The Possible Association of Non-Alcoholic Fatty Liver Disease with Acute Cholangitis: A Retrospective Multicenter Cohort Study

Non-alcoholic fatty liver disease (NAFLD) is increasingly encountered. It is associated with several comorbid diseases. However, its association with infectious biliary diseases is still unknown. Aims: We aimed to assess whether NAFLD is a risk factor for the development of acute cholangitis among patients with common bile duct (CBD) stones. Methods: We performed a retrospective study, including all patients with a documented diagnosis of CBD stone that had available data on the presence or absence of NAFLD. Descriptive analysis using univariate and multivariate models was used to assess whether an association existed between NAFLD and acute cholangitis. Results: We included 811 patients. Of them, 161 patients presented with acute cholangitis, vs. 650 patients who presented with symptomatic CBD stone without cholangitis. NAFLD was significantly more common in the cholangitis group compared to the non-cholangitis group (15.5% vs. 8.3%, p = 0.01). In univariate analysis, age (Odds ratio (OR) 1.04, p < 0.0001), male gender (OR 1.47, p = 0.03), hypertension (OR 1.81, p = 0.0008), hyperlipidemia (OR 1.59, p = 0.01), and NAFLD (OR 2.04, p = 0.006) were significantly associated with acute cholangitis. In multivariate analysis, NAFLD kept its association with acute cholangitis irrespective of age (OR 2.15, p = 0.005). Conclusions: NALFD showed a significant association with acute cholangitis among patients with a CBD stone. Clinicians should encourage treatment of NAFLD in general, and especially in the setting of gallstone disease.

P-BN39 The perils of MRCP requesting and early associations of data quality and likelihood of a diagnostic result

Background MRCP (Magnetic resonance cholangiopancreatography) is used most to assess the biliary tree for stones or strictures. Recently, MRCP availability has increased, and it is extensively used to detect of common bile duct (CBD)stones although very frequently no stones are seen. Indeed, the currently recruiting sunflower RCT aims to determine the clinical and cost effectiveness of expectant management versus MRCP in patients undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. However, it is critical when requesting an investigation that adequate information is provided. This work aimed, to describe the adequacy of information provided and correlate this with the MRCP result. We hypothesised that the less information that was provided the more common a normal result would be. Methods For a three month period (January 2021 to April 2021) all MRCP requests to detect the presence of a CBD stone were reviewed and data obtained from the Radiology CRIS (CDN Radiology Information System, CDN, Sydney, Aus.). The requesting information was compared to three pre-defined criteria (CBD diameter, presence of gallstones and LFT details) that were agreed as the optimal information that a reporting radiologist would require. The number of key pieces of information for each request and whether the request identified a CBD stone were identified. The proportion of MRCPs detecting a CBD stone was calculated according to the number of key pieces of information provided. Results 56 patients were identified, of which 16 (29%) patients had CBD stones. In 24/56 (43%) patients the presence of gallstones on a previous ultrasound was provided, 14/56 (25%) of patients had information about LFTs including bilirubin and a trend in LFTs was not stated for any patient (0/56; 0%). The rate of stone detection was calculated by the number of pieces of information provided. The rate was 71% (5/7) when all 3 pieces of data were provided, 31% (2/13) when two piece of information were provided, 30% (8/27) when a single piece of information was provided, and only 11% (1/11) when none of the specified data were provided. Conclusions It is uncommon for adequate clinical information to be provided in MRCP requests and in 16% of request no key information was provided. The LFT results were frequently omitted and the trend in LFTs never stated. The more key data provided in the request saw a higher proportion of MRCPs where a CBD stone was identified. We recommend that maximal clinical information is mandated for MRCP request perhaps using mandatory fields on electronic requesting systems and that these systems are also used to facilitate recruitment to clinical trials such the Sunflower RCT.

