Gallstone-related Complications Research Articles

ThP5.15 - "Unusual Impaction: A Rare Case of Gallstone Ileus''

Abstract Introduction Gallstone-related mechanical gastrointestinal tract obstruction is infrequent, manifesting in only 0.3%-0.5% of cholelithiasis cases. Typically, stones exceeding 2 cm find themselves lodged in the terminal ileum. However, in Bouveret's syndrome which is observed in 1 to 3% of instances the impaction occurs in the duodenum causing gastric outlet obstruction. The epidemiology and prevalence of gallstone impaction in the proximal jejunum remain inadequately documented, making this a rare case. Case Report An 83-year-old patient with known cholelithiasis and choledocholithiasis presented with acute abdominal pain and vomiting a week after undergoing ERCP, sphincterotomy and partial duct clearance. The presence of repeated bilious vomiting prompted investigation with abdominal CT scan. This revealed an approximately 4.5 cm gallstone impacted in the proximal jejunum, prompting emergency laparotomy which confirmed that the stone was impacted 10-15 cm from the dudeno-jejunal junction. Jejunotomy, stone extraction with primary closure was performed. Post-operative recovery was uneventful. Conclusion This case demonstrates gallstone impaction in the proximal jejunum causing bowel obstruction and necessitating emergency intervention. Timely diagnosis and prompt surgical intervention led to a successful outcome. The case highlights the need for awareness and consideration of the entire spectrum of possible gallstone-related complications in the acutely presenting patient with gall stones.

435 Post ERCP Pancreatitis at a Tertiary Centre - a Retrospective Incidence and Causal Analysis

Abstract Background Post Endoscopic Retrograde Cholangio Pancreatography (ERCP) pancreatitis (PEP) is a serious and potentially life-threatening complication of ERCP. The overall incidence of PEP varies between 3.5% and 9.7% as per the recent meta-analyses in 2014. We aim to evaluate the incidence of PEP, conduct a causal analysis and financial implications at our hospital for general surgical patients. Method All General Surgical patients who had ERCP done between 01/10/2022 and 31/03/2023 were included in the analysis. The patient records on TrakCare® were analysed for demographic details, admission records, ERCP details, pre-procedural laboratory values and length of stay. The successful ERCPs defined as cannulation of the common bile duct were divided into the PEP and the non-PEP groups. Results A total of 155 patients had ERCP attempted but only 131 were successful. Of these 131, 13 (9.92%) developed PEP. Females in their 60s were predominantly affected. Three out of six patients undergoing ERCP for malignant biliary obstructions were affected (50%). Patients with grossly deranged Liver Function Tests (mean bilirubin levels >=134.92µmol/L) had a higher risk of developing PEP (p-value=0.021). The mean overall hospital stay was 3.5 days longer (2-49 days) for patients who developed PEP costing an extra £20,475 - £35,763 over 6 months to the NHS. There were no mortalities recorded. Conclusions Patients with gallstone disease should receive prompt cholecystectomy adhering to NICE guidelines to reduce the risk of developing gallstone-related complications. This in turn would lead to a reduction in PEP and positively affect the financial implications for the NHS.

Symptomatic uncomplicated gallstone disease is associated with a high short-term risk of gallstone-related complications: a contemporary cohort study

Background The natural history of symptomatic uncomplicated gallstone disease is largely unknown. We examined the risk of progressing from symptomatic uncomplicated to complicated gallstone disease in a large regional cohort of patients, where disruptions in elective surgical capacities have led to the indefinite postponement of surgery for benign conditions, including cholecystectomies. Methods Patients with radiologically diagnosed incident symptomatic and uncomplicated gallstone disease were identified from outpatient clinics and emergency departments on the Island of Funen, Denmark. The absolute risk of complications (cholecystitis, cholangitis, pancreatitis, acute cholecystectomy for unremitting pain) was calculated using death and elective cholecystectomies as competing risks using the Aalen-Johansen method. Cox proportional hazards regression analysis was used to estimate hazard ratios (HRs) of gallstone complications associated with patient and gallstone characteristics. Results Two hundred eighty-six patients diagnosed with incident symptomatic, uncomplicated gallstone disease from 1 January 2020 to 1 July 2023 were identified. During 79,170 person-years of observation, 176 (61.5%) patients developed a gallstone-related complication. The 6-, 12- and 24-month risk of developing gallstone-related complications were 36%, 55% and 81%. The risk of developing complications related to common bile duct stones was lowest with larger stones (aHR per millimeter increase = 0.89 (0.82–0.97), p < 0.01), while no covariates were statistically significantly associated with the risk of cholecystitis. Eighty-five (30%) patients underwent elective laparoscopic cholecystectomy, with one patient (1.2%) developing a gallstone-related complication afterward. Conclusions The risk of developing complications to symptomatic gallstones in a general Scandinavian population is high, and prophylactic cholecystectomy should be considered.

