Laparoscopic Cholecystectomy Research Articles

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrence-associated risk factors

BACKGROUND There remain controversies regarding the surgical treatment of extrahepatic bile duct stones (EHBDSs) in clinical practice. AIM To explore the curative effect of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE) for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence. METHODS Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected. Among them, patients treated with open choledocholithotomy plus LC or open cholecystectomy (OC) were set as the control group (n = 40), and those treated with LC plus CBDE served as the observation group (n = 42). The surgical outcomes of the two groups were compared, the surgical complications and Gastrointestinal Quality of Life Index (GIQLI) scores were counted, and the one-year prognostic recurrence was recorded. Independent factors for postoperative recurrence were determined using univariate and multivariate analyses. RESULTS The two groups were comparable in the stone residual rate (P > 0.05). The operation time (P < 0.05), intraoperative bleeding (P < 0.05), and total complication rate (P = 0.005) were lower in the observation group than in the control group. The observation group exhibited a marked increase in the GIQLI score, which was higher than the control group (P < 0.05). A lower one-year recurrence rate was determined in the observation group vs the control group (P = 0.027). Sphincter of Oddi dysfunction [odds ratio (OR) = 5.712, P = 0.007] and the treatment scheme of open choledocholithotomy plus LC or OC (OR = 6.771, P = 0.008) were the independent risk factors for one-year recurrence in patients after surgery. CONCLUSION LC plus CBDE for patients with EHBDSs can reduce stone residuals, intraoperative bleeding, complications, and postoperative recurrence.

Effect of surgical timing on postoperative outcomes in patients with acute cholecystitis after delayed percutaneous transhepatic gallbladder drainage

BACKGROUND To date, the optimal timing for percutaneous transhepatic gallbladder drainage (PTGBD), particularly for patients who have missed the optimal window for emergency laparoscopic cholecystectomy (LC) (within 72 hours of symptom onset) has not been determined. AIM To study the effects of LC timing on outcomes of grade II/III acute cholecystitis (AC) in patients with delayed PTGBD. METHODS Data of patients diagnosed with Tokyo Guidelines 2018 grade II or III AC who underwent delayed PTGBD followed by LC at a single hospital between 2018 and 2022 were retrospectively studied. According to the interval between gallbladder drainage and cholecystectomy, the patients were divided into early and delayed LC groups. Outcomes including surgery time, postoperative complications and hospital stay, and patient satisfaction were analyzed and compared between the two groups using t - and χ 2 tests. RESULTS There were no significant differences between the two groups in intraoperative blood loss, postoperative abdominal drainage tube placement time, pain index, or total disease duration (all P > 0.05). Compared with those of the early LC group, the delayed group showed significant decreases in the length of procedure (surgery time), conversion rate to open surgery, degree of adhesions, surgical complications, postoperative hospital stay, and total treatment costs, and increased patient satisfaction despite a longer interval before PTGBD (all P < 0.05). CONCLUSION For patients with grade II/III AC with delayed PTGBD, LC should be performed 2 weeks after PTGBD to decrease postoperative complications and hospital stays and improve patient satisfaction.

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

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

Laparoscopic Cholecystectomy Under Combined Spinal and Epidural Anesthesia in the First Trimester of Pregnancy—Case Report and Literature Review

Can combined spinal and epidural anesthesia be the gold standard for laparoscopic surgery for pregnant patients? This case report presents a first trimester pregnant patient who was admitted for obstructive jaundice syndrome (pain in the right hypochondrium, nausea, and vomiting). Initially, because of the risk/benefit ratio of pregnancy, the treatment was medical and the patient was immediately discharged because her clinical condition improved, but she was rapidly readmitted to the surgery department because of worsening symptoms. Emergency surgical intervention (laparoscopic cholecystectomy) under combined spinal and epidural anesthesia (CSEA) was performed to reduce the patient’s risks. Since most analgesics are insufficiently studied in pregnancy, analgesia with ropivacaine 0.2% was used on the epidural catheter. No pathological changes were identified in the fetal Doppler ultrasound preoperatively and postoperatively. Similarly to other studies, our case highlights the necessity for cholecystectomy for acute cholecystitis even if the patient is in the first trimester of pregnancy. If the decision is delayed, the morbidity and mortality for mother and fetus become unjustified. The peculiarity of the present report is the type of anesthesia chosen. We consider that combined spinal and epidural anesthesia may become a possible gold standard suitable for laparoscopy in the first trimester of pregnancy.

