INTRODUCTION:A selection of international guidelines suggest that emergency cholecystectomy within 72 h of admission is the treatment of choice for acute cholecystitis. The aim of this study was to analyse the interval from presentation to operative intervention for acute cholecystitis in Ireland and its impact on peri-operative outcomes. METHODS:This was a national retrospective observational study of all patients that underwent an emergency cholecystectomy for acute cholecystitis in Ireland between January 2017 and July 2023. Data collected included: demographics, co-morbidities, length of stay, operative approach, post-operative interventions, in-patient mortality, and readmissions. Subjects were stratified based on time from presentation to theatre and outcomes were compared between groups. RESULTS:3585 patients underwent an emergency cholecystectomy for acute cholecystitis-2005(55.9 %) within 72 h of admission, 1072(29.9 %) within 72 hours-7 days, 416(11.6 %) within 8-14 days and 92(2.6 %) beyond 14 days. Earlier progression to theatre was predicted by female sex (X2(3) = 10.402,p = 0.015), less co-morbidities (X2(12) = 95.723,p=<0.001), and younger age (H(3) = 92.591,p=<0.001). On logistic regression, age >65(OR 1.565,p < 0.001), male sex(OR 1.348,p = 0.002), increasing co-morbidities(OR 1.586,p = 0.009) and increased "time to theatre"(72hrs-7days(OR 1.616,p < 0.001), 8-14days(OR 3.84,p < 0.001), >14days(OR 5.929,p < 0.001)) were risk factors for a composite of adverse outcomes (mortality, 30-day readmission, post-operative ERCP/IR drain, conversion to open, CBD injury). Subgroup analysis of the <72 h group displayed no difference in outcome. CONCLUSION:Despite international guidance, just over half of emergency cholecystectomies for acute cholecystitis are performed within 72 h in Ireland. Prolonging "time to theatre" is associated with a stepwise deterioration in outcomes across a wide variety of measures.

Backgrounds/Aims:Iatrogenic bile duct injuries (IBDIs) are an uncommon but potentially severe complication of laparoscopic cholecystectomy. The aim of this study was to assess both peri-operative and long-term outcomes of the current surgical management of IBDIs in Ireland and to estimate the associated costs. Methods:Patients who underwent management for IBDIs following laparoscopic cholecystectomy between 2014 and 2024 were retrospectively identified from the three hepatobiliary (HPB) centres in Ireland. Data collected included demographics, surgical details, and perioperative as well as long-term outcomes. Cost analysis was conducted using the activity-based funding in-patient price list from the healthcare pricing office. Results:A total of 34 patients underwent surgical intervention for IBDIs. Of these, 26 patients (76.4%) underwent Roux-en-Y hepaticojejunostomy, while primary bile duct repair was performed in five patients (14.7%). Three patients (8.8%) required right hepatectomy in conjunction with hepaticojejunostomy. Ten (29.4%) patients required re-operation, including four of the five who initially underwent primary repair. One patient ultimately required orthotopic liver transplant, and there were three (12.5%) peri-operative deaths. No statistically significant differences in peri-operative outcomes were observed between intra-operative and post-operative diagnosis of BDI. The median direct in-patient treatment cost was estimated at  €85,961. Conclusions:IBDIs pose a considerable risk of long term complications and mortality with substantial costs to the health service. Subspecialist HPB referral is key to successful management, which typically involves bilio-enteric anastomosis and occasional liver resection if associated with major vascular injury.

Abstract Background Defined criteria for the resectability of liver disease continue to be refined. In the era of enhanced recovery after surgery (ERAS), data regarding its safety and efficacy in specific patient populations is required. Patients with liver cirrhosis are particularly vulnerable, owing to both operative and peri-operative risk. However, the application of ERAS in cirrhotic patients undergoing hepatectomy is absent from the most recent ERAS Society Group recommendations from 2022. We present a meta-analysis assessing outcomes after liver resection in patients with cirrhosis following an ERAS protocol compared to standard post-operative care. Method A systematic literature search was performed using PubMed, Embase and Web of Science. Studies were included if comparing ERAS protocols versus standard post-operative care in patients undergoing liver resection in which more than 50% of the patient population had cirrhosis at time of surgery. The primary outcome analysed was overall complication rates with secondary outcomes of post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission and reoperation rates. Statistical analysis was performed using Review Manager by the Cochrane Collaboration. Results 930 records were screened for eligibility. Five articles were eligible for inclusion(ERAS n = 425 vs control group n = 423 patients). Cirrhotic patients enrolled in an ERAS program post-hepatectomy had a significantly reduced risk of overall complications (OR 0.45, 95% CI 0.33, 0.61, p<0.00001) and a shorter hospital stay when compared to standard post-operative care by 1.8 days (mean difference -1.83, 95% CI -2.22, -1.45, p<0.00001). No significant differences were noted in post-operative mortality, estimated blood loss, operation time, post-operative incidence of liver failure, readmission or reoperation rates between the ERAS group and control. Conclusion Application of an ERAS protocol for patients undergoing liver resection is safe and feasible in cirrhotic patients. ERAS protocols were successful in significantly reducing overall complication rates and length of inpatient hospital stay, and did not negatively impact secondary post-operative outcomes or mortality. ERAS protocols should be reflected in future guidelines, specifically for cirrhotic patients undergoing hepatectomy, and additional research on the utility of ERAS in higher risk patients is encouraged.

