883 Modified Framework for The Management of Acute Gallstone Disease During The COVID-19 Pandemic

Abstract Introduction On 12/03/2020 WHO declared SARS-CoV-2 a global pandemic. PHE and RCS advised non-operative management wherever possible, changing management of acute gallstone disease from early laparoscopic cholecystectomy to conservative treatment and frequent percutaneous drainage. Planning, prioritisation, and implementation of “COVID-Safe” pathways presented multi-factorial challenges throughout the NHS. Method Prospective data of patients admitted with acute gallstone pathology was collected at Chelsea & Westminster Hospital (23/03/2020-16/08/2020), and prioritised using Tokyo, FSSA and RCS Guidance. A restructured “Gallbladder-pathway” was implemented comprising trust-wide referral proforma, weekly clinical planning MDT meetings and dedicated theatre lists. Results Sixty-eight patients were prioritized as either “Urgent” (25), “Expedited” (12) or “Elective” (31); comprising gallstone pancreatitis (11), acute cholecystitis (53), obstructive jaundice (12) and biliary colic (8). 12 patients required cholecystostomies. During the “Peak” (23/3/20-02/06/2020) no cholecystectomies were performed, 10 in “Recovery” (02/06/20-06/07/20) in NCEPOD theatre, 21 in “Resolution” (06/07/20-18/08/20) since implementation of the “Gallbladder-Pathway”. Eleven patients (16%) re-presented while awaiting definitive treatment, none critically ill. The highest number of re-presentations was in “Urgent” patients (36%) and those with cholecystostomy (45%). Conclusions Early adoption of a modified “Gallbladder-pathway” during the pandemic allowed accurate case stratification, efficient resource allocation and safe care. Our model enabled prompt service recovery and a framework to navigate future disruption.

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Interventional radiology versus operative management for splenic injuries: a study protocol for a systematic review and meta-analysis

BMJ Open ◽

10.1136/bmjopen-2018-028172 ◽

2019 ◽

Vol 9 (8) ◽

pp. e028172

Author(s):

Masahiro Kashiura ◽

Noritaka Yada ◽

Kazuma Yamakawa

Keyword(s):

Systematic Review ◽

Interventional Radiology ◽

Meta Analysis ◽

Operative Management ◽

Sensitivity Analyses ◽

Definitive Treatment ◽

Controlled Trials ◽

Cochrane Central Register ◽

Statistical Heterogeneity ◽

Non Operative Management

IntroductionOver the past decades, the treatment for blunt splenic injuries has shifted from operative to non-operative management. Interventional radiology such as splenic arterial embolisation generally increases the success rate of non-operative management. However, the type of intervention, such as the first definitive treatment for haemostasis (interventional radiology or surgery) in blunt splenic injuries is unclear. Therefore, we aim to clarify whether interventional radiology improves mortality in patients with blunt splenic trauma compared with operative management by conducting a systematic review and meta-analysis.Methods and analysisWe will search the following electronic bibliographic databases to retrieve relevant articles for the literature review: Medline, Embase and the Cochrane Central Register of Controlled Trials. We will include controlled trials and observational studies published until September 2018. We will screen search results, assess the study population, extract data and assess the risk of bias. Two review authors will extract data independently, and discrepancies will be identified and resolved through a discussion with a third author where necessary. Data from eligible studies will be pooled using a random-effects meta-analysis. Statistical heterogeneity will be assessed by using the Mantel-Haenszel χ² test and the I² statistic, and any observed heterogeneity will be quantified using the I² statistic. We will conduct sensitivity analyses according to several factors relevant for the heterogeneity.Ethics and disseminationOur study does not require ethical approval as it is based on the findings of previously published articles. This systematic review will provide guidance on selecting a method for haemostasis of splenic injuries and may also identify knowledge gaps that could direct further research in the field. Results will be disseminated through publication in a peer-reviewed journal and presentations at relevant conferences.PROSPERO registration numberCRD42018108304.

