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INTRODUCTIONBowel obstruction continues to be one of the most common intra-abdominal conditions encountered by general surgeons in their practice. It remains a major cause of morbidity and mortality, accounting for 15% of hospital admissions for acute abdomen and up to 30% of these needs operative intervention.1,2 Patients may present acutely or as a chronic and relapsing problem with symptoms ranging from modest discomfort to extreme illness and shock. Small Bowel Obstruction (SBO) has been and continues to be a common clinical challenge. This is so because the proper management of small bowel obstruction requires a methodology which on one hand can promptly recognize the presence of strangulationobstruction and hence the need for urgent operative intervention; and on the other hand can avoid a nontherapeutic laparotomy along with its associated ABSTRACT Background: Small bowel obstruction is a common clinical challenge because the proper management of small bowel obstruction requires a methodology which on one hand can promptly recognise the presence of strangulationobstruction and hence the need for urgent operative intervention; and on the other hand, can avoid a non-therapeutic laparotomy along with its associated morbidities and further adhesion formation with its potential sequelae. The study was done to identify relevant features in the patient's clinical and CT abdomen findings which when present would be highly predictive of the requirement of an operative intervention in a patient with small bowel obstruction. Methods: The study was a hospital based analytical observational study on patients admitted from March 2013 to May 2014 with a diagnosis of small bowel obstruction and who underwent a concurrent CT abdomen. Correlation of line of management was done with respect to the three chosen parameters, obstipation (history), mesenteric edema (CT imaging) and lack of small bowel feces Sign (CT imaging). Results: A total of 74 patients were included with Male:Female ratio being 3.1:1. Forty patients were managed conservatively and remaining underwent surgery with adhesions being the most frequent etiology. The most common operative procedure performed was adhesiolysis with or without band release. Twenty-three cases were performed by open method and remaining laparoscopically. Evaluation of the three parameters revealed that these variables, when present independently or in combination, are predictive for need for operative intervention (p-value <0.001). The sensitivity and specificity to predict the need for exploration when all 3 features were present concurrently was 38.24% and 100%, respectively. Conclusions: Small-bowel obstruction is a common surgical dilemma, the management of which is dealt on a daily basis by surgeons and non-surgeons. The management using variables based on history and radiology may help classify patients into those requiring conservative management and those in need of early exploration.

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EP-204Introduction: Contrast cholangiograms still continue to be obtained prior to removal of intraoperatively or preoperatively placed intra-biliary tubes to look for filling defects, anastomotic leaks or stenosis, evaluation of radiological intervention or a controlled external biliary fistula. Post-cholangiogram cholangitis remains a major morbidity concern. Is it related to the technique? Methods: An observational prospective pilot study comparing hand held push injection (PIC) and gravity dependent (GDC) techniques of cholangiography in 30 consecutive patients with in-situ biliary tubes after administration of pre-procedure antibiotic, excluding patients with active cholangitis or complete biliary obstruction. In GDC group, dye was delivered under gravity from a height of 25 cm instead of injection. Outcomes analysed included adverse reactions -minor (two or more of low grade fever, tachycardia, pain/nausea without fever, subclinical cholangitis) and major (two or more of high grade fever, chills, tachycardia, hypotension, oliguria), readmission requirement, and the efficacy (opacification of the biliary tree and demonstration of the objective). Results: In the PIC group (n = 14), adverse reactions were minor in 6 (42.8%) and major in 4 (28.5%). Two patients required re-admission, and in two others discharge from the hospital was delayed. In the GDC group (n=16), adverse reactions were minor in 7 (43.7%), with no major adverse reaction or readmission. Major adverse reactions were significantly more common in PIC as compared to GDC (28.5% vs. 0% respectively, p-value = 0.03), and translated into higher treatment costs. Conclusions: When required, GDC, limiting rise in intrabiliary pressure, is a safer, completely efficacious and economical technique.

Re-resection of incidental gallbladder carcinoma (IGBC) is possible in a select group of patients. However, the optimal timing for re-intervention lacks consensus. Methods: A retrospective analysis was performed for a prospective database of 91 patients with IGBC managed from 2009 to 2018. Patients were divided into three groups based on the duration between the index cholecystectomy and re-operation or final staging: Early (E), < 4 weeks; Intermediate (I), > 4 weeks and < 12 weeks; and Late (L), > 12 weeks. Demographic data, tumor characteristics, and operative details of patients were analyzed to determine factors affecting the re-resectability of IGBC. Results: Twenty-two patients in 'E', 48 in 'I', and 21 in 'L' groups were evenly matched. Nearly two thirds were asymptomatic. Curative resection was possible in 48 (52.7%) patients. Metastasis was detected during staging laparoscopy (SL)/laparotomy in 26 (28.6%) patients. The yield of SL was more in the 'L' group (30.8%) than in the 'I' (11.1%) or 'E' (nil) group, avoiding unnecessary laparotomy in 13.6%. Only 28.5% of patients in the 'L' group could undergo curative resection (R0/R1 resection), significantly less than that in the 'E' (50.0%) or 'I' group (64.6%) (both p < 0.001). On multivariate analysis, presentation in intermediate period and tumor differentiation increased the chance of curative resection (p < 0.05). Conclusions: Asymptomatic patients in the 'I' group with well differentiated IGBC have the best chance of obtaining a curative resection.