PB03 Biliary: Gallstones (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB03-01 “Difficult Gallbladder” Incidence and Management at Speciality Surgical Unit
Dhaivat Vaishnav, India

D. Vaishnav, B. Patel
GI and HPB Surgery, Zydus Hospital, Ahmedabad, India

Laparoscopic cholecystectomy is deemed to common surgical procedure, however 'Difficult Gallbladder' requires modified surgical approach.
1. To define incidence of "difficult gallbladder“
2. To review bail out procedures for difficult gallbladder
Study period: January 2016 to December 2019.
“Difficult gall bladder” defined as:
1. acute cholecystitis with thick walled/necrotic/gangrenous/empyema of gall bladder.
2. chronic cholecystitis (fused calots triangle with thick contracted gallbladder).
3. Mirizzi syndrome.
4. Known/ suspected GB perforation.
Subtotal cholecystectomy defined as:
1. constituting type: infundibular stump cleared and suture closed.
2. Fenestrating type posterior wall on GB bed left behind and cystic duct closed.
Results: Total 745 patients underwent cholecystectomy. Out of 227 cases of acute cholecystitis, there were 119 cases were “difficult gallbladder”. Etiology of difficult gallbladder was as follows, Empyma gall bladder-46, Gangreneous/necrotic gall bladder-20, Chronic cholecystitis with fused calot's triangle-24, Mirizzi syndrome type I/II-8, Gall bladder perforation-21. Out of 119, difficult gallbladder, subtotal cholecystectomy was done in 74 cases-Fenestrating type in 49 cases while constituting type in 25 cases. There was no bile duct injury reported. Bile leak was encountered in 4 cases of constituting type of subtotal cholecystectomy, which was stopped gradually without any intervention.
Conclusion: It is advisable to look for cystic duct identification and close the duct whenever is possible. Subtotal cholecystectomy is viable bail out option in difficult gallbladder surgery to prevent bile duct injury.
PB03-03 What Is the Risk Factor for Converted from Total Cholecystectomy to Bail-Out Surgery?
Mitsugi Shimoda, Japan

M. Shimoda, Y. Oshiro, S. Suzuki
Department of Gastroenterological Surgery, Tokyo Medical University, Ibaraki Medical Center, Japan

Laparoscopic cholecystectomy is regarded as the first choice for patients with Gall bladder diseases, but, biliary injury (BDI) still had serious problem in LC.
Recently, bail-out surgery (BOS) has been proposed to avoid but BDI not also major vessels injury. In this retrospective study, we evaluated that pre- and peri operative risk factor for conversion from total cholecystectomy (TC) to conversion BOS.
Methods: This study included 584 patients who underwent elective LC for Gall bladder diseases were between Jan. 2006 and Apt. 2019. We divided into two groups of TC group (including conversion open total cholecystectomy) and BOS group. Univariate and multivariate analyses using pre and perioperative clinicolaboratory characteristics were performed to investigate the most significant risk factors for conversion to BOS.
Results: There were 33 cases in BOS group, which had 18 cases of female and 35 male. Procedures of BOS were as follow: open BOS was 19 cases; laparoscopic BOS was 14 cases. On univariate analyses, age, Albumin level, CRP level, WBC, Lymph ratio, Neutro. ratio, platelet count (PLt), NLR, PLR, CAR, with acute cholecystitis (AC), with previous biliary tract drainage(PBTD)were risk factor for conversion BOS. Multivariate analysis using thirteen parameters selected by univariate analyses demonstrated that AC (p=0.04), albumin level (p=0.01) and age (p=0.04) were significant different risk factors.
Conclusions: Patients with PBTD or AC are considered to have a high risk of conversion from LTC to BOS and it seems that LC should be cautiously applied.
PB03-04 Subtotal Cholecystectomy: Is it Really a Safe Option?
Rashid Ibrahim, United Kingdom

R. Ibrahim1, B. Mahendran2, H. Nawara1, S. Aroori1
1University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom, 2Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom

Background: The risks associated with subtotal cholecystectomy (STC) are unclear. The aim of this study is to review our experience with STC, and comparing outcomes to total cholecystectomy (TC).
Methods: This is a retrospective study of all patients that underwent STC at a Tertiary HPB unit between November 2011 to February 2019.
Results: A total of 4251 patients underwent a cholecystectomy during the study period. 78/4251 (1.8%) underwent STC. The median age of the patients was 70.4 years in the STC group compared to 54 years in the TC group. Overall morbidity (41 vs 1.5%, p< 0.00001), bile leak rate
(20 vs 1.7%, p< 0.00001), and readmission rates (23 vs 8%, p=0.00001) were significantly higher in the STC group compared to TC group. Seven (9%) patients in the STC group also required remnant cholecystectomy due to recurrent symptoms.
Conclusions: STC is associated with much higher and significant post-operative morbidity and open conversion rate compared to TC. Whilst STC may be an alternative option in difficult cases,
it is not risk free and surgeons must consider other options before proceeding to a STC. Further studies are also required to look into possible prediction models for patients who might undergo a STC.
PB03-07 Does an Experienced Laparoscopic Surgeon Need a Long Learning Curve to Start Robotic Single Site Cholecystectomy?
Kwan Woo Kim, Korea, Republic of

K.W. Kim, E.-J. Jang, S.H. Kang
Surgery, Dong-A University Hospital, Korea, Republic of

