EP.WE.726A snapshot audit of cholecystectomy for gallstone pancreatitis during the first wave of COVID-19

Aims COVID-19 has caused difficulties in providing efficient surgical care. We aimed to audit cholecystectomy provision for gallstone pancreatitis from January 2019 to June 2020. We audited time from admission with gallstone pancreatitis to cholecystectomy in pre-COVID and COVID cohorts in order to assess the effect of the first wave of the pandemic on service provision. Methods Patients with confirmed gallstone pancreatitis plus their age and gender were included using information software Cerner. We analysed length of stay, time to surgery and number of patients planned for surgery. We also looked at readmissions whilst awaiting surgery. Patients with previous cholecystectomies or deemed not fit for surgery were excluded. Results 68 patients were included; 42 admitted from Jan 2019 to Feb 2020 (non-COVID group) and 26 from March 2020 to June 2020 (COVID 19 group). Average length of stay was 11.8 days for non-COVID group and 8.8 days for COVID group. Average time to surgery for non-COVID group was 47.4 days. 25 patients underwent surgery. Average time to surgery was 56.7 days and 9 patients received surgery, in the COVID group. In this group, 3 patients had index admission surgery compared to 15 in the non-COVID group. Conclusions Albeit small, our data set shows a longer wait to surgery in the COVID group with fewer operations performed at index admission, compared to the non-COVID group. Future surgical services will require careful planning to ensure that urgent cholecystectomies continue to be performed in acute gallstone pancreatitis.

TP9.2.3Laparoscopic Cholecystectomy with Intraoperative Cholangiogram and Antegrade Biliary Stenting in Acute Gall Stone Pancreatitis: A Cohort Study

Aims To demonstrate feasibility and efficacy of laparoscopic cholecystectomy (LC), intraoperative (IOC) and antegrade biliary stenting (ABS) as compared to selective pre-operative biliary investigation and intervention in acute gallstone pancreatitis (AGP). Methods A cohort study was performed comparing patients who had IOC+/-ABS during LC versus those who had only LC in the treatment of AGP. 74 consecutive AGP patients were included in this study from January 2016 to October 2018. All patients were included in a prospective database with follow-up for one year. Results 47 (64.5%) patients underwent IOC during LC (7 required ABS insertion), with a mean age 51 years (SEM: 2.7), 72.3% were female. The median admission bilirubin was 24 (IQR:14-54). The average number of ERCP and MRCP per patient was 0.30 and 0.15 respectively. 27 (36.5%) patients underwent LC with selective pre-operative biliary investigation with a mean age 48 years (SEM: 2.9), 66.7% were female. The median admission bilirubin was 27 (IQR:14-48). The average number of ERCP and MRCP per patient was 0.41 and 0.52 respectively. Discussion In our pilot study comparing LC with IOC versus LC with selective pre-operative biliary investigation we demonstrate that, there is marked reduction in biliary investigations required in IOC group. Length of hospital admissions and rate of post-operative complications were comparable. An analytic study with a larger cohort may demonstrate further seniority of IOC.

EP.TH.916Managing Gallstone Pancreatitis: Are We Doing Enough?

Background Acute pancreatitis carries significant morbidity and has an estimated annual incidence of 30-50/100,000 in the U.K. 50% of these cases are related to gallstone disease. NICE/BSG guidelines recommend definitive management of gallstone pancreatitis during the index admission or within 14 days of hospital discharge. We audited our compliance against these national guidelines. Methods Retrospective data was collected for patients admitted with acute gallstone pancreatitis over a 12-month period. Patient demographics, admission details, length of stay, previous/future admissions, timing of cholecystectomy and ERCP were recorded. Results 47 patients were included (mean age: 50.7 years) with a mean length of stay of 6.2 days. Only 6% had a cholecystectomy during the index admission or within 14 days of hospital discharge. 12 (26%) patients had an ERCP performed with a mean time of 45 days. The mean time to surgery after initial discharge was 97 days. Conclusion There is poor compliance with national guidelines in the management of gallstone related pancreatitis in our cohort of patients. Definitive management reduces readmissions, resulting in financial savings and improved patient care. This audit demonstrates the need to develop a robust ‘hot gallbladder’ pathway to improve the management of patients with acute pancreatitis secondary to gallstones.

