Emergency Cholecystectomy Research Articles

Telemedicine and Access to Elective Cholecystectomy for Socially Vulnerable Adults

Socially vulnerable patients with symptomatic cholelithiasis are more likely to face barriers to accessing surgical care. This barrier to access can lead to delays in treatment, the need for emergent cholecystectomy, and worse outcomes. To determine the effectiveness of telemedicine vs in-person surgical consultation on access to elective cholecystectomy in socially vulnerable populations and to evaluate the association of scheduling navigation with access to elective cholecystectomy in these populations. This pilot randomized clinical trial conducted in a single academic center enrolled 60 adults from February 1, 2023, to February 21, 2024, with 3-month follow-up of clinical outcomes. Data were also collected retrospectively on a comparison group of 32 patients referred from June 30 to December 29, 2022. Adults with social vulnerability, such as being non-White or Hispanic or having nonprivate insurance or low income, with a diagnosis of symptomatic cholelithiasis and referral for outpatient surgical consultation were included. All trial participants were randomized to the telemedicine or in-person surgical consultation group, and received professional scheduling navigation. The latter intervention was compared with a historical cohort without navigation assistance. The primary outcome was completion of outpatient surgical consultation. Secondary outcomes included receipt of treatment and operative urgency. The trial enrolled 60 participants (30 per arm). Their mean (SD) age was 48.2 (18.2) years, 50 (83.3%) were female, 2 (3.3%) were Asian, 39 (65.0%) were Black, 8 (13.3%) were Hispanic, 11 (18.3%) were White, and 41 (68.3%) had no private insurance. The historical patient cohort included 32 participants (mean [SD] age, 45.9 [3.2] years; 27 [84.4%] female; 3 [9.4%] Asian, 15 [46.9%] Black, 10 [31.3%] Hispanic, and 6 [18.8%] White; and 18 [56.3%] without private insurance). In total, 18 trial participants assigned to telemedicine (60.0%) completed surgical consultations compared with 23 trial participants assigned to in-person visits (76.7%; P = .17). For telemedicine participants who underwent cholecystectomy, 3 of 7 (42.9%) underwent emergent cholecystectomy compared with 0 of 14 (0%) participants with in-person consultations (P = .03). Of 30 trial participants who received scheduling navigation, 23 (76.7%) completed surgical consultations compared with 15 of 32 patients in the historical cohort who did not receive scheduling navigation (46.9%; P = .02). Of 14 trial participants who received scheduling navigation and cholecystectomy, no participants underwent emergent cholecystectomy compared with 4 of 16 (25.0%) participants in the historical cohort without scheduling navigation (P = .04). In this pilot randomized clinical trial of socially vulnerable adults with symptomatic cholelithiasis, telemedicine consultation compared with in-person visits did not improve access to elective outpatient surgical care. However, scheduling navigation services may improve access to elective outpatient surgical care. Future large-scale studies are needed to identify possible barriers to virtual health care and mechanisms to address inequities. ClincialTrials.gov Identifier: NCT05745077.

ThP5.9 - Evaluation of cholecystectomy service in a general NHS hospital

Abstract Background Cholecystectomy is commonly performed for biliary pathologies, as elective, emergency, or at prioritised basis (Hot Gall bladder service). Aim Evaluating local performance of cholecystectomy, outcomes and areas for improvement. Results Over a 4-week period, 38 cholecystectomies were performed, all laparoscopically. Almost half had cholecystitis or cholangitis requiring at least 1 admission with 5 patients required more than 1 admission in 12 months prior to surgery. 50% of cholecystectomies were done in 6 months, while the longest waiting time was 13 months. 50% of procedures were done electively, whereas the rest in emergency and hot gall bladder lists. Indications included acute cholecystitis (13), biliary colic (11), chronic cholecystitis (6), biliary pancreatitis (4), GB polyps (3) and CBD stones (1). Only 2 had subtotal cholecystectomy, and Nassar operative difficulty was graded as one in 18, two in 15, three in 4 and four in 1 of the cases. Critical view of safety was obtained in 85% and biliary anatomy was unusual in 12 cases. Operative cholangiogram and CBD exploration were performed in 5 and 8 cases respectively. Complications included bile spillage (12/38), and bleeding (7/38). 30-day follow up showed 16 patients were discharged in 24 hours and only 3 readmitted. The incidence of complications was 37%, 11 cases had SSI and 3 had pulmonary complications). No bile leak or CBD injury. All specimens were sent for examination showing benign histology. Recommendation Emergency and hot cholecystectomy services not only cut down waiting lists but also reduce costs of reoccurring admissions, with no significant added complications. Selective gall bladder histological examination may reduce costs with no recognised risks.

