Mild Acute Biliary Pancreatitis Research Articles

SP4.14 - Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

Abstract Aims The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) reducing the risk of early recurrence. The MANCTRA-1 project disclosed a discrepancy in translating this evidence into clinical practice, estimating a 35 to 70% probability of narrowing this gap within 2025. This study assesses the safety of suboptimal ELC implementation in MABP, looking for risk factors for recurrent acute biliary pancreatitis (ABP) in patients awaiting interval cholecystectomy after an uneventful episode of MABP. Methods We conducted a post hoc analysis of the MANCTRA-1 registry. Clinicaltrials.gov ID NCT04747990. We included MABP patients who did not undergo ELC during the index hospitalization, excluding those who experienced disease-related complications. The primary outcome was the 30-day hospital readmission rate due to ABP recurrence. We performed univariable and multivariable logistic regression to identify risk factors for 30-day ABP recurrence. Results Between January 2019 and December 2020, a total of 2,253 MABP patients from 150 centres were included. The 30-day readmission rate due to ABP recurrence was 6%. The multivariable logistic regression showed that admission to a medical ward (internal medicine or gastroenterology) odds ratio (OR) 1.62 (95%[CI] 1.1;2.37), p=0.01 was an independent risk factor for 30-day ABP recurrence. Conclusion Our real-world analysis provides valuable insights to manage MABP, particularly in centres where ELC strategies cannot be fully implemented due to organizational and clinical constraints. Despite the admitting ward, it underscores the importance of timely access to surgical care in reducing the risk of early recurrence, disclosing the need to implement surgical consultation pathways in ABP care bundles.

Impact of Serum Triglyceride Levels on Severity and Outcomes in Acute Biliary Pancreatitis: A Retrospective Cohort Study.

Background Acute biliary pancreatitis (ABP), a major inflammatory illness, is primarily caused by gallstone blockage of the common bile duct. The pathophysiology of ABP has been linked to serum triglyceride (TG) levels, suggesting a potential role for TG in predicting disease severity. Objective The research objective was to investigate the association between serum TG levels and the severity of ABP. Methodology This retrospective cohort study sought to determine the relationship between blood TG levels and the severity of ABP. It was conducted at Lady Reading Hospital in Peshawar, Pakistan, from September 2023 to March 2024. A total of 530 ABP patients were divided into two groups based on their TG levels: normal (<150 mg/dl) and elevated (≥150 mg/dl). Clinical data were gathered, including demographics, comorbidities, laboratory results, severity ratings (APACHE II and Ranson's criteria), and clinical outcomes. Descriptive statistics, Chi-square tests, and multivariate logistic regression were used in the statistical analysis. Results Patients with elevated TG levels (n=130) demonstrated higher median Ranson's criteria (3.24 vs. 2.53, p<0.001) and APACHE II scores (10.53 vs. 8.73, p<0.001) compared to those with normal TG levels (n=400). Elevated TG levels were associated with increased severity of ABP, with ORs of 2.41 (95% CI: 1.23-4.74) for mild vs. severe ABP. Clinical outcomes such as ICU admission (21.54% vs. 3.25%, p<0.001), mortality (6.15% vs. 0.50%, p<0.001), and pancreatic necrosis (10.77% vs. 1.25%, p<0.001) were significantly worse in the elevated TG group. Conclusion Elevated serum TG levels (≥150 mg/dl) are independently associated with increased severity of ABP, as indicated by higher severity scores and poorer clinical outcomes.

Is Routine Intraoperative Cholangiogram Necessary in Patients With Mild Acute Biliary Pancreatitis Undergoing Index Admission Cholecystectomy?