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Gallstones: new insights into an old story

F1000Research ◽

10.12688/f1000research.8874.1 ◽

2016 ◽

Vol 5 ◽

pp. 1817 ◽

Cited By ~ 6

Author(s):

Evan Tiderington ◽

Sum P. Lee ◽

Cynthia W. Ko

Keyword(s):

Gallstone Disease ◽

Stone Disease ◽

Biliary Colic ◽

Cholesterol Stone ◽

Gallstone Pancreatitis ◽

Alcoholic Fatty Liver ◽

Cholesterol Gallstones ◽

Timing Of Cholecystectomy ◽

Clinical Associations ◽

Alcoholic Fatty Liver Disease

Gallstones, particularly cholesterol gallstones, are common in Western populations and may cause symptoms such as biliary colic or complications such as acute cholecystitis or gallstone pancreatitis. Recent studies have allowed for a better understanding of the risk of symptoms or complications in patients with gallstones. In addition, newer data suggest an association of gallstones with overall mortality, cardiovascular disease, gastrointestinal cancers, and non-alcoholic fatty liver disease. Knowledge of appropriate indications and timing of cholecystectomy, particularly for mild biliary pancreatitis, has gradually accumulated. Lastly, there are exciting possibilities for novel agents to treat or prevent cholesterol stone disease. This review covers new advances in our understanding of the natural history, clinical associations, and management of gallstone disease.

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Conservative Management of Gallstone Disease in the Elderly Population: Outcomes and Recurrence

Scandinavian Journal of Surgery ◽

10.1177/1457496919832147 ◽

2019 ◽

Vol 109 (3) ◽

pp. 205-210

Author(s):

I Mora-Guzmán ◽

M Di Martino ◽

AC Bonito ◽

VV Jodra ◽

SG Hernández ◽

...

Keyword(s):

Recurrence Rate ◽

Survival Curve ◽

Gallbladder Disease ◽

Gallstone Disease ◽

Operative Management ◽

Index Admission ◽

Consecutive Series ◽

Early Cholecystectomy ◽

Non Operative Management

Background & Aims: The prevalence of gallstone disease increases with age, being early cholecystectomy the most accepted treatment in the vast majority of patients in order to prevent complications and recurrence. The aim of this study is to determine the recurrence rate and its possible predictors after initial non-operative management. Materials and Methods: We reviewed a consecutive series of patients, older than 65 years, admitted for a gallstone-related disease and treated with a non-operative management between January 2010 and December 2013. We analyzed comorbidities, clinical data, diagnosis, management, recurrence, and its treatment. Median follow-up after the discharge was 2 years. Recurrence was analyzed by a Kaplan–Meier survival curve. Possible recurrence’s predictors were analyzed. Results: The study included 226 patients. Mean age was 80.4 ± 7.2 years, 127 (56%) were female. The main causes of index hospitalization were acute cholecystitis (58%) and biliary pancreatitis (18.1%). After 2 years of follow-up, the recurrence rate was 39.8%; mean time to recurrence was 255.2 ± 42.1 days, 81% of patients recurred within 1 year. Bile duct disease implied a higher recurrence rate than the gallbladder disease group (52% vs 33%, p < 0.001). Subjects with two or more diagnoses during index admission presented higher recurrence rate (32% vs 49%, p < 0.001). Conclusion: More than a third of elderly patients could present a recurrence within 2 years after initial non-operative management. Early cholecystectomy should be considered at index admission in order to prevent recurrence.

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Non-operative Management of Necrotic Pancreatic Collection and Bleeding Pseudoaneurysm Communicating with Bowel Lumen at Multiple Sites: a Case Report and Review of the Literature

Journal of Gastrointestinal and Liver Diseases ◽

10.15403/jgld.2014.1121.251.cll ◽

2016 ◽

Vol 25 (1) ◽

pp. 109-114 ◽

Cited By ~ 1

Author(s):

Roshan Razik ◽

Gary R. May ◽

Fred Saibil

Keyword(s):