ThP5.13 - Lessons learnt from a neuroendocrine tumour presenting as choledocholithiasis

Abstract A 79 year old male presented to A&E with obstructive jaundice. A computerised tomography (CT) scan of his abdomen and pelvis showed intra- and extra-hepatic duct dilation, a small calculus within the lumen of the common bile duct (CBD), and gallbladder distension. His liver function tests were deranged, with an alkaline phosphatase of 280IU/L. Successful stone retrieval was achieved by endoscopic retrograde cholangiopancreatography (ERCP), with an interim CBD stent inserted. Within the same admission, the patient underwent an uncomplicated emergency cholecystectomy. Histological analysis highlighted moderate chronic inflammation and fibromuscular hyperplasia, cholesterolosis, and ruled out dysplasia or malignancy. Four weeks later, the patient re-presented with septic obstructive jaundice. A repeat CT scan identified a dilated CBD of 2.2cm, suggesting an occluded stent. On ERCP for stent removal, ampulla narrowing was identified, hence concurrent brush cytology was performed. Due to clinical suspicion, a CT Positron emission tomography (PET) was requested, which identified metabolically active disseminated malignancy, likely pancreatic in origin, and with nodal, liver, and likely peritoneal metastases. A Ca 19-9 subsequently came back raised at 157 kIU/L. Liver biopsy confirmed a poorly differentiated neuroendocrine carcinoma (NEC) with intermediate features between small and large cell NEC. In such cases with discrepancies between treatment success and lack of biochemical improvement, a low threshold of suspicion for further investigation and oncological consideration is imperative.

ThP6.1 - Revisiting outcomes of laparoscopic cholecystectomy in an elderly population

Abstract Aims Laparoscopic cholecystectomy in the elderly patient is a challenging operation with variable outcomes. We evaluate the outcome of patients who underwent laparoscopic cholecystectomy in a hospital that serves a large ageing population. Methods Retrospective analysis of 53 patients over the age of 70 years who underwent cholecystectomy between January and December 2023. Outcomes were compared between elective vs emergency procedures, indications, age groups (70-74, 75-79, 80-84, 85+) and Charlson comorbidity index (CCI). Results The mean age was 77±4.9 years, and the mean CCI was 4±1. Of 53 procedures performed, 30.2% (n=16) were emergency and 69.8% (n=37) were elective. 6.3% (n=1) was converted to open. 11.3% (n=6) of patients underwent Rendezvous ERCP. Emergency patients had increased length of stay (LOS) (5.1±2.8 vs 1.6±4.1, p=0.04). The indication for surgery was noted to have a significant influence on LOS (p=0.003), however, age groups and CCI did not influence LOS. Non-biliary complications occurred in 13.2% (n=7) of patients. 7.5% (n=4) of patients had readmission within 30 days. 3.75% (n=2) had retained CBD stone and underwent postoperative ERCP. No significant differences between age groups in relation to complications were identified. Conclusions Emergency cholecystectomy in patients over the age of 70 is associated with a longer LOS. Rates of complications are not influenced by age or CCI. Laparoscopic Cholecystectomy can be safely offered to a diverse elderly population.

