant of choledochal cyst. The Kasai portoenterostomy procedure is a standard palliative surgical procedure for patients with biliary atresia to restore bile drainage. A high index of suspicion with early operative intervention is recommended to palliate cholestasis in the infant with cystic variant of biliary atresia.

VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy

Abstract Background Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum. Results The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life. Conclusion This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.

BN SO05 - Risk Factors associated with Complications Post-Laparoscopic Common Bile Duct Exploration: A Comprehensive Literature Review

Abstract Background Gallstone-related diseases, particularly common bile duct (CBD) stones, present a significant global health issue. The adoption of laparoscopic common bile duct exploration (LCBDE) has revolutionized the management of these conditions by providing a minimally invasive alternative to open surgery. This literature review aims to identify and analyze the risk factors associated with complications in LCBDE, thereby offering insights to improve patient care and outcomes. Method comprehensive search for primary research studies, systematic reviews, and meta-analyses pertaining to risk factors for complications following LCBDE. The search was conducted on PubMed, focusing on English-language articles published within the last 20 years and encompassing all age groups. Peer-reviewed journal articles were prioritized. All relevant studies reporting complications after LCBDE were eligible for inclusion if available as full texts, structured abstracts, or conference reports. The initial search yielded 826 articles. Exclusion criteria : open surgery, non-English articles, lacking full-text. A total of 29 records were identified by the literature search. Results Laparoscopic common bile duct exploration (LCBDE) is generally safe and effective, with complication rates influenced by patient and procedural factors. Older age, comorbidities, previous abdominal surgeries, high BMI, narrow common bile ducts, and difficult stones increase risks. Experienced surgeons and shorter operative times reduce complications. The transcystic approach and primary suture closure have fewer complications compared to the transductal route and T-tube drainage, respectively. Intraoperative imaging significantly reduces risks by ensuring complete stone clearance and identifying anatomical variations. Tailoring surgical approaches to patient-specific factors and leveraging surgical expertise are crucial for minimizing complications in LCBDE. Conclusion LCBDE emerges as a safe and effective therapeutic modality for addressing conditions impacting the bile ducts (31). The success and utility of LCBDE can be significantly enhanced through the meticulous optimization of patient-related, surgeon-related, and procedure-related factors. By addressing and fine-tuning these key elements, the occurrence of complications associated with LCBDE can be mitigated, thereby reinforcing its potential as a primary choice for managing various bile duct conditions. This strategic approach not only underscores the clinical efficacy of LCBDE but also advocates for its expanded utilization as a frontline intervention in the comprehensive management of bile duct disorders.

HPB SO54 - Outcomes of Isolated Bile Duct Resection for Cholangiocarcinoma; More Than 15 Years Experience in a Single Tertiary HPB Centre

Abstract Background Cholangiocarcinoma of the extrahepatic biliary tree usually requires a major resection to achieve clear margins with adequate lymphadenectomy. For perihilar tumours this involves extended liver resection with bile duct resection whilst distal tumours require pancreaticoduodenectomy. Occasionally a combination of both (hepato-pancreaticoduodenectomy) is required. These procedures are associated with high morbidity and mortality. In a small number of patients, cholangiocarcinoma is confined to the extrahepatic bile duct with no involvement of the liver or pancreas and a bile duct resection alone is an option. We reviewed the outcomes of patients who underwent bile duct resection for cholangiocarcinoma in our unit. Method We identified all patients who underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma between June 2007 and June 2023 in our centre from a prospectively maintained database. Patient demographics, complications, histology, resection margin status, follow-up, recurrence, and survival were recorded. Time to recurrence and overall survival were analysed using Kaplan Meier analysis. Results Thirteen patients underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma. 12 (92%) were male and the median (range) age was 72 (41-82). No patients received neoadjuvant treatment. 3 (23%) patients developed postoperative complications with 1 (7.7%) perioperative mortality. R0 margin was achieved in 6 (46%). The median (range) postoperative stay was 7 (5-25) days. 8 (61.5%) patients received adjuvant chemotherapy. 7 patients (53.8%) developed recurrent disease at a median of 12 (IQR 8-54) months following surgery. The most common sites of recurrence were the liver (23.1%) followed by local recurrence (15.4%). The median survival was 38 (IQR 20-95) months. Conclusion Extrahepatic bile duct resection with hepaticojejunostomy is an option for patients with cholangiocarcinoma of the extrahepatic bile duct without macroscopic involvement of the liver or pancreas. In our series this procedure was associated with a low morbidity and perioperative mortality with acceptable recurrence rates and overall survival despite only modest R0 resection rates. Isolated bile duct resection with hepaticojejunostomy should be considered for tumours without macroscopic involvement of the liver or pancreas, especially in patients of borderline fitness for a more extensive resection.