Background: There is controversy about whether intraoperative cholangiogram (IOC) should be performed routinely during laparoscopic cholecystectomy for patients with acute biliary pancreatitis, given significant false positive and negative rates and increased resource utilization. The aim of this study was to clarify the role of IOC in cases of mild biliary pancreatitis in patients undergoing index admission cholecystectomy, its impact on patient outcomes, and the impact of blood tests, imaging, and preoperative intervention on the detection of choledocholithiasis.Methods: A retrospective review of all patients presenting with acute mild biliary pancreatitis between January 2006 and December 2019 was conducted. Data collected included patient demographics, serum chemistry, IOC, and Endoscopic Retrograde Cholangiopancreatography (ERCP) findings, imaging findings, length of stay, operative length, and long-term follow-up outcomes.Results: 284 patients met the inclusion criteria for the study. The overall false positive IOC rate was 7.4%. Worsening bilirubin trend was a positive predictive value (PPV) for positive IOC and ERCP outcomes with a relative risk of 2.93 (P < .01) and 2.32 (P = .013), respectively. Improving preoperative bilirubin trend had a significant negative predictive value in IOC with a relative risk of .59 (P = .02). Positive IOC was shown to significantly increase operative length with a relative risk of 2.03 (P < .001).Discussion: A rising preoperative bilirubin is a predictor of a positive IOC and patients with normalizing bilirubin levels or a preoperative ERCP are less likely to have choledocholithiasis. These features may be used to select patients that would benefit from an IOC for index admission cholecystectomy.

Post-endoscopic Retrograde Cholangiopancreatography Air Leak Syndrome: An Overview of Current Perspectives

Post-endoscopic retrograde cholangiopancreatography (ERCP) air leak (PEAL) syndrome is a rare complication that includes pneumothorax, pneumomediastinum, pneumoperitoneum, air embolism, and subcutaneous emphysema. A 71-year-old female diagnosed with mild acute biliary pancreatitis, who underwent ERCP for stone retrieval developed neck, chest, and abdominal pain, as well as swelling of the neck, along with crepitus all along the neck and face. CT scan showed pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed as a case of PEAL syndrome, and was managed conservatively. She ultimately underwent an uneventful cholecystectomy with peroperative stone retrieval. PEAL syndrome, albeit rare, can be a potentially life-threatening complication following ERCP, which requires continuous monitoring. It may be managed conservatively, endoscopically, or surgically.

Post-endoscopic Retrograde Cholangiopancreatography Air Leak Syndrome: An Overview of Current Perspectives

Post-endoscopic retrograde cholangiopancreatography (ERCP) air leak (PEAL) syndrome is a rare complication that includes pneumothorax, pneumomediastinum, pneumoperitoneum, air embolism, and subcutaneous emphysema. A 71-year-old female diagnosed with mild acute biliary pancreatitis, who underwent ERCP for stone retrieval developed neck, chest, and abdominal pain, as well as swelling of the neck, along with crepitus all along the neck and face. CT scan showed pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed as a case of PEAL syndrome, and was managed conservatively. She ultimately underwent an uneventful cholecystectomy with peroperative stone retrieval. PEAL syndrome, albeit rare, can be a potentially life-threatening complication following ERCP, which requires continuous monitoring. It may be managed conservatively, endoscopically, or surgically.

Safety and Efficacy of Early Cholecystectomy in Acute Biliary Pancreatitis

Objective: This study was done to assess the safety and efficacy of early Cholecystectomy in mild to moderate Acute Biliary pancreatitis in own surgical setup.&#x0D; Methodology: This descriptive study was done in surgical unit 1, Fauji Foundation Hospital Rawalpindi from 1st January 2019 to 31st December 2022. Total 70 patients diagnosed as having mild or moderate acute biliary pancreatitis were included in study. Patients having severe acute biliary pancreatis, multi-organ dysfunction syndrome and pre-existing severe medical co-morbidity were excluded from study. After informed consent early cholecystectomy either laparoscopic or open was performed by senior consultant surgeon within 2-4 days of admission. Post-operatively patient subjective feeling of pain, intravenous analgesia and hospital stay were recorded. Post-operative complications were documented. Data were analyzed on SPSS version 26.&#x0D; Results: The age range was from 28 to 72 years with a mean of 45.2 ± 11.86 years. Majority of patients were of mild severity 44(62.9%), while 26(37.1%) cases were of moderate severity. Laparoscopic cholecystectomy was performed 28(40%) cases and open cholecystectomy was done in 38(54.28%) cases. Post-operative pain numerical scale mean was 4.31 ± 1.55. The duration of requirement of post-operative intravenous analgesia was mean 37.02 ± 18.12 hrs. Mean hospital stay of patients was 5.95 ± 1.39 days. Among post-operative complications, the most frequent was post prandial dyspepsia 10(14.3%) cases followed by surgical site infection 6(8.6%) cases, recurrent pancreatitis 4(5.7%) cases, pseudocyst formation 2(2.9%) cases, lobar pneumonia 1(1.4%) case and recurrent biliary sepsis in 1(1.4%) case.&#x0D; Conclusion: Early cholecystectomy is a safe surgical procedure in mild to moderate biliary pancreatitis. It shortens the course of illness, prevents complications and reduces hospital stay.&#x0D; KEYWORDS: Cholelithiasis, Acute biliary pancreatitis, cholecystectomy, safety, Efficacy.

