P-EGS05 Assessment of acute cholecystitis management during COVID-19 pandemic in comparison to the CholeQuic approach : A single centre experience

Background Acute cholecystitis is an emergency condition, typically arising from gall bladder stones and often leading to unplanned surgical admissions to hospital. In the UK, gall stone disease accounts for approximately one third of all unplanned general surgical admissions. According to the The Royal College of Surgeons' Commissioning guidance, early management of acute cholecystitis in particular is the key to prevent further development of more serious complications that can lead to mortality (up to 10%). Therefore, urgent admission to secondary care and laparoscopic cholecytectomy are recommended once diagnosis is confirmed . Conservative management is not recommended as gallbladder inflammation often persists despite medical therapy which can lead to further attacks and risk of developing gall bladder perforation ( mortality in 30% of cases). Early laparoscopic cholecystectomy is also associated with reduced hospital costs and earlier recovery. During the first wave of COVID-19, the guidelines changed in order to limit the admission rates to free up spaces for possible COVID-19 infected patients. Crisis approach entailed conservative management with pain relief, antibiotics plus or minus cholecystostomy. However, reviews of this approach have not been widely published to assess the results and in turn planning our future management approach in case of other COVID-19 surge. Methods Our study included all the patients diagnosed with acute cholecystitis who needed surgical intervention in one medical Centre in the UK. The time table of the study is divided into 3 periods the pre- COVID era from 16/12/2019 to 15/03/2020 (group I), then during the first lock down era from 16/03/2020 to 30/06/2020 (group II) and, finally after the ease of the lock down from 01/07/2020 to 02/09/2020 (group III). Pre- and post-lockdown time periods the CholeQuIC approach was followed while during the lockdown era, patients were initially treated conservatively followed by surgical managemnt in case of failure to improve. Laparoscopic cholecystectomy was performed, however, in difficult cases conversion to open surgery occurred. The primary outcome was to Compare and perform analysis of the three distinctive periods regarding, delayed presentation, the degree of operative difficulty, which was quantified by analysing the operative time, blood loss, rate of drain insertion and rate of conversion into open surgery. Furthermore, a review of unfavourable intra-operative findings such as extensive adhesion to surrounding organs, hydrops, empyema, gangrene, and/or perforation of the gallbladder was done. The post-operative results were also analysed, according to the length of hospital stay, and the rate of post-operative complications. Results Operative difficulty The mean operative time before the lockdown was 71.6 minutes while it was 81.0 and 78.0 minutes during and post COVID respectively. In terms of conversion to open, the rate reached 10.5 % during the lockdown, while the figures were 4.9% and 3.13% during the pre and after lockdown respectively. Moreover, intra peritoneal drains were used in more than one quarter of the patients (28.9%) during the lockdown era compared to 11.5 % and 12.5% pre and post the lockdown respectively. Considerable blood loss occurred in 10.5%. Intra-operative findings During the lockdown, 28.9 % exhibited extensive adhesions between the gall bladder and surrounding structures. This level is almost three times the percentage during the pre and post-lockdown time periods (8.2% and 9.4% respectively). As for gangrenous cholecystitis, it was 18.4 % during the lockdown, 6.6% before and 6.3% after the lockdown respectively. Post-operative results Before the lockdown the average LOS was 2.9 days which increased to 8.9 days during the lockdown, followed by a decrease to 2.4 days following the ease of lockdown. The lockdown era depicted the highest rate of post-operative complications (bile leakage 7.9%, missed stones 5.3% and duodenal injury 2.6 %). Conclusions During crisis periods tough measures and decisions are made to deal with the situation, however, these decisions can lead to grave consequences on the medical staff and most importantly on patients. As shown in this study and supported by the previous studies, conservative management of acute cholecystitis led to serious complications as many patients were re-admitted for emergency surgery as a result of failure of the non-surgical approach. Moreover, delayed emergency surgery was associated with increased operative difficulties and higher percentage of serious intra and post-operative complications. All this led to longer hospital stay which can prove the failure of this approach. Unfortunately in our Unit, whilst closely studying acute gall bladder disease, we have found that the conservative approach appears to have back-fired and did the exact opposite. Therefore, we believe that there is nil to support conservative treatment of acute cholecystitis in our Unit. We believe that the evidence as displayed suggests that rapid surgery provides best outcome for individual patients and our system, perhaps especially when under strain for other reasons.