Purpose: It is well known that a laparoscopic single site cholecystectomy has significant limitations associated with proper triangulation and instrument crowding and collisions. Although the da Vinci Single Site robotic system has been proposed to overcome these problems, the Single Site technology is non-wristed and, unlike other conventional robotic instruments, only provides rotation, the ergonomics. Therefore, many surgeons are reluctant to start robotic single site cholecystectomy (RSSC). The purpose of this study is to demonstrate that an experienced laparoscopic surgeon can safely RSSC with less learning curves using the robotic single site platform by showing objective data by single experienced surgeon.
Methods: Demographic, perioperative, and postoperative data of thirty nine patients who underwent RSSC between April 2019 and Oct 2019 were collected retrospectively.
Results: The mean age and BMI was 45.2 years, 24.69 kg/m2. Male/female ratio was 7/23 (27.3/72.7 %). The mean docking time was 10.2±2.85 min. The mean operation time (skin to skin) was 48.2 min (range, 29~65 min). The operation time is slightly longer than conventional laparoscopic cholecystectomy and shorter than the single site laparoscopic cholecystectomy. None of the patients required an additional laparoscopic arm, an additional robotic arm, or conversion to conventional laparoscopic cholecystectomy.
Conclusions: Although our cases are small, the results show that RSSC is a safe, feasible and useful operative procedure. In addition, our study results indicate that experienced laparoscopic surgeons can do RSSC with less learning curve because total operation time is almost the same as conventional laparoscopic cholecystectomy except for the docking time.
PB03-08 Preoperative MRI Assessment for Predicting Surgical Difficulty during Laparoscopic Cholecystectomy for Acute Cholecystitis
Kojiro Omiya, Japan

K. Omiya, K. Hiramatsu, T. Kato, Y. Shibata, M. Yoshihara, T. Aoba, A. Arimoto, A. Ito
General Surgery, Toyohashi Municipal Hospital, Japan

Introduction: The thickening of the gallbladder wall with low signal intensity on MRI in acute cholecystitis (AC) is associated with severe inflammation with necrosis and fibrosis. However, the associations between MRI findings and operative outcomes are unknown. This study aimed to assess the utility of MRI to predict surgical difficulty during laparoscopic cholecystectomy (LC) for AC.
Methods: We retrospectively identified patients who underwent both preoperative MRI and early LC for AC between 2012 and 2018. Based on the signal intensity of the gallbladder wall on MRI, we classified the patients into High Signal Intensity (HSI) group and Low Signal Intensity (LSI) group. Conversion rates to open cholecystectomy and operative time were compared between the two groups.
Results: Of 608 LCs performed for AC, 203 cases were eligible. Conversion rates were 5.3% (8 of 150 cases) and 26.4% (14 of 53 cases), and operative time were 100.5 min and 121 min in the HSI and LSI group, respectively (both P < 0.001). On multivariate analysis, the low signal intensity of the gallbladder wall on MRI was an independent predictor of both higher conversion rate (odds ratio 5.87, 95% confidence interval (CI) 1.72-20.00, P = 0.0047) and prolonged operative time (regression coefficient 19.99, 95% CI 6.26-33.73, P = 0.0046).
Conclusions: The low signal intensity of the gallbladder wall on MRI was significantly associated with a higher conversion rate and prolonged operative time of LC for AC. Preoperative MRI could be a novel method for predicting surgical difficulty during LC for AC.
PB03-11 Management of Gallbladder Remnant and the Cystic Duct Stump Calculi: a Retrospective Study
Anshuman Pandey, India

A. Pandey, S. Jha, S. Masood, D. Kumar, S. Kumar, M.M. Shibumon
Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India

Introduction: Gall bladder remnant and cystic duct stump calculi are reality in the era of Laparoscopic Cholecystectomy (LC). Despite a seemingly uneventful cholecystectomy, nearly 15% patients continue to have biliary symptoms; the post-cholecystectomy syndrome (PCS); which can manifest anytime from few days to several years after surgery This study aims to assess the safety and feasibility of Laparoscopic exploration of gallbladder remnant calculi leading to PCS
Materials and methods: In this study, surgical explorations was done in 25 patients. The study considered parameters like the operative time, conversion rate, post-operative complications, post-operative hospital stay and mortality in these patients. The duration of study was 2 years and the data was retrospectively reviewed.
Results: 25 patients diagnosed as symptomatic gallbladder remnant were identified. The most common symptoms at presentation included right upper quadrant pain (80%), Jaundice(12%) Cholangitis (4%). Symptoms began from 6 months to 25 years after index cholecystectomy. Diagnostic modalities utilized in the evaluation of these patients demonstrated that MRCP were effective with sensitivities of 100%. Of the 25 patients, 22 (88%) had completion LC . 3 patients (12%) were converted to open cholecystectomy because of dense adhesions and non-identification of structures laparoscopically.
Conclusion: Diagnosis of residual GB stone is difficult. In expert hands and standard approach, completion LC of the gallbladder remnant can be performed within a reasonable operating time. There is low conversion rate with minimal post-operative complications and shorter hospital stay and minimal morbidity. Completion cholecystectomy can be challenging but is highly effective.
PB03-12 Hybrid Interventions in the Treatment of Common Bile Stones
Aleksei Osipov, Russian Federation

A. Osipov, A. Demko, D. Surov, A. Svyatnenko
HPB, St. Petersburg Research Institute of Emergency Medicine named after I.I. Dzhanelidze, Russian Federation

