Index Cholecystectomy Research Articles

A critical view: Examining disparities regarding timely cholecystectomy

BackgroundImplicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy. MethodsWe performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit. ResultsOf 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit. ConclusionMore than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.

National analysis of outcomes in timing of cholecystectomy for acute cholangitis

BackgroundThe present study aimed to compare outcomes between cholecystectomy on index versus delayed admission for acute cholangitis. MethodsThe 2011–2020 Nationwide Readmissions Database was used to identify adult patients admitted for acute cholangitis who underwent cholecystectomy. Study cohorts were defined based on timing of surgery. Multivariable regressions and Royston-Parmar time-adjusted analysis were used to evaluate the association of cholecystectomy timing and outcomes. ResultsOf 65,753 patients, 82.0 ​% received surgery on Index and 18.0 ​% on Delayed admissions. Following adjustment, Delayed operation was associated with significantly increased odds of mortality (AOR 1.67 [95 ​% CI 1.10–2.54]), complications (1.25 [1.13–1.40]), repair of bile duct injury (1.66 [1.15–2.41]), conversion to open (1.69 [1.48–1.93]), and 30-day readmission (3.52 [3.21–3.86]). The Delayed cohort experienced a +$14,200 increment in hospitalization costs relative to Index. ConclusionsDelayed cholecystectomy for acute cholangitis is significantly associated with adverse postoperative outcomes, suggesting that index cholecystectomy may be safe to perform.

Index admission cholecystectomy for biliary acute pancreatitis or choledocholithiasis reduces 30-day readmission rates in children

BackgroundAdult patients with biliary acute pancreatitis (BAP) or choledocholithiasis who do not undergo cholecystectomy on index admission have worse outcomes. Given the paucity of data on the impact of cholecystectomy during index hospitalization in children, we examined readmission rates among pediatric patients with BAP or choledocholithiasis who underwent index cholecystectomy versus those who did not.MethodsRetrospective study of children (< 18 years old) admitted with BAP, without infection or necrosis (ICD-10 K85.10), or choledocholithiasis (K80.3x–K80.7x) using the 2018 National Readmission Database (NRD). Exclusion criteria were necrotizing pancreatitis with or without infected necrosis and death during index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmission.ResultsIn 2018, 1122 children were admitted for index BAP (n = 377, 33.6%) or choledocholithiasis (n = 745, 66.4%). Mean age at admission was 13 (SD 4.2) years; most patients were female (n = 792, 70.6%). Index cholecystectomy was performed in 663 (59.1%) of cases. Thirty-day readmission rate was 10.9% in patients who underwent cholecystectomy during that index admission and 48.8% in those who did not (p < 0.001). In multivariable analysis, patients who underwent index cholecystectomy had lower odds of 30-day readmission than those who did not (OR 0.16, 95% CI 0.11–0.24, p < 0.001).ConclusionsIndex cholecystectomy was performed in only 59% of pediatric patients admitted with BAP or choledocholithiasis but was associated with 84% decreased odds of readmission within 30 days. Current guidelines should be updated to reflect these findings, and future studies should evaluate barriers to index cholecystectomy.

Index admission cholecystectomy for acute cholecystitis reduces 30-day readmission rates in pediatric patients.

Adult patients with cholecystitis who do not undergo cholecystectomy on index admission have worse outcomes, however, there is a paucity of data of the role of cholecystectomy during index hospitalization in the pediatric population. Our aim was to determine outcomes and readmission rates among pediatric patients with cholecystitis who underwent index cholecystectomy versus those who did not. We performed a retrospective study of pediatric (< 18years old) admitted with acute cholecystitis (AC) requiring hospitalization using the 2018 National Readmission Database (NRD). Exclusion criteria included age ≥ 18years and death on index admission. Multivariable logistic regression was performed to identify factors associated with 30-day readmissions. We identified 550 unique index acute cholecystitis admissions. Mean age was 14.6 ± 3.0years. Majority of patients were female (n = 372, 67.6%). Index cholecystectomy was performed in (n = 435, 79.1%) of cases. Thirty-day readmission rate was 2.8% in patients who underwent index cholecystectomy and 22.6% in those who did not (p < 0.001). On multivariable analysis, patients who did not undergo index cholecystectomy had higher odds of 30-day readmission than those who did not (OR 10.66, 95% CI 5.06-22.45, p < 0.001). Female patients also had higher odds of 30-day readmission compared to males (OR 3.37, 95% CI 1.31-8.69). Patients who did not undergo index cholecystectomy had over tenfold increase in odds of 30-day readmission. Further research is required to understand the barriers to index cholecystectomy despite society recommendations and clear clinical benefit.

