Elective laparoscopic cholecystectomy: recurrent biliary admissions predispose to difficult cholecystectomy

Introduction Patients undergoing elective laparoscopic cholecystectomy (ELLC) represent a heterogeneous group making it challenging to stratify risk. The aim of this paper is to identify pre-operative factors associated with adverse peri- and post-operative outcomes in patients undergoing ELLC. This knowledge will help stratify risk, guide surgical decision making and better inform the consent process. Methods All patients who underwent ELLC between January 2015 and December 2019 were included in the study. Pre-operative data and both peri- and post-operative outcomes were collected retrospectively from multiple databases using a deterministic records-linkage methodology. Patients were divided into groups based on clinical indication (i.e. biliary colic versus cholecystitis) and adverse outcomes were compared. Multivariate regression models were generated for each adverse outcome using pre-operative independent variables. Results Two-thousand one hundred and sixty-six ELLC were identified. Rates of peri- and post-operative adverse outcomes were significantly higher in the cholecystitis versus biliary colic group and increased with number of admissions of cholecystitis (p < 0.05). Rates of subtotal (29.5%), intra-operative complication (9.8%), post-operative complications (19.6%), prolonged post-operative stay (45.9%) and re-admission (16.4%) were significant in the group of patients with ≥ 2 admissions with cholecystitis. Conclusion Our data demonstrate that patients with repeated biliary admission (particularly cholecystitis) ultimately face an increased risk of a difficult ELLC with associated complications, prolonged post-operative stay and readmissions. These data provide robust evidence that individualised risk assessment and consent are necessary before ELLC. Strategies to minimise recurrent biliary admissions prior to LC should be implemented.

The Effect of Pneumoperitoneum-induced Hypertension During Laparoscopic Cholecystectomy Under General Anesthesia on Postoperative Pain: A Randomized Clinical Trial

Background: Acute postoperative pain is a significant cause of morbidities. This study aimed to evaluate the effect of intraoperative blood pressure during laparoscopic cholecystectomy under general anesthesia on postoperative pain in patients without underlying disorders. Methods: In this randomized clinical trial, 72 patients undergoing general anesthesia for elective laparoscopic cholecystectomy were randomly assigned into two groups: Group A with higher than baseline preoperative blood pressure (MAP allowed to increase up to 20% higher than baseline MAP by inducing pneumoperitoneum) and group B with normal to low blood pressure (MAP deliberately controlled at a tight limit from normal baseline MAP values to 20% less than baseline by titrating TNG infusion). The Visual Analog Scale (VAS) after 2, 8, 12, and 24 hours of surgery, and the total dose of meperidine used to manage postoperative pain were recorded and compared between the two groups. Results: The pain scores in group A were significantly lower than group B (P = 0.001). The postoperative analgesia request time was different between the two groups (P = 0.53). During the first 24 hours, the total meperidine consumption dose in group A was significantly lower than in group B (P = 0.001). Conclusions: High intraoperative blood pressure may affect the postoperative pain after laparoscopic cholecystectomy and lead to less postoperative pain score and analgesic requirements.

Comparison of aprepitant and dexamethasone versus metoclorpramide and dexamethasone for prevention of post-operative nausea and vomiting in patients undergoing laparoscopic cholecystectomy.

Objective: To compare the efficacy of aprepitant and dexamethasone versus metoclopramide and dexamethasone combination in prevention of post-operative nausea and vomiting in females undergoing laparoscopic cholecystectomy. Study Design: Prospective Comparative study. Setting: Department of Anesthesia, CMH Lahore. Period: October 2019 to April 2020. Material & Methods: A total of 140 female patients planned for laparoscopic cholecystectomy under general anesthesia, of age ranges from 35-65 years and ASA classification I and II were recruited for the study and were divided into two equal groups. In group A (n=70), patients were given oral aprepitant 80 mg with once sip of water one hour prior to induction and dexamethasone 8 mg upon induction. In group M (n=70), patients were given a placebo one hour prior to induction and intravenous metoclopramide 10 mg and dexamethasone 8 mg upon induction. Results: Age range in this study was from 37 to 65 years with mean age of 46.82 ± 7.29 years. The mean age of patients in group A was 45.73 ± 6.77 years and in group M was 47.91 ± 7.66 years with p-value of 0.076. In our study, significant difference was found between the efficacy of two groups of drugs. The efficacy of aprepitant and dexamethasone was found in 62 (88.57%) patients, while with metoclopramide and dexamethasone, it was found in 51 (72.86%) patients with p-value of 0.031. Conclusion: it is concluded that aprepitant and dexamethasone combination has higher efficacy as compared to metoclorpromide and dexamethasone in prevention of post-operative nausea and vomiting in elective laparoscopic cholecystectomy.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital

Objectives With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. Materials and Methods A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. Results A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. Conclusion Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

Granisetron Versus Ondansetron for Prevention of Post-operative Nausea and Vomiting (PONV) in Patients Undergoing Laparoscopic Cholecystectomy

Aim: To determine the efficacy of single dose Granisetron versus ondansetron in preventing PONV in patients undergoing elective laparoscopic cholecystectomy. Methodology: A total of 100 patients were included in this study after the ethical approval of PUMHSW. Patients were randomly divided into two groups, in (Group G) 50 patients were given Granisetron and in (group O) 50 patients were given Ondansetron. Every patient was evaluated for PONV at one hour, two hours, three hours, six hours, twelve hours and 24 hours post operatively. Results: A sample of 100 patients with age between 20-60 years (mean age 43.72±5.67 years), were included in this study. Patients were received granisetron 1 mg I/V and other patients received ondansetron 4mg I/V before induction. Conclusion: we concluded that there was no significant difference between efficacy of granisetron and ondansetron as the p-value is found to be ≤0.05.

Intraoperative Diagnosis of Gallbladder Agenesis

Gallbladder agenesis is a congenital anomaly that often presents with symptoms of biliary colic. Due to the rarity of this condition, it is often difficult to diagnose pre-operatively. Here we present a case of a 33-yo female with a 6-month history of right upper quadrant abdominal pain and associated nausea. With false-positive imaging findings of cholelithiasis on ultrasound examination, an incidental intraoperative diagnosis of gallbladder agenesis was made during a routine elective laparoscopic cholecystectomy. This finding was confirmed with postoperative magnetic resonance cholangiopancreatography. The primary aim in reporting this case is to further promote awareness of this rare condition out of concern for increased risk of iatrogenic operative injury in the setting of a condition where conservative management is recommended.

P-EGS02 Impact of delayed elective laparoscopic cholecystectomy on incidence and complications from gallstone ileus

Background The negative impact of the COVID-19 pandemic on the provision of elective surgery in the UK has been profound. Per the latest National figures, a total of 4.59 million patients are awaiting an elective operation (1). In our Trust, emergency operations and cancer service took precedence as we worked to minimize risks of COVID-19 while providing life-saving procedures. Subsequently, our ‘hot gallbladder’ operating list was put on hold for a period of 18 months. In our Trust, the current waiting time for an elective laparoscopic cholecystectomy is 52 weeks for symptomatic gallstone disease. Gallstone ileus is a well-recognized but rare complication of gallstones (2) and needs operative treatment. We performed this study to investigate the impact of delayed cholecystectomy on the incidence of gallstone ileus and the morbidity and mortality associated with this. Methods Retrospective study reviewing all acute admissions with gallstone ileus for 4 years from 2016 to 2020. Total number of patients was 19. Data collated from patient’s notes to include demographics and co-morbidities, operative notes, theatre records, and WebICE. Results Demographically, there was significant female preponderance (M : F : 1 : 18). Mean age of patients was 76.7 years. 17/19 patients underwent laparotomy as the primary operation (89%) and 1 (5%) had a laparoscopic procedure. 1 patient (5%) was managed conservatively. All patients had a CT scan as pre-operative imaging. 7 (34%) also had USS and 4 (20%) had MRCP. Mean length of stay in hospital was 13 days. 3 (15%) patients required re-admission to hospital for surgical and medical complications within 30 days. 3 (15%) patients returned to theatre for a second laparotomy within the index admission for recurrence of gallstone ileus. 8 (40%) patients had post-operative complications. There were 2 (10%) mortalities. 9 (45%) patients had gallstone related complications preceding their index presentation; majority (66%) which was calculous cholecystitis. The mean time between diagnosis of gallstone disease and emergency laparotomy for gallstone ileus was 38 months. Conclusions Gallstone ileus can be a life-threatening complication of gallstone disease and needs prompt recognition and treatment. Patients with known gallstones with symptoms of bowel obstruction should have a CT scan at time of presentation. Surgery is the mainstay treatment following resuscitation and concurrent conservative management. Early elective laparoscopic cholecystectomy can prevent mortality and morbidity from emergency laparotomy for gallstone ileus.