The Multifaceted Impact of Gallstones: Understanding Complications and Management Strategies.

Gallstones, or cholelithiasis, represent a prevalent gastrointestinal disorder characterized by the formation of calculi within the gallbladder. This review aims to provide a comprehensive analysis of the complications associated with gallstones, with a focus on their pathophysiology, clinical manifestations, diagnostic methodologies, and management strategies. Gallstone-related complications encompass a broad spectrum, including biliary colic, acute cholecystitis, choledocholithiasis, acute pancreatitis, and cholangitis. The pathogenesis of these complications primarily involves biliary obstruction and subsequent infection, leading to significant morbidity and potential mortality. Diagnostic evaluation of gallstone complications employs various imaging techniques, such as ultrasonography, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP), each with distinct advantages and limitations. Therapeutic approaches are discussed, ranging from conservative management with pharmacotherapy and bile acid dissolution agents to interventional procedures like extracorporeal shock wave lithotripsy (ESWL) and percutaneous cholecystostomy. Surgical management, particularly laparoscopic cholecystectomy, remains the gold standard for definitive treatment. Additionally, advancements in endoscopic techniques, including endoscopic sphincterotomy(EST) and cholangioscopy, are highlighted. This review synthesizes current research findings and clinical guidelines, aiming to enhance the understanding and management of gallstone-related complications among healthcare professionals, thereby improving patient outcomes and reducing the burden of this common ailment.

Simultaneous cholecystectomy for asymptomatic gallstones during elective colorectal cancer surgery

Asymptomatic gallstones are commonly detected using preoperative imaging in patients with colorectal cancer (CRC), but its management remains a topic of debate. Clinicopathologic characteristics of patients who had asymptomatic gallstones presenting during the colorectal procedure were retrospectively reviewed. Medical records, including postoperative morbidity, mortality, and long-term gallstone-related diseases, were assessed. Of 134 patients with CRC having asymptomatic gallstones, 89 underwent elective colorectal surgery only (observation group), and 45 underwent elective colorectal surgery with simultaneous cholecystectomy (cholecystectomy group). After propensity score matching (PSM), the complications were similar in the 2 groups. During the follow-up period, biliary complications were noted in 11 patients (12.4%) in the observation group within 2 years after the initial CRC surgery, but no case was found in the cholecystectomy group. After PSM, the incidence of long-term biliary complications remained significantly higher in the observation group than in the cholecystectomy group (26.5% vs 0.0%; P<.01). Multivariable logistic regression analysis identified female gender, old age (≥65 years old), and small multiple gallstones as independent risk factors for the development of long-term gallstone-related diseases in patients from the observation group. Simultaneous prophylactic cholecystectomy during prepared, elective CRC surgery did not increase postoperative morbidity or mortality but decreased the risk of subsequent gallstone-related complications. Hence, simultaneous cholecystectomy might be a preferred therapeutic option for patients with CRC having asymptomatic gallstones in cases of elective surgery, especially for older patients (≥65 years old), female patients, and those with small multiple calculi.

Subtotal cholecystectomy; A substandard bail-out technique?

Introduction: While the open approach was previously mandated as the salvage procedure in difficult cholecystectomies, subtotal cholecystectomy has since been implemented. While this technique may prevent biliary duct injury intraoperatively, it comes with major pitfalls. Case Series: We present a series of four cases where a subtotal cholecystectomy was previously performed, in which further gallstone-related complications occurred. Conclusion: We aim to increase awareness toward recurrent symptoms that may require further evaluation and repeat procedures in patients with previous cholecystectomy; and drawbacks relating to performing subtotal cholecystectomies—opting instead for open cholecystectomy, recruitment of another senior or specialist hepatobiliary surgeon and/or transfer to a tertiary center with the appropriate facilities.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond.