Biochemical markers in differentiating gallstones pancreatitis from non-gallstone pancreatitis

Acute pancreatitis has many causes; however, the most common cause of pancreatitis is gallstones globally. We have searched for relevant studies in this field aiming at establishing a short review about the usefulness of biomarkers in the diagnosis of acute pancreatitis and the relevant biomarkers and tests that can differentiate acute gallstone pancreatitis from other etiologies. It is worth mentioning that for the diagnosis and prognosis of biliary pancreatitis, radiological and laboratory diagnosis plays a major role in this field. Three biomarkers including serum amylase, lipase, and trypsinogen are the most important and most frequently noticed biomarkers in association with acute pancreatitis. Serum amylase has a specificity rate of 95% and a sensitivity of 61% when it measures more than 1000 IU/l which is three times as high as the normal level. However, it can be also found in other intrabdominal inflammatory conditions, and therefore, it cannot be used alone in the diagnosis. It has been reported that the specificity and sensitivity were 95% and 94%, respectively, for detecting high trypsinogen-2 levels in the patients’ urinary samples, which were indicative of acute pancreatitis. For the diagnosis of biliary pancreatitis, liver function tests should be assessed. Although they might be specific, they are not always diagnostic in some cases, and therefore, other approaches for detecting gallstones as ultrasonography and MRCP should be considered together with the liver enzymes for an appropriate diagnosis.

Early Versus Late Laparoscopic Cholecystectomy in Patients with Acute Gallstone Pancreatitis

The laparoscopic cholecystectomy is the definite treatment of acute gallstone pancreatitis, but the timing remains controversial. We aimed to evaluate trends, prevalence, and outcomes of laparoscopic cholecystectomy amongst patients with acute gallstone pancreatitis in index hospitalization done at different time intervals. We performed a retrospective study using Nationwide Inpatient Sample (years 2003–2014) with adult hospitalizations with acute gallstone pancreatitis who underwent laparoscopic cholecystectomy using ICD-9-CM codes and divided them into subgroups of those who underwent immediately (72 h), early (1 week), and delayed (> 1 week) laparoscopic cholecystectomy. The weighted analysis using chi-square, paired Wilcoxon-rank-sum test, Cochran-Armitage trend test, and multivariable survey logistic regression analysis was performed to evaluate prevalence and outcomes. There was a total of 582,406 acute gallstone pancreatitis admissions of which 291,701 (50.09%) patients had laparoscopic cholecystectomy (p < 0.0001). Prevalence of immediate laparoscopic cholecystectomy 114,629 (40.55%) showed incremental trend (32.61 to 49.82%) compared to early 149,931 (53.03%) (57.83 to 46.59%), and late laparoscopic cholecystectomy 18,158 (6.42%) (9.56 to 3.59%) from 2003 to 2014. Immediate and early laparoscopic cholecystectomy had lower prevalence and odds of mortality [0.24% versus 0.37% versus 2.46%; aOR-immediate: 0.614; aOR-early: 0.615; p < 0.0001], morbidity [1.36% versus 3.64% versus 27.57%; aOR-immediate: 0.088; aOR-early:0.161; p < 0.0001], disability [62.47% versus 70.15% versus 84.26%; aOR-immediate: 0.584; aOR-early: 0.68; p < 0.0001], discharge to non-home [7.07% versus 13.04% versus 31.84%; %; aOR-immediate: 0.346; aOR-early: 0.473; p < 0.0001], hospital cost $39,466 versus $52,018 versus $129,317 (p < 0.0001) and stay 3 days versus 6 days versus 19 days (p < 0.0001) than delayed laparoscopic cholecystectomy. The immediate laparoscopic cholecystectomy showed better outcomes; more prospective studies with large numbers of patients should be planned to evaluate the beneficial effects of immediate cholecystectomy in severe acute pancreatitis hospitalizations.