O-EGS02 Effective use of afternoon Day Case Theatre Lists for Emergency Laparoscopic Cholecystectomy on Emergency Surgery Ambulatory Care (ESAC) Pathway

Background Gallstone disease is a common entity and affects up to 10-15% of the European population. The majority of these cases are asymptomatic but approximately 20% will develop complications such as severe biliary colic, cholecystitis, choledocholithiasis and pancreatitis. Early cholecystectomy in patients suffering from symptomatic gallstones can improve post-operative outcomes, avoid re-attendance and reduce overall length of hospital stay. We describe how two afternoon day case theatre lists were successfully utilised to prevent surgical admissions by enabling laparoscopic cholecystectomy on an urgent basis. Methods A sustainable pathway for symptomatic gallstones was introduced to Emergency Surgery Ambulatory Care (ESAC). Patients presenting with acute symptoms, well enough for ambulatory care, were referred to ESAC for diagnosis and management. Patients fit for surgery underwent pre-operative assessment before being operated on one of two weekly afternoon lists. A standardised, evidence-based approach was used for all laparoscopic cholecystectomies to ensure homogeneity of technique and patient care. This included pre-incision local anaesthetic, low flow and pressures intra-operatively, adequate analgesia to-take-home, and follow-up telephone consultation at 48hrs. Prospective data collection began in 2019 looking at hospital admission rate and 30-day re-presentation. Results Analysis was performed on data collected from September 2019 to July 2021. 151 patients had laparoscopic cholecystectomies, 107 were female and 44 male. Age range was 18-83 (median age 49) and median time to operation was 3 days. Overall, the spectrum of gallstone disease was 81 biliary colic, 44 cholecystitis, 20 pancreatitis and 6 choledocholithiasis. 18 patients were admitted post-operatively with length of stay ranging 1-6 days (median 1.5 days). 17 patients re-presented within 30 days, mainly for abdominal or pleuritic chest pain, although one patient required ERCP for CBD stones and another had pancreatitis. Conclusions Emergency surgery for symptomatic gallstone disease can be performed successfully on a day case basis. At our centre, the rate of post-operative admission was 12% and 30-day re-presentation was 11%. Standardisation of referrals, assessment and operative technique can achieve excellent outcomes with low rates of hospital admission and post-operative complications.

P-BN06 Percutaneous cholecystostomy rates are increased following COVID-19 induced disruption to elective surgical pathways

Background The COVID-19 pandemic has led to major service disruptions, including the cessation of elective laparoscopic cholecystectomies (LC), causing delays in managing symptomatic gallstones. We hypothesised that this would lead to an increased need for percutaneous cholecystostomy (PC) for acute cholecystitis. Methods We performed a retrospective cohort study in a single NHS trust. We included all patients who underwent either LC or PC during the periods of March 1st – August 31st over the years 2019 and 2020. Patient data was obtained from prospectively maintained patient electronic notes. Data are presented as median and interquartile ranges for continuous data and the percentages for categorical data and compared with Mann-Whitney U-test and Fisher’s exact tests respectively. Results We observed a substantial reduction in the number of LC performed in 2020 (n = 99) compared to 2019 (n = 198), whilst the number of PC performed in 2020 (n = 35) was more than double that in 2019 (n = 17) (Fig.1). This increase in numbers persisted even after our LC service was restarted. Comparing the patients who underwent PC in both years, there were no significant differences in age (2019: 68 (45-76) vs 2020: 72 (57-81), p = 0.41), comorbidities (Charlson comorbidity index≥4: 10 (59%) vs 16 (46%), p = 0.56), or in-hospital mortality (2019: 2 (12%) vs 2020: 3 (9%), p = 0.99). As a proportion of all biliary interventions for cholelithiasis, PC increased from 8% (17/214) in 2019 to 26% (35/134) in 2020 (p < 0.001). Conclusions These results show how the cessation of LC service was directly related to increased numbers of invasive ‘damage control’ procedures for acute cholecystitis, emphasising the importance of maintaining COVID-secure surgical pathways. The numbers of PC remained high even after the restart of LC service, consistent with a ‘COVID shadow’ resulting from interruptions to elective services that impacts patient care for a prolonged period.

O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

DAY-CARE VERSUS ROUTINE LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic cholecystectomy has been performed as a day-care procedure for many years. Few studies have been conducted with primary focus on patient acceptance and preferences in terms of quality of life for this practice compared with overnight stay. Data from 100 patients with symptomatic gallstones randomized to laparoscopic cholecystectomy performed either as a day-care procedure or with routine were analyzed. Complications, admissions, and readmissions were assessed. Forty-eight (92 per cent) of 52 patients in day-care group were discharged 4– 8 h after the operation. Forty-two (88 per cent) of 48 in the overnight group went home on routine basis after surgery. The overall conversion rate was 2 per cent. Two patients had complications after surgery, both in the day-care group. No patient in either group was readmitted. There was no signicant difference in total quality of life score between the two groups.