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

HPB P56 Service Evaluation of Hot Gall bladder Pathway

Abstract Background Management of acute cholecystitis has traditionally been conservative. Initially patients are treated with antibiotics posted for LC after 4-6 weeks.Surgery during acute settings was previously avoided due to fear of injuring surrounding structures. NICE guidelines published in October 2014 now advises that patients presenting with acute cholecystitis should have LC within a week which has been proven to be safe and effective. With respect to acute pancreatitis the standard of care should be lap chole during index admission for all non-severe cases. The purpose of this study is to evaluate the management of patients admitted with acute gall stone diseases. Methods It was a retrospective study of all the patients admitted with acute gall stone diseases and compare the outcomes after introduction of Hot Gall Bladder Pathway. We screened a total of 245 patients who had been included in this study between October 2018 to March 2020 with two groups: Data were collected form EZ Notes,IT Systems,Databases,Observations and Paper Records. Results Acute cholecystitis with no associated organ dysfunction who underwent Laparoscopic Cholecystectomy within week of diagnosis in the pre Hot GB List period was 43%(31/74) wheras in the Post Hot GB List period was 81% (93/116). Mild Acute Biliary Pancreatitis who underwent LC within index admission was 30% (5/17) in the preHot GB List Period wheras 78%(14/19) of patients with gall stone pancreatitis under went LC during the same admission after the beginning of Hot GB lists. Conclusions We had achieved almost 81% of the expected outcome in surgically dealing with patients presenting with acute cholecystitis and 78% with patients presenting with gall stone pancreatitis after introduction of Hot Gall bladder pathway. Safe and cost-effective hot gall bladder service can be provided by the EGS with input from upper GI surgeons with acceptable morbidity and a satisfactory outcome. Hot gall bladder pathway has proven to be effective in treatment of GS related diseases without significant increase in complication rate. It also helps avoiding readmissions, Gall stone related complications, reduces bed occupancy and improves patients’ quality of life.

Same-admission versus interval cholecystectomy for mild gallstone pancreatitis in pediatric patients

BackgroundThe timing of cholecystectomy for patients with gallstone pancreatitis has been a subject of debate in the past. Data in children are scarce and pediatric guidelines for the management of pancreatitis are mainly based on adult recommendations. The aim of this study was to evaluate the impact of the timing of cholecystectomy on the recurrences of gallstone-related complications and surgery-related complication rates in patients with mild gallstone pancreatitis. MethodsWe conducted a retrospective study on patients with mild gallstone pancreatitis who underwent laparoscopic cholecystectomy between March 2013 and October 2022. Patients were divided into two groups: same-admission cholecystectomy (SAC) and interval cholecystectomy (IC). The primary endpoint was a composite of gallstone-related complications (readmissions before or after cholecystectomy due to recurrent gallstone pancreatitis, choledocholithiasis needing endoscopic retrograde cholangiopancreatography [ERCP] and right upper quadrant [RUQ] pain). Secondary endpoints were total recurrent gallstone pancreatitis events (including those that occurred during the same admission); total number of RUQ pain episodes (regardless of the need for re-hospitalization); residual choledocholithiasis needing postoperative ERCP; cholecystectomy-related difficulties/complications (conversion to open surgery, common bile duct injury, or bleeding), operating time, postoperative length of stay (LOS) and total LOS. ResultsEighty-five patients were included in the analysis. Of these, 47 (55.3 %) had SAC and 38 (44.7 %) interval surgery. Readmissions for gallstone-related complications occurred in 18 (47.4 %) patients in the IC group, compared to 2 (4.3 %) in the SAC group (p = 0.0001). Same-admission cholecystectomy provides a relative risk reduction of readmission of 90.9 %. The incidence of total recurrent gallstone pancreatitis events was higher in the IC group (p = 0.008). Patients in the SAC group had a longer operating time (p = 0.019). There were no differences in the rates of choledocholithiasis needing postoperative ERCP, total number of RUQ pain episodes and total LOS. There were no cholecystectomy-related difficulties/complications in either group. ConclusionIn pediatric patients with mild gallstone pancreatitis, SAC is safe and reduces the risk of readmissions and recurrent gallstone-related complications, compared to IC.