BN O04 - Trends in the management of bile duct stones in the United Kingdom: Are we following the evidence?

Abstract Background Common bile duct stones (CBDS) are typically managed in two stages: Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). However, access to ERCP can be limited or require referral, has a high failure rate, often necessitates additional imaging, and may involve multiple procedures. Increasing evidence suggests that single-stage management, involving LC with intraoperative imaging and bile duct exploration when indicated, is cheaper, more effective, and reduces overall length of stay. British Society of Gastroenterology guidance states that it is a valid alternative to ERCP. This study aimed to determine whether clinical practice aligns with this evidence. Method National Health Service (NHS) Admitted Patient Care publications summarise Hospital Episode Statistics by financial year and are openly accessible. OPCS4 Procedure Codes were screened by two authors and categorised as “operative” or “endoscopic.” Codes detailing the management of CBDS or bile duct exploration were included, while ambiguous codes or those for non-stone indications were excluded. Data pertaining to these codes were extracted from the Admitted Patient Care publications for 2012 to 2022 and summarised in a Microsoft Excel spreadsheet. Trends were analysed using a Non-Seasonal Mann-Kendall Trend Test Results A total of 249,475 procedures for CBDS were performed over the ten-year period, with a mean patient age of 67. Annually, the total number of procedures increased from 21,365 to 27,668 (p=0.002). Endoscopic procedures increased from 19,716 to 25,976 (p=0.002), while operative procedures remained stable (1,649 to 1,692, p=0.431). Consequently, the proportion of endoscopic management rose from 92.3% to 93.9% (p&amp;lt;0.001). The mean age of patients undergoing operative procedures was ten years younger than those undergoing endoscopic procedures (57 vs. 67 years) Conclusion Despite evidence and guidance supporting single-stage procedures, there is a trend towards endoscopic management of CBDS in the UK. This may be due to operational pressures on the NHS, including the sequelae of the COVID-19 pandemic, or reflect challenges within hospital culture, skill mix, or equipment availability.

HPB SO59 - How do Previous Biliary Interventions Affect the Operative and Postoperative Outcomes Of Patients Undergoing Laparoscopic Cholecystectomy (LC) and Bile Duct Exploration (LCBDE)?

Abstract Background Laparoscopic biliary surgery is perceived to be difficult in patients who had undergone previous biliary interventions; ERCP, cholecystostomy or cholecystectomy. Our objective was to evaluate the referral pattern, the preoperative characteristics and operative and postoperative outcomes in such patients. Method Analysis of prospectively collected data from patients treated by a specialist biliary unit dedicated to index admission LC and single session laparoscopic management of bile duct stones. In spite of a policy of no preoperative endoscopic clearance of bile duct stones the unit inevitably received some patients who had had previous ERCP at other hospitals prior to referral or were initially unfit when admitted to the base hospital and required ERCP. In a series of 6140 LC and LCBDE 158 patients (2.57%) had already undergone ERCP and 31 (0.5%) had undergone cholecystectomies (18), cholecystostomies (9) or attempted cholecystectomy. Results Of 158 pre-referral ERCPs, 130 (82.3%) were referred from other hospitals, 36 (22.8%) having had more than one ERCP. 83.5% had suspected CBD stones. LC difficulty grade was IV to V in 48.7%. 112 patients (70.9%) required LCBDE. There were 10.1% biliary related complications, 3 re-operations, one conversion and one mortality. of 31 patients with previous biliary interventions, 58% came from other units or hospitals. A third had already undergone ERCP. 61.3% had LC difficulty grades IV or V. The 18 un-cholecystectomised patients needed LCBDE with no conversions or bile duct injuries. There were only 2 (6.5%) biliary related complications. Conclusion While previous biliary interventions understandably increased the difficulty of LC they did not adversely affect operative and postoperative outcomes. Such surgery should be undertaken in the specialist setting as 70.9% of those with previous endoscopic and 58.1% of those with previous surgical or radiologically guided biliary interventions require LCBDE. Implementing definitive surgical interventions during the index admission can achieve a substantial reduction in re-admission rates, and overall decrease in hospital episodes without significant morbidity, re-interventions or mortality. This enhances the quality of life for patients who would otherwise be subjected to multiple repeat ERCPs and yields significant cost benefits.

