Surgeons have hesitated early cholecystectomy because of cardiovascular comorbidities during adoption of guidelines

The introduction of the guidelines has resulted in an increase of laparoscopic surgeries performed, but the rate of early surgery was still low. Here, the initial effect of the introduction of the guideline was confirmed in single center, and factors disturbing early cholecystectomy were analyzed. This study included 141 patients who were treated for acute cholecystitis from January 2010 to October 2014 at Kanazawa Medical Center. Each patient was assigned into a group according to when they received treatment. Patients in Group A were treated before the Tokyo Guidelines were introduced (n = 48 cases), those in Group B were treated after the introduction of the guidelines (93 cases). After the introduction of the guidelines, early laparoscopic cholecystectomy was significantly increased (P < 0.001), however, the rate of early operations was still 38.7% only. There are many cases with cardiovascular disease in delayed group, the prevalence had reached 50% as compared with early group of 24% (P < 0.01). Approximately 25% of patients continued antiplatelet or anticoagulant therapy. In the early days of guidelines introduction, the factor which most disturbed early surgery was the coexistence of cardiovascular disease. These contents could be described in the next revision of the guidelines.

SP3.2.10 Establishing an Emergency Surgical Ambulatory Care (ESAC) pathway for acute laparoscopic cholecystectomies: a single centre experience from a District General Hospital

Aims Early laparoscopic cholecystectomy is the gold standard for acute cholecystitis and gallstone pancreatitis. In order to deliver this service, a local Emergency Surgical Ambulatory Care (ESAC) pathway with a dedicated ESAC theatre list was established. The aim of this audit was to determine whether ESAC was associated with (1) improved length of stay and (2) cost efficiencies. Methods Consecutive patients who underwent an emergency laparoscopic cholecystectomy between October 2018 to October 2019 were identified. Data related to patient demographics, operating time, complications length of stay (LOS), reason for inpatient stay and re-admissions were collected. A dedicated ESAC service was introduced in July 2020. Outcomes were re-audited (July – December 2020). Results Prior to the introduction of ESAC, 142 patients (42% male, mean age 51 years (range 14 -82 years)) underwent an acute cholecystectomy, of which 13% were discharged on the same day. Median pre-operative LOS was 2 days (range 0-12 days) and median post-operative LOS was 1 day (range 1-16 days). Following the introduction of ESAC, 78 patients (32% male, mean age 49 years (range 22 – 89 years)) underwent an acute cholecystectomy, of which 76% were discharged on the same day and 90% within 1 day. Median pre-operative LOS was 0 days (range 0 to 7 days) and median post-operative LOS was 0 days (range 0-16 days). Conclusions Our results show that the introduction of a dedicated ESAC pathway improved both pre- and post-operative LOS. This subsequently saves approximately £80,000 per annum in hospital bed days.

EP.FRI.1012 One plus one equals four: how NELA inspired a quality improvement programme that produced 4 distinct positive outcomes

Aim To describe how NELA inspired an ‘improving emergency surgery’ quality improvement programme that produced improvements in 4 distinct areas of surgical practice. Methods This paper describes how Kotter's improvement methodology was implemented in a district general hospital to achieve NELA targets, reduce the negative appendicectomy rate in children, implement NICE guidance on early laparoscopic cholecystectomy for acute cholecystitis and consistently deliver the 'S' and 'A' of SAFER within the surgery department. Results As a result of a systematic quality improvement approach, Conclusions Incorporating NELA into a local 'improving emergency surgery' quality improvement programme has delivered important and wide-ranging benefits beyond emergency laparotomy, and protected the service from 'crowding out behaviour' where focus on a single quality improvement can come at the expense of quality in other areas.

Early Versus Delayed Laparoscopic Cholecystectomy in Cases of Acute Calcular Cholecystitis

Background Acute cholecystitis (AC) is one of the important causes of abdominal pain on presentation to the emergency department. Early diagnosis and treatment of AC has a positive effect on morbidity and mortality. Laparoscopic cholecystectomy (LC) is an important approach for treating acute cholecystitis nowadays. Issued data indicated that approximately 917,000 and &gt;50,000 LCs were annually performed to treat acute cholecystitis in the United States and England, respectively. Although LCs have been extensively performed to manage acute cholecystitis, the optimal timing of LC for this given condition is inconclusive. Aim of the work The aim of this study is to prospectively compare between early and delayed laparoscopic cholecystectomy as a management of acute calcular cholecystitis along with their operative and post-operative outcomes. Patients and methods From December 2019 to December 2020 in Ain Shams University Hospitals, a prospective randomized study was conducted over 20 patients of acute cholecystitis: 10 of them underwent laparoscopic cholecystectomy from 3 day to 7 day of symptoms of acute cholecystitis, and the other 15 after 6- 8 weeks. Operation time, intraoperative and postoperative surgical complications and duration of hospital stay were assessed and compared in the 2 groups. Results Although the operation time was longer in the group with early laparoscopic cholecystectomy, but the overall complications along with the total hospital stay were less in this group of patients. Conclusion Early timing of laparoscopic cholecystectomy in relation to the onset of gall bladder inflammation may reduce the conversion rate and the total complication rate. So, early laparoscopic cholecystectomy for patients with acute cholecystitis has both medical and socioeconomic benefits and it is the preferred approach in comparison to delayed approach.