Surgical decision-making: key factors influencing the shift from laparoscopic to open cholecystectomy

Background: Recognizing the preoperatively and intraoperatively factors can aid surgeons in making timely decisions to shift from laparoscopic cholecystectomy (LC) to open cholecystectomy (OC). This study aims to identify the main factors leading to LC conversion to OC among Iraqi patients. Methods: One-year prospective research was performed using cross-sectional design between 1st April, 2023, and 3oth March, 2024, at Alkalis General Public Hospital and Al Hayat Private Hospital, Diyala, Iraq. Pre and intraoperative data were collected from the planned LC surgeries including demographics, medical history, laboratory and Ultrasound findings. Descriptive and bivariate analysis was carried out to compare variables between patients undergoing LC and those requiring conversion to OC. Results: Out of 172 LC patients (mean age 48.28±12.62), 52.9% were female, 55.8% obese, 50.6% aged 49+, 23.3% diabetic, and 19.8% had emergency cholecystectomy; 15 (8.7%) required conversion to open surgery. The conversion group was mainly men (66.7% vs. 46.5%, P = 0.001) and older (73.3% vs. 48.4% aged 49+, P = 0.003). Obesity (60.0% vs. 55.4%, P = 0.005) and diabetes (53.3% vs. 20.4%, P < 0.001) were more common. Public hospital referrals were higher (86.7% vs. 52.2%, P < 0.001). Elevated total bilirubin, direct bilirubin, and alkaline phosphatase levels were significant predictors of conversion to OC. Adhesions in Calot's triangle (20.0% vs. 13.4%, P = 0.021) were more common in the conversion group, along with unclear anatomy, thick gallbladder wall, bleeding, stone and bile spillage, and cystic duct injury. Conclusion: In conclusion, out of 172 LC patients, 15 (8.7%) required conversion to open surgery, predominantly older men with higher obesity, diabetes, and elevated bilirubin and alkaline phosphatase levels, and more adhesions in Calot's triangle.

Predictive Factors for the Development of Gallbladder Necrosis.

Introduction Acute cholecystitis is a common complication of gallstone disease. Likewise, gallbladder necrosis is a complication of cholecystitis associated with higher risks of morbidity and mortality. Identification of risk factors which portend to gallbladder necrosis is key in prioritizing the management of higher-risk patients. This study aimed to identify such factors that predict the development of gallbladder necrosis. Method A retrospective review of all patients undergoing emergency cholecystectomy in a tertiary hospital over a two-year period was performed. Gallbladder necrosis was diagnosed on histopathological examination of operative specimens. Multivariable logistic regression was performed to determine risk factors for gallbladder necrosis. Results A total of 163 patients underwent acute cholecystectomy and 43 (26%) had proven gallbladder necrosis. Multivariable analysis demonstrated that elevated white cell count (WCC) (OR 1.122, 95%CI 1.031-1.221, p=0.007), elevated C-reactive protein (CRP) (OR 1.004, 95%CI 1.001-1.008, p=0.022) and positive smoking status (OR 5.724, 95%CI 1.323-24.754, p=0.020) were independently predictive of gallbladder necrosis. Notably, advancing age, elevated BMI, diabetes mellitus or American Society of Anesthesiologists (ASA) grade were not found to be associated with developing necrosis. Conclusion Patients at risk of gallbladder necrosis include those with higher WCC, CRP, and active smokers. Given the increased potential complications, these risk factors should be identified early in the management of those admitted with gallstone disease to ensure such patients receive aggressive medical therapy alongside timely and guided surgical intervention.