HPB SO70 - Evaluating the Outcome of Laparoscopic Common Bile Duct Exploration Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Treatment of common bile duct (CBD) stone(s) can be challenging with a risk of significant complications. Laparoscopic common bile duct exploration (LCBDE) displays superior outcomes when compared to endoscopic retrograde cholangiopancreatography (ERCP). Acknowledging the impact of patient variables and surgical proficiency, the British Benign Upper GI Surgical Society (BBUGSS) developed Key Performance Indicators (KPIs) to optimize LCBDE outcomes. The present study comprises an audit of LCBDE outcomes with respect to the BBUGSS KPIs and aims to determine the feasibility and quality of LCBDE that can be achieved in a district general hospital (DGH) with a recently developed LCBDE service. Method This retrospective observational study examined all adult patients who underwent LCBDE between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH. This DGH also serves as a referral center for biliary cases from affiliated hospitals. The preference in our surgical unit is single stage management (laparoscopic cholecystectomy and simultaneous LCBDE) of CBD stones in surgically fit patients. The analysis included preoperative assessments, intraoperative observations, and postoperative outcomes, with respect to the published BBUGSS KPIs for LCBDE. Results 60 patients were eligible for inclusion; median age was 56 years (IQR 40-67) and 40 (66.7%) were female. 33 (55%) were emergency cases. 52 (86.7%) were transcystic exploration; of these 8 (15.4%) utilised basket-in-catheter and 44 (84.6%) utilised choledochoscopes. Median post-operative stay for transcystic exploration was 1 day (IQR 0-2) and for cholechodotomy 8 days (IQR 5-9). Key Performance IndicatorBBUGSS StandardOur outcomeConversion rates&amp;lt;10%0%Bile duct clearance rates&amp;gt;85%91.7%Bile Leak Rates&amp;lt;5%0%Returns to theatre&amp;lt;5%0%Readmission rates (within 30 days)&amp;lt;15%6.7%Overall Morbidity&amp;lt;15%3.3%Overall Mortality&amp;lt;1%0% Conclusion This study indicates that the BBUGSS KPIs for LCBDE are satisfactorily achieved in our centre. Adequate ductal clearance with minimal morbidity was achieved. Our outcomes are likely attributed to the recent commencement of a specialist biliary service and utilisation of predominantly transcystic approach, with the aid of electrohydraulic lithotripsy where needed, as opposed to choledochotomy. Furthermore, the present study suggests a high quality LCBDE service is feasible in a DGH setting if there is sufficient clinical and managerial motivation. We suggest that single stage management of bile duct stones model should be considered in other similar centres.

A04 - EGS Evidenced competency in benign biliary surgery amongst UK general surgeons at certification: A JCST/ISCP study

Abstract Background Symptomatic gallstones are the most common reason for evaluation by an Emergency General Surgery (EGS) service, with laparoscopic cholecystectomy (LC) being performed by most general surgeons. Previous studies show that most LCs in the United Kingdom (UK) are performed by colorectal surgeons (CR). Emergency cholecystectomy requires advanced skills including intra-operative assessment of the bile ducts, and the ability to perform intra-operative cholangiogram (IOC) is part of the procedure-based assessment (PBA) that evidences competency for certificate of completion of training (CCT). This study aims to assess documented evidence of competency in benign biliary surgery amongst general surgeons in the UK. Method PBAs relating to LC and CBD exploration (CBDE) were retrieved for all UK general surgeons who received CCT between 2016 and 2021 from ISCP (702; 285 (41%) colorectal; 212 (30%) Upper GI (UGI)). All eLogbook entries relating to LC +/- IOC +/- CBDE were also retrieved. Subspecialty interest was determined from Part 2 of the FRCS examination. Competence (Level 4) as well as a granular assessment of IOC and CBDE was compared amongst trainees, taking into account their subspecialty interest. Results 11,733 LC and 553 CBDE assessments from 160,570 LC +/- IOC +/- CBDE procedures recorded on eLogbook were retrieved. Knowledge of IOC indication was assessed in 467 (94%) surgeons, but performance was only assessed in 380 (75%) surgeons. Median satisfactory IOC performance assessments was 3 (2-5). UGI were more likely to do this than colorectal (4 (2-7) vs 2 (1-4) P &amp;lt; 0.001). Satisfactory CBDE was achieved by 86 surgeons (12 CR and 74 UGI). 486 surgeons (97% CR; 94% UGI) received Level 4 (independence) despite never achieving satisfactory ability to perform IOC. Conclusion Competency in acute biliary surgery for general surgeons at certification is extensively assessed using PBAs. Cholecystectomy training and assessment in the UK does not seem to include intraoperative bile duct anatomy assessment or treatment of CBD stones. Assumed competency in cholecystectomy by trainers in the UK does not seem to include the need to do this, as 97% of CR and 94% of UGI trainees achieve documented competence without the ability to perform IOC. This may have an impact on EGS service delivery of acute and emergency gallbladder surgery including the ability to deal with difficult cases.

