Complication Of Cholecystitis Research Articles

Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study

IntroductionA textbook outcome patient is one in which the operative course passes uneventful, without complications, readmission or mortality. There is a lack of publications in terms of TO on acute cholecystitis.ObjetiveThe objective of this study is to analyze the achievement of TO in patients with urgent early cholecystectomy (UEC) for Acute Cholecystitis. and to identify which factors are related to achieving TO.Materials and methodsThis is a post hoc study of the SPRiMACC study. It´s a prospective multicenter observational study run by WSES. The criteria to define TO in urgent early cholecystectomy (TOUEC) were no 30-day mortality, no 30-day postoperative complications, no readmission within 30 days, and hospital stay ≤ 7 days (75th percentile), and full laparoscopic surgery. Patients who met all these conditions were taken as presenting a TOUEC.Outcomes1246 urgent early cholecystectomies for ACC were included. In all, 789 patients (63.3%) achieved all TOUEC parameters, while 457 (36.6%) failed to achieve one or more parameters and were considered non-TOUEC. The patients who achieved TOUEC were younger had significantly lower scores on all the risk scales analyzed. In the serological tests, TOUEC patients had lower values for in a lot of variables than non-TOUEC patients. The TOUEC group had lower rates of complicated cholecystitis. Considering operative time, a shorter duration was also associated with a higher probability of reaching TOUEC.ConclusionKnowledge of the factors that influence the TOUEC can allow us to improve our results in terms of textbook outcome.

Laparoscopic therapy for Mirizzi syndrome: A case report with review of literature

Mirizzi syndrome (MS) is a rare entity and is due to extrinsic biliary compression. It is a rare complication of cholecystitis and chronic cholelithiasis. The impacted calculi at the infundibulum of the gall bladder or cystic duct lead to compression of the adjacent biliary structures, resulting in total or subtotal obstruction of the common hepatic duct (CHD). This leads to liver dysfunction. We, herein, present one such case of a 50-year-old female patient who was diagnosed to have MS. During surgery, at laparoscopy, she was unexpectedly also found to have a cholecysto-duodenal fistula. Both conditions were successfully treated laparoscopically.

Detection of Rare Gallbladder Microperforation by 18F-FDG PET/CT in a Patient with Maxillary Sinus Cancer.

Gallbladder perforation is one of the most serious complications of cholecystitis and is rarely seen in 2-11% of cases. Pericholecystic abscesses secondary to gallbladder perforation are rare. Rapid diagnosis is important because of high morbidity and mortalityrates. A subcapsular abscess secondary to gallbladder microperforation is presented on 18F-fluorodeoxyglucose positron emission tomography/computed tomography performed for restaging in a patient with maxillary sinus cancer.

The Many Hidden Faces of Gallbladder Carcinoma on CT and MRI Imaging-From A to Z.

Gallbladder carcinoma represents the most aggressive biliary tract cancer and the sixth most common gastrointestinal malignancy. The diagnosis is a challenging clinical task due to its clinical presentation, which is often non-specific, mimicking a heterogeneous group of diseases, as well as benign processes such as complicated cholecystitis, xanthogranulomatous cholecystitis, adenomyomatosis, porcelain gallbladder or metastasis to the gallbladder (most frequently derived from melanoma, renal cell carcinoma). Risk factors include gallstones, carcinogen exposure, porcelain gallbladder, typhoid carrier state, gallbladder polyps and abnormal pancreaticobiliary ductal junction. Typical imaging features on CT or MRI reveal three major patterns: asymmetric focal or diffuse wall-thickening of the gallbladder, a solid mass that replaces the gallbladder and invades the adjacent organs or as an intraluminal enhancement mass arising predominantly from the gallbladder fundus. The tumor can spread to the liver, the adjacent internal organs and lymph nodes. Depending on the disease stage, surgical resection is the curative treatment option in early stages and adjuvant combination chemotherapy at advanced stages. The purpose of this scientific paper is to fully illustrate and evaluate, through multimodality imaging findings (CT and MRI), different presentations and imaging scenarios of gallbladder cancer in six patients and thoroughly analyze the risk factors, patterns of spread and differential diagnosis regarding each particular case.

OGBN P08 Increasing Cholecystostomies: Is this a reflection of COVID, change in indications, or an easy option?

