P-BN17 Laparoscopic subtotal cholecystectomy is a safe and effective treatment for gallstone disease

Background Laparoscopic cholecystectomy is the gold standard treatment of gallstones in fit patients with symptomatic gallbladder disease. If the critical view of safety cannot be achieved intra-operatively, there are few options, one of which is laparoscopic subtotal cholecystectomy. This study aims to ascertain the outcomes of subtotal cholecystectomy. Methods Retrospective review of all patients who underwent laparoscopic subtotal cholecystectomy by a single surgeon over a 5 year period. Results 37 consecutive patients who underwent subtotal cholecystectomy were included in this study; seventeen of which were males (49%); the median age was 69, and 18 were emergencies (49%).The most common reasons for conversion to laparoscopic subtotal cholecystectomy were adhesions (57%) and fibrotic Calot’s triangle (22%). One patient required ERCP and biliary stenting for ongoing bile leak and another returned to theatre for post operative bleeding during index admission. 6 patients (16%) required further hospital admissions for gallstone disease (1 for biliary colic, two for cholecystitis and three for CBD stones). 3 patients required ERCP. None required further gallbladder surgery. Conclusions Laparoscopic subtotal cholecystectomy is a safe and effective alternative to total cholecystectomy when the critical view of safety cannot be achieved. In our experience, only a small proportion of patients have recurrent biliary problems.

P-BN41 Does performing percutaneous cholecystostomy in patients at risk of sepsis have better outcomes than patients in sepsis?

Background Gallstone related diseases account for almost one-third of acute surgical admissions with presentation varying from biliary colic to sepsis. There were various studies evaluating the role of ‘percutaneous cholecystostomy’ (PC) as part of the management in acute cholecystitis under ‘radiological guidance’ (RG). However, limited literature is conducted to evaluate patients’ outcomes based on the indication and optimal timing of cholecystostomy. Therefore, this study was set up to assess the difference in clinical outcome between the patients undergoing cholecystectomy with overt sepsis (OS) and impending sepsis (IS). Methods A retrospective observational study was conducted using a prospective database on patients who underwent PC under RG between 03/2014-03/2021. NICE’s sepsis risk stratification tool was used to divide patients into OS and IS groups. OS group included patients with 1 or > 1 high-risk criteria. IS group included patients with 2 or > 2 moderate to high-risk criteria. The primary outcomes are 30-day mortality and the ‘length of stay’ (LoS) and secondary outcome include post-procedural ‘bile leak’ (BL).Continuous and categorical variables were analysed using Mann-Whitney U and Chi-squared tests respectively. A p-value of < 0.05 was considered to be statistically significant. Results Some 27 patients were included. The median age was 80 (range 61-90).The majority of the patients (77.78%, n = 21) were unfit for surgery, with a Charlson Comorbidity Index ranging of 3 to 12. The median length of hospital stay of the OS and IS groups were 17 and 15 days respectively (p = 0.47).There was no significant difference in bile leak (IS-1/20 vs OS-0/7; p = 0.56) and drain accidents (IS-8/20 vs OS-1/7;p=0.35).Overall two patients in the IS group underwent an uncomplicated interval cholecystectomy. The 30-day mortality rate was significantly higher in OS (IS 0/20 vs OS-4/7; p = 0.00039). Conclusions Percutaneous cholecystostomy is generally safe to be performed irrespective of patients’ co-morbidities and has no significant long-term complications associated with mortality. Early cholecystostomy before overt sepsis results in a reduced 30-day mortality rate and better outcome. Further clinical studies may be required to determine specific patient groups who would benefit from percutaneous cholecystostomy.

P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Background Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix. Methods TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO. Results Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p < 0.001) were independently associated with TO. Conclusions Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.