Antibiotic prophylaxis in emergency cholecystectomy for mild to moderate acute cholecystitis: a systematic review and meta-analysis of randomized controlled trials

BackgroundEmergency cholecystectomy is the mainstay in treating acute cholecystitis (AC). In actual practice, perioperative prophylactic antibiotics are used to prevent postoperative infectious complications (PIC), but their effectiveness lacks evidence. We aim to investigate the efficacy of prophylactic antibiotics in emergency cholecystectomy.MethodsWe searched PubMed, Embase, Cochrane CENTRAL, Web of Science (WOS), and Scopus up to June 14, 2023. We included randomized controlled trials (RCTs) that involved patients diagnosed with mild to moderate AC according to Tokyo guidelines who were undergoing emergency cholecystectomy and were administered preoperative and/or postoperative antibiotics as an intervention group and compared to a placebo group. For dichotomous data, we applied the risk ratio (RR) and the 95% confidence interval (CI), while for continuous data, we used the mean difference (MD) and 95% CI.ResultsWe included seven RCTs encompassing a collective sample size of 1747 patients. Our analysis showed no significant differences regarding total PIC (RR = 0.84 with 95% CI (0.63, 1.12), P = 0.23), surgical site infection (RR = 0.79 with 95% CI (0.56, 1.12), P = 0.19), distant infections (RR = 1.01 with 95% CI (0.55, 1.88), P = 0.97), non-infectious complications (RR = 0.84 with 95% CI (0.64, 1.11), P = 0.22), mortality (RR = 0.34 with 95% CI (0.04, 3.23), P = 0.35), and readmission (RR = 0.69 with 95% CI (0.43, 1.11), P = 0.13).ConclusionPerioperative antibiotics in patients with mild to moderate acute cholecystitis did not show a significant reduction of postoperative infectious complications after emergency cholecystectomy. (PROSPERO registration number: CRD42023438755).

Management and patient outcomes following admission with acute cholecystitis in Ireland: A national registry-based study

IntroductionAcute cholecystitis is a common general surgical emergency, accounting for 3–10 % of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. There is a paucity of published data on the uptake of emergency cholecystectomy in Ireland. AimThe aim of this study was to evaluate the management of acute cholecystitis in Ireland and to establish the rate of emergency cholecystectomy performed. MethodsAll patients with acute cholecystitis 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, co-morbidities, length of stay, operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Propensity score matched analysis and logistic regression were performed to account for selection bias in comparing patients managed with cholecystectomy and those managed conservatively. Results20,886 admission episodes were identified involving 17,958 patients. 3585 (20 %) patients underwent emergency cholecystectomy in total. 3436 (96 %) of these were performed laparoscopically, with 140 (4 %) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1 %) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 v 60 years, p < 0.001) and more likely to be female (64 % v 55 % p < 0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced length of stay (LOS) (median 5 days (IQR 3–8) v 6 days (interquartile range (IQR) 3–10), p < 0.001) and fewer readmissions to hospital (282 (8 %) v 492 (14 %), p < 0.001). On logistic regression, age >65 (OR 1.526), CCI >3 (OR 2.281) and non-operative management (OR 1.136) were significant risk factors for adverse outcome. ConclusionUptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management, including shorter LOS and reduced readmission rates for matched cohorts.

Outcome of Emergency Cholecystectomy at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

&amp;lt;i&amp;gt;Background&amp;lt;/i&amp;gt;: Emergency cholecystectomy is the standard treatment for acute cholecystitis worldwide. However, in Ethiopia, it&amp;apos;s only performed in a limited number of healthcare facilities, despite its recognition as the preferred treatment by many physicians. To date, there is no study examining the prevalence and outcomes of emergency cholecystectomy in Ethiopia. In our setting, this practice is relatively new, and its outcomes remain unstudied. &amp;lt;i&amp;gt;Purpose&amp;lt;/i&amp;gt;: To assess the trends and outcome of emergency cholecystectomy at Yekatit 12 hospital medical college. &amp;lt;i&amp;gt;Method&amp;lt;/i&amp;gt;: We employed a longitudinal study design, encompassing all patients who underwent emergency cholecystectomy throughout the study period. Data entry and analysis were conducted using SPSS statistical software version 25. Qualitative variables were depicted in frequencies and percentages, while continuous variables were summarized with mean and standard deviation (SD). Binary logistic regression was applied to evaluate the impact of independent variables on the outcome variable. A significance level of p &amp;lt; 0.05 was taken for statistical significance. &amp;lt;i&amp;gt;Result&amp;lt;/i&amp;gt;: Between January 2022 and December 2023, 68 emergency cholecystectomies were performed. Females comprised 60.3% of the cases, with a mean age of 42.43 ± 14.03 years. Surgery for 44.1% of patients occurred between days 4 and 7 after symptom onset, while five patients underwent surgery after 10 days. The mean duration of surgery was 63.9 ± 17.14 minutes. Hospital stays ranged from 2 to 12 days, with a mean of 4.4 ± 2.47 days. Serum creatinine levels exceeding 1 mg/dl (p=0.004) were significantly linked to poor outcomes.