BN SO52 - Innovative Tools for Laparoscopic Bile Duct Exploration (LCBDE) in Torbay Hospital

Abstract Background Laparoscopic bile duct exploration (LCBDE) is a minimally invasive technique used to manage common bile duct (CBD) stones. The procedure has evolved significantly with the development of specialized tools that enhance efficacy and patient outcomes. This abstract aims to discuss the various tools employed for LCBDE at Torbay Hospital, highlighting their specific uses, benefits, and outcomes. Method We conducted a retrospective analysis of LCBDE procedures performed at Torbay Hospital. The tools used included the Pusen ‘Skinny scope’, Ambscope, Nathenson tipless basket, GB stone retrieval basket, and Rotacrusher. Data were collected on the types of tools used, procedural success rates, stone clearance rates, and any complications Results The Pusen ‘Skinny scope’ (3mm) was used in 60% of cases for transcystic exploration, showing high success in stone visualization and retrieval. The Ambscope (5mm) was used in 30% of cases for choledochotomy, effectively accessing larger stones. The Nathenson tipless basket retrieved up to 8mm stones in 45% of cases. The GB stone retrieval basket extracted non-disposable stones up to 2cm. The Rotacnsher, used for large stones in choledochotomy, was highly effective but needed larger port access. Laser and mechanical lithotripters fragmented stones larger than 1cm with an 85% success rate. Overall stone clearance was 90% with minimal complications. Conclusion The use of specialized tools in LCBDE at Torbay Hospital has significantly improved the management of CBD stones. The Pusen ‘Skinny scope’ and Ambscope provide excellent visualization and access, while the Nathenson tipless basket and GB stone retrieval basket offer reliable stone extraction capabilities. Advanced lithotripters further enhance the ability to manage larger stones. These tools collectively contribute to high success rates and favorable patient outcomes, reinforcing the value of LCBDE in modern surgical practice.

BN SO12 - Management Strategies for Complications in Common Bile Duct Exploration: A Single Unit Comprehensive Analysis

Abstract Background 10-20% of individuals with systemic gallstones are estimated to have common bile duct stones (CBDS)(1). Laparoscopic common bile duct exploration (LCBDE) and two stage laparoscopic cholecystectomy (LC) with subsequent endoscopic retrograde cholangiopancreatography (ERCP) are clinically equivalent in their purpose but associated with different risks and require different skill sets, training and facilities. This study has retrospectively reviewed all LCBDE in our Benign Upper Gastrointestinal Surgery Unit, in particular analysing complications, the management strategies employed, and the impact associated with these interventions. Method A retrospective analysis was conducted on all patients (n=427) who underwent LCBDE between November 2013 and May 2024 at our benign Upper Gastrointestinal Surgery Department to evaluate complications. Comparison is made with British Benign Upper Gastrointestinal Surgical Society (BBUGSS) standards. Results 16.6% (n=71) experienced complications; 3.28% (n=14) retained stone, 3.74% (n=16) bile leak, 9.6% (n=41) non-specific surgical complications. Bile leak approaches were transcystic (n=2), transcystic converted to cholecdochotomy (n= 3), and choledochotomy n=11. Leaks were diagnosed on ERCP (50%), drains (n=3), CT (n=4) and clinical suspicion (n=1). 50% (n=8) were managed by ERCP, n=6 laparoscopic washout, and n=2 conservatively. Of retained stones, n=5 were indicated intraoperatively, n=7 on readmission with pain, n=1 on tubogram, and n=1 due to increased drain output. 80% (n=12) managed via ERCP with sphincterotomy +/- stenting. Of the remainder n=1 underwent open exploration, and n=1 managed conservatively. Conclusion Bile duct complications can be life altering and thus early identification and management is paramount. BBUGSS’ recommended performance standards for LCBDE state that frequency of retained stones should be &amp;lt;15%, bile leaks &amp;lt;5% and return to theatre &amp;lt;5% (2). In our trust rates are 3.51%, 3.74% and 1.64% respectively. Our stone clearance rate is 96.49%, higher than the BBUGSS standard of &amp;gt;85% (2). Our findings conclude that a benign UGI unit in a District General Hospital can deliver a one stage approach with good management of complications from LCBDE.