O-BN02 Laparoscopic subtotal cholecystectomy for difficult gallbladders: A lifesaving bailout or an incomplete operation? A systematic review

Background Cholecystectomy is one of the commonest abdominal operations performed worldwide. Sometimes, the operation can be technically difficult due to dense adhesions in Calot’s triangle. Conversion to open surgery or subtotal cholecystectomy have been described to deal with these situations. A recent systematic review and meta-analysis on STC suggested high perioperative morbidity associated with STC. These findings are at odds with a previous systematic review and meta-analysis on the topic which concluded that morbidity rates for STC were comparable to those reported for total cholecystectomy. However, both these reviews included patients undergoing Open Subtotal Cholecystectomy (OSTC). This makes it difficult for us to understand the outcomes of LSTC as surgeons are not faced with the choice of converting to open surgery to perform a subtotal cholecystectomy. The choice they face is whether they should perform a LSTC or convert to open surgery to perform a total cholecystectomy. It is, therefore, important to establish the outcomes of LSTC alone (without including patients who underwent OSTC). This is all the more important during COVID-19 pandemic when the complexity of gall stone disease appears to have worsened. There is thus an enhanced need to understand technical nuances and outcomes of LSTC alone. Methods Search strategy: We searched PUBMED (Medline), Google Scholar, and Embase for all relevant English language articles describing experience with LSTC in adult human population (≥18 years) anywhere in the world using key-words like “subtotal cholecystectomy”, “gallbladder resection”, “gallbladder excision”, “gallbladder removal”, “partial”, “incomplete”, “insufficient”, “deroofing”, and “near-total”. Case reports, articles only published as conference abstracts, case series with <5 cases, and reviews were excluded. Only English-language studies were included. Participants: All studies with 5 or more cases, describing any experience with an adult cohort (≥18 years) of patients undergoing STC while attempting a Laparoscopic Cholecystectomy were included. Studies on patients who underwent preoperative cholecystostomy were excluded. Studies that had LSTC as part of another surgery were also excluded as we wanted to understand the morbidity and mortality of LSTC alone. Studies on patients who underwent OSTC (Open from start) were excluded as were those where the LSTC cohort was merged with the OSTC cohort and outcomes of LSTC were not separately reported. Study outcome: Primary outcome measure was early (≤30 days) morbidity and mortality. Secondary outcome measures were bile duct injury, bile leak rates, conversion to open surgery rates, duration of hospital stay, and late (>30 days) morbidity. Results 45 studies were identified, with a total of 2166 patients. Mean age was 55 +/- 15 years with 51% females; 53% (n = 390) were elective procedures. The conversion rate was 6.2% (n = 135). Most common indication was acute cholecystitis (n = 763). Different techniques were used with the majority having a closed cystic duct/gallbladder stump (n = 1188, 71%). The most common closure technique was intracorporeal suturing (53%) followed by endoloop closure. There were a total of four, 30-day mortality [1] in this review. Early morbidity (≤30 days) included bile duct injury (0.23%), bile leak rates (18%), intra-abdominal collection (4%). Reoperation was reported in 23 patients (1%), most commonly for unresolving intra-abdominal collections and failed ERCP to control bile leak. Long term follow-up was reported in 30 studies with a median follow up period of 22 months. Late morbidity included incisional hernias (6%), CBD stones (2%), and symptomatic gallstones in 4% (n = 41) with 2% (n = 22) requiring completion of cholecystectomy. Conclusions Laparoscopic subtotal cholecystectomy is an acceptable alternative in patients with a “difficult” Calot’s triangle. However, this has to be taken seriously as it is associated with a high early and late morbidity and mortality.

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.

P-BN54 The outcomes after a Laparoscopic subtotal cholecystectomy

Background Laparoscopic subtotal cholecystectomy (LSC) is a recognised option when the “critical view” cannot be safely delineated. It carries a high morbidity rate as there are increased frequencies of a bile leak occurring however reducing the risk of bile duct injury. LSC can be further divided into fenestrating or reconstituting cholecystectomy, the later entails closing the remnant. The literature state reconstituting cholecystectomy reduced rate of bile leak. We reviewed our cases to analyse the complication rates of LSC and there outcomes. Methods A retrospective review of patients who underwent a laparoscopic subtotal cholecystectomy (LSC) using electronic records between January 2015 to March 2021. A total of 160 patients, with a mean age of 65, 51% male and 49% female. Results 76% of LSC were performed as an emergency. Mean operation length was 96min and the mean blood loss 92ml. Complications occurred in 50% of patients. Post operatively 22% underwent an ERCP and the re-operation rate was 9%. The mean length of stay was 8 days. Conclusions Based on our results LSC carry a high rate of bile leak with the majority requiring intervention in the form of ERCP or laparoscopy and wash out. A reconstituting cholecystectomy, closing with an endoloop of suture seems to slightly reduce the rate of bile leak. LSC are only performed when managing a difficult gallbladder with a dense/ inflamed Calot's triangle. There were no mortalities associated with a LSC.