P-BN50 Transcystic CBD Exploration: The First-Line Treatment of CBD Stone - A Single Centre 12-month Review of Practice

Background In the UK around 15% of the population will have gallstones and as such biliary pathology makes up a significant proportion of emergency and elective general surgical practice. Within this 10% will have choledocholithiasis; the management of which remains widely varied. A single-stage laparoscopic cholecystectomy with transcystic common bile duct exploration has been shown to be a safe and efficient option avoiding a choledochotomy and risks associated with ERCP. The aim of this study was a 12-month review of data following the adoption of this approach; assuming that laparoscopic transcystic CBD exploration was the ideal treatment for CBD stones. Methods This was a retrospective, single-centre, observational study. All patients who underwent a laparoscopic transcystic CBD exploration from June 2020 to June 2021 were included both in the elective and emergency setting. Patient demographics were varied with ages ranging from 15 to 76 and ASA classification of 1 -3, showing a significant proportion with comorbidities. Data collection was done through a review of a contemporaneous operative database and a follow-up morbidity period of 30 days was cross-referenced with electronic healthcare records. The primary outcome studied was CBD stone clearance. With secondary outcomes measures including complications, length of stay and the role of preoperative imaging versus intraoperative cholangiogram. Results A total of 49 patients were included within the study, of which 61% were emergency. The primary outcome of CBD stone clearance was achieved in all elective patients with one emergency patient requiring ERCP for a retained fragment at day 8. There were no other complications in the remaining 48 patients, making the 30-day morbidity 2% upon review of electronic care records. One patient was converted to open due to concern with regards to potential CBD injury but this was demonstrated not to be the case. The median duration of hospital admission was 3 days with a range from 0- 15, with the median stay for elective cases being 1 day. Finally, 39 patients underwent intraoperative cholangiograms prior to duct exploration as a means of identifying CBD calculi and delineating anatomy. Those 10 that did not; all had an MRCP within 30 days of surgery demonstrating CBD calculi and as such proceeded straight to CBD exploration. Conclusions Laparoscopic cholecystectomy and transcystic CBD exploration, with adequate training and exposure, is a viable and safe first-line approach for all cases of choledocholithiasis both in the elective and emergency setting; demonstrating advantages by avoiding additional procedures thereby reducing costs, inpatient bed days and a risk of further complications and being truly minimally invasive. The principal findings of this study were that the transcystic CBD exploration route can achieve successful CBD stone clearance rates in close to 98 per cent of patients with a low morbidity rate, and a short median length of hospital stay. This study of course has several potential limitations; given it was a retrospective single-centre observational study there is likely a degree of selection bias and although follow up was complete in all patients to 30 days via electronic care record it was not routine practice to offer face to face follow up given the low incidence of delayed complications. On the basis of this review, the transcystic approach has become the primary strategy for patients with common bile duct stones within this unit.

P-BN30 Retroperitoneal biloma: a case report of spontaneous retroperitoneal bike leak and collection

Background Retroperitoneal biloma is a rare complication of gallstone disease. Only a handful of cases have been reported in the literature with various mechanisms postulated. Here, we report a case of spontaneous retroperitoneal biloma arising from gallbladder perforation. Methods An 87-year-old female patient presented with right upper quadrant pain in the context of known gallstone disease. Inflammatory markers and liver function tests were deranged. Cross sectional imaging found acute cholecystitis and a gallbadder neck perforation with an impacted 2cm proximal common bile duct (CBD) stone. A cholecystostomy was placed and she improved clinically. However, inflammatory markers remained high, and a subsequent computed tomography (CT) found a large collection in the retroperitoneum. Results The retroperitoneal collection measured 14cm x 7cm, and there had been evidence on prior CT scans of retroperitoneal inflammation. It was urgently drained under ultrasound guidance and found to contain bilious content. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was unable to retrieve the CBD stone, but left stents either side of the stone. The patient clinically and biochemically improved. She was discharged and had an elective ERCP, which successfully retrieved the stone, with a plan for urgent elective laparoscopic cholecystectomy. Conclusions Here, we report an interesting case of retroperitoneal biloma successfully managed with ultrasound-guided drainage. Perforation of the distal CBD can result in retroperitoneal bile leak, but the proximal CBD stone in this case would have likely prevented passage of bile. A more likely cause is adhesion of the gallbladder neck to the posterior parietal peritoneum due to chronic inflammation, with subsequent perforation and release of bile into the retroperitoneum. This has previously been described in the literature. Regardless of mechanism, knowledge of the potential for this rare complication is important for anticipating and appropriately managing complications of gallbladder perforation.

