P-EGS06 Evaluating the impact of COVID-19 on the trend of emergency laparoscopic cholecystectomy

Background Since the spread of the new SARS-CoV2 coronavirus in March 2020 to the UK, contradictory recommendations on the practice of laparoscopic cholecystectomies fuelled some debates among surgeons. The British Intercollegiate General Surgery Guidance recommended laparoscopic cholecystectomy as the treatment of choice for acute cholecystitis during the COVID-19 pandemic. Contradictorily, the Royal College of Surgeons of England warned about the unknown risk of viral infection and the release of pressurised gas from laparoscopic surgery. The audit aimed to identify the differences in surgical care before and during the pandemic to study their impact on patients. Methods Retrospective patient data was obtained from September 2019 to September 2020 to include data six months before the pandemic and six months during the pandemic. The data obtained had the patient hospital number, fitness for cholecystectomy, decision made regarding surgery, date of admission and date of surgery. Results 178 patients before COVID-19 and 242 patients during COVID-19 were admitted with gallstone disease. Before COVID-19, 60.67% (n = 108) patients were fit and consenting for surgery. Of these patients, 60.19% (n = 65) were discharged for surgery later and 39.81% (n = 43) had inpatient emergency surgery. During COVID-19, 71.49% (n = 173) patients were fit and consenting for surgery. However, 87.86% (n = 152) were discharged for surgery and only 12.14% (n = 21) had inpatient surgery. The average time from admission to surgery increased from 8 days to 51 days during COVID-19. Although majority of inpatient surgeries were performed within eight days, the percentage performed was fewer during COVID-19. Conclusions The COVID-19 pandemic significantly affected emergency laparoscopic cholecystectomies performed in the hospital with a substantial increase in the average time taken from admission to surgery. More emergency laparoscopic cholecystectomies should be included in the weekly elective lists, design for dedicated emergency cholecystectomy lists and increase utilisation of the CEPOD theatres along with staff availability are required to achieve the emergency cholecystectomy service as guided by the Royal Colleges.

O-EGS04 Is group and save necessary for all patients undergoing emergency cholecystectomy: A 6-year retrospective audit

Background Emergency cholecystectomy (EC) has a low perioperative bleeding risk. There is no current national guideline to suggest routine preoperative Group and Save (G&S) is necessary. Our Trust guideline recommends preoperative G&S for all EC operations. In 2018, a Trust-wide policy was adopted based on an audit, which concluded that routine preoperative G&S is unnecessary for elective cholecystectomy. All G&S require 2samples taken separately, which can delay surgery. The cost to process one sample for G&S is £28. Therefore, a study was set up to assess the need for routine G&S in patients undergoing EC. Methods This retrospective observational study was based on a prospectively collected hospital database from March 2015 to March 2021 using MS-Excel. All patients who underwent EC (laparoscopic and/or open) within 10 days during index admission were included. All elective cholecystectomies were excluded. Patients were divided into GS-patients (patients with G&S) and NGS-patients (patients without G&S). The primary outcome is the difference between the incidence of ‘Perioperative blood transfusion’ (PBT) between the studied groups. The overall cost-effectiveness is considered as a secondary outcome. The categorical data were analysed using the Chi-square test; a p-value <0.05 is considered statistically significant. Results In this 6year period, 2210patients underwent cholecystectomy. Of these, 496patients (22.4%) who underwent EC were included. 447patients (90.1%) were in GS group and 49patients (9.9%) were in the NGS group. None from the NGS group required PBT, whereas 3patients (0.6%) in the GS group received blood transfusion. However, PBT was truly indicated in 1patient due to the associated cardiovascular comorbidities. On the contrary, 2patients did not fit the ‘restrictive transfusion threshold’ criteria of JPAC. There was no statistically significant difference in PBT requirement between the studied groups (p = 0.331). Deferring routine G&S for EC could have saved our institution £24,976. Conclusions Our study has demonstrated that preoperative G&S is not indicated for all emergency cholecystectomies. It takes approximately 1 hour for G&S to be processed unless crossmatching is required. Group O-negative or O-positive blood can be provided to patients when urgent blood transfusion is needed depending on their age and gender. Thus, we conclude that G&S should be restricted to patients with low preoperative haemoglobin, bleeding and clotting disorders, those known to have abnormal blood antibodies and significant cardiovascular comorbidities.