In recent years, the incidence of gallstone disease has increased dramatically. Reports on the possibility of a one-stage minimally invasive treatment in the case of complicated cholecystocholedocholithiasis are increasingly found in the literature.
Objective: To improve the immediate results of treatment of patients with "difficult" cholecystocholedocholithiasis.
Materials and methods: 108 hybrid surgical interventions were performed between 2014 and 2020. Patients with "difficult" choledocholithiasis included with obstructive jaundice complicated by mild cholangitis and also with large single stones of AJP (with a diameter of more than 15 mm), with duodenal diverticula. All interventions were performed in an X-ray room using laparoscopic and endoscopic approach. The average age of the patients was 59.8 years old. Performed 64 laparoscopic cholecystectomy in combination with laparoscopic choledochotomy and lithoextraction. In these cases, the primary suture of the common bile duct was performed with bile duct drainage. 16 patients with duodenal diverticulum underwent a combination of laparoscopy with drainage, cannulation of bile duct and subsequent ERCP and lithoextraction. In 44 cases, simultaneous surgery included laparoscopy and ERCP.
Results: The average duration of surgical intervention was 94.2±26.4 minutes, the hospitalization duration was 9.6±4.2 days. In 4 (3.7%) case, residual choledocholithiasis was observed, requiring repeated endoscopic lithoextraction. There were no other complications and deaths.
So, hybrid surgical interventions can be used for the simultaneous treatment of patients with complicated cholecystocholedocholithiasis, further accumulation of experience and analysis of the results of these interventions are required.
PB03-13 Early Operation for Acute Cholecystitis in the TG18 Era
Masaru Koizumi, Japan

M. Koizumi, Y. Miyahara, H. Kitabayashi, M. Shiozawa, S. Kondo, M. Kodama
Surgery, Tochigi Medical Center Shimotsuga, Japan

Background: Tokyo Guidelines 2018: Updated Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis (TG18) were released in January 2018. Early laparoscopic cholecystectomy (LC) is recommended for acute cholecystitis within 72 hours when possible or within one week at the latest.
Aim: To assess current status of early operation for acute cholecystitis.
Methods: From 2018 to 2019, 31 patients who underwent early operation for acute cholecystitis were reviewed retrospectively.
Results: During the same period 185 cholecystectomies were performed. Early operations were performed in 17% including 21 males and 10 females, with an average age of 57.9 years. Median time from onset to admission was 1 day. Ultrasonography and CT scans were obtained for all patients and MRCP in 61%. X-ray showed stones in 65% of all patients. Severity score classified into Grade I; 25 patients (81%) and Grade II; 6 patients (19%). Median score of age adjusted Charlson Co-morbidity index was 3 points (0-7). Median time from admission to surgery was 1 day, and 61% underwent LC and 39% open cholecystectomy (OC). In Grade II patients, OC was performed in 83% because of a pericholecystic abscess with severe inflammation. Subtotal cholecystectomy was selected in 50% patients as a bailout procedure. Morbidity rate was 6%. Average postoperative hospital stay was 5.9 days.
Conclusions: According to the flowcharts in TG18, early LC is recommended for all patients, but OC was chosen in 39% in this series. OC does not make cholecystectomy easier, but OC must be considered when OC is safer.
PB03-17 Acute Cholangitis: Validation of TG07, TG13 and TG18
Ramkumar Mohan, Singapore

R. Mohan1, L. S Punjabi2, J. Wong Say Wei2, V. G Shelat3
1Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 2Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 3Hepatopancreaticobiliary Surgery, Tan Tock Seng Hospital, Singapore

Objectives: Tokyo guidelines have not been widely validated. We aim to validate TG07, TG13 and TG18 for acute cholangitis (AC).
Methods: A retrospective audit of AC patients managed from Jan-Dec 2016 is reported. Demographic data, clinical profile, serum and radiological investigations, and type of intervention(s) were recorded. Data was validated for TG07, TG13 and TG18 diagnostic, severity stratification and management guidelines.
Results: 272 patients were included. The most common presenting symptom was abdominal pain (n=179, 65.81%) and 53.31% (n=145) of patients met the systemic inflammatory response (SIRS) criteria on admission. The most common abnormal serum biochemistry was 'Raised GGT (>72 IU/L)' with 86.76% (n=236) of patients presenting with it. Common bile duct stone(s) were identified in 6.25% (n=17) of patients on ultrasonography (US), 12.87% (n=35) on computerized tomography (CT) and 22.43% (n=61) on magnetic resonance cholangiopancreatography (MRCP). 55.47% (n=147) of patients had an Endoscopic retrograde cholangiopancreaticography (ERCP), with ductal clearance in 44.90% (n=66) while 6.04% (n=16) patients had a PTC. 61.59% (n=85) of patients had an ERCP done within 96 hours of ward admission. Cholecystectomy was performed in the index admission in 5.66% (n=15), and in the elective outpatient setting in 4.91% (n=13) patients. In-hospital mortality rate was 5.66% (n=15), while 30-day mortality was 1.13% (n=3) and 90-day mortality was 4.04% (n=11) of patients.
Conclusions: TG13 and TG18 are more sensitive and specific.
n=272(%) TG07TG13/TG18
Diagnostic criteriaNo AC73 (26.84)46 (16.91)
 Suspected AC102 (37.50)30 (11.03)
 Definite AC97 (35.66)196 (72.06)
Severity criteriaMild AC260 (95.59)98 (36.02)
 Moderate AC(Mild/Mod severity merged)95 (34.93)
 Severe AC12 (4.41)78 (28.68)
[Validation of TG07, TG13 and TG18 diagnostic criteria and TG13/TG18 severity criteria of Acute Cholangitis (AC)]
PB03-18 A Snapshot of the Practice of Laparoscopic Common Bile Duct Exploration in the United Kingdom - (CholeS Data Set)
Andrei Tanase, United Kingdom

