Gallstones Research Articles

Intragallbladder versus intravenous indocyanine green (ICG) injection for enhanced bile duct visualization by fluorescent cholangiography during laparoscopic cholecystectomy: a retrospective cohort study.

Iatrogenic bile duct injuries (BDIs) prevention during laparoscopic cholecystectomy (LC) relies on meticulous anatomical dissections through direct visualization. Near-infrared fluorescence (NIRF) with indocyanine green (ICG) improves the visualization of extrahepatic biliary structures. Although ICG can be administered either intravenously or intragallbladder, there remains uncertainty regarding the optimal method for different patient populations. This study sought to assess the suitability of each method for specific patient groups. Between October 2021 and May 2022, 59 consecutive patients underwent fluorescence-guided LC at West China Hospital of Sichuan University. Among them, 32 patients received an intravenous injection of ICG (10 mg) 10 to 12 hours prior to surgery (Group A: the intravenous group), while 27 patients received an intragallbladder injection of ICG (10 mg) (Group B: the intragallbladder group). Baseline clinical factors, inclusion criteria, and measurements of parameters and complications were assessed. Data were retrospectively collected and analyzed to evaluate the comparability of the two groups and the clinical outcomes. Groups A and B included 32 patients (18 males, 14 females), and 27 patients (13 men, 14 women), respectively. In our statistical analysis, significant differences were observed in preoperative diagnoses between the two groups (P=0.041), but the majority of other baseline clinical factors were comparable. Notably, no statistically significant differences were found in complication rates. However, Group A had a shorter operative time (60.38±9.35 vs. 66.78±9.88 min, P=0.01) and superior bile duct fluorescence (P=0.04) than Group B. Interestingly, fluorescence was not observed in impacted gallbladder stones in Group B. Additionally, patients with cirrhosis (P=0.008) and fatty liver (P=0.005) in Group B had higher common bile duct-to-liver ratios (BLRs) than those in Group A. ICG fluorescence cholangiography allows to visualize extrahepatic biliary anatomical structures with both administration methods. However, the efficacy of bile duct fluorescence varies with different administration routes in diverse patient populations. Hence, appropriate administration route selection for ICG should be tailored to individual patients.

CANVAS For A Diagnosis: Can You Hear The Hooves Of Zebras?

Abstract Background A 75year old male presented to a Movement Disorder Service with complex multimorbidity including: chronic pain, type 2 diabetes mellitus, hypoventilatory obesity syndrome, biliary calculus, moderate aortic stenosis, marked orthostatic hypotension, pulmonary hypertension, coronary artery bypass grafting, permanent pacemaker for complete atrioventricular block, carpal tunnel release bilaterally, polypharmacy and bilateral cataracts. History elucidated a distal to proximal sensory loss over 20years and neuropathic pain without nerve conduction confirmation; and progressively ataxic gait over several years. He also complained of hypophonia, bruxism, excessive daytime somnolence, passages, transitions, visual agnosia, textural illusion, oscillopsia, irritability, inflexibility, hoarding, impulsivity, disorganisation, inattention, apathy, depression and aspontaneity. He was intolerant of nocturnal continuous positive airway pressure device. Epworth score was 21. Methods Examination demonstrated: marked orthostatic hypotension, preserved cognition, hypersomnolence, dyspraxic dysgraphia, palmar and antecubital agraphaesthesia, downbeat horizontal nystagmus at eccentric gaze positions, square wave jerks, bidirectionally impaired head impulse test, dysmetric saccades, asymmetric cerebellar signs in upper and lower limbs, rightward Pisa syndrome, kinesigenic dystonic axial posturing, rightward laterocollis and equivocal Babinski/Oppenheim reflexes. Gait assessment demonstrated sensory and cerebellar ataxic features with marked apraxia. No pes cavus. Results Computed tomography of brain had Fazekas 1 small vessel disease, Medial temporal atrophy score 1, Koedam 1 and age-commensurate cerebral and cerebellar atrophy. RFC1 gene testing confirmed biallelic intronic AAGGG repeat expansion disorder. Conclusion Cerebellar Ataxia Neuropathy and Vestibular Areflexia Syndrome (CANVAS) should be considered in patients with presentations from mid-life of progressive sensory ataxic neuropathy, altered vestibular ocular reflex, gaze evoked nystagmus and prominent dysautonomia. CANVAS is a rare autosomal recessive genetic disorder with a protean presentation. Referral to Genetics Services should be undertaken for family counselling. Keeping an open mind in complex, multimorbid patients to a potentially unifying diagnosis is important to guide prognostication. The rumble of hooves in the distance is not always that of horses.