1019 Timing of Laparoscopic Cholecystectomy in Patients with Acute Cholecystitis at a District General Hospital

Abstract Aim Early laparoscopic cholecystectomy (LC) is recommended in the treatment of acute cholecystitis (AC) as a balance between reducing gallstone-related complications and surgery-related complications. NICE guidelines recommend LC within a week of diagnosis for adults with AC or to be delayed once acute episode has subsided at least 4 weeks after diagnosis. This audit aimed to assess our Trust's compliance to these recommendations. Method A retrospective analysis was conducted on all patients who received cholecystectomy following a diagnosis of acute cholecystitis between June 2021 - July 2021. After implementation, a re-audit was conducted from May 2022 - July 2022. Results A 100% compliance rate was achieved in the first cycle of the audit. Out of the 35 patient sample of newly diagnosed AC, only 16 patients underwent surgery in 2021. Out of these 16 patients, 81.3% had LC within a week and 18.7% had the procedure performed after 4 weeks. The re-audit, with a sample size of 52 patients, had an overall compliance of 96.8%. Out of the 31 patients who had surgery, 71% had surgery within a week of diagnosis and 25.8% had surgery after 4 weeks of diagnosis. Only 1 patient (3.2%) had surgery outside of the recommended timeframe as the surgery took place 9 days from diagnosis. Conclusions This audit demonstrated that our Trust has very good compliance with the guidelines where &amp;gt;95% of patients received their surgery within the recommended time frame. Our Trust demonstrated high rates of LC during acute admission, which aims to improve long waiting lists for elective LC.

The Short- and Long-Term Safety and Efficacy Profile of Subtotal Cholecystectomy: A Single-Centre, Long-Term, Follow-Up Study.

Background Subtotal cholecystectomy (STC) has been reported as an effective method to remove the gallbladder if the hepatocystic triangle anatomy is unfavourable. However, the evidence regarding its long-term outcomes from the United Kingdom (UK) is lacking. This study aimed to assess its short and long-term outcomes with a minimum of one-year follow-up. Methodology We retrospectively analysed all elective and emergency STCs performed in a single UK NHS Trust between 2014 and 2020. Relevant data were collected using electronic patient records and questionnaire-based, long-term, telephonic follow-up (median follow-up of 3.7 years). Outcomes examined were immediate/short-term complications (biliary injury, bile leak, return-to-theatre) and long-term problems (recurrent symptoms, choledocholithiasis, cholangitis/pancreatitis). Results There were a total of 50 STC cases (58% females) out of 4,341 cholecystectomies performed (1.15%), with the median age, body mass index, and length of stay being 69.5 years, 29 kg/m2 and eight days, respectively. Twenty-eight (56%) were emergency. No patient endured bile duct injury. Seven (14%) patients had postoperative bile leak which was significantly more common when Hartmann's pouch was left open (33% vs. 8%; p = 0.03). No bile duct injury was reported. Most were managed conservatively (endoscopic retrograde cholangiopancreatography + stent: four; radiological drainage: one; no intervention: one). Only one patient required laparoscopic lavage and drainage. The true incidence of developing choledocholithiasis over the long term was 4/50 (8%) in our study. The median interval between STC and the diagnosis of postoperative choledocholithiasis was 15.9 months. All four patients had undergone type 1 STC (where the remnant of Hartmann's pouch was closed with sutures); however, subsequent cross-sectional imaging (magnetic resonance cholangiopancreatography or computed tomography) showed that the gallbladder remnant was visible in only two of these four patients. Conclusions STC is a safe option in difficult situations and prevents bile duct injury. Although the risk of bile leak can be reduced by closing Hartmann's pouch remnant, this may slightly increase the risk of subsequent stone formation. Infrequent occurrence of recurrent gallstone-related symptoms or complications favours its use.

Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations.

About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.

Gallstone-related complications and evidence base treatments. A scoop review

The incidence of gallstones is 10-15%, making it one of the most common causes of surgical admissions. The number of admissions and operations for gallstone disease is increasing. Commonly gallstones are formed in the gallbladder but can also develop in the biliary tree. Commonly, gallstones are made of cholesterol. Even though the exact cause of supersaturation of bile is not known, there are multiple associate factors for gallstone formation. Most patients with gallstones never experience any symptoms, but the risk of presenting with complications related to gallstones is 1%-4% a year. Patients with gallstones can present with pain or other more severe complications that demand surgical treatment and follow-up. This article looks into epidemiology, basic pathophysiology, complications, pregnancy and gallstones, diagnosis and recent evidence base treatment of gallstone disease.