Operative Management ◽

Gastroduodenal Artery ◽

Pancreatic Pseudocysts ◽

Gallstone Pancreatitis ◽

Endoscopic Retrograde ◽

Pancreaticoduodenal Artery ◽

Edematous Pancreatitis ◽

Walled Off Necrosis ◽

Non Operative Management ◽

Guided Therapy

Pancreatic pseudocysts and foci of walled-off necrosis (WON) are well-known complications of acute pancreatitis. We present a case of severe gallstone pancreatitis complicated by WON, fistulization to the bowel and gastrointestinal bleeding. Bleeding was localized to a pseudoaneurysm of the gastroduodenal artery within the WON using imaging and endoscopy. Angiography and image-guided therapy were then used to control bleeding with coil-embolization. To our knowledge, this is the first report of non-operative management of a patient with severe pancreatitis complicated by WON and a bleeding pseudoaneurysm with multiple communications to the hollow viscera. Therapeutic options are discussed and a thorough literature review is included. Abbreviations: EGD: esophagogastroduodenoscopy; ERCP: endoscopic retrograde cholangiopancreatography; GDA: gastroduodenal artery; GI: gastrointestinal; IEP: interstitial edematous pancreatitis; IPDA: inferior pancreaticoduodenal artery; WON: walled-off necrosis.

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594 Optimising Hand Trauma Care at a Major Trauma Centre (MTC) During the COVID-19 Pandemic

British Journal of Surgery ◽

10.1093/bjs/znab134.070 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A Khajuria

Keyword(s):

Operative Management ◽

Trauma Centre ◽

Definitive Treatment ◽

Face To Face ◽

Major Trauma Centre ◽

Treatment Centre ◽

One Stop ◽

The One ◽

Non Operative Management

Abstract Introduction This study evaluates the management of hand injuries during COVID-19 following the prompt implementation of the BOA guidelines; reconfiguration of hand services and implementation of the ‘one-stop’ model. Method 285 cases OVER A 1-MONTH PERIOD were RETROSPECTIVELY reviewed to evaluate the effectiveness of managing patients using the ‘one-stop’ model and the new Urgent Treatment Centre (UTC). Results 277 patients were included in the study. During Covid-19, operative cases fell by 62%. 86.3% (239/277) of cases were managed in the UTC; 54.4% (130/239) required conservative management and 45.6% (109/239) required minor procedures (in UTC). REMOVABLE SPLINT USE was optimized through design of ‘softcasts’ for non-operative management of distal radius fractures. A patient education video: ‘softcast removal at home’ was created and in cases requiring sutures, 95.1% (39/41) were absorbable, thereby avoiding COVID-19 exposure for follow-up. Only 50.5% (140/277) of patients had formal follow-up arranged and patient information follow-up cards were developed. Conclusions The one-stop model prevents delay in definitive treatment, allows effective initial treatment, and minimizes the need for face-to-face follow up. In light of a possible second wave of COVID-19 cases, this new model should be considered for implementation by all hand’s units for the foreseeable future.

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228 Outcomes of Gallstone Complications During the COVID Pandemic

British Journal of Surgery ◽

10.1093/bjs/znab259.826 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

J Isherwood ◽

B B Karki ◽

W Y Chung ◽

T AlSaoudi ◽

J Wolff ◽

...

Keyword(s):