P-BN13 How has the COVID pandemic affected outcomes in Elective Laparoscopic Cholecystectomy?An observational study in a UK Upper GI Surgical Unit

Background COVID-19 has a significant impact on elective surgery for benign disease. When routine services resumed in April 2021, surgeons were faced with higher number of complicated cases. The aim of this study is to examine the effect of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal unit in the UK. Methods Data were collected retrospectively on consecutive patients undergoing elective LC between 1/3/19 to 1/5/19 (Pre-COVID) and 1/4/21 to 11/6/21 (resumption of elective operating following COVID). The indications for surgery, intraoperative details, postoperative complications, length of stay (LoS) and 30- day readmission were compared between the two cohorts. We divided indications for surgery as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) vs non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). Data were analysed using the Mann-Whitney U-test and Chi-square or Fisher’s exact test. A p value of &lt; 0.05 was used for statistical significance. Results 159 patients were analysed, 106 in Pre-COVID vs 53 in Post-COVID. Both cohorts had similar age, gender, ASA-grade, BMI. 68 (64.2%) of the pre-COVID cohort were operated for a non-inflammatory pathology compared to 19(35.8%) of the post-COVID cohort (p &lt; 0.001). Less patients had total cholecystectomy (subtotal and failed surgery) in the post-COVID cohort [49(92.5%) vs 159 (100%) p = 0.01]. There was no difference in the operating time, conversion to open surgery, the need for drains, and no difference in the Clavien-Dindo grade complications. Two patients in pre- COVID cohort (1.8%) required re-operation for bile-leak and bowel injury and two in the post COVID cohort (3.7%) for bleeding and CBD-injury. There was no difference in day case discharge or 30-day readmission rate. Conclusions Surgery in the post-COVID cohort was associated with a higher incidence of inflammatory biliary disease, subtotal cholecystectomy and procedure abandoned. Although the numbers in our study are small they highlight the need for enhanced preoperative assessment in elective biliary surgery as the NHS emerges from the acute phase of the pandemic.

Post-ERCP Dormia basket impaction: a case report and literature review

The incidence of Common bile duct stones (CBD) in patients undergoing cholecystectomy is 10%. The present-day management of common bile duct stone may be pre-, intra-, or post-operative Endoscopic retrograde cholangio-pancreatography (ERCP) with stone extraction. The reported complications of ERCP and CBD stone extraction range from 5 to 10% cases, that might be life threatening. Herein, we reported a case of calculus obstructive jaundice and cholangitis. Unfortunately, trials for ERCP and stone retrieval was followed by impacted Dormia basket which was successfully managed by surgerys.

Outcome and early complications of Endoscopic Retrograde Cholangio-Pancreatography (ERCP): a cross-sectional study on 626 Patients

Background. ERCP is the gold standard procedure for diagnosis and potential treatment of biliary-pancreatic disorders with various distributions in different areas of the world. The study aimed to evaluate the findings, outcome, complications and technical experiences of ERCP, also by considering the correlation of findings with liver function tests (LFT) and imaging. Methods. In this descriptive – cross sectional data-based study for 12 years from 2007, 626 (43.9% male and 56.1%female; mean age 60 Ys) consecutive patients were subjected with therapeutic purpose at two referral hospitals. Results. Epigastric pain (40%), jaundice (39.4%) and pruritus (38.1%) were the most common indications. CBD was cannulated by optimal wire- guided sphincterotomy in 486(77.6%) patients. Precut was performed in 65(10.6%) with successful cannulation in 61 cases (93.8%) and 7.7% of complications, including perforation. A total success rate of 98% was obtained. The most common diagnoses were CBD stone(s) in 322 (51.4%) and biliary-pancreatic cancers in 114 (18.2%) of cases. No LFT (ALT, ALP and Bilirubin) predicted the diagnoses. The higher concordance rate of imaging studies in comparison with ERCP was 75% for stone(s) and the lower rate of 11.1% for tumors. Metallic stents were used in 15(2.4%) of inoperable malignant cases with life expectancy of more than 6 months. Complications occurred in 29 cases (4.6%) including duodenal perforation (0.8%), pancreatitis (1.6%) and bleeding (1.2%). Mortality rate was 0.4%. Conclusion. Although no single laboratory or imaging can exactly predict the finding or outcome, but by considering judicious case selection, appropriate use of available tools and standard techniques, the procedure could be safe with a few complications and higher success rates.

SP6.1.1 Cholecystectomy or expectant management after endoscopic sphincterotomy and bile duct stone removal?