Parameters for safe dissection at Calot's Triangle in Laparoscopic Cholecystectomy.

To explore the parameters critical to safe laparoscopic cholecystectomies. The prospective study was conducted at Al-Yarmook Teaching Hospital, Baghdad, from May 1, 2020, to December 31, 2021, and comprised patients with gall-stone disease who were admitted for laparoscopic cholecystectomy. Consecutive non-probability sampling technique was used for collecting the data which was analysed using SPSS (version 25). Of the 93 patients, 68(73.12%) were females, and 25(26.88) were males. The overall mean age was 40.7±8.1 years, and 52(55.91%) patients were aged >40 years. Calot triangle was seen in 72(77.4%) cases, while the sulcus of Rouviere, duodenum and right hepatic artery were spotted in 50(53.8%), 49(52.7%) and 19(20.4%) cases, respectively. There was a significant association of late presentation, lateral traction, 4-port option, good setting and difficult anatomy with anatomical landmark visualisation (p<0.05). There is a need for a national guideline to ensure safe laparoscopic cholecystectomy.

Investigating causal links between gallstones, cholecystectomy, and 33 site-specific cancers: a Mendelian randomization post-meta-analysis study

Background and aimThe association between gallstones/cholecystectomy and cancer remains inconclusive in the current literature. This study aimed to explore the causal connections between gallstones/cholecystectomy and cancer risk by utilizing a bidirectional two-sample multivariable Mendelian randomization approach with Genome-Wide Association Studies data.MethodsUtilizing Genome-Wide Association Studies data from the UK Biobank and FinnGen, this research employed multivariable Mendelian randomization analyses to explore the impact of gallstones and cholecystectomy on the risk of 33 distinct cancer types. Instrumental variables for gallstones and cholecystectomy were carefully selected to ensure robust analyses, and sensitivity and heterogeneity tests were conducted to verify the findings’ validity.ResultsMultivariable Mendelian randomization analysis, incorporating data from more than 450,000 individuals for gallstones and cholecystectomy, revealed nuanced associations with cancer risk. Cholecystectomy was associated with a significantly increased risk of nonmelanoma skin cancer (OR = 1.59, 95% CI: 1.21 to 2.10, P = 0.001), while gallstones were linked to a decreased risk of the same cancer type (OR = 0.63, 95% CI: 0.47 to 0.84, P = 0.002). Interestingly, the analysis also suggested that cholecystectomy may lower the risk of small intestine tumors (OR = 0.18, 95% CI: 0.043 to 0.71, P = 0.015), with gallstones showing an inverse relationship, indicating an increased risk (OR = 6.41, 95% CI: 1.48 to 27.80, P = 0.013).ConclusionsThe multivariable Mendelian randomization analysis highlights the differential impact of gallstones and cholecystectomy on cancer risk, specifically for nonmelanoma skin cancer and small intestine tumors. These results underscore the importance of nuanced clinical management strategies and further research to understand the underlying mechanisms and potential clinical implications of gallstone disease and cholecystectomy on cancer risk.

Nutritional and potential health benefits of chufa oil, olive oil, and anhydrous milk fat against gallstone disease in a C57BL/6N mouse model.