Gold Standard ◽

Gallstone Disease ◽

Gallbladder Perforation ◽

Gallstone Pancreatitis ◽

Biliary Disease ◽

Early Laparoscopic Cholecystectomy ◽

Significant Difference ◽

Risk Patients ◽

The Impact ◽

National Approach

Abstract Background The Intercollegiate General Surgery Guidance on COVID-19 recommended either non-surgical management or cholecystostomy drains for the management of acute biliary disease replacing gold standard practice of early laparoscopic cholecystectomy within 1 week of index admission with drainage reserved for high-risk patients where surgery is not appropriate. Method This is the retrospective study presenting the impact of gallstone disease in our unit during five months of the COVID- 19 pandemic (March 2020-August 2020) compared with the equivalent period in 2019. Results Patients presenting to the HPB unit with a coded diagnosis of gallstones were included and during the study period 1447 patients presented compared with 1413 in 2019. In 2020 compared with 2019 there was a significant decrease in patients presenting with cholecystitis (240 vs 313; p = 0.031) but no significant difference in patients presenting due to gallbladder perforation (44 vs 51). Interestingly the numbers of cholecystostomies were comparable, with 11 in 2020 and 15 in 2019 representing significantly less than the 7.2% figure published by Peckham-Cooper et al. Conclusions In our study there was a decrease in patients with cholecystitis and perforation and there was an increase in patients with gallstone pancreatitis, increase waiting lists with increase in the incidence of serious complications. In our trust we currently have 656 patients awaiting cholecystectomy compared to 280 in august 2019. With the recent elevation of the alert level to 4 and increased government restrictions, a consistent National approach is required to mitigate these risks.

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Prognostic Factors in the Decision-Making Process for Sigmoid Volvulus. Results of a Single-Centre Retrospective Cohort Study.

10.21203/rs.3.rs-302366/v1 ◽

2021 ◽

Author(s):

Zoe Slack ◽

Mohamed Shams ◽

Raheel Ahmad ◽

Roshneen Ali ◽

Diandra Antunes ◽

...

Keyword(s):

Operative Management ◽

Functional Condition ◽

Sigmoid Volvulus ◽

Definitive Treatment ◽

Rectal Tube ◽

Term Survival ◽

Average Survival ◽

Younger Age ◽

Non Operative Management

Abstract BACKGROUND: Sigmoid volvulus is a common cause of emergency surgical admission. It often affects older males who are institutionalized and are less suitable surgical candidates. Definitive treatment is surgical, but first line treatment is via endoscopic devolution with or without placement of a rectal tube. After non-operative management recurrence is likely and carries a high mortality, therefore an early surgical approach may be considered in patients who are fit for surgery. We have retrospectively analyzed a cohort of patients with sigmoid volvulus in order to clarify if and when a more aggressive management is indicated.METHODS: We have reviewed data on admitted patients diagnosed with sigmoid volvulus over a 2-year period. Demographic, clinical data, morbidity and mortality were recorded in a database. The primary endpoint was patient survival. Secondary endpoint was the estimation of the factors that condition surgical choice.RESULTS: We analysed 332 admission of 78 patients. 39.7% of patients underwent surgical resection. The average survival was 54.9±8.8 months from the first hospitalization, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low "social score", a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival.CONCLUSION: Early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.

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P-EGS27 Outcomes of disorders of the gallbladder, biliary tract, and pancreas during COVID pandemic

British Journal of Surgery ◽

10.1093/bjs/znab430.087 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Christophe Thomas ◽

Freddie Dowker ◽

Hettie O'Connor ◽

Liam Horgan

Keyword(s):

Conservative Management ◽

Significant Proportion ◽

Operative Management ◽

Definitive Treatment ◽

Categorical Variables ◽

Gallstone Pancreatitis ◽

Retrospective Audit ◽

Increased Risk ◽

Operative Complications ◽

Post Operative Complications

Abstract Background Biliary disorders make up a significant proportion of the acute general surgical workload. Effective management allows definitive treatment with relief of symptoms and reduced impact to patients due to recurrent admissions and complications. During the first COVID-19 wave and lockdown there were reduced surgical presentations to hospital and patients presented later. Surgical services were forced to implement different practices including more conservative/non operative management potentially increasing the possibility of recurrent presentations and greater complications in biliary-pancreatic presentations. Methods We performed a retrospective audit of patients presenting to our unit with ICD 10 codes: K80;Cholelithiasis, K81;Cholecystitis and K85;Acute pancreatitis. We used the period of the first wave of the COVID pandemic March – August 2020(COVID) and compared this to the same period in 2019(pre-COVID). On note review those with inaccurate coding were excluded. Patient demographics, admission details, investigations, surgical management, operative details, and post-operative complications were recorded. The primary outcomes were change in operative management, representation, and post-operative complications. χ2 test was used to test for significance of categorical variables. Results Conclusions The two groups were demographically similar with equal spread of primary diagnoses however there were significant differences in outcomes. Patients presenting with cholecystitis and gallstone pancreatitis had significantly reduced rates of definitive management. The increase in adverse operative findings is likely secondary to patients presenting later and initial conservative management. The increase in complications for the COVID cohort correlates with the increase in adverse findings/operative complexity. Conservative management with the aim of reducing COVID exposure inadvertently resulted in increased risk to patients with increased presentations/admissions. Despite this risk there were no COVID cases in our cohort.