Aims Following ERCP, NICE guidance suggests that surgically fit patients undergo cholecystectomy to prevent recurrence of choledocholithiasis and its complications. However, for many patients who are deemed unfit or who choose not to have surgery, ERCP is their definitive management. This study examines the clinical outcomes and costs of expectant management (EM) or cholecystectomy following ERCP. Methods All patients that underwent ERCP, sphincterotomy and common bile duct (CBD) clearance at St James’s University Hospital between January 2015 and December 2018 were identified from a prospectively maintained ERCP database. The clinical outcomes for patients that had undergone an ERCP, sphincterotomy and CBD clearance for gallstones were identified from their electronic patient record. A cost analysis for the complete patient pathway was performed. Results 820 patients underwent ERCP and CBD clearance for gallstones with a median 3.9 year follow up. 222 patients had undergone a cholecystectomy prior to ERCP and were excluded from analysis. 203 patients underwent planned cholecystectomy with 15% (31 patients) requiring complex surgery and 12% (24 patients) needing readmission. 395 patients received expectant management (EM). 9 (2.3%) patients returned with CBD stone symptoms, 6 (1.5%) went on to laparoscopic cholecystectomy (LC). The readmission rate in the EM group was 9%. The average cost per patient in the expectant management group was £7,487 and in the cholecystectomy group was £10,584. Conclusion The results from this study suggest that the need for cholecystectomy following ERCP is uncertain, with similar rates of biliary re-admissions in both groups.

EP.TH.49The Use of MRCP to Investigate Bile Duct Stones

Aim Association of Upper Gastrointestinal Surgeons (AUGIS) latest guideline advocates stratification of patients with gallstone disease to determine their risks of common bile duct (CBD) stone and to perform Magnetic resonance cholangiopancreatography (MRCP) for those at intermediate risk. The study assessed the appropriateness of our local hospital's MRCP requests in accordance to the AUGIS standard. Method Inpatient MRCP requests for suspected ductal gallstones between June and December 2019 were identified retrospectively. Admission history, ultrasound, MRCP findings and liver function tests were collected from hospital electronic records. Patients with previous cholecystectomy were excluded. Patients were categorized into ‘low risk’, ‘intermediate risk’ and ‘high risk’. Results 67 patients were included in the study and 24 patients were discovered to have CBD stones on MRCP. The majority of patients (54%) were considered ‘intermediate risk’, whilst the ‘low risk’ group consisted of 13% of the MRCP requests and ‘high risk’ group comprised of 33%. Amongst those in the ‘low risk’ group, only 1 of 9 patients (11%) had cbd stone identified on MRCP. 19% patients in the intermediate group were found to have CBD stone, whilst 73% patients in the high risk group were identified to have CBD stone. On average, patients underwent MRCP within a day of request. Conclusion A high proportion of patients at high risk for CBD stone were referred for MRCP, contrary to AUGIS guideline. Inpatient MRCP referrals should be considered carefully in this category as it potentially increases length of stay without change in clinical management.

EP.FRI.199 Impacted common bile duct stone managed by hepaticoduodenostomy

The management strategy of common bile duct stone will depend on personal experience, equipment availability, time and the availability of other departmental expertise. For a distally impacted common bile duct (CBD) stone in a low resource setting, an open approach will entail either leaving the stone where it is and carry out a choledochoduodenostomy, or removing the stone through a transduodenal sphincteroplasty. The latter has a significant risk of causing an acute pancreatitis. A case report of a hepaticoduodenostomy performed on a 40-year-old black African man for a retained, impacted distal CBD stone in a low resource setting with a good outcome is presented. The impacted CBD stone had complicated an open cholecystectomy for acute cholecystitis by causing the dehiscence of the cystic duct stump as a result of distal biliary obstruction. A bypass procedure such as a hepaticoduodenostomy may be an alternative to the traditional choledochoduodenostomy in the management of the retained, impacted distal CBD stone especially in the presence of sepsis. A wide side- to-side hepaticoduodenostomy (&gt;3cm d) is a safe and definitive procedure for the decompression of lower CBD obstruction and has good long-term results with infrequent complications including reflux cholangitis, hepatic abscess, stone recurrence, pancreatitis and the ‘sump’ syndrome. This case demonstrates that a hepaticoduodenostomy is safe and effective in rescuing the adverse sequelae of an impacted distal CBD stone in a low resource setting.