8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Aim

There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway.

Method

Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended.

Results

We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality.

Conclusions

A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

WE5.11 Intra-abdominal actinomycosis - an indolent masquerader of malignancy

Introduction

A 54 years old lady who presented with constitutional symptoms of lethargy, weight loss and asthenia. She had been extensively evaluated for a possible gynaecological malignancy but with no definitive outcome. The symptoms were persistent and a decision had to be made towards surgery in the present climate of the covid19 pandemic.

Method

Following oncology multi disciplinary meeting outcome she was taken up for a total abdominal hysterectomy and bilateral salpingo-oophrectomy. She was noted to have an incidental finding of an extensive tumour infiltrating the liver, colon, anterior abdominal wall and the urinary bladder. A surgical resection with ileostomy was performed on suspicion of an underlying malignancy.

Results

The histopathological diagnosis revealed a picture of actinomycosis which had evaded us previously. Following this she was treated with prolonged course of antibiotics and has recovered well, thus altering our entire management plan.

Conclusion

Actinomycosis albeit rare is an interesting mimic of tumours. This case also delves into the on-table decision making when in doubt about cancer.

Through the Looking Glass: Surveillance Following Colonoscopic Polypectomy of Malignant Polyps

Introduction Colonoscopic polypectomy is a well-established screening and surveillance modality for malignant colorectal polyps. Following the detection of a malignant polyp, patients are either put on endoscopic surveillance or planned for a surgical procedure. We studied the outcome of colonoscopic excision of malignant polyps and their recurrence rates. Methods We performed a retrospective analysis over a period of five years (2015-2019) of patients who underwent colonoscopy and resection of malignant polyps. Size of polyp, follow-up with tumour markers, CT scan, and biopsy were considered individually for pedunculate and sessile polyps. We analysed the percentage of patients who underwent surgical resection, the percentage of patients who were managed conservatively, and the percentage of recurrence post-excision of malignant polyps. Results A total of 44 patients were included in the study. Of the 44 malignant polyps, most were present in the sigmoid colon at 43% (n=19), with the rectum containing 41% (n=18). The ascending colon accounted for 4.5% (n=2), transverse colonic polyps were 7% (n=3), and the descending colon polyps were 4.5% (n=2). Pedunculated polyps made up 55% (n=24). These were Level 1-3 based on Haggits classification; 14 were Haggits Level 1, eight were Haggits Level 2, and two were Haggits Level 3. The rest were sessile polyps making up 45% (n=20). Based on the Kikuchi classification, these were predominantly SM1 (n=12) and SM2 (n=8). Out of 44 cases, 11% (n=5) underwent surgical resection on follow-up in the form of bowel resection. This included three right hemicolectomies, one sigmoid colectomy, and one low anterior resection. Seven per cent (n=3) underwent endoscopic resection as trans-anal endoscopic mucosal resection (TEMS) and 82% (n=36) of the remaining cases were managed with regular follow-up and surveillance. Conclusions Colonoscopic polypectomy offers excellent benefits in detecting colorectal cancer and treating pre-malignant polyps. Colonoscopic polypectomy provides excellent benefits in colorectal cancer (CRC) detection and treatment of malignant polyps. However, it remains to be seen if post-polypectomy surveillance for low-risk polyp cancers would require a change in surveillance.

TU8.3 The optimal timing of Laparoscopic cholecystectomy following percutaneous cholecystostomy in Acute cholecystitis

Introduction

Percutaneous cholecystostomy (PC) is an effective option for high risk and/or delayed presented Acute cholecystitis (AC). However, the optimal timing for subsequent laparoscopic cholecystectomy (LC) as a definitive treatment remains controversial.

Methods

This study includes 41 patients underwent LC following PC for severe AC. We compared the length of tube insertion, period from PC till LC and period from PC removal till LC against co-morbidities, another attack of AC, subsequent pancreatitis/jaundice and operative difficulties in terms of intraoperative adhesions, drain insertion, conversion to open, length of operation.

Results

The median time of length of tube insertion was 36 days (range 5–208) while the median time of PC insertion till LC was 144 days (range 31–744) and for period from PC removal till LC was 78 days (range 0–714). Patients with prolonged tube insertion (more than a month) showed higher risk of developing subsequent pancreatitis and or jaundice (P=0.04) while intraoperative adhesions was associated with prolonged time from tube insertion till operation (more than 4 months). There was no significant association between neither the length of tube insertion, period from PC insertion till LC nor period from PC removal till LC and other studied parameters.

Conclusion

Prolonged time of PC insertion and/or prolonged time form PC insertion till LC in patients with AC have higher risk of pancreatitis and surgical difficulties. Further studies including larger number of patients’ sample is warranted to confirm the outcomes and determine the optimal time of LC following PC in those patients.

14 NICE CG188; Hot Gall Bladder Pathway in Emergency General Surgery - Are We Following the Guidelines?

Aim

1 - To compare the current standard of practice to existing guidelines and to make appropriate changes. 2 - To set a clear pathway for referring patients to the ‘hot laparoscopic cholecystectomy’ pathway. 3 - Avoid inappropriate booking for laparoscopic Cholecystectomy for patients who are not fulfilling the criteria of Hot Gall Bladder Pathway. 4 - Avoid unnecessary delay in performing Laparoscopic Cholecystectomy in patient with Acute Cholecystitis and mild Biliary Pancreatitis.

Method

It was a retrospective audit of all the patients who underwent Laparoscopic Cholecystectomy through Hot Gall Bladder Pathway between 1st February 2019 to 1st March 2020.

We screened a total of 134 patients who had been included in this pathway, 36 patient excluded.

1- Acute cholecystitis with no associated organ dysfunction 63 patients

2- Mild Acute Biliary Pancreatitis 35 patients

Results

Mild Acute Biliary Pancreatitis who underwent Laparoscopic Cholecystectomy within index admission or within 2 weeks of diagnosis 69 % (25/35).

Acute cholecystitis with no associated organ dysfunction (mild or moderate; Tokyo guideline grade I or II) who underwent Laparoscopic Cholecystectomy within week of diagnosis 68.2 % (43/63).

Conclusions

WE2.8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Aim

There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway.

Method

Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended.

Results

We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality.

Conclusion

A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.