OGBN P27 Outcome of specialist-led urgent laparoscopic cholecystectomy for gallstone disease at a London District General Hospital

Abstract Background Laparoscopic cholecystectomy is the mainstay for treatment of symptomatic gallstones and its associated complications. Emergency cholecystectomy rates in the United Kingdom (UK) remain low despite NICE guidelines recommendations to offer surgery within 7 days for acute cholecystitis and index cholecystectomy for mild gallstone pancreatitis. We analysed our data over last 10 years to assess the safety and feasibility of providing an emergency cholecystectomy service in a London District general Hospital with a specialist Upper Gastrointestinal / hepatobiliary consultant workforce in line with NICE guidelines. Methods Data of 663 consecutive patients undergoing index admission emergency cholecystectomy during 2013-2023 from a prospectively maintained database was reviewed. Patient demographics, duration of hospital stay, complications, need for further interventions and re-admission rates were collected and analysed. Results Six hundred and sixty-three consecutive patients underwent emergency cholecystectomy gallstone disease and associated complications. The conversion rate was 5.2% (n=35). The median time from presentation to surgery was 2 days (Range 0-63), overall length of stay was 6 days (Range 1-91), and post-procedure stay was 2 days (Range 1-89). Overall complication rate was 7% (n=45), bile leak was observed in 8 patients (1.2%) with no evidence of major biliary injury. One patient had postoperative haemorrhage requiring laparotomy (No bleeder identified) (grade IVa) and 1 patient died within 90 days for reasons unrelated to the operation. The re-admission rate was 10.2%. Conclusions Index admission emergency laparoscopic cholecystectomy in district general hospitals is feasible and safe when performed by a specialist consultant workforce, leading to compliance to guidelines and a low rate of complications and readmissions to hospital.

1228 Predictors of Re-Intervention Following Index Cholecystectomy

Abstract Aim Index Cholecystectomy (IC) is safe and reduces patient morbidity. However, IC can be challenging due to inflammation of hepatocystic triangle, increasing the risk of postoperative complications. Study was conducted to evaluate factors influencing postoperative complications following IC. Method Retrospective review of consecutive IC performed as a primary procedure was carried out between February 2021 and July 2022 in our trust. Primary outcome was postoperative Grade 3 Clavien-Dindo (CDC) complication, in comparison to patients with uncomplicated recovery. Pre-operative factors including age, CRP, WBC, LFT, surgeon grade, modality (laparoscopic/open) and number of previous admissions were included for analysis. Categorical and continuous data were analysed using Chi-Square and Mann-Whitney-U tests respectively. P-value &amp;lt;0.05 was statistically significant. Results 100 IC were included. Most IC were consultant-led [80/100(80%)]. 11/100(11%) patients developed Grade 3 CDC complication; 4/100(4%) bile leak requiring ERCP and stent insertion, 3/100(3%) post-operative collection requiring radiological-assisted drainage, 2/100(2%) retained bile duct stones requiring ERCP, 1/100(1%) incision and drainage of port site seroma and 1/100(1%) biloma requiring laparoscopic washout. Re-intervention was common in older patients (61±18years vs 55±22years,p = 0.04) and higher median peak CRP levels (312±178 vs 154±284,p = 0.01). There were no differences in LFT parameters, number of previous admissions or timing of operation from day of admission between the two groups. Conclusions Age&amp;gt;65 and higher pre-operative CRP were associated with increased risk of postoperative procedural intervention. Larger prospective studies are needed to confirm these findings. Surgeons should consider these factors for consenting and risk assessment purposes.

FTP5.9 A review of post-operative outcomes following Cholecystectomy - Emergency vs Elective