Abstract Background Percutaneous cholecystostomy has been utilized in septic patients with non-malignant biliary pathology who are frail, where surgery is deemed too high risk or conservative management has failed (NICE guidance). The COVID-19 pandemic and the decreased access to surgery may have led to a rise in cholecystostomies. The aim of this study is to evaluate over the last decade, the changing trends, indications, and outcomes of cholecystostomies in our institution. Methods We retrospectively reviewed a prospective database of all patients who had cholecystostomy at our two sites; a Tertiary center and an associated district general hospital, between 2012 and 2022. Exclusion criteria included paediatric patients and biliary malignancies. Patients were grouped as Non-Septic (N-S: cholelithiasis, uncomplicated cholecystitis, choledocholithiasis), and Septic (S: complicated cholecystitis, empyema, systemic sepsis, MODS). Data collected for patient characteristics, co-morbidities using Charlson Co-morbidities Index (CCI), length of stay, duration of cholecystostomy, 90-day morbidity and mortality. Results Cholecystostomies were performed in 150 patients, median age 72 years, 52% female. There was an exponential rise of cholecystostomies over the decade. The overall mortality was 5% (8/150). Patients with CCI score <5 & ³ 5, were compared for mortality (2/98 vs 6/52, p<0.05). The cohort included two groups: N-S (n=105/150, 70%) and S (n=45/150, 30%). All mortalities were in the S group (n=8/45 p<0.001). During COVID interval, there was a rise in non-septic patients getting cholecystostomies, which has persisted post pandemic (figure 1). Cholecystostomies stayed in situ for a median of 76 days (0-830), with subsequent cholecystectomies in 77%. Conclusions There is an exponential rise in the number of cholecystostomies in the last decade, this persisted during and post COVID. The ratio of S: N-S patients getting cholecystostomies was much greater pre-pandemic, then peri- or post-pandemic. The latter may reflect a change in practice. With the increasing pressure of waiting times, need to achieve “hot gallbladders” targets; has cholecystostomy indications changed or does this reflect an easy option and at what cost?

Evaluating Clinical Outcomes of Laparoscopic Subtotal and Total Cholecystectomy for Complicated Acute Cholecystitis: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare clinical outcomes in patients with complicated acute cholecystitis undergoing laparoscopic total vs subtotal cholecystectomy. This systematic review and meta-analysis was conducted according to PRISMA guidelines and queried PubMed, Embase, ProQuest, Google Scholar, and Cochrane databases from inception to May 2023. The primary outcome was complication rates including common bile duct injury, wound infection, reoperation, bile leak, retained stones, and subhepatic collection, whereas secondary outcomes were in-hospital mortality and hospital length of stay. A total of 7 studies with 135,233 cases were included for meta-analysis. Patients who underwent laparoscopic total cholecystectomy had a significantly lower risk of postoperative bile leaks (RR: .15; 95% CI: .03, .80) and subhepatic fluid collection (RR: 0.19; 95% CI: .06, .63) and were 2.94 times less likely to die compared to those who underwent subtotal cholecystectomy (RR .34; 95% CI: .15, .77). Patients who underwent subtotal cholecystectomy had significantly longer hospital length of stay (mean difference 1.0days; 95% CI: .5days, 1.4days). In adult patients presenting with complicated cholecystitis, management with laparoscopic subtotal cholecystectomy presents a unique complication profile with increased risk of postoperative bile leak and subhepatic fluid collection, in-hospital mortality, and longer hospital length-of-stay when used as an alternative approach to laparoscopic total cholecystectomy. Further research into the most appropriate clinical scenarios and patient populations for the use of the subtotal cholecystectomy approach may prove useful in improving its associated outcomes.

Hemorrhagic cholecystitis causing an intrahepatic subcapsular hematoma: Case report and review of the literature

Hemorrhagic cholecystitis is a very rare condition. It can present very different clinical symptoms. It often occurs as a complication of cholecystitis. These patients are usually under anticoagulant therapy or they have coagulopathy.

