bluuebunny/crossref_metadata_2025_split huggingface dataset:
P-BN07 Identifying gallstones in acute pancreatitis. Are we undermanaging our patients?
Authors: Matthews Hannah , Emslie Katy , Smith Thomas , Heyes Natalia , Platt Timothy 
Published: December 2021

Abstract

Background
Acute pancreatitis (AP) is a common surgical presentation with a wide spectrum of severity and outcome. The most common cause of AP is gallstones, accounting for approximately 50% of cases, followed by alcohol excess. Reliable identification of gallstones is crucial as patients can be offered cholecystectomy to prevent recurrence. Current UK guidelines recommend a minimum of two negative ultrasounds to rule out gallstones. The aim of this study was to assess the pickup rate of gallstones on ultrasound for patients admitted with AP and audit our compliance with UK guidelines.

Methods
All patients admitted with acute pancreatitis between the start of January 2019 to the end of December 2020 were retrospectively analysed. All patients with a known pre-existing cause for pancreatitis such as alcohol excess, chronic pancreatitis, CBD stricture and pancreatic mass were excluded. Electronic records were examined to identify subsequent imaging investigations and final diagnosis. Particular interest was given to whether gallstones were identified, and adherence to UK guidelines.

Results
206 patients were identified following the exclusion criteria. 189 underwent an ultrasound on admission, 111 were positive for gallstones. Of the negative ultrasounds (78), 15 underwent a further USS (4 positive), 29 underwent an MRCP (12 positive), 15 had a CT (3 positive) and 3 had an ERCP (3 positive). This left 16 with an unknown aetiology after 1 ultrasound and did not undergo further imaging and therefore did not comply with the current guidelines. Of the 11 patients who had 2 negative ultrasounds 5 had further imaging and all were negative for gallstones.

Conclusions
In conclusion Gallstone pancreatitis is a common acute surgical presentation of which morbidity and mortality can be significant. Following our retrospective assessment, we deem secondary imaging in the form of USS or MRCP to be necessary in the investigation of acute pancreatitis due to the high pickup rate. Compliance with current guidelines aids diagnostics and ensures appropriate and timely management of this condition leading to improved patient care.
P-BN18 Cholecystectomy following ERCP: A retrospective audit from a single centre
Authors: Wallace Lauren , Brown Joshua , Calabrese Michele , Prasad Pooja , Chmelo Jakub , Hayes Nick 
Published: December 2021

Abstract

Background
15% of the adult population are estimated to have gallstones (GS) and managing GS related disease can represent a significant challenge to surgical and endoscopic services alike. One particular challenge is the management of bile duct calculi (BDC), and treatment can vary according to the unit/institution. NICE has published guidelines (CG188) on the management of GS disease with the recommendation that bile duct clearance and cholecystectomy be offered for symptomatic and asymptomatic BDC. This retrospective audit was performed to determine compliance of a single centre with respect to offering cholecystectomy following ERCP for BDC.

Methods
A retrospective audit was performed for the year 2018 at a single centre utilising the trust ERCP database. The audit was analysed against NICE guideline CG188 and specifically whether patients treated with ERCP for BDC were then treated with cholecystectomy or had a documented justification as to why cholecystectomy was declined. 2018 was chosen so that at least a 2-year period of follow-up could be analysed. As well as the trust ERCP database, the trust electronic documentation record and paper notes were consulted to determine compliance with the guideline.

Results
149 ERCPs were performed on 121 patients at this centre in 2018. Of these, 82 patients were included as 39 had an ERCP for malignant disease or had already had a cholecystectomy. Of those 82, 51 (62%) had an ERCP as an emergency while 31 (38%) had an elective procedure. The median age was 65, 54% being male and 46% female. 45 (55%) had a cholecystectomy following ERCP, 29 as an emergency, and 16 electively. Of those 37 who did not have a cholecystectomy, 20 (54%) had no recorded documentation to justify a decision not to proceed to cholecystectomy.

