P-BN41 Does performing percutaneous cholecystostomy in patients at risk of sepsis have better outcomes than patients in sepsis?

Background Gallstone related diseases account for almost one-third of acute surgical admissions with presentation varying from biliary colic to sepsis. There were various studies evaluating the role of ‘percutaneous cholecystostomy’ (PC) as part of the management in acute cholecystitis under ‘radiological guidance’ (RG). However, limited literature is conducted to evaluate patients’ outcomes based on the indication and optimal timing of cholecystostomy. Therefore, this study was set up to assess the difference in clinical outcome between the patients undergoing cholecystectomy with overt sepsis (OS) and impending sepsis (IS). Methods A retrospective observational study was conducted using a prospective database on patients who underwent PC under RG between 03/2014-03/2021. NICE’s sepsis risk stratification tool was used to divide patients into OS and IS groups. OS group included patients with 1 or > 1 high-risk criteria. IS group included patients with 2 or > 2 moderate to high-risk criteria. The primary outcomes are 30-day mortality and the ‘length of stay’ (LoS) and secondary outcome include post-procedural ‘bile leak’ (BL).Continuous and categorical variables were analysed using Mann-Whitney U and Chi-squared tests respectively. A p-value of < 0.05 was considered to be statistically significant. Results Some 27 patients were included. The median age was 80 (range 61-90).The majority of the patients (77.78%, n = 21) were unfit for surgery, with a Charlson Comorbidity Index ranging of 3 to 12. The median length of hospital stay of the OS and IS groups were 17 and 15 days respectively (p = 0.47).There was no significant difference in bile leak (IS-1/20 vs OS-0/7; p = 0.56) and drain accidents (IS-8/20 vs OS-1/7;p=0.35).Overall two patients in the IS group underwent an uncomplicated interval cholecystectomy. The 30-day mortality rate was significantly higher in OS (IS 0/20 vs OS-4/7; p = 0.00039). Conclusions Percutaneous cholecystostomy is generally safe to be performed irrespective of patients’ co-morbidities and has no significant long-term complications associated with mortality. Early cholecystostomy before overt sepsis results in a reduced 30-day mortality rate and better outcome. Further clinical studies may be required to determine specific patient groups who would benefit from percutaneous cholecystostomy.

P-BN42 Percutaneous cholecystostomy - A practice review

Background Percutaneous cholecystostomy (PC) is performed occasionally in a highly selected group of patients with variable outcomes. The World Society of Emergency Surgery (WSES) updated guidelines(2020) has recommended PC as a treatment modality in patients admitted with ‘acute calculous cholecystitis’(ACC) with who are not fit for surgery, including septic patients and those who show no improvement on conservative management within 48 hours. An audit was organised to review our patient selection for PC in the last 5 years in comparison to the latest WSES recommendations. Methods A retrospective observational study was conducted using a prospectively collected hospital database on patients who underwent PC between March 2016 and March 2021 in a teaching hospital. The patient cohort who underwent PC were compared and analysed against the set WSES guidelines. Results Some 23 patients were included. The median age was 82 years (range-61-90), with 13 females (56.5%) and 10 males (43.5%).19/23(82.6%) patients were at risk of sepsis on presentation, with two or more amber flag symptoms, whereas 4/23(17.4%) patients presented with confirmed sepsis. 19/23 (82.6%) were deemed unfit for surgery against 4/23 who were deemed fit based on the surgeons assessment. Patients unfit for surgery were treated with antibiotics following a diagnosis of ACC. The median time for patients to undergo PC from admission was 4 days. The 30-day mortality rate was 13 % (n = 3/23). Conclusions The study has demonstrated that our current practice for managing patients admitted with ACC and performing PC are mostly in line with the WSES guidelines. Considering individuals presentation and the surgeons clinical judgement into account, the practice was also likely impacted by COVID-19 the global pandemic. Further clinical studies may be required to determine specific patient groups who would benefit from PC.