Intraoperative Fluorescent Cholangiography Using Indocyanine Green Fluorescence for Identification and Treatment of Bile Leaks After Urgent Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide.1 Postoperative bile leaks caused by bile duct injuries (BDIs) are serious complications after LC, resulting in a prolonged length of hospital stay, increased costs, morbidity, and mortality rates.2 Incidence of BDIs during LC is ~0.4%–1.5%.1 Intraoperative fluorescent cholangiography using indocyanine green fluorescence (ICG-C) is a safe method to observe the biliary tree and may be useful to prevent postoperative bile leaks after LC and hepatic surgery.1,2 However, detection of bile leaks using the ICG-C during LC has limited evidence in international literature.3–8 This video illustrates how to use ICG-C to identify and treat a bile leak after an urgent LC. Materials and Methods: A 54-year-old man with a history of hypertension, diabetes mellitus, cholelithiasis, and hepatic abscesses was admitted with right upper quadrant pain and fever. An urgent CT scan of the abdomen showed acute cholecystitis associated with a large pericholecystic abscess. A percutaneous cholecystostomy (PC) was placed and nonoperative management with intravenous antibiotic was started. On the seventh postprocedural day, the PC was accidentally removed, and a second CT scan of the abdomen showed a reduction of the pericholecystic abscess size, and a subhepatic fluid collection. An urgent LC was performed, and two surgical drains were placed (one subhepatic and one suprahepatic). On the first postoperative day, a low-flow biliary output (250 mL/day) from the subhepatic drainage was associated with a gradual deterioration of the patient's clinical condition. Considering the low flow rate of the biliary fistula, nonoperative management was carried out; on the second post-operative day the patient presented hypotension, oliguria, fever (temperature 38.2°C), and worsening right upper abdominal pain with signs of diffuse peritonitis. The hematologic investigations showed a WBC 17,560/mL, Hb 10.7 g/dL, C-Reactive Protein 17.66 mg/dL, normal liver function tests, and normal bilirubin levels. Owing to signs of septic shock and diffuse signs of peritonitis, an urgent surgical exploration was performed. After the induction of anesthesia, 2.5 mg of Indocyanine Green was intravenously injected. Eight minutes later, the ICG-C demonstrated exactly and in real-time the biliary leak on the liver surface, coming from a subvesical bile duct. Two laparoscopic Roeder's knots were placed to repair the injury. Two surgical drains were placed. Results: The postoperative period was uneventful, with a progressive improvement of the patient's performance status, vital parameters, and laboratory tests. The surgical drains were serosanguinous with low output and both were removed on postoperative day 9. The patient was discharged on day 10 in good clinical condition. Conclusions: One of the most common causes of LC-associated biliary leaks are injuries to the subvesical bile ducts. ICG-C clearly identifies these bile spots on the liver surface during surgery, allowing them to be repaired immediately and prevent biliary fistulas. ICG-C is a safe, easy, repeatable, and noninvasive method to identify bile leaks during surgery. ICG-C may be useful to prevent and treat bile leaks after LC, especially in complicated cholecystitis.5,6 Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. Running time of video: 8 mins 27 secs

A Bayesian Network Meta-Analysis Comparing Biliary Stent Types' Outcome and Complications in Unresectable Malignant Biliary Obstructions.

To conduct a network meta-analysis (NMA) in comparing biliary stents types' outcomes and complications in unresectable MBO. The study was conducted in accordance with the PRISMA and NMA extension . Comprehensive searches of the Cochrane Library, MEDLINE, and Scopus were done analyzing randomized controlled trials that included subjects with unresectable malignant biliary obstructions that underwent biliary stents placement from any approaches. The types of stents that included were full-covered metal (FMS), partially-covered metal (PMS), uncovered metal (UMS), plastic (PLS), Iodine-125 seeds strands (IRS), antireflux (ARS), and paclitaxel-coated (PXS) stents. The outcome parameters were clinical success, median patency duration, medial survival, and early 30-day mortality. The complications included were stent occlusion, stent migration, cholangitis, cholecystitis, pancreatitis, hemorrhage, and hemobilia. The NMA will be done based on Bayesian method, Markov Chain Monte Carlo algorithm, using BUGSnet package in R studio. Transivity was controlled by methods and consistency of the NMA will be fitted by deviance information criterion. Data analysis in NMA were presented in Sucra plot, league table, and forest plot. Thirty-six RCTs were included with 3502 subjects. ARS had the best clinical success and longest median patency. However, it was associated with higher rate of complications. IRS had a good clinical success (RR 1.63; 95%CI 0.67-6.25), long median patency (MD 21.14; 95%CI -106.18 to 145.91), and high significant survival rate (MD 69.89; 95%CI 22 to 117.57) compared to others stents. It was associated unsignificant complications of cholecystitis, hemobilia, and hemorrhage. Iodine-125 seeds strands had the promising good outcome and tolerated complications among others and should be considered as a standard stent to be used in unresectable malignant biliary obstructions.

Chitotriosidase and Neopterin as Potential Biomarkers for the Evaluation of Complicated Cholecystitis-A Pilot Study.