Dietary lipids play a major role in many diseases, particularly cardiovascular diseases. Recently, the health value of plant oils, particularly heart health, has been recognized. Despite these facts, limited information is available on the potential nutritional and anti-arteriolosclerosis effects of chufa oil, olive oil, and anhydrous milk fat in C57BL/6N mice. In the present study, the effects of olive oil (OO), chufa oil (CO), and anhydrous milk fat (AMF) on 4-week-old C57BL/6N male mice, a model for studies of diet-induced atherosclerosis, were investigated. The AIN-93G-based diet was supplemented with 15% of either OO, CO, or AMF. The final mixture of the diets contained 15% fat, approximately 1.25% cholesterol, and 0.5% sodium cholate. The data obtained showed that most mice had gallstone disease. The highest percentage of the gallstones formed were found in AMF groups (approximately 85.7% of the mice). However, the lowest one was found in the chufa oil group (42.9%), followed by the olive oil group (57.1%). Although the mice's food intake significantly differed, their body weights did not change during the feeding period. The diet supplemented with CO resulted in a significant reduction in serum cholesterol compared with the other groups. Livers from the CO-fed group showed higher triglyceride levels than those from the AMF group. No significant differences were found in atherosclerotic lesions in the aortic valve between the groups. Collectively, our results show no deleterious nutritional effects of the fats used on C57BL/6N mice fed cholesterol-rich diets. Chufa oil improved cholesterol metabolism and atherogenic index in mice. However, the major issue is the formation of gallstones in all mice, which is most prominent in AMF, followed by olive oil and chufa oil diets.

Efficacy of Upper Gastrointestinal Endoscopy In Cholelithiasis Before Laparoscopic Cholecystectomy

Background: The most prevalent condition affecting the gallbladder and biliary tree is cholelithiasis. Presence of gall stones is discovered commonly during imaging tests for other pathologies. Laparoscopic cholecystectomy is a preferred modality for the treatment of gallstone disease. Objective: The primary aim of the study is to determine the efficacy of upper gastrointestinal endoscopy as a routine investigative modality in symptomatic presentation of cholelithiasis prior to laparoscopic cholecystectomy. Methods: A total 50 participants having single or multiple stones in the gall bladder found on ultrasound were included in the study. Enrolled patients underwent routine investigations. The baseline demographic details like patient name, age, gender, clinical presentation, and upper endoscopy findings were documented. The intensity of the pain was measured by visual analogue scale. Results: A total of 36% patients were in the age-group of &lt; 30 years. The highest incidence of cholelithiasis was observed in female gender. Abdominal pain was the most common symptom. The most common upper gastrointestinal endoscopy findings were gastritis followed by gastritis erosion. A significant reduction of pain was noted in group I as compared to group II at first- and fourth-week time durations. Conclusion: Cholelithiasis has common clinical presentations in similarity to other upper gastrointestinal diseases. Upper gastrointestinal endoscopy can be recommended for patients with atypical presentation to prevent post-surgical adverse outcomes.

Risk Factors for Gallstones in Crohn's Disease: A Systematic Review and Meta-Analysis.

Crohn's disease (CD) have an increased risk of gallstone disease. We aimed to systematically evaluate the prevalence rate and relevant risk factors of gallstones in CD patients. A comprehensive search of PubMed, Embase, and Web of Science databases from inception to September 10, 2023, identified studies investigating risk factors for gallstone development among CD patients. Gender, age, body mass index, disease duration, disease site, stenosis, prior surgery, hospitalization times, corticosteroids, immunomodulators, and total parenteral nutrition (TPN) were assessed as potential risk factors. Odds ratios (OR) and confidence intervals (CI) were calculated. Among 1184 articles, 11 observational studies (3588 patients) were included. The prevalence of CD patients with gallstones was approximately 14.7%. Factors significantly associated with increased gallstone risk included Age ≥ 40years old (OR 3.06, 95% CI 2.09- 4.48), disease duration > 15years (OR 3.01, 95% CI 2.06-4.42), lifetime surgery(OR 2.50, 95% CI 1.99-3.12), disease located in ileocolon (OR 1.38, 95% CI 1.04-1.83) and ileocecal(OR 1.93, 95% CI 1.16-3.21), multiple hospitalizations(OR 4.26, 95% CI 2.43-7.46), corticosteroid treatments(OR 2.65, 95% CI 1.52-4.63), immunomodulator therapy(OR 1.94, 95% CI 1.12-3.38), and TPN use(OR 2.66, 95% CI 1.29-5.51). Sex, stenosis, overweight, or low weight did not significantly increase the risk of gallstone developing. Age, long disease duration, specific disease locations (ileocolon, ileocecal), surgery, number of hospitalizations, corticosteroids, immunomodulator therapy, and TPN were identified as factors that increased the risk of gallstones in CD patients. About 14.7% of CD patients experience gallstones, so raising awareness and implementing prevention are needed. PROSPERO (CRD42023449299).