BACKGROUND:It is unknown if textbook outcomes (TBOs) correlate with patient-reported health-related quality of life (HRQoL) parameters in patients undergoing hepatic resection for colorectal liver metastasises. Understanding this relationship is required to inform treatment decisions and optimise patient care. This single-centre analysis aims to assess this correlation and provide insight into the impact of liver resection on patient well-being in this population. METHODS:Single-centre analysis of all liver resections performed for colorectal liver metastases (CRLM) at our centre from 2018 to 2023. The EuroQol-5D (EQ-5D) validated telephone questionnaire was used to assess HRQoL. The impact of a TBO on overall survival and recurrence-free survival was investigated using Kaplan-Meier curve analysis. A Cox model was used to determine factors associated with improved survival. RESULTS:185 patients underwent liver resection for CRLM between 2018 and 2023. 55% of eligible patients completed the EQ-5D telephone questionnaire. TBOs were achieved in 68.2% of CRLM at our institution. Achieving TBOs in this cohort was associated with improved HRQoL (p = 0.061). CONCLUSION:This study demonstrates excellent long-term HRQoL in patients who undergo resection for CRLM. Achieving TBO in this cohort is associated with improved patient-reported HRQoL. Our findings strengthen the utility of the previously defined textbook outcomes in CRLM.

Background: Acute cholecystitis is a common general surgical emergency, accounting for up to 10% of all patients attending with acute abdominal pain. International guidelines suggest that emergency cholecystectomy is the treatment of choice for uncomplicated acute cholecystitis where feasible. Methods: All patients with acute cholecystitis presenting to public hospitals in Ireland between January 2017 and July 2023 were identified using the National Quality Assurance and Improvement System (NQAIS). Data were collected on patient demographics, co-morbidities, length of stay (LOS), operative intervention, endoscopic intervention, critical care admissions, in-patient mortality, and readmissions. Results: A total of 20,886 admission episodes were identified involving 17,958 patients. Among them, 3,585 (20%) patients underwent emergency cholecystectomy in total; 3,436 (96%) of these were performed laparoscopically, with 140 (4%) requiring conversion to an open procedure, and common bile duct injuries occurring in 4 (0.1%) of patients. In comparison to patients treated conservatively, patients who underwent cholecystectomy were younger (median 50 vs. 60 years, P<0.001) and more likely to be female (64% vs. 55% P<0.001). Following propensity score matched analysis, those who had an emergency cholecystectomy had reduced LOS [median 5 days, interquartile range (IQR): 3–8 days vs. 6 days, IQR: 3–10 days, P<0.001] and fewer readmissions to hospital {282 (8%) vs. 492 (14%), age >65 years [odds ratio (OR): 1.526], Charlson comorbidity index (CCI) >3 (OR: 2.281) and non-operative management (OR: 1.136)} were significant risk factors for adverse outcome. Conclusions: Uptake of emergency cholecystectomy in Ireland remains low, and is carried out on a younger, fitter cohort of patients. In those patients, however, it is associated with improved outcomes for cholecystitis compared to conservative management.

Background: Oligometastatic colorectal cancer is increasingly treated with an aggressive multimodal approach, and recent data including the JCOG0603 trial highlight the central role of hepatectomy for colorectal liver metastases (CRLM). Minimally-invasive approaches to major hepatectomy have been recently described, with potential advantages in terms of postoperative pain and recovery of health-related quality of life.

Background: Gastrointestinal stromal tumours (GISTs) are the commonest mesenchymal tumours of the gastrointestinal tract, most frequently occurring in the stomach. While tyrosine kinase inhibitors have improved outcomes for patients with advanced or high risk GISTs, surgical resection remains the mainstay of treatment for localised disease. A minimally-invasive transgastric approach may be particularly useful for tumours in close proximity to the oesophagogastric junction.