Abstract Aim NICE (CG188) 2014 recommends index cholecystectomy (IC) for patients admitted with gallstone disease, particularly “acute cholecystitis”, within one week of diagnosis. Conversely, elective cholecystectomy (EC) patients are pooled via various pathways, from elective to emergency. Safety of ICs is well-established. A study was conducted to investigate difference in outcomes between IC and EC. Methods Retrospective study of prospective database of cholecystectomies performed as primary procedure was carried out between February 2021 and July 2022 in our trust. The primary outcome was hospital readmission, while secondary outcomes included postoperative complications graded by Clavien-Dindo classification (CDC), length of stay (LoS) and intensive care (ICU) admission. Categorical and continuous data were analysed using Chi-Square and Mann-Whitney-U tests respectively. P-value &amp;lt;0.05 was statistically significant. Results 202 patients underwent cholecystectomy. There were similar numbers in the studied groups; IC-49.8% (n=100/202) and EC-50.2% (n=102/202). Hospital readmission rates were higher in the IC – 11/100(11%) vs EC – 3/102(2.9%), p=0.02. Postoperative interventions (grade-3-CDC) (IC-11.0%, n=11 vs EC-2.9%, n=3, p=0.02) and ICU admission rates (IC-7.0%, n=7 vs EC-1.0%, n=1, p=0.03) were higher in IC compared to EC. Uncomplicated recovery (grade-1-CDC) was significantly higher in EC (p&amp;lt;0.0001). Postoperative LoS was significantly longer in IC (p&amp;lt;0.0001). There was no recorded mortality in either group. Conclusion Study confirms that IC is safe. However, postoperative procedural interventions were more common in IC, which is highly indicative of complex pathology (perforated/necrotic gallbladder/inflamed hepatocystic triangle) and may be contributed by timing of procedure. Further studies to assess underlying factors contributing to these outcomes are warranted.

FTP5.10 Predictors of re-intervention following index cholecystectomy

Abstract Aim Index Cholecystectomy (IC) is safe and reduces patient morbidity. However, IC can be challenging due to inflammation of hepatocystic triangle, increasing the risk of postoperative complications. Study was conducted to evaluate factors influencing postoperative complications following IC. Method Retrospective review of consecutive IC performed as a primary procedure was carried out between February 2021 and July 2022 in our trust. Primary outcome was postoperative Grade 3 Clavien-Dindo (CDC) complication, in comparison to patients with uncomplicated recovery. Pre-operative factors including age, CRP, WBC, LFT, surgeon grade, modality (laparoscopic/open) and number of previous admissions were included for analysis. Categorical and continuous data were analysed using Chi-Square and Mann-Whitney-U tests respectively. P-value &amp;lt;0.05 was statistically significant. Results 100 IC were included. Most IC were consultant-led [80/100(80%)]. 11/100(11%) patients developed Grade 3 CDC complication; 4/100(4%) bile leak requiring ERCP and stent insertion, 3/100(3%) post-operative collection requiring radiological-assisted drainage, 2/100(2%) retained bile duct stones requiring ERCP, 1/100(1%) incision and drainage of port site seroma and 1/100(1%) biloma requiring laparoscopic washout. Re-intervention was common in older patients (61±18years vs 55±22years, p=0.04) and higher median peak CRP levels (312±178 vs 154±284, p=0.01). There were no differences in LFT parameters, number of previous admissions or timing of operation from day of admission between the two groups. Conclusion Age&amp;gt;65 and higher pre-operative CRP were associated with increased risk of postoperative procedural intervention. Larger prospective studies are needed to confirm these findings. Surgeons should consider these factors for consenting and risk assessment purposes.

MOY 3 Management of acute cholecystitis in Scotland: A population wide cohort study

Abstract Aims Acute cholecystitis (AC) is a common Emergency General Surgery presentation, and is managed either by a cholecystectomy or conservatively. Surgery during the acute inflammatory phase has been shown to be safe and superior, however, operative rates vary widely. Also, medium-long term survival rates with each approach are still not definitively established. This real-world population analysis aims to describe the current management and outcomes of patients with AC across Scotland. Methods This was a national cohort study using data obtained from Information Services Division, Scotland. All adult patients with the admission diagnostic code for AC were included. Patient level data were used to identify all patients admitted to Scottish hospitals between 1997-2019 and outcomes tracked for inpatients or after discharge through the unique patient identifier. This was mapped to mortality data to establish date and cause of death. Results 47558 patients diagnosed with AC, admitted in one of 46 hospitals were included. These patients accounted for 58824 episodes (27.2% of patients encountered &amp;gt;1 episode). The study population had a median age of 58 years (IQR=43-71), 64.4% were female, and most had no comorbidities. 28741(60.4%) patients had an operative intervention during the index admission. Patients who had an operation during their index admission had a lower risk of 90-day mortality compared to non-operative management (OR 0.62, 95% CI 0.55-0.70). Conclusions In this comprehensive analysis of AC in Scotland, 60% of patients had an index cholecystectomy. Patients undergoing surgery had a superior survival to those managed conservatively, further advocating for an operative approach in this cohort.