ArtiSential® laparoscopic cholecystectomy versus single-fulcrum laparoscopic cholecystectomy: Which minimally invasive surgery is better?

In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential® LC with those of single-fulcrum LC. This retrospective study compared ArtiSential® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain. A total of 88 and 63 patients underwent ArtiSential® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01). ArtiSential® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential® LC is considered the better option for patients, compared to single-fulcrum LC.

Pre-Operative Evaluation of Risk Factors for Difficult Laparoscopic Cholecystectomy

Cholelithiasis or the gallstone disease is the most common biliary pathology. 10-15% population of western world is estimated to be affected by gallstone disease, of which majority remains asymptomatic (&gt;80%) and 1-2 % of these asymptomatic patients will develop symptoms needing surgery per year. In this prospective study, 77 patients years undergoing elective Laparoscopic Cholecystectomy (LC) and meeting all inclusion criteria in Department of General Surgery, Nepal Medical College and Teaching Hospital over period of 1 year. History, detailed clinical examination and laboratory investigations were performed as per the working proforma. Operative time and conversion to open cholecystectomy were recorded. The association between clinical, laboratory and sonographic factors with difficult laparoscopy were obtained. Data analysis was done using SPSS-17 version. Out of 77 patients, 63 were females. Body mass index (BMI) above 30 representing obese population were 33.2% with p value 0.0004. Also, 41.5% patients had history of acute cholecystitis while 12.9% patients had previous history of abdominal surgery and 70.1% patients had history of recurrent abdominal pain. Total of 19.4% patients had increased leucocyte count. On ultrasonography thickened GB wall of &gt;3 mm was seen in 42.8%, distended GB was seen in 41.5%, stone size of &gt;1 cm was seen in 70.1% patients and multiple stones were seen in 84.4%. Similarly, duration of surgery was &gt;90 mins in 31.1% and 7.04% patients underwent conversion to open cholecystectomy both of which were considered difficult laparoscopy. Our study reveled that clinical factors like age, BMI, history of acute cholecystitis, previous history of recurrent abdominal pain and past history of abdominal surgery had significant association in prediction of difficult LC.

Teleradiology-Based Referrals for Patients with Gastroenterological Diseases Between Tertiary and Regional Hospitals: A Hospital-to-Hospital Approach.

Teleradiology is recognized for fostering collaboration between regional and tertiary hospitals. However, its application in gastroenterological diseases remains underexplored. This study aimed to assess the effectiveness of teleradiology in improving gastroenterological care. This retrospective study analyzed patients with gastroenterological diseases in a tertiary hospital who were referred from a regional hospital using a cloud-based radiology image-sharing system between July 2020 and June 2023. Our primary focus was to conduct a descriptive statistical analysis to evaluate patient characteristics and the referral process and analyze the timeframes from referral to transfer and from the start of treatment to discharge and the outcomes. We analyzed 56 patients, with 45 (80.4%) presenting hepatobiliary pancreatic disease. The most frequent condition was common bile duct stones (17 cases). Forty-nine cases were transferred for inpatient treatments, four underwent endoscopic examinations as outpatients, and two had imaging consultation without subsequent hospital visits. On referral day, 16 patients were transferred, and the remaining 33 (67.3%) were placed on a waiting list starting from the subsequent day. The median time from referral to admission was 1day (range: 0-14days), and the median time from referral to treatment was 2days (range: 0-14days). Remote image-sharing systems ensure accurate imaging at referral, preventing care delays. In collaboration with regional and tertiary hospitals, teleradiology may also be useful for gastroenterological diseases.