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Biliary disorders

Best of Five MCQS for the European Specialty Examination in Gastroenterology and Hepatology ◽

10.1093/oso/9780198834373.003.0004 ◽

2021 ◽

pp. 72-100

Author(s):

Thomas Marjot

Keyword(s):

Biliary Tract ◽

Core Curriculum ◽

Operative Management ◽

Percutaneous Transhepatic Cholangiography ◽

Biliary Colic ◽

Biliary Disease ◽

Bile Formation ◽

Gallbladder Polyps ◽

Non Operative Management ◽

Indications And Complications

This chapter covers core curriculum topics relating to disorders of the biliary tract including physiology and biochemistry of bile formation and the pathogenesis of gallstones; complications of gallstones disease including biliary colic, acute cholecystitis, biliary obstruction, and cholangitis, and options for operative and non-operative management. Material is also provided on conditions of the gallbladder including adenomyomatosis, gallbladder polyps, and porcelain gallbladder; primary sclerosing cholangitis and other causes of cholangitistumours of the bile duct, gall bladder, and ampulla; indications and complications of endoscopic and radiological treatment of biliary disease including endoscopic retrograde choalngiopancreatography, cholangioscopy, and Percutaneous transhepatic cholangiography. There is also discussion on the diagnosis and management of biliary complications after liver transplantation. Additional curriculum material regarding disorders of the biliary tract will also be covered in the mock examination chapter.

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TP9.2.30Sigmoid Volvulus: Is a More Aggressive Approach Justified? Results of a Retrospective Cohort Study

British Journal of Surgery ◽

10.1093/bjs/znab362.127 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Zoe Slack ◽

Mohamed Shams ◽

Mahmoud Sallam ◽

Giles Bond-Smith ◽

Giovanni Tebala

Keyword(s):

Operative Management ◽

Functional Condition ◽

Sigmoid Volvulus ◽

Definitive Treatment ◽

Rectal Tube ◽

Term Survival ◽

Aggressive Approach ◽

Average Survival ◽

Younger Age ◽

Non Operative Management

Abstract Aims Sigmoid volvulus is a common cause of emergency surgical admission. It often affects older males who are institutionalised and are less suitable surgical candidates. Definitive treatment is surgical but first line treatment is via endoscopic devolution with or without placement of a rectal tube. After non-operative management recurrence is likely and carries a high mortality, therefore an early surgical approach may be considered in patients who are fit for surgery. We have retrospectively analysed a cohort of patients with sigmoid volvulus in order to clarify if and when a more aggressive management is indicated. Methods We have reviewed data on admitted patients diagnosed with sigmoid volvulus over a 2-year period. Demographic, clinical data, morbidity and mortality were recorded in a database. Analysis was carried out with statistical programs. The primary endpoint was patient survival. Secondary endpoint was the estimation of the factors that condition surgical choice. Results We analysed 78 cases. 74.4% had multiple admissions and recurrences. 39.7% of patients underwent surgical resection. The average survival was 54.9±8.8 months from the first hospitalisation, irrespective of the treatment. Long-term survival was positively influenced by being female, having a low “social score”, a younger age and surgery. Multivariate analysis showed that only being female and surgery were independently associated with better survival. Conclusions In conclusion, we believe that early surgery may be the best approach in patients with recurrent sigmoid volvulus, as it ensures longer survival with a better quality of life, regardless of the patient's social and functional condition.

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