A. Tanase1, T. Platt2, R.S. Vohra3, S. Aroori1, CholeS Study Group, West Midlands Research Collaborative
1Hepatopancreatobiliary Department, University Hospitals Plymouth NHS Foundation Trust, United Kingdom, 2UpperGi Surgery, Torbay and South Devon NHS Foundation Trust, United Kingdom, 3Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, United Kingdom

Introduction: The aim was to describe the utilisation/practice of laparoscopic bile duct exploration(LCBDE) option for the management of common bile duct stones across the UK. The data were obtained from a population-based cohort study of outcomes following cholecystectomy for benign gallbladder diseases (CholeS study).
Methods: We used the CholeS Study DataSet to analyse the use of LCBDE in the UK. Descriptive analysis and graphs were used to illustrate the current practice of LCBDE in the UK.
Results: Seventy-seven (46%) out of 167 Hospitals that took part in the CholeS study performed LCBDE. Their LCBDE workload was 5.4% out of the total Laparoscopic Cholecystectomies(LC) performed. Almost 90% of LCBDE was performed by hospitals who performed less than five LCBDE in two months. Only 5.2% of hospitals performed more than 10 LCBDEs; this accounts for 19.8% of their LC workload compared to between 2 and 8% for the rest. Out of 8820 LC, a total of 256(2.9%) and 932(10.6%) patients underwent LCBDE and pre-operative endoscopic retrograde cholangio-pancreatography and sphincterotomy(ERCP+ES) respectively for CBDS. Eighty-four per cent of LCBDEs were performed by Upper gastrointestinal surgeons and 16% by other specialities including 10% colorectal surgeons. Interestingly, only just under 5% of the LCBDEs were performed by trainees.
Conclusions: In the UK, a significant proportion of patients with CBDS are still treated in two stages: a pre-operative ERCP followed by LC. LCBDE remains an underutilised resource in the UK. Further studies are required to examine the possible reasons for the low utilisation of LCBDE.
PB03-19 Is Routine MRCP Needed in Symptomatic Gallstone Disease? - A Single Center Experience
Tanmay Pareek, India

T. Pareek, O.L. Naganath Babu, S. Rajendran, R. Prabhakaran, R. Rajkumar
Institute of Surgical Gastroenterology, Rajiv Gandhi Government General Hospital, Madras Medical College, India

Objectives: To assess the role of magnetic resonance cholangiopancreatography (MRCP) in the detection of choledocholithiasis in patients with symptomatic gallstone disease and to determine the anatomical variations of extra hepatic biliary tract and their relation to bile duct injury during laparoscopic cholecystectomy.
Methods: This is a retrospective observational study of 80 patients from a prospectively maintained database from October 2017 to September 2019. On the basis of findings from Preoperative liver function test and Ultrasound abdomen, patients were divided into 3 groups as per ASGE guidelines for the risk of choledocholithiasis[high risk(n=14),medium risk(n=13),low/no risk(n=53)]. MRCP was performed in all patients routinely.
Results: MRCP detected choledocholithiasis in 14 patients. 9 out of 14 patients had dilated CBD on Ultrasound and 7 had elevated ALP. Among 66 patients without CBD stone, ALP was elevated in 4 patients. Patients with MRCP detected stones were subjected to ERCP which was successful in 9 patients. From remaining 5 patients with unsuccessful ERCP, two patients underwent laparoscopic CBD exploration/T tube drainage, one patient underwent bilioenteric anastomosis, two patients with biliary pancreatitis were managed with laparoscopic cholecystectomy alone in view of passed out stone. MRCP diagnosed extrahepatic biliary tract variations in 15% cases(n=12). No patient suffered bile duct injury in this study.
Conclusion: In view of high sensitivity to detect choledocholithiasis even in normal LFT and USG abdomen and to delineate extrahepatic biliary anatomy, we suggest routine MRCP in all cases of symptomatic gallstone disease to aid in preoperative management and prevention of bile duct injury.
PB03-20 Prolonged Cholecystectomy Waiting Time for Complicated Gallstone Disease Was Associated with Increase Rate of Gram-negative Infection
Hon Ting Lok, Hong Kong

Y.S. Cheung1, H.T. Lok2, K.K.C. Wong1, A.K.Y. Fung2, C.C.N. Chong2, J. Wong2, K.F. Lee2, K.K.C. Ng2, P.B.S. Lai2
1Department of Surgery, North District Hospital, The Chinese University of Hong Kong, Hong Kong, 2Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong

Background: Early cholecystectomy for complicated gallstone disease is safe and has shorter hospital stay. However, no consensus recommendation about the timing of cholecystectomy for complicated gallstone disease is available in Hong Kong.
Method: A retrospective review using administrative data for all cholecystectomy in a public hospital regional network in Hong Kong, consisting of 3 hospitals, from January 2015 to December 2019 was performed. Patients requiring cholecystectomy not due to gallstone were excluded. Relationship between cholecystectomy waiting time and patient outcome were analysed.
Results: 1931 patients with cholecystectomy from 2015 Jan to 2019 Dec were retrieved from the hospital electronic patient record system. 723 Emergency Cholecystectomy and 82 patients receiving cholecystectomy unrelated to gallstone diseases were excluded. 1126 patients were recruited in this study. The median operation waiting time were 184 days. 10% of the cohort need to wait for more than 460 days before operation.
The readmission rate and mortality rate were 5.5% and 0.2% respectively. There was no significant difference in readmission rate, mortality rate and post-operative hospital stay according to operation waiting time. Thirty-five patients (3.1%) developed positive gram-negative bacilli in bile or blood while waiting for surgery. Patients with longer operation waiting time (>10 weeks) had a significant higher (p=0.019) positive culture rate.
Conclusion: Patients having cholecystectomy waiting time greater than 10 weeks were associated with higher rate of infective episodes requiring admission. To avoid gram-negative infection in patients with complicated gallstone disease, early cholecystectomy within 10 weeks should be arranged.
PB03-21 Acute Cholangitis in Octogenarians - Clinical Outcomes from a Singaporean Center
Ramkumar Mohan, Singapore

R. Mohan1, L. Punjabi2, J. Wong2, J.K. Low3, S. Junnarkar3,4, C.W.T. Huey3, V. Shelat3
1National University of Singapore, Singapore, 2Lee Kong Chian School of Medicine, Singapore, 3General Surgery, Tan Tock Seng Hospital, Singapore, 4Tan Tock Seng Hospital, Singapore

Objectives: Octogenerians have increased comorbidity and frailty which impact clinical outcomes. We report outcomes of octogenerians managed for acute cholangitis (AC).
Methods: All octogenarians diagnosed with AC between 2010-2016 were included in audit. Demographic data, comorbidities, clinical presentation, serum and imaging investigations, and type of intervention(s) performed were collected.
Results: 374 patients with a median age of 84 years (range 80-89) are included. The most common presenting symptom was abdominal pain (n=216, 57.75%) and 45.12% (n=169) of patients met the systemic inflammatory response (SIRS) criteria on admission. 18.72% (n=72) of patients were stratified as having mild, 47.33% (n=177) had moderate and 33.42% (n=125) had severe AC as per TG13. 63 patients (16.9%) were admitted to critical care unit. 147 patients (39.3%) had positive blood cultures and Klebsiella pneumoniae was the commonest organism (n=43, 29.2%). Eight patients (2.14%) had qSOFA score of 2 or more. Common bile duct stone(s) were identified in 8.02% (n=30) of patients on ultrasonography (US), 17.91% (n=67) on computerized tomography (CT) and 26.74% (n=100) on magnetic resonance cholangiopancreatography (MRCP). 63.36% (n=237) of patients had an ERCP, with ductal clearance in 42.62% (n=101) and 11.23% (n=42) patients had a PTC. Cholecystectomy was performed in the index admission in 2.67% (n=10), and in the elective outpatient setting in 5.88% (n=22) patients. In-hospital mortality rate was 9.36% (n=35).
Conclusions: TG13 diagnostic criteria are more sensitive and specific in octogenarian AC patients. Acceptance for definite cholecystectomy is low. Mortality in octogenerians remains high.
PB03-22 The Application of Tokyo Guideline 2018 (TG18) and Outcome Analysis in Patients with Initial Diagnosis of Both Acute Cholecystitis and Acute Cholangitis
Yau-Ren Chang, Taiwan, Republic of China

Y.-R. Chang1, C.-N. Yeh1, S.-Y. Wang2, Y.-Y. Jan2
1General Surgery, Chang Gung Memorial Hospital, Taiwan, Republic of China, 2General Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan, Republic of China

Purpose: TG18 established the golden rule for clinicians to manage both acute cholecystitis and acute cholangitis. However, seldom does TG18 mention about the management of combined diagnosis of both acute cholecystitis and acute cholangitis initially. Our aim is to investigate the clinical characteristics and outcome of this disease group.
Materials and methods: From January, 2012 to October, 2017, we retrospectively collected 154 patients with the initial diagnosis of both acute cholecystitis and acute cholangitis. We surveyed the disease pattern, subgrouping them based on the severity system in TG18 and compared outcome between management of both diseases following TG18 or not.
Results: Of all the 154 patients, 23(14.9%) had grade III acute cholecystitis and acute cholangitis., which was higher than grade III disease in all patient diagnosed as acute cholecystitis (119 of 942, 11.0%) and acute cholangitis (38 of 454, 8.4%), respectively. Recurrent BTI rate showed significant difference between these 154 patients (28.6%) and patients diagnosed as either acute cholecystitis and acute cholangitis (16.3%). All 154 patients were categorized into 4 groups according to the treatment from TG18 for the 2 diseases in different severities. In all groups, the recurrent biliary tract BTI rate had no statistically difference between treatment following TG18 suggestion and not.
Conclusion: In this study, we found when patient is impressed with both diagnosis initially, the severity system and treatment management from TG18 may not provide favorable outcome, resulting in new prospect of research for this specific disease group.
PB03-23 Laparoscopic Subtotal Cholecystectomy for Gangrenous Cholecystitis in a Liver Cirrhosis Patient: A Case Report
Jae Uk Chong, Korea, Republic of

J.U. Chong, J.H. Lee, H.S. Lee, K.H. Kwon
Surgery, National Health Insurance Service Ilsan Hospital, Korea, Republic of

