Gallstone disease Paras Jethwa MD FRCS Consultant Upper GI Surgeon SASH

A changing landscape First LC in 1987 Early 1990’s - regularly 3 hours+ Routine surgery 8 mins - 4 hours Morbidity - 4% Mortality - 0.1% National conversion rate of 5%

Gallstones Increasing incidence  Fatty diet  Post obesity surgery  Crash dieting  Diabetes 4 F’s no longer diagnostic criteria  Increasing % male  15 to 94 Very frequent cause of acute admission

Controversy Recent AUGIS proposal that only UGI surgeons should perform LC Rejected by ALS - but - should there be a basic laparoscopic competence NPSA alert on iatrogenic complications

Results > 250 cholecystectomies performed  No biliary complications  30% daycase  >20% patients over 70 In last year <1% conversion to open  Includes acute admissions Pancreatitis Acute cholecystitis Empyema Perforations BMI up to 50 (45 as DC)

SASH Lowest in patient stay in the region  3.4 to 1.4 days since 2008  92% patient satisfaction  Lowest readmission rates Clear drive to increase daycase LC rates  Dedicated team & equipment  Anaesthesia & nursing  Risk stratification  95% of DSU stayed as daycase

Acute Gallbladders Conventional wisdom  Antibiotics +/- repeat scan  Clinic  6/52 operation  Acute operation High rates of conversion(10%) High rate of CBD injury Representation Severity of disease  Pancreatitis  Fistulas Not for the unwary surgeon!

VW video

Acute perforated GB 55 year old A&E attendee with RUQ peritionism Op on day 2 - home day 3 - back to work day 10

Acute/non resolving Cholecystitis 47 year old Multiple attacks Unable to work due to pain

Deranged LFT’s Obstructive jaundice  Dark urine/pale of stools  No history of ETOH Coordinated approach  Discussion at weekly MDT  Dedicated ERCP service/UGI surgeon  GI radiologist/Specialist nurses/Oncologist  Surgical high dependency/ITU Accurate diagnosis  MRCP +/- CT

CBD stones USS MRCP EUS IOC LCBD ERCP

Obstructive Jaundice ERCP vs. Lap CBD  Younger patient  Impacted stones (at time of LC) Short/Longterm effect of sphincterotomy  Concern of dysplasia  Stricture formation

Case study Elderly lady Impacted CBD stone Expedited admission Cholecystodudodenal fistula Large stone in her CBD Multiple comorbidities

Complications Bleeding  Rare - cause of conversion  Haematoma +/- collection  Acute setting Bile leak  1 % incidence  CBD stump/ undersurface of liver/duct of Luska  Repeat scope - drainage CBD injury  1:300 in recent Swiss study (31 000)  Injury with LC greater magnitude than OC  IOC - not protective  Best dealt with by dedicated centre

Complications 2 Dyspepsia Post Chole syndrome Iatrogenic injury to other viscera Retained (dropped) stone Persistent fatty induced pain Diarrhoea

I didn’t get where I was today…

The Future? > 60% daycase rate  Increasing obese population  Extensive comorbidity  Social factors Modification of anaesthetic techniques  Intrapertioneal instillation of topical anaesthesia  Currently designing RCT of IP vs. IT block Use of surgical high energy for removal of viscera (SHERV)

Questions?