Inverclyde Royal Hospital

Stone impaction is an obstacle to successful laparoscopic common bile duct exploration (LCBDE). This study aims to identify the incidence, operative difficulties and techniques used to disimpact and remove impacted stones during LCBDE. Prospectively collected data from a large series of LCBDE. Preoperative and operative findings in patients with impacted stones including the difficulty grading, impaction site, disimpaction methods, operative complications and postoperative outcomes were analysed. 136 of 1447 (9.4%) LCBDEs had impacted stones; 63.2% females, median age 54years. 88.2% were emergencies including 94 Jaundice (69.1%), 19 acute pains, 6 acute cholecystitis and 5 pancreatitis. 16.9% had previous ERCP, all at other units pre-referral. LCBDE was transcystic in 52 (38.2%) and via choledochotomy in 84 (61.8%), all requiring choledochoscopy. LCBDE was difficulty grade IV in 60 (44.1%) and grade V in 76 (55.9%).The number of stones ranged from 1 to 70 (median 2) and stone size 4-30mm (median 11). Impaction was at lower CBD in 83 (61%), Mid-CBD 29 (21.3%), Intra-hepatic 15 (11%), intra and extra hepatic in 6 (4.4%) and intramural in 3. Disimpaction was by biopsy forceps fragmentation in 37 patients (27.2%), basket dislodgment in 35 (25.7%), biopsy forceps plus basket/hook retractor or cholecochoscope push in 20 (14.7%), Fogarty/Foley balloon with or without basket in 15 (11%), laser in 12 (8.8%), grasper fragmentation in 9 patients (6.6%), and open conversion in 7 (5.1%); 3 stone removal, 2 choledochoduodenostomy and 2 hepaticojejunostomy. Stones left for postoperative ERCP in four patients (2.8%). The median operative time was 160min. Impacted stones increase the difficulty of LCBDE. The evolution of techniques and instruments over the course of this study increased the success of transcystic exploration and reduced reliance on choledochotomy. The prediction of impaction, availability of lithotripsy and increasing experience should improve postoperative outcomes.

Abstract Background While the management of acute gallstone pancreatitis (AP) has recognised guidelines, there are wide variations in compliance with these in various institutions for different reasons. The primary objective of this review was to evaluate the effects of implementing proactive management strategies on a specialist biliary firm receiving most biliary emergency admissions by protocol on the incidence of index admission laparoscopic cholecystectomy (LC) for AP. The secondary aims were to study the admission to LC interval, if such policy was safe and how it can help the optimisation of outcomes of AP. Method Analysis of prospectively collected data from AP patients treated by a specialist biliary unit dedicated to index admission LC and single session laparoscopic management of bile duct stones. Almost all patients were referred to the unit as soon as the diagnosis of AP was made. Only patients with severe pancreatitis on imaging or requiring intensive care were not included in the index admission pathway and subsequently underwent delayed surgery. Routine MRCP and ERCP were not part of the management protocol. Following clinical optimisation patients had LC with routine cholangiography (IOC). and if necessary bile duct exploration. Results 495/6140 patients were identified (8%), 70% females. Median age was 55 years. 92.3% had suspected ductal stones, half with jaundice. 11.9% had previous episodes. Only 6.2% had MRCPs and 2% ERCPs. Admission to LC interval was 5 days. 33.2% required bile duct explorations. LC difficulty grade was III to V in 37.2%. The median operative time was 62 minutes with no conversions, ductal injuries or mortality. Complications occurred in 9.2%, including 14 persistent pancreatitis/collections resulting in 6 of 25 readmissions. Two re-operations resulted from t-tube complications. Median hospital stay was 7 days, 72% having had only one admission. Conclusion Index admission LC on all AP patients fit for surgery is perfectly safe in the specialist setting. It optimises preoperative radiological investigations and endoscopic interventions and ,subsequently, a third of the patients require bile duct exploration. Implementing definitive surgical interventions during the index admission for AP offers a substantial reduction in hospital stay, re-admission rates and an overall decrease in hospital attendances. This not only yields significant cost benefits for the health service but also enhances the quality of life for patients.