Conclusions
GS disease has the potential to cause significant morbidity. If an ERCP has been performed for BDC, NICE recommends that cholecystectomy should be offered to mitigate further GS related complications. Patients may of course decline an operation, or a joint decision made not to pursue operative management due to identified surgical risks. This audit demonstrated that 54% of patients at this institution who did not have a cholecystectomy following ERCP had no documented reason why cholecystectomy was declined. Robust follow-up and documentation measures have since been put in place and a follow-up audit is being performed to monitor improvement.
P-BN21 Diagnostic accuracy of transabdominal ultrasound for assessing gallbladder polyps
Authors: Young John , Belhasan Anas , Kansal Nisheeth , Taribagil Sanjay 
Published: December 2021

Abstract

Background
Gallbladder polyps are common findings on transabdominal ultrasound (TAUS) and their implications are not entirely clear. Current guidelines advise monitoring with serial TAUS and to offer laparoscopic cholecystectomy if criteria are met to minimise risk of malignant transformation. TAUS is easily accessible and useful at identifying gallbladder polyps, however, has limitations when differentiating between pseudopolyps and true gallbladder polyps with malignant potential. This study looks at a district general hospital’s outcomes for patients undergoing laparoscopic cholecystectomy for gallbladder polyps.

Methods
This retrospective study identified patients who had polyps identified on TAUS and subsequently undergone laparoscopic cholecystectomy from 2011 to 2021. We identified patients using hospital coding and subsequently assessed their pre-operative imaging and clinic letters to ensure gallbladder polyps were the reason for cholecystectomy. The size of polyp on TAUS was noted and pathology reports were assessed to determine if polyps had been correctly identified on TAUS and if these were true or pseudopolyps. Clinic letters were assessed to determine if patients were symptomatic pre-operatively.

Results
66 patients were identified as having polyps pre-operatively. The size of polyp ranged from 2-19mm with a mean of 7.4mm. 39 (59%) patients were symptomatic pre-operatively. TAUS findings correlated with pathology findings of polyps in 45 (68%) patients. Of the 21 patients with no polyps on pathology: 11 had gallstones, 9 had chronic cholecystitis and 1 normal gallbladder. Of the polyps identified 44 were pseudopolyps and only 1 was a true adenoma – 39 cholesterol polyps, 3 inflammatory polyps and 2 adenomyomatosis. There was no evidence of dysplasia on the adenoma, it measured 5mm on TAUS and the patient was symptomatic.

Conclusions
This study highlights the limitations of TAUS in correctly identifying true polyps. The 41% of asymptomatic patients all had benign findings on pathology and likely had no benefit from surgery. Whilst TAUS is a useful method of identifying potential polyps these findings would suggest that other methods of identifying true polyps should be sought to minimise patients undergoing unnecessary surgery.
P-BN23 Cholecystectomy in Octogenarians – Is there a benevolent bias?
Authors: Kuan Jen Yee , Chaudhury Madhu , Shetty Vinutha Daya , Rajendran Ilayaraja 
Published: December 2021

Abstract

Background
Cholecystectomy is one of the most commonly performed general surgical operations in the UK. Around 50,000 patients undergo cholecystectomy every year. Recently a meta-analysis has raised concerns regarding the increased risk of performing cholecystectomy in octogenarians. Therefore, a study was organised to assess the safety and outcomes of octogenarians undergoing cholecystectomy compared to patients aged 65-79.

Methods
This is a retrospective observational study of a prospective database of all cholecystectomies performed from January’15 to December’20, including patients aged≥65 (elective and emergency). Adjunct cholecystectomies and age&lt;65 were excluded. Patients were divided into OCG (age&gt;80) and UE (age 65-79) groups. The primary outcome was ‘30day mortality’ (TDM). Secondary outcomes were graded ‘post-operative complications’ (POC) based on ‘Clavien-Dindo Classification’ (CDC), Length of Stay (LoS) and the total number of ‘Intensive care unit’(ICU) admissions. The categorical and continuous variables were assessed using Chi-square and Mann-Whitney U’ test, respectively. A p &lt; 0.05 was considered statistically significant.