P-BN62 Predictive factors for subtotal cholecystectomy in delayed elective cholecystectomy after acute biliary presentation

Background Laparoscopic cholecystectomy is introduced as a treatment option for symptomatic gall bladder disease in 1987 and it is now the gold standard treatment for symptomatic gall bladder disease. The rate of conversion from laparoscopic to open ranges between 5 and 10% .The step of paramount importance in cholecystectomy is the clear identification of the cystic duct and artery, which in some situations can be difficult especially in presence of dense adhesions or severely inflamed gall bladder, increasing the risk for common bile duct (CBD) injury. The traditional response to encountering a difficult laparoscopic cholecystectomy procedure is to perform conversion to an open procedure but the open conversion has its drawbacks; The subtotal cholecystectomy has been shown to reduce the need for conversion to an open procedure, thus reducing complications associated with the open cholecystectomy. Studies have also shown that this procedure decreases the bile duct injury rate . Subtotal cholecystectomy rates increased nationally over the past decade. The aim of our study is to identify factors which could predict the need for a subtotal cholecystectomy in the acute biliary admission group having delayed elective Laparoscopic cholecystectomy ,hence proper planning in terms on theatre timing, expertise and patients consenting Methods We conducted a retrospective analysis of patients who had delayed elective laparoscopic subtotal cholecystectomy after admission with Acute Biliary disease and managed conservatively in a tertiary London hospital, between 01/03/2019-29/02/2020 We collected data for all patients whose primary diagnosis was either Acute Cholecystitis, Cholelithiasis, Ascending Cholangitis, Choledocholithiasis and Gallstone Pancreatitis, and analysed these in terms of patient demographics, , duration of index admission, laboratory and radiological results during the acute admission and need to intervention during the acute phase either as a drain (cholecystostomy) or ERCP during initial management. Data were collected from electronic patient records, regarding age, gender, indication for surgery, operative notes, preoperative gall bladder wall thickness on US scan, laboratory results during acute admission. BMI, other interventions such as endoscopic retrograde cholangiopancreatography (ERCP) and cholecystostomy Odds ratios were calculated to assess the risk of patients having a subtotal cholecystectomy. Results 243 patients presented between 01/03/19-29/02/2020 which acute biliary pathology – 95 Male and 148 Female, 230 patients had delayed elective laparoscopic cholecystectomy at least 6 weeks post-acute admission Of 230 laparoscopic cholecystectomies, 22 (9.56%) cases had a subtotal cholecystectomy 13(59.9%) patients were male patients, median age 72 (54.5%) had BMI more than 30 No open conversion. The indication for cholecystectomy in the subtotal group was as follows: Acute cholecystitis 12 (54.54%), Ascending cholangitis 4 (18.18%), Choledocholithiasis 3(13.63%), gall stone pancreatitis 1(4.5%), Cholelithiasis 2 (9.09%)The subtotal cholecystectomy group had Gall bladder wall thickness during index admission documented 4 (18.18%)patients had Gall bladder wall thickness less than 4 or equal 4 mm, 18(81.81%) patients had Gall bladder wall thickness more 4 mm. Odds ratios were calculated to assess the correlation between several characteristics and the likelihood of having a subtotal cholecystectomy in the delayed elective cholecystectomy, we concluded that Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC &gt; 15000 during acute admission, all increased the likelihood of having a subtotal cholecystectomy Conclusions Older age, male sex, BMI more than 30, previous ERCP, thickened GB wall on ultrasound scan more than 4 mm WCC &gt; 15000 during acute admission all increased the likelihood of having a subtotal cholecystectomy. We recommend all these information should be documented during planning for laparoscopic cholecystectomy to allow proper theatre time planning and patient consenting for the possibility of having a subtotal cholecystectomy.