228 Outcomes of Gallstone Complications During the COVID Pandemic

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.

267 An Audit of The Management of Acute Cholecystitis At ELHT

Aim Acute cholecystitis is a common condition on the surgical take. The evidence shows that the optimal approach is with early laparoscopic cholecystectomy in patients suitable for surgery (Cao, 2015). The aim of this audit was to assess the adherence of the surgical department at ELHT to NICE guidance CG 188 in the management of patients with gallstone disease (NICE, 2014): Offer early laparoscopic cholecystectomy (within 1 week of diagnosis) for acute cholecystitis. Method Retrospective study of all patients with image confirmed diagnosis of acute cholecystitis between 25th January to 1st October 2018. Any unsuitable candidates for surgery were not counted. Results The case notes of 153 patients were reviewed. 109 were included in this study, as the other patients were not likely to be offered surgery due to their comorbidities. Of these 109 patients, 51 (47%) had a laparoscopic cholecystectomy within a week of diagnosis. Conclusions ELHT is not meeting the target of management within 7 days for over half of patients. The modifiable reasons for not meeting the targeted treatment time are a lack of capacity in theatre and Consultants’ decisions to delay treatment. The addition of a dedicated hot gallbladder theatre list can increase the numbers treated within the target time.

Time to abandon the old dictum of delayed laparoscopic cholecystectomy after acute cholecystitis has settled in Caribbean practice

Although laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis, many Caribbean surgeons are reluctant to operate during the acute attack. We collected data for all consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis from January 1 to 31 December 2018. Delayed cholecystectomy was done >6 weeks after acute cholecystitis settled. We compared data between early and delayed groups. Delayed laparoscopic cholecystectomy was performed in 54 patients, and 42 had early laparoscopic cholecystectomy. Delayed surgery resulted in significantly more complications requiring readmission (39% vs 0), longer operations (2.27 vs 0.94 h) and lengthier post-operative hospitalisation (1.84 vs 1.1 days). Caribbean hospitals should abandon the practice of delayed surgery after cholecystitis has settled. Early laparoscopic cholecystectomy would be financially advantageous for our institutions, and it would save patients recurrent attacks of gallstone disease.

Early versus Delayed Laparoscopic Cholecystectomy in Acute Calculus Cholecystitis in Southern Odisha - A Prospective Comparative Study

BACKGROUND Acute cholecystitis is a pathology of inflammatory origin, usually associated with cholelithiasis, with a high incidence in the world. Its treatment involves an important socioeconomic impact. There are two surgical therapeutic options: early laparoscopic cholecystectomy (ELC) done within 72 hours of onset of pain or delayed laparoscopic cholecystectomy (DLC) done after 6 weeks of conservative treatment. The present study intends to compare between the effectiveness of ELC vs DLC in the management of acute cholecystitis in a tertiary care setup. METHODS The study sample included 65 patients who were clearly documented and radiologically proven cases of acute calculous cholecystitis, met the inclusion criteria, admitted to the surgery department of MKCG MCH, Berhampur, between August 2018 and July 2020. Out of 65 patients, 33 and 32 patients were selected randomly for ELC and DLC respectively. In ELC group surgery was done within 72 hours of the onset of pain while in DLC group surgery was done after 6 weeks of initial conservative treatment. The study was conducted using a case record proforma, prepared in their local language. The questionnaire included timing of cholecystectomy, duration of antibiotic coverage, mean duration of hospital stay, number of intraoperative and postoperative complications, conversion to open cholecystectomy, and follow-up. The data was compiled and tabulated in MS ® Excel and statistically analysed using IBM ® SPSS 22.0. RESULTS The overall morbidity and mortality were less in ELC compared to DLC. The mean duration of surgery was less in ELC (47.36 minutes) compared to DLC (65.75 minutes). The mean duration of antibiotic coverage was lesser in ELC (3.58 days) compared to DLC (5.50 days).The mean hospital stay was less in ELC (4.67 days) to DLC (6.50 days). The overall morbidity and mortality were less in ELC. CONCLUSIONS ELC is considered to be a safe modality of treatment in patients with acute cholecystitis and leads to an economical treatment. KEYWORDS Acute Calculus Cholecystitis, Early Laparoscopic Cholecystectomy, Delayed Laparoscopic Cholecystectomy

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

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.