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.

Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis.

Endoscopic retrograde cholangiopancreatography (ERCP) within 72h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24h) improved outcomes compared to early ERCP (24-72h) in patients admitted with predicted mild ABP. Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs). Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3days (IQR 3-4), p < 0.01]. Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue. To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP. This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023. Mortality and morbidity after EC. Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P < .001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003). This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC.

External application of mirabilite before surgery can reduce the inflammatory response and accelerate recovery in mild acute biliary pancreatitis

ObjectiveMild acute biliary pancreatitis (MABP) is one of the most common diseases that require surgical treatment. Previous studies have focused on the timing of laparoscopic cholecystectomy (LC) for MABP. However, the impact of its inflammatory response process on the clinical outcome has been rarely reported. This study aimed to investigate the effect of preoperative external application of mirabilite on the inflammatory response and clinical efficacy in MABP.MethodsMedical records of patients undergoing LC due to MABP from November 2017 to June 2022 were retrospectively reviewed. Prior to surgery, the control group received the same baseline treatment measures as the study group. The difference was the addition of external application of mirabilite in the study group.ResultsA total of 75 patients were included in the final analysis: 38 patients in the mirabilite group and 37 patients in the control group. Repeated-measures ANOVA (P < 0.01) showed that the white blood cell count (WBC) on the 3rd day of admission and the WBC and C-reactive protein (CRP) level on the 5th day of admission decreased rapidly and significantly in the mirabilite group, compared with the control group. The mirabilite group had earlier anal exhaust time. The number of patients in the mirabilite group and control group with gallbladder wall ≥ 3 mm before the operation was 16 (42.11%) vs. 24 (64.86%), p = 0.048, respectively; and the number of cases with surgical drain placement was 2 (5.26%) vs. 9 (24.32%), p = 0.020, respectively. The intraoperative modified American Fertility Society (mAFS) score of adhesions was lower in the mirabilite group (1.08 ± 0.59 points) than in the control group (1.92 ± 0.60 points), p = 0.000. The mirabilite group, compared to the control group, p = 0.000, had a short waiting time for surgery (5.68 ± 0.70 days vs. 6.54 ± 0.59 days), short operation time (38.03 ± 5.90 min vs. 48.51 ± 8.37 min), and reduced hospitalization time (8.95 ± 0.96 days vs. 9.84 ± 1.07 days).ConclusionThis study demonstrated that preoperative external application of mirabilite can reduce the inflammatory response, decrease the edema and peribiliary adhesions at the surgical site, and accelerate recovery in MABP.

The 2023 MANCTRA Acute Biliary Pancreatitis Care Bundle: A Joint Effort Between Human Knowledge and Artificial Intelligence (ChatGPT) to Optimize the Care of Patients With Acute Biliary Pancreatitis in Western Countries.

To generate an up-to-date bundle to manage acute biliary pancreatitis using an evidence-based, artificial intelligence (AI)-assisted GRADE method. A care bundle is a set of core elements of care that are distilled from the most solid evidence-based practice guidelines and recommendations. The research questions were addressed in this bundle following the PICO criteria. The working group summarized the effects of interventions with the strength of recommendation and quality of evidence applying the GRADE methodology. ChatGPT AI system was used to independently assess the quality of evidence of each element in the bundle, together with the strength of the recommendations. The 7 elements of the bundle discourage antibiotic prophylaxis in patients with acute biliary pancreatitis, support the use of a full-solid diet in patients with mild to moderately severe acute biliary pancreatitis, and recommend early enteral nutrition in patients unable to feed by mouth. The bundle states that endoscopic retrograde cholangiopancreatography should be performed within the first 48 to 72 hours of hospital admission in patients with cholangitis. Early laparoscopic cholecystectomy should be performed in patients with mild acute biliary pancreatitis. When operative intervention is needed for necrotizing pancreatitis, this should start with the endoscopic step-up approach. We have developed a new care bundle with 7 key elements for managing patients with acute biliary pancreatitis. This new bundle, whose scientific strength has been increased thanks to the alliance between human knowledge and AI from the new ChatGPT software, should be introduced to emergency departments, wards, and intensive care units.