Gallstones are a common surgical pathology. Laparoscopic cholecystectomy represents the elective treatment. Complicated cases can increase the rate of conversion, the duration, and the difficulty of the intervention, along with the hospitalization period. A prospective cohort study was conducted on 51 patients with gallstones. Only subjects with normal renal, pancreatic, and hepatic functions were included. The severity of cholecystitis was evaluated by considering the ultrasound examination, intraoperative findings, and pathology report. We evaluated two potential biomarkers, namely neopterin and chitotriosidase, by comparing their levels before and after the intervention for chronic (n = 36) and complicated (n = 15) cases, as well as their eventual association with the hospitalization period. Subjects with complicated cholecystitis had significantly higher (p = 0.01) neopterin levels at presentation (16.82 nmol/L vs. 11.92 nmol/L, median values), but the differences in chitotriosidase activity between complicated (170.00 nmol/mL/h) and chronic (160.00 nmol/mL/h) cases were not significant (p = 0.66). Patients with neopterin levels above the cut-off value 14.69 nmol/L had a 3.34 times higher risk of complicated cholecystitis. Twenty-four hours after the laparoscopic cholecystectomy, the differences in neopterin level and chitotriosidase activity between chronic and complicated cases were not significant. A significant decrease in chitotriosidase activity was observed after the intervention, only for complicated cases (190 nmol/mL/h vs. 145 nmol/mL/h, p = 0.007); for neopterin, the postoperative decrease was not statistically significant (19.42 nmol/L vs. 10.92 nmol/L, p = 0.06). No significant association with the hospitalization period was observed. Neopterin may be a useful biomarker for complicated cholecystitis, and chitotriosidase may have prognostic utility in early patient follow-up.

The role of frailty score in early surgical treatment of elderly cholecystitis patients

Objectives: The average life expectancy is increasing all over the world, and as a result, the number of elderly patients is increasing. Acute cholecystitis is one of the most common diseases requiring emergency surgical treatment in the elderly. In the literature, it has been reported that in the treatment of elderly patients with acute cholecystitis, physicians do not fully comply with the current literature recommendations due to some concerns and do not apply surgical treatment in the early period. The concept of frailty, which has come to the fore in geriatric assessment today, provides objective information about the general health status of the patient. In our study, the role of frailty assessment in the decision made regarding the early surgery in elderly patients with acute cholecystitis treated in our hospital was investigated. Methods: In our study, the clinical features, comorbidities, American Society of Anesthesiologists (ASA) scores, Canadian Study of Health and Aging (CSHA) frailty scale, treatment modalities and prognosis of patients over the age of 65 who were treated with the diagnosis of acute cholecystitis between January 2018 and January 2021 were evaluated retrospectively. Results: Of the 182 patients included in the study, 24 (13.2%) were found to be frail. It was observed that the mean age and multi-morbidity were higher in the frail group (p < 0.001). It was observed that the mean C-reactive protein and leukocyte values, which are inflammatory mediators, increased in both groups, both fragile and non-fragile, and complicated cholecystitis accompanied by cholangitis or pancreatitis was observed in a total of 64 (35.16%) patients. There were 57 (31.3%) patients using anticoagulant or antiaggregant agents. The patients were most frequently treated with medical treatment (n = 108; 59.3%), the other treatment methods were early surgery ( (n = 46; 25.3%), endoscopic retrograde cholangiopancreatography (n = 22; 12.1%) and percutaneous cholecystostomy (n = 11; 6.0%). Surgical treatment was more common in ASA I and II patients, and percutaneous cholecystostomy was more common in frail patients (p < 0.001). There were 20 (14.70%) patients who were re-admitted to the hospital and 6 (3.29%) patients ended up with mortality. No statistical relationship could be demonstrated between these conditions and frailty (p > 0.05). Conclusions: In the treatment of the elderly cholecystitis patients, early surgical treatment is the most favorable treatment method in order to reduce re-admission and prevent possible complications. However, we think that a detailed geriatric evaluation should be made in a multidisciplinary manner for the decision making regarding the of surgical treatment of elderly patients, and frailty evaluation should also be made in this context.

EGS P22 Management of acute cholecystitis during the Covid-19 pandemic - A complete cycle

Abstract Background Acute cholecystitis is a common surgical emergency. NICE guidelines recommend early laparoscopic cholecystectomy should be performed within 1 week of diagnosis. Emergency and elective surgical provision was affected during the first wave of the covid pandemic due to high postoperative mortality and pulmonary complications. The objectives of this audit were to assess and improve the local management of acute cholecystitis during the Covid-19 pandemic. Methods A retrospective review of all patients who presented with acute cholecystitis over 2 months was performed in April 2020. Several interventions were introduced following the first cycle to improve our adherence with NICE guidelines, including ‘green elective surgical pathway’, clinical priority coding for elective surgeries, a hot gallbladder pathway, and a dedicated weekend and evening list. A re-audit was performed over 2 months in July 2020. These findings were presented at the departmental meeting. Results 34 patients were reviewed in the first audit and 37 in the re-audit. A higher number of patients with acute cholecystitis in cycle 2 had admission covid swabs (97.3% vs 64.7%) and interval covid swabs (54.1% vs 0%) compared to cycle 1. One patient was tested positive for Covid-19 in cycle 2 and was listed for elective operation. Cycle 2 revealed a higher rate of hot gallbladder (from 8.8% to 10.8%) and a shorter median length from admission to operation (from 4 to 1.5 days). A higher rate of patients was readmitted due to complications of cholecystitis in cycle 2 (29.7% vs 20.6%) compared to cycle 1. Conclusions The overall performance is still behind the NICE guideline recommendation. We have identified factors such as pressure on theatre facilities and resources and cancer fast-track priority surgeries during the Covid-19 pandemic. Ongoing audit and optimisation of the hot gallbladder pathway, elective surgical pathway, extra lists, and clinical priority of operations are important to improve the quality of care for patients with acute cholecystitis.