Introduction: Subtotal cholecystectomy should be considered when structures of calot can not be identified or critical view of safety can not be achieved. Here, we present a case of laparoscopic subtotal fenestrating cholecystectomy for gangrenous cholecystitis in a liver cirrhosis patients.
Case report: A 64 year-old male came to emergency room after suffering from RUQ pain for 4 days. Underlying medical conditions included hypertension, diabetes, and alcoholic liver cirrhosis with BMI of 22.5. Initial laboratory results were as following: WBC count of 12670/ul, platelet count of 90000/ul, C-reactive protein of 20.35 mg/dL, AST/ALT of 58/52 IU/L, Total bilirubin/Direct bilirubin of 3.88/2.37 mg/dL. Computed tomography showed gangrenous cholecystitis with cystic duct stones and liver cirrhosis with splenomegaly. The patient underwent laparoscopic cholecystectomy using conventional four port approach. Upon entering the peritoneum, severe adhesion around the gallbladder and macronodular cirrhosis were noted. Due to severe adhesion and collateral vessels, calot dissection was not possible. After identifying the cystic duct and retrieving the stones, cystic duct stump was sutured internally with 4-0 vicryl and laparoscopic subtotal cholecystectomy was completed after inserting a drain. Total operation time was 210 minutes with blood loss of 100cc. Patient was discharged on postoperative day #10 after conservative care for ascites.
Conclusion: Subtotal cholecystectomy is an important tool for hepatobiliary surgeons facing complex intra operative situations with high risk of postoperative complications.
Figures: A, B) preoperative CT, C) postoperative 1 month CT, D) Dissection of gallbladder, E) Identification of cystic duct, F) Cystic duct stump internally sutured
[Figures: A,B)preoperative CT, C)postoperative 1 month CT,]
PB03-24 Rate of Choledocholithiasis on Routine Intra-operative Cholangiogram and their Management in a Regional Australian Hospital
Moon Soo Choi, Australia

M.S. Choi, K. Hung
General Surgery, Bundaberg Base Hospital, Australia

Methods: A retrospective audit of all elective and emergency cholecystectomies and their IOCs from January 2019 to December 2019 was done. The method of management and their outcomes were evaluated.
Results: 113 emergency cholecystectomies were performed with a 93% (105/113) rate of intra-operative cholangiograms. Of these 19% (20/105) found filling defects on IOC. 14 underwent laparoscopic exploration with a choledochoscope of which 10 were successful. 6 were managed with a referral to a tertiary centre for an ERCP. The remaining 4 were either successfully flushed, milked out or left to pass spontaneously. For emergency cholecystectomies, laparoscopic CBD explorations added 48 minutes to operation time (185 vs 137 minutes). Hospital stay for laparoscopic CBD exploration was an average of 4.4 days while patient managed with an inter-hospital transfer and ERCP had a total average hospital stay of 8.0 days. For elective cholecystectomies, 90% (65/70) had an IOC of which 3 found choledocholithiasis. All 3 were successfully managed with a choledochoscope.
Conclusion: In a regional Australian hospital with no in-house ERCP facilities, laparoscopic treatment of choledocholithiasis is safe, efficient and reduces the duration of hospital stay and the cost of an inter-hospital transfer.
PB03-27 Risk Factors for Recurrence of Common Bile Duct Stones after Common Bile Duct Exploration Surgery
Huisong Lee, Korea, Republic of

H.H. Choi, H. Lee, D.J. Park, S.K. Min, H.K. Lee
Surgery, Ewha Womans University School of Medicine, Korea, Republic of

Purpose: Recurrent common bile duct (CBD) stone is a significant delayed complication after CBD exploration surgery. However, no definite risk factors for recurrence have been established. The aim of this study is to identify the risk factors of recurrent CBD stone following surgical CBD stone removal.
Methods: In total, 253 patients who underwent CBD exploration surgery from Jan 2000 to Jan 2018 were identified and included in this study. We retrospectively collected clinical data based on the medical records of the patients and investigated risk factors with logistic regression analysis.
Results: A total of 31 patients (12.3%) developed recurrent CBD stones. The median follow-up period was 9.6 months. Univariate analyses showed that the following factors were associated with recurrent CBD stones: delayed diet start after 7 days, longer hospital duration, and preoperative endoscopic sphincterotomy. However, sex, age, gallstone, operation time, transfusion, T-tube insertion, and postoperative complications were not associated with recurrent CBD stone. In multivariate analysis, longer hospital duration and preoperative endoscopic sphincterotomy were associated with recurrent CBD stone (OR = 1.047; CI 1.001 to 1.095; p = 0.048 and OR = 3.615; CI 1.081 to 12.087; p = 0.037, respectively).
Conclusion: Recurrent CBD stones can often occur and require regular follow-up although it is safe to remove by surgical CBD exploration. Further investigation is needed on the risk factors of recurrent CBD stones.
PB03-28 Incidence of Microflora from Cultures of Gall Bladder Bile of Laparoscopic Cholecystectomy
Hyuk Jai Jang, Korea, Republic of

H.J. Jang
Surgery, Ulsan University. Gangneung Asan Hospital, Gangneung, Korea, Republic of