Results
587 patients were included in this cohort. Majority of the patients were in UE (87.2%,n=512 vs OCG-12.8%,n=75). There was one TDM noted in each group (UE-0.2%,n=1 vs OCG-1.3%,n=1; p = 0.11). Intervention requiring grade-3 CDC were significantly common in OCG (OCG-18.6%,n=14 vs UE-6.8%,n=35; p = 0.00054). However, grade-2 CDC complications were significantly common in UE (UE-16.6%,n=85 vs OCG-2.7%,n=2; p = 0.0015). Number of intensive care stay was similar between the groups (UE-0.9%,n=5 vs OCG-1.3%,n=1; p = 0.77). However, uncomplicated postoperative recovery (p = 0.91) and grade-4 CDS (p = 0.77) were comparable between the studied groups. Median LoS was 1-day in both groups with no statistical difference, p = 0.078.

Conclusions
This study demonstrates that cholecystectomy could be safely offered to a selective group of fit and well octogenarians. Octogenarians who had more complications requiring intervention may be due to factors comprising comorbidities and delayed presentation. However, the TDM and LoS of octogenarians were comparable to the control group. Therefore, age should not be considered as a solitary defining criterion in patient selection for cholecystectomy. Nevertheless, the retrospective nature of this study and skewed patient distribution are the limitations of the study.
P-BN28 The Consistency of Operative Safety Markers and the Critical View of Safety During Laparoscopic Cholecystectomy: A Pilot Study
Authors: Nassar Ahmad H M , Sallam Mahmoud , Kilpatrick Rhona , Ali Kiren 
Published: December 2021

Abstract

Background
Safe laparoscopic cholecystectomy(LC) depends on surgeon's experience, operative difficulty, utilisation of traditional safety markers, adapting the dissection technique and, where possible, displaying the critical view of safety (CVS) to confirm cystic pedicle structures prior to division. The Safe Cholecystectomy Multi-Society Practice Guidelines and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy identified no direct comparative evidence to support the CVS over other methods of anatomic identification. The aim of this study, therefore, was to examine the consistency of safety markers guiding the dissection and to determine the value of displaying the CVS.

Methods
A pilot study was conducted, reviewing video recordings of 241 LCs (144 retrospective and 97 prospective). The consistency of the Rouvier Sulcus (RS), the cystic lymph node (CLN), identification of the common bile duct (CBD) and duodenum and a new marker; the “cystic duct fold” (CDF), the peritoneal fold stretching between the retracted Hartman's Pouch and the CBD guiding the dissection at its distal end over the gallbladder neck, was documented. Data on the safety marker used to commence dissection, gallbladder condition, the LC difficulty grade, the selected technique and whether the CVS was achieved was recorded and analysed.

Results
Although the CBD and duodenum were visualised in 77%, the CDF was identifiable in 56% (CLN in 52.3%, RS in 50.2%) and the most consistently used to commence dissection in 51.4% (CLN 17.4%, CBD in 11.6% and RS in 6.6%). 12.8% required access to the infundibulum using sub-serosal or trans-vesical dissection (41% had acute cholecystitis, empyema or gangrenous gallbladders). Infundibular dissection was used in 88%. CVS was achievable in 56.8%. The CDF dropped form 87% in difficulty grades 1 and 2 to 16.5% in grades 4 and 5 with the CLN used in 21% of these difficult LCs.