Reconsidering Routine Histopathological Examination of Gallbladder Specimens in Cholecystectomy: Optimizing Clinical Practice and Resource Management.

Introduction Cholecystectomy, the surgical removal of the gallbladder, is a common procedure worldwide. Despite no visible anomalies, routine histopathological examination (HPE) of gallbladder specimens post-surgery is standard practice to exclude pathologies, notably gallbladder cancer (GBC). Incidence rates of GBC vary geographically and ethnically. Surgical intervention is recommended for advanced GBC stages, while early stages may require cholecystectomy alone. Although rare, GBC and bile duct cancers pose increased risks in certain demographics, such as women and individuals over 65. Routine HPE practices vary globally based on resource availability and GBC incidence. This study assesses the necessity of routine HPE by evaluating the selective processing of gallbladder specimens suspected of GBC, prioritizing patient safety. Materials and methods This retrospective cohort study conducted at Redland Hospital, a district general hospital in Australia, investigated the necessity of routine HPEfor excised gallbladder specimens. Adhering to routine HPE policy, the study encompassed all elective and emergency cholecystectomies performed from January 2023 to December 2023, excluding pediatric cases, concurrent surgical procedures, and those with suspected malignancy. Demographic data, surgery indications, intraoperative findings, histopathological results, and incidental gallbladder cancer (IGC)outcomes were analyzed. Pathology reports and case documentation were reviewed for cancerous pathology indicators. Results Over the one-year study period from January 2023 to December 2023, a total of 266 gallbladder specimens were subjected to HPEpost-cholecystectomy. Of these, 201 were female and 65 were male, yielding a male-to-female ratio of 3:1. Elective cholecystectomy was performed on 56.4% (150) of patients, while 43.6% (116) underwent emergency procedures. Laparoscopic cholecystectomy (LC) was the primary surgical approach, except for one case requiring conversion to an open procedure. None of the patients exhibited GBC; however, 3.3% (9) displayed premalignant histopathological features in their specimens. Conclusion In conclusion, adopting a selective approach, where only gallbladder specimens with macroscopic abnormalities undergo HPE, seems prudent, especially in regions with low GBCincidence. Our study, which revealed no cases of GBC, supports this approach. It not only reduces the risk of missing incidental carcinoma in clinically unsuspected cases but also proves cost-effective and reduces the histopathology department workload without compromising patient outcomes. Therefore, we advocate for routine macroscopic examination of gallbladder specimens for abnormalities before HPE submission, particularly in cholecystectomy patients with gallstone disease.

Laparoscopic vs open approach for acute cholecystitis in octogenarians. A prospective multicenter observational nationwide study