Background: Gallstone disease is one of the most common problem affecting the digestive tract. Through experience it has been accepted that bile in normal conditions remains sterile. Bactibilia is a common finding in individuals at high risk or with complicated cholecystolithiasis, however few data prevails about the prevalence of bactibilia in patients operated on for uncomplicated laparoscopic cholecystectomy. There is a common usage of preoperative and postoperative antibiotics in the different patients without the existence of any actual bacteriologic and epidemiologic evidence.
Material and methods: 222 patients with diagnosis of cholecystolithiasis postoperated of laparoscopic cholecystectomy had a bile sent to bacteriology. Bile was aspirated from the gall bladder during laparoscopic cholecystectomy.
Results: Bactibilia was identified in 50 (23%) of the cultures of mild chronic cholecystitis. A total of 172 negative cultures were obtained (77) and 50 positive (23%). In the present study out of 50 patients, 32 (64%) were females and 18 (36%) were males. We found total of 25 (50%) black pigmented stones, 15 (30%) were brown and 10 (20%) were cholesterol stones. In this study bile culture was showing growth of the following organisms. The commonest organism was Enterococcus (32%) followed by E. coli (26%), Klebsiella (14%).
Conclusions: Bactibilia has long been known to be associated with biliary tract diseases and culturable bacteria in bile can represent a state of asymptomatic bactibilia which can disseminate after any intervention causing infective complication. Exploring the microflora of gall bladder bile important role in choosing the appropriate antibiotic to prevent complication.
PB03-29 Laparoscopic Cholecystectomy in Acute Cholecystitis - "Any Time Is Good Time"
Hamza Wani, India

H. Wani, M. Ibrarullah, M. Modi, U. Srinivasulu, S. Meher
Surgical Gastroenterology and Hepatopancreatobiliary Surgery, Apollo Hospital Bhubaneshwar, India

Acute cholecystitis is a huge burden on the healthcare system. Laparoscopic cholecystectomy is the gold standard in the care for patients with acute cholecystitis
Aim: Analyzing clinical aspects and outcomes in patients diagnosed with acute cholecystitis undergoing laparoscopic cholecystectomy. Variables studied 1. Mean operative time 2. Morbidity profile 3. Duration of hospital stay 4. Conversion to open
Study design: Prospective hospital based study
Material and methods: 103 patients with acute cholecystitis irrespective of duration of symptoms were evaluated, and investigated. After confirming the diagnosis all patients underwent laparoscopic cholecystectomy
Results: 103 patients (60 females, 43 males). 102 procedures were completed laparoscopically (one conversion). All cases showed features suggestive of acute cholecystitis (18 - gangrenous cholecystitis) (14 - empyema) and (12 - mucocele). 97.08% of cases were completed in less than 90 minutes duration. Intra peritoneal drains were used depending on surgeon choice and local operative factors, this was done in 44 cases. Mean post-operative stay was observed as 2.19 ± 1.22 days with all but four cases having their drain removed before discharge. These four patients underwent subtotal cholecystectomy and the drains were subsequently removed after two weeks post operatively. There was no incidence of any biliary injury, one patient died due to sepsis and multi organ failure (converted to open).
Conclusion: Acute cholecystitis can be dealt with by laparoscopic cholecystectomy irrespective of duration of symptoms with excellent results provided it is performed in a specialized tertiary care referral centre with vast experience in laparoscopy and hepatobiliary surgery.
PB03-30 Safety and Effectiveness of Percutaneous Cholecystostomy (PC) as a Treatment O Acute Cholecystitis (AC) in Selected Patients. Prospective 10 Years Study of Adverse Events (AE)
Francisco Garcia Borobia, Spain

F. Garcia Borobia1,2, N. Bejarano3, A. Romaguera Monzonis3, N. Garcia Monforte3, E. Criado4, M. Llabro5, M. Sola6, P. Rebasa7, S. Navarro8
1HBP Surgery, Parc Tauli, Hospital Universitari, Spain, 2Surgery, Universidat Autonoma de Barcelona, Spain, 3HBP Surgery, Parc Tauli. Hospital Universitari, Spain, 4Intervencional Radiology, Parc Tauli. Hospital Universitari, Spain, 5Surgery, ALTHAIA Centre Hospitalari, Spain, 6Radiology, Parc Tauli. Hospital Universitari, Spain, 7Surgery, Parc Tauli. Hospital Universitari, Spain, 8General Surgery, Parc Tauli. Hospital Universitari, Spain

Introduction: Definitive treatment for AC is cholecystectomy. However in patients with medical comorbidities or critical illness, PC could be and effective and safe alternative.
Methods: We evaluated 1223 patients with AC recovered from 2008 to 2017. Medical treatment was used in 273 patients. In 66 out of 273 a PC was indicated. PC was performed under ultrasonography and local anaesthesia. A minimum follow-up of one year was done. AE were recorded prospectively according to Clavien-Dindo Classification.
Results: PC was indicated due to severe comorbidities (55%), critical illness (31%), or long-time AC evolution in weak patients (8%). Median age was 79 years. Eighteen patients were admitted in ICU. Sixty-two patients were ASA III or superior. Twenty patients were treated with delayed cholecystectomy (30%). Two patients needed emergent cholecystectomy due to PC failure, one of them died due to sepsis. Six more patients died with PC (mortality 10%). Effectiveness 48/66 (88%)
Twenty-two AE were observed in 14 patients during hospitalization. Seven grade V and 4 grade III in 4 patients. Thirty patients presented AE during follow-up related to the PC.
Thirty-two out of 59 patients died during follow-up. Five died in the group of patients with delayed cholecystectomy. Twenty patients died in the group of PC without cholecystectomy.
Conclusions: PC is safe alternative to cholecystectomy in critically ill or high-risk patients and could be the only treatment. AE are high. The high mortality during follow-up is due to other medical problems. Delayed Cholecystectomy should be done in very selected patients.
PB03-31 Relations between Hepatobiliary Scintigraphy Findings and Histopathological Factors in Patients with Recurrent Biliary Colic
Hae Il Jung, Korea, Republic of