Laparoscopy in the management of post-cholecystectomy bile leaks

IntroductionOver 1% of cholecystectomies are complicated by a post-operative bile leak. Most bile leaks are managed with endoscopic retrograde cholangio-pancreatography (ERCP) with decompression of the biliary tree. This paper reports our outcomes of using early re-laparoscopy in the investigation and treatment of post-operative bile leak. Materials/patients and methodsWe analysed our prospectively compiled database to identify all patients suffering a bile leak after cholecystectomy. Demographic data, details of the index cholecystectomy, post-operative investigations and procedures, and readmissions to hospital were analysed. Results4870 cholecystectomies were performed between 2016 and 2020; 1793 (36.9%) were urgent cholecystectomies performed at the index admission. 41 patients were identified with unexpected post-operative bile leaks. 40 patients underwent urgent re-laparoscopy as initial management. 17 patients required ERCP subsequent to re-laparoscopy. Median post-operative stay was 5 days. No cases were converted to open surgery, and there were no mortalities. DiscussionUrgent repeat laparoscopy is an effective tool to manage an unexpected post-cholecystectomy bile leak. Re-laparoscopy allows thorough peritoneal washout and diagnosis of the cause of the leak, and provides definitive treatment for the majority of patients. It is associated with a short hospital stay with minimal morbidity and mortality.

Comprehensive assessment of the management of acute cholecystitis in Scotland: population-wide cohort study.

Acute cholecystitis is one of the most common diagnoses presenting to emergency general surgery and is managed either operatively or conservatively. However, operative rates vary widely across the world. This real-world population analysis aimed to describe the current clinical management and outcomes of patients with acute cholecystitis across Scotland, UK. This was a national cohort study using data obtained from Information Services Division, Scotland. All adult patients with the admission diagnostic code for acute cholecystitis were included. Data were used to identify all patients admitted to Scottish hospitals between 1997 and 2019 and outcomes tracked for inpatients or after discharge through the unique patient identifier. This was linked to death data, including date of death. A total of 47 558 patients were diagnosed with 58 824 episodes of acute cholecystitis (with 27.2 per cent of patients experiencing more than one episode) in 46 Scottish hospitals. Median age was 58 years (interquartile range (i.q.r.) 43-71), 64.4 per cent were female, and most (76.1 per cent) had no comorbidities. A total of 28 741 (60.4 per cent) patients had an operative intervention during the index admission. Patients who had an operation during their index admission had a lower risk of 90-day mortality compared with non-operative management (OR 0.62, 95% c.i. 0.55-0.70). In this study, 60 per cent of patients had an index cholecystectomy. Patients who underwent surgery had a better survival rate compared with those managed conservatively, further advocating for an operative approach in this cohort.

O003 Comprehensive assessment of the management of acute cholecystitis in Scotland: a population wide cohort study of 47,558 patients

Abstract Introduction Acute cholecystitis (AC) is one of the most common diagnoses within Emergency General Surgery, managed either operatively (cholecystectomy) or conservatively. Surgery in the acute phase has been shown to be safe and superior, however, operative rates vary widely. Furthermore, medium-long term survival rates with each approach are still not definitively established. This real-world population analysis aims to describe the current management and outcomes of patients with AC across Scotland. Methods This was a national cohort study using data obtained from Information Services Division, Scotland. All adult patients with the admission diagnostic code for AC were included. Patient level data were used to identify all patients admitted to Scottish hospitals between 1997–2019 and outcomes tracked for inpatients or after discharge through the unique patient identifier. This was mapped to mortality data to establish date and cause of death. Results 47558 patients diagnosed with AC, admitted in one of 46 hospitals were included. These patients accounted for 58824 episodes (27.2% of patients encountered &amp;gt;1 episode). The study population had a median age of 58 years (IQR=43-71), 64.4% were female, and most had no comorbidities. 28741(60.4%) patients had an operative intervention during the index admission. Patients who had an operation during their index admission had a lower risk of 90-day mortality compared to non-operative management (OR=0.62, 95%CI=0.55-0.70). Conclusion In this comprehensive analysis of AC in Scotland, 60% of patients had an index cholecystectomy. Patients undergoing surgery had a superior survival to those managed conservatively, further advocating for an operative approach in this cohort.

Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

IntroductionCholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown. MethodsA prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative. ResultsData were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%–87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%–35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R2 = 25.8, elective cholecystectomy model R2 = 50.6). ConclusionsNotable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Optimal perioperative therapy for incidental gallbladder cancer (OPT-IN): A randomized phase II/III trial—ECOG-ACRIN EA2197.