Laparotomy Versus Laparoscopy Cholecystectomy for Surgical Treatment in Patients with Gallstone Disease: A Comparative Cost-Effectiveness Analysis

Background: Due to the increasing costs of the healthcare system and limited financial resources, healthcare policymakers should adopt more cost-effective strategies. Objectives: This study aimed to compare the cost-effectiveness of laparotomy cholecystectomy with laparoscopy. Methods: This economic evaluation was conducted on patients with cholecystitis who were candidates for surgery in a private hospital in Ahvaz in 2021. Data collection tools consisted of four parts: (1) demographic information checklist; (2) clinical information checklist; (3) cost checklist; and (4) effectiveness assessment tool. SPSS22 and STATA14.2 were used for data analysis. One-way sensitivity analysis and Tornado diagrams were performed using Tree Age software. Results: The mean total effectiveness score in patients treated with laparoscopy was 83.44 (SD = 11.34), which was higher than those treated with laparotomy at 68.39 (SD = 13.61). This difference was statistically significant in all effectiveness criteria, except for postoperative infection rates and length of operation (P < 0.001). The mean cost for patients undergoing laparoscopy was significantly higher than for those undergoing laparotomy ($481.43 vs. $459.49). However, overall, laparoscopic treatment (5.77) was more cost-effective than laparotomy (6.71). The laparoscopic procedure was approximately $1.47 per effectiveness unit cheaper than laparotomy, according to the ICER. One-way sensitivity analysis showed that the laparoscopic method remained more cost-effective, even when adjusting for cost and effectiveness components. Conclusions: Although laparoscopic cholecystectomy was more expensive than laparotomy cholecystectomy, it was generally more cost- effective. The results of this research may assist Iran’s healthcare policymakers and managers in promoting laparoscopic cholecystectomy in hospitals.

Comparison of da Vinci Robotic Cholecystectomy and Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis of Postoperative Outcomes and Cost-Effectiveness

Comparison of da Vinci Robotic Cholecystectomy and Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis of Postoperative Outcomes and Cost-Effectiveness

The role of fluorescent cholangiography to improve operative safety in different severity degrees of acute cholecystitis during emergency laparoscopic cholecystectomy: a prospective cohort study

The role of fluorescent cholangiography to improve operative safety in different severity degrees of acute cholecystitis during emergency laparoscopic cholecystectomy: a prospective cohort study

Comparing Analgesic Efficacies of Combined Fascial Plane Blocks for Postoperative Pain Following Laparoscopic Cholecystectomy

Comparing Analgesic Efficacies of Combined Fascial Plane Blocks for Postoperative Pain Following Laparoscopic Cholecystectomy

BN SO57 - Transversus Abdominis Plane (TAP) Block in Laparoscopic and Robot-Assisted Cholecystectomy: Is it worth the effort?

Abstract Background Minimal access cholecystectomy is a common procedure undertaken worldwide. These are usually performed on an ambulatory basis and given the short timeline, strategies to optimize pain control and reduce nausea or vomiting are key factors to facilitate early hospital discharge. There has been studies showing that both TAP block and wound infiltration deliver superior pain relief after laparoscopic cholecystectomy, but TAP blocks are not used routinely after cholecystectomy in the U.K. This study aims to assess the efficacy of post-operative subcostal TAP block in laparoscopic and robot-assisted cholecystectomy in reducing post-operative opioid requirements and facilitating same day discharge. Method A retrospective cohort analysis was performed at a single centre (January 2022 – July 2023). Patients undergoing laparoscopic or robot assisted cholecystectomy under a single surgeon who performs cholecystectomy with additional use of postoperative TAP block were included. The primary outcome of post-operative opioid requirements was assessed. Secondary outcomes included length of post-operative stay and individual morphine/fentanyl requirements. Results Among 87 patients, 22(25.3%) underwent TAP block and 65(74.7%) had local anaesthetic infiltration of the port sites. Of the two cohorts, there were no significant differences in the age, M:F ratio or ASA grade. There were more obese patients (BMI > 30kg/m2) in the TAP block cohort (63.6% vs 47.7%; p= 0.012). Of the patients in the TAP block, 88.2% were discharged the same day. 95.5% of these patients had no post-operative morphine or fentanyl requirements.The difference in outcomes were not statistically significant. There were no post-procedural complications from use of the TAP block in any patient. Conclusion These results demonstrate that use of TAP block can provide a safe alternative approach for post-operative analgesia, with low post-operative opioid requirements and facilitation of same-day discharge.