EGS P21 A review of emergency laparoscopic cholecystectomies during the COVID-19 pandemic compared to pre-pandemic. Is there a difference in patient and financial outcomes?

Abstract Background The COVID-19 pandemic was declared the greatest challenge the NHS would face since its creation. As a means of combatting the unprecedented strains COVID-19 was expected to force upon hospitals and their staff, NHS England sanctioned the postponement of all non-urgent elective surgery during the first wave of the COVID-19 pandemic. Approximately 70 000 cholecystectomies are performed every year in the UK, with the vast majority of these being elective laparoscopic cholecystectomies (LC). However, in the early stages of the pandemic, both national and international surgical bodies warned of the potential risks of aerosol virus transmission with the use of laparoscopy. Therefore, conservative management for emergency general surgical pathologies was recommended where possible. Delays in performing LC are associated with recurrent cholecystitis, pancreatitis and cholangitis; all of which present as emergencies with significant associated morbidity and mortality. This in turn has an economic impact on the NHS. We aimed to evaluate if patients undergoing emergency LC during the COVID-19 pandemic at our site, had different outcomes compared to those treated prior to the pandemic. Has the COVID-19 pandemic negatively impacted their patient journey? Furthermore, has the pandemic led to increased costs for our site? Methods A retrospective data collection was performed to identify all patients who had an emergency LC from March 2019 – March 2021. Patients were subsequently categorised into ‘pre-COVID-19’ and ‘during COVID-19’ groups. Hospital computer systems were used to review operative admission length of stay (LoS), rate of conversion to open surgery/subtotal cholecystectomy, operative time, post-operative complications/return to theatre and readmission rate. Histopathology reports were analyzed to assess if the ‘during COVID-19’ cohort had a higher rate of complicated cholecystitis. Finally costs of the operative admission and associated admissions (pre and post-operatively), as well as the tariff for investigations performed for gallstone disease were calculated for each cohort of patients. Results 158 patients were included in the study. A 42% reduction in emergency LC cases was observed during the COVID-19 pandemic compared to pre-pandemic. No statistically significant differences were seen between the two groups when reviewing the rate of conversion to open surgery or the incidence of post-operative complications/need to return to theatre. The rate of subtotal cholecystectomy was higher in the ‘during COVID-19’ group (12% vs. 3%) and this was found to be statistically significant (p-value 0.024). Operating times were longer during the pandemic (93 vs. 80 mins), as was the LoS for the operative admission (5 vs. 6 days), however these results were not statistically significant. Interestingly, same day emergency care (SDEC) reviews were more frequent in the ‘during COVID-19’ group (13.1 vs. 29.3%) and this was statistically significant (p-value 0.015). There was no statistically significant difference between the groups in relation to histopathology results. The most prevalent histopathology of both cohorts was chronic cholecystitis (58 vs. 48.28%). Acute on chronic cholecystitis (23 vs. 25.86%) and necrotising/gangranous changes (11 vs. 12.07%) were more prevalent in the ‘during COVID-19’ group. When reviewing costs between the two groups, no statistically significant differences in LoS, nor investigation tariffs was observed. Conclusions Our study shows that the COVID-19 pandemic has had a negative impact on two clinical aspects of emergency LC – an increase in the rate of subtotal cholecystectomy, as well as SDEC reviews. This could be explained by delays in elective surgery encountered during the pandemic, leading to patients experiencing recurrent infections, or other associated complications of gallstone disease and consequently requiring more frequent clinician/SDEC reviews. These complications can also result in unclear anatomy, diffuse scarring, necrosis and abscess formation, all of which can lead to increasingly complex cases encountered intra-operatively. If surgeons are unable to safely achieve a critical view of safety, guidance recommends subtotal cholecystectomy as a bail out procedure, in order to avoid serious damage to the bile duct or blood vessels. This could justify the statistically significant higher rate of subtotal cholecystectomy in the ‘during COVID-19’ group. Currently, there are approximately 6 million patients on NHS surgical waiting lists and this issue must be addressed urgently in the COVID-19 recovery phase, so as to prevent adverse outcomes for both patients and the NHS.