Immediate feeding tolerance in patients with mild acute biliary pancreatitis

Immediate feeding tolerance in patients with mild acute biliary pancreatitis

Outcome of Early Cholecystectomy in Mild Biliary Pancreatitis

Acute biliary pancreatitis (ABP) caused by gallstones and biliary sludge1 is the most important cause of Acute Pancreatitis (AP). Aim: Effect of early cholecystectomy in mild acute biliary pancreatitis. Methods: This was a hospital based observational study, by convenience sampling recruited 60 patients of mild acute biliary pancreatitis eligible as per inclusion criteria within study duration of one year reported at Department of Surgery, Sardar Patel Medical College, PBM Hospital, Bikaner. Results: mean age was 44.76±9.88 yr (range 30- 70), 60% were female, 51.67% had pain &amp; nausea as chief complaint, 71.66% patients had Cholelithiasis on MRCP. 6.68% had 3 CT severity score preoperatively whereas 1.66% had 3 CT severity score postoperatively. 56.67% cases had surgery after 72-96 hr. Success rate of early cholecystectomy was 98.33%. 56.67% cases had surgery after 72-96 hr mean 101.6± 14.89 hr. Only one case had recurrence on 3 months follow up. Conclusion: Early Cholecystectomy for patients with acute mild gallstone pancreatitis was found to be a safe procedure when performed during the index admission. Keywords: Early Cholecystectomy; Biliary pancreatitis. Introduction Acute biliary pancreatitis (ABP) caused by gallstones and biliary sludge1 is the most important cause of Acute Pancreatitis (AP), accounting for up to 75% of cases.2 Although most cases of ABP are mild and Self-limiting, a small group (20%) of patients may develop severe pancreatitis, which is associated with high morbidity and mortality.3 Commonly, after resolution of the initial attack of APB, patients may experience a recurrent attack (40% to 60%) within 2 weeks or other gallstonerelated complications such as biliary colics, acute cholecystitis, acute cholangitis or common bile duct (CBD) obstruction. Acute pancreatitis is a common disease in the emergency room with an annual incidence rangin.

Optimal Timing and Outcomes of Minimally Invasive Approach in Acute Biliary Pancreatitis.

BackgroundWe analyzed the outcomes of early biliary decompression by a minimally invasive approach in acute biliary pancreatitis (ABP).Material/MethodA retrospective study was conducted on 143 patients with ABP who underwent biliary decompression by laparoscopic or endoscopic approach between January 2015 and March 2022. Data from the observation sheets and surgical protocols were analyzed in terms of demographic characteristics, clinical and paraclinical features at admission, comorbidities, therapeutic management, and outcomes.ResultsThe mean patient age was 62.3±11.4 years. Mild ABP had a higher frequency in men (75.5%) and urban areas (70.4%). The comorbidities associated with a higher risk of severe forms were diabetes mellitus (odds ratio [OR]: 11.250), chronic bronchopneumopathy (OR: 29.297), and ischemic coronary disease (OR: 2.784). The mean hospital stay was 7.6±3.8 days and was significantly higher in severe forms (10±2.4 days, P<0.001). The time from onset to presentation was significantly higher in severe vs mild forms (5.6 vs 1.8 days, P<0.001) and was associated with systemic and local complications. Creatinine over 2 mg/dL (OR: 4.821) and leukocytes >15 000/mmc at admission (OR: 3.533) were risk factors for systemic complications, while obesity was associated with increased local complications (OR: 5.179). None of the patients with an early presentation developed severe ABP.ConclusionsEarly biliary decompression, as soon as possible after onset, either by an endoscopic or minimally invasive approach, is a safe and effective procedure in ABP. The type of procedure and optimal timing should be individualized, according to the patient’s local and general features.