BN SO56 - Post-ERCP clearance of bile duct stones: Should the gallbladder be left in-situ?

Abstract Background Laparoscopic cholecystectomy (LC) has become the gold standard treatment for patients with cholelithiasis and co-existing common bile duct stones (CBSD) with the ultimate goal to prevent further biliary complications. Despite the procurement of ERCP and LC skills, there still remain a significant proportion of patients who are treated non-operatively. There has been debate on the safety of a ‘watch-and-wait’ policy post ERCP for clearance of CBDS alone. The objective of our study was to review our current practice and compare the outcomes of expectant management (EM) versus LC with an aim to evaluate the necessity of LC after ERCP. Method A retrospective review of patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019 was performed. Exclusion criteria applied to patients with previous cholecystectomy, absence of CBDS, gallbladder/pancreatic malignancy, biliary stricture and patients lost to follow-up. Patient characteristics, details of ERCP, initial plan for EM or LC, details of LC and further changes in treatment plan were extracted from the prospectively maintained database of a single institution. Age 70 years is used as cut-off to define elderly group. Primary outcomes measured were biliary-related morbidity and mortality. Secondary outcomes included all-cause mortality, operation-related morbidity and mortality. Results 265 patients were identified, with 136 patients primarily planned for EM and 129 patients initially booked for LC. The median age of patients in the EM group was greater than LC group (80 vs 62 years). 20.6% patients in the EM group re-presented with biliary events compared to 3.9% in the LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. There was no significant correlation between age and complications from LC. However, 51.4% of our EM group died during follow up with a median survival of 29.5 months. Conclusion Prophylactic cholecystectomy should be performed for patients with concomitant cholelithiasis and choledocholithiasis. A conservative approach should be reserved for the elderly population who are not ideal surgical candidates. A follow-up of up to 2 years is recommended for patients who opt for a ‘watch-and-wait’ approach. Early LC is preferrable due to the risk of recurrence of biliary events and the higher risks of surgery if patients require emergency surgery. Further study is warranted to determine the optimal timing for LC. Patients should be informed about the potential recurrence of symptoms if the waiting time to surgery is longer than expected.

HPB SO48 - Evaluating the timeframe for the provision of laparoscopic cholecystectomy in acute cholecystitis patients at a regional hospital

Abstract Background Acute biliary disease comprised a substantial proportion of the general emergency surgical workload. AUGIS and NICE guidelines recommend early laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) patients as it is associated with reduced readmission rates, healthcare costs and faster recovery without notable complication risks. According to the local trust policy, it advocates early LC to be performed within 72 hours of admission for AC patients. If this is not possible a delayed LC should be performed within 8 weeks of admission. Our aim is to examine variations in the provision of LC between current practice and local trust/ NICE guidelines. Method This is a retrospective audit looking at the total number of surgical patients diagnosed with AC between Jan and Dec 2023. The number of patients who had LC in 2023, unfit for surgery and did not consent for the procedure were also included. This data was obtained from electronic patient records (investigative reports, discharge letters, outpatient letters) and then collated on a Microsoft Excel sheet for analysis. Surgical patients who were not diagnosed with AC such as those with biliary pancreatitis, cholelithiasis or cholangitis but subsequently underwent LC were excluded. Results The number of AC patients who were fit and consented to surgical intervention in 2023 was 88. The total number of delayed procedures done was 75 (85.2%). The number of patients who had early LC within 1 week was 13 (14.8%). Of the 75 patients who had delayed LC, 19 (25.3%) patients had delayed LC within 8 weeks from the diagnosis date. The remaining 56 (74.7%) patients had delayed LC after 8 weeks. For patients who had delayed LC, the readmission rate within 6 months of their discharge while waiting for their operative dates was 29 (38.7%). Conclusion One-third of AC patients were readmitted while waiting for LC, some had complications of gallstone disease such as perforation/ gallstone ileus. Therefore, the early provision of LC is crucial in minimising the readmission and complication rates. This data was highlighted in a departmental meeting and teaching session for consultants and junior doctors. We plan to liaise with stakeholders and theatre managers in implementing further solutions to improve compliance where possible. One critical area is auditing the condition of surgical patients in order to be put on the hospital’s twice-weekly hot gallbladder list to consider prioritising AC patient surgical time.

