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.

Unusual cause of gas complicating a biloma, postcholecystectomy

A 50-year-old man presented to the emergency department with abdominal pain, vomiting and fever. He had been admitted 6 months ago with acute cholecystitis when he underwent endoscopic retrograde cholangiopancreatography (ERCP) to remove ductal gallstones. Elective cholecystectomy was performed 3 days prior to the current admission. CT demonstrated a fluid and gas containing collection in the gallbladder fossa, biliary gas and free intra-abdominal gas. ERCP revealed a retained common bile duct gallstone and leakage from the cystic duct remnant. We postulate that the gas within the collection originated from intrahepatic gas post-ERCP or from a gas forming organism. The free intra-abdominal gas originated from the collection rather than an intraoperative bowel injury. This complicated case highlights an unusual appearance of a common complication. It demonstrates the importance of discussion with the clinical team to ensure that an accurate diagnosis is made and the correct treatment is provided.

The Relationship Between Waiting Time for Elective Cholecystectomy and Emergency Admission in KFMMC: Single Centre Experience

Introduction Patients with symptomatic cholelithiasis may undergo cholecystectomy, as an emergency or elective, in the outpatient clinic after discharge from the emergency department (ED). Increasing waiting times for elective cholecystectomy may lead to multiple ED visits for pain management or admission for emergency cholecystectomy. The aim of our study was to determine the relationship between waiting time for elective cholecystectomy and emergency admission. Methods This retrospective, observational study was designed and conducted at a single institution. The medical records of 239 patients with gallstone diseases who underwent emergency or elective cholecystectomy between January 2013 to November 2017 were obtained from the clinic. Result Approximately 76% (182/239) of the study participants underwent elective cholecystectomy and ∼24% (57/239) visited the ED during their waiting period, of which 42% (24/57) proceeded with emergency cholecystectomy during the waiting time for elective cholecystectomy and the remaining 58% (33/57) were managed in the ED and eventually underwent elective cholecystectomy. A waiting period of 60 days or more increased the risk of emergency cholecystectomy 5.21 times compared to a waiting period of less than 60 days. A waiting period of 31 to 180 days and above increased the chances of emergency cholecystectomy 4.13 (risk ratio) times and 25.5 (risk ratio) times, respectively, compared to a waiting period of 30 days or less. Conclusion Waiting time for elective cholecystectomy should be less than 30 days to reduce the risk of emergency cholecystectomy and multiple ED visits.

EVALUATION OF HAEMODYNAMIC AND CAPNOGRAPHIC CHANGES IN OPEN AND LAPAROSCOPIC CHOLECYSTECTOMY

Introduction: Laparoscopic cholecystectomy is one of the most commonly performed operations worldwide and gold standard treatment for benign gall bladder pathology. Increasing practice of lap cholecystectomy demands concurrent advancement in anaesthetic technique and monitoring standard. Objectives: Comparison of haemodynamic and ETCO2 changes intraoperatively during laparoscopic and open cholecystectomy and evaluation of any additional effects of insufated CO2. Study Design: Hospital based observational study done over 24 months Subjects and methods: 60 patients of both sex scheduled to undergo elective cholecystectomy under general Anaesthesia, selected on the basis of the inclusion criteria , were included in this study. Patients are assigned into two groups namely Group O[ planned for open cholecystectomy] and Group L[laparoscopic cholecystectomy], each group having 30 patients. Heart rate, systolic BP, diastolic BP, mean arterial pressure, EtCO2, SpO2 and ECG monitored continuously and record maintained before surgery, during induction, intubation, extubation and every 10 min interval up to the completion of surgery in both group.CO2 insufation and exsufation time also noted in laparoscopic cholecystectomy cases. Result: Age, sex, weight, height, ASA grade and duration of surgery of all the patients of both the groups were comparable. The HR, MAP and ETCO2 of group L started increasing during the intraoperative period and P values these were statistically signicant from t=20 minutes after intubation to t=60 min. In our study CO2 insufation done within 8 to 15 minutes after intubation. .It is clear from our study that pneumoperitoneum created during laparoscopic cholecystectomy might have caused this increase in HR,MAP and ETCO2. There was a decrease in SpO in Group L during the intraoperative period i.e from t=20 minutes after intubation to t=80 min after intubation and the P values during this 2 period were statistically signicant. Conclusion: From our study we come to the conclusion that in laparoscopic cholecystectomy there is signicant increase in HR, MAP, ETCO2 and decrease in SPO2 following insufation of the abdomen with CO2 and institution of the reverse Trendlenberg position.