Comparison of severity and complication rates of acute cholecystitis during pandemic and pre-pandemic periods?

Cancellations of surgeries for elective cases and late admissions of symptomatic cases during the pandemic period might have increased the number of cases of acute cholecystitis and its complications. To compare the severity of acute cholecystitis and complication rates during the pandemic and pre-pandemic periods. We evaluated the computed tomography (CT) findings observed for the diagnosis of complications for both acute simple and acute complicated cholecystitis during both the pandemic and pre-pandemic periods. Patients admitted to the hospital between March 2020 and December 2020 made up the study group and the corresponding appropriate patients from one year earlier were studied as the control group. In addition to the CT findings, clinical and laboratory findings, co-morbidities such as diabetes, as well as the admission time to hospital from the onset of the initial symptoms to hospital admission were also evaluated. A total of 88 patients were evaluated (54 in the study group, 34 in the control group; mean age = 64.3 ± 16.3 years). The male-to-female ratio was 51/37. The number of patients diagnosed with complicated cholecystitis were significantly higher in the study group (P = 0.03). Murphy finding and diabetes status were similar between the two groups (P = 0.086 and P = 0.308, respectively). Admission time to the hospital was significantly different for study and control groups in simple cholecystitis patients (P = 0.045); with no significant difference in cases of complicated cholecystitis (P = 0.499). Our study reveals the course of acute cholecystitis during the pandemic period was much more serious with higher complications.

S2676 A Case of Hemorrhagic Cholecystitis and Bleeding Duodenal (Ulcer): A Rare Coincidence!

Introduction: Hemorrhagic cholecystitis is a life-threatening condition and may result in death if not treated promptly. Here, we present an atypical case of hemorrhagic cholecystitis that presented with melena but no abdominal pain. Case Description/Methods: A 43-year-old man with a past medical history of hypertension and paraplegia presented to the hospital with black tarry stools for 1 day. He denied fever, abdominal pain, and diarrhea. Vital signs were normal. Physical examination was significant for conjunctival pallor. Laboratory showed Hb 6g/dL, Hct 22.3%, WBC 8.20 k/µL, platelet 339 k/µL. The patient was transfused but continued to bleed and was taken to endoscopy. Further history revealed that the patient is T8 level paraplegic. Esophagogastroduodenoscopy showed a duodenal ulcer with oozing hemorrhage which was treated with thermotherapy; however, oozing continued, thermotherapy was avoided to prevent deep tissue injury and perforation as exact bleeding source could not be identified. Interventional radiology was consulted for embolization. After embolization, his hemoglobin continued to drop requiring blood transfusion. Computed tomography (CT) with angiography of the abdomen and pelvis was then performed which revealed a small focal area of active bleeding in the gallbladder. Patient was taken for emergent cholecystectomy. Intraoperative finding revealed active bleeding with clot in the gallbladder lumen. Following surgery, patient’s hemoglobin stabilized. Histopathology of the resected gallbladder revealed multiple stones impact in the gallbladder wall. (Figure) Discussion: Hemorrhagic cholecystitis is an extremely rare complication of cholecystitis. Our patient has no risk factor for developing hemorrhagic cholecystitis and his clinical presentation was ambiguous since the patient is paraplegic and does not have normal sensation in his abdomen. Patients with upper gastrointestinal bleeding (UGIB) usually undergo EGD for the management of the bleeding. However, UGIB refractory to an endoscopic treatment often requires endovascular intervention by radiology and surgery as appropriate. In our case CT angiogram of abdomen and pelvis revealed second source of the bleeding which was in the gallbladder leading to emergent cholecystectomy.This is a rare coincidence in which a patient with simultaneous bleeding from duodenal ulcer also found to have hemorrhagic cholecystitis. One hypothesis includes cholecystoduodenal (bilioenteric) fistula which is the infrequent complication of untreated cholelithiasis.Figure 1.: (A) Laparoscopic performed for total cholecystectomy showed actively bleed with clot in gall bladder lumen (B) EGD showed duodenal ulcer with oozing hemorrhage (C) Ongoing bleeding despite thermotherapy (D) CT angiography of abdomen and pelvis showed contrast extravasation in the gall bladder lumen (yellow arrow) suggesting active bleeding into gall bladder.