EGS SO01 - A retrospective study on understanding the dangers of delaying emergency laparoscopic cholecystectomies in patients with acute cholecystitis

Abstract Background Gallstone related diseases account for approximately one-third of emergency general surgery admissions and referrals. Acute cholecystitis (AC), a major complication of gallstones, is typically treated with laparoscopic cholecystectomies (LC), the gold standard for treating symptomatic gallstone disease. According to NICE guidelines patients with AC should preferably undergo a LC within 72 hours. Similarly, SAGES recommends that patients who can tolerate the procedure should have a LC within 24-72 hours of diagnosis. This study aimed to determine if surgical outcomes differ among patients managed within 24 hours, between 25-72 hours, and more than 72 hours from onset of symptoms. Method This retrospective analysis evaluates wait times between onset of symptoms and surgery, as well as subsequent surgical outcomes for patients booked for emergency LC over a twelve-month period from September 2022 to September 2023. The data assessed included demographics, indications, imaging results, alkaline phosphate (ALP) levels, alanine transaminase (ALT) levels, total bilirubin levels, C-reactive protein (CRP) levels, white cell count levels, american society of anaesthesiologists (ASA) grade, type of intraoperative complications, time of day operated, length of hospital stay, duration of symptoms prior to decision for surgery and wait until surgery. This data was compared against NICE and SAGES standards. Results Sixty-one patients underwent emergency LC in the twelve-month period reviewed, mean age was 49.7 years. The sample was approximately 70% (n=43) female and 28% (n=17) male. 62% (n=38) of patients were booked for a LC within 72 hours of symptom onset. 5% (n=3) of patients had their surgery within 24 hours of presenting to hospital with symptoms, 41% (n=25) had their surgery within 24-72 hours and 54% (n=33) waited more than 72 hours for their LC. 84% (n=51) of the total patients had no adverse intraoperative findings. The 16% (n=10) patients who had complications were part of all three groups. Conclusion This study found that 46% of the patients presenting with symptoms of AC undergo emergency LC within 72 hours as per NICE and SAGES guidelines. Intraoperative complications were found in all groups of patients, waiting from 0 to 72 hours for their surgery. 80% of the complications seen were in patients waiting more than 24 hours for their LC. Increasing local awareness on the importance of not delaying emergency LC by creating pathways, such as dedicated LC lists, to allow same-admission LC will enable us to adhere more closely to current guidelines and reduce morbidity from gallstone disease.

HPB SO66 - Has the Complexity of Laparoscopic Cholecystectomies Increased Following the COVID-19 Pandemic?

Abstract Background Laparoscopic cholecystectomy (LC) is recognized for its diverse complexity between cases, which profoundly influences perioperative progression and patient outcomes. It is notoriously difficult to accurately predict surgical complexity pre-operatively. The COVID-19 pandemic notably contributed to substantial delays in the definitive management of gallstone disease. The present study aimed to compare the intraoperative complexity grading of LCs performed post-pandemic with data previously reported in the literature. Method A prospectively collected database of all LCs and laparoscopic common bile duct exploration (LCBDE) performed between August 2022 and June 2024 was analysed. The database was populated from a single benign biliary center by two specialized biliary surgeons. The study focused on clinical and intraoperative parameters, with particular emphasis on assessing the cholecystectomy operative difficulty using the Nassar scale. Parameters from the database were compared with previously published data from a single surgeon over a 29-year period (n=5,391 cases). P value was calculated using Pearson uncorrected chi-square test. Results 201 patients were eligible for inclusion. Median age was 54 years (IQR 40-66) and 124 (61.7%) were female. 86 (42.8%) were emergency cases. 118 (58.7%) patients were classed as socially and economically deprived. 80 (39.8%) cases were carried out for acute cholecystitis and 48 (23.9%) were for gallstone pancreatitis. 52 (25.8%) underwent LC alone, 89 (44.3%) also had intra-operative cholangiogram and 60 (29.9%) underwent LCBDE. Grade-1 LC (33.2% vs 8%, p<0.001) were significantly less prevalent than grade-4 LC (14.2% vs 33.8%, p<0.001) in the post pandemic period when compared to the previous published data. Conclusion The present study suggests there has been an increase in the complexity and operative difficulty of LC in the immediate post COVID-19 pandemic period. The reasons are likely multifactorial, however delays in the timely management of gallstone disease, resulting in repeated episodes of acute inflammation is hypothesised to be the key driving factor. Minimising a delay to definitive treatment through the establishment of efficient dedicated biliary care pathways could reduce the incidence of complex LC. Further work is required to determine if reducing the incidence of complex LC has a beneficial impact on complications and length of hospital stay.