Early Versus Interval Cholecystectomy in Mild Acute Biliary Pancreatitis. A Retrospective Study in Tertiary Care Hospital

Objective: The objective is to determine the adequacy of early cholecystectomy (EC) versus interval cholecystectomy (IC) in terms of recurrence, duration of hospital admission, and perioperative complications after mild acute biliary pancreatitis (MABP). Methodology: After endorsement from the ethical committee, clinical data and files of all the admitted patients having MABP in the general surgery department of Holy Family Hospital, Rawalpindi, was collected retrospectively from August 2017 to July 2020. The patients’ demographic profile, clinical findings, diagnostic investigations, timing of cholecystectomy, operating surgeons, operative time, biliary complications, intraoperative bleeding, conversion rate, duration of admission, and recurrence were reviewed. Patients presented with abdominal pain, vomiting, jaundice, or fever. The diagnosis was confirmed on the basis of a CT scan of the abdomen showing an inflamed pancreas and stones in the gallbladder. Outcomes were compared and reviewed between the two groups. Results: In this research proposal, 263 patients admitted were analyzed. EC was performed were discharged after conservative management and followed up after 12 weeks for interval laparoscopic cholecystectomy (IC). It was observed in patients of IC (EC 2 [1.2%] vs IC 7[7%]; p value &lt;0.01) while duration of hospitalization was prolonged as compared to patients of EC (EC 5.53+0.58days vs IC 5.82+0.78days; p value &lt;0.001). lar in both EC and IC. Conclusion: EC performed after MABP is associated with shorter duration of hospitalization and reduced recurrence with similar rate of perioperative complications.

Early Versus Delayed Cholecystectomy for Acute Biliary Pancreatitis: A Systematic Review and Meta-Analysis.

Recommendations regarding the timing of cholecystectomy for acute biliary pancreatitis (ABP) require a systematic summary of current evidence to guide clinical practice. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing early cholecystectomy (EC) versus delayed cholecystectomy (DC) in patients with ABP. We searched databases Medline, Embase, SCOPUS, Web of Science and Cochrane CENTRAL for randomized controlled trials addressing this question. Pairs of reviewers abstracted data and assessed the risk of bias in included studies. A random-effects meta-analysis was done to study the effect of the timing of cholecystectomy on outcomes of interest in patients with ABP. GRADE methodology was used to rate the quality in the body of evidence for each outcome as high, moderate, low, or very low. 11 randomized trials (1176 participants) were included. High-quality evidence from seven RCTs (867 participants) showed a statistically significant reduction in the risk for recurrent biliary events in favour of early cholecystectomy (RR 0.10, 95% CI 0.05 to 0.19, I2 = 0%). High-quality evidence from five trials was in favour of early cholecystectomy with a significant reduction in the risk 7of recurrent pancreatitis (RAP) in comparison to delayed cholecystectomy (RR 0.21, 95% CI 0.09 to 0.51, I2 = 0%). This review showed that EC has definite advantages over DC in terms of reducing recurrent pancreaticobiliary events and LOS following mild ABP. However, more RCTs are required to study the role of EC in patients with moderately-severe and severe ABP. Trial Registration Protocol registered on Prospero (CRD42020192823).

14 NICE CG188; Hot Gall Bladder Pathway in Emergency General Surgery - Are We Following the Guidelines?

Abstract Aim 1 - To compare the current standard of practice to existing guidelines and to make appropriate changes. 2 - To set a clear pathway for referring patients to the ‘hot laparoscopic cholecystectomy’ pathway. 3 - Avoid inappropriate booking for laparoscopic Cholecystectomy for patients who are not fulfilling the criteria of Hot Gall Bladder Pathway. 4 - Avoid unnecessary delay in performing Laparoscopic Cholecystectomy in patient with Acute Cholecystitis and mild Biliary Pancreatitis. Method It was a retrospective audit of all the patients who underwent Laparoscopic Cholecystectomy through Hot Gall Bladder Pathway between 1st February 2019 to 1st March 2020. We screened a total of 134 patients who had been included in this pathway, 36 patient excluded. 1- Acute cholecystitis with no associated organ dysfunction 63 patients 2- Mild Acute Biliary Pancreatitis 35 patients Results Mild Acute Biliary Pancreatitis who underwent Laparoscopic Cholecystectomy within index admission or within 2 weeks of diagnosis 69 % (25/35). Acute cholecystitis with no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or II) who underwent Laparoscopic Cholecystectomy within week of diagnosis 68.2 % (43/63). Conclusions

Comparison of Early and Late Laparoscopic Cholecystectomy Results in the Treatment of Mild and Moderate Acute Biliary Pancreatitis

Comparison of Early and Late Laparoscopic Cholecystectomy Results in the Treatment of Mild and Moderate Acute Biliary Pancreatitis

Predictors of same-admission cholecystectomy in mild, acute, biliary pancreatitis.