Conclusions
A new safety marker, the CDF is proposed, being more reliable and safer on account of starting the dissection away from the CBD and potentially aberrant ducts, contrary to the line of RS. The CLN is more reliable in difficult LC, especially with acute inflammation. Infundibular dissection remains the default approach to “target identification” required to display the CVS. The true value of the CVS, as an end product of the process of dissection, lies in “target confirmation” before dividing any structures and in clearing the cystic plate to avoid injury to Couinaud Types C, F and hepato-cystic ducts.
P-BN37 Audit of the Management of Gall Bladder (GB) Polyps according to European Joint Guidelines (EJG), 2017
Authors: Karunanithy Vithurshanan , Richardson Tom , Kumar Akshay , Thomas Sudeep , Khan Saad 
Published: December 2021

Abstract

Background
Gall Bladder (GB) polyps are abnormal growths of the inner lining that project into the lumen. They are a rare incidental radiological finding, with prevalence ranging from 0.3% to 9.5%. The majority of these frequently turn out to be pseudopolyps, however, correct follow up and management is essential as to ensure that true polyps, which may be malignant or have malignant potential, are not missed. EJG on the subject, published in 2017, tried to address controversial issues including which patients require cholecystectomy, which patients require follow up and how frequently this should be. We carried out an audit assessing adherence of our center’s management of GB polyps to the EJGs.

Methods
Patients were identified for this retrospective ten year cohort study bv identifying patients listed under ‘International Statistical Classification of Diseases and Related Health Problems (ICD 10) code K 82.8, other specified diseases of gall bladder’ on our database. Patients with other diagnoses, such as gall bladder dysfunction were excluded after review of electronic patient record (EPR) (Sunrise, Allscripts). EPRs facilitated review of emergency attendances, clinic letters, investigations and histological results for those diagnosed with a gall bladder polyp. Analysis was performed with Microsoft Excel.

Results
Since publication of the guidelines, 71 patients were diagnosed with a polyp. Of these, 73% were diagnosed by general surgeons and only 36% were managed according to the guidelines. We did, however, identify a strong positive trend (0.9) in improved adherence to guidelines over time. We found that guidance was more likely to be followed if the polyp was &gt;10mm versus smaller (p &lt; 0.01). 18% of patients (50% of those adherent to guidelines) were booked straight for laparoscopic cholecystectomy but there was a much poorer adherence to guidance concerning surveillance of polyps. There was no statistically significant difference (p = 0.32) in adherence to guidance when comparing management by surgeons versus non-surgeons.

Conclusions
Adherence to EJG’s overall is poor in our cohort. The adherence has improved over time, and at 3 years post introduction is 62% compared to an average of 35%. The guidance is also best followed when laparoscopic cholecystectomy is indicated straight from diagnosis compared to patients who meet the criteria for surveillance. Initial diagnosis by a non-surgical specialty does not affect adherence to guidance. Better local education amongst junior surgical grades about GB polyps, as well as increased awareness of the EJG’s may improve adherence to guidance. Further research into risk stratification and the optimal follow up of GB polyps may make surveillance guidance easier to follow and further improve compliance.
P-BN41 Does performing percutaneous cholecystostomy in patients at risk of sepsis have better outcomes than patients in sepsis?
Authors: Li Wing Ching , Elboraey Omar , Kilani Mohammad Saeed , Ward Jeremy Bruce , Rajendran Ilayaraja 
Published: December 2021

Abstract

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 &gt; 1 high-risk criteria. IS group included patients with 2 or &gt; 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 &lt; 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-BN57 The impact of COVID-19 pandemic on management of patients with acute uncomplicated gallstone pancreatitis
Authors: Staniszewska Aleksandra , McCready Rebekah , Grocock Christopher , Gunasekera Rohan , Hartley Mark , Howes Nathan , Stephens Nathan , Rao Rohith 
Published: December 2021

Abstract

Background
Current British Society of Gastroenterology guidelines suggest that patients presenting with acute uncomplicated gallstone pancreatitis should ideally undergo laparoscopic cholecystectomy during the index admission or within two weeks of discharge from hospital. COVID-19 pandemic had a significant impact on the delivery of elective and semi-elective surgical services in the National Health Service (NHS) due to limited availability of theatre resources. The aim of this study was to evaluate compliance with the BSG guidelines during the COVID-19 pandemic and the impact of the newly introduced `Hot’ lists at our centre.