P-BN30 Retroperitoneal biloma: a case report of spontaneous retroperitoneal bike leak and collection

Background Retroperitoneal biloma is a rare complication of gallstone disease. Only a handful of cases have been reported in the literature with various mechanisms postulated. Here, we report a case of spontaneous retroperitoneal biloma arising from gallbladder perforation. Methods An 87-year-old female patient presented with right upper quadrant pain in the context of known gallstone disease. Inflammatory markers and liver function tests were deranged. Cross sectional imaging found acute cholecystitis and a gallbadder neck perforation with an impacted 2cm proximal common bile duct (CBD) stone. A cholecystostomy was placed and she improved clinically. However, inflammatory markers remained high, and a subsequent computed tomography (CT) found a large collection in the retroperitoneum. Results The retroperitoneal collection measured 14cm x 7cm, and there had been evidence on prior CT scans of retroperitoneal inflammation. It was urgently drained under ultrasound guidance and found to contain bilious content. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was unable to retrieve the CBD stone, but left stents either side of the stone. The patient clinically and biochemically improved. She was discharged and had an elective ERCP, which successfully retrieved the stone, with a plan for urgent elective laparoscopic cholecystectomy. Conclusions Here, we report an interesting case of retroperitoneal biloma successfully managed with ultrasound-guided drainage. Perforation of the distal CBD can result in retroperitoneal bile leak, but the proximal CBD stone in this case would have likely prevented passage of bile. A more likely cause is adhesion of the gallbladder neck to the posterior parietal peritoneum due to chronic inflammation, with subsequent perforation and release of bile into the retroperitoneum. This has previously been described in the literature. Regardless of mechanism, knowledge of the potential for this rare complication is important for anticipating and appropriately managing complications of gallbladder perforation.

P-P53 Textbook outcomes in pancreatoduodenectomy are improved in high volume specialist pancreas-only centres

Background Traditional single surgical quality indicators are commonly used however they are poor for assessing global outcomes for patients. Composite outcomes such as the ‘Textbook Outcome’ (TO) is a composite outcome to determine the success of the quality of the surgical process, and compare outcomes between institutions and patient groups, described by the Dutch Pancreatic Cancer Audit Group for Pancreatoduodenectomy (PD). They reported national TOs for PD of 58.3%, we compared this to TOs in a UK high volume specialist pancreas-only centre, Royal Stoke. Methods Patients who underwent PD from January 2017 to December 2020 were identified from our database. TO was defined as absence the following: post-operative pancreatic fistula (POPF) (grade B/C), post-pancreatectomy haemorrhage (PPH), bile leak, severe complications (Clavien Dindo grade III or more), 30-day readmission and 30-day mortality. Results 153 patients underwent PD during the 4-year study period. The median age was 71years (range 37-85 years), and there was a slight male preponderance (54.9%, 84/153). 47% had pancreatic ductal adenocarcinoma (72/153), 17% ampullary carcinoma (26/153), 9% cholangiocarcinoma (14/153), 9% duodenal carcinoma (14/153), and benign pathology included cases with IPMN and duodenal polyps with high grade dysplasia. There was a statistically significant difference in textbook outcome in our cohort compared to the Dutch Study (70.3%, 108/153 vs 58.3%, 895/1536; p=0.003086), with components of TO shown in Figure 1. Conclusions TO represent composite outcome for identifying good practice, areas for shared learning and areas for improvement. PD performed in high-volume pancreas-only specialist centers appear to have better outcomes following PD than lower-volume centres. Further investigation is required to assess why outcomes are different between centres, and identify how best practice can be shared.