Failure to perform same-admission cholecystectomy (SA-CCY) for mild, acute, biliary pancreatitis (MABP) is a recognized risk factor for recurrence and readmission. However, rates of SA-CCY are low and factors associated with these low rates require elucidation. Primary MAPB admissions were pooled from NIS 2000-2014 (weighted n=578258). Patients with chronic pancreatitis, pancreatic masses, alcohol-related disorders, hypertriglyceridemia, acute cholecystitis and AP-related organ dysfunction or complications were excluded. Annual rates of SA-CCY were calculated. Regression model for prediction of SA-CCY was built on 2010-2011 subset (weighted n=74169), yielding 96.3% of complete observations. Nationwide rate of SA-CCY in the U.S. was 40.8%. In multivariate analysis, SA-CCY was positively associated with BMI>30 (OR=1.4, 95%CI 1.2-1.6), Asian ethnicity (vs. Black; OR=1.2, 95%CI 1.0-1.5), private insurance (vs. Medicare; OR=1.1, 95%CI 1.0-1.3), large (vs. small; OR=1.3, 95%CI 1.2-1.4) urban hospitals (vs. rural; OR=1.5 95%CI 1.3-1.7) of the South (vs. Northeast; OR=1.5, 95%CI 1.3-1.7), as well as with chronic cholecystitis (OR=17.0, 95%CI 15.4-18.7) and abdominal-wall hernias (OR=5.2; 95%CI 3.0-8.9); the latter two predictors were not included in the final model. SA-CCY was negatively associated with age >40 (OR=0.72; 95%CI 0.66-0.79), male gender (OR=0.86, 95%CI 0.80-0.93), dementia (OR=0.88, 95%CI 0.72-1.1), chronic comorbidities (OR=0.64; 95%CI 0.54-0.77) and ostomies (OR=0.51; 95%CI 0.31-0.86). Adherence to SA-CCY guidelines for MABP remains inadequate. Independent geographic variation in SA-CCY rates may be related to reimbursement differences, ownership of AP patients, accessibility to surgical care, or cultural characteristics of the patient population.

Prospective study of EUS guided ERCP or IOC approach in the detection of common bile duct stones in patients undergoing cholecystectomy

Introduction: Choledocholithiasis (common bile duct stones) develops in up to 20 percent of patients with gallbladder stones. It is generally accepted that stones in the common bile duct (CBD) should be removed, even if patients are asymptomatic, because they may be associated with severe complications such as pancreatitis and cholangitis. Materials and Methods: This is a Prospective and analytical study conducted at Department of Surgical Gastroentrology in a Tertiary care Teaching Hospital with suspected common bile duct stones consenting to study protocol were recruited and outcome on management was recorded for each arm of the study over a period of 1 year. In positive EUS group, therapeutic ERCP was performed at the same EUS session or later if CBD stone was found. In the EUS group negative for CBD stones, IOC was performed during laparoscopic cholecystectomy. Result: Mean patient age was 62 years (range, 44 to 74 years), 12 were women and 7 men. Eight of 19 patients (42%) had undergone a previous cholecystectomy; none had undergone previous ERCP. Seven patients (37%) had mild acute biliary pancreatitis (Glasgow score &lt;3) at admission. Six patients, who were referred by other hospitals for EUS, previously had undergone MRCP without evidence of biliary stones. Conclusion: MRCP and EUS have only diagnostic roles, and ERCP is needed for therapeutic purposes. It has been suggested that, when CBDS are found at EUS, they should be treated in the same session. Ideally EUS should be performed in a facility that allows ERCP and to be performed immediately thereafter with no interruption.