P-BN03 A systematic review of pre-operative low-calorie diets for laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy is the fourth most common procedure in the UK. Increased liver adiposity, commonly encountered in obesity, anecdotally may increase technical difficulty and surgical risk. Pre-operative low-calorie diets are well-established in bariatric surgery to reduce liver bulk, thereby ameliorating difficulty and risk. Similar diets are often used before laparoscopic cholecystectomy, however, the supporting evidence base is unclear; we performed the first systematic review on their use in this context. Methods PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched in February 2021. We included English language clinical studies describing pre-operative low-calorie diet for laparoscopic cholecystectomy. Data were extracted for specifics of / adherence to diet, weight change, operative time / difficulty, complications and length of stay. Study quality was qualified using Scottish Intercollegiate Guidelines Network criteria and Jadad score. Results One randomised controlled trial (RCT) and one prospective observational study were identified. Both utilised a pre-operative very low-calorie diet of < 800 kcal/day. Overall weight loss was greater in patients deemed compliant with the intervention. Both demonstrated tendency towards reduced operative difficulty with the intervention. Only the RCT found improvement in operative time. Conclusions Pre-operative very low-calorie diets (< 800 kcal/day for two weeks) may aid weight loss and reduce operative difficulty in laparoscopic cholecystectomy, although evidence supporting their continued use is limited. Further RCTs are warranted to fully evaluate their role in clinical and cost-effectiveness.

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.

TP6.2.8 Impact of patients’ characteristics on operative difficulty and clinical outcomes of laparoscopic cholecystectomy

Background Laparoscopic cholecystectomy (LC) is a common surgical procedure. Intraoperative findings are highly unpredictable and the operative difficulty varies from straightforward to very challenging procedures. Several studies described predictors of technical difficulty and graded intraoperative findings of LC, however none specifically reported on the effect of such factors on clinical outcomes. This study aims to evaluate the impact of patients’ preoperative characteristics on operative difficulty of LC and clinical outcomes. Methods Data of patients who underwent LC from 2015 to 2017 retrospectively analysed. Subjects were divided into four groups, according to Nassar’s classification of intraoperative difficulty. Differences in frequencies were evaluated with the Fisher’s exact test; logistic regression analysis was used to identify independent variables that were predictors of postoperative morbidity and length of stay. Results A total of 1069 patient were included. Male to female ratio of 1:2.5. Older age, male gender and comorbidities were associated with higher Nassar score (p < 0.0001); Nassar 3 and 4 were predictors of postoperative morbidity(P£0.01). The day case rate was 88.8% (Nassar 1), 86.1% (Nassar 2), 69.6% (Nassar 3), 62.3% (Nassar 4), respectively. Age of 60 and above(P£0.018), ASA 2 or 3(P£0.04) and Nassar 3, 4 (P£0.012), were predictors of increased conversion from day case to in-patient stay. Conclusion LC can be performed on a day case basis even when surgery is technically challenging. However, the need of in-patient stay can be predicted in comorbid old adult men with anticipated higher Nassar’s score.

SP3.1.7 Performance of ultrasound in the diagnosis of cholecystitis and prediction of the “difficult cholecystectomy”

