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.

Future Directions of Percutaneous Biliary Interventions

We are at an exciting cross-road in biliary interventions. While other services such as surgery and gastroenterology have learned to use imaging guidance to improve the safety and efficacy of their procedures, it is time for interventional radiologist to learn endoscopic interventions to achieve the same. The future of interventional radiologists in managing patients with biliary disease depends on (1) increasing comfort of our procedures, (2) publishing our data on biliary interventions, and (3) increasing collaboration with other services to manage biliary disease. We need to appropriately understand the limitations of interventional radiology to help guide the future directions of our specialty in this very interesting space.

Noninvasive Imaging Prior to Biliary Interventions

Noninvasive imaging is a crucial and initial step in the diagnostic algorithm of patients with suspected biliary pathology and directs the subsequent diagnostic and therapeutic workup, including the endoluminal and percutaneous biliary interventions. This article reviews the current noninvasive imaging methods for the evaluation of biliary system and further discusses their roles in the diagnostic workup of different biliary disease.

Biliary Anatomy

The hepatobiliary system is known to have high anatomic variability, as studies have shown variant rates of over 40% among individuals. This review will describe biliary anatomy and the most common anatomic variants, knowledge of which is critical to ensuring safe and effective biliary interventions.

Advancements in Endoscopic Biliary Interventions by Gastroenterology

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic technique in which a specialized side-viewing endoscope is guided into the duodenum, allowing for instruments to access the biliary and pancreatic ducts. ERCP was initially developed as a diagnostic tool as computed tomography was in its infancy during that time. ERCP has evolved since its inception in the 1960s to becoming not only a valuable diagnostic resource but now an effective therapeutic intervention in the treatment of various biliary disorders. The most common biliary interventions performed by ERCP include the management of biliary obstructions for benign and malignant indications. Additionally, endoscopic ultrasound (EUS) has been increasingly utilized in diagnosing and intervening on pancreaticobiliary lesion. This article will discuss the various methods currently available for various endoscopic biliary interventions and future interventional techniques. For the management of biliary strictures, EUS can be utilized with fine need aspiration, while ERCP can be used for the placement of various stents and diagnostic modalities. Another example is radiofrequency ablation, which can be used for the treatment of hilar strictures. Achieving bile duct access can be challenging in patients with complicated clinical scenarios; other techniques that can be used for bile duct access include EUS-guided rendezvous approach, transluminal approach, Choleodochoduodenostomy, and hepatogastrostomy, along with gaining access in complicated anatomy such as in patients with Rou-en-Y anatomy. Another useful endoscopic tool is nonsurgical drainage of the gallbladder, which can be a suitable option when patients are not optimal surgical candidates. There has also been an increase in outpatient utilization of ERCP, which was previously seen as a predominantly inpatient procedure in the past. Possible future evolutions of biliary interventions include robotic manipulation of a duodenoscope and direct infusion of chemotherapeutic or immunomodulatory agents into the pancreaticobiliary tree. These advancements will depend on parallel advancements in other imaging and laboratory as well as breakthrough technology or techniques by other disciplines including interventional radiology and minimally invasive surgery.