BN SO61 - Modern Surgical Training: A Comparative Commentary

Abstract Background Laparoscopic cholecystectomy is a cornerstone of benign upper GI surgery; approximately 3% of the population have symptomatic gallstones and over 61,000 laparoscopic cholecystectomies are performed every year in the UK (1). Whilst a relatively safe procedure, bile duct injury is an iatrogenic catastrophe with increased incidence according to the bile duct injury registry. We must consider if the requirements for completion of training (CCT) are robust enough. Indeed, non-surgeons have performed 170 laparoscopic cholecystectomies and would arguably meet the same requirements (2). Method Here we compare CCT requirements for general surgery with upper GI special interest with the requirements for certification in diagnostic endoscopy. This is a procedure performed by upper GI surgeons, with accreditation criteria determined by Joint Advisory Group (JAG) (3) rather than the Joint Committee on Surgical Training (4). Results CCT requires 110 cholecystectomies. Endoscopy requires 250 cases. Within the final 3 months of training, 95% of cases should be physically unassisted and D2 intubation and J manoeuvre should be achieved in 95% of 15 cases. Endoscopy also requires five reflections and attendance of a basic skills course. Cholecystectomy requires three level 4 PBAs (performed fluently without guidance or intervention). Endoscopy requires >25 DOPS with the 5 most recent scoring >90%. 4 summative DOPS must demonstrate competence for independent practice. After CCT, consultants undergo appraisal. After JAG accreditation there is a defined period of supervision. 100 OGDs must be performed a year. Conclusion Diagnostic OGD is an arguably safer and more simple procedure than a laparoscopic cholecystectomy. However, accreditation requirements for each procedure are wildly different. Comparatively, laparoscopic cholecystectomy lacks stringent indices and has no ongoing accreditation requirements. We suggest that a more robust process might act to combat the increasing rate of life-changing bile duct injury during laparoscopic cholecystectomy.

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

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

HPB SO68 - Evaluating the Outcome of Laparoscopic Cholecystectomy Against Key Performance Indicator (KPI) of the British Benign Upper GI Surgical Society (BBUGSS)

Abstract Background Laparoscopic cholecystectomy (LC) presents inherent challenges and potential for significant complications, influenced by both patient factors and surgical expertise. Recognizing this variability, the British Benign Upper GI Surgical Society (BBUGSS) has established Key Performance Indicators (KPIs) aimed at enhancing LC outcomes. This study conducts an audit of LC outcomes in a single centre district general hospital (DGH) in accordance with BBUGSS KPIs and thus aims to determine if quality LC by modern standards is achievable in a DGH. Method The present retrospective observational study examined all adult LC conducted between August 2022 and June 2024 by two specialized biliary surgeons at a single surgical unit within a DGH, which also serves as a referral center of biliary cases from affiliated hospitals. The analysis encompassed preoperative assessments, intraoperative observations, and postoperative outcomes, with a focus on aligning these findings against the benchmarks established by the BBUGSS KPIs. Results 141 patients were included; median age was 54 years (IQR 41-64) and 59.6% were female. 37.6% were emergency cases, 44.2% were for acute cholecystitis, 22.7% for gallstone pancreatitis and 63.1% underwent intra-operative cholangiogram. KPIsBBUGSS StandardOur resultDay case for elective cases50%42%Readmission (within 30 days)<10%4.3%Laparoscopic cholecystectomy for acute cholecystitis (within 7 days)>35%97%Laparoscopic cholecystectomy for gallstone pancreatitis (within 2 weeks)>95%100%Conversion to open<5%0.7%Morbidity<10%1.4%Bile leak after elective surgery<1.5%0%Retained bile duct stones<2.5%0%Bile duct injury<0.3%0%Mortality<0.1%0% Conclusion This study shows that with the exception of day-case rate in elective LC, all KPIs were satisfactorily achieved, indicating that high quality LC is achievable within a DGH. The majority of readmissions within 30 days were related to inadequate postoperative analgesia. We have since enhanced pain management pathways. It is hoped that this will also improve same day discharge for elective cases to achieve BBGUGS standard. We are committed to conducting annual audits to monitor and optimize surgical outcomes and would encourage other centers to consider adopting the same approach.