Unmasking The Prevalence Of Subclinical Hypothyroidism In Gallbladder Stone Patients: Prospective Study From A Tertiary Care Institute

Unmasking The Prevalence Of Subclinical Hypothyroidism In Gallbladder Stone Patients: Prospective Study From A Tertiary Care Institute

The incidence of complications in Laparoscopic Cholecystectomy in Acute Cholecystitis in tertiary Care Setup

Abstract Laparoscopic cholecystectomy is the procedure usually performed in our setups for both acute &amp; chronic Cholecystitis and simple gall stone disease. Objective Find the outcomes of laparoscopic cholecystectomy in acute cholecystitis in our hospital setup. Methods This prospective cross sectional study was conducted in Hazrat Bari Sarkar Hospital Islamabad on 10th Nov 2022 to 30 June 2023. The patients from above 10 year age with both genders were included by convenient sampling. All Diagnosed cases of gall stone disease with acute cholecystitis, acute on chronic cholecystitis, abscess, and empyema or mucocele gall bladder were included in this study. SPSS 22 was used for data analysis that was recorded on a performa. Results This study included 77 laparoscopic cholecystectomies done for Acute Cholecystitis. 53 female &amp; 24 male patients with female to male ratio of 2.2:1 undergoing laparoscopic cholecystectomies were included in the study. The mean age of patients was 47.6 years + 11.6 SD. The mean operative time was around 90min + 13.5 SD and the mean hospital stay was 2.23 days + 0.77 SD with a range of 1-4 days. Conversion rate to open cholecystectomy was noted in 8 cases. The operative complications were bleeding in 2 cases, minor bile duct injury in 2 cases, surgical site infection 15 cases, retained stone in 2 cases. Conclusion Laparoscopic cholecystectomy for acute cholecystitis has better results in patient outcomes as regards post-operative recovery &amp; length of hospital stay &amp; safety.

Association of apolipoprotein E gene polymorphism with gallstone disease in Iraqi Kurdish women

Gallstone disease (GSD) is a worldwide problem; the frequency of GSD varies greatly amongst different ethnic groups, possibly due to environmental and genetic factors. One circulating lipoprotein involved in lipid metabolism is apolipoprotein E (APOE). The APOE gene is polymorphic, has three distinct alleles, APOE2, APOE3, and APOE4. The an APOE polymorphism is linked to a variety of diseases, including Alzheimer's and type-two diabetes, so this study aimed to assess the relationship among various APOE genotypes and alleles with gallstone cases in Iraqi Kurdish women. The present case-control study involved 81 cases with laparoscopic cholecystectomy for gallstone disease and 80 healthy women without GSD. Genomic DNA samples were taken from blood to find the genotype of APOE using allele-specific sequence-primers and a method based on polymerase chain reaction (PCR). lipid profiles were examined using an automated biochemical analyzer. SPSS and GraphPad Prism 9.1.1 software were used to conduct the statistical analysis. No significant relationships were found between healthy people and GSD patients in genotype and allele frequencies. However, the genotype for E3/E4 and the APOE4 allele in GSD patients were higher than the controls (9.88% vs. 5.0% and 4.94% vs. 2.5%, respectively; P &lt;0.05) but statistically nonsignificant. serum levels of cholesterol, low-density lipoproteins, and very low-density lipoproteins were higher, and the levels of serum high-density lipoprotein was lower than controls. These findings revealed no connection between the examined polymorphisms and gallstone cases. Additionally, it was demonstrated that gallstone disease and lipid parameters had a favorable relationship. Keywords: Apolipoprotein E, APOE, Gallstone disease, Genotype, Polymorphisms.