Aims Ultrasound has long been the radiological investigation of choice for right upper quadrant pain for the detection of gallstones and cholecystitis. However, previously reported sensitivity, specificity and other diagnostic metrics have varied widely and the underlying patient numbers have been small. We present robust and exhaustive diagnostic metrics based on a large series of 793 patients. Methods All laparoscopic cholecystectomies at our university hospital were prospectively logged between 2017 and 2020. The ultrasound findings, Nassar operative difficulty and histopathological findings were all collected in addition to patient biometrics. Results In our large patient series, sensitivity of ultrasound for cholecystitis was lower than previously reported at 75.7% for acute cholecystitis, 34.6% for chronic cholecystitis and 42.7% overall. Moreover, we show that sensitivity degrades with the time between ultrasound and cholecystectomy, falling below 50% at 140 days. Finally, we show that ultrasound strongly predicts Nassar difficulty grade of cholecystectomy and that its ability to do so is greatest where the interval between ultrasound and cholecystectomy is less than 27 days. Conclusions We present robust diagnostic metrics for ultrasound in the diagnosis of cholecystitis. These should caution the clinician that ultrasound may miss a quarter of cases of acute cholecystitis and over half of all cases of cholecystitis. Conversely, the finding of a thickened gallbladder on ultrasound can predict a “difficult cholecystectomy” and highlight the need for appropriate expertise and resources. Both this prediction and the diagnostic sensitivity are best if the ultrasound is done less than 27 days before cholecystectomy.

505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover

Introduction There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon. Case Report We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail. Discussion This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.

736 Optimal Time for Cholecystectomy After ERCP

Introduction Recent research on the management of cholecystolithiasis with co-existing choledocholithiasis suggests performing cholecystectomy within 24 hours after ERCP has favourable outcomes. However, this target can be difficult to achieve in the NHS due to limited resources. Method This retrospective study includes 444 patients who underwent successful ERCP before cholecystectomy. We examined the impact of the duration of ERCP to cholecystectomy and post ERCP complications on operative difficulty and patient outcomes. We also report on gallstone related readmissions and rate of retained stones. Results The median duration from ERCP to cholecystectomy was 75 days, with a 14% readmission rate between their first successful ERCP and cholecystectomy. Our analysis showed a statistically significant negative correlation between ERCP-to-cholecystectomy duration and postoperative stay. Readmissions increased with time, but this did not reach statistical significance. The occurrence of post ERCP complications significantly increased postoperative stay and the open conversion rate. Conclusions In contrast to recent research, our analysis suggests that early cholecystectomy post ERCP is not associated with better outcome. However, the impact of gallstone related readmissions needs further analysis. Post ERCP complication could serve as a predictor for operative difficulty and longer postoperative stay. It should be considered when planning the cholecystectomy.

Impact of visceral obesity on operative outcomes of laparoscopic nephrectomy: comparison between visceral fat area and body mass index

Background Obesity has been considered as a risk factor influencing operative difficulty. It was reported that body mass index (BMI; kg/m2) did not always properly reflect the degree of a patient’s visceral fat. The purpose of this study is to retrospectively investigate the association of operative outcomes and obesity indices including visceral fat area (VFA; cm2) and BMI in retroperitoneoscopic nephrectomy (RN). Methods We retrospectively reviewed consecutive 96 RN procedures performed from September 2016 to June 2020. We divided patients into BMI obese group (BMI ≥ 25, n = 25) and BMI normal group (BMI < 25, n = 71), VFA obese group (VFA ≥ 100, n = 54) and VFA normal group (VFA < 100, n = 42). Patient characteristics, operative and postoperative outcomes were compared between the two groups for each index of obesity. Results In two groups divided by BMI, the only specimen weight was significantly greater in the obese group (320 vs. 460 g, p < 0.001), whereas VFA obese group had longer insufflation time (165 vs. 182 min, p = 0.028), greater estimated blood loss (34 vs. 88 ml, p = 0.003) and greater specimen weight (255 vs. 437 g, p < 0.001) than VFA normal group. In a logistic regression analysis, high VFA value was a significant predictor for greater specimen weight and high VFA value and large size of renal tumor were significant predictors for greater blood loss. By contrast, BMI was not a significant predictor. Furthermore, in the case of non-obese patients (BMI < 25), VFA obese group had significantly longer insufflation time, greater estimated blood loss and greater specimen weight than normal group. Conclusions The present data suggest that VFA is a more useful parameter than BMI for predicting the operative difficulty associated with obesity, and VFA has a higher use value in non-obese patients (BMI < 25) than in obese patients (BMI ≥ 25).