EP.TH.341Creating and testing the online multimedia platform aboutmyop.org

Introduction The value of patient focused registries and the use of patient reported outcomes is well documented. However, despite the availability of technological advances the use of multimedia interfaces with patient interaction and real time digitalised data collection has yet to become routine practice. As a modern-day solution, aboutmyop.org was developed as a patient-facing website to improve patient-clinician communication and information sharing. The aim of this study was to pilot the platform in routine clinical care, to identify acceptability, strength and weaknesses. Method Patients identified with symptomatic gallstones and referred for consideration for elective laparoscopic cholecystectomy were invited to use aboutmyop.org by postal invitation. Patient demographics, and information on patient recruitment were collected prospectively. Results The process of approvals to implement and integrate aboutmyop.org with NHS systems took over 18 months. Due to difficulties with onboarding, 349 (38.9%) of the 898 eligible patients registered, and fewer continued to participate post-operatively (7 days: 46.5%, 30-days: 30.5%, 3-months: 27%, 6-months: 19%). Participants were significantly younger than non-participants (47.6 vs. 51.8 years, p < 0.05), but were otherwise equally matched for gender and comorbidities. Despite system and implementation issues, participants were accepting and supportive of aboutmyop.org. Conclusion The aboutmyop.org system demonstrates a method to improve information accessibility for patients, and a novel method for data-sharing between patients and clinicians. Despite difficulties with system access, users demonstrated a willingness to engage in virtual recruitment and digital surveys. Subsequent improvements in access to a aboutmyop.org should help to facilitate long-term patient engagement and quantify real world benefits.

Awareness of patients with symptomatic gallstones regarding their own disease

Aim: To evaluate the awareness of patients presenting to a government sector hospital in Lahore with gall stones regarding their disease and factors influencing it. Methodology: A cross sectional observation study was conducted at the Department of General Surgery, Services Hospital, Lahore from 1st January 2020 to 30th June 2021. A simple questionnaire to collect and analyze the data of the patients admitted for cholecystectomy. The content of the questionnaire included socio-demographic characteristics and questions to access the awareness of patients regarding gallstones. Data was entered and analyzed using EXCEL 2013. Frequencies and Percentages were calculated as descriptive statistics whereas Fisher's exact test was conducted as inferential statistics. Value of p less than 0.05 was considered as significant. Results: Only 13.5% patients had a good awareness of their own disease. Direct education about the disease from doctor (p=0.0320), media (0.0316) or self-study (0.0001) were significantly related to awareness. Conclusion: The awareness of the patients with symptomatic gall stones regarding their own disease is poor. Role of physicians and lack of its impact on this needs to be investigated further. Keywords: Patient Awareness, gall stones

Excess Body Weight and Gallstone Disease

<b><i>Background:</i></b> Approximately one fifth of adults are diagnosed with gallstones worldwide. Of these, around 25% develop gallstone disease (indicated by the presence of symptoms) and undergo cholecystectomy. <b><i>Summary:</i></b> The risk of gallstones is influenced by a combination of genetic and lifestyle factors, such as excess body weight. In fact, body mass has been demonstrated to be a major risk factor for symptomatic gallstones. Rapid weight loss can also initiate a prolithogenic state and further increase the likelihood of either gallstone formation or existing gallstones becoming symptomatic; however, sensible weight loss strategies can mitigate this risk. This review discusses the role of excess body weight and the risk of gallstone disease, as well as the options available for the prevention of symptomatic gallstones. <b><i>Key Messages:</i></b> Healthy weight loss diets combined with regular physical activity can promote successful weight loss and weight maintenance and reduce the risk of gallstones. Should rapid weight loss be required for health reasons or be expected, e.g., after bariatric surgery, prophylactic ursodeoxycholic acid during the period of weight reduction has been demonstrated to reduce the incidence of gallstones formation or symptomatic gallstone occurrence. The recent German guidelines on gallstones recommend simultaneous cholecystectomy during bariatric surgery but only for those with preexisting symptomatic stones.

P71 Investigating the rate of successful day case discharges for laparoscopic cholecystectomies between June-November 2019

Introduction Laparoscopic Cholecystectomy (LC) is the gold standard treatment for symptomatic gallstones. The British Association of Day Surgery (BADS) recommend that at least 60% of LCs are performed as day cases. We investigated the rate of successful discharge for LCs and factors contributing to unexpected overnight stays. Methods Retrospective data analysis was performed on elective LCs between June-November 2019. Electronic records were reviewed for: admission and discharge date; time of procedure; length of procedure; training grade of the surgeon; use of total intravenous anaesthesia (TIVA) or volatile anaesthesia; use of IV morphine in theatre/recovery and reasons for failed discharge. Results A total of 119 patients underwent elective LC, of which 63 were planned day cases. 46 patients (73.0%) listed as day cases were successfully discharged the same day. LCs performed before 1pm had a success rate of 78.8% compared to 45.5% after 1pm (p &lt; 0.05). There was no statistically significant difference in success rates due to length of procedure; training grade of the surgeon; method of induction (TIVA or Volatile) or use of IV morphine in theatre/recovery. 17 planned day cases failed same day discharge. 7 of these patients (41.2%) reported pain and 4 (23.3%) reported nausea, vomiting or dizziness. Conclusion This centre successfully discharged 73.0% of planned day case LCs, although only 52.9% of elective LCs were listed as day cases. Success rates were positively associated with am procedures compared to pm. We recommend a review of operation scheduling and evening staffing in order to increase the probability of discharge on the same day.