Fenestrating vs reconstituting laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis.

Laparoscopic cholecystectomy is one of the most frequently performed procedures by general surgeons. Strategies for minimizing bile duct injuries including use of the critical view of safety method, as outlined by the SAGES Safe Cholecystectomy Program, are not always possible. Subtotal cholecystectomy has emerged as a safe "bail-out" maneuver to avoid iatrogenic bile duct injury in these difficult cases. Strasberg and colleagues defined two main types of subtotal cholecystectomies: reconstituting and fenestrating. As there is a paucity of studies comparing the two subtypes of laparoscopic subtotal cholecystectomy (LSC), we performed a systematic review and meta-analysis comparing the reconstituting and fenestrating techniques for managing the difficult gallbladder. A search of PubMed, Embase, and Cochrane databases was conducted to identify prospective and retrospective studies comparing fenestrating and reconstituting LSC. The outcomes of interest were bile leak, reoperation, readmissions, completion cholecystectomy, postoperative ERCP, and retained CBD stones. We screened 2855 studies and included 13 studies with a total population of 985 patients. Among them, 330 patients (33.5%) underwent reconstituting LSC and 655 patients (55.5%) underwent fenestrating LSC. Twelve studies were retrospective, and one was prospective. Notably, reconstituting STC was associated with decreased incidence of bile leak (OR 0.29; CI 95% 0.16-0.55; p = 0.0002; I2 = 36%). We also noted increased rates of postoperative ERCP with fenestrating STC in sensitivity analysis (OR 0.32; CI 95% 0.16-0.64; p = 0.001; I2 = 31%). In addition, there was no difference between the two techniques regarding the rates of completion of cholecystectomy, reoperation, readmission, and retained CBD stones. Fenestrating LSC leads to a higher incidence of postoperative bile leakage. In addition, our sensitivity analysis revealed that the fenestrating technique is associated with a higher incidence of postoperative ERCP. Further randomized trials and studies with longer-term follow-up are still necessary to better understand these techniques in the difficult gallbladder cases.

Mirizzi syndrome: Mastering the challenge, characterization and management outcomes in a retrospective study of 60 cases

BackgroundMirizzi Syndrome (MS) is a rare complication of gallstone disease that poses diagnostic and management challenges. MethodsThis retrospective study aimed to review our institutional experience in diagnosing and managing MS over seven years and four months. ResultsAmong 8200 cholecystectomies, 60 cases of MS were identified, with type 1 being the most prevalent (90%). The mean age of the patients was 44 years, with male predominance (75%). Southeast Asians comprised 56.7% of the study population. The most common presenting symptom was right upper quadrant pain, and 58.3% of the patients were diagnosed with acute cholangitis. Liver enzyme and bilirubin levels were significantly higher in the advanced types. Preoperative diagnosis was achieved in 70% of patients, with MRCP and ERCP being the most effective diagnostic tools. Laparoscopic cholecystectomy was the most common surgical approach (76.7%), particularly in type 1 (79.6%), and decreased to 50% in advanced types. Hepaticojejunostomy was more common in the advanced types. ConclusionThis study highlights the importance of early diagnosis and appropriate management of MS considering its rarity and potential complications. The laparoscopic approach is reasonable, especially for type 1 MS and noncomplicated cases. Further research is needed to optimize treatment strategies for this challenging condition.