Methods
Patients admitted with first presentation of acute uncomplicated gallstone pancreatitis between 01/03/19 and 25/02/21 were identified from electronic records. Pregnancy and lack of fitness for surgery were the exclusion criteria. Patients admitted between 01/03/19 and 31/12/19 were defined as the pre-COVID cohort. Those admitted between 23/03/20 and 25/02/21 formed the COVID cohort and had access to urgent gallbladder lists. Baseline characteristics, choice of imaging and timing of laparoscopic cholecystectomy were compared between the two cohorts using STATA software. Continuous variables were compared with Mann Whitney test and categorical variables were compared with Pearson’s Chi-Squared test.

Results
53 patients were identified in the total cohort with 27 being hospitalised prior to COVID-19 outbreak and 26 presenting after the national lockdown. Baseline characteristics did not differ significantly between the two groups. Biliary imaging pathway was similar between the two cohorts and importantly there appeared to be no delays in radiological tests during the lockdown. The overall proportion of patients undergoing cholecystectomies remained similar between the two groups and percentage of patients having it during the index admission did not differ. However, patients undergoing cholecystectomy post discharge had a significantly shorter waiting time during the lockdown (p = 0.021) as they were prioritised on the ‘Hot lists’ created to meet the demands of reduced planned theatre service.

Conclusions
During the 2020 COVID pandemic our service for patients with uncomplicated gallstone pancreatitis continued to be delivered. Despite clinical pressures, there were no notable delays in biliary imaging. The introduction of the urgent operating lists has significantly reduced the time to laparoscopic cholecystectomy following admission for patients with acute uncomplicated gallstone pancreatitis during this period.
P-EGS16 Lemmel Syndrome due to Duodenal Diverticulitis, an Infrequent Cause of Biliary Obstruction
Authors: Natale Joseph , Abdelrahman Mohamed , Wheatley Timothy 
Published: December 2021

Abstract

Background
Lemmel syndrome, first described in 1934, is the presence of biliary obstruction as a consequence of duodenal diverticula. The precise aetiology remains uncertain. Multiple causative theories have been proposed. These include mechanical biliopancreatic duct occlusion, functional disruption of the sphincter of Oddi and alteration of the course of the distal biliary and pancreatic ducts. We present a case of biliary obstruction caused by diverticulitis of a solitary duodenal diverticulum.

Methods
A 71-year-old woman with no co-morbidities presented with early satiety, cachexia and upper abdominal pain. An epigastric mass was palpable, alkaline phosphatase was 247 iu/L, alanine transaminase 124iu/L, bilirubin 4umol/L and C-reactive protein 68mg/L. Computed tomography (CT) of the abdomen and pelvis revealed obstructed biliary tree with D2 duodenal diverticulitis. Magnetic resonance cholangiopancreatography (MRCP) displayed a causative enterolith. Treatment with antibiotics was initiated and the patient commenced on liquid diet. Liver function tests and inflammatory markers normalised. After a seven day admission patient was discharged and oral intake normalised. Interval MRCP revealed resolution of obstruction and inflammation.

Results
Duodenal diverticula occur in 1-20% of individuals. Complications are symptoms are uncommon. Diverticulitis is a rare complication. Malignancy and cholelithiasis should be excluded in diagnostic workup. The mainstay of therapy for duodenal diverticulitis is conservative. CT and MRCP are effective diagnostic tools. Diverticulectomy carries substantial risk of morbidity and mortality. Endoscopic sphincterotomy or lavage have a role in relief of biliary obstruction when present. Comparative prospective studies of management do not exist and retrospective enquiry is sparse. Management is thereby best determined clinically on a case by case basis. Surgery is reserved for failed conservative and medical therapy.

Conclusions
Duodenal diverticulitis should be considered in patients with unexplained upper abdominal pain and elevated inflammatory markers. In combination with obstructive jaundice, suspicions should be raised for acute inflammation causing obstruction to the biliary tree. Cross sectional imaging is useful in determining the diagnosis. Antibiotics and conservative therapy are prudent first line management in the absence of perforation. Where these measures are inadequate endoscopic and operative strategies may be employed but have no robust evidence basis.