S.H. Bae, H.I. Jung
Soonchunyang University Cheonan Hospital, Korea, Republic of

Background: The histopathological factors of gallbladder that affect the findings of hepatobiliary scintigraphy is not fully known. The aim of the present study is to investigate the relationship between hepatobiliary scintigraphy findings and histopathological results in patients with recurrent biliary colic.
Methods: A total of 107 patients who underwent hepatobiliary scintigraphy for recurrent biliary colic and subsequent cholecystectomy were retrospectively enrolled. According to the hepatobiliary scintigraphy findings, patients were categorized into three groups; patients with non-visualization of gallbladder activity (non-visualized GB group), gallbladder ejection fraction (GBEF) of < 35% (low GBEF group), and GBEF of ≥ 35% (normal GBEF group).
Results: Of all patients, 31 patients were classified as non-visualized GB group, 33 were low GBEF group, and 43 were normal GBEF group. Non-visualized group showed higher rates of patients with severe neutrophil, lymphoplasma cell, and eosinophil infiltrations and empyema and showed more increased cystic duct wall thickness than other groups (p< 0.05). Low GBEF group showed higher muscle-to-total wall thickness ratio and muscle-to-fibrosis thickness ratio than those with normal GBEF group (p< 0.05). On multivariate logistic regression analysis, Severe degrees of lymphoplasma cell infiltration (p=0.027) and eosinophil infiltration (p< 0.001) were independent predictors for non-visualization gallbladder activity, and muscle-to-fibrosis thickness ratio (p=0.030) was an independent predictor for low GBEF.
Conclusions: In patients with recurrent biliary colic, non-visualization of gallbladder activity on hepatobiliary scintigraphy was related with the degree of inflammation in the gallbladder, while GBEF was related with muscular hypertrophy of the gallbladder.
PB03-32 Laparoscopic Cholecystectomy - Two-Decade Experience of over 3000 Cases from a Tertiary Care Center
Mayank Jain, India

V. Bansal1, A. Baksi1, M. Jain1, A. Krishna1, P. Om1, S. Kumar1, H. Bhattacharjee1, P. Garg2, M. Misra3
1Department of Surgical Disciplines, AIIMS, India, 2Department of Gastroenterology, AIIMS, India, 3Department of Surgical Disciplines, Mahatma Gandhi University of Medical Sciences, India

Introduction: Laparoscopic Cholecystectomy (LC) remains the gold standard for benign gall bladder diseases. It is associated with higher risk of biliary injury (0.1%-1.5%) resulting in prolonged morbidity, decreased overall survival. This complication counterpoises the benefit of minimal invasive surgery. If we adopt the principle of safe cholecystectomy under supervision, laparoscopic cholecystectomy can be done safely even in difficult situations.
Methods: Retrospective review of the data of patients who underwent LC in a single surgical unit from January 2003 - December 2018 at a tertiary care center was done. 5 consultants and 12 residents (operating ratio of 70:30) conducted the surgeries. Demographic variables, intra operative findings, conversion rate, morbidity and mortality were evaluated.
Results: A total of 3095 patients underwent LC in the mentioned period, 75.05% females and 24.95% males. Difficult calot's triangle anatomy was identified in - 66 (2.132%) patients. 30 (0.969%) were converted to open procedure with one major bile duct injury (CBD transection), one accessory duct injury and one lateral CBD injury. 31 (1.01%) patients developed post operative bile leak. 15 (48.3%) patients were managed by ERCP and 10 (32.2%) underwent re-laparoscopy. 6 (19.35%) patients required pig tail drainage. None of the patients developed bile duct stricture in long term follow up.
Conclusion: LC offers shorter hospital stay and low morbidity. Procedure is safe and effective both for uncomplicated and complicated cholelithiasis. The incidence of major Bile Duct Injury can be kept to minimum with proper training and supervision in a tertiary care centre.
PB03-33 Gall Stone is 'Active' in Elderly Males
Chunyan Sun, China

J. Dong1, C. Sun2, X. Wang2, C. Xiang2, L. Gong2, J. Dong1, J. Zeng2, S. Yang2, L. Wang2
1Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China, 2Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, China

Introduction: Complicated gall stone disease (GSD) is a common surgical entity worldwide. However, the age distribution of complicated GSD has not been well described. We studied the age distribution of complicated GSD in both males and females, and compare the metabolic traits between the complicated GSD group and the non-complicated group.
Methods: We consecutively assembled a retrospective cohort of patients with GSD at Beijing Tsinghua Changgung Hospital from 1/11/2015 to 1/10/2019.
Results: Out of the 1395 patients, 859 (42.6% male) and 536 (35.6% male) patients were with and without complicated GSD. The number of females with complications peaked in the fifth decades, so did that without complications(p=0.217). However, the age distribution in males was significantly different (p=0.005). The number of males with complications peaked in the sixth decades, while the peak of that without complications appeared in the fifth decades. The frequency of complicated GSD was higher among males aged >60 years than that among males aged ≤60 years (72.7% vs. 61.3%, p=0.006). 35.6% and 21.6% female patients aged ≤60 years with and without complicated GSD had dyslipidemia(p=0.000). The percentages in the males aged ≤60 years were 55.5% and 34.8%(p=0.000). In females or males aged >60 years, there was no significant difference in the two groups (32.4% vs. 42.1%, p=0.092 and 41.4% vs. 47.4%, P=0.423). Nor hypertension or diabetes were significantly different between the groups with and without complications.
Conclusion: GSD is “active” in elderly males. Patients aged ≤60 years were more likely to develop complications with dyslipidemia.