HPB P33 Management of Gallstone Disease with Deranged Liver Function Tests – Single Centre Experience
Authors: Taggarsi Meghana , Sultana Asma 
Published: December 2022

Abstract

Background
Laparoscopic cholecystectomy (LC) has emerged as the gold standard for the treatment of symptomatic cholelithiasis, however, things are not quite so clear when it comes to managing cholelithiasis with suspected common bile duct (CBD) stones and debate continues among surgeons about the optimal pathway of management. The current recommendation is that patients with symptomatic cholelithiasis should be investigated for CBD stones. There is controversy because investigating for suspected choledocholithiasis by means of Magnetic resonance cholangiopancreatography (MRCP)/ pre-operative or post-operative Endoscopic retrograde cholangiopancreatography (ERCP)/ laparoscopic cholecystectomy with on-table cholangiography (OTC) may lead to subsequent over or under treatment with significant morbidity, readmissions, decline in Health Related Quality of Life (HRQoL) and costs to the health service. We conducted a retrospective clinical audit to compare our care provision for symptomatic gall stone disease with suspected choledocholithiasis against the guidelines laid down by Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) in 2016, NICE (2014) and European Society of Gastrointestinal Endoscopy (ESGE). This also highlights the importance of a single stage approach (LC with OTC) for management of gall stones with suspected CBD stones.

Methods
A retrospective audit was conducted for 18 months at a referral centre for hepato-pancreato-biliary (HPB) diseases, with available expertise for management of CBD stones, endoscopically and surgically. All patients admitted to general surgery facility with a diagnosis of gallstone disease with deranged liver function tests (LFTs), and suspicious of having or diagnosed to have common bile duct stones were included in the study. Patients aged 18 years and above with symptomatic gall stones suspected to have or diagnosed with choledocholithiasis were included, while patients with cholelithiasis but no evidence of stones in CBD on initial investigations were excluded. A total of 95 patients who met the inclusion and exclusion criteria were included in the study. We used the guidelines put forth by AUGIS (2016), NICE guidelines (2014), British Society of Gastroenterology (BSG) in 2017 and European Society of Gastrointestinal Endoscopy (ESGE) 2019 to compare management of symptomatic gallstone disease.
Data with regards to length of hospital stay, comorbidities, investigations done, diagnosis, management, readmissions before undergoing further investigations or having a surgery (laparoscopic cholecystectomy) with or without on-table cholangiogram (OTC) were analysed. Data analysis for this set of data was done using numbers, percentages and descriptive statistics, using SPSS 25.0.

Results
Out of 95 patients, 90 had deranged LFTs at presentation (3 presented with cholangitis) and 5 had suspicious findings on initial imaging. The diagnosis included Mirizzi syndrome, pancreatitis, Choledocholithiasis, Biliary colic, Acute cholecystitis and benign CBD stricture. Out of 95 patients, 76 of them had Ultrasound abdomen as their initial investigation, mostly on the day of admission. 41 patients had MRCP, 73% of them during their index admission. Amongst the 95, 59% underwent ERCP, 76.8% of them during the index admission. The median time from admission to MRCP and ERCP was 5 and 8 days, respectively. Out of 56 patients who underwent ERCP, 9 of them had it done within 72 hours of admission. Overall, 22 patients underwent LC with OTC. Out of 95 patients, 51 patients underwent LC. Out of 79 patients who were fit for surgery, 28 of them were still awaiting surgery. Amongst 18 patients who had Pancreatitis at presentation, 14 of them underwent ERCP. Out of which 3 of them had LC during index admission.
The maximum length of stay observed amongst 95 patients was 36. Amongst the 95 patients, the study also records that 13 patients had readmissions before they underwent ERCP or LC.

Conclusions
We found 16% compliance with the guidelines in regards to the timing of biliary decompression with ERCP. Our results show 66.66% compliance with guidelines, with regards to timing of biliary decompression in Cholangitis. The study reflects a significant non-adherence to the guidelines as 68.40% of patients could not have definitive management within the recommended time frame. Looking into the finer details, we found that 35.40% of the patients did not have their surgery at the time of the audit. 22% of patients had LC performed in accordance with the recommendations, while the timing of surgery in 78% of patients showed no compliance with the guidelines.
Guidelines for management of patients with gallstone disease associated with CBD stones was not met for majority of patients. A significant number of patients were readmitted to the hospital because of delay in receiving further investigations or definitive surgery. There may be a role for multidisciplinary team meetings to identify patients requiring expedited ERCP, which in turn may translate into early definitive surgical management. Laparoscopic cholecystectomy with OTC, with or without laparoscopic CBD exploration or post-operative ERCP can be incorporated as an alternative to pre-operative ERCP to reduce patient morbidity and length of hospital stay.