P-BN59 Danger is there, do we want to know about it? Routine intra operative cholangiography highlights dangerous biliary anatomy for safer cholecystectomy

Background Normal biliary anatomy is uncommon. Different classification for biliary anatomy has been described, with Huang Types A4 & A5 of great interest for laparoscopic cholecystectomy (LC) due to the proximity of aberrant bile duct to Cystic duct (CD). These types of dangerous anatomy might contribute to bile duct injury. This study aims to analyse the prevalence of dangerous biliary anatomy. Methods Prospectively collected data for all patients who underwent laparoscopic cholecystectomy was analysed. All LC were performed by single surgeon or under his direct supervision, between 01/07/2020 and 20/08/2021. Index admission and single session management of cholelithiasis disease with routine Laparoscopic cholecystectomy + intra operative cholangiography (IOC) +/- LCBD exploration were standard practice. Results Laparoscopic cholecystectomy was performed in 137 patients. Mean age was 56y (17-84). 62% were females. 66% of Laparoscopic cholecystectomies were emergency. IOC was performed in 92% of cases. Abnormal biliary anatomy was found in 54% : Huang A1 - 48%, A2 - 29%, A3 - 12%, A4 - 9.7% and A5 - 0.7%. Dangerous anatomy (A4 and A5) was found in 10.5%, 78 % were females. Female with dangerous anatomy were younger than males 49 y, 60y respectively. Nassar difficulty grading for dangerous anatomy was as follows: G2 28%, G3 42% and G3 28% Abnormal cholangiogram was found in 48%, due to filling defect in 58%, no contrast flow into duodenum in 4%, Cystic duct stone in 4%, and short CD in 8%. CBD stones were treated using transcystic approach in 92% of cases. No intra-operative or post operative complications were recorded for patients with dangerous anatomy. Conclusions This study demonstrates that dangerous biliary anatomy, that could lead to bile duct injury is relatively common, occurring in 10.7% of LCs. Routine intra-operative cholangiography highlights these high-risk variations in biliary anatomy and may prevent inadvertent bile duct injury in such cases.

P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis

Background After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI. Methods This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI. Results The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p < 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate. Conclusions Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.

P-BN51 Subtotal cholecystectomy: risk factors and patient outcomes

Background A subtotal cholecystectomy (SC) is indicated when a total cholecystectomy (TC) cannot be achieved without the risk of causing significant harm, the most feared complication being a bile duct injury. The aims of the present study were to identify patients at risk of SC, to compare the peri- and post-operative course between SC and TC and to compare outcomes between fenestrated and reconstituting subtypes. Methods All planned laparoscopic cholecystectomies across three surgical units over a population of 493,000 between 2015 and 2019 were considered. Data were collected retrospectively using electronic databases and included pre-operative, operative and post-operative data over a 100-day follow-up period. Variables associated with SC were identified using multivariate logistic regression. Outcomes following SC were compared with TC using univariate analysis, specifically chi-squared and Mann-Whitney U tests. The subtype of SC was documented and outcomes were compared between groups. Results The rate of SC was 3.4% (94/2768). Variables positively associated with SC included male sex (OR-2.33;p<0.001), age≥60 (OR-1.79;p=0.009), 2 previous admissions (OR-1.76;p=0.043), ≥3 previous admissions (OR-3.10;p=0.003), emergency cholecystectomy (OR-2.01;p=0.002); cholecystitis (OR-4.92;p<0.001) and pre-operative ERCP (OR-2.23;p<0.002). Patients with SC versus TC were more likely to suffer intra-operative complications (RR-13.1;p<0.001), post-operative complication (RR-6.7;p<0.001), require post-operative imaging/intervention (RR-4.0;p<0.001) and be re-admitted (RR-4.2; p < 0.001). The rate of bile duct injury was 0% in SC patients. The rate of post-operative bile leak was higher where the cystic duct was left open versus closed (RR-2.9;p=0.03) and in fenestrating SC versus reconstituting SC (35.7% versus 0%;p=0.002). Drain duration was reduced in reconstituting SC (p < 0.001). Conclusions The risk of SC can be explained by a number of patient specific factors and the risk should be emphasized in these patients during the consent process and should influence surgical decision making. The morbidity following a subtotal cholecystectomy is markedly higher than that of a total cholecystectomy but can be performed without significant risk of bile duct injury. Reconstituting SC and closure of the cystic duct reduces rates of post-operative bile leaks and duration of drains.