S1738 Hemorrhagic Cholecystitis: A Rare Cause of Brisk Upper Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding is a commonly seen problem in the hospital and timely identification of the source is important in brisk bleeds to allow for prompt interventions. Unfortunately, the cause of the bleeding can sometimes be difficult to identify and can require thinking outside the box. We present a rare case of hemorrhagic cholecystitis manifesting as hematochezia and hypotension in the setting of chronic liver disease. Case Description/Methods: A 55-year-old man with history of alcoholic cirrhosis (Meld-Na 24, Child-Pugh C) initially presented to an outside hospital with one week of nausea, vomiting, abdominal pain and watery diarrhea in the setting of alcohol withdrawal. He underwent an esophagogastroduodenoscopy (EGD) revealing a single gastric varix with red nipple without active bleeding and no esophageal varices. His liver function began to worsen and improved with supportive care. His improvement interestingly correlated with acute onset of hematochezia. A repeat EGD and colonoscopy revealed numerous blood clots in the colon without an active source of bleeding. He was transferred to our academic medical center for higher level of care. Upon arrival, he continued to have hematemesis and hematochezia. Repeat EGD/colonoscopy showed small non-bleeding gastric varices as well as massive maroon-colored clots throughout the colon and terminal ileum but no signs of active bleeding. CT angiography (CTA) revealed hyperdense material within the gallbladder lumen and extrahepatic biliary ductal systems suspicious for hemobilia and acute hemorrhagic cholecystitis. Pt underwent capsule endoscopy revealing an irregular oozing of blood in the proximal small intestine. A push enteroscopy then revealed actively oozing blood from the ampulla of Vater (Figure). Patient subsequently underwent successful cholecystostomy tube placement and cystic artery embolization with resolution of his bleeding. Discussion: Hemorrhagic cholecystitis is an infrequent complication of cholecystitis with few published case reports. Due to the rarity of hemorrhagic cholecystitis causing brisk upper gastrointestinal bleeding with hematochezia, the cause of the bleeding was overlooked despite numerous endoscopies and not found until a capsule endoscopy was performed. This case teaches us to keep our differentials broad when the cause of the gastrointestinal bleeding is unclear. Prompt recognition can lead to earlier diagnosis and intervention to improve outcomes in this patient population.Figure 1.: Enteroscopy demonstrating bleeding at the Ampulla of Vater.

Predictive value of immature granulocyte and delta neutrophil index in the diagnosis of complicated acute cholecystitis.

The complicated gallbladder disorders are associated with increased mortality and morbidity. Thus, this study was aimed at evaluating the predictive value of immature granulocyte count and delta neutrophil index in the prediction of complicated cholecystitis. We retrospectively reviewed patients who underwent surgery for acute cholecystitis between January 2018 and April 2022. Overall, 351 patients fulfilling the inclusion criteria were included in the study. In all patients, demographic data, immature granulocyte count (IGC), delta neutrophil index (DNI), white blood cell (WBC) count, C-reactive protein (CRP), and albumin levels were recorded. Based on operative findings and histopathological examination, the patients were classified into 2 groups uncomplicated (group I) and complicated (e.g., perforation, gangrenous and emphysematous cholecystitis; group II) groups. The IBM SPSS version 26.0 (SPSS Corp, Armonk, NY, USA) was used to assess differences in blood parameters between groups. The predictive values of the parameters evaluated were estimated using ROC analysis. A p-value<0.05 was considered statistically significant. Acute complicated cholecystitis was found in 138 of 351 patients. No significant difference was detected in age and gender distribution between groups (p=0.352 and p=0.214, respectively). When blood parameters were assessed, it was found that IGC, DNI, WBC, and CAR values were significantly higher in group II (p<0.001; p<0.001, p<0.001, and p=0.036, respectively), while there was no significant difference in CRP and albumin between groups (p=0.099 and p=0.53, respectively). In the ROC analysis, the highest AUC value was found for IG count and DNI (0.784 and 0.775, respectively). The sensitivity and specificity were found as 68.8% and 86.9% for IG count and 49.3% and 96.2% for DNI, respectively. The IG count and DNI are two novel parameters with strong predictive value in the early diagnosis of acute complicated cholecystitis, which may support clinical findings, imaging studies, and other laboratory parameters.