Background: Mortality in infected pancreatic necrosis (IPN) is dynamic over the course of the disease, with type and timing of interventions as well as persistent organ failure being key determinants. The timing of infection onset and how it pertains to mortality is not well defined. Objectives: To determine the association between mortality and the development of early IPN. Methods: International multicenter retrospective cohort study of patients with IPN, confirmed by a positive microbial culture from (peri) pancreatic collections. The association between timing of infection onset, timing of interventions and mortality were assessed using Cox regression analyses. Results: A total of 743 patients from 19 centers across 3 continents with culture-confirmed IPN from 2000 to 2016 were evaluated, mortality rate was 20.9% (155/734). Early infection was associated with a higher mortality, when early infection occurred within the first 4 weeks from presentation with acute pancreatitis. After adjusting for comorbidity, advanced age, organ failure, enteral nutrition and parenteral nutrition, early infection (<= 4 weeks) and early open surgery (<= 4 weeks) were associated with increased mortality [HR: 2.45 (95% CI: 1.63-3.67), p < 0.001 and HR: 4.88 (95% CI: 1.70-13.98), p = 0.003, respectively]. There was no association between late open surgery, early or late minimally invasive surgery, early or late percutaneous drainage with mortality (p > 0.05). Conclusion: Early infection was associated with increased mortality, independent of interventions. Early surgery remains a strong predictor of excess mortality. (C) 2021 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Background: At presentation, 50% of patients with gastric cancer have metastases, 40% of which are peritoneal metastases. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) was first described as a treatment for metastatic gastric cancer patients in 19891. In 2019, a randomised multicentre trial on CRS and HIPEC in these patients demonstrated a significant benefit in the treatment arm with a median overall survival of 18.6 months and 5-year survival of 20.2%2.

Background: Despite developments in minimally invasive technology, there is a lack of consensus among surgeons regarding the optimal technique for resection of colorectal liver metastases. The aim of this study was to compare outcomes for robotic hepatectomy (RH), laparoscopic hepatectomy (LH) and open hepatectomy (OH) via a systematic review and network meta-analysis. Methods: A systematic literature search was performed using the PubMed, Scopus and Cochrane databases. Only randomised controlled trials or propensity score matched studies were considered for inclusion. Studies reporting on patients undergoing hepatectomy for indications other than colorectal liver metastases were excluded. Studies comparing non-operative management, liver ablation or other treatment strategies were excluded. Outcomes included intraoperative blood loss, operative time and survival, amongst others. Results: Seventeen papers, with 5,534 patients, were found to meet the inclusion and exclusion criteria. RH was associated with a significantly lower length of stay in comparison to LH and OH. There was no significant difference in intraoperative blood loss or operative time between the groups. Five-year survival was 50.5% for OH, 67.5% for LH and 42.5% for RH. Conclusions: RH is associated with reduced length of stay in comparison to LH and OH. Intraoperative blood loss and operative time did not differ between the groups. LH appears to infer an improved 5-year survival in comparison with RH.

Introduction: Percutaneous cholecystostomy tube (PCT) placement is a treatment method for acute cholecystitis, both in adult patients unsuitable for surgery and those failing to improve with conservative management. The purpose of this study was to assess the outcomes of patients undergoing cholecystostomy. Materials and Methods: A review of consecutive patients who underwent PCT insertion over a 10-year period was performed. Outcomes assessed included cholecystostomy dwell time, tubogram requirement, cholecystostomy reinsertion, cholecystectomy, bile leaks, and mortality. Results: One hundred eight patients (77 male individuals, 31 female individuals) were included. The mean age was 70 years (range: 29 to 93 y). A total of 89 transhepatic and 19 transperitoneal PCTs were inserted. Fifty-nine patients (55%) had a subsequent tubogram to assess cystic duct patency or catheter position. Mean catheter dwell time was 17 days (range: 1 to 154 d). Eleven (10%) required PCT reinsertion. Time to reinsertion ranged from 2 to 163 days (mean=38 d). Fifty-three patients (50%) had no further biliary intervention after removal of the cholecystostomy catheter. One patient required subsequent drainage of a hepatic abscess, and another developed a biloma. Thirty-two patients (30%) underwent cholecystectomy (66% laparoscopic, 34% open). Thirty-day mortality after PCT insertion was 8.3%. Twenty patients (19%) died of non–cholecystostomy-related illness during the 10-year follow-up period. Conclusions: Cholecystostomy is an important treatment method of acute cholecystitis as a bridge to cholecystectomy or as an alternative definitive treatment option in those unsuitable for surgery. A tubogram is not always necessary before tube removal. Cholecystostomy tubes can be removed safely with little risk of bile leak if patients are clinically well, and clean-appearing bile is draining.