P-EGS22 Emergency cholecystectomy: A comparative study of patient outcomes during COVID-19 pandemic with pre-COVID-19 period

Background Emergency cholecystectomy is recommended for all acute admissions with symptomatic gall stones. The Royal College of Surgeons and AUGIS on 25th March 2020 recommended that all laparoscopic procedures should be avoided during the COVID-19 pandemic with the view to minimise the risk of virus transmission from aerosol-generating procedures. This retrospective study compares the outcomes of patients undergoing emergency cholecystectomy during the COVID-19 period with the pre-COVID-19 period. Methods All patients who underwent emergency cholecystectomy (EC) from March 2019 to March 2021 were included. ‘Pre-COVID-19’ period was defined as 25th March 2019 to 24th March 2020, whereas the ‘COVID-19’ period was from 25th March 2020 to 24th March 2021. Mortality was considered as the primary outcome. Secondary outcomes include the 30-day postoperative complications based on the Calvien-Dindo classification (CDC) and the length of stay (LOS). Mortality and postoperative complications were assessed using the Chi-squared test, whilst LOS was studied using the Mann-Whitney U test. A p-value of < 0.05 was considered statistically significant. Results A total of 143patients underwent EC during the 24-month study period (75patients pre-COVID-19 and 68patients during COVID-19). The 30-day mortality was nil. 9patients;12% in pre-COVID-19 period and 11patients;16% in COVID-19 period underwent conversion to open cholecystectomy (p = 0.47). 18patients;24% from pre-COVID-19 and 19patients;27.9% from COVID-19 periods developed postoperative complications (p = 0.59). Grade-2-CDC complications were seen in 12patients;17.6% during COVID-19 period and 5patients;6.7% in pre-COVID-19 period (p = 0.0043). However, grade-3,4 CDC complications requiring intervention (p = 0.39), and ICU-admission (p = 0.62) were comparable in both periods. 1patient developed COVID-19 infection but made a full recovery. Mean LOS was 6-days in both periods, with no statistical difference (p = 0.28). Conclusions This study demonstrated no significant difference in patient outcomes who underwent emergency cholecystectomy during the COVID-19 pandemic compared to the pre-COVID-19 period. Emergency cholecystectomy should be offered to all surgically fit patients with symptomatic gall stones.

Use of percutaneous cholecystostomy for complicated acute lithiasic cholecystitis: solving or deferring the problem?

Objective: Percutaneous cholecystostomies are not infrequently used as an adjunct in the treatment of severe lithiasic cholecystitis, particularly in unstable and comorbid patients. However, their out of proportion liberal use tends to substitute the performance of emergency cholecystectomy, which the definitive treatment. Our aim was to assess the short and long-term outcomes of patients who had percutaneous cholecystostomy insertion due to severe lithiasic cholecystitis, aiming to define areas for improvement of our institutional practice. Materials and Methods: Retrospective review of our institutional practice including all patients who had a percutaneous cholecystostomy for complex lithiasic cholecystitis, over a 5-year period, allowing for an additional 1-year follow up. Results: A total of 34 patients were included in our final analysis. Percutaneous cholecystostomy insertion enabled quick and efficient control of the source of biliary sepsis without major procedural complications in all cases. In 14 (41.2%) patients, cholecystostomy alone served as definitive treatment, while in 20 (58.9%) cases it was used as bridging strategy for delayed elective cholecystectomy. In the delayed cholecystectomy group of patients, we noted a high conversion rate from laparoscopic to open surgery rate of 70%, with an overall subtotal cholecystectomy rate of 60%. Conclusion: Percutaneous cholecystostomies should be reserved only for complex lithiasic cholecystitis patients who are unwilling and/or unfit for surgery. We advocate the performance of upfront emergency cholecystectomy in any other case with liberal use of operative bail-out strategies, as a delayed elective operation is anyway likely to be converted to open and/or subtotal cholecystectomy.

TP6.2.5 Post-operative recovery following emergency laparoscopic cholecystectomy: a need to redefine the consent for emergency cholecystectomy

Aims Understanding the risks of emergency LC is necessary before patients can make an informed decision regarding operative management. Our primary aim was to provide a comprehensive analysis of the post-operative course of these patients. Methods Emergency LC performed for all biliary pathology across three surgical units between January 2015 and January 2020 were included. We followed each patient up for 100 days postoperatively and data was collected retrospectively. Data collected included demographic data, operative data, post-operative recovery, imaging, additional interventions and re-admissions. Results A total of 605 patients were identified (median age, 53 years (range 13-92); M:F, 1:2.7). 36.9% of patients had a complicated postoperative period, either suffering a significant complication, requiring prolonged post-operative stay (>3 days), further imaging, additional interventions or re-admission. The rate of complication was 13.5% (including retained stones 3.5%; collections 3.8%; bile leaks 3.3%). The rate of prolonged post-operative stay was 25.1%. 16.2% required postoperative imaging and 6.1% required post-operative intervention.12.9% were re-admitted for assessment related to the LC. The rate of bile duct injury was 0% (0/605). Conclusions Although LC has the reputation of largely an uncomplicated procedure, our data illustrates the substantive morbidity associated with emergency LC. Patients should be counselled about the high morbidity rates. This involves patient education and will improve consent which should help decrease litigation. Surgeons should take a more selective and pragmatic approach when offering the procedure.