P-EGS21 The impact of COVID-19 on operative difficulty and outcomes of laparoscopic cholecystectomy

Background The COVID-19 pandemic resulted in substantial delays to surgery among patients with symptomatic gallstones due to cessation of elective surgical procedures. As this exposed patients to a longer period of time during which complications from gallstones could develop, we hypothesised that the operative difficulty and complication rate of laparoscopic cholecystectomy (LC) increased following the first wave of the pandemic. Methods This was a retrospective cohort study of patients receiving emergency or elective LC at a single NHS trust comprising three sites. We included patients undergoing surgery in the pre-pandemic period (July-September 2019) and after resumption of elective surgical services following the first wave of the pandemic (July-September 2020). We compared data on operative duration, length of hospital stay, complications (bile leak, bile duct injury and mortality) and need for subtotal cholecystectomy. Categorical data are reported as n(%) and were compared with Fisher’s exact test. Continuous data are reported as median with interquartile range and compared with Mann-Whitney U Test. Results 220 patients were included; 106 in the pre-pandemic group and 114 in the pandemic group. There were no significant differences in median operative times between the pre-pandemic (91 (71-121 minutes) and post-first wave (86 (69-114) minutes) groups (p = 0.48). The proportion of prolonged operations (over two hours) was similar in the pre-pandemic and pandemic groups (50% versus 46%, respectively, p = 0.59). Median length of hospital stay was 0 days for both groups (pre-pandemic 0 (0-1) days; pandemic 0 (0-1) days, p = 0.42)). There were no significant differences in the rates of bile leak, bile duct injury, mortality, or the conversion to subtotal cholecystectomy. Conclusions Interruption of elective surgery following the first wave of the COVID-19 pandemic did not result in a discernible change in the technical difficulty or complication rate of LC at our centre. Longer term studies are required to assess the effect of prolonged delays to surgery and the impact of subsequent waves of the pandemic.

Management of Post Cholecystectomy Bile Duct Injury: Pertinent Factors Contributing to Good Surgical Outcomes

Objective: Surgical management remains the mainstay treatment for bile duct injury (BDI) post-cholecystectomy. Achieving long-term patency and lessening anastomotic failure depends on important factors including the types of repairs, timing of repairs, and surgical expertise. The present study focused on the impact of these factors on the surgical outcomes of BDI repair. Materials and Methods: Fifty-nine patients who were treated with BDI post cholecystectomy at the surgical department between January 2003 and December 2018 were retrospectively reviewed. The patients were categorized as 11 in-house and 48 referral patients, of which 22 patients had bile duct repairs prior to referral. Surgical outcomes and factors, including types of repairs, timing of repairs, and surgical expertise, impacting on the treatment results were analyzed. Results: The mean age of the patients was 47.6 years. The BDI incidence in the authors’ hospital was 0.14%. Complications occurred in 21 patients (35.6%), of which intraabdominal collection was the most common at 10 patients (16.9%). The median length of hospital stay was 16 days for in-house patients and 17 days for the referral group (p=0.542). The mortality rate was 1.7%. The overall patency was 93% with mean follow up 106.4 months. Concerning the primary patency rate, the partial segments IV/V liver resection and hepaticojejunostomy techniques had better long-term patency compared to primary repairs at 92.3% versus 37.5% (p=0.017), and biliary bypass at 92.3% versus 80% (p=0.44). BDI repairs performed by primary surgeons increased the risk of anastomotic failure in comparison to those done by hepatobiliary surgeons with 10-year patency at 53.3% versus 95.4% (p=0.014). Delayed repairs longer than six weeks after injury offered positive long-term outcomes compared to early repairs done within six weeks after injury, with a 10-year patency at 85.4% versus 31.3% (p<0.001). Conclusion: Delayed repair performed by the hepatobiliary surgeon with appropriate surgical techniques decreased anastomosis stricture and achieved good overall surgical outcomes in the management of post cholecystectomy BDI. Keywords: Bile duct injury; Cholecystectomy; Surgical management