Abstract Aim To evaluate the rate of bile duct stone recurrence and possible risk factors in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (LCBDE) on a unit adopting routine cholangiography and LCBDE. Methods A prospective database of LC and LCBDE with confirmed ductal clearance spanning 30 years was reviewed. Those returning with clinical and laboratory suspicion of recurrence were included whether or not MRCP confirmation was obtained or intervention required. Apart from annual follow up electronic records were examined in 2020 and 2023 to capture unreported episodes. Results 1447 patients underwent LCBDE. 56 (3.8%) had suspected recurrence after a mean of 36.6 months (5-144). Mean age was 67.6 years and 57.1% were females. 12 (21.4%) settled on conservative management, including Glucagon administration, and MRCP was negative. 44 patients (78.6%) had 59 confirmed recurrence episodes; 53 needing 63 ERCPs and 6 settling conservatively. 12/44 (21.4%) had repeat recurrences. Only one biliary-enteric anastomosis was required. Only 11 of 4693 LC (0.23%) had recurrent stones (5 repeatedly) after a median interval of 30 months (5-120). 19 recurrence episodes occurred during which 13 settled spontaneously and 6 needed 9 ERCPs. In spite of average rates of ERCP morbidity no biliary related deaths resulted from stone recurrence. Compared to the rest of LCBDEs those with recurrence were more male, older, with more dilated CBD on USS & required more choledochotomies for larger stones. Conclusions CBDS recurrence occurs in 3.8% after LCBDE with 3% confirmed and requiring intervention, significantly lower than after sphincterotomy. Glucagon may help small stones pass. 21.4% have repeat recurrences justifying stone dissolution agents. Identifying recurrence risk factors require further studies.

Abstract Aim To evaluate the accuracy of preoperative diagnosis of acute cholecystitis (AC). Methods A prospective database of cholecystectomies and bile duct explorations spanning 30 years was analysed. Results 593/6140 patients (9.6%) had a preoperative diagnosis of AC (Group 1) 12.3% had no AC at surgery. 300/5547 patients (5.4%) had AC without preoperative criteria (Group 2).Group 1Group 2Emergency admission588 (99.1)203 (67.6)Presentation with Jaundice96 (16.2)110 (36.6)Previous acute cholecystitis76 (12.8)3 (1)USS:GB Thick wall or contraction389 (65.6)112 (37.3))Bile duct dilatation66 (11.1)179 (36.6)Preoperative imaging:MRCP23 (3.8)21 (7)CT76 (12.8)15 (5)ERCP8 (1.35)11 (3.6)Operative GB findingsAcute193 (32.5)140 (46.7)Empyema313 (52.8)160 (53.3)Difficulty Grading I&II20 (3.4)--III177 (29.8)117 (39.1)IV344 (58)168 (56.2)V52 (8.8)15 (4.7)Adhesions GB to:Duodenum503 (84.8)241 (80.3))Hepatic flexure410 (69.1)169 (56.3)Difficult cystic pedicle524 (88.3)273 (91)Fundus first dissection39 (6.6)19 (6.3)Bile Duct Exploration:106 (17.8)98 (32.6)Transcystic93 (15.6)72 (24)Choledochotomy13 (2.2)26 (8.7)Operative time (median, range)80 min (32-280)85 (35-350)Open conversion3 (0.5)3 (1)Morbidity40 (6.7)30 (10)Hospital stay (median, range)9.9 (1-62)13 (1-100)Mortality4 (0.67)1 (0.3)Resolved in one episode427 (72)189 (63) Conclusions 300/806 (37.2%) of AC or empyema encountered at operation do not have preoperative criteria. 25% of all AC require bile duct exploration. Emergency biliary admissions should be dealt with by specialist surgeons.

Abstract Background/Aims Giant cell arteritis (GCA) has been revolutionised by fast track pathways that ensure early secure diagnosis. The GiACTA study provided evidence for the beneficial role of tocilizumab in the treatment of GCA and encouraged us all to reconsider the role of corticosteroids. These data relate to real life experience of the use of tocilizumab, including current status of patients after completing the initial year of treatment. In Scotland, tocilizumab was initially used for patients with relapsing disease or steroid complications. However, since 2018, the Scottish Medicines Consortium has supported use from disease onset and it has become increasingly common to consider adding at diagnosis. Methods The case notes of 23 patients treated with tocilizumab were reviewed back to 2017. Patient demographics were collated including whether cranial (C) or large vessel vasculitis (LVV) variant. The diagnosis of GCA had to be confirmed by biopsy or imaging with GCA rheumatology clinic review. Any patients who discontinued tocilizumab prior to completing one year had the reason recorded. Duration on tocilizumab was intended to be one year. Data were reviewed to capture outcomes after treatment was withdrawn. Results 2 patients with non-relapsing disease discontinued tocilizumab within the first month due to early relative neutropenia (1.4). 5 of 21 patients who completed treatment have since had additional tocilizumab treatment. 1 patient with particularly severe relapsing disease and steroid complications remains on long term tapered tocilizumab monotherapy without attempt to stop (C and LVV). 4 patients (LVV=C) flared within 1-9 months (median 6 months) and resumed with steroids and subsequent tapers; all had commenced for relapsing disease. 1 patient (C), commenced on tocilizumab at diagnosis, opted for MTX when flared. 15 remaining patients are on no steroid, methotrexate or tocilizumab and are free of disease activity as yet, but undergoing monitoring for flare (12C 3 LVV variant). Conclusion Tocilizumab is effective, limits steroid exposure and is well-tolerated by patients. The most common reason for discontinuing tocilizumab was relative neutropenia (neutrophils 1-1.4). The majority of patients discontinued tocilizumab and have not yet flared off all treatment. Cranial variant was less associated with relapse after tocilizumab treatment versus LVV. New diagnoses appear less prone to relapse off tocilizumab than patients already known to have relapsing disease prior to using tocilizumab. Patients discontinuing tocilizumab benefit from ongoing monitoring to recognise the early stages of returning disease; this would need to be provided for at least one year. Patients discontinuing treatment, their GPs and carers need advice on routes to escalate concerns about returning symptoms. Fast track services need to provide a flare service in addition to a diagnosis pathway if there is to be safety, confidence and expert support for this patient group and primary care colleagues. Disclosure L.M.M. Hutton: Other; 2022 Roche educational grant to attend BSR.