Percutaneous cholecystostomy as a definitive treatment for moderate and severe acute acalculous cholecystitis: a retrospective observational study

Background In this study, we aimed to investigate risk factors for the relapse of moderate and severe acute acalculous cholecystitis (AAC) patients after initial percutaneous cholecystostomy (PC) and to identify the predictors of patient outcomes when choosing PC as a definitive treatment for AAC. Materials and methods The study population comprised 44 patients (median age 76 years; range 31–94 years) with moderate or severe AAC who underwent PC without subsequent cholecystectomy. According to the results of follow-up (followed for a median period of 17 months), the data of patients with recurrence versus no recurrence were compared. Patients were divided into the death and non-death groups based on patient status within 60 days after PC. Results Twenty-one (47.7%) had no recurrence of cholecystitis during the follow-up period after catheter removal (61–1348 days), six (13.6%) experienced recurrence of cholecystitis after PC, and 17 (38.6%) patients died during the indwelling tube period (5–60 days). The multivariate analysis showed that coronary heart disease (CHD) or congestive heart failure (odds ratio [OR] 26.50; 95% confidence interval [CI] 1.21–582.06; P = 0.038) was positively correlated with recurrence. The age-adjusted Charlson comorbidity index (OR 1.53; 95% CI 1.08–2.17; P = 0.018) was independently associated with 60-day mortality after PC. Conclusions Our results suggest that CHD or congestive heart failure was an independent risk factor for relapse in moderate and severe AAC patients after initial PC. AAC patients with more comorbidities had worse outcomes.

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.

P-EGS23 Efficacy of Percutaneous Cholecystostomy and Timing of Tube Removal: An Observational Study from a busy District General Hospital

Background Percutaneous cholecystostomy (PC) has traditionally been reserved for high-risk patients with cholecystitis who are unfit for surgical intervention, or as a temporizing measure for septic biliary patients to relieve sepsis and symptoms. However, there are currently no guidelines regarding the timing of tube removal following PC. The aim of this study is to evaluate the timing of tube removal following resolving inflammation and patency of biliary ducts, and its associated risks. Methods Patient notes and imaging reports were retrospectively reviewed from those who underwent percutaneous cholecystostomy from January 2015-Dec 2020. Data collected included demographic details, symptom presentation, requirement of ITU admissions, details of cholecystostomy, post-operative complications from the tube, outcomes following PC, and mortality rates within 30 days of the procedure. Patients were graded by their severity of their cholecystitis according to the 2018 Tokyo Guidelines, and these were correlated with morbidity and mortality outcomes within 1 year of the procedure. Results There were 55 females and 65 males, with a mean age of 75.2 years (range 45-96 years). Approximately 45% of patients were diabetic and had comorbidities. On presentation, 54% (65/120) patients had elevated inflammatory markers (WCC/CRP), and 20% of patients had associated deranged liver function tests. Majority of patients had moderate or severe acute cholecystitis, with over 25% (31/120) of patients presenting with sepsis, and 6 required admission to intensive care. The median time from diagnosis of acute cholecystitis to percutaneous cholecystostomy was 8.5 days (range 1-64 days). Tube removal was performed after a median time of 31 days (range 1-142 days). Morbidity rate was observed to be 8-10%, comprising of complications such as tube displacement, leakage around the drain, bleeding and liver abscesses. Only 18.3% (22/120) of patients were deemed to be fit for further surgical intervention, of which 13 of those underwent a cholecystectomy thereafter. Unsurprisingly, 38% of these patients had recurrent biliary symptoms, and a 30% mortality rate. Conclusions Percutaneous cholecystostomy is a safe option in high-risk surgical patients for symptom relief, and is a crucial step in temporizing and de-escalating sepsis. However, this study suggests that timing of cholecystostomy removal is variable, and is associated with high morbidity. Consideration needs to be given to shorten the time to tube removal, to minimise risks, if certain criteria are met to ensure safety and efficacy.