Background: At presentation, 50% of patients with gastric cancer have metastases (40% of which are peritoneal metastases). The median survival, without treatment, is 3–7 months with a 5-year survival of 0%. Palliative chemotherapy improves the median survival to one year. Heated intraperitoneal chemotherapy (HIPEC) was first described as a treatment for gastric cancer patients in 1989. Multiple studies have assessed it’s validity. In 2019, a randomised multicentre trial demonstrated a significant benefit with a median overall survival of 18.6 months and a 5-year survival of 20.2% (4). Methods: A gastric cancer program was started at the peritoneal malignancy unit at the Mater Misericordiae hospital in July 2019. Advice from other international centres was sought in devising a protocol for patients. Patients are assessed based on their age, fitness, treatment history, extent of disease on initial presentation and response to treatment. Results: Five patients have undergone treatment. The average age was 60 years. All patients received neoadjuvant chemotherapy. Three of 5 patients had washings that were cytology positive only, the remaining two had peritoneal deposits. At theatre 4/5 patients required extended resections which included either spleen, pancreas, or colon. One patient had a grade 3 complication [anastomotic leak requiring interventional radiology (IR) drain]. The average length of operation was 7.5 hours. The average length of stay was 22 days. All patients had poorly differentiated lymph node positive adenocarcinoma with a poor tumour regression grade. Eighty percent had adjuvant treatment. Conclusions: Cytoreductive surgery and HIPEC is safe in selected patients with peritoneal metastases from gastric cancer.

Background: Gallbladder cancer is rare but associated with significant morbidity and mortality necessitating the early identification of premalignant and malignant lesions to improve overall prognosis. Despite limited evidence regarding the effectiveness of transabdominal ultrasound (US) in the detection of gallbladder polyps, it plays a key role in current European guidelines. The aim of this study was to investigate gallbladder polyp prevalence in a western European population and assess the diagnostic accuracy of transabdominal US. Methods: Data from patients who underwent cholecystectomy for US detected gallbladder polypoid lesions at four hospitals in Ireland and the United Kingdom between 2010 and 2018 were retrospectively collected. Patient demographics, ultrasonographic, and histopathologic findings were analyzed. Results: A total of 134 patients underwent cholecystectomy for US-detected gallbladder polyps. After histopathologic examination, pseudopolyps were found in 75 (56%) specimens with dysplastic or malignant polyps seen in only six (4.5%) specimens. Mean size for neoplastic polyps was 33 mm. The positive predictive value for US in detecting neoplastic polyps in this study was 4.5%, which is significantly lower than the 10%-15% reported previously. Conclusions: Although the prevalence of neoplastic polyps in this study is higher than in the previous literature, the distribution of pseudopolyps and true polyps is as expected. With all malignant polyps being >10 mm in diameter, these findings support the current size thresholds stated in European guidelines. The poor diagnostic accuracy of US demonstrated may have led to significant number of patients undergoing unnecessary surgical intervention, further supporting the argument for improved strategies for the investigation of gallbladder polyps. Crown Copyright (C) 2020 Published by Elsevier Inc. All rights reserved.

Background: The conditions that can make a laparoscopic cholecystectomy “difficult” include cirrhosis, anatomical anomalies, and acute and chronic inflammation. Anatomical anomalies of the biliary tree can occur in up to 25% of patients. Failure to recognize abnormal anatomy can have catastrophic consequences for patients, including transection of the common bile duct. The objective of this case series is to highlight the increasing practice of abandoning cholecystectomy when an unexpectedly difficult gallbladder is encountered. Methods: We present a case series of five abandoned laparoscopic cholecystectomies. Two cases underwent their initial laparoscopy under our service and three cases had abandoned laparoscopies in other centres and were referred for a specialist HPB opinion. Results: The reasons for abandoning the procedure were due to difficult or abnormal anatomy in three cases. One case was referred with suspected malignancy. In one case it was not possible to mobilize and retract the gallbladder due to inflammation and the burden of stone disease. Two patients went on to have elective open cholecystectomy, one patient had a laparoscopic cholecystectomy which was converted to open, one patient had a laparoscopic procedure and one is currently awaiting laparoscopic cholecystectomy. Three patients underwent magnetic resonance cholangiopancreatography (MRCP) between the abandoned procedure and the completion procedure. Two of the cases were discussed at the Gastrointestinal Multidisciplinary team meeting after referral to our centre. There were no significant perioperative morbidities encountered at the initial or subsequent procedures. Conclusions: Our experience has demonstrated that abandoning laparoscopic cholecystectomy is a safe and reasonable response when one encounters a “difficult” gallbladder, either due to unclear anatomy or in a setting that lacks adequate facilities for patients in the event of conversion to an open operation.