BackgroundThe world population is aging, with octogenarians expected to reach over 400 million by 2050. Acute cholecystitis is a serious complication in the elderly. Age is not a contraindication for emergency cholecystectomy, an option that can both save lives and preserve quality of life. MethodsThe present study aimed to compare open and laparoscopic surgical approaches. Over six months, 38 emergency surgery units enrolled all consecutive octogenarians with acute cholecystitis undergoing cholecystectomy. Postoperative outcomes were compared after propensity score matching analysis. ResultsThe study included 212 patients (84 years [81–86], 47.2% women). The open approach was used in 32.1% of patients, and the laparoscopic approach in 67.9%. After propensity score matching, a decrease in hospital stays (open, 8 days [6–13]; laparoscopic, 5 days [4–8]; P < .001), 30-day morbidity (open, 48.5%; laparoscopic, 26.5%; P = .01), and 30-day mortality (open, 13.2%, laparoscopic, 1.5%; P = .02) was found. Among the specific postoperative complications, a decrease in septicemia (open, 14.7%; laparoscopic, 0%; P = .001) was observed. ConclusionsLaparoscopic approach was used in two out of three octogenarians. After propensity score matching, octogenarians undergoing laparoscopic approach had shorter length of hospital stay, fewer 30-day postoperative complications, fewer episodes of septicemia, and less 30-day mortality than octogenarians undergoing open approach. These findings suggest that the laparoscopic approach may be the preferred choice for octogenarians with acute cholecystitis undergoing cholecystectomy.

Robotic assisted common bile duct exploration for management of complex gallstone disease.

Minimally invasive cholecystectomy and common bile duct exploration offers single- stage management for complex gallstone disease (cholelithiasis and choledocholithiasis). Robotic platform presents benefits in improving operative precision, which has not been extensively evaluated in the acute setting of managing complex gallstone disease, as well as in performing transcholedochal or post cholecystectomy common bile duct exploration. We report an early series of emergent and expedited robotic assisted cholecystectomy with common bile duct exploration (RC-CBDE) or robotic common bile duct exploration (R-CBDE) alone. Retrospective analysis from a specialist unit in the United Kingdom was undertaken from April 2022-September 2023 inclusive. All patients that underwent RC-CBDE or R-CBDE were included. Data was collated on patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Twenty-three consecutive patients were identified. Median (IQR) age was 51 (33-66) years. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0-4). Five patients underwent operative intervention as an emergency and 18 on an expedited basis. Two patients underwent post cholecystectomy R-CBDE. Fourteen (61%) were transcholedochal and nine were transcystic (31%) CBDE. Median (IQR) bilirubin was 51 (34-253). Median (IQR) operative time was 176 (124-222) minutes. Median (IQR) post-operative length of stay was 2 (0-4) days. There were no bile leaks requiring intervention. The clearance rate of CBDS was 100%. No patients developed postoperative pancreatitis. One patient required intervention for port site hernia following RC-CBDE. One patient developed subhepatic collection post-operatively and required laparoscopic washout and placement of drains. No patients had retained stones after 3-month follow-up. Early experience confirms that RC-CBDE and R-CBDE in feasible, safe, and effective treatment for complex gallstone disease. Integrated adjuncts (intraoperative robotic ultrasound - IORUS and Firefly® - fluorescence guided surgery - FGS) and superior ergonomics of the robotic platform may assist in reducing the learning curve and increase wider uptake of this complex procedure.

Severe cholecystitis during the COVID-19 pandemic : Influence of the COVID-19 pandemic on the frequency of surgery and outcome for elective and emergency cholecystectomy: a monocentric retrospective cohort analysis

With the outbreak of the COVID-19 pandemic medical care focused on management of the infectious event. Elective interventions were cancelled and the general advice was to stay at home. How this impacted urgent and elective cholecystectomies is the subject of this work. Urgent and elective cholecystectomy patients during the first year of the pandemic were compared with those of the previous year. The primary endpoint was the frequency of surgery. Furthermore, the American Society of Anesthesiologists (ASA) score, symptom duration until presentation as well as until surgery, preoperative inflammatory parameters, imaging, positive Murphy's sign, type and duration of surgery, intraoperative drain placement, intraoperative and histological severity, need for and duration of postoperative antibiotic therapy, intensive care stay, length of stay and occurrence of postoperative complications were recorded. During the pandemic patients were sicker (ASA2.13 vs. 2.31; p = 0.039), the operating time was prolonged (64.4 min vs. 74.9 min; p = 0.001) and patients were more likely to have concomitant peritonitis (15.4% vs. 29.1%: p = 0.007). Furthermore, there was atrend in the presence of leukocytosis, apositive Murphy's sign, intraoperative drain placement, intraoperative severity of inflammation, duration of postoperative antibiotic therapy and complication rate. During the COVID-19 pandemic cholecystitis presented with more pronounced inflammation, the surgical conditions were more difficult and postoperative recovery was prolonged.