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

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

WP3.5 - Laparoscopic cholecystectomy: analysis of indications, time to surgery (TTS) and complications

Abstract Aims Our aims are to establish whether current waiting times for cholecystectomy in our local trust between 01/2021 and 01/2022 are in line with NICE guidelines and compare with average national waiting times. We aim to establish the indications for cholecystectomy (CBD stones, cholecystitis, biliary colic, pancreatitis) and compare waiting times and readmission rates during the waiting period; estimate the rate of conversion to open/subtotal cholecystectomy and any subsequent complications. Methods Data collection and analysis for the period of 01/2021 – 01/2022: average waiting times, rate of conversion, indications, complications. Results 269 patients were analysed after exclusions. Of these, mean waiting time from booking to TTS for uncomplicated biliary colic was 63.26 days. The median TTS from booking was 14 days for hot gallbladders. Of patients diagnosed as biliary colic, the TTS following an acute hospital admission was 63.26 days. Similarly, the patients referred via GP to the outpatient surgical clinic for the same diagnosis was 78.88 days. 5 patients who were referred routinely via GP to the outpatient surgical clinic had complications requiring an acute surgical admission during the waiting period. The rate of conversion to open was 0% during the 1-year period. 2 patients had subtotal cholecystectomies, one of which had persistent bile leak managed with drains and subsequent ERCP. Conclusion The median TTS for hot gallbladder is in line with national standard. There is a tendency to opt for subtotal cholecystectomy as bail out as compared to the previous years.

WP3.3 - Surgical Management of multiple mega large stones of a congenitally low inserted Cystic Duct – A Case Report

Abstract Introduction Low cystic duct insertion is uncommon, and the presence of multiple large stones in the cystic duct with normal laboratory investigation is rare. The infrequency with which it is encountered and the management done makes this an interesting presentation. Case presentation A 61-year-old female with incidental gall stones and possible CBD/cystic duct stones on a CTAP during a workup for management of an incisional hernia of the abdomen. The patient initially presented with abdominal pain that was thought to be due to the incisional hernia. On examination, the patient had a soft abdomen with no jaundice and normal laboratory investigations. MRCP scan demonstrated multiple gall stones and cystic duct stones suggestive of Mirizzi syndrome. The patient underwent laparoscopic repair of the incisional hernia and cholecystectomy with an on-table cholangiogram. Cholangiogram showed a low inserting cystic duct joining the common hepatic duct at the sphincter of Oddi with an almost nonexistent common bile duct and a cystic duct containing multiple mega-large stones. The cystic duct was explored and stones were milked out except the most inferior stone which was impacted at the sphincter of Oddi. This was dislodged with a Fogarty catheter and all stones were retrieved. Completion cholangiogram demonstrated complete clearance of the biliary tree with dye entering the duodenum. The patient recovered well postoperatively with no complications at 1 month post-operative. Conclusion This case illustrates a rare presentation of large cystic duct stones in the presence of abnormal anatomy and provides an option for surgical management.

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

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

SP4.8 - A Systematic Review on The Safety and Efficacy of Percutaneous cholecystolithotomy (PCCL)

Abstract Aims To summarize the evidence available thus far on the safety and efficacy of percutaneous cholecystolithotomy (PCCL). So, the research question we set out to answer is: Is PCCL a safe and efficacious procedure? Methods This is a secondary research project involving a literature search to gather evidence on the research question raised above. An SR protocol and search strategy are developed, literature search is conducted using two search engines: Ovid Medline and Ovid Embase. The two search terms used were: (a) (Percutaneous and (removal or extract) and (Gallstones* or Gall stone* or cholelithiasis or cholecystolithiasis*)), (b) Cholystolithomy. Our inclusion/exclusion criteria are clear and appropriate. PRISMA protocol was followed. Results The collected data from the 29 studies that fit our criteria is analyzed, and the results showed that the procedure is safe and effective compared to the gold standard which is laparoscopic cholecystectomy. The clinical and technical success is over 90%, and the combined complication rate is 14.8%, 9.3% major complication rate, and 6.9% minor complication rate. The 30-day mortality of the procedure is 0.8%. Conclusions This systematic review shows that PCCL is a safe and efficacious procedure with high technical and clinical success rates. The reported low 30-day mortality and major complication rates, despite multiple comorbidities and frequently old and sick patients, make PCCL outcomes comparable to the gold standard treatment. However, the current evidence is based on single-center data with heterogeneous reporting standards. Further research should aim at an appropriate sample size, a clear definition of recorded variables, and a refinement of current technologies and techniques.