SP6.1.5 Morbidity following emergency and elective laparoscopic cholecystectomy for cholecystitis: a retrospective comparative cohort study

Aims A comprehensive comparison of post-operative outcomes between emergency and elective laparoscopic cholecystectomy (LC) for cholecystitis has not been conducted and the relative morbidity associated with emergency LC remains uncertain. Our aim was to evaluate the difference in early post-operative outcomes between emergency and elective LC for patients with cholecystitis. Method LC performed for cholecystitis across three surgical units between January 2015 and January 2020 were analysed retrospectively from multiple regional databases using deterministic records-linkage methodology. Rates of complications, further imaging, re-intervention, prolonged post-operative stay and re-admissions over a 100-day follow-up period were compared between emergency and elective groups using univariate and multivariate analysis. Results LC were performed for cholecysitits in 962 cases (median age, 52 years; M:F, 1:2.7; emergency:elective; 1:3.9). Emergency cholecystectomy had higher rates of complication (15.8% versus 8.8%;p<0.0001), prolonged post-operative stay (40.3% vs. 12.7%;p<0.0001), post-operative imaging and intervention (19.1% vs. 9.4%;p<0.0001) and readmission (11.1% vs. 7.0%;p=0.017). In the multivariate regression analysis, emergency LC was associated with prolonged admission (OR,5.7;p<0.0001), complication (OR,2.97;p<0.0001), post-operative imaging and intervention (OR,2.4;p=0.002) and readmission (OR,1.9; p = 0.06). Conclusions Despite current guidance, an emergency cholecystectomy remains a morbid procedure and we demonstrate increased risks of emergency LC versus elective LC. The increased risk of an emergency LC needs to be weighed up against the risk of further attacks from biliary pathology until elective surgery. Our data indicates that we need to readjust our selection criteria for the ‘emergency cholecystectomy patient’ and identify patients who will specifically benefit from earlier surgery.

SP6.1.6 Rule of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

Aims Incidence of gall stone disease is estimated at 10-15%of population. Intraoperative cholangiography (IOC) diagnose choledocholithiasis, delineates the anatomy of the biliary ducts, facilitate the dissection and reduces injuries. Our aim is to assess the feasibility and role of IOC and the incidence of choledocholithiasis in acute cholecystitis (ACC). Methods Retrospective analysis of prospectively collected data for patients admitted with ACC and undergoing same-hospital-stay laparoscopic cholecystectomy (LC). IOC was systematically attempted in all cases. Results 475cases included. Female to male ratio1.9:1. Conversion to open was done in 3 cases. Preoperative cholelithiasis was confirmed in 439cases versus 34cases with no stones. USS CBD abnormality (dilated or contain stone) found in 53 cases, out of which 8(15%) cases had CBD stones. Jaundice was found in 69cases, where 25(39%) cases had confirmed choledocholithiasis. IOC was successful in all cases except one. Abnormal IOC was found in 99(21%) cases. Of those; CBD stones were confirmed in 76 (77%) cases regardless the presence of cholelithisasis on USS. Empyema was found in 237 cases and it was associated with higher risk of abnormal IOC in 59(25%) cases where CBD stones were confirmed in 45(76%) cases. Cystic duct (CD) stones found in 80cases, of those 27(34%)cases had choledocholithiasis. Conclusions Females have double the risk of ACC. Preoperative jaundice and CD stones are stronger indicators than CBD diameter for presence of choledocholithiasis. The incidence of choledocholithiasis in ACC is (20-25%) regardless the presence of gall stones on USS. IOC is feasible and highly recommended in emergency LC.

555 Should All Acutely Presenting Gallstone Disease Be Managed Surgically?

Aim This audit aims to assess if gallstone complications can be prevented by performing an emergency cholecystectomy in acutely presenting gallstone disease. Factors taken into consideration include number of presentations to hospital before surgery, secondary admissions of pancreatitis or cholangitis, subsequent requirements of ERCP as well as complication rates of elective and emergency surgery. Method Retrospective audit looking at 387 cholecystectomies carried out, within a year, at Walsall Manor Hospital. Results Approximately 20% of patients had an emergency cholecystectomy. A total of 192 patients had at least one admission, with 17% having a minimum second. Seven patients went on to develop gallstone pancreatitis subsequently, as well as eight requiring at least a minimum of one ERCP. The complication rate in elective surgery was higher at 4.1% compared to 2.7% in emergency cases. Long waiting times for surgery put patients at greater risk of complications. 96% (26/27) of elective cholecystectomy patients, who suffered an attack of pancreatitis, had to wait more than four weeks. Furthermore, 39% (47/119) of those who had a minimum of one admission had to wait more than 20 weeks. On the other hand, three-quarters of patients who were operated in emergency went home within 48 hours, with the figures being not too dissimilar from elective cases with a history of admission (76%). Conclusions Performing emergency cholecystectomies in the same admission or on a dedicated hot list would not only decrease the risk, but also the potential risk of developing gallstone complications.