TPS620 Background: Gallbladder carcinoma (GBC) is a rare disease with a poor prognosis, with an overall estimated 5-year survival rate of 5-13%. Approximately 70% of gallbladder cancers in the US are found incidentally on pathologic analysis after elective cholecystectomy for presumed benign disease. Current management guidelines for incidental gallbladder cancer (IGBC) recommend re-resection for T1b, T2, and T3 lesions, which entails a partial hepatectomy and lymph node dissection. Up to 75% of patients have residual locoregional disease and 20% have disseminated disease at the time of re-resection, both factors strongly associated with poor prognosis and inoperability, respectively. For those who undergo re-resection, the recurrence rate at one year can be as high as 40%. Therefore we designed a Phase II/III trial to assess the benefit of a perioperative chemotherapy approach around the re-resection procedure compared to standard of care adjuvant therapy alone. Methods: We have enrolled 18 of 186 planned patients (Phase III design) on study NCT 04559139/EA2197. Current eligibility criteria include: Incidentally diagnosed T2 / T3 gallbladder cancer with no evidence of metastatic disease or inoperable locoregional disease. At randomization, patients must be within 12 weeks of their index cholecystectomy. Patients are randomized 2:1 to receive perioperative chemotherapy with gemcitabine and cisplatin vs adjuvant therapy alone. The primary endpoint is overall survival. Secondary endpoints include resectability, presence of residual disease, and progression-free survival. Clinical trial information: 04559139 .

WE8.4 Acute Pancreatitis during COVID-19 Pandemic: An Overview of Patient Demographics, Disease Severity, Management and Outcomes in Western Health and Social Care Trust (Altnagelvin Area Hospital)

BackgroundAcute pancreatitis is a common disease requiring admissions under surgical and critical care units. The two most common causes are alcohol and gallstones. COVID-19 pandemic had a significant impact on service delivery and patient management throughout all surgical specialties. In this study, primary aim was to ascertain incidence of COVID-19 in acute pancreatitis patients.MethodsA retrospective observational review of all patients admitted under General Surgical team from March 2020 till September 2020 was performed. Information regarding demographics, severity of acute pancreatitis (using Glasgow score, Atlanta classification and CT severity index score), ICU admission and organ support, treatment modalities and follow-up data for outcomes was collected.ResultsForty four (44) patients were admitted with acute pancreatitis. Only one patient (2.3%) was diagnosed with COVID-19 at time of pancreatitis. Aetiology of pancreatitis was found comparable to aetiology reported by large scale studies (2). Mortality was 7% (3 patients). Five patients (11%) needed ICU admission due to organ dysfunction. Three patients (7%) developed ARDS.ConclusionsThe overall incidence of COVID-19 in pancreatitis in our population of study was low. Therefore, results were compared to patients who were COVID-19 negative in COVID-PAN study. Patients with acute pancreatitis in our target population were mostly elderly, about one in five had moderate to severe or severe pancreatitis and in 16.3% the aetiology could not be identified. As has been observed in other centres globally, urgent for gallstone pancreatitis faced significant delays with no patients being offered index cholecystectomy and only 4/19 patients having undergone interval cholecystectomy.

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.

O001 SARS-CoV-2 pandemic has impacted on patterns of aetiology for acute pancreatitis and management of gallstone pancreatitis in the United Kingdom

IntroductionThe impact of the SARS-CoV-2 pandemic on patterns of aetiology of acute pancreatitis (AP) and management of AP in the UK is unknown.MethodsA prospective multicentre cohort study of consecutive patients admitted with AP between 01/03/2020 and 23/07/2020 was undertaken. Patients were followed up for 12 months.Results1628 patients presenting with AP were included in the analysis. Gallstones (GSP) were the predominant aetiology (43.6%), followed by alcohol associated (25.8) and idiopathic (21.5%) AP. After completing aetiological investigations, 14.4% of the idiopathic cohort remained to have an idiopathic aetiology. 113/187 patients were readmitted during the ‘second wave’ of SARS-CoV-2 pandemic (after September 2020) with predominantly alcohol-related AP aetiology (49, 43.3%). Patients readmitted during the ‘second wave’, more commonly had alcoholic AP compared to the index cohort (43.4% vs 23.5% respectively; p<0.001); however, there were no significant differences in AP severity (p=0.268). Of the 1358 patients with complete follow-up data, 620 (45.7%) presented with GSP of which only 66 (10.6%) underwent index cholecystectomy and 108 (17.4%) had an interval cholecystectomy with median waiting time of 32 days (IQR 16–56). Accounting for 44/456 patients with previous cholecystectomies, and 24 patients deemed unfit for cholecystectomy, the remaining 388 (77.3%) were still awaiting cholecystectomy at the end of 12 months.ConclusionThe patterns of aetiology for AP changed during the SARS-CoV-2 pandemic with an increase in alcohol associated AP. Most significantly, access to cholecystectomy was restricted during the pandemic and readmission to hospital may have been driven by the need for cholecystectomy.Take-home messageThe patterns of aetiology for AP changed during the SARS-CoV-2 pandemic with an increase in alcohol associated AP. Most significantly, access to cholecystectomy was restricted during the pandemic and readmission to hospital may have been driven by the need for cholecystectomy.