Percutaneous cholecystostomy in acute cholecystitis – Narrative review article

Percutaneous cholecystostomy is often performed to treat high-risk patients with acute cholecystitis who are not suitable for cholecystectomy. It is performed by the interventional radiologist and can be performed through the transhepatic or transperitoneal route (direct gallbladder puncture, without passing through the liver). Percutaneous cholecystostomy is used as a bridging procedure to stabilize high-risk patients with acute cholecystitis. We prepared this narrative review article to describe the indications for performing this procedure and the consequences of its performance and to compare it with emergency cholecystectomy.

INDURG TRIAL Protocol: A Randomized Controlled Trial Using Indocyanine Green during Cholecystectomy in Acute Cholecystitis

Introduction: Laparoscopic cholecystectomy is one of the most common gastrointestinal surgeries, and bile duct injury is one of its main complications. The use of real-time indocyanine green fluorescence cholangiography allows the identification of extrahepatic biliary structures, facilitating the procedure and reducing the risk of bile duct lesions. A better visualization of the bile duct may help to reduce the need for conversion to open surgery, and may also shorten operating time. The main objective of this study was to determine whether the use of indocyanine green is associated with a reduction in operating time in emergency cholecystectomies. Secondary outcomes are the postoperative hospital stay, the correct intraoperative visualization of the Calot’s Triangle structures with the administration of indocyanine green, and the intraoperative complications, postoperative complications and morbidity according to the Clavien-Dindo classification. Methods: This is a randomized, prospective, controlled, multicenter trial with patients diagnosed with acute cholecystitis requiring emergency cholecystectomy. The control group will comprise 220 patients undergoing emergency laparoscopic cholecystectomy applying the standard technique. The intervention group will comprise 220 patients also undergoing emergency laparoscopic cholecystectomy for acute cholecystitis with prior administration of indocyanine green. Conclusion: Due to the lack of published studies on ICG in emergency laparoscopic cholecystectomy, this study may help to establish procedures for its use in the emergency setting.

Endoscopic transpapillary gallbladder stenting for acute cholecystitis

Background Cholecystectomy is the treatment of choice for acute cholecystitis. However, the mortality rate of emergency cholecystectomy in high-risk patients with severe comorbidities remains unsatisfactory. Endoscopic transpapillary gallbladder stenting (ETGBS) has emerged as a useful interventional endoscopic technique for the management of acute cholecystitis. Aim The purpose of this research was to assess the safety and effectiveness of ETGBS in the treatment of acute cholecystitis in elderly individuals who were not good candidates for surgery. Patients and methods We studied 35 elderly patients, 60 years of age or older, receiving treatment at Aswan University Hospital’s surgery department for acute cholecystitis. Every patient had ETGBS, involving the insertion of a 7-Fr stent into the gallbladder. If ETGBS was unsuccessful, percutaneous transhepatic gallbladder draining was carried out. The effectiveness of ETGBS was the primary outcome measure in this investigation. Results ETGBS was successful in 30 (85%) individuals with acute cholecystitis. 8.57% (3/35) of the cases had early adverse events (AEs). Three patients had endoscopic sphincterotomy hemorrhage, one had minor pancreatitis, and one patient experienced obstructive jaundice as early AEs. There were 8.57% (3/35) late AEs. Late AEs included cholangitis in one patient and cholecystitis recurrence in two others. Percutaneous transhepatic gallbladder drainage was used for the five individuals in whom ETGBS failed. Conclusion ETGBS appears to be a successful treatment for elderly patients with acute cholecystitis who are unsuitable for surgery.

Never Too Late to Go Home: Declining Same-Day Discharge Rates Throughout the Day After Emergent Laparoscopic Cholecystectomy.