HPB SO23 - Implementation and Outcomes of Index Admission Management of Acute Gallstone Pancreatitis on a Specialist Biliary Unit

Abstract Background While the management of acute gallstone pancreatitis (AP) has recognised guidelines, there are wide variations in compliance with these in various institutions for different reasons. The primary objective of this review was to evaluate the effects of implementing proactive management strategies on a specialist biliary firm receiving most biliary emergency admissions by protocol on the incidence of index admission laparoscopic cholecystectomy (LC) for AP. The secondary aims were to study the admission to LC interval, if such policy was safe and how it can help the optimisation of outcomes of AP. Method Analysis of prospectively collected data from AP patients treated by a specialist biliary unit dedicated to index admission LC and single session laparoscopic management of bile duct stones. Almost all patients were referred to the unit as soon as the diagnosis of AP was made. Only patients with severe pancreatitis on imaging or requiring intensive care were not included in the index admission pathway and subsequently underwent delayed surgery. Routine MRCP and ERCP were not part of the management protocol. Following clinical optimisation patients had LC with routine cholangiography (IOC). and if necessary bile duct exploration. Results 495/6140 patients were identified (8%), 70% females. Median age was 55 years. 92.3% had suspected ductal stones, half with jaundice. 11.9% had previous episodes. Only 6.2% had MRCPs and 2% ERCPs. Admission to LC interval was 5 days. 33.2% required bile duct explorations. LC difficulty grade was III to V in 37.2%. The median operative time was 62 minutes with no conversions, ductal injuries or mortality. Complications occurred in 9.2%, including 14 persistent pancreatitis/collections resulting in 6 of 25 readmissions. Two re-operations resulted from t-tube complications. Median hospital stay was 7 days, 72% having had only one admission. Conclusion Index admission LC on all AP patients fit for surgery is perfectly safe in the specialist setting. It optimises preoperative radiological investigations and endoscopic interventions and ,subsequently, a third of the patients require bile duct exploration. Implementing definitive surgical interventions during the index admission for AP offers a substantial reduction in hospital stay, re-admission rates and an overall decrease in hospital attendances. This not only yields significant cost benefits for the health service but also enhances the quality of life for patients.

BN SO01 - Fluorescent Precision: Advancing Laparoscopic Cholecystectomy with Indocyanine Green ( ICG )

Abstract Background Laparoscopic cholecystectomy represents a significant advancement in surgical techniques for gallbladder disease. However, challenges persist in accurately identifying critical structures such as the bile ducts, leading to complications. Indocyanine Green (ICG), a fluorescent dye with unique properties, has emerged as a promising tool to enhance precision and safety in laparoscopic cholecystectomy. Originally developed for infrared photography, ICG's fluorescence capabilities have been harnessed in various medical applications, including ophthalmology and surgical procedures. Its ability to provide real-time visualization of the biliary anatomy facilitates better surgical navigation, reducing the risk of inadvertent injury and improving overall outcomes. Method Comprehensive review of existing literature and research on laparoscopic cholecystectomy, with a focus on the role of Indocyanine Green (ICG) in enhancing surgical precision and safety. Relevant articles, clinical trials, and meta-analyses were identified through databases such as PubMed, Google Scholar, and Scopus. Search terms included "laparoscopic cholecystectomy," "Indocyanine Green," "fluorescence imaging," and related terms. Results The results of this study highlight the significant role of Indocyanine Green (ICG) in laparoscopic cholecystectomy. Through a comprehensive review of existing literature and research, it was found that ICG integration enhances surgical precision and safety by providing real-time visualization of the biliary anatomy. The use of ICG reduces the risk of inadvertent injury and improves overall surgical outcomes. Despite challenges such as technical complexities and safety considerations, the evidence strongly supports the transformative potential of ICG in modern surgery. Conclusion In conclusion, the integration of Indocyanine Green (ICG) into laparoscopic cholecystectomy represents a pivotal advancement in surgical practice. The findings of this study underscore the importance of cautious navigation and collaboration in maximizing the benefits of ICG. By addressing challenges through innovation and evidence-based guidelines, ICG has the potential to revolutionize the landscape of minimally invasive surgery, offering patients safer procedures and better outcomes. As research continues to evolve, the journey of ICG in laparoscopic cholecystectomy holds promise for a future where precision and safety converge, ultimately shaping the standard of surgical excellence.