To study the low-pressure pneumoperitoneum laparoscopic cholecystectomy

Aim: The aim of this study to determine the low-pressure pneumoperitoneum laparoscopic cholecystectomy.Materials and methods: This research comprised a total of 80 patients who were hospitalised for elective laparoscopic cholecystectomy. patients undergoing open cholecystectomy after conversion. The research did not include patients with acute inflammation or any other choledocholithiasis or gallstone-related complications. Every patient was asked for written informed permission after being told about the research.Results: The most prevalent presenting symptom (85%) was pain in the right upper quadrant. All of the patients had cholelithiasis confirmed by ultrasonography but no symptoms of inflammation. The majority of the patients (80%) had numerous gallbladder stones. The gallbladder was normal in 40 instances (50%), distended in 24 cases (30%), and constricted in 16 cases (20%) intraoperatively, cholesterosis was present in 10 cases (12.5%), and biliary sludge was found in 16 cases (20%). There were no severe intraoperative complications. There was no conversion to normal pressure laparoscopic cholecystectomy or open cholecystectomy. The average surgical time was 35.85±5.85 minutes. The visual analogue scale pain ratings for postoperative shoulder tip pain were 4.5±0.33, 2.4±0.12, and 0.22±0.04, respectively, at 5, 10, and 24 hours. In 91.25% of the patients, oral feeds were begun on the first postoperative day. On the 0th postoperative day, 95% of the patients were ambulating. The average length of stay after surgery was 1.2±0.51 days. On average 6 months of follow-up, no serious problems were notedConclusion: Experienced surgeons may safely use low-pressure pneumoperitoneum to perform laparoscopic cholecystectomy with a lower risk of early postoperative problems, such as shoulder tip discomfort. Only the lengthier learning curve holds it back from being optimal for general usage; in certain circumstances, its reduced intraoperative impact on hemodynamics makes it a worthwhile alternative.

CLINICAL AND EPIDEMIOLOGICAL EVALUATION OF COMPLICATIONS ASSOCIATED WITH GALLSTONES IN A TERTIARY HOSPITAL.

Gallstones are the presence of bile clay in the gallbladder or bile ducts. The disease can be asymptomatic or symptomatic and can lead to complications and consequently a worse prognosis, such as acute cholecystitis, choledocholithiasis, cholangitis, and acute pancreatitis. The risk of complications increases after the first episode of biliary colic. A clinical-epidemiological evaluation of patients admitted to a gastroenterology ward of a tertiary care hospital with gallstone-related complications. We evaluated 158 patients admitted through discharge reports and medical records analysis from January 1, 2013, to February 24, 2021. The female sex was predominant (76.6%), and the mean age of patients was 51.6 years. Men were significantly older than women (P=0.005). Most (57.6%) had some comorbidity, the most frequent being systemic arterial hypertension, diabetes mellitus, and obesity. The mean hospitalization time was 24 days, significantly longer in men (P=0.046) but without a direct relationship with age (P=0.414). The most frequent complication was choledocholithiasis, and 55.7% of patients without previous cholecystectomy had a report of biliary colic before admission, on average 1.5 years previously. A history of a prior cholecystectomy was present in 17.1% of those evaluated. Abdominal ultrasonography followed by magnetic resonance cholangiography was the most frequently performed exam for diagnostic definition. Regarding therapeutic measures, endoscopic retrograde cholangiopancreatography was necessary for 47.3% of patients without previous cholecystectomy and 81.4% of patients who have already had a cholecystectomy. Among patients not yet cholecystectomized, 84% underwent the procedure before discharge. The female patients were predominant. Men were significantly older than women and had more extended hospital stays. The most frequent complication was choledocholithiasis, and around half of the patients reported previous biliary colic. endoscopic retrograde cholangiopancreatography has been necessary for the majority of the patients.