Never Too Late to Go Home: Declining Same-Day Discharge Rates Throughout the Day After Emergent Laparoscopic Cholecystectomy.

Optimizing the consent process for emergent laparoscopic cholecystectomy using an interactive digital education platform: a randomized control trial.

Informed consent is essential for any surgery. The use of digital education platforms (DEPs) can enhance patient understanding of the consent discussion and is a method to standardize the consent process in elective, ambulatory settings. The use of DEP as an adjunct to standard verbal consent (SVC) has not been studied in an acute care setting. We conducted a prospective randomized control trial with patients presenting to the emergency department of a tertiary care hospital with acute biliary pathology requiring a laparoscopic cholecystectomy (LC) between August 2021 and April 2023. Participants were randomized 1:1 to receive either a DEP module with SVC or SVC alone. Baseline procedure-specific knowledge and self-reported understanding of risks and benefits of LC were collected using a questionnaire. Primary outcome was immediate post-intervention knowledge assessed using a 21-question multiple choice questionnaire. Secondary outcomes were delayed procedure-specific knowledge and participants' satisfaction with the consent discussion. We recruited 79 participants and randomized them 1:1 into the intervention group (DEP + SVC, n = 40) and the control group (SVC, n = 39). Baseline demographics and baseline procedure-specific knowledge were similar between groups. The immediate post-intervention knowledge was significantly higher for participants in the intervention versus the control group with a Cohen's d effect size of 0.68 (85.2(10.6)% vs. 78.2(9.9)%; p = 0.004). Similarly, self-reported understanding of risks and benefits of LC was significantly greater for participants in the intervention versus the control group with a Cohen's effect size of 0.76 (68.5(16.4)% vs. 55.1(18.8)%; p = 0.001). For participants who completed the delayed post-intervention assessment (n = 29), there continued to be significantly higher retention of acquired knowledge in the intervention group with a Cohen's effect size of 0.61 (86.5(8.5)% vs. 79.8 (13.1)%; p = 0.024). There was no difference in participants' self-reported satisfaction with the consent discussion between groups (69.5(6.7)% vs. 67.2(7.7)%; p = 0.149). The addition of digital education platform to standard verbal consent significantly improves patient's early and delayed understanding of risks and benefits of LC in an acute care setting.

O196: Gallbladder Necrosis: Predictive Factors in Patients Undergoing Emergent Cholecystectomy

Abstract Introduction Gallstones are present in up to 25% of the general population and approximately 2% of these become symptomatic. Gallbladder necrosis is a complication of gallstones associated with higher risks of morbidity and mortality. Identification of risk factors which portend to gallbladder necrosis is key in prioritising investigation and treatment for higher risk patients. Method A retrospective review of all patients undergoing emergency cholecystectomy in a tertiary hospital over a 2-year period was performed. Gallbladder necrosis was diagnosed on histopathological examination of operative specimens. Multivariable logistic regression was performed to determine risk factors for gallbladder necrosis. Results 152 patients underwent acute cholecystectomy and 44 (29%) had proven gallbladder necrosis. Multivariable model demonstrated that white cell count (WCC) (OR 1.122, 95% CI 1.031-1.221, p=0.007), C-reactive protein (CRP) (OR 1.004, 95% CI 1.001-1.008, p=0.022) and smoking status (OR 5.724, 95% CI 1.323-24.754, p=0.020) were independently predictive of gallbladder necrosis. Notably, advancing age, elevated BMI, diabetes mellitus or ASA grade were not found to be associated with developing necrosis. Conclusion Patients at risk of gallbladder necrosis include those with higher WCC, CRP and active smokers. Given the increased potential complications, these risk factors should be identified early in the management of those admitted with gallstone disease to ensure such patients receive aggressive medical therapy alongside timely and guided surgical intervention.

Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series

Background and study aimThe development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective.Patients and methodsThe investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023.ResultsA complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred.ConclusionThis procedure has proven to be feasible, safe, and effective.