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

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

BN SO13 - Re-Audit of Biliary Pancreatitis Management: Enhancing Compliance with Timely Laparoscopic Cholecystectomy

Abstract Background Biliary acute pancreatitis requires timely management to prevent complications. Guidelines recommend laparoscopic cholecystectomy within two weeks of admission. A previous audit in our surgery department showed only 32.6% compliance with this guideline. This re-audit aimed to evaluate improvements in compliance, identify barriers, and provide insights for enhancing patient care. By retrospectively analyzing patient data from January to November 2023, we assessed progress and highlighted areas needing further improvement to align with established guidelines and ensure better patient outcomes. Method A retrospective analysis was conducted on a cohort of 32 patients admitted to the general surgery department with a diagnosis of biliary acute pancreatitis between January 2023 and November 2023. Patient records were reviewed to gather data on the timing of laparoscopic cholecystectomy performed within two weeks of the index admission. The compliance rate from this period was compared to a previous audit to assess improvements. Key barriers to timely intervention, such as the availability of ultrasound slots, hot gallbladder lists, and pre-assessment clinics, were also identified and analyzed. Statistical methods were used to confirm the significance of observed changes. Results he re-audit revealed a significant improvement in compliance with guidelines for the management of biliary acute pancreatitis. The percentage of patients undergoing laparoscopic cholecystectomy within two weeks of admission increased from 32.6% in the initial audit to 64.5% in the re-audit. However, the analysis identified persistent barriers to timely intervention, including limited availability of ultrasound slots, insufficient "hot gallbladder" surgical lists, and fear of difficulty of acute laparoscopic cholecystectomy. These findings highlight both the progress made and the areas needing further attention to enhance compliance and patient care. Conclusion The re-audit demonstrated a notable improvement in adherence to guidelines for the management of biliary acute pancreatitis, with a significant increase in timely laparoscopic cholecystectomy. Despite this progress, persistent barriers such as limited ultrasound availability, insufficient "hot gallbladder" lists, and pre-assessment clinics need to be addressed. Continuous evaluation and targeted interventions are essential to further enhance compliance, reduce complications, and improve patient outcomes. Ongoing efforts to refine clinical practices will help achieve the highest standards of care for patients with biliary pancreatitis.

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

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

HPB SO75 - Burden and Pattern of Gallstone-Related Acute Surgical Admissions

Abstract Background Gallstone disease accounts for nearly one-third of emergency general surgery admissions, with a considerable number resulting from recurrent episodes. Laparoscopic cholecystectomy (LC) is the only definitive treatment for gallstones. This study aimed to examine the burden and patterns of acute biliary admissions. Method This prospective cohort study was conducted over a continuous 12-week period in 2022 within a single surgical unit, focusing on all gallstone-related admissions. The total number of admissions for various surgical pathologies was documented, and the proportion due to biliary disease was determined. The analysis encompassed patient demographics, reasons for biliary admission, prior gallstone history, and any planned laparoscopic cholecystectomies (LC). Results There were 532 acute admissions, 98 (18.4%) were gallstones related. Median age was 62 years (IQR 47-72) and 58 (59.2%) were female. 40 (40.8%) had acute cholecystitis, 24 (24.5%) had gallstone pancreatitis, 16 (16.3%) had bile duct stones, 10 (10.2%) had biliary colic and 8 (8.2%) had ascending cholangitis. 43 (43.9%) patients were known to have gallstones and 26 (26.5%) patients had prior admission related to gallstones. 35.7% patients had outpatient LC, 23.5% had no documentation, 19.4% had inpatient LC, 18.4% were not fit candidates and 3.1% patients declined LC. Median total length of stay was 6 days (IQR 4-11). Conclusion In our study, the rate of biliary-related admissions was lower than previously reported in the literature. This reduction may be attributed to our semi-aggressive management approach for gallstone disease. To further improve patient outcomes, we suggest implementing more aggressive management strategies for gallstones during the initial admission for patients who are deemed fit for surgery. Such an approach could potentially reduce the recurrence of biliary admissions and enhance overall treatment efficacy.