EP-617 Early vs delayed laparoscopic cholecystectomy for acute cholecystitis: A systemic review

Abstract Background Gallstones are present in approximately 10% to 15% of the adult western population with 1% to 4% of patients becoming symptomatic each year. Laparoscopic cholecystectomy for acute cholecystitis is usually performed after the acute cholecystitis episode settles because of the perceived fear of higher morbidity and of need for conversion from laparoscopic to open cholecystectomy. However, delaying surgery may expose the individual to gallstone-related complications. Aims &amp; objectives To compare early laparoscopic cholecystectomy, defined as less than seven days of clinical presentation with acute cholecystitis, versus delayed laparoscopic cholecystectomy more than six weeks after index admission and conservative treatment for acute cholecystitis. Search Criteria Clinical databases were searched for suitable studies. Randomised and non-randomised clinical trials comparing early versus delayed laparoscopic cholecystectomy in participants with acute cholecystitis published after 1994 were included. Results 16 studies were identified for this review and the outcomes measured were operation time, conversion to open surgery, postoperative complication, post operative pain and analgesia use, length of hospital stay, and duration of antibiotic therapy. For all but one of the criteria it has been found that early and delayed laparoscopic surgery were equivalent for these end points. The endpoint antibiotic duration post-surgery still remains an area of contention. Conclusion Early and delayed cholecystectomy for the treatment of uncomplicated acute cholecystitis is both safe and feasible. Early laparoscopic cholecystectomy is preferred over delayed laparoscopic cholecystectomy mainly because of decreased length of hospital stay in the early laparoscopic cholecystectomy group. This is a clear advantage.

EP-603 What a difference a year makes: Long-term follow-up of non-operative management in acute cholecystitis

AimSurgery is currently the recommended treatment for acute cholecystitis and the Association of Upper Gastrointestinal Surgeons (AUGIS) recommends that laparoscopic cholecystectomy be performed within 72 hours of admission. However, given the impact of the COVID-19 pandemic on healthcare delivery, this is not always possible. So, what happens to those who are managed conservatively?We observed the long-term impact of conservative management of patients admitted with acute cholecystitis over the course of one year.MethodsTwenty-eight patients were admitted with acute cholecystitis to a large tertiary hospital in November 2020; twenty-three were discharged without having had a cholecystectomy. These patients were followed up for one year and observed for the development of any gallstone-related admissions and surgical procedures.ResultsOf the 23 patients observed, 30% (n=7) were admitted for gallstone-related complications. Biliary colic was responsible for 43% of these admissions with pancreatitis (14%), cholangitis (14%), choledocholithiasis (14%), and cholecystitis (14%) causing the rest. Only 9% (n=2) received a laparoscopic cholecystectomy. In both cases, it was in an emergency setting during admission for biliary colic.ConclusionLong-term observation of conservatively managed acute cholecystitis was possible in around two-thirds of patients as no gallstone-related hospital admissions were observed. Biliary colic was the most common cause of gallstone-related admissions. Longer observation is required to assess the feasibility of long-term non-operative management in acute cholecystitis.

Moynihan Prize 3 Financial implications of gallstone-related complications whilst awaiting elective cholecystectomy: a single institution experience of 900 patients.

AimsOver 65,000 cholecystectomies are performed each year in the United Kingdom with increasing waiting-list times due to the COVID-19 pandemic. This study set out to understand the cost to the NHS of complications experienced whilst awaiting cholecystectomy.MethodsA retrospective cohort study was carried out for all patients who had been awaiting elective cholecystectomy for more than 20 weeks on the 17th September 2021 at a large NHS Foundation Trust. Demographic data was collected at the time of listing. Re-admission data was collected from patient notes. It included clinical history, blood results and imaging investigations. Associated costs were calculated.Results900 patients included in the study (median age 56 years, 71.7% female). 138 patients (15.3%) re-presented to hospital whilst on the waiting list with complications of gallstone disease. Of these, 51 had more than one presentation to hospital with 18 patients having more than three presentations. This was equivalent to 625 days in hospital, with only 79 same day discharges, and multiple investigations were performed (ultrasound scan = 79; CT scan = 31, MRCP = 47, ERCP = 21). This was estimated to have cost a minimum of £364,917. Assuming an average time for an elective cholecystectomy of 90 mins at a cost of £1,200 per hour, 202 additional cholecystectomies could have been performed.ConclusionThis study highlights the enormous potential to reduce patient suffering by increasing the number of elective cholecystectomy lists, and at no overall additional cost to the trust.

The Utility of Abdominal Ultrasound Following Negative Computed Tomography in Diagnosing Acute Pancreatitis.