EP-434 Is Cholecystostomy the correct temporising strategy for complicated cholecystitis and how should it be utilised to meet the NICE criteria for ‘early cholecystectomy’

Abstract Aims The incidence of undiagnosed gallstones is reported in up to 22% of females, with acute cholecystitis (AC) being a common emergency presentation. NICE guidance recommends index cholecystectomy for patients with proven gallstones. Emergency Laparoscopic Cholecystectomy (LC) in co-morbid patients carries a risk, with percutaneous cholecystostomy tube (PTC) insertion utilised as a temporising measure to relieve sepsis. Whilst effective at decompression, the long-term outcomes are unclear. Methods We retrospectively reviewed all patients undergoing emergency PTC between 2019 and 2021 in our hospital. Data collection included: demographics, ASA classification, Clavien-Dindo grades, cholecystostomy complications. Results A total 24 patients (12:12 male:female) underwent emergency PTC. Median age was 73 years (range 31–89) and median ASA grade of 3 (ASA 1 n=3, ASA 2 n=8, ASA 3 n=7, ASA 4 n=6). Median time from PTC insertion to LC was 20 weeks (range 6–73 weeks). Morbidity post PTC according to Clavien-Dindo grades were: 4 with grade 3 (16.7%), 5 with grade 4 (8.3%) and 5 with grade 5 (20.8%). 8 patients (33.3%) re-presented with further cholecystitis. 4 (16.7%) patients had completion LC, without complication. Conclusions Our findings highlight significant morbidity and mortality in this high-risk cohort secondary to complicated AC. 20 patients (83.3%) did not undergo a completion cholecystectomy, despite 18 being ASA 1–3. We suggest a judicious use of PTC and a greater focus on index multi-disciplinary surgical fitness assessment in order to optimise a patient for acute LC. This strategy is key to enable full adoption of AUGIS guidance for performing LC within 72 hours.

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study.

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m2 underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Single Ascending Dose Study of a Short Interfering RNA Targeting Lipoprotein(a) Production in Individuals With Elevated Plasma Lipoprotein(a) Levels

ImportanceLipoprotein(a) (Lp[a]) is an important risk factor for atherothrombotic cardiovascular disease and aortic stenosis, for which there are no treatments approved by regulatory authorities.ObjectivesTo assess adverse events and tolerability of a short interfering RNA (siRNA) designed to reduce hepatic production of apolipoprotein(a) and to assess associated changes in plasma concentrations of Lp(a) at different doses.Design, Setting, and ParticipantsA single ascending dose study of SLN360, an siRNA targeting apolipoprotein(a) synthesis conducted at 5 clinical research unit sites located in the US, United Kingdom, and Australia. The study enrolled adults with Lp(a) plasma concentrations of 150 nmol/L or greater at screening and no known clinically overt cardiovascular disease. Participants were enrolled between November 18, 2020, and July 21, 2021, with last follow-up on December 29, 2021.InterventionsParticipants were randomized to receive placebo (n = 8) or single doses of SLN360 at 30 mg (n = 6), 100 mg (n = 6), 300 mg (n = 6), or 600 mg (n = 6), administered subcutaneously.Main Outcomes and MeasuresThe primary outcome was evaluation of safety and tolerability. Secondary outcomes included change in plasma concentrations of Lp(a) to a maximum follow-up of 150 days.ResultsAmong 32 participants who were randomized and received the study intervention (mean age, 50 [SD, 13.5] years; 17 women [53%]), 32 (100%) completed the trial. One participant experienced 2 serious adverse event episodes: admission to the hospital for headache following SARS-CoV-2 vaccination and later for complications of cholecystitis, both of which were judged to be unrelated to study drug. Median baseline Lp(a) concentrations were as follows: placebo, 238 (IQR, 203-308) nmol/L; 30-mg SLN360, 171 (IQR, 142-219) nmol/L; 100-mg SLN360, 217 (IQR, 202-274) nmol/L; 300-mg SLN360, 285 (IQR, 195-338) nmol/L; and 600-mg SLN360, 231 (IQR, 179-276) nmol/L. Maximal median changes in Lp(a) were −20 (IQR, −61 to 3) nmol/L, −89 (IQR, −119 to −61) nmol/L, −185 (IQR, −226 to −163) nmol/L, −268 (IQR, −292 to −189) nmol/L, and −227 (IQR, −270 to −174) nmol/L, with maximal median percentage changes of −10% (IQR, −16% to 1%), −46% (IQR, −64% to −40%), −86% (IQR, −92% to −82%), −96% (IQR, −98% to −89%), and −98% (IQR, −98% to −97%), for the placebo group and the 30-mg, 100-mg, 300-mg, and 600-mg SLN360 groups, respectively. The duration of Lp(a) lowering was dose dependent, persisting for at least 150 days after administration.Conclusions and RelevanceIn this phase 1 study of 32 participants with elevated Lp(a) levels and no known cardiovascular disease, the siRNA SLN360 was well tolerated, and a dose-dependent lowering of plasma Lp(a) concentrations was observed. The findings support further study to determine the safety and efficacy of this siRNA.Trial RegistrationClinicalTrials.gov Identifier: NCT04606602; EudraCT Identifier: 2020-002471-35