Objectives: To evaluate the impact of adult learning and simulation-based learning (SBL) on surgical trainees’ learning experiences and Fellowship of the Royal College of Surgeons (FRCS) Section 2 General Surgery examination pass rate. Methods: This was a cross-sequential study involving 148 surgical candidates (72 UK trainees, 75 non-UK trainees) who had attended our revision course (Phoenix FRCS Course) from June 2017 until 2023. Each course comprised a two-day weekend preparation with dedicated sections for clinical, viva, and academic reading, incorporating SBL as its key learning style. We maintained a prospective database of candidate and course details, examination results, and feedback since the course inception. Results: We found that 97% of candidates passed the FRCS examination after their first attempt. The course was attended once by 89% of candidates, and only 3 of the 148 candidates exhausted all four attempts at the examination. Candidate feedback for the course and its style of learning was positive, with simulation-based table viva sessions and virtual clinical sessions proving the most popular learning sessions (95% and 80% of candidates attending courses run in December 2017, April 2018, and May 2021 rated them “Excellent” respectively). Conclusions: The course is centered around shared adult learning and mindfulness tools to encourage candidates to learn from each other and develop confidence and mastery in all domains of surgical practice. These methods have been shown to be effective in achieving high success rates in the Intercollegiate and International FRCS examinations for UK and overseas surgeons.

Tension Band Wiring (TBW) has traditionally been the cornerstone of operative management for simple displaced olecranon fractures but its success is limited by high complication rates, mainly related to metalwork irritation and fixation failure. Over the last twelve years, a number of novel fixation methods not involving metalwork have been described in case series (suture fixation, SF and suture-anchor fixation, SAF) with promising early results. In this systematic review, the outcomes of SF and SAF techniques are presented alongside those for TBW for the treatment of closed olecranon fractures without elbow instability. Five databases (Medline, Scholar, Scopus, Prospero and Cochrane) were searched for clinical studies involving TBW/SF/SAF for closed Mayo 1A/1B/2A/2B olecranon fractures from January 2010 onwards. Primary outcomes included overall complication and reoperation rates, as well as the rate of each specific complication. Elbow range of movement, surgeon and patient-reported outcome measures were defined as secondary outcomes. Eighteen studies were included, nine of which involved SF/SAF (99 patients) and nine TBW (382 patients). SF/SAF techniques were associated with lower rates of fracture/implant displacement (2% versus 9.7%, p = 0.01), implant irritation (1% versus 30.1%, p < 0.001) and overall complications (8% versus 46.1%, p < 0.001) when compared to TBW. Reoperation rates were lower for SF/SAF (3% versus 37.2%, p < 0.001). Total flexion/extension arc achieved was similar (130.16 ± 2.11 versus 129.45 ± 0.93 degrees). On average, patients regained a functional arc of flexion (135.21 ± 4.81 TBW versus 131.32 ± 12.99 SF/SAF) and extension (1.16 ± 7.54 SF/SAF versus 5.76 ± 7.98 TBW). Current evidence suggests that SF/SAF of simple olecranon fractures is a safe and effective alternative to the current gold standard TBW fixation, with preliminary evidence suggestive of lower complication and reoperation rates. Firm conclusions of equivalence or superiority are not possible based on the current poor quality of literature available. Until the outcomes of high-quality prospective studies are available, patients should be carefully counselled that suture methods remain novel and outcomes should be regularly audited.