AimAcute pancreatitis is a diagnosis established by fulfillment of at least two out of three clinical features, including epigastric pain, elevated lipase, and/or radiographic evidence of acute pancreatitis. Computed tomography of the abdomen and pelvis (CTAP) is the gold standard imaging modality for evaluating acute pancreatitis. Although abdominal ultrasound (AUS) is increasingly utilized given the widespread availability and high sensitivity and specificity for detecting gallstone-related complications, including gallstone pancreatitis, the leading cause of acute pancreatitis in the US. However, recent literature has concluded that performing AUS following a negative CTAP rarely led to changes in management and imparted an increased length of service (LOS) in the ED. Our study investigated whether a similar relationship was observed when managing acute pancreatitis in the inpatient setting. We aimed to quantify how performing AUS influenced inpatient LOS for patients admitted for acute pancreatitis without radiographic evidence of acute pancreatitis on CTAP. We also aimed to quantify how AUS influenced the likelihood of subsequent intervention via endoscopic retrograde cholangiopancreatography (ERCP) or cholecystectomy, including the relative impact of certain demographic or clinical features.MethodsA retrospective analysis was performed using a cohort of 6069 patient encounters extracted via the HCA Healthcare enterprise data warehouse (EDW) database. Inclusion criteria were all adult patients with an index admission for acute pancreatitis between January 1 and December 31, 2019, who underwent CTAP during admission. Patients younger than 18 years, with prior cholecystectomy, or without documentation of demographic or clinical data of interest were excluded. The primary outcome was to quantify how performing AUS within 48 hours impacted LOS for patients admitted for acute pancreatitis following negative CTAP. Secondary outcomes examined whether AUS changed management (i.e., per likelihood of subsequent ERCP or cholecystectomy). This included determining the influence of various demographic or clinical characteristics on the likelihood of intervention via ERCP or cholecystectomy. Linear regression was used to determine the effect of performing AUS on the duration of LOS. Logistic regression was used for covariate analysis based on demographic (BMI, sex, race, age) and clinical data (comorbid conditions, abnormal labs, and vital signs).ResultsPatients with acute pancreatitis who underwent AUS within 48 hours had a reduced LOS of 1.099 days. Patients who underwent AUS were 1.126 times more likely to undergo subsequent ERCP than those who received CTAP alone. Patients who received AUS following CTAP were also 2.711 times more likely to undergo subsequent cholecystectomy. Increasing age and BMI were correlated with an increased likelihood of ERCP and cholecystectomy. Males were less likely to undergo cholecystectomy (OR = 0.753) and ERCP (OR = 0.815) compared to females.ConclusionPerforming AUS within 48 hours following negative CTAP in this cohort of patients admitted for acute pancreatitis was associated with a decreased LOS. Furthermore, patients who underwent AUS were more likely to undergo ERCP and even more likely to undergo cholecystectomy. The likelihood of ERCP and cholecystectomy increased proportionally to both age and BMI. Females were more likely than males to undergo subsequent ERCP or cholecystectomy.

Timing of laparoscopic cholecystectomy in patients with non-severe biliary pancreatitis.

IntroductionIn patients with acute biliary pancreatitis (ABP), cholecystectomy is mandatory to prevent further biliary events, but the precise timing of laparoscopic cholecystectomy (LC) for non-severe disease remain a subject of ongoing debate.AimTo prove which method – early or delayed LC – is the method of choice in the non-severe disease by examining rates of gallstone-related complications, dissection difficulty, conversion rate, morbidity, mortality, and length of hospital stay.Material and methodsWe retrospectively analysed the data of patients diagnosed with non-severe ABP, who were followed and underwent LC in our department. Patients who met the inclusion criteria were divided in to the early (< 2 weeks) and the delayed groups (> 2 weeks).ResultsThe patients in the early and delayed groups (n = 43/39) were similar in terms of demographic characteristics, comorbidities, and severity of biliary pancreatitis. The mean time to surgery was 1.7 vs. 6.5 weeks in the early and late groups, respectively. Patients in the delayed group had a 17.9% readmission rate. The causes were acute pancreatitis (10.2%), cholangitis, and cholecystitis. The conversion and the difficult dissection rates were 11.6% vs. 12.8% and 13.95% vs. 20.51% in the early and delayed groups, respectively. Mortality was not observed in the groups. Morbidity rates were 4.6% vs. 5%, and mean length of hospital stay was 10 vs. 17 days in the early and delayed groups, respectively.ConclusionsDelayed LC increases the rate of biliary events and early LC does not increase the operative difficulty or morbidity in patients with ABP.