Does Timing of Completion Radical Cholecystectomy Determine the Survival Outcome in Incidental Carcinoma Gallbladder: A Single-Center Retrospective Analysis.

IntroductionIncidental discovery of gallbladder cancer (GBC) on postoperative histopathology or intra-operative suspicion is becoming increasingly frequent since laparoscopic cholecystectomy became the standard of care for gallstone disease. Incidental GBC (IGBC) portends a better survival than primarily detected GBC. Various factors affect the outcome of re-resection with the timing of re-intervention an important determinant of survival.MethodsAll patients of IGBC who underwent curative resection from January 2009 to December 2018 were considered for analysis. Details of demographic profile, index surgery, and operative findings on re-resection, histopathology and follow-up were retrieved from the prospectively maintained database. Patients were evaluated in three groups based on the interval between index cholecystectomy and re-resection: Early (<4 weeks), Intermediate (4-12 weeks) and Late (>12 weeks), using appropriate statistical tests.ResultsNinety-one patients were admitted with IGBC during the study period of which 48 underwent re-resection with curative intent. The median age of presentation was 55 years (31-77 years). The median duration of follow-up was 40.6 months (Range: 1.2-130.6 months). Overall and disease-free survival among the above-mentioned three groups was the best in the early group (104 and 102 months) as compared to the intermediate (84 and 83 months) and late groups (75 and 73 months), though the difference failed to achieve statistical significance (p=0.588 and 0.581). On univariate analysis, factors associated with poor outcome were node metastasis, need for common bile duct (CBD) excision and high-grade tumor. However, on multivariate analysis, poor differentiation was the only independent factor affecting survival.ConclusionEarly surgery, preferably within four weeks, possibly entails better survival in incidentally detected GBC. The grade of a tumor, however, is the most important determinant of survival in IGBC.

Cost analysis of index versus delayed cholecystectomy for acute cholecystitis in a New Zealand Provincial Centre.

Evidence suggests index cholecystectomy (IC) in patients with acute cholecystitis is safe, has decreased hospital stay and is cheaper than delayed cholecystectomy (DC). Costs of cholecystectomy have not previously been investigated in New Zealand. The aim of this study was to compare cost of IC with DC for patients with acute cholecystitis. A retrospective analysis of adults admitted to Northland hospitals with acute cholecystitis between 1 January 2015 and 31 December 2019 who underwent subsequent cholecystectomy, was performed. Actual patient-level costs were utilized for cost comparison between IC and DC. Factors associated with increased costs were assessed using multivariate analysis. Two hundred and eleven patients were included in the study; 72 (34%) underwent IC and 139 (65%) DC. There was no significant difference in total cost for IC ($12 767) versus DC ($12 029) (p =0.192); this persisted on multivariate analysis. Patients having IC had more severe cholecystitis, and 90-day representation rate following DC was 35%. Costs were increased by severity of cholecystitis, age, American Society of Anesthesiology score (ASA) and travel distance. This study showed there is no significant difference in cost between IC and DC for patients with acute cholecystitis in Northland, New Zealand. Severity, increasing age, ASA and travel distance were drivers of costs. To recognize the cost benefits of IC, it is likely that increased rates of IC are needed.

Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures.

ObjectivesTo estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy.Design, setting, participantsAnalysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 ‒ 30 June 2018.Main outcome measuresCholecystectomy classification (index or interval). Secondary outcomes: all‐cause mortality (30‒365 days), emergency re‐admissions with gallstone‐related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone‐related disease over six months).ResultsA total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re‐admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six‐month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08‒1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13‒1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03‒3.31).ConclusionsMost NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease‐related emergency re‐admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.