Measuring the impact of delayed access to elective cholecystectomy through patient’s cost-utility: an observational cohort study

Background Deferral of surgeries due to COVID-19 has negatively affected access to elective surgery and may have deleterious consequences for patient’s health. Delays in access to elective surgery are not uniform in their impact on patients with different attributes. The objective of this study is to measure the change in patient’s cost utility due to delayed elective cholecystectomy. Methods This study is based on retrospective analysis of a longitudinal sample of participants who have had elective cholecystectomy and completed the EQ-5D(3L) measuring health status preoperatively and postoperatively. Emergent cases were excluded. Patients younger than 19 years of age, unable to communicate in English or residing in a long-term care facility were ineligible. Quality-adjusted life years attributable to cholecystectomy were calculated by comparing health state utility values between the pre- and postoperative time points. The loss in quality-adjusted life years due to delayed access was calculated under four assumed scenarios regarding the length of the delay. The mean cost per quality-adjusted life years are shown for the overall sample and by sex and age categories. Results Among the 646 eligible patients, 30.1% of participants (N = 195) completed their preoperative and postoperative EQ-5D(3L). A delay of 12 months resulted in a mean loss of 6.4%, or 0.117, of the quality-adjusted life years expected without the delay. Among patients older than 70 years of age, a 12-month delay in their surgery corresponded with a 25.1% increase in the cost per quality-adjusted life years, from $10 758 to $13 463. Conclusions There is a need to focus on minimizing loss of quality of life for patients affected by delayed surgeries. Faced with equal delayed access to elective surgery, triage may need to prioritize older patients to maximize their health over their remaining life years.

Quality of life and surgical outcomes of laparoscopic cholecystectomy in patients over the age of 80: a retrospective study

Background: As the United Kingdom’s population ages an increasing number of patients undergoing elective cholecystectomy are over the age of eighty. The current literature base focuses on a younger patient cohort and fails to consider quality of life benefit from the intervention. Assessing quality of life benefit as well as operative morbidity and post-operative complications together is important in the assessment of whether patients of this age should be managed surgically or conservatively.Methods: A retrospective study was conducted on all patients above the age of eighty undergoing elective cholecystectomy between January 2017 to January 2019 at a tertiary care centre in London. Intra-operative morbidity and post-operative complications were obtained from inpatient notes and quality of life was measured using the gastrointestinal quality of life questionnaire (GIQLI) pre and post operatively.Results: 120 patients over the age of eighty underwent laparoscopic cholecystectomy in the three-year timeframe. 11% experienced post-operative complications. A statistically significant improvement in GIQLI score was noted post-operatively across all domains including social function, gastrointestinal symptoms, physical function and emotional function.Conclusions: Post-operative complication rates were higher amongst this cohort compared to series studying a younger cohort of patients. However, quality of life significantly benefited from the intervention for patients over the age of 80. Hence, amongst carefully selected patients, laparoscopic cholecystectomy remains a viable treatment option and can greatly benefit the individual.

Minimising the hidden dangers of cholecystectomy in vascular Ehlers Danlos syndrome through a multidisciplinary approach

We present a 47-year-old with Ehlers-Danlos syndrome (EDS) type IV (vascular subtype) referred with recurrent episodes of severe biliary colic requiring elective cholecystectomy. Successful surgical management required extensive planning and multidisciplinary teamwork. This report is intended as a guide for clinicians in the perioperative planning of elective EDS typeIV patients.